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475 Fred Bahnson Dr (2)* DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001277 Tax PIN/EH #: 5872-59-1423 Billed To: Bleeker Strand Subdivision Info: Reference Name: Bleeker Strand Location/Address: Fred Bahnson Drive -27006 Proposed Facility: Residence Property Size: 200 + Acres ATC Number: 2494 **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 oom IA #People z #Bedrooms 3 #Baths -2_— Dishwasher: 03"� Garbage Disposal: ❑ Washing Machine: 13 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) ZUQ Site: New 2( Repair ❑ System Specifications: Tank Size ID Pump Tank GAL. Trench Width Rock Depth t2•Linear Ft. ' .ten � t�� a � Other: I S1 ��i}fi�0� —&, y ! �is1'NL1- p.G. VXA,1 3' Required Site Modifications/Conditions:�t �"-TALL C•) C -0 J()09, 4-0,--P 5 6cr N1-�• j4L=� -fSD1 r—e-c", 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: or 00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** r �Ul) / L'�j Environmental ;;%�Specialist's Signature: DCHD 05/99 (Revised) );10Date: , Account #: 990001277 Billed To: Bleeker Strand Reference Name: Bleeker Strand Proposed Facility: Residence ATC Number: 2494 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5872-59-1423 Subdivision Info: Location/Address: Fred Bahnson Drive -27006 Property Size: 200 + 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-CONSTRCC—RUCISAGALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's CERTIFICATE OF COMPLETION Date: **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) ID WEI1 Date: APPUCATION FOR SITE EVAUTATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environment/ Health Se. cxion P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Jul 1 2 2000 (336) 751-8760 EtVVi1 ***IM80RTANT*** THIS APPLICATION CAMOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed b lee ke. ff ' 'Wand Mailing Address _5A4 FoeA —pon-ho'50oN/� /fir City/state/ZIP &(b o (i' . i c) ZIDO (0 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. system to service: 5. If Residence: W151.hwasher Q/Ifite Evaluation ❑ House "bile Home # People Contact PersonG'fe q Of -Nel-e ke-c ��il CcYi� Home Phone �( NiC Business Phone City/State/Zip ❑ Improvement Permit/ATC Both ❑ Business ❑ Industry ❑ Other # Bedrooms # Bathroomsy� ❑ Garbage Disposal 0-% aching Machine ❑ Basement/Plumbing ❑ 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 bell ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 4O 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: -?'Dv --- Tax Office PIN: # 587 2 59 14 a 3 Property Address: Road Name �Qe'A �W\Mft-D'( City/Zip MVavice- , If in a Subdivision provide Information, as follows: a It0G Name: WRITE DIRECTIONS (from Mocksville) to PROPERTY: CO, u70 �So Q N -Q' `s, t)f a, c -u) Sectinn: Black: Lot: Date Pronertv FlaLyged: 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 ant responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE —1" I A � C SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, ands atiogs). Revised DCHD (07/99) A AI Site Revisit Charge Date(s): Client Notification Date: 77cco-2unt No. / Ind ice No. i, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001277 Tax PIN/EH #: 5872-59-1423 Billed To: Bleeker Strand Subdivision Info: Reference Name: Bleeker Strand Location/Address: Fred Bahnson Drive -27006 Proposed Facility: Residence Property Size: 200 + Acres Date Evaluated:1 Water Supply: On -Site Well 'i// Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position IL Slope % S120 HORIZON I DEPTH Q - c., - Texture group 40, Gk_- C t_ !