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215 Mohegan Trail . l � � - � , DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003731 Tax PIN/EH#: 5754-13-6347 Billed To: Clayton Homes Subdivision Info: Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028 Pro osed Facilit Residence Property Size: 2.529 acres ATC Number: 4204 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. �1 / Environmental Health Specialist's Signature: /` ('��' Date: � CERTIITCATE OF COMPLETION **NOTE** The issuance of this Certificate of Completio s 1 ind'cate the system described on Improvement/Operation Permit has been installed in compliance with Articl 1 of G. Chapter 130A, Section .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY t en as guarantee that the system will function satisfactorily for any given period of time. � � ��) � ��� � C S . � �s, � : : � � Septic System Installed By: r� �C���� Environmental Health Specialist's Signature:�� Date: � ��`� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � "'• '' P.O.Boz 848/210 Hospital Street � 'f- .z(— � S Mocksville,NC 27028 (33G)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990003731 Tax PIN/EH#: 5754-13-6347 Billed To: Clayton Homes Subdivision Info: Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028 Proposed Facility Residence Property Size: 2.529 acres �,T�,�y�ro b�r: 4204 **N �s mprovement/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 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: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size v � Type Water Supply y�� Design Wastewater Flow(GPD)� Site: NewJ� Repair❑ S stem S ecifications: Tank Size �� �� y p ��GAL. Pump Tank GAL. Trench Width�� Rock Depth� Linear Ft�� As stat�d in 9.�vR C��AC 18A.1969(5) Other: ��ccepted Systam� may�iso be used Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROV D EFFLUENT FILTER RISER(S) IF G"BELOW FINISHED CRADE. ****NOTICE: Contact a representative f e avie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m. n e ay of installation. Telephone#is(33C)751-87G0.**** � o� � Environmental Health Specialist's Signature: Date:---�� DCHD OS/99(Revised) r . C , . ..� ��}� � � �..ei'�'�� '�(� 'Y � . • �F'�3 1'��• � � . �rq / � �� V �' tl' � TIUN FOR SITC CVALUATION/L51PIi0VCh1ENT PCRb11T&ATC $ 244�j Davie County Health Department SEP • Environmenta/Hea/t/�Section P.O. Box 848/210 Hospital Street : r�����`���� Mocksville, NC 27026 �. �i;�'��;;���pU��� (336)751-8'160 ' *IFtPORTANT*** THIS APPLICATION CIlNNOT BE PROCESSED UNLESS ALL TIiE RLQUIRED INFOI2bil�TION IS PROVID�D. Refer to the INFOR2SATION BULLETIN for inatruc�iona. r 1. Nama to bc Dilled Ci-J Contact Pcrnon n J�1i"�- Mailing Addrasn l.� KC� � �U v� � lioma Phone �`i' �' �U� l CiCy/stata/ZZP 1 vL Dusine�a Phono V � ��D�"�� 2. Namn on Permit/ATC if DiffQrent tharl Abova � C� I ��� Mailing Addroas ��� N�oh�eaar� � ra�I City/StatQ/Zip ���C�JV� �IG � IvC-, a7oag 3. ApplicaCion For: ❑ Si.te �valuation ❑ Tmprovement Permit/ATC �B th 4. Syalem eo service: O Houae �Mobile Home ❑ IIusines3 ❑ Induutry ❑ Other 5. Typo u}•utom requeatad: MJ Convantional ❑ convantional modified � innovaLivo pacCepted 6. If Ra�idence: IF People 1 # Eiedrooms �_ I� I3athrooms �_ ldDin2iwanhor ❑Oarbago Dinpo�al 4dWashing 24achino ❑Danoment/P1iu�J�ing ❑Uanemont/tto Plun�ing 7. If Duainesa/Induutry /Othar: verify type # Peopla fF Sinka # Commodoa R