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462 Frank Short RdAccount #: 990003928 Billed To: Shane Poplin Reference Name: 3roposed Facility: Residence ATC Number: 4441 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5757-55-7362 Subdivision Info: Location/Address: Frank Short Rd -27028 Size: 1 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 -GO CT N IS kALIa FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's -1 CERTIFICATE OF COMPLETION Date: 19 **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. 11►' IL, 1 8 20 pow .-� is -ro,)tCCco -7i Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 1;� DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street • Mocksville, NC 27028 i (336)751-8760 (,�I �f 1 IMPROVEMENT/OPERATION PERMIT Account #: 990003928 Tax PIN/EH #: 5757-55-7362 Billed To: Shane Poplin Subdivision Info: Reference Name: Location/Address: Frank Short Rd -27028 Proposed Facility: Residence Property Size: 2 1/2 acres ATC NuMber: 4441 **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 J #People #Bedrooms #Baths_ Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: 12"" Basement/No Plumbing: ❑ Commercial Specification: Facility Type { ' #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply WAX, Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width lo Rock Depth I Z Linear Ft. As stated in 15A NCAC 18A.1969(5) Other: 3 71 S i (z 1 �'x�l Ohl � yj"�' accepted Systems may also be used Required Site Modifications/Conditions: �(�S"j-nLl, 0,) C-J"�TD`)r- , Via 5!3, V�2CM Wi:IL, L/G& 10, C�(F 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.**** 1" Environmental Health NQNICPI DCHD 05/99 (Revised) "w 2'' 133' /33" Date: -7 10 0 ('e f ,.APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC t Davie County Health Department r o�,41 Environmental Health Section 1 1' P.O. Box 848/210 Hospital Street MAR 2 8 2006 Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 �N G -©CP App icZtjWVdTZ c e Evaluatio mprovement Permit Vutho ization To Construct(ATC) El Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed n R, I' Contact Person S�a,rl r_ �d (J t°..� Billing Address y (, Fra -. , S b, v r 1, Home Phone 336- '7W - / 6 3 1 City/State/ZIP ,/(Pr ,Gr S v ; l C NC. A 7 0 . - 9- Business Phone Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION Ci NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) .e Street Address Fr, „ K S �• ac i �': Ci C 1<-S Y ► l )e Tax PIN# % S,S 7 Subdivision Name Section/Lot# Lot Size .2 tie ,-r o. - Directions To Site: Kn Q/ Sort I)% 7`re y,, /YIDe 4 S y 0/cg 09r -0/r» ,% To /I -el -I t1,1 r 0a, a' 0 e LP i Tra 11C / Thea �/I7n,1 /act alba )(o2 M/11 -r -tom �.-arl IC 5A ,-7`-RCI, Dn ,Ce P7'-. G O f"o P nc A-f'fn.,/ 5 I V,1. l;) -a We/ dry-ve-V,ay ,, A R. ;a 1,4- Gn :.3 /)1)'�- a', -/Pftr- Date House/Facility Corners Flagged .3- X N ` O b If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑ Yes Fff o Does the site contain jurisdictional wetlands? ❑Yes [Ko Are there any easements or right-of-ways on the site? ❑Yes Q'1'Vo Is the site subject to approval by another public agency? ❑Yes R-1 l0 Will wastewater other than domestic sewage be generated? ❑Yes Grf�o TF R'P(ZM Mr'P FTT T 0T TT TNF RC)Y RFT C)W # People Ly /vL I zLy v # Bedrooms`— Bathrooms 3 Garden Tub/Whirlpool es ❑No es ❑N Basement: o Basement Plumbing: YT es ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats /Type system requested: (/Conventional []Accepted ❑Innovative ❑Alternative ❑Other Water,Supply Type: ❑ County/City Water R