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615 Fred Lanier Rd / , `o`�O�0 5 ` � , � + • DAVIE COUNTY HEALTH DEPARTMENT �' Environmental Heaith Section _ P.O.Boa 848/Z10 Hospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990002650 Tax PIN/EH#: 5719-29-2745.02 RR Billed To: Robert Rogers Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Pro osed Facilit : Residence Pro e Size: 18 acres ATC Number: 4205 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 AUTHORIZATTON FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Date: ��_��Q�� 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. ZZ e(r /Z� S�.opF S.T• C2� � �L looe�«Q. _ � 2 �`Cl���.+'�'� Z s y� , . � r CZZS'> � » �_ � ���c.�►L 1�w�Q. � �i ��,K,►�2 (.cu.Q.. �� t h 1 y R �/ � ��W v � �-� S�c f�� � �� Septic System Installed By: S E1 t�w►a—��l t'+''� Environmental Health SpecialisYs Signature: Date: �O -a 1-0 �i DCHD OS/99(Revised) , DAVIE COUNTY HEALTH DEPARTMENT � ' • ` " � Environmental Health Section � � , ' P.O.Boa 848/210 Hospital Street � ' O Mocksville,NC 27028 `b, (336)751-8760 �01 IMPROVEMENT/OPERATION PERMIT Account #: 990002650 Tax PIN/EH#: 5719-29-2745.02 RR Billed To: Robert Rogers Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility Residence Property Size: 18 acres ATC Number: 4205 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 STTE PLANS OR THE INTENDED USE C�iANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People �� #Bedrooms�_ #Baths � n Dishwasher� Garbage Disposal: 0 Washing Machine� Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:0 Lot Size ° Type Water Supply�� Design Wastewater Flow(GPD)� Site: New�Repair❑ �� i/, ✓ System Specifications: Tank Siz�BO GAL. Pump Tank GAL. Trench Width(�� Rock Depth 1,� Lmear Ft�� pther; As stated in 15A NCAC 18A.1969(5j "ceptect�pstem s�traY�iS o—b e—cr Required Site Modifications/Conditions: INIPROVE111ENT/OPERATION PERMIT LAYOUT- APPROVED FFLUENT FILTER RISER(S) IF 6 K BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe ' C unty Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on e ay nstallation. Telephone#is(336)751-8760.**** 1� - � Environmental Health S ecialist's Si ature: Date: � P Sn DCHD OS/99(Revised) ' • t{ . , � . . . � T' . , • APYLIC�l7tUN FOR SITE EVALUATION/IM1tYROVL•h1FM PE � &{�C � , Davie County Health Department L� � � f2 , � • Environmenta/hlea/th Section LS • P.O. Hox F34F3/210 Ho3pital Stroe Mocxsviiie, Nc 2�o2a � SEP � 6 2005 ��. (336)751-8760 • ***I1�IPORTANT*** THIS APPLICATION CANNOT �E PROCESSED UNL ^ ALL &� INFOR2dI�TION IS PROVID�D. Refer to thn INFORhSATIOri BULLETIN for onu. ,� 1. Nama Co be Dilled Qc- 1 �. U- �S Contaet Pernon�a '�c�� v t' tdailing Addru�a ��� �� lfomo P2ionQ '19a�5�1p� Ci�y/Stato/ZZP �U(,�SOi � � /V � `�.7[7�.p , IIusinoaa Phono `5lr/��� . 2. Namo on Permit/ATC if DiPferont than Abova 2dailing Addraua City/Stato/Zip 3. Application For:�Sitc �valua�ion ❑ Improvement PermiL•/ATC CJ Doth \ 4. Syal•em �o sorvico: �Iiouua ❑ 22obilo Homo ❑ IIuaine3� ❑ Induatry � Other 5. Typo ayatom requnaCod: �.Convnntional ❑ convontional modified ❑ innovativo pacCepted 6. If Ita�idenca: It Pcople �7 � I3edrooms �3 11 DaLhrooma �' ,�� No bRseme��r L`!'bi�hwa�har ❑Carbac�o Diuposal �hing Machino ❑IIasementJPlunJ�ing ❑Dauemant/27o P1umUing 7. IE Duninesa/Induutry /Othar: verify typo it People 1� Sinka � Commodoa !1 Showorn • t1 Urinals 1f WaLor Coolora IF FOOD�ERVICE: �� Seata Eatimated Wa�er Uaagn (gaiiona per day) a. Typo of wator aupply: l�" County/City ❑ Well O Communi�y 9. no You anticipata adclition� or cxp:insions of tlic tacilil��tl�is systetii is intciidcd to scrvc? Cl 1'cs �No If��cs,�ti•l�at typc? � ***IdIP TANT'�**CLILNTS�llUS OAIPLCTL•Tlt� REQUIRED PROPGRTY IM�OR�•IATIOIY RLQULSTLD f31;(.011'. rithcr�PI,AT or SiTG PLAN hIU.ST IlESU1Tdl1777;D by Uic dicnt �vith T111S A1'Pl.ICATION. 