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730 Howell RdDAVIE COUNTY HETH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street �¢ Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002771 Tax PIN/EH #: 5823-60-8717 Billed To: Evon Crooks Subdivision Info: Reference Name: Location/Address: Howell Road -27028 Proposed Facility: Residence Property Size: 17.41 acres ATC Number: 3476 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 A/ #People S #Bedrooms #Baths Dishwasher: tr Garbage Disposal: ❑ Washing Machine: Rill" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑ LOO System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width—' Rock Depth Linear &-9V--O Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT AYOM FINISHED GRADE. ****NOTICE: Coa arepre: system tween 8:30 a.m t� 0 api. or 1:.m. to 1 i A VED EFFLUENT FILTER RISERS) IF G "BELOW Ie of the Davie County Health Department for final inspection of this p.m. on thhekday, oaf installation. Telephone # is (336)751-8760.**** �j -',P Fs'j- �- per, Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990002771 Billed To: Evon Crooks Reference Name: Proposed Facility: Residence ATC Number: 3476 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section n P. O. Boa 848/210 Hospital Street U` Moclksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5823-60-8717 Subdivision Info: Location/Address: Howell Road -27028 Property Size: 17.41 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �lkll Date: �J CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completi 11 indicate the system described on Improvement/Operation Permit has been installed in compliance with Arti ell f G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WA t en rantee that the sy will function satisfactorily for any given period of time. pl- F--*' -- ^Ir Septic System Installed By: L& P, Environmental Health Specialist's Signature :f lr Date: _4�`�`ZIA DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department �j- Environmenta/Hea/th Section D/ P.O. Box 848/210 Hospital Street I� 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 �y1VA L1 4c 0.0 0 V a 6p— Contact Person _ 6110AI d Je 00/rS_ Mailing Address LHOk%f.�e, Home Phone A? —76S- —, A?4T City/State/ZIP �•��C/�11 V/l �` x209 Business Phone 2. Name on Permit/ATC if Different than Above J14104 Ar A& les Mailing Address City/State/Zip 3. Application For: ite Evaluation Improvement Permit/ATC Both 4. System to service: House Mobile Home Business Industry Other 5. If Residence: # People .r # Bedrooms 5 r # Bathrooms --r Dishwasher Garbage Disposal Washing Machine Basement/Plumbing 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 Well s. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes If yes, what type? Community No '**IMPORTANT*** CLIENTS MUST C0h1PLETE THE REQUIRED PROPERTY INFORMATION REQUESTED 3ELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:f.� ei2U -/�cL At Tax Office PIN: # VIN, p 1 Property Address: Road Name 9004 /90t City/Zip 0/0 rill f ✓/l/G A/ C If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners flagged:. 0`3 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 anz responsible fur all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE xoZ�- oZ00 SIGNATUREy4c,�� 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 Sign given Account No. Revised DCHD (07/99) Invoice No. % ��' ------------------ I - z DAVIE COUNTY HEALTH DEPARTMENT <' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002771 _ Tax PIN/EH #: 5823-60-8717 Billed To: Evon Crooks Subdivision Info: Reference Name: Location/Address: Howell Road -27028 Proposed Facility: Residence Property Size: 17.41 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring c/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position A— F Sloe % 64 HORIZON I DEPTH 1-1 -- a Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 v SITE CLASSIFICATION: EVALUATION BY: Zhd/z 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) a ■ ME No ■■ i ■■■■■■■■E■■■■a■ ■■■■■■■■■■■MENK ■■■■■■■■■■■■■■M ■■■■M■MM■■E■■■■ ■■■MM■M■■■■■■W■ M■M■■M■■■■■N■■■ "M■■■■■■■■■■■■r .990M■■■■■■■■ELIN APR■■■■■■M■■n■ m-■■■■■■N■■M■■ol■ ■■■■N■■■M■■S■■■ ■■■■■M■■■■■■■■■ ■M■MMMM■MM■■MM■ ■E■■■■E■■■E■■ ■■E■■■■■■■■N■ ■■■■■M■■■M■■■ moss■m■■m■■m■ ■■■■■■M■■■■■■ ■■■■EMMME■M■■ ■M■■ME■■MME■■ ■EME■■■E■■■E■ ■M■M■■EM■■MM■ ■■■■m■■■m■mm■ ■■MMEM■MENM■■ iii mom MEN ■■ ■■■■�iE■■■E■■■EE■■■■■■■■■mEMEE■t■■■■■■ ■■■■■t■■t■tE■■sE■■■■■■■■■■■■EMs■■■■Mt■ ■E■■■■■■■ttEE■■■■■■■■■■EmtotEe■■■■■■ ■■■■■■■■t■■■■tE■E■ME■t■■t■■■SM■■EEE■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■■■ Mee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■ ■■■■■■■■e■n■■■tmE■■■■■M■■■■E■E■■■■■■ ■E■t■■■tt■m■■em■■E■■■■■■■■■tot■■■■■■■■ ■■■■■■■■■■■■■■■■■e■eeee■■■■■eeee■eeee■ ■eeEl�■■tese■sE■■■■■■seE■e■■■■■■■■tot■ ■■■■ ■■■aMN■■So■■■■■■■■■est■■■■■■■■■■ ■■■■Nee■N■SN■■■Mee■ecce■■e■■Mee■■eee■■ ■■■■■■.....■■,�■eeeee■■■■■Mee■eeee■■■e■ ■■■■■■■■■■■S■■■■■■■■E■■■■■Emmettt■■■ ■■M■ ■■M■ NONE MEMO ■E■■ NONE ■■N■ ONES ■E■■ ■■■■■E■■■VION ■■■■■■■■■NI■■ ROME iiiiii■■■■■■ ■■M■■■■■■■■■ ■NFEREE■■■M■ ■MIS=MMMM■MM■ ■NII■■■■■■■■■ ■SOMME■■EM■■ ■■■■■■■■■■ ■■■■■■■ ■■■E■■■ ■EEE■■■ ME No ■■ ■■