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136 Galadrin WayDAVIE COUNTY HEALTH DEPARTMENT b Environmental Health Section • ppP. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000771 Billed To: Roman Hernandez Reference Name: Elender Johnson Proposed Facility: Residence Tax PIN/EH #: 5870-147859 Subdivision Info: Location/Address: Galadrin Way -27006 Property Size: 2.91 Acres ATC Number: 2187 **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 #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 A e Type Water Supply 0-0 Design Wastewater Flow (GPD) uG a Site: New 000' Repair ❑ System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width .V4 "Rock Depth A2 �Linear Ft.(F&40 Other: Required Site Modifications/Conditions: 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.**** F Environmental Health ' S ecialists Signature: /q,/X1. �'�. Date: p gn d'��" O� 99 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street MockrAlle, NC 27028 (336)751-8760 Account #: 990000771 Billed To: Roman Hernandez Reference Name: Elender Johnson Proposed Facility: Residence ATC Number: 2187 Tax PIN/EH #: 5870-147859 Subdivision Info: Location/Address: Galadrin Way -27006 Property Size: 2.91 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 WASTEWATF CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ��� .n / Date: 00P1 *9 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. M Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: "7�:�Z APPLICATION FOR SiTE EVA111ATION/IMPROVEMENT PERMIT & AT Davie County Health Department Environmental Health Section 1 P.O. Box 848/210 Hospital Street Mocksville, HC 27028 (336)751-8760 ***MVCRVJM** THIS APPLICK210H CU= BB PR=58= MMZSS ALL THE REQUIRED INTORMATIOH 18 PROVIDED. Rotor to the INy'ORM1lTION SULLZ21H for instructions. 1. name to be Billed(11Ai�.}'l�i _ Contact D.r.00 rn d o 1 t�—`�?% Nailing Address �[1�ir�n^,n. �.J Au Rose Phone ����te t�,-36 "��1 U -b CA city/state/stv A-,4 C -A- WL -2200L Business Phoneo,� Z. name on permit/M it Dittarent than Lbms Nailing Address City/skate/Sip 3. Application Tor: to Eval tion 0 improvement Permit/ATC Both e. syatea to service: 17 House 'tdobile Home 0 Business O Industry O Other a. st' Residence: 1 People �i ! Bedrooms ! Bathrooms O Dishwasher O Garbage Disposal Washing Nachiae O Basement/plumbing O Basement/No plumbing S. It Business/Industry/other: Specify i people t Sinks i Commodes i showers 4 urinals i bates Coolers Ir rOODSzMC=: ii seats Dstimated Nater Usage tgalme p" day) 7. Type of water supply:*-.ounty/CLty 0 Well 0 Community a. Do you anticipate additions or espauslons of the facWty this system is Intended to serve? 0 Yea o Ifyes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED 41 the client with THIS APPLICATION. Property Dimensions: / ���. WRITE DIRECTIONS (from MockMlle) to PROPERTY: 6TT ani Ta:c mc; .�:t �sg � SBS � — iW �1�Sq .�: m;�f,�,,., � � ��gm��� Property Address: Road Name 66 �V �c Gb -iy ed -rig o L+. 40 LAe►u Ni ��� . ia�� �z— 1 --trr E City/Zip , a `�- �QU c, �i:7.,� ns n A Q. • ..� � � [ma.�a litl • �� .• e If In a Subdivision provide information, as follows: Name: Section: Blockt Lott a-4 Its .40: + (d 1)a_. n rJ RT . Date Property Flagged: This Is to certify that the information provided Is correct to the beat of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, if the site plans or Intended ase change, or If the Information submitted in this application is fabilied or changed I, also, understand that I am responsible for all charges lncarrtd from this appUcatiom I, hereby, give consent to the Authorized Representative of the Davie County Heaith Department to enter upon above described property located in Davie County and owned by to conduct ail testing procedara as necessary to determine the site suitability. MIMIitill I�l� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: EsistingInd proposed property Uses and dimensions, structures, setbacks, and septic locations). --D Revised DCHD (07/99) Site Revisit Charge Date(s): Cilent Notillestlon Date: I EHS: Account No. 72/ o �/ Invoice No. J & U Al 194 5372 p 2 9269 �' X18 IL GnC2 On6 93A 71 r ; o IND XED ON 870.13 OaD TA 2 4838 OnC2 This map is for PERC TEST " and BUILDING PERMIT purposes only. The Davie County J Tax Administrator's Office p assumes no liability for any information contained on this map 1.99A 4725 fb.37AJ 0825 GnB2 COUNTYID:F700000025 September 10, 1999 3:01 PM i " qa, IParcel Identification Number 5870-14-7859 F DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000771 Billed To: Roman Hernandez Reference Name: Elender Johnson Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5870-14-7859 Subdivision Info: Location/Address: Galadrin Way -27006 Property Size: 2.91 Acres Date Evaluated: Pi Water Supply: On -Site Well Landscape position Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 1 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 3 `• Texture groupG Consistence Structure c/i> Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 0"S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: r v___!/ 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 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 ■ ■ ■ ■ MEMO ■■■■M■■■■■ ■■■■M■■■■■ ■■M■M■MEM■ ■N■E■■■MN■ ■■■E■E■E■■ ■■■N■■■■■■ ■■■MME■ME■ ■ENE■■■ME■ MENEMENMEM ■EN■EM■■E■ ■N■MM■■■M■ ■EM■■■ENN■ ■N■■M■■■■■ ■■■■■■■■■■ ■■■■■■O■■■ MEMENMEMEM MENOMMEMEM ■N■ME■■■E■ MEMEMMEMEM ■■MEM■■■■■ ■■■■■■MNE■ ■E■M■MM■■■ ■■■■■■MEN■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ENE■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■O■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■M■■■■■ ■■■■■■M■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■N■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■MR■■■ ■■■N■■■■■"■ss■ ■■■■■■■■WS■■■W ■■■■■MENU■■N■■ ■■■■N■■i■■■■■■ �■■■■■m MEN■■ ■■MMEMM■■■■■■■ ■M■■■UMMEM■■■■ ■■M■■NMENNO■■■ ■■M■■■■bo■■N■■ ■■M■■■■■■NNEEM ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ iii►iiiiiiiiMENNNEMEMNON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■Mrs■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■NNE ■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■ ■�iiM■■■M■■ME■■M■■■ ■■■E■■■M■■ME■■E■O■ ■■MM■■■M■■EM■■ME■■ ■■■ME■O■MEMEM■■ME■ ■E■NEM■■EM■■■■■■E■ ■■■■■MENMENNMEMME■ ■■■■■■■■N■■■■■■■■■ ■"■■MEN■M■■M■■EM■ ■E■M■M■■■■■■ ■E■EM■EMMEM■ ■N■■M■NN■■M■ ■■■E■MEMEM■■ ■ONN■■■■N■■■ ■M■■■■MEME■■ ■E■■■■ENN■■■ ■■MEM■■EEME■ ■■■■■ME■■■■■