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170 County Line Rd ..-HEALTH DEPARTMENT RELEASE For Office Use Only. *CDP File Number 200516- 1 Davie County Health Department f 210 Hospital Street County ID Number P.O. Box 848 Evaluated For HDR/V1IWC Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 3 / 0 9 / a 0 a 1 UNTIL Applicant: Trent Drum Property Owner: Trent Drum Address: PO Box 64 Address: PO Box 64 City: Harmony City: Harmony State2ip: NC 28634 State/Zip: NC 28634 Phone#: (336)492-2013 Phone#: (336)492-2013 Property Location& Site Information Address 170 County Line Road Subdivision: Phase: Lot Road# Harmony NC 28634 SINGLE FAMILY Township: 'StruGure: Directions #of Bedrooms: #of People: Hwy 64 West,right on 901 then right on County Line Rd 'Water Supply: WA Basement: M Yes E]No Type of Business: Total sq. Footage: No.Of Employees: "Proposed Improvement: Carport 20x21 'Release Conditions ` This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Rep;.Signature Required? Oyes ONo Applicant/LegaLReps.Signature; *Date: *Issued By: 2140-Nations,Robert *Date of Issue:_ 0 , 3 0 9 x 0 1 6 Authorized State Agent: **Site Plan/Drawing attached.** ®Hand Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE 200516 - 1 L�' ens a Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 3 / 0 9 / 2 0 1 6 Olnch Scale: OBlock Drawing Type: Health Department Release ON/A ------------ Ole- s r 1 c Page 2 of 2 .. Davie County Health Department 0 18 DEllvironmental Health Section { 11EC.14 E P.O.Box 848 210 Hospital Street �7 Courier# : 09-40-06 1911 U Mocksville,NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEW ER ATION (Check One) Replacement Remodeling J Reconnection Name: D, Phone Number Yj(-g92_- 2013 (Home Mailing Address:— ?, da (Work) -1 �-✓�6 v�, /� �2 �� Email Address:hGy, 1-vo-) Yctd 4el A)P'f' Detailed Directions To Site: �p u�-c! �C_ ��(• � ►�r'^o r1�/ , (�C rr `w Co Property Address: 'h r Please Fill In The Following Information About The EXISTING Facility: �J Name System Installed Under: -1� n- V' "1 Type Of Facility: Date System Installed(Month/Date/Year): /q 9 Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: C Q/'p 6 r 4-- Number Of Bedrooms: Number of People 'Pool Size: Garage Size:a D YA I Other: Requested By: I Date Requested: A /,L i ignature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: �� 51p Invoice#: /II i � k I 14 f f I •.." .. Nf r y 1. r f v Iz .,t �._ 71 •y,a /�- yr Y y. > t i �.a L. If r Z >> < 4. , 1 t 7.c. i f• r I i � S t> .l. t 77 k � I t i _ (11 747 — + •.',,. .��'. .. ..is �. .i. .1'. "—: CO/ •• ..(. ::.. .i: -�' '',:• Pat 1`0 (r�. WO ty'C s Printed:Feb 26, 2016 NE All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. "9Z ty.y.x, K/ il. nr'F I J k� :•1,�Ft:� k .. <<'t FX;/i'1{J x Nr_,t a r� F•S. �,. t>�•v^7 SV : s:M-'w � s s,`m.ry-� t-'�• }y,t '::.-,rsr•... vr• !'va - �✓�� . AUTHORIZATION NO: '0557 DAVIE,COUNTY HEALTH DEPARTMENT . ' Environmental Health Section PROPERTY INFORMATION Pkrmittee's P.O.Box 848 j Name: � Mocksville,NC 27028 Subdivision Name:* Phone#:704-634-8760 Directions to property: t Section: Lot AUTHORIZATION FOR WASTEWATER Tax Office PIN:# o SYSTEM CONSTRUCTION 11 Road Name: ' �"�ip: **NOTE**This Authorization for.Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits..This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for:Building Permits. (Incompliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAT.T&6ECIALIST DATE ISSUED '+:a-�+...,-i 4ra v, z� �f,-4s+r' 7-♦ -,,^ •-•� ... ,, �'j1'`r.... -.t- -, « +.1� .