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1221 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000991 Billed To: Ron and Susan Kirk Reference Name: Ron & Susan Kirk Proposed Facility: Residence Tax PIN/EH #: 5841-69-1443 Subdivision Info: Pi S--,f-ev Location/Address: Farmington Road -27028 Property Size: 2.355 Acres **NOVE* i�liIss Improvement/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 —S� #Bedrooms #Baths y? Dishwasher: t4 Garbage Disposal: 7r Washing Machine: 0 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) Site: New ❑ Repair ❑ System Specifications: Tank Size,%kb GAL. Pump Tank GAL. Trench Width,2,��� Rock Depth Linear Linear Ft.v140 / Other:fifLh 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.**** F Q Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000991 Billed To: Ron and Susan Kirk Reference Name: Ron & Susan Kirk Proposed Facility: Residence Tax PIN/EH #: 5841-69-1443 Subdivision Info: Location/Address: Farmington Road -27028 Property Size: 2.355 Acres **NO"C * Iselin rovement/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 1 l of G.S. Chapter I30A, 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 _ nz��"— #Baths Dishwasher: a Garbage Disposal: e Washing Machine: � Basement w/Plumbing: C3'*-- Basement/No Plumbing: ❑ Commercial Specification: Facility Type El/I #People #People/Shift #Seats Industrial Waste: Lot Size f�C. Type Wer Supply [ d Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Sizo6gGAL. Pump Tank 66 GAL. Trench Width 34�- "Rock Depth Linear Ft,46b Other: 4 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 inspecti2oofthis system be 8:30 a.m. to 9:30 a.m. or 1:00 .m. to 1:30 n4 elfin f installation. Telephone # is (336)751-8 /0,00 F Environmental Health i i '/ enta H eat Spec al sts Signature: Date: , ? 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 #: 990000991 Billed To: Ron and Susan Kirk Reference Name: Ron & Susan Kirk Proposed Facility: Residence ATC Number: 2344 Tax PIN/EH #: 5841-69-1443 Subdivision Info: Location/Address: Farmington Road -27028 Property Size: 2.355 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: L Date: 3-o?-yr/%L..• (.-to ��✓ 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. o - C, ",,too "LP %a a. Nom sir ;o axe Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) J APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmenta/Hea/tfi Section P.O. Bos 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 o FT R 9 W R FEB 1 5 2000 ENVIRONP,1ENTAL HEALTH 001EL COII ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROVIDED. Refer �to /t�h�e INFORMATION BULLETIN for �i�npstructions . 1. Name to be Billed �,, y� q- dt"jt 1 KfCQ� Contact Person e i {Qa (� / ' 7 Mailing Address �IQL4 Cel(Y d -e tf ^-P0J,p Home Phone n�Q/pp `,�D / Q City/state/ZIP _fl �(Sv11P. ��(, 0�7(�}�1-p Business Phone `�9 'f= Z:51—�j 7V� 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip / 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both 4. system to service: 106ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. �If Residence: ^ j # People # Bedrooms_ # Bathrooms_ J(I Dishwasher 1p Garbage Disposal Washing Machine Basement/Plumbing ❑ 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) 7. Type of water supply: County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes X] No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. ro erty Dimensions: / np 0 -5cf'o(0 fY1 Tax Office PIN: # O� — L993 Property Address: Road Nameo� . City/Zip 11 1 O Ck5 V Tfle If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: U,4 - Date Property Flagged: ��� O 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 Ona (a C • SuSan (, -e/RK- to conduct all testi g procedures as necessary to determine the � e sm bility. . DATE (7 SIGNATOR 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). Revised DC HD (07/99) Fa-em'Y6�?X-- Site Revisit Charge Date(s): Client Notification Date: I EHS: Account No. Invoice No. Q � co IRON PIPE SET Civ _O (A NEW CORNER) co S 8.300,9,28 ~" 28 E 518.96, (rorAt_ I � iA