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194 Foster Dairy RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001121 Tax PIN/EH #: 5840-83-9878 Billed To: Kelly Reeves Subdivision Info: Reference Name: Kelly Reeves Location/Address: Foster Dairy Road -27028 Proposed Facility: Residence Property Size: 2 Acres **NU'1"1J" *-Tliisbginproveme 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 I 1 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 _ G't �S'" #People .-7t #Bedrooms 7 #Baths Dishwasher: G" Garbage Disposal: Washing Machine: l;-`� Basement w/Plumbing: P--�Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industr ial Waste: 13Lot Size •i Type Water Supply I =� Design Wastewater Flow (GPD)3U,2— Site: New � Repair ❑ System Specifications: Tank Siz%,11S GAL. Pump Tank GAL. Trench Width t Rock Depth j, , / Linear F _ Other: ---�7°f�/ t'1�� ( C�� r Y'-:5'441 //` 1� � . (�f-'� /) /1J Required Site Modifications/Conditions: �;l.G'y'" /�.�-{ . / G /a,E/'LAI C.. "A IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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.**** qpol +ak� PLO Environmental Health Specialis 's Signature: _ DCHD 05/99 (Revised) Date: 0 Account #: 990001121 Billed To: Kelly Reeves Reference Name: Kelly Reeves Proposed Facility: Residence ATC Number: 2410 F CU DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5840-83-9878 Subdivision Info: Location/Address: Foster Dairy Road -27028 Property Size: 2 Acres I:1i1 I�M IV C91 RVA.,I4 M]011111"1 tiwixil 11111�.1yo a Ca6vi-4I li 9iTC��]i��i81�1111 **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: CERTIFICATE OF COMPLETION Date: 7-- Z/-(�Or **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 Svstems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any riven period of time. I t LoT IOD 01 7Z- ( ? Y y /!� e t S em Installed B Health Specialist's Signature : / -z _ Date: DCHD 05/99 (Revised) i y i APPLICATION FOR SFFE EVALUATION/IMPROVEMENT P MITI& ATC Davie County Health Department APR 17 200, Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ��;S1y� its iLiH (336) 751-8760 DJ`'VIE 00UiJ)' ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to Qthe INFORMATION BULLETIN for pinstructions. C 1. Nana to be Billed ( �//��I I \/ P� � Contact Person C(� I / y Re e--72-90 ve- S Mailing Address' +�V'/ U` rS \ W \J C0 4 F �[ Nome Phone/ -336 � (� 1 V City/state/ZIP Hoc -sV i ! I e Lir. Q � 2O�U Business PhoneO3& 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: Asite Evaluation ❑ Improvement Permit/ATC pith 4. system to service: @'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence- 4 People 2--i Bedrooms/' 9 # Bathrooms 2- t vishwasher ItYGarbage Disposal Machine Li'Basement/Plumbing 11 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 f ' �'� e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes vino 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. Propeely i inuensions: '2 �,CLE,5 _ Tax Office PIN: # 5S 4 (] `3 3-q S -7 9 Property Address: Road Name �yS+GY o I rN i•Lt CitylZip He- WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: V l 6 V 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. 1, also, understand that I am responsible jar all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the�avie County Health Department to enter upon above described property located in Davie County and owned by -) eVe52 Va to conduct all testi n procedures as necessary to determine the site swit4bility. DATE D �/ I. 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 Date(s): Client Notification Date: EHS: Revised DCHD (07199) Account No. Invoice No. �� °~' / � � -' '__--_-_-_- / __-.r / --'_ "~ /� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001121 Tax PIN/EH #: 5840-83-9878 Billed To: Kelly Reeves Subdivision Info: Reference Name: Kelly Reeves Location/Address: Foster Dairy Road -27028 Proposed Facility: Residence Property Size: 2 Acres Date Evaluated:��' Water Supply: Evaluation By: Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH n 'Cl r Texture group Ci Consistence ,`��" 77 S Structure Mineralogy HORIZON II DEPTH — -- ^ D Texture group Consistence VP. < i Structure Mineralogy ` ` HORIZON III DEPTH – L4, Texture group1 Consistence $ Structure Mineralogy; HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE -< CLASSIFICATION LONG-TERM ACCEPTANCE RATE ` SITE CLASSIFICATION:y LONG-TERM ACCEPTANCE RATE:y REMARKS: EVALUATION BY:1G��'---- r OTHER(S) PRESENT: U D v / / LEGEND —' Landscape Position v 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)