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2950 Hwy 158 (2)DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street O 3 Mocksville, NC 27028 (336)751-8760 l IMPROVEMENT/OPERATION PERMIT Account #: 990002786 Billed To: Maxie Harrison Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5850-05-6201 B Subdivision Info: Location/Address: Foster Dairy Rd -27028 Property Size: see map ATC Number: 3604 **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 #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 Type Water Supply(Al Design Wastewater Flow (GPD) c�-S I Site: New 0"' Repair ❑ System Specifications: Tank Size &&GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. 11 Trench Width,,9C Rock Depth ZZ Linear Ft. M -R i 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.**** Li � v Environmental Health Specialist's Signature: &W �z Date: DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002786 Tax PIN/EH #: 5850-05-6201 B Billed To: Maxie Harrison Subdivision Info: Reference Name: Location/Address: Foster Dairy Rd -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3604 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 CON,S�TRRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /�/� Date: 1 L -F` 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. 1� C Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: APPLICATION FOR SITE EVALUATION/IiIPROVE-MENT PERMIT & ATC Davie County Health Department EnvironmentaiHeaith Section P.O. Box 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 1_0}x! F3P.)? 1-'1J Contact Person Mailing Address /1�'' „C K1e13/y hk7v'eeJuR �p(y�// MDn/Yvz��' FIomc Phone _60 0 Jam( % 0 City/State/ZIP 0,0 )eVFW &I.e. 2,W3 Business Phone 513rr-1C __ _ 2. Name on Permit/ATC if Different than Mailing Address 3. Application For: 2 Site Evaluation City/State/Zip ^, "� .0 L,[Improveme t Permit/ATC ❑ Both 4. System to service: use ❑ Mobile Home ❑ Business 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ Industry ❑ Other ❑ innovative 6. ,I�,f/Residence: it People It Bedrooms It Bathrooms [O/Dishwasher []Garbage Disposal 2Washing Machine ❑Basement/Pliunbincg ❑basement/No PluLibing 7. If Business/Industry /Other: verify type It People It Sinks It Commodes # Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) __ 8. Type of water supply: VCounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this systeni is intended to serve? ❑ Yes ❑ No If yes, what type? 'IMPORTANT" CLIENTS /BUST COAIPLETCTHE REQUIRED PROPERTY INFORMATION REQ(JESTGD BELOW. Either a PLAT or SITE PLAN A1UST BESU&VITTL•D by the client ii-itli THIS APPLICATION. Property Diensions: � mA C Tax Office PIN: # o - c, S Property Address: Road Naine 4 City/Zip If in a Subdivision provide information, as follows: Nanic: WRITE DIRECTIONS (from Moclavillc) to 1'1t011"RTY: f tD129d X 3 Ty f-/ m i e s Xeo , /2io e b,d l c' — rJ1 l u c/ %S c� %J L),1r D S eIemm —I -T - 3tn5 t iAST Tf`tf"m rnl2%ref �C�— /--z s -der C<o7 Section: Block: Lot:.- Date home corners flagged: 03 This is to certify that the information provided is correct to the best of my knowledge. I understand that any periiiit(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 clianged. I, also, understand that I run responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilea Ith Depar(In elH 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 6-a-6 3 SIGNATURE '-r r-'_ 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 Revised DCHD (05/03 Site Revisit Charge Date(s): Client Notification Date: EIIS: Account No. , y-7 Vo Invoice No. 7"O"AtF_ r G 6775 g'tl l 158 (� t -j (16.48A) 9820 1_I / 1 1►M11 NI 4_ M. DEP4VUVUADEP: • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002786 Tax PIN/EH #: 5850-05-6201 B Billed To: Maxie Harrison Subdivision Info: Reference Name: Location/Address: Foster Dairy Rd -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 6 x�2y Water Supply: Evaluation By: On -Site Well Auger Boring_ Community Pit !/ Public ' Cut FACTORS 1 2 3 4 5 6 7 Landscape position 4— -Slo Slope e % HORIZON I DEPTH Texture group rc Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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: LONG-TERM ACCEPTANCE RATE: 1 0 REMARKS: EVALUATION BY: 4 �' 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) ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 d ... ,.. Phone #, (336)75175760111'. June 20, 2003 Maxie Harrison 6641 Monford Drive Lake Hickory RV Resort Conover, NC 28613 Re: Site Evaluations/ Foster Dairy Road Sites A,B,C, and D Tax Office Pin : #5850-05-6201 Dear Client(s): As requested, a representative from this office visited the aforementioned site on June 20 , 2003. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Ag444 vs. 6;uaA. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df