N 488.s�' � NEW PROPEr. UNE NIP AR AE2 PARCEL 30.0$• R/R SPIKE SET IN THE ROAD M _ �\Q .355 ACRES M PR/ CORNER) lL w^ N n' 400.14' o �O „M & P �_ N 830 , „ 30.05' .n ,CI 08 28 W 430.19, op ROrAQ y1 GRE(;OR 3I IRON PIPE FOUND IN THE E s� Z c ,c ANGE AND E, yPILLIA /' PAVEMENT C/L THE NORTH�r MS � EAST CORNER OF THE WILLIAMSJ PROPERTY ORN&R) ", DEED 800K I?' 7WILUAMS TqX P OCL 63 iN0 'TMS E 457 / R 83 >> 0 G TAX, MAP p N PORPON 1_ 0.99 m �. a:•:.s gh .g w NRIE UNE) �P 7„�l aN 8.3-10 3 0' 7 114.98. / GREGOR oE. jyILLI I DEED a�"4„R �wR'ILLIA E1MS m DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000991 Tax PIN/EH #: 5841-69-1443 Billed To: Ron and Susan Kirk Subdivision Info: Reference Name: Ron & Susan Kirk Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 2.355 Acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position LSlope % G HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure !/? 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 SITE CLASSIFICATION: 4�r a� 2f LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: /IVIYl/ 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) ON :: i ii i ■■.■■■■■■■■■■.■■■ ■■■■■■ ......................... ......................... ......................... ......................... ■■■■■■■■■■■■■■■■■ we■■■■ ■e■M■.■■■■■■■.■■■.....■ ■■ ■■■ SEE MEN ■■■ MEN ■.■ ■■■■■...■■■■■■■ ■■■■■■.■■..■■■■ ■■..■....C.■.■. ■■■■■■■■. ■■■.■ ■■■.■■■.■■.■.■. ■■.■■■■...■.■■. ■■■.■■■■.■■■.■■ ■■■■■■..■..■■■■ ■■■■■.e...■■■■. ■.■■■■..■.■■■■■ ■■■■■■.■.■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■.■■.■..■■ ■■■■■■■■■■■■■■■ ■.■■■■■■■■■■■■■ ■■w■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■..■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■■.■■.■■.■■■ ■■■.■■■■..■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■..■■■.■■■■...■■■■■■ONE ■..■■■■■■■■■■■■■■■■ ��-.�■■■■iii■■��■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■Ldp■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■fir■■■■■■■■■■■■■■■■■■■■■■ ■■■F, MEN ■■■ ■.■■.■ ■■■■■■ \m===■■■■■■■■ ■■■.■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■.■■■...■■■■■ ■■■■■■■■■■■■■ ■■..■■.■■■■■■ ■■■■■■■■■■■■■ ■■■■■■.■■■■■■ ■■■■■■■■■■■■■ ■.■■■■■■■■■■■ No i■ ■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME 1 �' PROPOSED FACILITY 4Ct�� SUBDIVISION Water Supply Evaluation By: On -Site Well Community, Auger Boring Pit Sir& z SECTION LOT DATE EVALUATED s5kh? PROPERTY SIZE c7- QC.�'s5 dr ROAD NAME .+1)(0_r0t� Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % q ZD 27 HORIZON I DEPTH -10 - 17 - Texture group C c_4 CIL- Consistence - S >lI as PC f Structure k IS 6 k Mineralo 7.'1 ` HORIZON II DEPTH 1 Z ' 4 - ZJ Texture group CXSfto I GO G Consistence S Structure k I` Mineralogy1vV1 .'`fl HORIZON III DEPTH 24— o Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS ZZ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 1 05 P -S I P S LONG-TERM ACCEPTANCE RATE I 0.2 1 U .7— SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: O.2 - REMARKS: A43 .SCAa Arx- o -a" LEGEND DCHD (01.90) Landscape Position EVALUATION BY: OTHER(S) PRESENT: t411- garrli"i" 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 _01 SA 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 ■ ■ No No ■MMUME ■MEMEMEMMMEMM■S■M ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■ ■■■■■■■■■■■■■■■■■ ■ENNEN ■MMMMM■■■NE■MMSE■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■NOM■ ■E■■■E■EMM■■■ ■E■ ■EN■■■�■■■■■NE■■m/■m■■t■ ■■■■■■■■■■■■■ on ME ME ■ ■ MOONS ■MM■■ MOONS MEMO ■EE■ SEEM NONE moms L ■E■ENE■MENEEMEN■ ■MMMMMMM■MMMMMM■ ■■■■///■■/■■11!x7■ ■EMMEME ■MMIWM■ ■EMMEMMEMOMMMMEN ■MMMMMMM■MMMIIMMM ■MMEMMEMEMEMIlm■r ■EMMEMME■ONNII■1!#1 ■ENEENNOEENEIIMI■ ■ON■OONm■mil■■m ■■■■MEMS ■■MMul1N■ ■■E■■MSEE■M■Liic■ ■ MM■O■■■MMM■■ME■■■■ ■■■MMMMMMMMMMM■E■■ ■■■m■EMEMMS■s■■OS■ ■■■■■■■O■■M■SMEMEM ■NMM■M■■M■■■MM■MM■ ■SNIISSNt■■MMM■M■M■ ■11EIIM■Mtt11Mt■■Etm■ llyIS11OSNSl�Et1111SSSE 1■Nt■m■tMll■ IMStmSSt■11■ IRl:�m11■■■11■ Ifiimmm■/■fl■ ■ME■■M■ ■/NEEM■ SOMEONE ■■MMM■■ ■OSE■E■ ■ommmom ■■ ■EMEME■ MONSOON ■MEMEM■ ■MMMMM■ MONSOON ■ESS■ ■MM■■ ■N/■■