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161 Duard Reavis RdDAVIE COUNTY HEALTH DEPARTMENT //. `j6 Environmental Health Section d / S"-� • `' v _ P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 ) �-%• N `� �' �`C (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001656 Tax PIN/EH #: 5802-71-4805 Billed To: Matthews Reavis Subdivision Info: Reference Name: Location/Address: Duard Reavis Road -27028 Proposed Facility: Residence Property Size: 15.03 acres **NOTE**'1 ibfmprovee ent/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 (W aDNirf'— #People I #Bedrooms 'L. #Baths :2 - Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 13f Lot Size FS A CIES Type Water Supply WV --L- Design Wastewater Flow (GPD) 246 Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width —13to Rock Depth 2 Linear Ft. 3►STOa�1o14 rsox r It g7aLL LAt- _:S °i4a.c, Other: Required Site Modifications/Conditions: yet � S, € . M - 4o e. �cP -'S()I fes,. wei- _ IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 « BELOW FINISHED GRADE. ****NOTICE: Contact a representative 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 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** M. Oomc 8 Envir ental Health Specialist's Signature: e: 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 #: 990001656 Tax PIN/EH #: 5802-71-4805 Billed To: Matthews Reavis Subdivision Info: Reference Name: Location/Address: Duard Reavis Road -27028 Proposed Facility: Residence Property Size: 15.03 acres ATC Number: 2773 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,. t1900ewae Treatment d Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONVALI FO RIOD OF FIVE ARS. Environmental Health Specialist's Signatur . ate: 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 773" given period of time. T z. �10 Septic System Installed By: Environmental Health Specialist's Signature: Dater' DCHD 05/99 (Revised) A APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department EnOmmenfal Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 W( /o :00 MAR 2 32001 ENVIRONIVENTAL HEALTH ***ZHPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed &i- kos 11). R ear , S� / Contact Person � ws �eG- v 5 Hailing Address X9-2 DvafA IZC2r-v ; 5 FC Home Phone 331 x'76? -7,3c- '76?- 7,31 3 City/state/zzP A)G %0o2q Business Phone / jamSte/ "Doll , PS�,;J�� 2. Nasty on Permit/ATC if Different than Above�u�`S� T�.Mlf^l Mailing Address City/State/Zip 3. Application For: P Site Evaluation ❑ I:provement Permit/ATC ❑ Both 4. system to service: ❑ House fit Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: i People i Bedrooms i Bathrooms n Dishwasher n Garbage Disposal 0 washing Machine U Basement/Plumbing U Basement/No Plumbing 6. If Business/industry/Other: Specify type i People i Sinks i Commodes i Showers i Urinals i Water Coolers s IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes }(No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI77ED by the client with THIS APPLICATION. Property Dimensions: f s • © Ll WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # �70 /A -lake a 4e/'+ ovu 2 ' Property Address: Road Name : o ee- w %rock +-,Lle I_eAf ow CityaipgO6hu, fle �a7oag If In a Subdivision provide Information, as follows: Name: Section: Block: Lot: elf Cre-er Ctirl.)Ch i� . , 4,wI(e ct Rah+ OA-) *bo-f,C Rge"U \s Date Property Flagged: 3 .a 3 -0 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 ani 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 —11VII-4 e_wS �. Gv: S to conduct all testing procedures as necessary to determine the site suitability. DATE - � !) — O I SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing -and proposed property lines and dimensions, strpctures, setbacks, and septic locati9n4). Revised DCHD (07/99) 5a v Site Revisit Charge Date(ajs I Client Notification Date: EHS: 1 ►� i 5 %O 2 Account No. 7 n S e,.. Invoice No. f _ 117 i. :.49 A C.) )1 �1 .92 I 4GI 201.5 5.01. 