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1141-1143 Deadmon Rd,, . DAVIE COUNTY HEALTH DEPARTMENT J Environmental Heaith Section � �'-�- �� � ,., . P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Account #: 990001763 Bilied To: Robert Thies Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5757-31-6363 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: 2.14 acres **NOT�*��iibginpro 8ement/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 Specification: Building Type #People � #Bedrooms � #Baths � Dishwasher� Garbage Disposal: � Washing Machine;,�'� Basement w/Plumbing: � Basement/No Plumbing: � < Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size _� 1� C Type Water Supply e/� Design Wastewater Flow (GPD) 3� D Site: Nevv� Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank GAL. Trench Width �� Rock Depth � Linear Ft �� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33G)751-8760.**** Environmental Health Specialist's Signature: � Date: ��l �/ � DCHD OS/99 (Revised) Account #: 990001763 Biiled To: Robert Thies Reference Name: Proposed Facility: ResidenCe ATC Number: 2862 DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section P. O. Boz 848/210 Hospital Street Mceksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5757-31-6363 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: 2.14 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � / **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 WASTEWAT C NSTRUCTION IS VA ID� A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �ff � � - ' Date: .S —�l �� 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: � � �/ X����L ��D Environmental Health Specialist's Signature :�Q �'��� Date: t��/Z5� �� � DCHD OS/99 (Revised) APPUCATION FOR SITE EVALUATIOW/111�1Pii0VEh9�l+IC I'�fif�9iT & A7�� p . Davie County Health Department Environmenia/ Hea/th Sect�ion P.O. Hox 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 U U � � g 240E ***IMPORTANT*** THIS APPLICATION C�INNOT BE PROCESSED UNLESS ALI, THE REQUIRED INFORMI�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be IIilled. J 1 RZ�� Contact Peraon �. Mailing Addreae Home Phone �J.�� 10 `VL-t 1 __ City/State/ZIP �OVhUyllll. I V� �lV`� Busineas Phone �0�-{'' ������ 2. Name on Permit/ATC iE Difierent than Above Mailinq 1kldresa 3. Application For: � ite Evaluation City/State/Zip � Improvement Permit/ATC ❑ Both a. syst� to service: � House O Mobile Home ❑ Business ❑ Industry ❑ Other s. =f Residence: � People � # Bedrooms � � Bathrooms _�_ � Diahxasher (1 Garbaqe Diaposal (k Waehing Machine ❑ Dasement/Plumbing ❑ IIasement/No Plumbing 6. Zf Businesa/Induatry/Other: Specify type � Commodes � Shoxers N Urinals ij People # 3inka # Water Coolers IF FOODSERVICE : # Seats Es�imated Water Usage (gallona per a$y) 7. 2�pe of water supply: ❑ County/City � Well � Community s. Do you antici�ate additions or eapansions of the facility this system is intended to scrve? If ycs, what type? ❑ Ycs ,� No ***IMPORTANT*** CLIENTS MUSTCO�lPLETETHE ,REQUIRBD PROPERTY INFORMATION REQUES7'CD BELOW. Either a PLAT or SITE PLAN �1USTI3ESUBMITTED by the clicnt with THIS API'LICATION. Property Dimensions: � � ` �' Tux Once PIN: # ���'�' `���"�� Property Address: Road Name �9C.IJ�4�lJ1 1 1 Vi l�� ��ty,Z�p YY�C�Sv�'Il�- �-�D� lf in a Subdivision provide information, as follows: Namc: Section: Block: Lot: WRITE DIRGCTIONS (from Mocicsvillc) to PROPER'i'1': (� d I � af.