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173 Crows Nest LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street r. Mocksville, NC 27028 (336)751-8760 Account #: 990001800 Billed To: Betty Crowe Reference Name: Proposed Facility: residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5823-61-8345 Subdivision Info: Location/Address: Howell Road -27028 Property Size: 6.95 acres OTE h-ro8e**Nsmprvemnt/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specificati . Building Type e- -- - - #People . #Bedrooms � #Baths Dishwasher: Garbage Disposal Washing Machine: Basement wlPlumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size b� S Type Water Suppl Design Wastewater Flow (GPD) J: l/ Site: Nely.,12' Repair ❑ System Specifications: Tank Siz��P GAL. Pump Tank Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APP: FINISHED GRADE. ****NOTICE: Contact a representative system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.92! GAL. Trench Width—�' Rock Depth Linear Ft:o?Pj `LUENT FILTER RISER(S) IF 6 " BELOW County Health Department for final inspection of this installation. Telephone # is (336)751-8760. * * * * t� Environmental Health Specialist's Signature: Date: Z1— DCHD 05/99 (Revised) Account #: 990001800 Billed To: Betty Crowe Reference Name: Proposed Facility: residence ATC Number: 2895 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5823-61-8345 Subdivision Info: Location/Address: Howell Road -27028 Property Size: 6.95 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER, NS RUCTION IS VALIDFOR PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date'/, -,.24La CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Im rov4ent/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1 00 " �i+age Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system; notion satisfactorily for any given period of time. r vI �P Septic System Installed By: Environmental Health Specialist's Signature: Date: �r--2 DCHD 05/99 (Revised) 1. 2. 3. 4. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &/A'ffLEC�Davie County Health Department Environmental Health Section P.O. Box Mockvi/ leo o pital 27028treet 8200, (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THERE MY INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed T I�(. �� Contact Person �� V Mailing Address (s7 s / 4oL-,e— � Home Phone City/State/ZIP C- SyrJ" 3 3aBiPh yy,� h P,,Jtr`` - 5 Name on Permit/ATC if Different than Above A' �- Mailing Address City/state/zip Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both System to Service: W House ❑ Mobile Home tBusiness ❑ Industry ❑ Other 5. Iff Residence: # People # Bedrooms _ # Bathrooms M Dishwasher ["Garbage Disposal f(Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 17/ County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes i/No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name tic l\ Z& City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: �yr-� cam. Am. tom- 4-b 4A- . Date Property Flagged: ( 51— `\ 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 to conduct all testing procedures as necessary to determine the site DATESIGNATURE1 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. I '� U O Invoice No. —D— a ` 9 vX 5A - 0300000/2405 6968 0 560.73 �ry c30=12401 w a 1.79A 4745 0 468 (11.31 A) C30000012402 9475 6.95A 4308 z _ 1Y� APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC 0. S Davie County Health Department Environmental Health Section P. O. Box 848 ti Mocksville, NC 27028 .., (R0VRWA XXX (336)751-8760 Q ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS V ALL THE REQUIRED INFORMATION IS PROVIDED. L. Name to be Billed d,(, Contact Person Mailing Address `F� 0 ?,� G L /2 Home Phone 7 ^3 f City/State/Zip T3 V,(6U 2 % 02-1i Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address �p_City/State/Zip 3. Application For: Site Evaluation Improvement Permit & ATC A' Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other i 5. If Residence: # People Z # Bedrooms # Bathrooms Z �V ❑ Dishwasher ❑ Garbage Disposal ❑ 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: County/City r 8. Do you anticipate additions or expansions of the f i ity thi s If yes, what type? f PROPERTY INFORMATION REQUIRED: ❑ Well ❑ Community is intended to serve? ❑ Yes ❑ No EITHER A PLAT OR SITE PLAN *** A Pjj THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: A I Tax Office PIN: #� I Property Address: Road Name'` — I --���City/Zip If in Subdivision provide information, as follows: Name: Section: Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY - 0 4. 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 as necessary to determine the site suitability. DATE 7k SIGNATURE Revised DCHD (06-96) NXI YOU MAY USE THE BACK OF THIS FORM FOR DRAWINQ YOUR SITE PLAN. conduct all testing procedures DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community DATE EVALUATED PROPERTY SIZE ROAD NAME `_c&,zev/ Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position A— Slo e % HORIZON I DEPTH X, . • �! Texture group Consistence Structure Mineralogy HORIZON II DEPTH � Texture groupC Consistence .� Structure !� 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: X aal it /O' �Q LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND DCHD (01-90) Landscape Position EVALUATION BY: &,/// OTHER(S) PRESENT: 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 SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable 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 s w N87°-20-a51E N880 -34'E—►= 1 o �r r spike = 5" tree 249.42 F O - v- 3d' point _cof a O S 10(0,8,-30�E' ' r , 1 `� iron placed 1. 1 Total 1,372.44' pond 1; t p`oce d run found 208.35 S 15°- E ,- 3d' point 48.891 U S 10(0,8,-30�E' ' 80.47 point S 050- IQ - 30' E _- 299. IO'new5li e41 30.18 poen S 880- 58 W Totol 329 x iron 218 ploced u0 j ov 3 T 0) ¢a PARCEL 124 BOBBY G. BODFORD U3 D. B. 158- 732 O Q 0 f� w 0 = 359.68 jj7 cont, mon. found PLAT 1=0R R UDI FAAK SCALE: I - 100 APPROVED BY DRAWN BY DATE: .10- 22 -93d --- PARCEL 124, DAVIE COUNTY TAX MAP C-3. SEE DEED BOOK 158- 732 CLARKSVILLE TOWNSHIP. DAVIE COUNTY NORTH CAROLIN, C. RAY CATES Telephone DRAWING NUMBER 119 DEPOT STREET 3198-A MOCK S V I L L E, N. C. 27028 704/634-3735 BEa. Davie County Heafth Department NSM 189 and.Come Health Agency �G P��N�CN V. Agency N� vE MP °° 4F-G�L�6115 a't Environmenta(Health Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 May 21, 1998 Rudi Faak 806 Howell Rd. Mocksville, NC 27028 Re: Site Evaluation Howell Road/15 Acre Tract Tax PIN: #5823-61-8345 Dear Client(s): As requested, a representative from this office visited the aforementioned site on May 15, 1998. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of a modified, oversized on—site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure(s)