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899 Duke Whitaker Rd,y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • — _ P. O. Boz 848/210 Hospital Street C-3 r Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003131 Tax PIN/EH #: 5801-97-5320 Billed To: Barbara Mason Subdivision Info: Reference Name: Location/Address: Duke Whitaker Rd -27028 Proposed Facility: Residence Property Size: see map TE **NOS*-umlier: 3733 This mprovement/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 (�P #Baths 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 _ Design Wastewater Flow (GPD) ! (W Site: New Repair ❑ System Specifications: Tank Sizel&D GAL. Pump Tank GAL. Trench WidthQ?lo Rock Depth 1Z Linear Ft Old Other: 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. p.m. on the da of ins tip. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990003131 Billed To: Barbara Mason Reference Name: ATC Number: 3733 DAVIE COUNTY HEALTH DEPARTMENT \ Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5801-97-5320 Subdivision Info: Location/Address: Duke Whitaker Rd -27028 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 CONS ,gU-C/TION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � 1 !� 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: zo DCHD 05/99 (Revised) v TION 1`011 SITE- [VALUATION/IMPROVEMENT I'L'ItiMIT Sc JUG OR2 9 Davie County Health Department Enlrironwanta/Hea/t/j Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IrSPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROVIDED. Refey�r� to the INFORMATION BULLETIN for � instructions. 1. Name to be Dilled 9'4kbYa ContacL Person �l /,e— At Wa Mailing Addreas' 6 014 ll4 F"') t kA -1Home Phone City/state/ZIP 6y/�a/'JS /V C. Z ! 6 2 Business Phone _� � J...... . 2. Name on Permit/ATC if Different than Above _____...... Mailing Address City/Stale/"Lip 3. Application For. ite Evaluation ❑ Tmprovemcnl. Peiinit/ATC Or-q�' tli 4. system to service: ❑ House P(Mobile Home .❑ Businebs ❑ Industry ❑ Othcl S. Type system requested: 0 Conventional b ❑ conventional modified ❑ innovaLive 6. If Residence: It People It Bedrooms 3 II Bathrouim; Z- ❑Dishwasher ❑Garbage Disposal ®Washing Machine ❑DasemonL•/Plumbing ❑Bas:emonL•/Ito i'lumbing 7. If Business/Industry /Other: verify type 4 People It Sinks 8 Commodes It Showers # Urinals It WaLor Cooleru IF FOODSERVICE: it Seats Estimated Water Usage (gallons per day) 8. Type of water supply: OQ County/City ❑ Well ❑ Conununity 9. Do you anticipate additions or expansions of the facility Ellis system is inteilded to scrl,e? R es ❑ No If yes, what type? Gl��4�/�` ` ! ��ye /,/Ad- /Yuz k6 nye b1 4175'4c�-iu P.S'- ***IdIPORTAIYT*** CLIENTSillUSTconlrLLTL• THE It.Li(2UIlfLD I'1tOI'ElClrY INI-OltnIA'I'ION KLQI)ES•ri l) IIELOIY. Mimi- a PLAT orSITE PLAN 111USTIIESUI111II7TBD by the client ivitli't'1IIS AI'PI,1G1'I'ION. Property Dimensions: x{32. X l D°7 k / 90 X /067 wit!TL DIRECTIONS ([runt Mucksville) to PROPE;ItTY. Tax Orrice PIN: # S80 7 32.0 4,01 /V 40 le�-� a�► l_� be�� Property Address: Road Name DUk2 WA; -1-A%t? e/C� (� • ( -1-o >' �`t-'T D D P_G tt— City/Zip InookS VIS -1 (e- tj If in a Subdivision provide information, as follows: Nucke- W A / k�e R-- 9d, Nallic: & M t r Section: Block: Lot: Date Iionie cormcrs flagged: % _ `4 This is to certifythat life information provided is correc touest f nI a owled gc. de • d t ' I • y l 1 b I un Istall that ani pc.i i nl(s) issued licrcaftcr are subject to suspension or revocation, i c sit! p1 or intended use change, or if the inforivalion submitted in Ellis applica(iotl is falsified or clianged. I, also, understaig Ihall tun responsible for all charges incurred. i-om llris application. I, licreby, give consent to the Authorized Representative of the 1)a1'ie Cuumty Ilealth Ucp:u•lrtluld to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine fife site 5u1tabi1i(3'. DA'I'S— Zg — D� SIGNATURE MIS 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). Com' Sign given Revised DC (05/03 Site Revisit Charge Datc(s): -- Client Notification Date: EIIS: Account No.3� Invoice No. (16.72A) 4549 861., 0 • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003131 Billed To: Barbara Mason Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5801-97-5320 Subdivision Info: Location/Address: Duke Whitaker Rd -27028/ Property Size: see map Date Evaluated: Water Supply: On -Site Well ' Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope % HORIZON I DEPTH �c c/ Texture group Consistence Structure Mineralogy HORIZON II DEPTH z` ' - Texture group Consistence r Structure a/ Mineralo l 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: LONG-TERM ACCEPTANCE RATE: 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 EVALUATION BY: OTHER(S) PRESENT: DCHD 05/99 (Revised) ■ ■■ ME ■e■e■ee■■e■e■e■ecce■■■■■eM■■■eec■■E■Ee■■■■a■■e■■■■■e■■■■■■■ ■■■e■eee■e■eeee■■■■■■■■■■ ■s■ee■■■eeeee■■■■■eee■■eeeeee■e■ ■■■■■■■■■■■■■■ME■■■■■■EEE■■■■E■■E■■■e■EE■■■■■eEEE■EEE■■■■e■ ■■■■■■■■■■ee■e■■■■■■■Mec■■■■■eeee■■■■e■eeeM■.e■■■■e■Eee■■■■ Mee■■■■■■■e■■■e■ee■■■■Mee■■■■■c■■■■■■e■■■■■■■e■■Me■■■ecce■■ ■■■■■■■■■■■e■■■■e■■■■■■■■■■■■ee■■e■■ee■e■■eee■eeeee■■e■e■■■ ■■■■■EE■s■■Ee■■■■■■■■■E■■r�■e■■■e■■■■e■■■■■e■■■■■■■■■■Mee■■ ■ee■ee■■e■ee■■■e■■■ee■■■■ ■e■■■■ce■■■■■■e■■■eee■■es■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■e■■■■■eeee■■■■■e■■■■eee■■ese■■e■■■■■■eM■■eee■■e■e■■■■■■ ■■c■■ee■■■■■■■■■eee■■■■■Mee■■eeee■e■■■e■■■■■■■■Mee■■■■■■■■■ Mee■eee■■■■■e■■■■■■■■■e■■■■■■eeeecee■Mee■e■■■■es■eeM■■■■■e■ ■eee■e■■■■■e■■e■■■■■eeee■■■■■■■■■■■■■■■■■■e■■es■eee■■e■■■ ■■■■■■■■■■■■■■■■■■■■EEE■■E■■■EEE■E■E■■E■E■EEEE■■EE■E■EE■EE■ ■■eeeeeee■■■■■■e■■e■seee■■■■■■e■e■ee■■■■eee■eeeeee■eceee■■■ ■■■■■■■■■E■■■■■■■■■■■EE■■■■■■■E■■■■■■■■■■■■■■■■■es■■■eeeee■ ■■■■■eee■■■■■■■■o■■■■■■e■■■■■■■■■■eee■e■eee■■esee■e■■■■e■e■ ■■■■eee■■■■■c■■r:��■■■■■■■■■■■■e■s■■see■ee■■■■■■■e■■e■■■■■■■ ■e■■es■■acs■■e■■■.ses■■es ■■■■eee■■■■■■■■e■eee■■■e■■ee■■■■ ■■■eee■Sec■■Mee■e■■e■■ecec■■■■e■e■■■■Mee■■e■■e■■eec■■eee■■■ ■■■■■■■■Mee■■■e■eee■■■■■■■■■■■e�►s■■■e■eee■e■■eeee■eeee■■■■■ ■■eee■■eee■■■ee■■e■■e■■■■■■■■■ecr�e■■e■■e■■■■■eee■■e■ee■■■■■ ■■■■ecce■■■e■■■■■■■■eee■■r�r■eeee■■eee■■■■■■e■Mee■■es■se■■■■ ■eeee■eec■E■■■■■■■■■eeec■ ■eee■eec■e■■■■■■ee■eee■e■■■■■■■■ ■■■■■■■■■■■e■■eeesc■■■■■■■■■■■■■■■■■■■■■■■■■■■■ee■e■■■■eee■ ■■■eeccc■■■■e■ee■eE■eeee■■■■eeeee■■■■ce■e■■■■Mees■see■■e■■■ ■■■■■■■■■■■E■■■■■■■■DEEM■■■■■■Ee■■eE■■■s■■E■■■■e■e■E■■■■■E■ iMENNENMUMMEMMEMNONEMMEMEMEMNON MEMNONMENNEN se■■se■■■■■■e■■eE■■■eeE■■■■■■e■ee■■■■■■■■■■■■■■■■■■■■eeeee■ ■■■■■e■■■■■■■■■■■■■■■r.�:c.:■■►•■■■■■■■■■■■■■■■■■■■■■■■Mee■e ■■■e■■eecc■■■■■■■■■Erie■■■■■■■■■�■■■■■■■■■■■eeeee■eee■■e■ec■ ■■■■■■■■■■■■■■■■■■■■u■■■■ ■■■u■■ese■■■■■■■■■■■■■■■■■■■■■■■ wwwwwswwwwwwwwwwwwww�.wwwwwwwwwt■wwwwwwwwwwwwwwwwwwwwwwwwwwww ME ii ME ii ii