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123 Kluenie Rd DAVIE COUNTY HEALTH DEPARTMENT • - .., �- Environmental Health Section , P.O.Boa 848/210 Hospital Street . Mocksville,NC 27028 (33G)7S]-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002221 Tax PIN/EH#: 5736-34-9779 Billed To: Michael Hicks Subdivision Info: Reference Name: Location/Address: Kluenie Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3109 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prioi 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 STTE PLANS OR THE INTENDED USE CAANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type /�� #People�'�'. _ #Bedrooms � #Baths�_ Dishwasher� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply f✓L/� Design Wastewater Flow(GPD)��v Site: New� Repair❑ i� �' System Specifications: Tank Size/�Q�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ftoi� Other: Required Site Modifications/Conditions: I1V'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FiLTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis 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(336j751-8760.**** /D''����?f0�. �.1� ` ��� � " . � ► `l '��'Q � �� � :r� . �r�Pi � � Environmental Health Specialist's Signature: Date: �-���— DCHD OS/99(Revised) . . ' DAVIE COUNTY HEALTH DEPARTMENT ' , Environmental Heaith Section � . ` ��,. , P.O.Boz 848/Z10 Hospital Street � Mocksville,NC 27028 ��� � (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002221 Tax PIN/EH#: 5736-34-9779 Billed To: Michael Hicks Subdivision Info: Reference Name: Location/Address: Kluenie Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3109 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AtTfHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance ofa building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE iNTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ,,�� #People� #Bedrooms V� #Baths�_ Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:❑ Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �`/AG Type Water Supply��� Design Wastewater Flow(GPD)_ i����te: New.� Repair❑ System Specifications: Tank Size�AL. Pump Tank GAL. Trench Width��`Rock Depth���Linear Ftm.?P.�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie Count�—� al inspection ofthis 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 instalL� )751-8760.**** ��� �-1 r r Environmental Health Specialist's Signature: Date: �����v DCHD OS/99(Revised) .. • • , DAVIE COUNTY HEALTH DEPARTMENT ��. ' Environmental Heaith Section ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002221 Tax PIN/EH#: 5736-34-9779 Billed To: Michael Hicks Subdivision Info: Reference Name: Location/Address: Kluenie Road-27028 Pro osed Facilit : Residence Pro ert Size: see ma ATC Number: 3109 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /1'��Date: ��^�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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 i be taken as a guarantee that the system will function satisfactorily for any given period oftime. � /Y>t7 � �S� � 3� � ic tem Installed B : � Sept Sys y . Environmental Health Specialist's Signature: Date: ���-� DCI�OS/99(Revised) , � . ' � ` . � , � • � Q � PLICATION FOR SITE EVALUATION/IMPROVEMENT PERM13�C ItTC � � � Davie County Health Department � ,��� Environmenta/Hea/th Section D ���Q 2�2 � P.O. Box 848/210 Hospital Street ������ N�����`j� Mocksville, NC 27028 4�e�� OV�� (336)751-8760 c�v�R ��E� ** 1�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORNATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions. 1. Name to be Billed F�11C-�'11�ef t '. ��C�S Contact Person /�/1�"^E �-//� Mailinq Address '''1 Q �-1�Q Sf'�r��5 �N P Fr.J Aome Phone Q�� •��S� �.,� City/State/ZIP 1"'1d7J1�1(�C.� Business P e 3�10 3YS��Q��O� )Vis�J:�� 2. Name on Permit/ATC if Different than Above � ��o �.- J Z S'3 �4 S��- ��� Mailing ]�dcltess City/State/Zip 3. Application For: ite Evaluation�' ❑ Improvement Permit/ATC �Both 4. system to sezvice: D House �Mobile Home � Business ❑ Industry ❑ Other 5. If Residence: � People � # Bedrooms � # Bathrooms � Dish�►asher ❑ Garbaqe Disposal ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People $ Sinks N Commodes 1k Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Z�pe of water supply: ❑ County/City Well ❑ Community s. Do you Anticipate additions or expansions of the facility this system is intended to serve? �Yes �O If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETH� REQUIRED PROPERTY INFORMATION REQUESTGD BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. Property Dimensions: /�- �� ( ) � �� WRI7'E DIRECfIONS from Mocksville to PROPERTY: Tax Office PI • # �,�3 �d- 3 y I ��� �e�� So�� PAST �E� ��Y�t�S Property Address: Road Name �.O'L`'�-n /`� ' " • c� ('�0�'��• I�T ��� �L' ��a�q�. � c�tyiz�P �"�� � Tp Q�- �n v a�nc:� Kd• (��oJ� lf in a Subdivision provide information,as follows: o( C�"1 f (�,S fi(uEi�l � 1� �J2nj' Name: t �� �� 0!1 ��Jti►�C �n1e1T. }4�� 35 io o�� nt��.bcx� Section: Block: Lot: Date Property Flagged: �— "�-D'- � 2 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 sitc plans or intended use change,or if the information submitted in this application is falsified or changed 1,also,understand that I ain responsible for all cltarges iucrrrred fron: this application. I,hereby,give consent to the Authorized Representative of the Davie County Heaith Dcpartment to enter upon above described property located in Davie County and owned by to conduct all testGn proced res as neccssary to detcrmine thc site suitability.�� ^ DATE— ag �a SIGNATURE ��� 5��..��'�'� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of thc following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). � Sitc Revisit Charge., Date(s): �- Clicnt Notification Datc: EHS: Account No. ��� 1 � Revised DCHD(07/99) Invoice No. � �9 � w - o `� �t�9 �'0 �) L�b�bZ •- �z£ � , � �� os �Z9Z r� �-�- Z �95 R � � �s� (b'�bE'�) 58 �� . �dC _ t � 66L � � _ � � � " 61L6 � �b'L l.' �) N � 65� o oss000000�� i��b88 N o� s<< . . s�s _ zs $6 . ,s ��0 � rn � � �96L J 96�J N �� � o�£ �9< <L (80�) � OLZ8 r . �S 8�� . �� - . � : .. � � S�ZL � �! _- ,- � . � ab�� s • nn i ��� �. . .� • �� � •V ;j,• �,• DAVIE COLTNTY HEALTH DEPARTMENT ' � � Environmental Health Section . Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002221 Tax PIN/EH#: 5736-34-9779 Billed To: Michael Hicks Subdivision Info: Reference Name: Location/Address: Kluenie Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: z�'l�� � Water Supply: On-Site Well Community Public ./ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEP'TH " G�' Texture rou �'i Consistence Structure / Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH ` Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , � SITE CLASSIFICATION: r � EVALUATION BY: � G/ LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Lineaz 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 ois VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 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-gaUday/ft2 DC�ID OS/99(Revised) ■�■��������■■■■■�■�■■��■����■■��■■■�■�e■��■��■����■■�■����������■■ ■�����■����■�■■■���■��■■�■■���■��■■�■�■■�■���■����■■�■■�■���■ ■��■ ■�■e�■■�������e■����■��■������s��■����s�■■���■�■�■��■■���o������■ ■�■���■�������■���■�■��■��■�■�■■ 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