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252 McAllister Rd DAVIE COUNTY HEALTH DEPARTMENT � ". Environmental Health Section ' P.O.Boz 848/210 Hospital Street nj �1 2�'� � 103 r Mceksville,NC 27028 � ' � (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002593 Tax PIN/EH#: 5728-05-2420 Billed To: Robert DuChemin Subdivision Info: Reference Name: Location/Address: McCallister Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3363 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR T��INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ,��`l #People_� #Bedrooms� #Baths �� Dishwasher: Y Garbage Disposal: ❑ Washing Machine;�� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply �/i// Design Wastewater Flow(GPD) �G� Site: New.� Repair❑ System Specifications: Tank Size��iAL. Pump Tank GAL. Trench Width���Rock Depth��Linear Ft�Q(? Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent 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(336)751-8760.**** � �� Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) / � d'v ' • DAVIE COUNTY HEALTH DEPARTMENT ' � � Environmental Health Section . P.O.Boa 848/210 Hospital Street • Mocksville,NC 27028 (336)751-8760 Account #: 990002593 Tax PIN/EH#: 5728-05-2420 Billed To: Robert DuChemin Subdivision Info: Reference Name: Location/Address: McCallister Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3363 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSLTED 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 CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.. Environmental Health SpecialisYs Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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. !� f � Septic System Installed By: ' � '� Environmental Health SpecialisYs Signature: Date: �ot%'�� DCHD OS/99(Revised) �- . _ � , _ . _ .- ,, � �°�- � � � nn� '�' � /� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER �i c U U � � Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street JAN 3 Q Z003 Mocksville, NC 27028 (336)751-8760 ENVIRONMENTALHEALTH ***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL T INFORI�TION IS PROVIDED. Refer to the INFORI�TION BULLETIN for instructions. '1. Name to be Billed /� Q/3�/1� /� �v �.'�j,C/�/// Contact Person y-� �/o -3d G 6` � Mailing Address ��� Q0/ f �/�/V/C . Home Phone m0 City/state/z=p /yoG�k',f�/��.�i� /✓,G, eL 7�.Z� susiness Phone 2. ttame on Permi.t/ATC if Different than Above Mailiag Address CitY/3tate/2ip �� �� 63 3.: Application For: �CTSite Evaluation B"Improvement Permit/ATC G'doth a. system to servicec � House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People' .�.. � Bedrooms 3 # Bathrooms` � L`f Dishxasher C3�Garbage Disposal �L7 Washing Machine . ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industsy/Other: Specify type �k People 9 3inks + # Commodes N Showers # Urinals � Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gallons per aay) 7. Type of water supply: 0 County/City B�Well ❑ Com�unity a. Do you anticipate additions or cxpansions of the facility this system is intended to serve? ❑Yes �3-1'�0 .� . If yes,what tyPe? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. � Property Dimensions: f �hA� WRITE DIREGTIONS(from Mocksviile)to PROPGRTY: Tax Ot�ice PI1V: #S�?2�=a S=�Z 4�,D fj.� ! r�► '�"a \J �`Y����r-�o� . . . . . . . . . . . � .. . �. . . Property Address: Road Name M� flG�.�sr��p /r'� � �� -{-a /�'`'cC Q �1`�`'�- � � City/Zip l'�.c,rf✓i�c,� 2 7 O� � � l � � � � If in a Subdivision provide information,as follows: �[ �_�` Name: Section: Block: Lot: Date Pro Fla ed. �U Pe1`tY gg • . � � . . . . . . . . . � , . . y�. . . � � . 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 pians or intended use change,or if the information submitted in this application is falsified or changed I,also,undersland t/rat I mn responsible for all clrarges iitcrrrred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health De artment to enter upon above described property located in Davie County and owned by f�?,EG/Nl�'�'��13��,dj,�C��%�� to conduct all testing proccdures as necessary to determine thc site suitability. a DATE SIGNATURE_�I,/����c ��-.--�-� - THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inctude all of the following: Existiag and proposed property lines and dimensions, structures, setbacks, and septic locations). - -------------------_---------- - ` Site Revisit Charge . �-= S'G��„c _ Date(s): t-� ' _ -/� Client Notification Date: �v c�� � �� �,f EHS• R`'_ � - .� � ,�� � � � - .._��0.� ����,. 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I l� ..'3i �„ �„ ,,,; 'w � 4�b�,`'�,�,'J; � ;; .; �a�a € w.wwr �y G�ii�ia'p ., � k�ft �€I E � � e €E€°, "E E€€E( � �'9"1 f"'�+.`"'"",,,� ,:��"' ��� ��5����C€ o��� � w�, . . � • , DAVIE COUNTY HEALTfI DEPART'MENT � • Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002593 Tax PIN/EH#: 5728-05-2420 Billed To: Robert DuChemin Subdivision Info: Reference Name: Location/Address: McCallister Road-27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: ���/�,� 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 % HORIZON I DEPTH �� � Texture rou L C Consistence Structure Mineralo - HORIZON II DEPTH �� �� Texture rou Consistence Structure i< G , Mineralo . •. �, HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON N DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY:T/G�f 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-Tenace 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 firtn 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-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic MineralogX 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) ■�■���������■���■�■■�■�����■■o■■�����■�■��■���■��■�■��■��■�s���■�■ ■■���a��������■�s■�■�����■��■�■��■��������■���■��e��■�■■���■s��■�� ■■������■�■���■�o■�����■��■�■�����■�■��■�o■��■�■■■�■o�■■��������■ ■■��������■����■����■��������■�■ ■�����■����■�■■�■��■�■■�������■■ 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' . � , . ..rn-*r�,.r-`-'9"z"t'-.�•' �,*sq-�-.�. .r� .�, �5:� n .;...r.:gc�r x �,�.r•S'•--3s",,, ---`"+:: `;�s ' �a��� �" ��`- ' I�1��'I�'��'f�Ul�'1�`�:il���il����''1�$`lTlt��'C��;�`�; ..u..�� _;���h�`��r ,.,,....�.�r�. c_ �..,..�..,_..�..,_.d.>......yu�,.�-- ..� ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 , � � �_e.x�� � �w , .�,._ ..1.. ,,.�.. ., ...� ,�. Phone;,#._,.�336)75;�1 8760s..� , ., �...�.� ��.�.�W .A.atiu.�m� � February 3, 2003 Robert R. DuChemin 150 Dot's Lane � Mocksville,NC 27028 Re: Site Evaluation/McCallister Road Tax Office Pin : # 5728-OS-2420 Dear Client(s): • As requested, a representative from this office visited the aforementioned site on February 3, 2003. 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, /�.4��c� "��i' Robert B. Hall, Jr.,R.S. ^ Environmental Health Specialist RH/df