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222 McDaniel Rd N j � • . . � DAVIE COUNTY HEALTH DEPARTMENT • Environmental Heaith Section . P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002901 Tax PIN/EH#: 5870-12-6919 Billed To: Michael Campbell Subdivision Info: Reference Name: Location/Address: McDaniel Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3565 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). 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 UCTION IS VALID FOR A PERIOD OF FIVE YE . Environmental Health Specialist's 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. �� ��,-� X���r � Septic System Installed By: � I� � n l` Environmental Health SpecialisYs Signature: �LPi ,� Date: f'�,�`? �� DCHD OS/99(Revised) A r DAVIE COUNTY HEALTH DEPARTMENT �"�""°Q"` �-S� . � . Environmental Health Section � — ✓' �" ' � '' '. P.O.Boa 848/210 Hospital Street ���(,ti� Mocksville,NC 27028 . ' (336)751-8760 • � �--e o� � vv IMPROVEMENT/OPERATION PERMIT . Account #: 990002901 Tax PIN/EH#: 5870-12-6919 Billed To: Michael Campbell Subdivision Info: Reference Name: Location/Address: McDaniel Road-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3565 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 �� #People_� #Bedrooms�_ #Baths_� Dishwasher� Garbage Disposal: �7 Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ ; Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply L7l Design Wastewater Flow(GPD) Site: New❑ Repair❑ , �.K �� � System Specifications: Tank Size/�Qf2 GAL. Pump Tank GAL. Trench Width� Rock Depth � Linear Ft.�� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FiNISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Deparhnent 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)751-87G0.**** � � Environmental Health Specialist's Signature: Date: � b DCHD OS/99(Revised) ��� y �,�=�-- � �/-�� �° �� . .. . � . . : f ' . : . . , . �. . . . . � - . . . . - . A ' . 1'..� . . � . . . . . . . . . . .. ' .. � . . s_" _ _ ___ - • . . � �• ? . . ' . . . . " • � APPUCATION FOR SITE EVALUATION/IMPRUVEh1[NT PLRh11T& � _ � , � Davie County Health Department � � Envrronmenta/Hea/th Section O � P.O. Box 848/210 Hospital Street /� Mocksville, NC 27028 �� (336)751-8760 ��P �� . M . . � . ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�S LL T IR�D INFORMATION IS PROVIDED. Re�er to the INFORMATION DULL�TIN fo r�}} 1. Name to be Billed (�11 C�'lQp �( \_?�A[1�t�Sl `�rt`�(.�'Je.�� Contact Peraon C� ,__._. e.{� Mailing Address _�� �.Q YY� C 1�l� n 12 � ��1�• Home Phone ��l '�C18 ' y �1L^ . City/State/ZIP ���C�� CP , h�C_ �1 00 �o Susiness Phone 33�P '�0-1 2'�2y 2. 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip __ , 3. Application For: C�Site Evaluation F� Tmprovement Permit/ATC {d Both 4. syatem to service: ❑ House ❑ Mobile Iiome ❑ Busine�s ❑ Industry C'}�Other �QY 5. Type system requested: �` Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People o2 11 Bedrooms �� �� Bathrooms a �Dishwasher ❑Garbage Disposal L7Washing Machine ❑Basement/P1umUing ❑Basement/No P1umUing 7. If Business/Industry /Other: verify type �� People 4! Sinks # Commodes $ Showera # Urinals 4k Water Cooler� IF FOODSERVICE: # Seats . Estimated Water Usage (gallons per day) e. 2ype of water supply: I3'County/City ❑ Well ❑ Community 9. no You anticipata additions or expansions of tlic facility tliis systcm is intcndcd to scrvc? �Ycs ❑ Nu If ycs,what type? ***IMPORTANT'k**CLIGNTS t�1UST COMPLETL•THG Ii�QUl/tGD 1'ROPLR'fY 1NG'ORMA'1'ION R['sQUL:S'I'1'sU [3ELOW. Eitl►er a PLAT or SITE PLAN AIUST IlESU13MI7TL•D by tlic clicnt �r�iW 7'FIIS AI'I'LICA7'ION. I'roperty Dimcnsions: �XSc WRl'TL D1RLC7'IONS(from 11-Iocksvillc)lu 1'I20P1'slt'I'1': Tax Officc PIN: # -�jg7p' �Z`(O�''11 � � eh.