� �,l'� `fi� � � %.�i� � � , �� , , r. � i.�, �., � . , •11 . / /�. /. � .J.//�! ,� � ' �� ' � '� � � ' This is to certify that the information provided is correct to the 6est of my knowledge. I understand that auy permit(s) issued hereafter are subject to suspcnsion or revocation, if the site plans or intcnded usc cl�ange, or if the information submitted in this application is falsified or changed I, also, understand that I am responsible for all charges i�rcr�rred front this application. I, 6creby, give consent to the Authorized Representative of tLe Davie County �Iealtli Dep�rtmcnt to cntcr upon abovc describcd property located in Davie County and owned by to conduct all testing procedures as necessary to determine tl�e site suitability. DATE � � `�' �' SIGNATURE ( + THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Eaisting and proposcd property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Cl�arge Da tc(s): Client Notification Date: EHS• Revised DCHD (07/99) Account No. l 1 � � Invoice No. �-�� 7 � � � ���> `. `7'f,/r1•S' I �'"� ����� ��f,X� � ��� �9�9 -- � � O �� : 6- . (d �� �z) _ O � � � �. � . ZOZz0000009� �'� �� � � �p� : 0 � °s �- ` �� � �56 �) o � � �� � �J = �b69� ' �E6Z) . ,�, ,� _ . . ,' . APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soi]/Site Evaluation PROPERTY INFORMATION Account #: 990001763 Tax PIN/EH #: 5757-31-6363 Billed To: Robert Thies Subdivision Info: Reference Name: Location/Address: Deadmon Road-27028 Proposed Facility: Residence Property Size: 2.14 aCres Date Evaluated: �-�� � �� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �% Pit Cut i ex[ure grui .�___:_.__..,. 1CXlUiC �1V1 �'(111 Cl StCi1Ce leXLUIC �'IVI n.._.....a....,.,. HORIZON IV DEPTH SOIL WETNESS SITE CLASSIFICATION: %�_ LONG-TERM ACCEPTANCE RATE: � REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - Very plastic tructure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - T'hickness 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 Classiiication - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gaUday/ft2 DC�ID OS/99 (Revised) ■ ■■ ■■ ■■ ii ■■ ■■ ■ ■��■ ■■■■ ■��■ ■■■■ ■��■ ■��■ ■��■ ■■■■ ■��■ ■■�■ ■��■ ■��■ ■��■ ii ii ■■ ii ii iii ■■■ ■■■ iii ■■����■�■��■■■��■■■■■■��■�■■��■���■■■■■��■■�■�■■���■■�■ ■������■�■��■■■■■■■����■■■���■���■���■��■��■��■■�����■ ■�■■■�■��■■�■�����■�■ ■■����■■�■�■��■��■■��■�■■����■�■ ■■�■■a�■�■��■�������■��■■�■���■�■�■�■■�e���■������■���■ ■■�■■�■o��■���■■�■■■■��■��■��������■■�■���■■�■■■■����■■ ■■■�■�����■�■��■�■■�■■�■■�■�■■�����■■�e��■■■■���■��■�■■ ■�■��■��■�■�■■�■����■��■��■�■■��■��■■�■��■����������■�■ ■m�■■�oos■��■��■�■��■■�■■�■�■��■��■■■�■�■■�������■■■■�■ ■■■■■�■�����■�■����■■��■���■���■��■��■■�■����■��■■����■ ■■■���■���■■■�■��■�■v���■■o�■�■��■�■��o■��■■��■����■�■ ■��■■����■����■�����■ ■�■�■�■■�����■■�����■���■�����■■ ■■�■�■■�■�■■���a.■■��■■■�■���e�.