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1315 Fork Bixby Rds A& DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002445 Tax PIN/EH #: 5769-93-0467 Billed To: Gail Long Subdivision Info: Reference Name: Location/Address: Fork Bixby Road -27006 Proposed Facility: Residence Property Size: 50+ acres **NO'il-"�*Nffrpr4il%nt/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 7T,J#People #Bedrooms � #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) Site: NeWI! alRepair ❑ System Specifications: Tank SizeGAL. Pump Tank Other: Required Site Modifications/Conditions: IMD GAL. Trench Width "( Rock Depth / Linear FQjff IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the unty Health Department for final inspection of this system between 8:30 a.rn 0 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on X of ijqsiallation. Telephone # is (336)751-8760.**** �(v 0 1 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 Account #: 990002445 Tax PIN/EH #: 5769-93-0467 Billed To: Gail Long Subdivision Info: Reference Name: Location/Address: Fork Bixby Road -27006 Proposed Facility: Residence Property Size: 50+ acres ATC Number: 3439 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 g�YEARS. Environmental Health Specialist's Signature: �� // Date: � — (,z 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. l� Septic System Installed By: d::�� Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) r1A d 6CIAle /(` APP TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & li Davie County Health Department C5 ` S l Environmenta/Health Section p �V ©) P P.O. Box 848/210 Hospital Street 1 c<� ' Mocksville NC 27028 SEP 1 1 ` (336) 751-8760 '� 2042 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 )it No If yes, what type? 'IMPORTANT' CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: ;i U WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 5 L&J (,Ltj— Property Address: Road Name . N —]�, % l St City/Zip k If in a Subdivision provide information, as follows:T j /mss 7Pu I i G .1—OA-06 Name:VFn0 3 Int • - W 1 pgsT A�rpd�--�, Section: Block: Lot: Date Property Flagged: C) 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 frons this application. I, hereby, give consent to the Authorized Representative of the Davie County Health De artment to enter upon above described property located in Davie County and owned by M/ Wti �} W, � l Lok to conduct all testing procedures as necessary to determine the site suitability. —� DATE '6 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). Site Revisit Charge Datc(s): Client Notification Date: EHS: U Revised DCHD (07/99) Account No. 7 5 Invoice No. 3 i Wo ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS HE #�`J PROVIDED. Refer to the INFORMATION BULLETIN for ins �. 4( 6a, L wiq �/� 1. Name to be Billed L. Q Contact Person ! t, Ala Mailing Address f 41 �(u 2 k I_ Al r I PJ F q pO 1, QA �(� Home Phone /,33& city/state/ZIP �Q Gly SII/ LL F_ Business Phone 2. Name on Permit/ATC if Different than Above Mailing AddressCity/StaJt/ / v 3. Application For: Df Site Evaluation �fImpr ement Permit/ATC ❑ Both 4. System to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People �_ # Bedrooms_ # Bathrooms_ )( Dishwasher ❑ Garbage Disposal Washing Machine 11 Basement/Plumbing FI 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 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes )it No If yes, what type? 'IMPORTANT' CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: ;i U WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 5 L&J (,Ltj— Property Address: Road Name . N —]�, % l St City/Zip k If in a Subdivision provide information, as follows:T j /mss 7Pu I i G .1—OA-06 Name:VFn0 3 Int • - W 1 pgsT A�rpd�--�, Section: Block: Lot: Date Property Flagged: C) 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 frons this application. I, hereby, give consent to the Authorized Representative of the Davie County Health De artment to enter upon above described property located in Davie County and owned by M/ Wti �} W, � l Lok to conduct all testing procedures as necessary to determine the site suitability. —� DATE '6 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). Site Revisit Charge Datc(s): Client Notification Date: EHS: U Revised DCHD (07/99) Account No. 7 5 Invoice No. 3 i Wo I r < ®1 1 256 , w„ � �,,.ae., 3,.oa. rr � IN 41ms, � u., 12 �r 3� ,�,i:3�3s1 / / /0 i'r 4s� ♦ .�� '* wt, r s s �%, �\��� y �,� \\�. E � 136 U ',,r t y 40 MP t / n 4 6 tlM14 E EE 1420 ' v -m 7J EEEE EEIEE J I ��%En � E A s \aC- 13E 3E3 33 3 � EEEw t F/' � r. \ Mal a 7 fff� , r��i73�IE� 833333393 \\� ll �i E E jE� X1:3 j71 EIEI x z %ii raw '1 FE £ /////%x '� ,� / ��� 'moi, /✓ �(7 ! 2 06 ,a\ < .. � 62 %`T 22 2 15 , IMIAKI I ,sem -42 ® 45 ., \\ 1022 38 34 1 269 X00 APPLICANT INFORMATION Account #: 990002445 Billed To: Gail Long Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5769-0-93-0467 Subdivision Info: Location/Address: Fork Bixby Road -27006 Property Size: 50+ acres Date Evaluated: C%d 7i Community Evaluation By: Auger Boring i_-,-, , Pit Public t--� Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH < < Texture group Consistence / Structure Mineralogy! 7 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE /77 CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: e REMARKS: EVALUATION BY: YAG OTHER(S) PRESENT: 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm SS - Slightly sticky S SP - Slightly plastic 1 Structure SC - Single grain M - Massive CR - C SBK - Subangular blocky PL - Platy 1 Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches fro Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to fref Classification - S(suitable), PS(provisionally LTAR - Long-term acceptance rate - gal/day/1 DCHD 05/99 (Revised) VFI - Very firm EFI - Extremely firm ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■ ■■■■■■■■■■mein■■■■■■■■■■■■■■■■ ZSEMMESi�mommillm MENCEMMEESE ■■■■■■■■■■■■1111■■■■■■■■■■■■.■■■ ■■■■■■■■■■■■711■■■■■■■■■■■■■■■■ ■! ■ ON NEMMMEMEM MENOMONEE MOMMENE .......eel ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 September 18, 2002 Gail Long 142 Turrentine Church Rd. Mocksville, N.C. 27028 Re: Site Evaluation/ 50 Acres Fork -Bixby Road Tax Office Pin : # 5769-93-0467 Dear Ms. Long: As requested, a representative from this office visited the aforementioned site on September 17, 2002. 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, A4ae & 6-:;1aaA . Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df