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774 Pine Ridge Rd r , � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r.o.Bog sasnio x�p���sr��t Mocksville,NC 27028 (33G)751-8760 Account #: 990001200 Tax PIN/EH#: 5745-31-9077 Billed To: Bobby Cope Subdivision Info: Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.30 Acres ATC Number: 2447 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 wage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA TION VALID FOR A PERIOD OF FIVE ARS. , Environmental Health Specialist's Signature � Date: � f1� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has n installed in compliance with Article 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and Di posal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any g' en period of time. � t� �� � � �' � � �� �� C� Q° � �� � . or � Septic System Installed By: Environmental Health Specialist's Signature: �_ Date: / ��`�� DCHD OS/99(Revised) � �' � �, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �'�� IMPROVEMENT/OPERATION PERMIT Account #: 990001200 Tax PIN/EH#: 5745-31-9077 Billed To: Bobby Cope Subdivision Info: Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.30 Aeres **NOT�*�'�iibgrriprove�inent/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 �� �-�0��- #People Z #Bedrooms Z- #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size , v�,;�c.�i� Type Water Supply�,�VN�i Design Wastewater Flow(GPD) ��V Site: New�Repair❑ u i� System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench Width � Rock Depth �� Linear Ft.2DO� Other: � +�,�Q.I��TI,a�_—�� ,'�!� ���.��p I Required Site Modifications/Conditions: ���l.l� �cJ GD+�'1a�Q � �� '�� � �'''"�v F-t%� � � . _/t IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISNED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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(33G)751-8760.**** , �� � ,�' ' ,F. l. � . '`�. � �,+> f �P�,e�,x. b ��,, �.�.: � ���_.. ..� o�. � �' �° o .�. v � � —to' n.�N. �� Ll,JS. Environmental Health Specialist's Sigr�a Date: �� DCHD OS/99(Revised) , �d �- � - o � � �r • R � � �J � � V � • • APPLICATION FOR SITE EVAUJATION/IMPROVEMEM'PERMIT&A � Davie County Health Department � Envi�nmenta/Hea/th SE+crion MAY 2 4 %��`:� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ` ***II�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED INFORI�►TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. xama to be sillea lf � "`• O' � contact Peraon �U v""j' �n�� Mailinq Addreas � � Gc-S 7� !>�[ J Home Phone �G!) T'""'���� city/state/z=r �lLr���l� ./��02 �G����Sineas Phone '— 2. Namo on Permit/ATC if Different than Above � ��/yL L Maili.nq 1lddress City/State/Zip 3. Appiication For: ❑ Site Evaluation ❑ Improvement Permit/ATC � a. syatem to service: 0 House iYMobile Home ❑ Business ❑ Industry ❑ Other 5.. If Residence: � People _�_ � Sedrooms �2 � Bathrooms � ❑ Diahraeher ❑ Garbaqe Diapoeal ashing Machine C] Basement/Plumbing ❑ Sasement/No Plumbinq 6. Zf Huaineae/Induatsy/Other: SpeciPy type B People �i Sinks � Coa�odea � Shoxera � Urinals � Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallona �= any� �. �pe of water supply: County/City ❑ Well O Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes 0 No If yes,what type? ***IMPORTANY�**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 1, �� !"T�n�s WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taa Of�ice PIN: # �� ys�/- 9��� �U�� � //�e ��>e /`'�'' ' �' / /71�1eJ / Property Address: Road Name �/��/\ip�c-�� � t� � ;� '"��/�a C�� ��.