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2455 Farmington Rd (2))t Account #: 990003013 Billed To: Rose Ray Reference Name: Proposed Facility: Residence ATC Number: 3637 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5843-74-5929 Subdivision Info: Location/Ad ss: 2455 rmington Rd -27028 Property ' e: 2- 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 Treatme t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA S ION VA FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : ate: A Ilt 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. Ito, 3 X/a�A' 4 Environmental DCHD 05/99 (Revised) N Installed By: Signature : • ,�1 Date:/(�'� ✓ se-yn j,L4 Account #: 990003013 Billed To: Rose Ray Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT /�V Environmental Health Section d (� P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5843-74-5929 Subdivision Info: Location/Address: 2455 Farmington Rd -27028 Property Size: 2 ACRES ATC Number: 3637 **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 #People #Bedrooms LA #Baths 7 - Dishwasher: Dishwasher: IZ/. Garbage Disposal: ❑ Washing Machine: I Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size T'A' C&2� S Type Water Supply C -'00`-'T Design Wastewater Flow (GPD) LISD Site: New E( Repair ❑ System Specifications: Tank Sizrre''� GAL. Pump Tank GAL. Trench Width73 lr I Rock Depth j Z" Linear Ft. Psi Other: `l Required Site Modifications/Conditions: l 0�T& L 0-) I� ePP PLC -42 Ll.J,a j4jj f jam` A- 0Q , t Ctl 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.**** Lj o� 1..`�AT.:�� �►J�LSIo� 001- OF Environmental Health Specialist's Signature: t7 ' DCHD 05/99 (Revised) �l'-S I I V dQo_8. N APPLICATION FOR SITE EVALUATION/IM PROVEN! ENT PERNIIT & T Davie County Health Department EnYir0n1ne17ta/Bea/t1i Section D EC 15 2003 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 E1IMROWLVAI HWIH DAVIE COUNly ***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 '& 6e J ACLU Contact Person Mailing Address A4,56. FOrMiqHome Phone 33b - Qqg City/State/ZIP MbCk6Vt1Je , No- a AS Business Phone 33tt- 151- 38'71.0 / i i 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: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: I/Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms_ r # Bathrooms IYJDishwasher []Garbage Disposal 13Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7.` - If Business/Industry /Other: verify type It People It Sinks #`Commodes # Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats 8. Type of water supply: lJd County/City Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes tkt 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 TIIIS APPLICATION. Property Dimensions: AP pJy Tax Office PIN: # D d�lSa` Property Address: Road Name r ✓mi nn A city/zip !til oc'k6yi lie, a 1"9 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: _,vllota 6S -/z, Farminnhn "Ad. Turn I efon i1 v &ra; na-O n fin►. 1'011 o cJ roam,r��n kd. -la eaub on l iahl. do .31ya I Am I �ah1t`` tt of rbLl�l�IJ 15 Ul C�✓i uP tti/ (>7 l��� u�f Date home corners flagged: / This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 ant responsible for all charges incurred.from this application. I, hereby, give consent to the Authorized Representative of the Davic County health Department to enter upon above described property located in Davie County and owned by an to conduct all testing procedures as necessary to determine the site suitability. DATE a-16-03 SIGNATURE D d Klti t, 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). new double wide 600 mo ile hvme Sign given Revised DC (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. V 3 Invoice No. 3 S M22 r �; 1228 1 (425) v (11.61A) O 385853 r� 1206 L 363 LL 21% R 704SN ry _ 0058 2so----- _ (35.55A) y 251 O 1007 2 '5(1.93A) (1.93A) — 0 784.7 ---- m- (1.353) 5, N 9972 409 253 Z 10.52 A J 1082 5421 Q_ --• (10.54A) 2466 4341 233 187 1197 338 151 2 '--- a i 1395 329 V' ^ 3.000A " 6181,/ Z 2934 zloi / / p 2� 2 5929 / (1959) 245- -------------------------- 186 ,� 5 1959 L(�j, 339 � --479—_______-- _ �m 637 ---- — m � 168 193 200 96 106 1 66 I 8 � 200 389 C HATT I E LN 1 00 �I CHOLAS % AY 133 1 CV 100 200 303 7202 8213 %4A) 104 �/ ! N *9260 , 1200§?A) V + / / N / ip / I 1 / / ; V-4 7 :\ (5.23A) 200 1 5111 Q �p7� t 'ny i /200 / 100 1 1 67 • / 601 L 1pp I 200 j a / (OY06 / m � "300 (343) � ry � 11 _ 1.553) 1817 (�/�•y�)� 400 . 23 5.10A 5666 / / / s2s Q 417 Z O )5 l � i. DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003013 Tax PIN/EH #: 5843-74-5929 Billed To: Rose Ray Subdivision Info: Reference Name: Location/Address: 2455 Farmington Rd -270 8 Proposed Facility: Residence Property Size: 2 ACRES Date Evaluated: Water Supply: On -Site Well Community Public V/ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position !✓ Sloe % 7j HORIZON I DEPTH Texture group Consistence SS `3 S Structure (L Mineralogy HORIZON II DEPTH c - r L7 C Texture group Consistence Structure Mineralogy4 P HORIZON III DEPTH Texture group 0+ - G r Consistence Structure t Mineralogy1 •` 1� ' 1 HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE c,). SITE CLASSIFICATION: y LONG-TERM ACCEPTANCE RATE: J EVALUATION BY:, OTHER(S) PRESENT: C. ✓0_1b2 _9;p ' l REMARKS: LWAEV, eat W1 0,sv,\ " 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) ■■ ME ON ■■■MM■ ■EN■E■ ■■■EM■ ■■MONS ■■MME■ ■MEME■ ■E■■E■ ■■ti■■■ ■■■■E■ ■■NME■ ■MM■■■ ■■■■■■ ■Et■M■ OM1■■■ ■■LL■M SEEMS ■E■■■ ■■■■■ ■ ■ ■■ME■■E■■ ■E■■■■■E■ ■■MM■M■■■ MEMEMMEME ■M■■E■EM■ ■■■■■MEMS ■E■EME■E■ ■MEMS■■E■ MEMEMENME ■■M■■E■■■ ■EEE■■■E■ ■EE■E■■■■ ■■■EEE■M■ ■E■■■■■■■ ■EEE■EEE■ ■■■■■MMM■ ■■■■■■■■■ ■■■E■■■■■ ■■EM■EEM■ ■MEM■M■■■ ■E■■E■E■■ ■■■■■■■■■ ■■E■M■M■■ ■■■M■■■M■ ■■■■■■M■■ ■■■E■■■■■ ■E■■■E■■■ ME 0 ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■lea■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ No ■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■