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134 Parkway Court Lot 26 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street ' Mocksville,NC 27028 (336)751-8760 Account #: 989900571 IMPROVEMENT/OPERAiFjpff Woo 4§20.41-1803 Billed To: Shuler Building Subdivision Info: North Brook Lot#26 Reference Name: Location/Address: Parkway Court-27028 Proposed Facility: Residence Property Size: 7.8110 acre ATC Number: 2900 **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 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 J Dishwasher:: Garbage Disposal: Washing Machine:Oo" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) -256o!� Site: New O'� Repair❑ System Specifications: Tank Size"GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft Other: Required Site Modifications/Conditions: 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.**** ld we 6 �led e, Environmental Health Specialist's Signature: D� Dater,, DCHD 05/99(Revised) rd � t • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900571 Tax PIN/EH#: 5820-41-1803 Billed To: Shuler Building Subdivision Info: North Brook Lot#26 Reference Name: Location/Address: Parkway Court-27028 Proposed Facility: Residence Property Size: 7.8/10 acre ATC Number: 2900 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS/. Environmental Health Specialist's Signature: Lx'`� Date: oL lJ 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 aarantee that the system will function satisfactorily for any given period of time. �°Z� 4 'w L Septic System Installed By: 44W. - 01 VA,M101 Environmental Health Specialist's Signature: / j,9/�a Date: /Z F69 DCHD 05/99(Revised) M LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department JUN 2001 Environmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer/�to.the INFORMATION BULLETIN foal instructions. 1. Name to be Billed j) Jer , L&%n Contact Person gen p S >Ine'r- Mailing Address Home Phone City/State/ZIPBusiness Phone 9!// 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation V�- provement Permit/ATC ❑ Both 4. System to Service: 8"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: �# People # Bedrooms 3 # Bathrooms f4Dishwasher Q Garbage Disposal fYWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats �/ Estimated Water Usage (gallons per day) 7. Type of water supply: I3 county/City ❑ Well ❑ Community �OU,��o�, idj /!ate�i l7c�.rr lJS� 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes Imo If yes,what type? 'IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �"7%D ! WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # SO c?� 7 ��Q d3 �o�� �0�7� �O.�S��irr , Tom.^•,� Property Address: Road Name j"`�'lC�-�.r C a -'e.1 City/Zip /fr�yL O� /�/7G ia. C:a- If in a Subdivision provide information,as follows: /l iy�4� z rq /4/.fu/ay C_vf- -7RL a Name: ND!'70i16 .r Section: Block: Lot: �_ Date Property Flagged: "o —o7c3 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 plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Day' ounty Health Department to enter upon above described property located in Davie County and owned by. to conduct all testing procedures as necessary to determine the site suitability. DATE W"" SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: 917 7 01) Account No. 5-7/ Revised DCHD(07/99) Invoice No. �� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department Environmental Health Section SEP 1 8 1995 P. O. Box 665 Mocksville, NC 27028 ENVIRONMENTAL DAVIE COUc 1. Application/Permit Requested By ZrI4 4a& Mailing Address xa,.e Na Home Phone !?9,9#7 1 7 Business Phone 2. Name on Permit if Different than Above 3. Applidation/Permit for: IVGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: [P/House _ ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ In Other £1 erl ! El Unknown 5. If house, mobile home:Subdivision w03V Seton Lot#, ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal . . r 6.`If,business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals S No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ErPublic 7. ❑ Private ❑ Community 8. Property Dimensions (� 6keuz/ Sewage Disposal Contractor 7 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation,if site plans or the intended use change. Effective October 1, 1989. Directions to Property: , (J This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATff SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. 1 ❑ 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(12.90) DAVIE COUNTY HEALTH DEPARTMENT ko \ b + Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED j 0 - 0 ADDRESS S� � PROPERTY SIZE �`-01 x 3Q��1 PROPOSED FACIILTY V`% o SQ LOCATION OF SITE 1 Ca— 10�00� Water Supply: On-Site Well _ Community Public Evaluation Bytom Auger Boring Pity Cut FACTORS 1 2 3 4 Landscape position Slope 6 HORIZON I DEPTH 1A It Texture groupl., Consistence Structure MineralogX ' 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 5 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �'S " EVALUATED BY: LONG-TERM ACCEPTANCE RATE: t� 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 :lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vf.--y 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(01-901 MEN 0 MIEN MEMMEMEMEMES no ■.■.■�....■■■■.■....\..i.111■ %.....■■..■.■..0..■■:■■■■■■■■■■■■■O■■ ■....%.....■■.■...■■.■■■.Y.■/I.■1H SEEMS■■■■■■.■.■■...■■■■.■■■■■■■■ ■■..■1\■■...■■■...■...■..■....■■■.■■■■■■■■■■■■■■ ■ �EEEEEOE■■EEE■■■ :.:.:.:.:.:.:.:H::■:■�■..:.:.:.:.:.:.:.:.:.:.:.:■O::.:■:.:.:.:a:::.■....:.:H:�s. ....:..:.:..E.m.m...m.. :EMO: : NuME:/I■■ ■■....��.■■.■.■....■..u..■.■■...■..N■.■■..o■. .■■m MEMM■■■.■r/■� ;�EMEMEN ■■■M.►. _ .......,..................................�.■.... �.■_.. .._.■■► EEM ■..■■■\1■MM■Oc■..■■..■■.■■■..■..■.■■■EEE.E ■O■■■■E No ■■■■I ■■■�%.■■ ■.■...\■.\79x1.O..■■ON..O.■■M.■�...OH■ONMHNNO.M■O. .■■■.■■■ ■:::: \ ■N■ . s■:::'■�'::o■:::■ :H■M �H/1■■■I MEN■.■....■■■■■■..■■■...■■.■■.■■■■■■.■ ■■ Hp� HOO ■■ EAMON ■■MEME : ■■■■■■ ■■■■■. ■E■O■O EE■■.■ ■.■■ .■.■■ ME'E: ■■II■■■ , ■■■EMI."■MMEMMU■■EMME�IMM■ME MEMO ■ ■ ■■■■"■■11■■. ■.■■OE■11■.■■■■■...■■■■■EHE■■■■■■.■■■. 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