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264 Potts RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001901 Billed To: Sandra Micozzi Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5880-15-5684 Subdivision Info: Location/Address: 264 Potts Road -27006 Property Size: see map ATC Number: 3024 **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 Dishwasher:�Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size PAC _ Type Water Supply " Design Wastewater Flow (GPD) L1 4�� Site: NewzRepair ❑ System Specifications: Tank Size 1,0& GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width c p Rock Depth W Z Linear Ft." 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.**** 11 ,I I Environmental Health Specialist's Signature: c, Date: DCHD 05/99 (Revised) Account #: 990001901 Billed To: Sandra Micozzi Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5880-15-5684 Subdivision Info: Location/Address: 264 Potts Road -27006 �d- Pro osed Facility: Residence Property Size: see ma ATC Number: 3024 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 WASTEWAT NSTRLLTION IS VALID O A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 02',;2 —Al 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. Q F Septic System Installed By: 7 7� �r J�Is'i J. Wea- no v 4`� Environmental Health Specialist's Signature: �/�� Date: /"� " �? DCHD 05/99 (Revised) A IE EVALUATION/IMPROVEMENT PLIIRIIT & ATG Tr Davie County Health Department �i En vironmental Health Section P.O. Box 848/210 Hospital Street _�- Mocksville, NC 27028 (336) 751-8760 Mailing Address r • U •tz3o^ City/State/Zip L 3. Application For:5-9Evaluation Improvement 4. System to service: ❑ House V Mobil Home ❑ Business ❑ 5. If Residence: 01 It People A" / It Bedrooms 13 I:) Dishwasher U Garbage Disposal Washing Machine U Basement 6. I£ Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People t/ATC II Both Istry II Other It Bathrooms �— .ng II Basement/No Plumbing It Sinks i! Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per. day) ' 7. Type of water supply: ❑ County/City Well Il Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? l] Yes I(N0 If yes, what type? ***Id1PORTANT*** CLIENTS h1USTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBA117TED by the client with THIS APPLICATION. Property Dimensions: S�-- -- YY>�S%, a Tax Office PIN: # 8 !J t !���1 (� Property Address: Road Name (0 (1 ib �s CA City/zip _()(-A0 aV) C4? If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE D1RECHONS (from Modisville) to PHOPI�IZ Y: Ci! %0g,� L 'S A-,-, rh Date Properly Flagged: � N 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. 1, also, understand that I am responsible fur all charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Ilealth Department to enter upon above described properly located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE 1\i Ib 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). Revised DCHD (07/99) v Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. d/ Invoice No. 7 ANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED 0 TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions___ Oame to be Billed�Q�� �((`L 1 MI, Cc Z 2 j Contact Person � -1 0 Mailing Address Home Phone City/State/ZIP �` C Op (_ �p7� Business Phone -i Lot - Db ke K1 �3% •t 2. Name on Permit/ATC if Different than Above IL Mailing Address r • U •tz3o^ City/State/Zip L 3. Application For:5-9Evaluation Improvement 4. System to service: ❑ House V Mobil Home ❑ Business ❑ 5. If Residence: 01 It People A" / It Bedrooms 13 I:) Dishwasher U Garbage Disposal Washing Machine U Basement 6. I£ Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People t/ATC II Both Istry II Other It Bathrooms �— .ng II Basement/No Plumbing It Sinks i! Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per. day) ' 7. Type of water supply: ❑ County/City Well Il Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? l] Yes I(N0 If yes, what type? ***Id1PORTANT*** CLIENTS h1USTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBA117TED by the client with THIS APPLICATION. Property Dimensions: S�-- -- YY>�S%, a Tax Office PIN: # 8 !J t !���1 (� Property Address: Road Name (0 (1 ib �s CA City/zip _()(-A0 aV) C4? If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE D1RECHONS (from Modisville) to PHOPI�IZ Y: Ci! %0g,� L 'S A-,-, rh Date Properly Flagged: � N 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. 1, also, understand that I am responsible fur all charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Ilealth Department to enter upon above described properly located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE 1\i Ib 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). Revised DCHD (07/99) v Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. d/ Invoice No. 7 (8.90A) 2856 co 0 Q 0 w Cf) 0 n (273) 5880155684 (2.72 a) 5684 F800000122 50 a 28s 1.50A 8535 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • , Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001901 Tax PIN/EH #: 5880-15-5684 Billed To: Sandra Micozzi Subdivision Info: Reference Name: Location/Address: 264 Potts Road -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: AO 2 Water Supply: On -Site Welly Community Public Evaluation By: Auger Boring r/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position .L L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH fz/�• Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:il J/ -r 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) ■ ■ ■ ■ ■ SEEN NONE ROME ■N■■ MEMO NOON ■E�M NONE ■■N■ NONE MEMO ■■■■■■■■■■■■■■■■■■■■■■■■Mir■�//.■■■■■■■■■v■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ f D �IIE COUNTY �I LT i D PMT�I�NT v.,ti _ ...... .v.._....._. r_ w.._.. _ _.._.. _ _ ... ENVIRONMENTAL HEALTH SECTIONM P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 October 31 , 2001 Sandra C. Micozzi P.O. Box 203 Advance, N.C. 27006 Re: Site Evaluation/Potts road Tax Office Pin: # 5880-15-5684 Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 02, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, A 4'A vs. g � 4 aA. Robert B. Hall, Jr., R.S. Environmental Health Specialist Quincy W. Comatzer / and wife Faye H. Comatzer - 66 O PG 180 ~_ 181/2" EIP Fhd L-2 ) ' 2" QP / 158.50 bent / Fnd S s?� IRS T—Bar w/c Bent Fr ) Part of Tax Lot 122 / Tax Map F.:8 . i n/f Paul A. Potts Part Of j DB 52 0 PG 63 Tax Lot -122 1.000 Acres 4 NApproximate Locafian of 0 Drainage Ditch != r / j ,rye 4 - Tax Lot 122.02 IRS - ' 114.62' N 86009'58"W . IRS Tax Tax Map F-8 n/f`---- / Glenda C. Lane