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777 Jack Booe Rd (2)4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 848/210 Hospital Street MocksviIle, NC 27028 NW0UjfVL-7L5"T' l ae� (336)751-8760 Account #: 990001367 Tax PIN/EH #: 5812-37-2689.05 Billed To: Gary Brannon Reference Name: Mackie McDaniel Proposed Facility: Residence ATC Number: 2558 Subdivision Info: % Location/Address: Jack Booe Road -27028 Property Size: see map 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 Treatm t and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRJ4eTr01TjS VAlFOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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. I , ,YOB N„ too /-3(, -71 V, r'M S tj,.) ^ If Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) P, F a4oti 7— Date: 10 12160 DAVIE COUNTY HEALTH DEPARTMENT ? /L '7,`/ -• ' Environmental Health Section C >V 317 ` `"" �' ' • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990001367 Billed To: Gary Brannon Reference Name: Mackie McDaniel Proposed Facility: Residence Tax PIN/EH #: 5812-37-2689.05 Subdivision Info: x„77 7 Location/Address: Jack Booe Road -27028 Property Size: see map **Nibgrriprove5ment/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 (n. 1"I W #People Z #Bedrooms 5 #Baths' 2 Dishwasher: 171" Garbage Disposal: ❑ Washing Machine: li' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water SupplCtj Design Wastewater Flow (GPD) Site: New Ef" Repair ❑ System Specifications: Tank Siz6-0—GAL. Pump Tank GAL. Trench Width tet./ Rock Depth Linear Ft.LW Other: Required Site Modifications/Conditions: .J�+1�Q�.1. (}�l C, �� EP 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 be een 8:30 a.m *^ 9.30 X405?,`• 1 •nn p he day of installation. Telephone # is (336)751-8760.**** lCo� I Cd X5k0"x.4Z., S T Ga ' CPRoi'osi✓D Qavv)t 10 Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLICATION cU1 A TION AOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC ' Davie County Health Department D EnVllnnmentdl Health SL -Won P.O. Box 848/210 Hospital Street f 7 2�dd Macksville, NC 27028 (336) 751-8760. n �intioni KHTAI HEALTH ***Z14PCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE �UIRED I INFORMATION IS /PROVIDED. Refer to the INFORMATION BULLETIN for instructions. G ` 1. Name to be Billed A O � 1' e e. QR'P'0 0f� i p Contact Person � V a. GAS C�i S Pyr)( X Mailing Address Home Phone % 51 - �l � - 1 0 City/state/SIP V V ti lQ Business Phone 2. Name on Persit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation improvement Permit/ATC 0 Both s. system to Service: 0 House 8 ;bile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms_ # Bathrooms �— Dishwasher O Garbage Disposal Zrwashing Machine O Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/other: specify type # People # sinks # Commodes # showers # urinals # Water Coolers IS FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Mater supply: &-county/City 0 Well 0 Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 881 1 X SL� 3L -i Z `i?. p3X (;�31 .WRITE DIRECTIONS (from Mocicsville) to PROPERTY: Tax Office PIN: # 5 � 3 9 a 6 S6 0 S ED 4' 0 1� "-e Rtil C 6t2e'L.N. Na Property Address: Road Name J At_�< ao2 Rnac) -L-.Dta City/Zip I k oC_N4'SvM e nIC n — 2 Ulu a Subdivision provide information, as follows: Name: Section: Block: Lets 1 FL tAc,NAN :7_A,- 326- 731 it),! D Date Property Flagged: R-- 19 - O 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 1, also, understand that I am responsible for all charges Incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to eater upon above described property located in Davie County and owned by �� A, to conduct all testing procedures as necessary to determine the site suitability. DATE k- I / ` Dy 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): Client Notification Date: I EHS• Revised DCHD (07/99) Account No. `P Invoice No. r i -3 IRS 347.03, IRS _ t t7 "I'\ t "I'\ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section APPLICANT INFORMATION Account #: 990001367 Billed To: Gary Brannon Reference Name: Mackie McDaniel Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5812-37-2689.05 Subdivision Info: Location/Address: Jack Booe Road- 0 8 Property Size: see map Date Evaluated: 5 Community Auger Boring Pit f Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position l� Slope % r4 Ll HORIZON I DEPTH O O - l Texture group 'S e -t— S L_ C -t_ Consistence 5 S F S Structure C AUL Mineralogy l :1 1-. L HORIZON II DEPTH I \ - Texture group : C Consistence Structure 13 1e- L 0 Mineralogy i X6► Y ` HORIZON III DEPTH 32 - 3 3 0 - o Texture groupC +- S�p L See Consistence rr S �-r {' r7 5 V Structure k Mineralogy HORIZON IV DEPTH 3 Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P LONG-TERM ACCEPTANCE RATE O - Z J 0,' SITE CLASSIFICATION: EVALUATION BY: �} LONG-TERM ACCEPTANCE RATE: ®� OTHER(S) PRESENT: REMARKS: �?O (y_ `r-0 N �14� YbD r 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 05/99 (Revised) ■M■ee■us■Ee■M■E■M■ ■■MONS ■MMM■■ EE■■M■ ■N■N■■ ■ENN■■ ■E■■■■ ■ IM■M■ ■■■■■■ ■M■■N■ ■MMON■ ■EMNO■ ■MMON■ ■EMN■■ ■EMM■■ ■M■■■■ ■MM■■■ ■EN■E■ ■■■ON■ ■M■■E■ ■EMO■■ ■ENNE■ ■E■■� ■O■■ ■E■■■■ ■■■■■■Mir■■■■M■■ecce■■■■■■■■ ■MN■M■■l1EMMM■■■■■■■■■■■eee■ ■eee■■■NEMN■■■M■■■■■O■■E■■■ ■e■■■■M■►�■■eeeeee■■■■■■■■E■ ■s■■■■■■n■■eeeeee■■.■sa■eee ■M■M■e■■■■■S■■■■■■eee■■■■ll■M■■■■■■■■e■■■■eO■ ■■■■■■■■EOE■■■■■E■■■■eee■■OE■■MON■■■■■■■■■■■�■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■crlr■■■MM■■■■■■■ecce■ ��■■■■■■■■■■■■■■E■■■■■■■■■■One■■■■■■■■ ►��w■■■■■■■■■■■■■e■■■■e■■■■■■��e■■e■Mee■ ■►�■■ecce■■■■■■■■E■■eee■■■■MEMIr■E■■M■■■ ■lie■eee■■■■■■■■Mee■e��e■■■■■■��■■■■■■■■ ■■■■■eee■■■■Mee■■■■■■■■■■eMEM�e■■■■■■■ ■■►�■■■■■■s■■■■■■■■■■■■■E■■■EMM■■M■■■■■ ■■1�■■■eee■■■■■■ ■M■M■■■■Mee■M,�M■■■■■■ ■■�■■■■■■■■■■■■■E��■■■e�MM■c■■11■■■Mee■ ■■■11■■■■!!eeeee■er�il�7a■i ■■■■■l�MeeMee■ ■■elle■eflil�J■■E��i■■■■■■■!!■■eee!■■■■■■■ ■■■\■■■L'iO�:�I�e■■■■■■■■■■■■■■■■\■■eee■ S■OM�:a/■■■■■I.P■■■■■■■■■■■■■■■■It■ecce■ ■E■■:IIS■■Mee■■dLi ■■■SS■■■■■■■■e►rM■■■S■ ■■■�IaSe■■■■■■■■ ■■Mee■■■■■eeeM11■■■■M■ ■■■■�'■■■■eeeee■■■■■■■■■■■■■■■■■ll■Mee■■ ■■■■■■■■■■■■■■eee■■e■■e■■■■■■■■�'■■■■■■ ■■■■■■■■■■■eee■■■■■■■■■■eMee■■■eeeMee■ ■■■■■■■e■■Mee■■■■■■■Mee■■■■■■■■■�■■■■■ ■■■■■■■■■■e■■Mee■■■■■■Mee■■eee■MIS■Mee■ ■■■■■■■■■■■■■■ESE■■■e■■MM■E■■■■■Nee■e■ IMMEMEMMUMMEM '�iMEMNONMENNENIMEMEM ■■eeM■■■M■■M■MM■E■■■■eee■■MEMM■■�■■■■■ ■eee■■NM■■■NMe■■EM■■■M■■e■■eMee■■es■■■ ■■■■eee■■■■■■eM■EMe■■e■■e■■■■e■e■��■■■■ ■■■eee■■■■E■■eMMEM■■MMM■■■■■■■eMM►r■■M■ ■eee■■■■■■■■■■■■■■■■■e■ee■e■■ee■Mn■■■■ ■■■e■■■■■eeeeee■■■■■■■■■■■■e■■■■■Mea■■ ■■eee■■■■e■■■ee■c■■■MMM■■■■■■■MM■■ll■■■ ■NeeM■■■■eeeMee■cMee■■■M■■eee■■■■■��■■■ ■M■■■■■■e■■■M■s ■eMee■■■■■■■■■■■■■■e■ ■■■■■■■eeeeee■M�iM■■M■■MM■■s■■Mee■■�M■ ■■eMee■■■eeee■■■■■■■■■■■MON■■■e■eM■ne■ ■■■eMee■eeeMee■■eeeee■eee■■ae■■a■■■li■■ ■■e■M■N■■eee■■eec■M■■■■■■■■■M■■eee■�■■ ■■■■Mee■eee■■eMee■■■■■■■■eMMM■■e■■■■�■ ■■■eN■■e■■eMM■■1�■e■■s■■■eeee■■■■e■■,�■ ■■■Mee■■■■M■■■■ ■■■e■e■■■M■■■■■■■■■u■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■a■t■M■■■EN■■■IIeeEM■EMM■■ ■■■N■E■■M■■■■■■