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968 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002734 Tax PIN/EH #: 5841-75-3995 Billed To: Ricky Bodenhamer Subdivision Info: Reference Name: Proposed Facility: Residence ATC Number: 3469 Location/Address: Farmington Rd -27028 Property Size: 11 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 FIVZP S. Environmental Health Specialist's Signature: Date: CERTIFICAT OF COMP **NOTE** The issuance of this Certificate of Completion h 11 i dicate the has been installed in compliance with Article 1 S. Chapter Disposal Systems," but shall in NO WAY be ak s a guarantee given period of time. r' Septic System Installed By: 9D 6 N scribed on Improvement/Operation Permit ction .1900 "Sewage Treatment and system will function satisfactorily for any i Environmental Health Specialist's Signature: A��2z Date: CiD./ e E DCHD 05/99 (Revised) "11 13DIZ10,4035151M Environmental Health Section ) 7� • P. O. Boz 848/210 Hospital Street pCv �v G -7 - a� Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002734 Tax PIN/EH #: 5841-75-3995 Billed To: Ricky Bodenhamer Subdivision Info: Reference Name: Proposed Facility Residence Location/Address: Farmington Rd -27028 Property Size: 11 acres ATC Number: 3469 **NOTE** This 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 I't #People '�-/ #Bedrooms .-? #Baths Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: e Basement w/Plumbing: a Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply 4#People ( & Design Wastewater Flow (GPD) J& D Site: New _ Repair ❑ System Specifications: Tank Siz%at GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �A � 'Rock Depth �_Linear Ft." ' IMPROVEMENT/OPERATION PERMIT LAYOUT - APPRO FINISHED GRADE. ****NOTICE: Contact a representativ system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 n ' IDI %f!j,UENT FILTER. RISER(S) IF 6 " BELOW 9iiee Coun Health Department for final inspection of this day of tion. Telephone # is (336)751-8760.**** I" Environmental Health Specialist's Signature: 11-1,0911 Date: DCHD 05/99 (Revised) pt�"4 L t ce" DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002734 Tax PIN/EH #: 5841-75-3995 Billed To: Ricky Bodenhamer Subdivision Info: Reference Name: Proposed Facility: Residence Location/Address: Farmington Rd -27028 Property Size: 11 acres r` Am ATC Number: 3469 **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 /7 #People_ #Bedrooms 7 #Baths I_ Dishwasher: 15/ Garbage Disposal: ❑ Washing Machines Basement w/Plumbing: la' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) J440 Site: New Repair ❑ System Specifications: Tank Size 11 Y P �0 G/AL. Pump Tank GAL. TTrrench/JWidth�� Rock Depth /,Y Linear Ft. -6,04 Other: _ Z �/ Grlc�, yalex 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.**** APic e-4'4 T lXaT � ba co, )C// o tT Cr to cj elre-aS— Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) a 1 2. H�H1dltJ3 lAAV ' 8 203 \\\\ Q )N FOR SITE EVALUATION/IMPROVEMENT PERNIIT & ATC Davie County Health Department � EnvironmentaiHeaith Section a P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 r ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed Is—YDt:7� /-�`e/Z Contact Person Mailing Address K PUjJ 041 Vit Home Phone City/State/ZIP ockS II u -t &C 2?o215 Business Phone Name on Permit/ATC if Different than Above 3,2 t C1�y W / D CO— 4-Q,CI,� Mailing Address .J� C City/State/Zip 3. ARplication For: ite Evaluatio Improvement Permit/ATC Both 4. System to Service: House Mobile Home Business Industry Other 5. If Residence: # People_ # Bedrooms # Bathrooms lZ Dishwashe Garbage Disposalas Ing Machine Basement/Plumbing Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City Well Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes ON� 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 cliatt with TMS APPLICATION. Property Dimensions: Tax Office PIN: Property Address: Road Name C, WRITE DIREC'T'IONS (from Mocksville) to PROPER'1'1': � / /J a iz� INS 4,J !'ROA , �7 1 W D `(-r A -JS eL ),v 1fWJA1*-1 City/Zip l IVC I - spinJ-t 011Rce,vt 7z> %�eczw If in a Subdivision provide information, as follor Name:fJ Section: Bloc v Lot: Date home corners flagged: _ % Lo,3 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 kit responsible for all charges incurred franc this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by_Y=t`�, *P&.K'F�1- _ to conduct all testing procedures as necessary to determine the site suitability. DATE .S%%4O 3 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). C -4v -ko i n ven 1; Revised DCHD (07/99) Site Revisit charge Date(s): Client Notification Date: EHS: Account No. �'� "? Invoice No. �� 7 i-� 4.68A 4.304 332 314,76091 •r•.�vC• i 241 248 407 775 2.AA 2.00A 4 4023 8030 1969, A (2.03A) ` 3692 ------------------- 4.94A 7?�96 4188182 A)078 326 -- 842 842 311 2.50A y 4987 (46.59A) 4249 2127.93 Tot 14.96A 3686 (20.80A) 0699 (4.88A) 3434 (15.58A) 1242 14.62A 3383 5.18A 3067 6.515A 9915 30 35.09A 5946 2565209 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002734 Billed To: Ricky Bodenhamer Reference Name: Proposed Facility: Residence Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5841-75-3995 Subdivision Info: Location/Address: Farmington Rd -27028 11 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 Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 7 Texture group Consistence Structure L 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: /0 LONG-TERM ACCEPTANCE RATE: REMARKS: uZ /Y`4 LEGEND EVALUATION BY: 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 Mineralog 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)