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294 Powell RdDAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000665 Billed To: James Goforth Reference Name: James Goforth Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5719-61-2874 Subdivision Info: i9v Location/Address: Powell Road -27028 Property Size: 1.348 Acres ATC Number: 2096 **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 & W #People #Bedrooms �. #Baths Dishwasher: 0""- Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size`*7C Type Water Supply �� Design Wastewater Flow (GPD) Site: New 0 Repair ❑ System Specifications: Tank Size/,OL GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width1 ee Rock Depth Linear Ftd 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 (3336)751-8760.**** gpoV�'�� C Environmental Health Specialist's Signature: /,J Date: DCHD 05/99 (Revised) Account #: 990000665 Billed To: James Goforth Reference Name: James Goforth Proposed Facility: Residence ATC Number: 2096 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5719-61-2874 Subdivision Info: Location/Address: Powell Road -27028 Property Size: 1.348 Acres 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 WASTEWAT4R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /r', Date: 2�V 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. Septic System Installed By: Environmental Health Specialist's Signature: z {,`!��/ C7 v Date: — 12 DCHD 05/99 (Revised) PU(AIION FOR SITE EVAUTATiON/IMPROVEMENT PERMIT & ATC Q O Davie County Health Department Environmental Healtfi Suction l P.O. Box 848/210 Hospital street Modcsville, NC 27028 (336) 751-8760 *' * THIS APPLICATION CANNIOT BE PROCESSED UNLESS ALL THE REQUIRED ON rm�,SPROVIDED. Refer to/�the INFORMATION BULLETIN for instructions. '.S a. name to be Billed 75;Fkn C9/4ek GoJ ocJ -• contact PersonSL-414.-t Mai .+ng Address 323 Powe 1' eA ma BoPhone citl?/State/ZIP .?OC, L1L_1 /( /0 .0 2Q Z Op it Business Phone / % % — 20 q3 Z. flame on Permdt/ATC if Different than Above !-'ailing Address City/state/Lip 3. Application For: U Site Evaluation 0 Improvement Permit/ATC /KBoth 4. systam to service: 0 House Mobile Home 0 Business ❑ Industry 0 Other S. If Residence: # People # Bedrooms dIC3 # Bathrooms Dishwasher 0 Garbage Disposal 6Qp--ashinq Machine 0 Basement/Plumbing 0 Basement/no Plumbing 6. If Business/industry/Other: specify type # Commodes # showers # urinals # People # sinks # Nater Coolers IP FOODSERVICE: # Seats Estimated hater Usage (gallons per day) 7. Type of Mater supply: 1W County/City 0 hell 0 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes "o If yes, what type? ***IMP0RTAN7*** CLIENTS AIUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PIAN MUST BESUB111ITTF.D by the client with THIS APPLICATION. Property Dimensions: I , 7J 7 ��c� -�� WRITE DIRECTIONS (from Aocksville) to PROPERTY: Tax Office PIN: ) # 'a) / -1 l� 17 (o'/ CU eg,� C- M,, , mocks V1 I� / j Property Address: Road Name co 20SS b lie2 X�'to -Tll2J�1CityiZip i � SOCKS`�11 I N AX r 6#4j LOw C' u A4 mU NIC, �CiIf in a Subdivision provide information, as follows: dc.c> r° � Name: pa -i LJ—e A o � Section: Block: Lot: Date Property Flagged:" oZ This is ttp certify. that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued bereafter 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 responsiblefor all charges Incurred from this application. 1, hereby, give consent to the Authorized Representative or the Davie County Health Department to enter upon above described property loomed in Davie County and owned by to conduct all testing procedures as necesur, to determine the site ility. DATE 5 _ /2- - / 92 SIGNATU -- - THIS AREA MAY BE USED FOR DRAWENG YOUR STk. i. WAclude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, Pod new +c t tlons). Account No. Revised DCHD (07/98) Invoice No. �O DORIS WILLIAMS D.13.108 PG. 610 i EIP ADJUSTED l r 13.44 1 .1 L,-1MARKEO POINT +-0 { INBF >NCH NIP OWN LINE N 52. 40'59-- W NIP - N 74. 26 48" '+ 194.74 KERMC D.B. IC DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME CS/o Y DATE EVALUATED 6',,1&94W PROPOSED FACILITY PROPERTY SIZE ! '-t5z e SUBDIVISION ROAD NAME 1 G e & Water Supply: On -Site Well Community Evaluation By: Auger Boring I Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slo e % 157, HORIZON I DEPTH Texture group Consistence Structure ` Mineralogy HORIZON Il DEPTH V4 Y 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 1 SITE CLASSIFICATION: e LONG-TERM ACCEPTANCE RATE: REMARKS: r' -v,) P 1 At Landscape Position V i /" /_ e -,,C-- ell. EVALUATION BY: '14 l/ LEGEND OTHER(S) PRESENT: "'/ ')\_ �� R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope Ve CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Q V Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt ICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam �it' SC - Sandy clay SIC - Silty clay C - Clay Moist CONSISTENCE 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 (01-90)