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135 Potts Rd' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Bog 848/210 Hospital Street Moeksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002821 Billed To: Earlie Beauchamp Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5880-14-0218.A Subdivision Info: Q,5 Location/Address: Potts Road -27006 Property Size: see map ATC Number: 3508 **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 ��y #People 3 #Bedrooms 3 #Baths Dishwasher: d Garbage Disposal: ❑ Washing Machine: G!r Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size J AQPJI�S Type Water Supply ` 000TIDesign Wastewater Flow (GPD) 3(OD Site: New Repair ❑ System Specifications: Tank Size /000 GAL. Pump Tank GAL. Trench Width if Rock Depth );,22., 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 .m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** a' -Z Qi 7 r�Li� u'`�C lr, b �a Zi, Environmental Health Specialist's i I p s S gnature: � Date: / Jn 2� DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002821 Billed To: Earlie Beauchamp Reference Name: Proposed Facility: Residence ATC Number: 3508 Tax PIN/EH #: 5880-14-0218.A Subdivision Info: Location/Address: Potts Road -27006 Property Size: see map 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 a Treatpent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA CTIO IS V LID FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signature: Date: 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, Se ion .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee t at the s tem will function satisfactorily for any given period of time. N_ �lV`S /Z F'ATi o S �/ 'V Septic System Installed By: 1 W Environmental Health Specialist's Signatur. ate: DCHD 05/99 (Revised) �4. APPLICATION FOR SITE EVALUATION/IMPROVBIENT PEIIh1IT S ATC /% D Davie County Health Department v, B7Vir0nmenta/1fea/t1i Section P.O. Box 848/210 Hospital Street 3 Mocksville, NC 27028 ?O (336) 751-8760 04 FNTAI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIR n' l INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed L�lr/;C EE,,,ycrz,- Contact Person Mailing Address /3Lo per fan e' Home Phone City/State/ZIP (/aN C e , Ale 2 766 Business Phone 2. Name on Permit/ATC if Different than Above _ Mailing Address City/State/Zip 3. Application For:—/6-5i.te Evaluation improvement Permit/ATC ❑ Both 4. system to service: 0 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: dConventional ❑ conventional modified ❑ innovative 6. If Residence: It People It Bedrooms -3 It Bathrooms Z E Dishwasher ❑Garbage Disposal QWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type It Commodes It Showers IF FOODSERVICE: #I�Seats 2Se 8. Type of water supply: County/City It People It Sinks $ Urinals It Water Coolers Estimated Water Usage (gallons per day) _ ❑ well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? A ***L1fP0RTAN7*** CLIENTS AIUSTCOMPLE•TETHE REQUIRED PROPER'L'Y INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN 4IUST BE• SUBillITTED by the clieat witli 'PHIS APPLICATION. Property Dimensions:e Tax Office PIN: i# Property Address: Road Name PO 7TS' PJad City/Zip _ l -dye n e -C , 27,0L If in a Subdivision provide information, as follows: Nannc: Section: Block: Lot: WRITE DIRECTIONS (from Mocl:s%,ille) to PROPERTY: -Tyke I- V,� E4ST/4o M,J'Q/ s Cid aenro�c, �/fn �m%f�S Qrot�pr'/r Un �e7a� TJ -Orner acP PO& ACO -v Date hone corners flagged: This is to certify that the information provided is correct to the best of ny knowledge. I understand that any perunit(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 aur responsible fur all cluuwes incurred front this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilealth Departncuil 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. 77 DATE G � � D SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the follo}vingi Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 49 - Sign given Revised DCHD (05/03 v r Site Revisit Charge Da Client Notification Date: EIIS: Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002821 Billed To: Earlie Beauchamp Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5880-14-0218.A Subdivision Info: Location/Address: Potts Road -27006 c, Property Size: see map Date Evaluated: d Community. Pit Public Cut SITE CLASSIFICATION: I/ J LONG-TERM ACCEPTANCE RATE: o • REMARKS: EVALUATION BY:'d rim OTHER(S) PRESENT: 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 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 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 05/99 (Revised) Landscape position Texture group Consistence Mineralogy Texture group Consistence Mineralogy HORIZON III _D_EPTR Consistence SOMME Mineralogy HORIZON Texture group Consistence Mineralogy SOIL WETNESSSAPROLITE CLASSIFICATION SITE CLASSIFICATION: I/ J LONG-TERM ACCEPTANCE RATE: o • REMARKS: EVALUATION BY:'d rim OTHER(S) PRESENT: 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 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 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 05/99 (Revised) ■ ■o ■■ ■ ■ ►fir■■■■■■■■■■■■■■►�■!:■�\■■■■■ i • '_-- � �' I - � o , �8 � v//,,, 74�J�' � �. � �Z�� �zc :�;3 i_ � . � � 126 ����� �� �� �� ' 232 � � � 'F � i7A) f47 *" t � N ��� � i , s2z �a3 .-'"J� �g �' ' 1.fl8A 7 `�9� ._ . 7312 , '-----�.. � �, I � �� o {2.01A} � m �°� � ' S244 � 3 ! 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