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455 Merrells Lake Rd . . ~ • . DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 � �� l'yle%�/S ��e Account #: 990003509 Tax PIN/EH#: 5768-53-5815 Billed To: Sheila Stone Subdivision Info: Reference Name: Location/Address: Merrells Lake Road-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 4005 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS. ,_--- Environmental Health SpecialisYs Signature: Date: � �Y -� 2 �4d s CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of . hapter 130A, Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be ta a guarantee that the system will function satisfactorily for any given period of time. � ��? � � � r ' " � C 4 � / Septic System Installed By: � l 1/ Environmental Health Specialist's Signature: , �/ Dat � DCHD OS/99(Revised) ' DAVIE COUNTY HEALTH DEPARTMENT i . � , . Environmental Health Section 3y yl�,s. ,, P.O.Boz 848/210 Hospital Street ��� Mocksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003509 Tax PIN/EH#: 5768-53-5815 Billed To: Sheila Stone Subdivision Info: Reference Name: Location/Address: Merrells Lake Road-27028 Proposed Facility Residence Property Size: 3/4 acre ATC Number: 4005 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 ,m`/ #People '� #Bedrooms�_ #Baths `'S� 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 �b Design Wastewater Flow(GPD)12�� Site: New� Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width����Rock Depth�U Linear Ft ,!`�� Other: Required Site Modifications/Conditions: I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Cont ct a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:0 p m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.**** /S� �s� � 4 �� .-�"✓. Environmental Health Specialist's Signature: Date:��1��Lr�?_S DCHD OS/99(Revised) � p � c� � a a �P ION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Environmenta/Hea/th Section �EB 2 2 200� P.o. BoX sas/2io Hospital Street Mocksville, NC 27028 QJYIROii2�9EM{`,LHf1,IJi{ (336)751-8760 ICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BiTLLET2N for instructions. � 1. Name to be Billed � �' =� Contact Peraon ����5 �� �e���—S�C1N� Mailing Address / Homa hona_��C% ! �O �� �J��/ City/State/ZIP �, � . � E��e�hone �3� �/�/'—�D 7 ,L 2. Name on Permit/ATC if Different than Above ,�j� � Mailin Address �/� J � ' City/State/Zip „ �jt d� 3. Application For: Site Evaluatioz}, l�'Improvement Permit/ATC , �Both ��r.G[�t.c.. 4. syatem to service: ❑ House Mobile Home ❑ Business � Industry ❑ Other 5. 1�pe aystem requested: �Conventional ❑ convantional modified ❑ innovative e. if Residence: # People � # Bedrooms �,_ # Bathrooms � ❑Diahwasher ❑Garbaga Diaposal �Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Susinesa/Industry /Othar: veriPy type # People # Sinks # Couunodes � # Showera / # Urinals _[�� # Water Coolers`-� IF FOODSERVICE: # Seats Estimated Water Usage (gailona per day) 8. Type of water supply: � County/City ❑ W811 0 Community 9. no You anticipate additiona or expansions of the facility this system is intended to scrve? ❑Yes �io I[ycs,what typc? ***IMPORTANT�**CLIGNTS MUST COdIPLETE TIIG R�QUIRED PROPGRTY INfORMATION ItEQUESTED BELOW. Eithcr a PLAT or S1TE PLAN MUSTBESUB1117TTED by tlic clicnt with THIS APPLICATION. Property Dimensions: �`� Q�Cn.P� WRITE DIRECTIONS(from Mocicsville)to PROPGRTY: � Tax Officc PIN: # '� ! � �`�� �C� � � �L� [� n � ��"Y� Property Address: Road Name .f�.1Ul X X, riv�K.P � � � � A, , 1 J �� � -- � /�' City/Zip `���.�_� �-�_�2�`� O��c� L �� �Y� 4 ^ Q � If in a Subdivision provide information,as follo�vs: '� ��-�C L�D Name: . ` �D�.L'`z4ti� � �� a 2 Section: Block: Lot: Date home corners ilagged: , � � � 5 Tl�is is to ccrtify ti�at tl�e information provided is correct to tlie best of my knowledgc. I underst�nd tliat any permit(s) issued I�creafter are subject to suspension or revocation,if tlie site plans or intended usc cliange,or if tl�e information submitted in this application is falsi�ed or changed. I,nlso,trndersta��d thnt I nm responsiG/e for a/l clrarges incrrrred jroni t/ris applicalion. I,liereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above dcscribed property located in Davie County and o�vned by to conduct all testing procedures as necessary to determine the site suitability. � DATE ��'l�'Z'c �, � , , i , THIS A1t�A MAY B�USED FOR DRAWIN de all of tlie following: Existing and proposed property lincs and dimensions, structures, setb cks, and septic locations). Sitc Rcvisit Cliarge �� Datc(s): Client Notification Date: jo . EHS: Sign given � " Account No. '�� Revised DCH (05/03 Invoice No. L' O ! ` �i �� �9A�, �' � . ,� @ '� il .�" nz � � � � � �879��: �� f a/ 'I . . _. 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Proposed Facility: Residence - Property Size: 3/4 acre Date Evalu�ted: ����� Water Supply: On-Site Well Community Public 1/ Evaluation By: Auger Boring`�_ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L ' Slo e% �b HORIZON I DEPTH �� y<' Texture rou CfC L -S " Consistence r Swcture r Mineralo � /,- HORIZON II DEPTH �. �� Texture rou G l% Consistence - Swcture /�— Mineralo HORIZON III DEPTH � � � � Texture rou Consistence SWcture Mineralo HORIZON iV DEI'TH Tcxture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HOKIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �� EVALUATION BY: ` LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: REMARKS: LEGEND � Landscapc 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 Tc_ xture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy day loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE ois VFR-Very friable FR-Friable FI-Firm VFI-Very�rm EFI-Extrcmely 6rm .Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky � � NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic trctr 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo� 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restricdve 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 suitabte),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 , DCHD OS/99(Reviscd) . , r. . . -' .��,������,s � �w�r � -- -�-� `� ' �s., , �� ' � ���� �� - . �J'l t� a r f ��