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P3840 Duard Reavis Rd". .. Account M 990003313 Billed To: Lonnie Reavis Reference Name: Proposed Facility Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5802-85-7193 Subdivision Info: Location/Address: Duard Reavis Road -27028 Property Size: 14.31 acres ATC Number: 3840 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 1799 6.�b 4 W1✓ #People 2 #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 14 AZOE Type Water Supply Design Wastewater Flow (GPD) I�ZO Site: New Repair ❑ System Specifications: Tank Size1CM GAL. Pump Tank GAL. Trench Width3a� Rock Depth l Z� Linear Ft. 6CIE� Other: I -2i-tom' Required Site Modifications/Conditions: �'`���u- o� C.`��tR-t�[�''1�t'-?,-=E �C0 t 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.**** ,o i- ►�'►7to Sr u.. toot Environmental Health Specialist's Signaturer___�, Date: DCHD 05/99 (Revised) Account #: 990003313 Billed To: Lonnie Reavis Reference Name: Proposed Facility Residence ATC Number: 3840 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5802-85-7193 Subdivision Info: Location/Address: Duard Reavis Road -27028 Property Size: 14.31 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 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatm and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONST R AL FOR A PERIOD OF F VE YEARS. Environmental Health Specialist's Signature: Date: `O - 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. eo Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 0 2) 4�S 14 Rb 1 10 :�` ArMaP� D �CEPWE APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC -- Davie County Health Department Environmental Health Section AUG 2 2004 P.O. Box 848/210 Hospital Street 1 Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH DAVIE COUI N ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PRnOVIDED.0 Refer�{ntoo tJhe./INFORMATION BULLETIN for in(strruuctions. 1. Name to be Billed �y�/�p // F,/T/V S Contact Person Mailing Address y -/,T/ GSA �/ Home PhoneZ��J�..7 City/State/ZIP Jt� / ! i(e Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip / 3. Application For: 13 Site Evaluation 13 Improvement Permit/ATC E Both 4. system to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry R'Other CA/'�f L� 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms # Bathrooms ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7.,' If Business/Industry /Other: verify type # People # Sinks ` # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City i2rWell ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No 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. Property Dimensions: ' ` `�, �L� WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # o'Z' OS k-ovI I -to Vt7 Property Address: Road Name k7VQJ—) City/Zip`�C%k—S If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date home corners flagged: 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 suita ility. DATE 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). Sign give Account No.�(_� Revised DCHD (05/03 Invoice No, / 5 �N'/ APPLICANT INFORMATION Account #: 990003313 Billed To: Lonnie Reavis Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/sAe, Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5802-85-7193 Subdivision Info: Location/Address: Duard Reavis Road- 028).D47 27 Property Size: 14.31 acres Date Evaluated: Water Supply: On -Site Well c/ Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: f i� EVALUATION B LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:- 1 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 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) Landscape position Texture group Consistence NAMMA MEN KWOM HORIZON II DEPTH Texture group Consistence MpjM A&M Mineralogy HORIZON II DEPTH - • .®-�-®- -a�®®�-- Consistence MjAr' Mineralogy Texture group Consistence Mineralogy SOIL WETNESS NTA V 'Rei NJ I ICLASSIFICATION • SITE CLASSIFICATION: f i� EVALUATION B LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:- 1 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 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 - 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