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520 Juney Beauchamp Rd. DAVIE COUNTY HEALTH DEPARTMENT //� _ /� o { Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000764 Tax PIN/EH #: 5861-52-1223 Billed To: James Bailey Subdivision Info: Reference Name: Jeff Bailey Location/Address: Juney Beauchamp Road -27006 Proposed Facility: Residence Property Size: 2.54 Acres **NOTE** This Nprov3ement/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 #People_ #Bedrooms _�� #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine: 2< Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply L'10 Design Wastewater Flow (GPD) C��� Site: New Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank GAL. Trench Width ��4 Rock Depth Id Linear Ft.��� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED El FINISHED GRADE. ****NOTICE: Contact a representative of the Davi system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day c Environmental Health Spec DCHD 05/99 (Revised) ,TER RISER(S) IF 6 K BELOW h Department for final inspection of this Telephone # is (336)751-8760.**** Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000764 Tax PIN/EH #: 5861-52-1223 Billed To: James Bailey Subdivision Info: Reference Name: Jeff Bailey Location/Address: Juney Beauchamp Road -27006 Proposed Facility: Residence Property Size: 2.54 Acres ATC Number: 2321 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: 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. 07 cA"r 0 Septic System Installed By: a Environmental Health Specialist's Signature: Date: P DCHD 05/99 (Revised) APPLICATION FOR WE EVAWATION/IMPROVEMENT PERMIT & ATC Q � � IFTV Davie County Health Department S Enfdnanmentel Health Sa fon L.O. 8dl8/210 Hos tel Street /U % e1 �1�` �G� �ey Peoz Mackavillo, NC 27026 (336) 751-8760 ***nW01RT7INT*** THIS APPLICRTION Calm= BW PR=StIWD muses ALL Tisa REQUIRED IN F4WION IS PROVIDED. Refer to the INrOR1401011 BULLETIN for instructions. 1. Now to be Billed Nailing Address Cttx/state/s:p Z. 3. s. HEALTh rle V % Contact Toon <<o��i'I f L d D Business Phone Nan* on Permit/ATC if Different then Above LO , Waiting Address A ✓ Cit. ip sowers Application fors81te swaluation �Isap ement Persit/l►TC System to services X Bouse 0 Mobile Home 0 Business 0 Industry 0 Other 0 Both s. If Residence: i People E Bedrooms # Bathrooms :>9 Dishwasher a Garbage DisposalKrlaehing Naobine Baaement/Pl:sbing 13 sasemant/No Plussbin 6. If Business/Indnatsy/Other: specify type t# People i sinks # Commodes ; ahowere 4 urinals # Nater Coolers Ir rWD8ERVICZ: () Seats Estimated Water Usage (oanons per day) 7. Type of Mater oupply: County/City 0 Well 0 Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ffio If yes, what type? ***IMPORTANT*** CUENE'S MUSTCOH-Pr-F—M, ra E®F's1�np wn ;+C ; C„ ri u�irG-Rhi/►ION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITIRD by the client with THIS APPLICATION. Property Dimensions: -11 5V 141-6 Tax 0111ce PIN: 5�' / -57:2 Property Address: Road Name - & / Pi914 City/Zip If in a Subdivision provide information, as follows: Name: WRITE DIRE//CnONS (from Mocksv(lle) to PROPERTY: ffST Dom/ ZS7 - .p Ul/Y/e/ ✓ Section: Block: Lots Date Property Flagged: !�2,9 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 I, also, understand that I am responsible for all charges incurred from this appUcadon. % hereby, give consent to the Authorized Representative of the Davie County Health De sa ent 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 -�/,!� "/ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge I Date(s): Client Notification Date: I EAS: Revised DC® (07/99) Account No. 2 ,! Invoice No. '9" 5� (I - ------ INDEXED ON5. 1.16 ees oee GnB2 36 470A A 5T -W 1578 GnB2 A. /MrC2 MrCz 0 INDEXED ON 6861.15 ig w )QL EXED ON 5861.15 QnB2 MrC2 &0, Ale - Pearn PSI 215A This map is for PERC TEST and BUILDING PERMIT purposes 3239 only. The Davie County Tax Administrators Office GnBZ assumes no liability for any information contained an this map 2 IND ED ON6861.19 310 20 Rai 2 V K ChA COUNTY -ID: E70000005201 ChA September 01, 1999 3:55 PM ChA Parcel Identification Number 5861m52-1223 Ms D 1 11 1 APPLICANT INFORMATION Account #: 990000764 Billed To: James Bailey Reference Name: James Bailey Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5861-52-1223 Subdivision Info: Location/Address: Juney Beauchamp R ad -27006 2.54 Acres Date Evaluated: d Property Size On -Site Well Community Auger Boring Pit Public 1/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % L HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 3 Texture group Consistence Structure 5-A !C Alb !' t 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: /05 LONG-TERM ACCEPTANCE RATE: r r REMARKS: EVALUATION BY: ! X�`Z OTHER(S) PRESENT: LEGEND Landscape Position R - Ridge IS - 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■E■■.e�.■■■■■■■Mee.■■■■ ■■eee■■■■■e■..E■■N..N■■.e■■■■■■■■■.■■■■ ■ecce■■eee■MN■■■■■■■■■■e■■.■■■■.■■■■�■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mee■■� ■■■■■■■■ ■ MENEM CMEMEMEMENNENMEMEME ............................... ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■.■.■■■■■■■■■■■■.Ste■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ DAME COUNTYHEALTH DEPARTMENT. - ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09.40-06 Mocksville, NC 27028 Phone #: (336)751-8760 September 21, 1999 Mr. James C. Bailey 1162 Beauchamp Road Advance, NC 27006 Re: Site Evaluation/Juney Beauchamp Road Tax Office PIN: #5861-52-1223 Dear Mr. Bailey: As requested, a representative from this office visited the aforementioned site on September 20, 1999. 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, J&*t re gv4eA - Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s)