� Consistence Pr 55 5 r s 5 5P (49;5f Structure CQ Mineralo ' I 1 HORIZON II DEPTH 1Z_ , ZZ Texture group C- C Consistence (- F; 5 ,- Structure A 4k- C Mineralo 1 HORIZON III DEPTH ' 2 - ZZ 22' Texture groupG S� -F SAf Consistence G ; Structure Mineralogy1: ( ;- M l x u HORIZON IV DEPTH 224 f Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: F3 LONG-TERM ACCEPTANCE RATE: 1 -r) R L REMARKS: LEGEND EVALUATION BY: agK_ OTHER(S) PRESENT: 34 slges�'�> 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 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) i ■■■■■■■■■■■■■■ ■■■■■■■■M■■■M■ ■■■■■■■■■■■■■■ ■M■■■■■■■■■N■■ ■►1■■M■■■■■■ENO ■■R■M■■■NmQomm ■■■\MM■REMB■■■ ■■■\S■■SYN■■M■ ■■NN\■■■■■M■■■ ■■■M■n■■M■M■■■ ■■■■■\MM■■M■■■ MENN■UM■■M■■I L■■M■ 1■■M■■ ■\■■■■■\N■■■Ni ■\1■■M■■■l\■NMI/■ ■MMM■■■■EMEMNi ■■M■■■■■E"Mom■ ■NMS■■N■■\■■[1■ ■■■►i■■■■■■MMME ■■■SM■M■■OMMEM ■■■■4\■M■■O\■■\ ■■N■■dOMM■■■1\■■ ■■M■■MEMEM■\1■■ ■MM■M\1■AA■■MM■ ■■■■■■`w■e■■l\■ ■■N■■■ ■M■■M■ ■■NN■■ ■■NN■■ ■■■O■■ ■■MO■■ ■■MONS ■■■N■■ ■■MOM■ ■■■N■■ ■■■■■■ ■■MEMO■■■■■N■■■■ ■■■N■NU■■N■M■M■ ■■■■■■ ■■■■■■■■ ■■■■■■NM■■■■■■■■ ■■■■■■N■■■N■■■■■ ■■M■■M■M■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■M■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■U■■■■M■■■ ■■■■■■ ■■■■■■■■ ■M■■■M■■M■■■M■M■ ■■M■M■■N■M■ MM■MM■■M■M■ ■N■■■■M■■■■ MN■■■■■■■N■ ■■■MMM■MMM■ ■■■■M■■■■■■ ■■■■MMM■■■■ ■■■■■MMM■M■ ■■■■■M■■■■■ ■■■■■M■■M■■ ■■■■■M■MM■■ ■■■■MM■M■■■ ■■■■MMM■■■■ ■NN■N■■■■M■ ■■■■MMMM■M■ ■■■■■■M■■M■ ■■M■■MMM■M■ ■■MM■■MM■M■ ■M■N■■■■■N■ ■SSSS■■N■■■ ■■■■■■■■■■■ ■■■NN■■■■■■ ■■MM■MM■■■■ ■■■N■■M■■■■ ■■■■■■■■■■■■■ ■■■■M■■■■M■■■ ■■MMS■■■■■■■■ ■MOMMMN■■MM■■ ■■MMM■M■■M■■■ ■■MM■MMMM■■■■ ■■■■MMOMM■M■■ ■■■UMM■■MMU ■■■ ■■NN■■ ■■■■M■M■■MMM■ ■■■■MMM■■■■M■ ■■MM■M■M■M■■e ■M■MM■■MMMMM■ ■■M■■M■■■■■■■ ■■MMMMMM■MMM■ ■■M■■■■■■■■■■ ■M■■■MMMMM■M■ ■■■■■■■■■■■■■ ■■■■■■■■MMM■■ ■■M■■S■■■S■■■ ■■MM■M■■■MMM■ ■N■■MM■■■■OM■ ■■M■M■M■■■■M■ ■■■■MM■■■■MM■ ■■M■■MN■■MMM■ ■■■■■■■■■■■��■■moi■■e■■■■■■■■■■■■■■■■■■■■gin■■■■■■■■■■■■■■■■■■■■■■ ■■■■■N■■■N■�i■■nn■■M■■■M■N■■■NN■■■■■■■■oma■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■N■N■i■■ars■■i■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■ ■eeeeee■NNNNi�■ree■■■■■■■■■■■■■■■■■■■■■■Mee■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■eee■��Nr-���■■i■Mee■■Mee■■■MNNNN■MM■■■ecce■■■■■■■■■■■■■■■■ ■■NN■■■■■■■■�iN■N\�NN�INNNN■N■■■�i■■■■■■■■Mee■■NNN■NNMNNM■■■■■■■■ . _ . . ., .� _�- . i� i1 ... � ��.v. � g��� . . . . . . . . . � . - . t ... ",. .,� . . ; � � . .. .. . .. . � . (Y �S ��� . . � � � . :.. ... VO I 000.oO�OV V . . . �. . .. ... ' �'�b�, �. DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section P. O. Bo= 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account M 990001277 Billed To: Bleeker Strand Reference Name: Bleeker Strand Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5872-59-1423 Subdivision Info: Location/Address: Fred Bahnson Drive -27006 Property Size: 200 + Acres ATC Number. 2494 **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 1 oro 1 #People 'Z #Bedrooms 3 #Baths -2_— Dishwasher: 09"' Garbage Disposal: ❑ Washing Machine: Q� Basement w/Plumbing:13 Basement/No Plumbing: 13 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply Design Wastewater Flow (GPD) LZj.,g_ Site: New 2( Repair n System Specifications: Tank SizeIDD(DGAL. Pump Tank GAL. Trench Width Rock Depth 12" Linear Ft. eA`U Other: �►5 1�1H Boa U I �.1STc� t t- c.+.J�: S p.G. A.r,J, Required Site Modifications/Conditions: ��ST(al _C L� cD'1`A4va K - S' 6rr (k.t �.: �4=� �1 �^-• 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 systein between 8:30 a.m. to 1�bq!,�r 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** L r� T n- �� 0-.J -T--� �:% Specialist's Signature: wrA- Environmental Date: n J DCHD 05/99 (Revised) ��