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245-247 Knoll Crest Rd DAVIE COUNTY HEALTH DEPARTMENT .•_ � ._ Environmental Health Section • .-�., � ' P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 �� )���`?,'c%J' (336)7.51 87G0 �� �� ��� 1S �� ' IMPROVEMENT/OPERATION PERMIT Account #: 990Q02012 Tax PIN/EH#: 5757-01-2730 Bilied To: Donafd Leonard Subdivision Infa , Reference Name: LocatioNAddress: Knoll Crest Road-27028 Proposed Facility: Residence Property Size: 5 acres ATC Number: 2987 **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 I5 SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT 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� Design Wastewater Flow(GPD)�_ Site: New�Repair❑ System Specifications: Tank Size/��GAL. Pump Tank GAL. Trench Width�' Rock Depth���Linear Ft.3�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMTT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 y of installation. Telephone#is(336)751-87G0.**** f �' � � f Environmental Health Specialist s Signature: % Date: /� ��� 3 "!�I DCHD OS/99(Revised) , ��il.. . ' � �' ' ' . DAVIE COUNTY HEALTH DEPARTMENT ' - � Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002012 • Tax PINlEH#: 5757-01-2730 Billed To: Dona(d Leor�ard Subdivision Info: Reference Name: LocatioNAddress: Knoll Crest Road-27028 P osed Facilit : Residence Property Size: 5 acres ATC Number: 2987 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). 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 WASTEWAT C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: � Date: � ;�'�� CERTIFICATE OF COMPLETION **NOTE** �e issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. � p Y Se tic S stem Installed B : C-�6 �Z�"v P Y Y Environmental Health SpecialisYs Signature: Date: ��-'�'�� DC�ID OS/99(Revised) � �. .,, _��� � Q `f � LICATION FOR SITE EVALUATION/IMPROVEMENT PEfi611T&ATC . � Davie County Health Department OC.� ' 2 2U�� Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTA�HEALTH (336)751-8760 DAVIE CQUN?Y ***IMPORTANT*** TFiIS APPLICATION CANNOT BE PROCESSED UNLESS �ALL THE REQUIRED INFORMATION IS PROVIDED. fer to the INFORI�TION BULLETIN for instructions. � 1. Name to be Billed � � Contact Person ✓ ��� Mailinq Address ��t�/U��/( ��`7� /PG1 �,/ Home Phone ����/�(J" ^'�v V City/State/ZIP f��n �f�(Lr���� /V�� „//Q�C O Business Phone '7 S ,��_/�f- ��� S 2. Name on Pesmit/ATC if Different than Above Mailing Address City/State/2ip 3. Application For: 0 Site Evaluation p Improvement Permit/ATC sth 4. system to sezvice: ❑ House' L�'Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People z # Bedrooms 3 # Bathrooms �_ �hwasher O Garbage Disposal U Washing Machine ❑ Basement/Plumbing II Basement/No Plumbing 6. If Business/Industsy/Other: Specify type # People # Sinks �! Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estiniated Water Usage �gaiions per day) 7. T�pe of water supply: � County/City I��r+Tell l.l Community e. Do you anticipatc additions or expansions of thc facility this systcm is intcndcd to scrvc? ❑ Ycs � lf ycs,what typc? ***IMPORTANT***CLIENTS MUST COd�PLETETHE REQUIRED PROPERTY INrORMATIOIV Ii[:QUESI'CD BELOW. Either a PLAT or SITE PLAN MUSTI3ESU6MI7TED by the clicnt with THiS AI'I'LICATION. F Property Dimcnsions: ��`�� WRITG DIRCCI'(ONS(from Mocksvillc)lo PROPGR'fl': Tax Officc PIN: #�� �� 1 � � � � .�. b d/ �� ��/���ll d 1�'1 �"� Property Address: Road Name (l /l� !�//�/��S � T`Q ��A�/L7� �'� �� /L iV0 l/�/'�,s'� / i . I / J : City/zip D�lC 4 t/j ���/V�,. (�/� k�G� � GI b 70 �/1l�G .�'� �" � r � If in a Subdivision providc information,as follows: ,U� l�� G�f�1�G� l+�!T f �G`'� r Namc: _ J 1� �/��/� �iQ� Scction: Block: Lot: Datc Property Flaggcd: ������o�� This is to ccrtify that thc information providcd is corrcct to thc best of my knowlcdgc. 1 undcrstand thut any permit(s) issucd hcrcaftcr are subjcct to suspcnsion or revocation,if thc sitc plans or intcndcd usc cl�angc,or if thc informalion submitted in this application is falsified or changed I,also,rurderstaud tkat I nut responsiGle jor rr//chcrrges ivairred f'ront 11:is application. l,hereby,give consent to thc Authorizcd Rcprescntative of tl�c Davie County 1-icultl� Dcp.u•tmcnt to enter upon above dcscribed property located in Davic County and owned by to conduct all tcsting p occdures as ncccssary to dctcrminc thc sitc suitability. DATE (U �/ V� SIGNATUR� ����'���� L .• THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of thc following: Existing and proposcd property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Cl�arbc � l Datc(s): �� Clicnt Notification Datc: � EHS: � O Account No. v�/ �` ��. 5 �. � �- 8 � Reviscd DCHD(07/99) ! n"' �3����1�� �w Invoicc No. � �� -ri`^'"�� rti� �� � �� �� �� � �.¢ P ' ' �r.� � �'_ G"�'2' `� r(- .�""`.�- ��.t' �° ./V V • . • : • _` � � �0� ��� � s :���� w z� � . � � � � � - �---� � � r 80�9 '� � w � � . ��``,� �' � \ doo � � ,� � � � _ � � o , o�� � ,� � O�LZ $�� 6899 �c100'� o�� . o� �� EO I. �0000009�1 � 6L� - � ; ��J w , 668L , � � �`d99 0 �) 08� • ;. �� - DAVIE COUNTY HEALTH DEPARTMENT - ' " � ' Environmentoi Health Section ' ' ' '� � � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002012 Tax PIN/EH#: 5757-01-2730 Billed To: Donald Leonard Subdivision Info: Reference Name: LocatioNAddress: Knoll Crest Road-27028 Proposed Facility: Residence Property Size: 5 acres Date Evaluated: 1.3��/_ Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring �� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure - Mineralo HORIZON II DEPTH ' %' 6�' Texture rou Consistence j Structure / Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo • HORIZON IV DEPTH Texture ou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , � SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: 1� 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 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo¢v l:l,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 wemess-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 DCHD OS/99(Revised) ■�������■��■�������■��■■����■���■���■■■���■�����■�■■��■■■�■ f■ ■■ ■����■�����■�■������■����������������■����■■�����■�■��■�■��������■ ■������������■����■�����■��■�0���������■■�������■■�■�■■�����■�■�■ 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