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1733 Peoples Creek Rd (2)�Tu Account #: 989900611 Billed To: Jeff Jones Reference Name: Jeff Jones Proposed Facility: Residence ATC Number: 2084 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5880-30-8385 Subdivision Info: Location/Address: Peoples Creek Road -27006 Property Size: 375 x 402 **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 11605E #People #Bedrooms #Baths o�• 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 Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size%GAL. Pump ank /OOOGAL. Trench Width "` Rock Depth 1� Linear Ft. Other: Required Site Modifications/Conditions://:2n!AU�57y 'lIw 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.**** �: �T�Dd�ln[S � �.ri�gll� jiffs i� AA T X, ap�n�i°niA� q� 4D 4 Environmental Health Specialist's Signature: " DCHD 05/99 (Revised) 3--13oX LARGE Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900611 Tax PIN/EH #: 5880-30-8385 Billed To: Jeff Jones Subdivision Info: Reference Name: Jeff Jones Location/Address: Peoples Creek Road -27006 Proposed Facility: Residence Property Size: 375 x 402 ATC Number: 2084 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: 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 a guarantee that the system will function satisfactorily for any given period of time. I CZ l Septic System Installed By:� Environmental Health Specialist's Signature : Date: DCHD 05/99 (Revised) 1. 2. APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A Davie County Health Department d EnvfMimental Health Section P.O. Box 848/210 Hospital Street JUN 10 1999 Mockaville, NC 27028 (336)751-8760 ***ZMPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL INFORMATION IS PROVIDED. Refer to the INFORMATION BULL$TIN for instructions. Name to be Billed &Y-0 Contact Person Nailing Address Lg-tl �C 5 ��� -� Home Phone �7 % ELL 0 �Cl ("'s City/State/ZIP — J L �� Business Phone / .2-`7 7 / Name on Permit/ASC if Different than Above /1SCi Nailing Address 3. Application For: Site Evaluation City/State/Lip 0 Improvement Permit/ATC Both 4.•at _= so. 4 NIQb4Z u noniie Home 0 Business� / 0 Industry 0 Other is If Residence: # People _/ # Bedrooms T # Bathrooms a) 4-% V/Dishwasher ei arbage Disposal D stashing Machine 13Basement/Plumbing 0 Basement/no Plumbing 6. If Business/Indastry/other: Specify type # People # Sinks # Conmodes # Showers # Urinals # Nater Coolers IF FOODSERVICE: # seats �� Estimated Water Usage (gallons per day) 7. 7"m of water supply: IS County/City 0 Well 0 Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes BTIo If yes, what type! ***IMPORTANT*** CLIENTS A1UST COIIIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 39 S X LS 0 D, fax Ullice PIN: # .5-yeo-3 b- F3K5— Property Address: Road NamegeoQ —'5 �f-4-J4 City/Zip MVUAP—Q, �,-706(- If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Moclevllle) to PROPERTY: (� -6S ��(-�S - QeoQI� eSC��e(� Date Property Flagged: S -a S —59 This is to certify that the information provided Is correct to the best or my knowledge. 1 understand that any permits) 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 front this application. ii, hereby, give consent to the Authorized Representative of the Davie County Health Department to utter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE �' _ _ SIGNATtURR _ LA THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all ttf the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. all, Invoice No. s--� TCS �' �' >�'08� :fir - - 2.•i4�3`« $5 . a 8�� ` e4 3 E r L• two 0 4.7 $8' 16. P.A s5 40E .� r \ � 13 L6 2 =2G 141.5'7 cM ' t � SIGMT QprtC ; �. UD 6 i x.53 +4c..* -C, \ - -7- 4- P4 4-4f."7 CERTIPICATE OF OWERs,4 'Mte horeby certify that property shownnd ad*z. F►or.by n4*Vt thiel F1.4 A -rrst consent, sstatbliat Anel a*diaat• all stress snd othor sites. rurtti . hu" F *r*M is Mitten 4f bovie Cownty. . 40 Dive •{ t.l �• }�+1. � 11.i•1G, MGn�r S , to ,• UtJLdL.S JVA"t'Cb r .A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation "PLICA -NT INFORMATION PROPERTY INFORMATION Account #: 989900611 Tax PIN/EH #: 5880-30-8385 Billed To: Jeff Jones Subdivision Info: Reference Name: Jeff Jones Location/Address: Peoples Creek Road -27006 Proposed Facility: Residence Property Size: 375 x 402 Date Evaluated:c?_ — 1_— Water Supply: On -Site Well Community. Evaluation By: Auger Boring Pit Public Cut •• ao©�©asap Landsca position Texture group Consistence MAMMA ON -00 V MONW-A i�►i_.�.���� Mineralogy_ --- HORIZON 11 DEPTH Texture group W�%'=WON ��� �M0ME W12MMineralogy Consistence Structure WWA jr Consistence Mineralogy SOIL WETNESS SAPROLITE LA­SSIFICATION CM 'MAIM SITE CLASSIFICATION: J LONG-TERM ACCEPTANCE RATE: &c3g 40 REMARKS 0 EVALUATION BY: OTHER(S) PRESENT: Landscape Positio lr 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 Tex ur 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 - 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 MineralQU 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 su: ;ace 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 (Revised 05/99) ■■■■■■■■■■!■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■►-,;: ■■■■bi ■■■Itl/1 ■■NFAWN lIliii■■I■■■■■�iiiiiiGC��!!I•■■■■■■■■■■■ ■■!■/■■■■■■■■■■■■■■■■■■I,UfI %117\II■�■II ■■■■■\■■■■■■■■■■■■■■■■■■■■■■Illi)■■■■■ OEM ONE ■■■ ■■■ ■■■ ■■■ ■■■ ■ UA■■■■■!R■■■■I■■■ ■■■■■■■I■■■■/IS■■ \1■■■■■/■■■/!■S■■ I1■■■■■■■■!%■■/■■ ■■■■■■■■■i■■■■■■ ■■M■■■■Mr■■■■■■■ ■WA■■■■I.■■■■■■■■ ■I■■■■■■■■■■■■■■ n■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■\■■H■■■■■■ ■■■■■\■■■P/■■■■■ ■■■■■■►7■■ ■■NEEM ■■■■■■■■■■■■■■/■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■11■■■■■■■■■■■ ■■■ ■■■ ■■■ ■■■ mom MEN ■■■ ■ ■ ■ ■