New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ro If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(&r ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in Davie County and owned by r nr, Site Revisit Charge Property own is r owner s'legai representative signature { Date(s): 3- •2, (/ ( Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 2/06 Invoice # 9 4.1, sq S 4 9 I x I ya. ia4 --------------------- CD yr APPLICANT INFORMATION Account #: 990003928 Billed To: Shane Poplin Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5757-55-7362 Subdivision Info: Location/Address: Frank Short Rd -2702, Property Size: 2 1/2 acres Date Evaluated. G l Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: 1�� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: nl i & i Z� Z� N 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 u. VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 motes 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 05105 (Revised) Landscape position Slope % HORIZON I DEPTH ConsistenceTexture ���---� Mineralogy HORIZON II DEPTH group,., ­ «�r�-�r���s®■�■ Structure -�■1�_W�100M ■� Mineralogy��s�-��m�������■�� HORIZON Texture group .. MineralogyHORIZON IV DEPTH Texture group Consistence ��■■■��■���®oma Mineralogy • SAPROLIT& ICATION • .. SITE CLASSIFICATION: 1�� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: nl i & i Z� Z� N 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 u. VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 motes 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 05105 (Revised) ■■■■■■■■■■■e■rle■■■■■ee■■e■■■■■■■■■■■■■■■■■■■■■e■eee■e■■■■■■■■e■■1/■ ■■■■■■■■■■■■Ile■■■■■■■e■■■■■■■■■■■■eee■e■■ecce■■■■■■■■■■■■■■■■■■Il■■ ■■■■■■■e■■��e■■■■ee■■■■■■■■■■■eee■■■■e■■e■■■■■■■■■■■■■■■■■■e■ee�■■■ ■■■ee■■■■�e■■■■■n■■ee■■■■■■■■■■■ ■■■■e■■■■■■■■■■■■■■■■■■■■epi■■■■■ ■■■■■■■■fle■■tea■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■��Gii■■■■■e'�■■■■■ ■■■■■■■■■■■■■`I■■■■■■11■■■■■■■Ileiiiiiiii■■■■■■■■■■■■■■■�■■■■Ciee■■■■ ■■■■■■■n■■■■■■■■■■■e■Ilea■■■■■11■■■■■■■■■■■■■■■■■■■■■�.%■■■■■rl■■■■■■ ■■■■■■■rl■■■■■■■■■■■■■11■■■■■■ell■■I�e■■■■■■■■■■■ee��%■■■■■■■■11■■■■■■ ■■■■■!■■■■■■■■■■■■■■/J■It■■■■ [''Ufa■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■ i iiiileil�iiii�■Ifi� ���,�: 9iiiiil�' MENNENiiiiiiMOMEMEl�l - - --- -- -------- ■■ee■■■■■■■ee■e■■■■■■■■■■■■eee■■ ■■■■■■■■■■■■■■■■■■■■■■■■ecce■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■e■■■■■e■■e■■■■■■■■■■■■■■■■■■ ■■■■eee■■■■■■e■■■■■■■■■■■■■c■■e■�■■■e■■e■■e■■■■ee■■■■■■■■■■■■■■■■ ■■■■■■■■e■■■■■■■■■■■■ee■e■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■eee■eee■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■e■■ec■■■■■■■■■■■■■■■ecce■■■e■e■ccee■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ee■■■■■■■■eee■ee■■■■■■■■■■■e■■eee■■■ee■e■■ee■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■e■■■■■■■■■■■■■■ece■eee■■■■■■■■■■■■■■■■■■■■■■■■■■eee■■■ ■■e■■■■■■■■■■■■■c■■■■e■■■■■■■■■■1�■■■■■■■c■■■■■■■eee■■■■■■■■■■■■■■ I Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 April 7, 2006 Shane Lee Poplin 462 Frank Short Road Mocksville, NC 27028 Re: 2.5 Acre Tract/Frank Short Road Tax PIN# 5757557362 Dear Client(s): As requested, a representative from this office visited the above site April 4, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Wastewater Design Flow: System Type: ❑Conventional KA-ccepted ❑Innovative ❑Alternative ❑Other System Location:FRQ,JT I S0L-)ru St Valid: ?5�Years ❑No Expiration Site Modifications/Permit Conditions: �^��,r} C.�A►—, `��1� ps-i.p.letter 2/06