����■■■��■■o������■■■�■ ■■�■■■■�■��■��■��■■��■��■■■■�■■����������■■■����■■����■ ■■�■������■■■■�■■■■��■■�■�����■��■����■■■■■■����■■■�■�■ ■■����■��■����■��■���■��■�■■�■■�■■��■�■��■w�����■■�■��■ ■■■■��■��■■■�������■■■����■�����■■�■����■■■�����■����■■ ■■■■��■��■■■�■�■■��■■■�■■����■��■��e�■��■■�■■��■■�■�■■■ ■■��■��■���■�■■�■�����■■�■�■■�■■■���■��■■■■■���■■��■■■ ■�■■���■���■�■ ■■�■■■■�■■���■■�■■���■��■■■��■■■ ■�����■■�■�■�■��■■��■���■��■��■��■��������■��■�■ ■��■■�■��■�■�■■�■■��■■��■����■■�■������■�■■■�■�■ ■�����������■■■��■�■■■■�■��■�■��■��■■����■■■��■■ ■�����■��■���■■��■��■■��������■■����s■■�■■■���■■ ■��■■�■��■���■■�■������■■�■��■�����■■■■■�■■■��■■ ■�■■■�■��■�■�■■�■��■■■�■■���■■���������■■■���■■■ ■■��■�■������■ ■���■■�■��■����■■��■■���������■■ ■■■■■�■������■ ■��■���■�■■�■��■■�■■■■■�������■■ ■■■■��■�■�■��■�■■�■���■��■�����■■�■■�■�����■�■�■ ■��■■■■�■■�■�■�■■���■��■�■��■��■■�■■■■�����■■■�■ ■■■■�■■�■���■��■����■��■����������■■■���■��■■��■ ■■■■�■■■■���■■�■�■■■��■��������■�■■■�������■�■■■ ■■■■�■■�■■■■■���■�■■■�■■�■�■■��■��■■■■������■��■ ■��■�e��■�■�■■�■■�■�■�■■�■■�■��■��■■�������■�■�■ ■■■���■�■■■■■■ ■�■■�����■■■■■�■������■���■�■■�■ ■■�■�■��■�■■■■ ■■■���■��■■���■■��■�■■�����■■��■ ■■�■■■■■■■■�■■■■�■■■�■■�■■�■�■��■���■■■�■■■�����■��■�■■ ■■�■�■�■■■■�■�■��■■■�■■��-.���■��■■■■�■��■■�■■����■■��■■ ■�■�e��■■■��■��■��c:::��■■■��■■�■��■�■■�■■■���■■■■■��■■■ ■������■■���■��■�■�■�■����■��■■�■����■���■■���■■�■�■��■■ ■■■�■������■■��,�■�■�■■�■■��n�■�■�■■��■�■■■�■■■■■■■■���■ ■�■�■��■����■��i��■■�■■■■■���i■■�■■�■■■���■■■■�■�■■■■���■ iiiii�iiiiii�iiiiiiii '�iiiiiiii�iiiiii�iiiiii�iiiiiii� ■■�■■������■�■���■�■����■■�■��■■���■■�■■�������■■■■■��■■■ ■����■■�■�■■�■���■�■����■����■�������■■�■■����■■■�■■�■■■ ■�����■�■�■■�■��i■���■■�■����■■►�■��■�■■������■■������■�s ■����■■■■■■�■■��i■�■�■■■■��������■��■�■■��■����■���■��■�■ ■�������■■■��■��■�.......==�i■�i■■�■�■��■■■�■■����■■■■■■ ■��■�■��■���■■�■��■�■��■■�������■�����■�■■■�■�����■■■■�■ ■■�■�■�■����������■■��:�■�■���■����■■�■■■�������■■���■ ■■�■�■�■��■�■�e■��■�■ :���■�■��������■■�■■����■��■■����■ ■■�■�■�■�■��■�■■�O�■��Y��■■■���I����■■��■��■���������■�■ ■��■■■�ve�����■■��■■��■�■■�■��r�����■■��■�����■■■■■��■■■ ■�■�■��■�■�■■��■�■�■�■■��■��������■■■�������■■■■■■■��■■ ■■■����■�■��■�a■■�■�■��■��������a■�■����■■��■�■■■■■■■��■ ■������������������■�����.�■��s�����■���■�t����■�■■■■�■ ■�■�������►.������■�■�•-.�■�■■������■■■■■�■�����■■■■■■■��■ ■�■���■��i�■���■_=:-■�����■■■��■o■������■��■■�■■■■■■���■ ■���■�■��►:�-.�■�����■ ■■�■��■■�■■�■■�■���■■�■�■�■��■■■ ■�������■■����������■�■�����■■■■■■�������■■�■■■�■���■�■ ■���■■■�■�■��■��■�■��■��■���■■�■��■■��■�■■■■■�������■■■ ■��■�■����■►�n■��■■■�■■�■��■■■■����■�■■■��■■��������■■■■ ■■���■■�■��i�L'�i����■■��■■�■�■��■�■■��■■�■�■�����■�■■■■■ ■��■�■�\■�■��■■�����■�����■■■■■■■���■■���■��■�����■■��■ ■■�■�■■■■�■■�■�■■■■�■�■■����■■■■�■��■■■�■■�������■■■■�■ ■�■■�■�■��■�■■�■■���■ ■���■■■■�■�■�■■��■■��■����■■���■ ■■■■■■�■■�■■■���������■�■■■■■■��■■■�■�■■���■��■�■■■■■■ ■■�■�■�■■������■��■■��■■�■■■■�■■�����■�■���������■■���■ ■���■■�■■■�■■��■�■����■■�■■■�!■■��■�■■■���■■����■■���■■ ■■■■�������■�■����■■��■�������■�■■��■■����■■����■■■■■■■ ■■■��■�■�■��■����■���■■��■����■�����■��■���■�■■■■■�■�■■ ■■�■�■�■■■��■����■�■■���■■�������■�■■■■■��■�■■■�■����■■ ■■�■���■�■■�■�■��■���■��■■���■��■���■�■�■�■�■■�����■■■■� ■■�■�■�■�■�■■�■��■■■■������■■��■��■■■■■■■�■■■�������■�i ■■■�����■■■■�■■�����■ ■■����■��■��������■■■■■■����■■��I ■�������������■�■���■■■■■��■■����■■�■����■■■■�■�������� ■�■■■■��������■■�■■�����������■�■����■���■■■�■����■■■■■ ■�■�■■���■�■��■■�■■�■��■■���■����■■■��������■■■�����■�■ ■�■�■�■��■�■��■■■■■■■�■■���■�■■��■■■�■�■����■■■���■���■ ■���■■■■�■■■■������■■�■��■�■�����■■��■�■���■�■■�������■ ■���■�■■■■�■�■�■■��■�■■■■■�■������■■��■■�����■■■���■■�■ ■■■■■��■���������■�■■ ■�■�■■■■■��■■■■�■�������■■���■�■ ■�■�■�■���■�■■�����■■���■■����■■���■■��■�■■■■��■■■■■�■ ■���■■�����■■■�■���■■■��■�■����■�������■■����■■��■■�■�■ ■