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653 Duke Whitaker RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section 1.10�0� P. O. Boa 848/210 Hospital Street " Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990001117 Tax PIN/EH #: 5801-84-3247.02 Billed To: Travis Hedrick Subdivision Info: Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 1.9 Acres **NES* Thi bfmproveeme OTnt/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 I 1 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 !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 gAYl Type Water Supply Ld Design Wastewater Flow (GPD) C4 D Site: NewEr Repair 11 System Specifications: Tank Size AtV GAL. Pump Tank GAL. Trench Width Rock Depth _ZL Linear Ft.&,V,* Fell= Required Site Modifications/Conditions: 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.**** Fe�e� L. ," G S I° Wo dS � 7WA& C!52 y E Environmental Health Specialist's Signature: U ` Date: DCHD 05/99 (Revised) olzz pe'f_ ' DAVIE COUNTY H,pd �ylo-0I HEALTH DEPARTMENT Y Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001117 Tax PIN/EH #: 5801484-3247.02 Billed To: Travis Hedrick Subdivision Info: Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 1.9 Acres ATC Number: 2923 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 WASTE WATE C NST UCTION IS VALLIID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /`� Date: -21-0 7�1 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. f Septic System Installed By: 4 / Environmental Health Specialist's Signature: 141 (y �� Date: DCHD 05/99 (Revised) ON FOR SITE EVALUATION/IMPROVEMENT PERMI Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) ?51-8760 EC EOV El MAY 14 2001 � (IMRONMpViAt NEALiN OAVIECOUNly ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the. INFORMATION BULLETIN for instructions. 1. Name to be Billed oox - V1 Contact Person , Mailing Address (O�J D', &_ wy`1 iTl,t ,-f /7 Home Phone AJ I . // A/ /J n r -i „ e-, City/state/2IP 2. Name on Permit/ATC if Different than Above Business Phone Mailing Address City/State/Zip =,Q 3. Application For:_ " ImprovemenPermit/ATCc ❑ Both 4. system to service: . ❑ House EVMobile Home ❑ Business n Industry ❑ Other 5. If Residence: # People �! #,Bedrooms 3 J*Bathrooms IK Dishwasher II Garbage Disposal hf Washing Machine 11 Basement/Plumbing 11 Basement/to Plumbing 6. If Business/Industry/Other: Specify type # Commodes # showers # Urinals # People # sinks I Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 1. 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 U-14-0— If yes, what type? ***IAfPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with Tit IS APPLICATION. Property Dimensions: 0 OuG t'GS WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # -SUI" 0 `t Property Address: Road Name�� City/zip 'MOO ,41/1/d/e _ % ag t Sli//b' lo lie . � Id &J, ! 1w If in a Subdivision provide information, as follows: / n✓I' 6) O 01ali�_e UAi ff& ke/ t � Name: U o Section: Block: Lot: Date Property 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 1 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilealth Department to enter upon above described property located in Davie County and owned by to conduct all /testing precedures as .^.^.c-cssai y `ao deter wine the site suits itity. DATE 1 ' �� —O ® 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): I Client Notification Date: EHS: Revised DCHD (07/99) Account No. Invoice No. _ C APPLICATION FOR SFFE EVALUATION/IMPROVEMENT Davie County Health Department Enlrironmenfal Health Section P.O. Bou 848/210 Hospital Stre Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. yy 1. Name to be Billed �^ V� Hedrlcl Contact Person Mailing Address 4� &L 1/y , j J� Some Phone City/State/ZIP /!/OGKS61/ Xe' 17mp Business Phone 2. Nam& on Permit/ATC it Different than Above Mailing Address City/State/Zip 3. Application For: fYSite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: ❑ House iYMobile Home ❑ Business 0 Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms I /a In Dishwasher II Garbage Disposal Pf Washing Machine 11 Basement/Plumbing II 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) 1. Type of water supply: W-county/City O Well O Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes WKO- If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. 