1 2 AC. 1 �I 6 m 13.31 Ac }"`q 1 • h � 1 CD to, 4 N 8 ._ ' N S U) ROAD 50 19 508 ti c 10 Ac.) 512 82 ��� 1412` ON iJ f� y � i •tom w . �: .:- � ' t a • Y4. ' * • r Lv� 25 113.61 Ac Z k �N x :• X84 ; 2 01 r . r X65.6 306 12 �' se f4' 15.03Ac.10 1 2j3. (NJ Co ��- 13.6"Ac ' 37, 8 A. 15 1po ,,. .�x r �.�-+P?;s a 4.2AC- 3�G __# r 2;C. 400 DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section S4 E Sal ti U il/ >< e v ua on APPLICANT INFORMATION V PROPERTY INFORMATION Account #: 990001656 a Tax PIN/EH #: 5802-71-4805 Billed To: Matthews Reavis Subdivision Info: Reference Name: Location/Address: Duard Reavis Road -27028 Proposed Facility:. Residence Property Size: 15.03 acres Date Evaluated: 7i Water:Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: YS LONG-TERM ACCEPTANCE RATE- O REMARKS: EVALUATION BY: c UU1 OTHER(S) PRESENT: 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 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 05/99 (Revised) HORIZON I i EFI©M%EIi MUST M Texture group .Consistence Consistence HORIZON II DEPTH swam, Texture group W&1�10_ law. Consistence 92396M PRIM Mineralogy Texture group Consistence HORI7.()N IV DEPTH Texture group Mineralogy CLASSIFICATI• SITE CLASSIFICATION: YS LONG-TERM ACCEPTANCE RATE- O REMARKS: EVALUATION BY: c UU1 OTHER(S) PRESENT: 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 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 05/99 (Revised) ■■ ME ■■ no ■■ No io ■■ ME BE NEON OMEN NONE ■■■■ ■MME ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■ems■■■■■■■■■■■■■■■■■■■■■s■ms■■■■sae■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■��■■■■■■■■■■■■■nos■■m■e■■ ONE ■■■■■■■■■■■\r1OO■O■N■N■■■■o■NONE o■■■■■■■■mono■■ ■■■■m■■■■■■■■■■■■■■■m■■■■■■■■e■■mom■■■■■■■m■■■■■■ ■■■■■■■■■■■■■■■■s■■■■s■■■■■■■■■■■■N■■■■■■■■■■■■ ■■■■■■■■■■■mn■■E■■■■■mom■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■m■■■■■■■■■■■ ■■■■■■e■,�■■■■■■■■■■mos■■m■m■n■■■ ■■■■■m■■■memmom ■■■■■■■■■��■■■■■■■mom■■■mnm■■■■■■ ■■■■■■■■■■■■■e■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■One■■ ■■■■■■■11■■■■■■■■■m■■■■s■Ori■■n■■■■■■■■■■■■■One■m■■ �iMEMNONmmmumm'SsNl■►,TIllim FREMMEM MEMNON MEMNON ■■M■M■■■I■■uc■i■■a■i�■■��■■i■■■■m■■m■■■■■■■■■■■■■■■■ ■■��..■.�,�■e■NN■■■NNN■■■■1��■■■■e■■■■■■■■■Nee■■■■■■ ■■11■■■■r■■■mos■�� I�mc--.m■■■i�■■■■■■■■■■■■■■■■■■■m■■■ ■el!■■■■■I■■■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■NN■■■■N■■ ■■■■■■■■nen■■■■I■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■Noes■■■■■■■■ ■■M■■E■■E■■■lMON'■ ■EMEMM■■■■M■ME■■ Nom■■m■■■■m■mmo■ ■■■■■■■■■■■■■■■■ ■■■mono■■■■■■Mm■ ■■■■■■■■■■■■■■N■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■m■■■■■■■■■■■■ ■momm■■■ommmoom■ ■■■■■■mmomm■■■m■ ■■■m■■m■ono■■m■■ FA ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■M■■■M■■■MM■■■ONE ■■■■■■■■■MEN "WOMEN ■EEMM■■ ■mm■■■■ ■■■■■■■ ■■■■■■■ ■■■m■■■ ■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■ems■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■Nim■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■