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181 Hartley Rd• • ` : DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001089 Billed To: James Ward Reference Name: ATC Number: 4373 Tax PIN/EH #: 5755-87-6897 Subdivision Info: Location/Address: Hartley Road -27028 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 WASTEWAMTRUCTION IS VALID FOR A PERIOD OF FIVE YE/� 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 System Installed By: Environmental Health Specialist's Signature Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • ` ' ' . P. O. Boz 848/210 Hospital Street t Mocksville, NC 27028 (P (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990001089 Billed To: James Ward Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5755-87-6897 Subdivision Info: Location/Address: Hartley Road -27028. Property Size: see map **NO lQ'r lhmt�er: 43,73 is mprovemeut/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: FeK Garbage Disposal: ❑ Washing Machine: ET" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size lee Type Water Supply e 1/ Design Wastewater Flow (GPD) 3e'Site: New ❑ Repair ❑ System Specifications: Tank Size %DDOGAL. Pump Tank GAL. Trench Width JV 'elRock Depth � Linear Ft3'0y/ Other: As stated in 15A NCAC i8A Required Site Modifications/Conditions: aceentAd a„�. _ _ 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.**** Environmental Health',gpecialist's DCHD 05/99 (Revised) Date: (- I' -'P6 SITE EVALUATION/IMPROVEMENT PERMIT & ATC :Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751=8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) �,e YBoth ***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 _0,-9MES lA%R I) Contact Person 5,41)2,E- Billing ,41%7,Billing Address 16?/ /21MrLE y " Home Phone ' City/State/ZIP MoCk V i ffi 17C 2702,8 Business Phone 73 3.0 776 - 95 -65 - Name on Permit/ATC if Different than Above Mailing Address /-91l��R%)/ R C PROPERTY INFORMATION v d`IYW�S 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.) Street Address /Y,b City M6,Cklyllle Tax PIN# Subdivision Name Section/Lot# Lot Size Directions To Site: Aa I Seu7 & fBEL& 7$tii/,✓ ,v oM L 4&7* 4, Date House/Facility Corners Flagged 3 Z/AZ- 1046 If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes J$No Does the site contain jurisdictional wetlands? ❑Yes XNo Are there any easements or right-of-ways on the site? ❑Yes XNo Is the site subject to approval by another public agency? ❑Yes KNo Will wastewater other than domestic sewage be generated? ❑Yes lNo IF RESIDENCE FILL OUT THE BOX BELOW e /A # People 3 # Bedrooms _ 3 # Bathrooms 2 Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes Wo Basement Plumbing: ❑Yes l<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: XConventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑ County/City Water , ❑ New Well VExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes DiNo 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(s) or 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 d termine compliance with applicable laws and rules on the above described property located in Davie County and owned by Z?ZF-S 604)gly 6rope owner's or owner'slegal represe tive signature A-0 4 D e Sign givenes ❑No pf rJ Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # % Invoice # 308 (3.56A) 8930 8641 \ (20B) (4.90A) 0332 176 (9.70A) 2834 M600000056 0 .111111:1 B3 396 �o (7.85A) 6897 M 5574` N 204 L--L-21W Z OD J w w 0 (9.07A) 0864 (9.04A) 4824 (14.70A) 7023 DAVIE COUNTY HEALTH DEPARTMENT k Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001089 Tax PIN/EH #: 5755-87-6897 Billed To: James Ward Subdivision Info: Reference Name: Location/Address: Hartley Road-27Q2,8.j Proposed Facility: Residence Property Size: see map Date Evaluated: /Df 0g� Water Supply: Evaluation By: On -Site Well Community Auger Boringy Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture groupL Consistence Structure e/' r - Mineralogy r- ( lJ ` HORIZON H DEPTH " Texture group Consistence Structure c�A K b- Mineralogyi HORIZON III DEPTH ` Texture group Consistence j,,//Ll Structure Mineralogy X' i' HORIZON IV DEPTH . Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION - LONG -TERM ACCEPTANCE RATE r SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: l REMARKS: EVALUATION BY: //%,d 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 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 Nato 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) 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 11; 2006` Mr. James Ward 181 Hartley Road Mocksville, NC 27028 Re: Hartley.Road Tax Pin #: 5755-87-6897 Dear Mr. Ward, As requested, a representative from this office visited the above site April 10, 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 f System To Serve: Ael/ Wastewater Design Flow: System Type: ❑Conventional /Accepted ❑-Innovative ❑Alternative ❑Other System Location: rllP, A " Valid: Years ❑No Expiration Site Modifications/Permit Conditions: Environmental Health Speciali Date ps-i.p.letter 2/06