� MQ�w�'� —� S�'P�^� _ �j�ao �. Property Address: Road Namc M("_�.c�lI� C_,'qllr�h' /�-/ ( �-1 Y�hO.t�.-a�� �.58 City/Zip DI�I,C�,I���G o�7dOCo SO( -�-t.,,.-. („" g���.S�Pf If i�i a Subdivision providc information,as follo�vs: _�> CAu f1C�-.ZG� C� � ��e- ��� Namc: ��_ M��✓�' Gko�O �� SCc C� Scction: Block: : Lot: Datc liomc coriicrs IIagbcd: � � aJ �O �j Tl�is is to ccrtify that thc information providcd is corrcct to tlic best of my kno�vlcdbc. I undcrstaud tliat any permil(s) issucd herealter are subject to suspension or revocatiou,if thc site plans or inteudcd use cliangc,or if llie information submitted in this application is falsificd or clianged. I,also,rrnderstaiid t/iat I un�respu�tsiGle for al!chaib•es i�rcrrrrerl fi•nm this app/icalioii. I,hereby,give cousent to the Authorized Representative of thc Davic County IIcallh llcpartuicnl to cntcr upon aUove described propa•ty locatcd i�i Davic County and o�vucd by __ _ lo conduct all testing procedures as necessary to deteriuine tl�e site suitability. ' DATE__ ��z -�: 2�'� SIGNATUR�_ ���•91•��..,r��F'"��l THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Licludc all of tltc follo�ving: �aisti�ib.uid propused �'+:•. property lincs and dimensions, structures, setbacks, and septIc locations). �� � �e �'r� Sitc ltcvisit Cl�arbc �- - ���-__ /��� ��.,�,,.w..... � �/`y ' Datc(s): �w"^"�^�� � / . Clicnt Notificatioii llatc: G� �i`-� ? y �� �IIS: Sign given • Accow�t No. �`-1 0 � Revised DC D(OS/03 Invoicc Na _-s;z--f--F Z7 " , , \ , ,�..�:. 4 :% ..:, �" � �^,. 2 -"i�. � '�'1 / ' � H. +�'Y��'z � ��'�����O�' � 3 ) �3J a, 11��3 aew�l��l������1. �/%' ���� � 1 ,.ff n��`- ih ,�3��'''�,.# i � ���pi��� .��� / � . � � � "�s e 3a� ��.& �� � 4'. , i�'M3� .�3 �,. 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' � - �� E � IIIIIIII�IIIIiV����ll �� ���� , � �II�4..: `� : � Q i; K1 � �. � � �. , , ' � � ; : � � �, ,.,,i., �„ �,.,< � � „ ,. .: �y � �.,.,, _... � - ..y. . . .,.... , . :` . ...�- i' in '� "� ' ,; , DAVIE COUNTY HEALTH DEPARTMENT � • Environmental Health Section � � " Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002901 Tax PIN/EH#: 5870-12-6919 Billed To: Michael Campbe0 Subdivision Info: � Reference Name: Location/Address: McDaniel Road-27006/ lX� Proposed Facility: Residence Property Size: see map I Date Evaluated: �` /C1� Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring �„� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo % HORIZON I DEPTH 1l � Texture rou Consistence Structure _ Mineralo HORIZON II DEPTH � Texture rou Consistence ✓- Structure l 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: - EVALUATION BY: �J� LONG-TERM ACCEPTANCE RATE: r OTHER(S)PRESENT: REMARKS: LEGEND � LandscaQe 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 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 Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed otes 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 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