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232 Beauchamp Rd Lot 1 � a APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Application For:Asite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION i L Name to be Billed 041,t -� fvi'--�ontact Person (SIL Billing Address 4 1-90 LL Je Home Phone O — S l� City/State/ZIP fin,&jC6! 7,7tO 0& Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan /Plat(to scale) (Permit is valid for 60 n1priths with site plan,no expiration with complete plat.) Owners Name OGILPhone Iyulnber Owner's Address City/State/Zip ( A44 ee- /y K--C-7--04 P,6 Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) I]Weg 7 axS Section/Lot# Directions To Site: r v 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 VNO Does the site contain jurisdictional wetlands? El Yes INo Are there any easements or right-of-ways ori the site? ❑Yes tNo Is the site subject to approval by another public agency? ❑Yes ZNo Will wastewater otli ratan domestic sewage be generated? ❑Yes No IF RESIDEN E FILL OUT-'THE BOX B OW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No 1;"WINON-RESIDENCE FILL OUT THE BOX BELOW f 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 s y-stern requested: eats-Typesystemrequested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O No 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakin a house/facility to ion,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative si ture Date(s): q`lvw-or Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLA?A- M t I 39F(919M SW M Tax PIN/EH#: 587B��T�INFORMATION Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan,Lot#1= Reference Name: Location/Address: Beauchamp Rd-27006 Proposed Facility:. Residence Property Size: 2.966 acres Date Evaluated: 'S-2-0S Water Supply: On-Site Well Community Vvy Public Evaluation By: Auger Boring Pit- v Cut FACTORS 1 2 3 4 5 6 7 Landscape position Ir IV Slope % , HORIZON I DEPTHp-- Texture group C_ Consistence __L Structure (� Mineralogy HORIZON H DEPTH G 0 , Texture group Consistence Structure S Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION p S LONG-TERM ACCEPTANCE RATE vZ 'LSI Z15 SITE CLASSIFICATION: ?`S EVALUATION BYe"ZkeD �1J LONG-TERM ACCEPTANCE RATE: „?��tOTHER(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 ,CONSISUNC , 1?I41S1i 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 tes 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 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account M 990005064 Tax PIN/EH M 5870-65-2977.01 Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan Lot# 1 Address: 130 Oakhill Road Location/Address: Beauchamp Rd-27006 City: Advance Property Size: see map Reference Name: Proposed Facility: Residence **NOTE**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,plat or the intended use change. Permit Type: ew ❑Repair ❑Expansion Permit Valid for: 05Years 3110'-Expiration Residential Specifications: #Bedrooms#Bathrooms—a#People Lf Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 4-90 Type of Water Supply: ounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1969(5)_-wed SyGtoma may also be use System Type LTAR Initial Repair , Site Plan ` nt� S � � a N �c 2 Environmental Health Specialist Date 0 W i.p.l l-06