11 Property Dimensions: APS ck/- S -� (WRITE DIRECTIONS (from Mockcville) to PROPERTY: Tax Office PIN: $I l" �`f'-�� �'�l- �'2J4JI Property Address: Road Name A16- City/Zip 1 City/Zip D ksv,2/ 17a If in a Subdivision provide information, as follows: -ru- ml 8-4 &ems Name: Section: Block: Lot: Date Property 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 front 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 precedures ws ^.ccrs;a;y ;v dete-:uine the site suitagiiity. DATE q -J�-O ® 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: I EHS• Revised DCHD (07/99) Account No. 111-7 Invoice No. I q,16 t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section v SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Accouht #: 990001117 Tax PIN/EH #: 5801-84-3247.02 Billed To: Travis Hedrick Subdivision Info: Reference Name: Travis Hedrick Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 1.9 Acres Date Evaluated: Water Supply: On -Site Well / Community Public Evaluation By: Auger Boring I/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group�'. Consistence Structure /L S"111 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 r. SITE CLASSIFICATION: G`)�_ EVALUATION BY:5� 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 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 - CrumbGR - 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) ■■EMMEMMEM■■■■■ ■■■■■■■■■E■■■■■ MEMO■■■■■■■■O■■ ■■■M■■■■■■■■M■■ ■E■O■■■M■■■■M■■ ■■■O■■■e■■M■■M■ ■■■■■■■■M■■E■■■ ■■■MMM■■■■■■■■■ ■MMM■ME■EMME■ME ■■■■■M■■■■■■■■■ ■e■e■■■■E■e■■■■ ■■■■■■■■MMM■■■■ ■■■■MMM■■■■M■■■ ■■■■■■■■■MM■■■■ ■E■■■■■■■E■E■■■ ■■■M■■■■■MM■■■■ ■■■M■M■■M■M■■■■ ■■M■M■■■M■■■■■■ ■■MMM■■■■■■■■■■ ■M■■■■■■■■■M■■■ ■■■■■■■■■■■■■O■ ■■e■E■■■■■■■■■■ ■■■■■■■■■■■■■E■ ■■■■MMM■■■■■■M■ ■■■■■■■■■■■■■■■ ■■■■MMM■■E■■■M■ ■■■■■MM■■■■Mae■ ■■M■■ME■■■■■M■■ ■■O■■E■■■■■■E■■ ■■■■■■M■■M■■■■■ ■■■M■■■M■■■■■■■ ■■■MMM■■■■■M■■■ ■M■■■e■■■■■■■■■ ■M■■■M■■■■■MM■■ ■■e■■■■■■■■■■■■ ■■■■■■■■■■■■■E■ ■■■■■■E■■■■■EE■ ■■■■■■■EMM■■■■■ ■■■■■e■■■■■■■E■ ■MENS■■■■E■■■■■ ■E■■■E■■■■■MMM■ ■■■■■■■■■■■■■■■ ■■■■■■ ■■■■■ ■■■■■■ ■■■■■ ■M■M■■■E■■■MMM■ ■■■■■■■O■■■■■■■ ■■■■■■■E■■■■■■■ ■E■E■■■E■E■■■■■ ■■■e■MMMM■MMM■■ ■E■■■■E■■E■■■■■ ■E■■■■E■■E■■E■■ ■E■■■■■E■■■■■■M ■■■M■■■■M■MMM■■ ■MMM■■■■M■■M■■■ ■■■■■M■■■■■■■■■ ■■■■■E■■■■M■M■■ ■■EEE■■■■■■M■M■ ■■■■■E■■■■■E■■■ ■■M■MM■■■■■M■M■ ■■E■■■E■■■■■■■■ ■■E■■■■■■■■■■■■ ■■E■M■M■■EM■■■■ ■■■■■■■■M■■■ME■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ■■E■■E■■■■■■ ■■■■■■■■■■■■ecce■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■Oce■s■■■■■■■■■■■■■e■ ■■■EMee■�eMae■■■■■es■ ■■■■■e■■ ■■■■■■■■■■E■ ■■■M■■■M■■■e■■■■■■■■O■ ■■■■■■■Mee■■■■■■■■■■■■ ■■■■■■■■ ■■■■■■■■■■■E ■■■■■■■■e■■■■■■■■Mee■■ ■■■EMEMEME■ ■■■MMMM■■■0 ■■■■M■MEMME ■■■■■■E■■■■ ■MMEOE■■■■■ ■■■■■■■■■■■ ■EMM■■■■■■■ ■■■■■■■E■■■ ■M■■■M■EM■■ ■■M■■■■■■■■ ■■■■EEE■■■■ ■■EEE■■■■■■ ■■■■■■■E■■■ M■■■■M■■■Oe ■■■■■■■■■■■■■■■■■■■■■■a■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■s■■■■■■■■■■■■■■e■s■■■■■■■■■■Oce■EEa■ sass■■■■■■■■■■■■■■M■■■■■■■■■■s■■■Es■■■■■■■■■■■ eee■■■■■■■■■■se�■■■■■■■EEe■E■■■■M■see■■■■■■■■ eeeE■■■■e■e■es■■■■�■■■■■■cease■e■e■■■■a■■■■■ses ■o■erne.:■■■■■■■■■■II■■■■■■■■■■■YY■■■■■■■■■■■■■■■ ■■Ery■■■■■■■■■e■ ��■E■■■■■■oma:■■■■■■■■■■■■■■■■■ ■ers■■■ae■■■■■■■■sir_=�■■■■Mee■■■■■■■■■■■■■■■■s■ ■■■■■■■■■s■■s■E■■�■■■■■EE■■■■■■■■■■■■■■■■■■■Mae ■■■■■■■■■■■eee■�■■■■■■■■■■■■■■■■■■Mee■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DAVIE COUNTY HEALTH"D�'�TM�NT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 May 3, 2000 Mr. Travis Hedrick 653 Duke Whittaker Road Mocksville, NC 27028 Re: Site Evaluation/Duke Whittaker Road Tax Office PIN: # 5801-84-3247.02 Dear Client: As requested, a representative from this office visited the aforementioned site on May 2, 2000. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s) of i (3.88A) 3247 722 � ,\ ! , i ' / 321 J�) AAA 3161 ,4R (15.15 8865 (1.39A) 9167