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901 Danner Rd _ DAVIE COUNTY HEALTH DEPARTMENT • - Environmental Health Section P.O.Boz 848/210 Hospital Street co Mocksville,NC 27028 Q� (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003169 -Tax PIN/EH#: 5820-37-0250 Billed To: Ronnie Barnette Subdivision Info: Reference Name: Location/Address: 901 Danner Road-27028 Proposed Facility: Farm Shop Property Size: 15 acres **NOTE *This �rovemPHORIZATION ation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An 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 Specification: Building Type #People #Bedrooms #Baths_J Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply lj� Design Wastewater Flow(GPD)Z,1j Site: NewZr"ORepair❑ System Specifications: Tank Size,�ft GAL. Pump Tank GAL. Trench Width 4L Rock Depth ZZ)fLinear Ft.&/? Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a represent ' e of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1: p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003169 Tax PIN/EH#: 5820-37-0250 Billed To: Ronnie Barnette Subdivision Info: Reference Name: Location/Address: 901 Danner Road-27028 Proposed Facility: Farm Shop Propedy Sffize7 15 acres ATC Number. 3754 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 CONSTRUCTION IS VALID FOR A PERIOD OF F VE YEARS. Environmental Health Specialist's Signature: /�"[/ Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) ti I FORSITE EVALUATION/IMPROVEMENT PERMIT&ATC Da CATION vie County Health Department D Environmental Health Section P.O. Box 848/210 Hospital Street t+ Mocksville,', NC 27028 RO��' 1 (336)75.1-8760 ***IM ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed r°/ ! (i Contact Person Mailing Address / Home Phone �Jl� -l1,G- y37>v City/State/ZIP ✓� /-/0 Business Phone ��:l� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: , (Site Evaluation Improvement Permit/ATC /Other [3 Bot h �' S P 4. System to Service: ❑ House 11 Mobile Home ,O; Business 13 industry S. Type system requested: ET Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms # Bathrooms ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/IIndustry /other: verify type�Qt # People # Sinksy # Commodes / # Showers # Urinals �_ # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) a. Type of water supply: ❑ County/City (SLWell ❑ Community /� 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes allo If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. < 3 _ Property Dimensions: `��/,1�j�P WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: #� �CJ o�,/ �o 0l /''✓ z� & Property Address: Road Name enz 4,cY.l_a® ��/' aL�27 z,!,�; CityiZip /yo CIA P-2662/ C ; r90 .�1, X �' /l ,r If in aL Subdivision provide information,as follows: e3 i1/ �/ ( U!�� L�✓l Name: a a p. Section: Block: Lot: Date home corners flagged: e 4 LJ 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 suitabili DATE .-ip `" SIGNATURE 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). Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given 'Pl C� Account No. Revised DC (0"03 Invoice No. f 243 72 •• 914 237 380 (227) j'5E � a rn (5.76A) 0040 (6.91A) 6911 � 371 NER�ReA 26' 4791 +� + 4395 1 (5. a (17.66A) 0250 737 2 -0� !9 PT` o 131 265 (653) 2 .44 r .2 6 502 N (1.89A) � . 2'w 6327 � w 'fl `% 409 %% `° (10.18A) 90 l5 5234 0 1�J ' - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME Ito, e_ DATE EVALUATED- PROPOSED T � FACILITY , ao PROPERTY SIZE SUBDIVISION ROAD NAMEi9�n ✓�, f Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cuter/" FACTORS 1 2 3 4 5 6 7 Landscape position I-- Slope% V 10 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON R DEPTH Texture group 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: OT EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 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 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 oiA 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) LIAR-Long-term acceptance rate-gal/day/ft2 DCHD(0I-90) i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■SM■S■■■■S■■■■■■■■■■■■■■■■■■■■■MEMO■ ■■■■■M■MM■■■■MMM■MMMM■■■MMMM■■M■■■■■■■■■■■■■■■■■■/■■■■/■■■■■■■■■■■ ■��■�ME■■ON MEMEMEMEMOIR► ,-J■/■■IiEME■E■ ■■MOO■ M■M■O■ ■■■■■■■■■■■■■■E■■■■■■■n�:ii■■■■■■■MMMEMM■■MMM■■■■■■■■■11■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■aM■■�i■■M■MM■MMM■■■■MM■wMM■MMMM■M■■MMns■■■■/■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■S■S■EII■ll■■■■■■■■■��■■■■/■MESO■ ■■■■■■■MMMM■■M■M■■MM■■■■■■/■■■■■■■■■■EM■�■■■�■■■/■■■■Sul■■■/■■■■/■■ ■■■■■s■M■■■■M■■MMM■■■■■MM■M■■■■c1eM■/■■■■■/■■■■■/■■■MM■■■■■■■■■■■■■ ■■■■MM■■■■M■■■■MMM■■■■■■M■M■■■■�■■■■■■■■■■M■�.■■■MM■■■�i■■■MMM■■MMM■ ■■■■//■■■/■■■■■//■■■■■■■/■■■■■//■■■///■■■■■Eli■■■■/■■■SIM■■■■M■M■EM■ ■///■■■■■M■SMMMM■■M■MMM■SM/MMM■MMM■■■/■■■■■MIIM■■■■■■■tl■■■■■■■■■■■■ ■/■/■■■■/■■■■■/■■■■■■//■■■M■MMS■�■■■■■■■■■M11■■M■■■■MAIMS■■MS■■■■■■ ■■■■MM■■■/MMM■■MMMM■M■■■■MMMM■■■MM■■■/■/■■■Mie■MM■■■MM1�■■■■■■■■■/■■ ■■/■/■■■■//■■■■/■■■■■■■■■■/■■■/■/■■■■/■■■■■/�■■■■■■■MIIMM■■■■■■MEMO ■MMMMM■■■/M■■■MMMM■■■■■MM■■■■■■MMM■■MMM■■■■■/MM■■■MM■w■MM■■■■M■■M■ ■MMM■■M■■M■■MMM■■M■■■■■■■■■M■■■M■MM■■■MM■MM■■M■■M■■■■M■MM■■■■■MMM■ ■■■M■MM■■MMMM■■M■MMM■■■■MM■M■■■■ ■■■■■MMMMMi■■■■MMM■■MM■■■■■MMM■■■ ■�■■MM■MM■■M■■M■■■MMM■■■MMMMM■■■M■■MM■■MMMMM�M■MMs■■MM■■■■■■M■■■M■ ■■■■MMM■■■■MM■M■■■■■/M■MM■■■■MM■MMM■■■MM■■■�MMMM■■■MM■■■■■MMM■■■M■ ■■■■■M■■■■■■■■■■■■■■■■■■■MMM■■■■M■■■■■■■■■Mr�MMMM■■MM■■■■MMMMM■■■M■ ■■■MMM■■■■■■■■■■■■■■■■■■■■■■■■■■�1■■■■■■■■■a■■■■■s■■■■■■■■■■■■■■■■