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144 Hoose Lno DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001156 Billed To: Robert Romanchuk Reference Name: Robert Romanchuk Proposed Facility: Residence Tax PIN/EH M 5747-81-4404 Subdivision Info: Location/Address: Hoose Lane -27028 Property Size: 1.29 Acres ATC NThDb fer: 2423 **NOTE** is mprovement/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 T/ #People 2— #Bedrooms P #Baths Dishwasher: z Garbage Disposal: ❑ Washing Machine: 2100" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 13Lot Size / f/7C Type Water Supply_ Design Wastewater Flow (GPD) 261� Site: New Repair ❑ System Specifications: Tank Size At2XAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth ,Linear Ft. 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 Specialist's Signature: ► Date: j` / 7 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001156 Billed To: Robert Romanchuk Reference Name: Robert Romanchuk vroposea vacuity: rtesiaence ATC Number: 2423 Tax PIN/EH #: 5747-81-4404 Subdivision Info: Location/Address: Hoose Lane -27028 Size: 1.29 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 WASTEWATE ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ,( Environmental Health Specialist's Signature: C/Y Date:,��%`'� CERTIFICATE OF COMPLETION 1bD **NOTE** The issuance of this Certificate of Completion shall in irate dm. ibedouln has been installed in compliance with Article 11 Chapter 130A, Section .1900 " Disposal Systems," but shall in NO W� be en as a gua sys nt given period of time.41 64f I 9� ient/Operation Permit Treatment and satisfactorily for any Septic System Installed By:��G02 L a s.1/m-el Environmental Health Specialist's Signature: / lenle Date: t 6'��,g)d DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & L5@ 8aV 15 Davie County Health Department Enviivnmenta/Health Section MAY — 2 2000 P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ' k66 e 4 Rt-, 1C1 ty�) Contact Person f4 �_¢. Mailing Address ] �� U nd D,V (ASS ICC1, Home Phone s1C( qX -29R-7 City/State/ZIP A'd lI'd ry-:e� pvl(,- bZ`1Business Phone, /(11� ^ c2 �67 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 0 Site Evaluation 0 Improvement Permit/ATC XBoth 4. system to service: 'House ❑ Mobile Home 0 Business 0 Industry 0 Other S. if Residence: # People # Bedrooms #Bathrooms c� _ XDishwasher LI Garbage Disposal AI Washing Machine fl Basement/Plumbing CI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats 7. Type of Water supply: Estimated Water Usage (gallons per day) X County/City 0 Well a. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? 0 Community 0 Yes ?I�No ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: --19J, GtAAC d_ Tax Office PIN: # -As -74 -?`'R I— 4q04 Property Address: Road Name ,[-665Q_ Lak-,2— City/Zip ,-N De <'1 a'?O'ls If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: (001 S -k� le -Aly -ccs, W - Li 11 4 Date Property Flagged: y/%0 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Dvie County Health Depar ent to enter upon above described property located in Davie County and owned by R; yr Lt Z to conduct all testing procedures as necessary to determine the site suitability. DATE 2 60 SIGNATURE �� THIS AREA 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 Date(s): I Client Notification Date: EUS: Revised DCHD (07/99) Account No. Invoice No. 7 1" EIP Bent Gravel Road 30' Easement 31.59' •- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- � •------------------------- P -- RS N 19.45'15"E 242.53' -0 ggbq Part of Tract 1 Existing Iron Drive Shaft Tax Lot 68.01 Tax Map K Billy L Hellard and Wife Stella O.' Hellard DB 125 ® PG 88 M `v Tar. Lot 66.01 4r' Tax Map K-5 o Gerold S. Home: / and Wife Darlene E. Hoc:: DB 138 0 PG 24 ivision of the Charles V. Hoose OG Emily Tr. Hoose Property Tax Lot 66 Tax Map K-5 3p or drawing and any accompanying ants are furnkhrd to the person(s) named and no of'.erations or use by others fitted unless aut�:orized by _and Surveying Co. t for reconlation. n 1:10,000+ Deadmon Road S.R. 1801 1" EIP Bent '--—----- - - - - -- - 30' Easement 31.59' "E 242.53' 1f 1 coon Road S R. 1802 Vicinity Map (Not to Scale) Tax Lot 66.01 Tax Map K-5 Gercld S. Hoose: and Wife Darlene E. Hoc,.i DB 138 ® PG 247 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001156 Tax PIN/EH #: 5747-814404 Billed To: Robert Romanchuk Subdivision Info: Reference Name: Robert Romanchuk Proposed Facility: Residence Water Supply: On -Site Well Location/Address: Hoose Lane -27028 Property Size: 1.29 Acres Date Evaluated: /-�_ Community, Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % ` HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 740 Texture groupL !i Consistence Structure i0 / 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:', EVALUATION BY:Mj LONG-TERM ACCEPTANCE RATE:_ OTHER(S) PRESENT: REMARKS: 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)