1'roperfy lliincnsions: 4'G��- IYIiITC DIRGCTIOn'S(G•un�11•Iucicsvilic)co PKOI'!iK'1'1':� •r:�x orr,r�riN: f� � '�� � 4� 7� g (� ' rron�rc3�Address: Road N��nc ��v�.'Ft'��� /� , ..flc.r/�� c,�yiz,n�lac�sv,�l�- �7D�-� If in a Subditi�ision providc inlorn�alion,as follotivr. Namc: Sccfion: Blocic: Lot: Datc liomc corncrs JIaggcd:_�"�?�v S I'l�is is to cer[i!y tl�al tl�e iuformation provided is correct to tlie besi of m}�l:notivledge. I unclers(and tliat any permil(s) issucd hcrcaftcr are subjcct to suspcusiou or rcvocation,if thc sitc plans or intcnJcd usc ch;iugc,or if tLc iiifoi•malion subniiticd iu (his application is fzlsiCcd or cliangcd. I,also,�rrrrlcrsla�ld[hatl nu!respousiLlcfur n!1 clrrrrgcs i�rcru•rcrl frunr r/ris applicntion. I,l�crcby,givc conscut to tLc Autl�orizcd Rcprescutati��c of tl�c Da �' Couuty�IIcalll�llcpzrtmcnt to cc�lcr upon abovc dcscribcd propci•ty locatcd in Davic Cou�ity and otiviicd by �e1�o,,�,�' w Cre.c>1A ,��� to conduct all tcsling proccdw•cs as ucccssary to dc(crtninc thc silc suit. 'lic �. D��'1'L s lG`�S SIGNA'I'URL �^�/ � TIIIS AR�A A1AY B�US�D rOR DI2AIVING YOUR SI'fL PLAN(IncIudc all ol'tLc tollotivilig: Lxisting�nd proposcd property li►ics and dimcnsions, structures, setbacics, �II(I SCjlt1C IOCI�IOIIS�. � Sitc Itcvisit Cl�argc . �(�_ .. Datc(s): �r. - — Clicnt Nolificatiou Datc: ' �I�IS: Sign given � / '. ,Account No. ��`�P� \ r- r., r, Rc��ised llCIIll 5/03 Li��oicc No. � �� y • . �„ � I13.sen) � � . Y , • 1591 �.q�) � �o ` — se �ff J,m,� � 669 ,� � x � � �' _' � � �� ,,, 649 � a+�i � — _. � � (9.81A) � 7788 � �w 1.74A) $ 7618 s��J � . • � 6 3 ,,,s, : � h � ,m w�s . _ ur+r+�° * �" uss � p9°1 .:�. R�s�l. �� (��) .�� R h � (8.37A) 1267 yj : 4�� . .. � �. . . -��� . � � � � . (2ABA) . . � . _ � 7878 . � i � � (16.17A) . 2745 @ �h � .. '... ,..:... . . . . . (5.t8A) . . - . "� , 0672 2i� eoo ,.. m 61��0 �� 49 '�. � � > �r �+ �,.x� �„� ,� �A) ' (2.O6A) ('�) � � 36 ,�19P . 825.�r �f� o� ! �7 � (2.O6A) �13� .5 Sf ��`''�) �� �7107 S 5118 t 9796 � '� R�) Y� ,�y. �8 �'\ �i � � � h 1 n� S�s �x� w+u O � � aaq � 3 210A '` (2.mA) M1 . 4847 . m� `�j �� o � a psen� . 0599 vr (75.79A) (B.BBA) $5y3 � 1638 I � . 4� ��8 I ) � I I �s af�I w,. :�' oa2 � � �is.iso.� r $ � � naa/ � � � �l Q A� \ I ,m' I . � �d . \ I • ' ' '_ ' DAVIE COUNTY HEALTH DEPARTMENT ,'` ' Environmental Health Section Soil/Site Evaluation � AFPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002650 Tax PIN/EH#: 5719-29-2745 Billed To: Robert Rogers Subdivision Info: Reference Name: Location/Address: 615 Fred Lanier Ro d-2702 j Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo % HORIZON I DEPTH �� i� Texture rou 1' Consistence / . Structure Mineralo - • � HORIZON II DEPTH �� y �/ . Texture mu ' . Consistence Structure � Mineralo � HORIZON III DEPTH f Texture rou Consistence Swcture Mineralo � HORIZON IV DEPT'H Texture rou Consistence � Structure Mineralo � SOIL WETNESS RESTRICTIVE HORIZON ' SAPROLITE CLASSIFICATION I LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: I OTHER(S)PRESENT: REMARKS: LEGEND Landsca�e 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 �g . 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 coNsis�rrcE MQisi VFR-Very friable FR-Friable FT-Fum 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 . _ StT.11st13rg _ . . SC-Single grain ' M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineralo�,' ' 1:1,2:1,Mixed . �� Horizon depth-In inches � - - � Depth of fill-In inches . Restrictive horizon-Thickness and inches from land surface . Saprolite-S(suitable),U(unsuitable) � Soil wemess-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-gaUday/ft2 . 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