< , - . ..e-•, rr.:.O� ���". DAVIE COUNTY HEALTH DEPARTMENT j IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION pei'�tt f 1- � Subdivision Name: jlrect3'6ns"to-property: D t I.. Section: Lot: IIIZPROVEMENT PERMIT Tax Office PIN:# Road Name: `'':. c .:l�P :Q - f **NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS-#BATHS #OCCUPANTS_ GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No r 4:, / LOT SIZE TYPE WATER SUPPLY < DESIGN WASTEWATER FLOW(GPD) % NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEQDd GAL. PUMP TANK GAL. TRENCH WIDTH 7K ROCK DEPTH.1Z LINEAR Fr. OTHER� k REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT.LAYOUT >i r- **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. .t' OPERATION PERMIT SY TEM INS IC BY: �-] eo AUTHORIZATION NO.C)`"' OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96(Revised) ~ APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI v M 0 v IE Davie County Health Department Environmental Health Section EB -4 1997 P.O.Box 848 Mocksville,NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 7vf/_871_90�� 1. Name to be Billed /V'P,j2 ��l• i'G 1�-;► Contact Person Mailing Address 20 �l3 6 !K Home Phone b City/State/Zip /J&22� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: le Site Evaluation V( Improvement Permit&ATC 00'Both 4. System to Serve: ElHouse ElMobile Home ElBusiness ❑ Industry ;06 / Other -W 5. If Residence: # People _� # Bedrooms _ 13 # Bathrooms ❑ Dishwasher ❑ Garbage Disposal EY"Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: lZ�County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 12r No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: f "s`S 1 WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # 77 S3 - 72) g;v 1 1 - Property Address: Road Name ' 0007 City/Zip 1 If in Subdivision provide information,as follows: Name: 1 1 ci d a 4 Z S d 1 C.tl^ Section: Lot #: 1 1 1 This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed.I,also,understand that I am responsible for all charges incurred from this application.I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by S�t l a. 1 A.Umo to conduct all testing procedures as necessary to determine the site suitability. DATE i- 144- 97 SIGNATURE -/n.►= /f�.s,�- .y, Revised DCHD(06-96) (32. 5A �. �� ot� 4a10� `a ( 14.4Ac .� l 3 6A/02 ` N2 �, N 9 1z �`� 24 33.3 Ac. 0 7 " 8CJ ( 25 Ac.) ( 77Ac.) 4401tih „0 i 6.97 AC � m o 18.01 IE CO. ti s0a. a • �/ 5 10.55 Ac (20.9Ac. ) c \ mIn et, 5 e 19 - " m22 23 :)6 84 • Qs�5;4c ,a0 �� >,. 20 2Ac s sg It •� L � � 4 A c m 73.qtim 3.0 3A N 71 M — 19g 6 " HWY. 90 , ° 1 rtoo .` r (� 21 , - (I.sAc.) 2 .28A c. 73 1 5 Ac. CA,. -AND r:3i�. 50 SEE I-1 - II 0 3.15A, . D 42 .01 5.59AC - h Z NN N 0 J o s 20 Q 445- a 49 CD42 U / OAKLAND HTS o MAP s _ w I E' i5 307.48AC' :R.+* DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME Gf/Yt DATE EVALUATED1J !�j PROPOSED FACILITY 4� �� PROPERTY SIZE SUBDIVISION ROAD NAME �i Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH -y f Texture group (i Consistence Structure y� / Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: Ky OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam Sl-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE oiA VFR-Very friable I FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD(01.90) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMNONMENNEN :REC: "iiiiii iiiiiiiiiiiiMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■en■■■■■■■■■■■�s■■■■■■rye!■■■■■■■■■■■■■■!■!s■■■■ ■■■■■■■■■■■■■■■■■■■..�■■■■■■■■■■■ ■■■■■■■■cam■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■