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893 Howardtown Rd (2) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000713 Tax PIN/EH#: 5860-70-0600 Billed To: Johnny Robertson Subdivision Info: Reference Name: Johnny Robertson Location/Address: Howardtown Road-27028 Proposed Facility: Residence Property Size: 170 x 200 ATC Number: 2132 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: � 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. G O Septic System Installed By: Environmental Health Specialist's Signature• Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT pd Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 gyp: Ro (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990000713 Tax PIN/EH#: 5860-70-0600 Billed To: Johnny Robertson Subdivision Info: Reference Name: Johnny Robertson Location/Address: Howardtown Road-27028 Proposed Facility: Residence Property Size: 170 x 200 ATC Number: 2132 **NOTE**This Improvement/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 CONTRA/C//TOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 7`t' #People #Bedrooms #Baths e Dishwasher: Ele' Garbage Disposal: ❑ Washing Machine: 2""' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type -;F� #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply��_ Design Wastewater Flow(GPD) Site: New Repair❑ J > System Specifications: Tank SizelQ(h GAL. Pump Tank GAL. Trench Width (2 Rock Depth Linear Ft,)::�P� Other: Required Site Modifications/Conditions: 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.**** did Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPUCA110N FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC R fat 12 a M Davis County Health Department � L� lH l5 U I lJ EnPfmmental/fealth.SeW017 y � �,�� P.O. Box 848/210 Hospital Street 8 l J,G,e �g� Moakaville, HC 27028 (336)751-8760 n� v ENVIRONMENTAL HEALTH ***ZMPORTANT*** THIS APPLICATION CANNOT BE PIW=SSZD UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Hamm to be Billed -r./1 0 AJ`/ /v ,y/} i4�/�SO/Cl Contact Person Mailing Address �� //)IRIA/ V [ Bane Phone City/state/ZIP ��: �. }��I/, � ,�G 1 D�-9 Business Phone Z. Name on Pewit/ATC if Different than Above ' Nailing Address City/state/Zip 3. Application For: U Site Evaluation 0 Improvement Permit/ATC Both +. system to service: 0 House dmobile Home 0 Business 0 Industry 0 Other s. If Residence: # People # Bedrooms # Bathrooms 0 Dishwasher 0 Garbage Disposal /lashing Machine 0 Basement/Plumbing U Basement/No Plummbing 6. If Business/Industry/other: Specify type # People # sinks # Coamodes # Showers # Urinals # Nater Coolers IF FOODSERVICE: 11 Seats Estimated crater Usage (gallons per day) 7. Type of water supply: S'County/City 0 Well 0 Community s. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes B Iqo U yes,what type' 11"IMPORTANT"t CLIENTS 11fUST CODIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PIAN MUST BESUBMITT ED by the client with THIS APPLICATION. Property Dimensions: 2LL� /1 WRITE DIRECTIONS(from MockrAllee)to PROPERTY: Tax Office PIN: # 00--'— (>I��G�t'�U/✓ Property Address: Road Name Ff ff�G1 V�-f/S/d V OVir1t� -e I- Y �(/_V N City/Zip Zia/,J S�i �1✓r��dg ��. YJfIG✓.V If in a Subdivision provide information,as follows: lr i Name: pq Section: Block: _ Lot: Date Property Flagged: 3—JF— This is to certify that the information provided is correct to the best or my knowledge. I understand that tiny permit($) 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,smAnxtand that I am reVonsMlefor all chxges 1nc7ure4from this application. 1,hereby,give consent to the Authorized Representative of the 94vie C unty H t Depprtment 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 .3--g —q / 9 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include al the following: Existing and proposed prope iy lines and dimensions, structures, setbacks, and septic locations). Account No. Revlw6 DCH@(07/98) Invoice Na 41&� w L DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE �c� SUBDIVISION ROAD NAME aim—�le ld h Water Supply: On-Site Well Community Public L/ Evaluation By: Auger Boring t,,-' Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 41�" Texture groupC' C Consistence Structure • - 4' 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: l Arl � P �'`�`J he EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: o ►� Z"e&W brl-j 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(01-90) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■e■■■■■■e■e■■ ■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■��■■■■■■■■■■■■■■■■e■►�■■■■■■■icy■■■■■■■■■■■■■■■■■■■■ MENNENiiiiiiMEMNON MENNENommoiiiiNNEN MENNEN ■■■■■■■■■■■■■■e■■■■e.-_.eee�c:�e■■■e■■■ee■ee■■■e■■ecce■■ee■ee■■ecce SENSE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ecce■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiiii:�:�■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■ ■cccc■■ecccccccccceccecc■ecce■■e■■■■c■■cececcecceececccccceeccece■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■