Showora tf Urinala 1! S•faCor Coolora IF FOODSERVICE: �� Seatu Estimated j4ater Uaaga (gailons per day) a. Typo oi• wator supply: ❑ County/City '�Well ❑ Community s. no you anticipato adQition� or expansions of tl�c facility tliis systcm is iutcndcd to scrvc? C�1'cs [�Yo If��cs,�ti•h1t typc? ***IAIPOItTf1N7't**CLILN'I'S I�tUST COhlPLETETlI� REQUlItED PROPCRTY 1N1�OIt111ATION REQULSTGU [31;i3O�V. �tthcr 1 PI.nT or SITI's PLAN hIU.ST BESUI1dfITTED by tl�c clicnt wilh TIIIS APPLICATION. I'roperty Dimcnsions: ' � ��/ 1VItITC DIRGCT10N5(1'rum 11�locicsvillc)tu I'1tOPLR'I'1': •r:�a orr,�o i�iN: i� �� �'-� � �j ' � ��-� Property Address: Road Namc d��� �� 1Ct,l ���y�Z�n,�o�l���I I� N a7�a g . If in a Subditi�ision providc iuforniatia�,as follotivs: Nainc: � / I � --��_ �-- Scction: Bloclt: Lot: Datc l�onic coriici•s 17aggcd: � o s 'I'l�is is to cci•lify tl�at tlic infoi•iiiation providcd is ca•rcct to tlic best of iu}�l.notivlcdgc. I undcrstaiid tliat any peririil(s) issucd l�crcaftcr are subjcct to suspcnsion or rcvocation,if ttic sitc plans or intcndcd usc chaugc,or if lhc information submicccd in �his applicacion is falsiGcd or changed. I,also,rrndcrstaird tlrrrll�tni resf�onsiGlc fa•n!1 clirubrL'S!/!C!I/'Ycrl frurrr tlris applicntio�r. I,t�crcby,givc consciit to tlic Autt�oi•izcd Itcpresciitati��c of tlic Da��ic Couuty IIcallh llcpai•t�ucnt to ciitcr upoii abovc dcsc�•ibcd property locatcd in Davic County and oiti�ucd by to conduct all tcsting proccdures as ucccssary to dctcrmi»c tlic silc sui Uility. DAT� �7/Lo�D`� SIGNAT'UItl: � TIIIS AR�A 111AY B�US�D I'OR DRAtiYING YOUR SIT�PLAN(I udc all of ilic follo�viiig: Laisting aiid proposcd property li►ics and dimeiisioi�s, uctures, set cics, and septic locations). � ,� oT � � Sitc IZcvisit Cli�rgc � a 8 . D:itc(s): , � � . ��a � Clicut Nolircation Datc: � Z� `f � � �I-IS: / �' , . . _ ' Sign givcn Q� "• �lccouut No. � ��" , ����Rcviscd llCII (OS/03 I�ivoicc No. • • DAVIE COUNTY HEALTH DEPARTMENT . -� ', �• Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003731 Tax PIN/EH#: 5754-13-6347 Billed To: Clayton Homes Subdivision Info: Reference Name: James&Jean Daniel Location/Address: 215 Mohegan Drive-27028 Proposed Facility: Residence Property Size: 2.529 acres Date Evaluated: ��'�fJ�` Water Supply: On-Site Well �r Community Public Evaluation By: Auger Boring Pit Cut^�� FAC'I'ORS 1 2 3 4 5 6 7 Landsca e sition ,L Slope % �/ � HORIZON I DEPTH „"<- . �- Texture grou ' S' ,L Consistence r i� ls/- Structure — � Mineralo ,' HORIZON II DEPTH �' �' Texture rou Consistence � i Structure rl! > Mineralo l' •/ HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTNE HORIZON SAPROLITE r CLASSIFICATION LONG-TERM ACCEPTANCE RATE -+ SITE CLASSIFICATION: EVALUATION BY: �/�// LONG-TERM ACCEPTANCE RATE: f OTHER(S)PRESENT: REMARKS: LEGEND i.�ndc�ca_pe 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 Textur� 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 ONSIST .N . Moic VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic , r> > 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 lY� 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 OS/OS(Revised) ■�������■�■�■�■���■■■■■��������■���■�■■■��\��■����■■■����■■������■ ■�■�■■��■�■�■���■����������■�■■���■��■�������■■����N�■■■■�������■ ■�■■���■■■■��■■��■��■��■�■■■■��■ ■�■���■■�■���■■���II�■■■����■■��■ 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