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391 Powell Rd.t I Account #: 990002243 DAVIE COUNTY HEALTH DEPARTMENT / o ' o Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Billed To: Dinna Johnson Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5718-69-8639 Subdivision Info: Location/Address: Powell Road -27028 Property Size: see map ATC N�rtib r: 3505 **NOTE** This �mprovement/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 I/ #People_ #Bedrooms j! #Baths Dishwashente Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: 173 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply Aell Design Wastewater Flow (GPD) 0 Site: New 0"' Repair System Specifications: Tank Size IOWGAL. Pump Tank Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPI FINISHED GRADE. ****NOTICE: Contact a represent e system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. tgll p n %S !P;.. Ae C�X19j/ %3 GAL. Trench Width 5�G Rock Depth 1Y Linear Ft.*, IO 0�RD EFFLUENT FILTER. RISER(S) IF 6 " BELOW tht'15a'vie County Health Department for final inspection of this the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: 2A& DCHD 05/99 (Revised) Account #: 990002243 Billed To: Dinna Johnson 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 #: Subdivision Info: Location/Address: 5718-69-8639 Powell Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3505 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 - ONTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICAZa O PLETION **NOTE** The issuance of this Certificate of Completiothe system described on Improvement/Operation Permit has been installed in compliance with hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in N AYuarantee that the system will function satisfactorily for any given period of time. X e-72 ,1�. A Septic System Installed By: / Q. r' v�� �� �� l Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Al ,1UN 2 6 2003 r�nI1R(1:.��1•i'IIisL H1J14ti �l ON FOR SITE EVALUATION/IMPROVEMENT PER6IIT S ATC Davie County Health Department B=ironmentaif/eaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ' ***XKPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed So rA Mailing Address ..J a3 PAY, A City/State/ZIP IOf'�C�-Il N,4 2. Name on Permit/ATC if Different than Mailing Address 3. Application For: 11 Site Evaluation k H 4. System to Service: ou8e ❑ Mobile Home 5. Type system requested�onventional 6. If Residence: # People2,- Contact Person Q�� _ Home Phone 3 36 — Aq ? ­5_1Business Phone 3 3�' — /10 —0 Za '74 City/State/Zip ❑ Improvement Permit/ATC oLli ❑ Business ❑ Industry ❑ Other ❑ conventional modified It Bedrooms 7,— innovative innovative 77 It Bathrooms A 2 'UDishwasher ❑Garbage Disposal t ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type It People 11 Sinks _ # Commodes It Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City ka Well ❑ Community 9. Do you anticipate additions or expansiolrs of the facility this systeinl is• intended to serve? k1<1cs ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COAIPLETETHE REQUIRED PROPLRTY IMORMATION REQULSTEI) BELOW. Either a PLAT or SITE PLAN AIUST BESUI3MITTED by the client with '1'l1IS APPLICATION. Properly Dimensions: -,QA-e- �--�-'q / Q I'ax Office PIN: 4 S7�ap - / �(� � / Property Address: Road Name U 0�✓�l ' City/Zip .2- 70 14' If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (1'rom Mocksville) to PROPER Y: clevLrteol- ye) 2oa�ff APA Date !Ionic corners flagged: _& This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernrit(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 uni responsible for all charges incurred frons this application. I, hereby, give consent to the Authorized Representative of the Da��Ic County IIcalth /cpartmcul to enter- upon above described property located in Davie County and owned by to conduct all te`stin procedures as necessary to determine the site suit ilily.—r DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all ethe following: Existing and proposed property lines and dimensions, structures, -setbacks, and septic locations). Site Revisit charge S Sign given -1 3 - o '_J 3 ^vised DCH (05/03 Datc(s): Client Notification Date: EIIS: Account No. Invoice No. 3 � �� s. �: ,, g 16�5� �� � (3.14A} �. ,,�, , � � 111'[ � ��� : , 3 � _ .� , �� , . : � � _ , - , z _ ___ _, � � . - _ , � , , ,r , � � � � - , � �__.. �{7.22, A� j � � (1.12A) _,_?��-� i ��� _ __ __________$�83 3�7 '"� � "" -- 0990 . - � "'---� , I , i; , , _ . 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' . i �[ (42q � 1 ) ^�.."'"'^�-. t, � / ���.5�A) � � ��$� J� ��t( ♦ . ` .— O � v r� � � .�. , � ; � � � �. � � � � � � � ' ' 1 7 ,(6.23A) ,�^'� ' --�� 6024 �� ,. �, I � � i rpb ` , , , �, � � � APPLICANT INFORMATION Account #: 990002243 Billed To: Dinna Johnson Reference Name: Proposed Facility: Residence Water Supply: Evaluation By DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5718-69-8639 Subdivision Info: Location/Address: Powell Road -27028 - Property Size: see map Date Evaluated: On -Site Well Auger Boring Community Public Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH " Texture group Consistence r Structure / Mineralogyi r— 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 113 SITE CLASSIFICATION: l LONG-TERM ACCEPTANCE RATE: ' y REMARKS: EVALUATION BY: ) tl/ 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) ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■E■N■■E■N■ NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENEM iUNSEEN MENNEN MENEM" Emmmu ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■EMEM■■E■MEM■ ■MMMOM■M■■M■■ ■M■MMMM■MMM■■ ■ ■ ■ ■ ■■N■ ■EM■ NONE ■EE■ ■N■■ ■■■■ ■■■■ MEMO SOME ■ON■ MOON MEMO NONE ■■■■ ■■■■ ■■■■ ■ ■OM■■ ■■■E■E■E■ MENOMONEE ■■■■E■■■■ ■■■■■■■■■ ■MMEM■■E■ ■MMM■■ME■