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264 Jesse King Rd DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section ' P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003359 Tax PIN/EH#: 5863-47-5731 Billed To: David O'Brien Subdivision Info: Laurel Brook Lot#3 Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility Residence Property Size: 5.815 acres ATC Number: 3890 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 CONS VO"VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate: 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. ----14 T ►sr S 30 �r ctv �--1>aTC 4 -s'- Septic System Installed By: Environmental Health Specialist's Signature: Date: 0 to DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003359 Tax PIN/EH#: 5863-47-5731 Billed To: David O'Brien Subdivision Info: Laurel Brook Lot#3 Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility Residence Property Size: 5.815 acres ATC Number: 3890 **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 1 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: d Garbage Disposal: 12( Washing Machine:Ir Basement w/Plumbing: 12( Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift � )#�Sjeats Industrial Waste: Lot Size 5.8 AW Type Water Supply 6�� `7 - Design Wastewater Flow(GPD) b o Site: New Ell"Repair 0 " r System Specifications: Tank Size ICCOGAL. Pump Tank GAL. Trench Width 30Rock Depth Linear Ft.i�CV Other: 25?o NDtUlyrl cSIST61`f1WT• r4e I& •'l Roll P=Q TS . Ll �S01�� Required Site Modifications/Conditions:),NS- TALL W (,9,JW0k j_'=@ )0d Q2ar--- OtaAl l r--e Js"ow L*Vj 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 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.**** loot < wZI Lo= � � 1 «'`j�'`� �'q,p.G• SLS .�j tr'iS ��tT S19�tY�� -re��A (C.�QQ _lrod - C sr , u rS 04:;r Ic;C-1 Rte- To Tvb.s-31,1 Environmental Health Specialist's Signature Date: Iwo fT F l'E�1-14rS ( lam(' FOLDCHD 05/99(Revised) Fk-Xl :EMA RESOURC FAX NO. :9193639529 Sep. 17 2004 09:19AM P1 Uep US 04 12:51p devie county envhealth 335 751 07US APPIItATION FOR SITE EVALLATION/IMPRO MENT P(•ERMf'f StATC f�9 xd";re-� Davie County Health Department EVVIM111"Onte/Ht utlfh Section' Q P.O. Box 610/210 Hospital Street �'Gl !�/f�rt,� Mocksville, NC 27028 (336)751-8760 tb -4WV r•*IMPCttTAt1T'•• T&ZS APPLICATI011 CANNor 88 -RocrenD UImEss ALL Txx BEQumD rNFORICATION IS PRDVZD3't. ReEor,•te the I3T>,ORMdTiox BML1:TSrt for inetructittns. 1. Name to bo BLllod O�CLV, l78r leis contact reason G1 lb, (XV4 Or L.or't :tailing bddross J� C�a9tes_ nom* rAoaa City/statefztr k)C- Z-62-5 ausinved Phone I. Have an Petah/ATG if Diffe_oat than Above " (tailing Address __ City:state/zlp i. Applicaticr. For: 13 Sit•:• Evaluat un ❑ Improvement Permit/AT'c isoth a. Byetem to sorvieer YIL Houeie ❑ Hobile ltomo Q Business Ll Industry ❑ Other S. Type nyttats ToQuestedr ❑ canvoational ❑ conventional tsoditted 0 tanovative c. if Raeid•nce. a.People 7 N SeCreotstt i Bathrooms 3 �lDlal:waeAer �OaYJe�i iTi:IpO0a1 $jVes},irfl ttat:taine ®HaatmenC/rlvaLieQ-� ODaNea+.atiAo PSuttDiaq 7. it ausioese/industry /otzrr: .arLey type A PeCD1s 1 9inke It Cetmodoa s Snorers 0 Urt.nals M Water Coolore w" IP r00D813RVZCY2 Soots * Natiaeated NiAter Usage (galieeu per day) e, typo of water '.apply: 0 C;tuaty/city 19 Wall ❑ Comunity s, no you ant:*ipata.aaditron:. or cxpamioas of the fsellity this system is intended to sort?❑YCS a No If yes.what type? N CdVl t l �N1? *-*1MP0RTANT`CLWNTS MUST COMPUrETHE REQUIRED,PROI•ERTY INFORMATION REQUESTCD r 13ELOW. Either a PLAT o1 SITWP�LAN MUST-ry SUBnf/TTED by the dlent with THIS APPLICATION. f Property Dimensions: • g�J��1- E"iV __`_: WRITE DIRECTIONS(from Mocksvlllc)to PROPERTY: Tax Office PIN: o— 3!� 44 "1 .5-7 31 _ -�-o `dot IJ0174A Property Address: Rudd Narne _.ill. - ,•j-1!`' ��II � t— Cltylllp-.;. If in a Subdivision provide infor.-aatfon,as follows: O Section: Mock; _••- Lot: Date hortec eorners flagged: Cl 0 LJ This Is to certify that Elie information provided is eorroet to the beet ofpty knotrledgc. I understand that any pertettf(s) Issued hereafter are subject to sus-,ension or revocation,if tl:e site•plans or fntentlett use thange,or if the Information submitted in that IIpplieation is fae::fied ar ehttngcd..1,alts,rnrdarstond rJrerlaur rrspousiblcfor all charges Ir,trltredJhont flits nppficarforr. I,hereby,give co:;sent to rho Authorized Atpreseutative of the Dpyge Cour.. Hearth Depart eat • Q to enter upon above described pre)erly lorries:in Davit County and owned by ( ['P j� i't► i. (Dd LOYI QUYiC� to conduct all Icstiug proced ures s i ncce-scary to determine the site suitability. DATE -!'l G-D 7 S1 GNATVRE .---s THIS AREA MAY Ilk-USED FOA DRANVING YOUR SITE PLAN(include all of the following: Esistiul:and proposed property Iities.atid ditnctisitiaa. structures, setbacks, attfl septle locations), i FROM :EMA RESOURC FAX NO. :9193639529 Sep. 17 2004 09:20AM P2 T� Date(s): _ Client Notification Date! _ Sien given Account No. Revised DCIID(05/03 l nvoice No. Fk M :EMA RESOURC FAX NO. :9193639529 Sep. 17 2004 09:20AM P3 1 ^ 5.002A j 7403 98 J 203 i ----•-tom., . 5.10AJ B7010B0003 w 1820 N � x'31 �\ � �•\ � • • n . ► 73Q ..` 1 (1.06A) ,,-`- 9462 ,44 5.014A < < 3301 53 DAVIE COUNTY HEALTH DEPARTMENT .l Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003359 Tax PIN/EH#: 5863-47-5731 Billed To: David O'Brien Subdivision Info: Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility: Residence Property Size: 5.815 acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 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: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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)