����%''�- . City/Zip i�oG/�cT�/�l�i`' .,�%�� �� e 2 ���/./�ir. � � / G �� / � � l If in a Subdivision provide information,as follows: �G S d � � ��� / Name: ` Section: Block: Lot: Date Property Flagged: ..' '� � y�C, This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafiter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted ia this application is falsified or c6anged I,also,understand that I am responsible jor a/l charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to eater upon above described property located in Davie County and owned by to conduct all testing procedures as nece to determine the site suitability. DATE S��F� �� �� NATURE��.—r�y�(�/ /`"/ •� � �_ � x�--�` -I THIS AREA MA B�S D FOR D G YOUR S �(Include all of the following: Eaisting and proposed property lines and�i ns' ns, structur , setbacks, and septic I ations). � Site Revisit Charge � � ( Date(s): �/ � / Client Notification Date: t , EHS: F Account No. y 2 � Revised DCHD(07/99) Invoice No. �'�� �Qt� � 05i24i00 14:40 DAVIE TAX ADM � 13367510335 N0.031 D01 , . r �, �� -. � ..—.F��_ . ..�,; � -. .'�::�; _:� , \ ' :�« �"' f�� - =:s ��•' _ __ ?�O :_ Y. _.r�j,'�..:� _ - . __ '�r._'.:'� ' _ TY F'•_: ��'�, -r =_ �•: . ,}.� i...__ _ _ " ��r._ , __ "_+„� . •:;yyu.::__ __ .�.. � •._'a•: � ' N ;��: ...;.�� :� •� �A `� ±��• -G. = -�-y; � - _- -� }�•=,"--_�--�.- , ^ � .. • ��',x�.�, ,�" � n �.�_' •y�, — - 1� __� .'.�.' 'r�-. . O �a 5,�,,-��'::�;, •.-�.,+ - a,, � __�������Ip .,,. �:�.�', _T.., •:�"_."'�,:�._ "• __ _��- :'.,-�+—• :!.�,. _.�. :y:.�:. '� • � ''T'��i�;� ��:'::~ -,—, :��:_ •;:�-. �:�.:'•. = '��;-•.. �,-•�.'' �:a� _ �::'�,:�' -- .•_, __ • _ .i`'�=; ,rt . _ - •�C': , s.•• :S�-- . _•,T.•`-� _ :.�'. - i'�'. - ,:��� . . �; ... __ :��' ' '�_ �. _ .�:�i� I - •j,'= 1 _ - T r � ��\1 �� 1 ( � . '; ,'� DAVIE COUNTY HEALTH DEPARTMENT . � � Environmental Heatth Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001200 Tax PIN/EH#: 5745-31-9077 Billed To: Bobby Cope Subdivision Info: Reference Name: Bobby Cope Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.30 Acres Date Evaluated: ' � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% �'v HORIZON I DEPTH - - �O Texture rou (� G Consistence ' � Structure L Mineralo �: I ' HORIZON II DEPTH -� - � Texture rou G �- Consistence • Structure L Mineralo i ; I l: HORIZON III DEPTH -� k -,3 Texture rou G� Consistence r Structure c Mineralo % ) HORIZON IV DEPTH i Texture rou Consistence Structure ' Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE �`� � � CLASSIFICATION � S LONG-TERM ACCEPTANCE RATE n•3 �• c�• � , . SITE CLASSIFICATION: EVALUATION BY: C�� � LONG-TERM ACCEPTANCE RATE: D'� OTHER(S)PRESENT: �oV ���� 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 clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist n VFR-Very friable i`FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm �' Wet (� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky /J NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic (� Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky � � SBK-Subangular blocky PL-Platy PR-Prismatic � � /1/� Mineraloav 1:1,2:1,Mixed Notes f1,- �,� Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface n0 Saprolite-S(suitable),U(unsuitable) n�l�� Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less ` V�� Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/99(Revised) ■■��■��■����■�■■��■■■�■�■��■����������■■■�%\�������■■�■■���■�■■■�■ ■����■■����■�■��■��■�■�■�■�������a■��■��■■����■■�������■�����■■■�■ ■■����■■�■������■�■��■������■■■�������■■�����■�■��■�������■�■�■�■ ■�■��■■��■��■�■�■��■■■�■�■�■■■�■ ■��■�■�■■■■��■■�■�■�■■■■�����■�■■ ■����■�■��■���■��■����■�o■■�■��sm■■��■■■��:��t�■■se���■■�������■�■■ ■�■��■���■■���o�■s���■���■■■�■oi�������■���a����■■�■■�■■■■■������■■■ ■■��■��■■■�■���■�����a■��■�a■�i���:s����i��i�ir,������s�v��■■�■��■����■�■ ■��■■■�����■■■�■�■���■■�■■■�����������������■�r������■�■���■���■■�■ ■��■��■�a��■■e■■�■m�■�e■■■��■����■�■■�■��■■�����■��■o���■�����■��■ ■■��■■■����■■����■�■■����■��■������■■e��■■����Vr���■��■■■■�■■■■��■ ■����■■����■■�■■���■■�����■���:\���■■���■��■■�Ir\O�O■�■■����■■���■■ ■■�■■�■����■■�■■�����■■�■�■■�i1\! 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