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203 Kayla TrailAccount #: 989900612 Billed To: Edwin Newsom Reference Name: Edwin Newsom Proposed Facility: Residence ATC Number: 2086 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5833-43-0497 Subdivision Info: Location/Address: Kayla Trail -27028 Property Size: 850 x 410 **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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type t' 00SE-- #People Ll #Bedrooms 3 #Baths Z Dishwasher: 15"-- Garbage Disposal: ❑ Washing Machine: Eff Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size AGQ.� Type Water Supply Design Wastewater Flow (GPD) '3G -XD Site: New [2 Repair ❑ System Specifications: Tank Size ICIDC AL. Pump Tank GAL. Trench Width —:3U" Rock Depth I2'' Linear FtLo(D& Other: `5�11�T10^)LA JAS uired Site Modifications/Conditions: �N'�T� Oji �',�� io. (.i►.ir fJ(I J=2tSlo� PROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW �JFTNISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of thistem 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.**** t -v: 1 Dl V �2'T SJ t2F wA�-ti7,2-10, Paas. Pour 120' x-3co'x-�2" y 12 �2+=�.9Cr�1tor� 3tP I �> V3% I o� 0t2 C-�Co9 °- > sent I Environmental Health Specialist's Sign tore: G-- Date: DCHD 05/99 (Revised) !1 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900612 Tax PIN/EH #: 5833-43-0497 Billed To: Edwin Newsom Subdivision Info: Reference Name: Edwin Newsom Location/Address: Kayla Trail -27028 Proposed Facility: Residence Property Size: 850 x 410 ATC Number. 2086 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 C UCTIO IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature Date: 7,?J,::2q 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. !3p' 1�1 o' o -RT � Septic System Installed By: Environmental Health Specialist's Signa re : Date: Q DCHD 05/99 (Revised) APPUCAnON FOR 611E EVAWAHON/IMPROVEMENT PERMIT do Davie County Health Department Envimnmental Health SaWon P.O. Box 848/210 Hospital Street 10 M Mockaville, NC 27028 (336) 751-8760ENVIRONMENTAL HEALTH DA 1E `t**2WCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED IT.'XORIATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Rama to be Billed i�d W; n /,J tw5byy-) Contact Person 8J win ori ane U . -bro- Mailing Address<:? 0-3 K 0.V 1 o— 1 r -Ga 1 (� name Phone J --3t(, - " 44 � � 4Z0/- / City/state/ZIP 1 1 racks � l U AX,�,�0� D Business Phone I `1 �' (.0 a00 2. Name on Permit/A1C if Different than Above Mailing Address City/state/Lip 3. Application For: U Site Evaluation ❑ Improvement Permit/ATC-yftBoth 4. system to service: X House 0 Mobile Home 0 Business 0 Industry ❑ Other a. If Residence: # People 4 # Bedrooms 3 # Bathrooms � *KDishwasher 17 Garbage Disposal Washing Machine 13 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/industry/Other: Specify type # People # Sinks # Coamodes # Showers # urinals # Nater Coolers IF FOODSERVICE: Seats Estimated slater Usage (gallons per day) 7. Type of Nater supply: 0 County/City JK Well 0 Community S. Do you anticipate additions or expansions of the faciaity this system is Intended to serve? 0 Yes 00 If yes, what type? ***IMP0RTAN7*** CLIENTS A1USTC0JfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PLAN MUST BESUBb11TTED by the client with THS APPLICATION. Property Dimensions: ,& SD X 4l d Tax Offiee PIN: # 57-3-3- q 3- O y q -1 Property Address: Road Name �lQ.-7TYc=11 City/Zip �noaSoiVIL If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from MocksAlle) to PROPERTY: 1 QNra-h -Vo Cc�no, 9-J !�I gh-1' on C04101 gd - Ciro 5S SO l orrb 'i�r,t� R& , Civ Rig4+ on 4'PinO. Go AID RUalrr4 flu Ka+.iln�rG1�. �f�a�ri �5 o�n-2-�-I-• Date Property Flagged: l.er 3- 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 ra ponsible for all charges incurred from this application. I, hereby, give consent to ths: Authorized > eOvesen!2tive c! the Davie C -.:u ; Hexhb ;Verpr, to enter upon above described property located in Davie County and owned by t= d wi n Q. to conduct all testing procedures as necessary to determine the site suitability. DATE ��y� SIGNATURES„ ��• — 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). lti 1'0 `Y Revised DCHD (07/98) Account No. r� Invoice No. 781 I r� This map is for PERC TEST and BUILDING PERMIT purposes only. The Davie County Tax Administrator's Office assumes no liability for any information contained on this map COUNTY -ID: C400000040 June 02,199911:47 AM Parcel Identification Number 5833-43-0497 4 w APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Account #: 989900612 Billed To: Edwin Newsom Reference Name: Edwin Newsom Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5833-43-0497 Subdivision Info: Location/Address: Kayla Trail -27028 Property Size: 850 x 410 Date Evaluated: '� 1 Water Supply: On -Site Well t/ Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: Ps 7DOC O Aa v� T EVALUATION BY: M mpp LONG-TERM AC PTANCE RATE: Of OTHER(S) PRESENT: ►fr q REMARKS: •'Jl� y LEGEND _1 Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope p �� CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope N v'`� Po a 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 ois VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm "No � NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic u ture I SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky �� g e < SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Nqte5 4s, 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 1JCHb (Revised 05/99) L—andsic—ape position— Consistence s• MUM EM1`aW������� HORIZON 11 DEPTH • r►►.�nr�r.��nr:�r�rr�■i����� Mineralogy HORIZON III DEPTH Consistence Structure Mineralogy Texture group Consistence ����e������■a Structure Mineralogy SAPROLITE CLASSIFICATION SITE CLASSIFICATION: Ps 7DOC O Aa v� T EVALUATION BY: M mpp LONG-TERM AC PTANCE RATE: Of OTHER(S) PRESENT: ►fr q REMARKS: •'Jl� y LEGEND _1 Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope p �� CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope N v'`� Po a 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 ois VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm "No � NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic u ture I SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky �� g e < SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Nqte5 4s, 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 - 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