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273 Feezor RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900478 Billed To: Jimmie Caudle Reference Name: Jimmie Caudle Proposed Facility: Residence Tax PIN/EH #: 5727-97-5071 Subdivision Info: Location/Address: Feezor Road -27028 Property Size: 200 x 238 TC lyfbrr: 2460 **NO E** is 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 IS #Baths � Dishwasher: 9 Garbage Disposal: ❑ Washing Machine: 125"- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply C p Design Wastewater Flow (GPD) jv/d Site: Newz Repair ❑ System Specifications: Tank Size GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width,!Z`C Rock Depth _` Linear Ft.7O' 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.**** VEnvironmental Health Specialist's Signature: Date: 45 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900478 Tax PIN/EH #: 5727-97-5071 Billed To: Jimmie Caudle Subdivision Info: Reference Name: Jimmie Caudle Location/Address: Feezor Road -27028 Proposed Facility: Residence Property Size: 200 x 238 ATC Number: 2460 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: iN� V cZC Date: e!!� •2,`�C7 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: DCHD 05/99 (Revised) ED NO Date:" `� Z APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ArliKINE�11.KiTY Davie County Health Department Environmental Healtfi Section 0 P.O. Box 848/210 Hospital Street Mocksville, NC 27028(336)751-8760 TH ***IWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to//the INFORMATION BULLETIN for instructions. 1. Name to be Billed `';;y',' C (i" %� LL.�J �{ Contact Person Mailing Address 3RA. {1aJ)/ 101AZ Home Phone 11(9a 6 �� City/state/ZIP l�ks &- C- 4),q S Business Phone 2a — JL9 3 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/state/Zip Improvement Permit/ATC j'Both 4. system to service: O"'House ❑ Mobile Home ❑ Business ❑ Industry 0 Other s. If Residence: # People # Bedrooms 3 # Bathrooms W Dishwasher ❑ Garbage Disposal YeWashing Machine (J Basement/Plumbing ❑ Basement/No Plumbing . 6. If Business/Industry/Other: specify type # Commodes # showers # Urinals # People # sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 91County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ao 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 THIS APPLICATION. Property Dimensions: nt zU X a 3 p Tax Office PIN: # � / `J L 22 - fJ D Property Address: Road Name 7e, e"ZQ 4' )?G/ City/Zip A76cko y/// ct If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: J Ll 3fL '0 bU2, W y a05'6111) Date Property Flagged: 7 oU 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 Dam, Co my H Ith Depar/�me, ,C to enter upon above described property located in Davie County and owned by �a17S/ to conduct all testing procedures as necessary to determine the site suits ' ity. / r DATE b ` �— 61 U SIGNATURE ,171 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAW,#nclude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations . Q 1 � � i Revised DCHD (07/99) Client Notification Date: EHS• Account No. / Invoice No. /�� art'utAl1UN FOR ENT PERMIT do ATC Davie County rt nty Health Oepatfi EnvironmentaiHeaith SftWon P.O. Box 868/210 Hospital Street APR f 5 f999 J Mockaville, SC 27028 (336) 751-8760 ENVIRONMEiifAL HEALTH DAVIE COUNTY ***n?WORTAIVT*** THIS APPLICATION CANNOT Br PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 6Z7 1. Mame to be Billed C -a %? t 1 cLW , vm Contact Person / pe 7:7i h Mailing Address rel.—Z-) /o P-� /� r7 Home "me �© [� city/state/zip `�S V/ J / Ei�9Bnsiness Phone Z. Maar on Persdt/ATC It Different than above Mailing Address City/state/tip S. Application For: Asite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: 'A House ❑ Mobile Rome ❑ Business ❑ Industry ❑ other a. ISE Residence: # People a # Bedrooms 5 # Bathrooms ADishwasher n garbage Disposal )(, mashing Machine 11 Basement/Pla Bing O Basement/Mo Plumbing A. It Business/Industry/other: Specify type # People # sinks # Cammodes # showers # Urinals # Nater Coolers Ir FOODSERVICE: 11 Seats Estimated water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Coammunity s. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes ❑ No If yes, what type? ***IMNDRT'ANT"** CLIENTS AIUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBWZTED!% the client with THIS APPLICATION. Property Dimensions: ,rQ4"0 X a��` ��� WRITE DIRECTIONS (from Mocluvilie) to PROPERTY: Tax Omce PIN: # v� � a �i� b u r - s -. `/-17-,L �-- 10 Ptp,;.4y AY4..4IROiu Name'e1Cko d City/Zip G�/cs ✓/. E �AY T(J7i E7'�-T7c� l� If in a Subdivision provide information, as follows: / ?;YJ!! C�aClt Name: _ oC /tip - r Section: Block: Lot: Date ProT Flagged: �!` a7l-f's � e r,Je_ This Is to certify that the iurormatlon provided is correct to the best of my knowledge. 1 understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site pians or Intended nae change, or if the information submitted in this application is falsified or changed. I, also, anAnwand that Ion reronsible for all charges incxrnad f vm this application. 1, hereby, give consent to the Authorized Representative of the Davie County 1Tealjh epartment to enter upon above described property located in Davie County and owned bar G'a ni 1/ % ''�7'''�%�� to conduct all testing procedures as necessary to determine the site suitability. DATE _ SIGNATURE THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all or. the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. 6 69 Revised DCHD (07/98) Invoice Na ;�'13 - 29 932. '52 . .2Z1.G to Ac� !3.78Ac ICU P o� W Of too 00.58 74 54 iA 223 k LO -j OLk c -4136f 224 C, E11.121 iAc co F//V 5Ac 53 co p 23.15Ar-V— cU Lm g 50 Z) C\j 15. 7 pu 6 p- 350 2 Xr 51.02 5���,� L4DO :.. *�' .. 6.84 Ac Rr A 4. 5 Ac. 00 IA Z2 n7 U U 93 T 7— '3� R 3 p -._..3: _L i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �1Ory,f%S8^ DATE EVALUATED PROPOSED FACILITY /r �! PROPERTY SIZE J SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring � Pit ROAD NAME / P ---Z7 ` Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 3 F Texture group Consistence Structure 4 < /Z 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 5— SITE CLASSIFICATION: P'� LONG-TERM ACCEPTANCE RATE: . S REMARKS: LEGEND DCHD (01-90) Landscape Position EVALUATION BY: ALel OTHER(S) PRESENT: 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 March 15, 1999 Camilla H. Thompson 273 Feezor Road Mocksville, NC 27028 Re: Site Evaluation/Feezor Road (250' x 223') Tax Office PIN: #5727-97-5071 Dear Client(s): As requested, a representative from this office visited the aforementioned site on March 10, 1999. 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/wd Enclosure(s)