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165 Griffith RdDAVIE COUNTY HEALTH DEPARTMENT • • • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002461 Billed To: Roy Walker Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT /, o/ f i Tax PIN/EH #: 5863-55-5436 Subdivision Info: Location/Address: Griffith Road -27006 Property Size: 2 + acres ATC Ngmber: 3287 **NOTE** is Improvement/Operation Permit DOES NOT authorize the construction of septic tank system or any wastewater system. An AUTHORIZATION FOk 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 H #People 1--,� #Bedrooms -,? #Baths !D_` Dishwasher: 21 -, Garbage Disposal: ❑ Washing Machine Basement w/Plumbing:)2ro' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size _ o416 Type Water Supply 46:: / Design Wastewater Flow (GPD) ' 1611) Site: New,21"' Repair ❑ System Specifications: Tank Size/,!UV GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width �/ Rock Depth L Linear FKQr 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.**** sN� gee Environmental Health Specialist's Signature: - Date: DCHD 05/99 (Revised) ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002461 Tax PIN/EH #: 5863-55-5436 Billed To: Roy Walker Subdivision Info: Reference Name: Location/Address: Griffith Road -27006 ATC Number: 3287 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 WASTE WAT CONSTRUCTION IS VAL D FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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. Septic Systen Environmental Health Specialis DCHD 05/99 (Revised) . , APPLICATION FOR SITE EVALUATION/INIPROVBIENT PERMIT & O " Davie County Health Department SEP ' EnWronmenta/Health Section Z 3 P.O. Box 848/210 Hospital Street ? a2 Mocksville, NC 27028 RON Welk(336)751-876.0 � IF�pA1H ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDDED. Refer to the INFORMATION BULLETIN for instructions./, �( 1. Name to be Billed o�/ Al('it ill- ocilk Contact Person �0y Eu4en� G��1K C17�_nC) Mailing Address :)•�{ is ple!4 J'a 1� �d, Home Phone IN, %a g `$75 City/State/ZIP ooiiAl e_ „AIC, 22011 Business PhonPJ4,0.:Xg0-7 2. Name on Permit/ATC if Different than Above SCi'VI'P Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC Both 4. System to Service: souse ❑ Mobile Home Cl Business ❑ Industry 11 Other 5. If Residence: # People �_ # Bedrooms # Bathrooms V Dishwasher I:I Garbage Disposal -r Washing Machine 44-�asement/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 P--geell lJ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes o (ryes, what type? ***IAIP0R7ANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESfEU IIF.LOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client witli THIS APPLICATION. Property Dimensions: Tax Office PIN: A 165 Property Address: Road Name City/Zip A eh ,19 00, If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (fr m Mocksville) to PROPERTY: ® �Gd1 ftp �l. a. z Date Property Flagged: .d 4 P- « r— This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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, unulerstannd that I am responsible for all charges incurred %tont this application. 1, 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 (o conduct all testing procedures as necessary to determine the site suitability. , DATE SIGNATURE 1 THIS ARCA 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 Datc(s)• Client Notification Date: Revised DCHD (07 IJ I�/e--a EHS: Account No. -::>V( Invoice No. 01 / 223 375 3.93A 1536 IQ 12.000A , 3445 B7000 (10.154. co co 5436 5863555436 rsnni 1 312 1 423 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002461 Tax PIN/EH #: 5863-55-5436 Billed To: Roy Walker Subdivision Info: Reference Name: Location/Address: Griffith Road -27006 Proposed Facility: Residence Property Size: 2 + acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring 1, Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH fJ� Texture group Consistence r Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: I LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: 4& Z// 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tt�t■■t■t■■r■■■■t■■■t■■■■etre/■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■■■■■■■■r■■■■■■■■■ ■■■■■ ■err■■■■r■■■■■■■■■■■■■■/■■■■■■■■■■■■■■t■■■■■t■■tt■■■r■tt■ttt■■ttr■ SEMMESiiiiiiiiiiiiiiiiiiiiiiiiiiSEMMESMEMNON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■!::ii■■■■■�:��rrr■■■■■■■■■■■■■■■■/■■■■■ ■■■■/rt■■■■■■■■■■■■■■■■■■■■err■■�■■■■■■■t■r■■/■■■t■■■■t■ert■■tt■■ ■■r■■■■■r■■■r■r■■■■r■■■■■■■■■■■■ ■t■■■■rc■t■■■t■■■■■■■cert■/■r■■■ ■ter■■r■■■■■■■■■■■/■■■■■■■■e■■■■■■■■e■■■■■t■■■■t■■■■r■■■■t■■■r■■■■ ■■■■■■■■■■■■■■■■■■■■■■■err■■■■■■■■■■■■■■■■t■■■tr■■■■■■■tt■■■tt■■■■ ■■t■/■■tet■■■■rrr■■■■■■■■■■■■■■■/■t■■tet■ct■■//■■■■■■■■/■■■■■t■■■■ ■//■/■■■■■■■■■■■t■/■■■■t■■■tr■tt/■■■■■■■■■■■■■/■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■