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217 Pratt Farm LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section "?qC, P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002053 Tax PIN/EH #: 5813-79-4399.RR Billed To: Ralee Ross Subdivision Info: Reference Name: Location/Address: 217 Pratt Farm Lane -27028 Proposed Facility: Residence Property Size: 5.10 acres ATC Number: 3090 **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: L;' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ 1 Lot Size 3 l C Type Water Supply.. aZz Design Wastewater Flow (GPD) Site: New K' Repair ❑ System Specifications: Tank Size// GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width/Rock Depth // �Linear F IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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.**** ,�Ow c�rea.r CI Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990002053 Billed To: Ralee Ross 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 #: 5813-79-4399.RR Subdivision Info: Location/Address: 217 Pratt Farm Lane -27028 Proposed Facility: Residence Property Size: 5.10 acres ATC Number: 3090 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:,/ Date: 3 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. Septi Environmental Health c DCHD 05/99 (Revised) N M Eh ` cn: for lot 6,13 '- Tax lot 6.QS •+,•, ,,:*' a owwopow Tax Mnp 8-3 0 3H Io M Oa � J. car C w., •• 61 eft •}C 1S1 7 8=3 P/O to:lot 614 Tex Mo \ Tar lot &14 tax map 0-3 Vo Saw L &wvn It T*t lot 9.12 Qd "Pl i11dt8" Tax 'Yap 8-3 CD w h.vr ar of 76.0 K 1N Ln -in N7a 1Nr[ u�.+r ri w LO 4.2 M M ' Tot lot 7 1 Tor 1100 o � cn JO �- v �_ — '\ r LOi �- - N L - CD N , C.... / 49-- (S)_ 1p 4 cx ,�, c6 03/01/02 14:36 Narr 01 02 12:0Dp MPH OR 336 751 8786 NO.191 1?01 davit' ooutlty envhealzh 936 751 6706 p.2 APPuCAT1oN FOR 617ri: EVAL1111T10WIMPROV011ENT PERMIT & ATC Davi@ County 14ealth Department Evs"Manwntal N&vtlth 51e&� N(J�✓ G P.O. Bou 848/210 hospital attest �. Mockaville, WC 27029 (996)751-8760 r e e • S►ipC RTJIiR'e R • THIS 7157LIC?LTI()V CANT nV BROOC E&SW DNI.ti99 ALL WtL AEQUTABD XWF103QMTXCW IS PACMYZAZD. he=ar t:e the ZMr*2MW=ZCla 19=CTIN tar AnatruotAons . a..ma to r— a441ed Contact ewraan �itelura sd metelykP > atter» ¢itq//Baat�a/DSD ntLiOMs Yhasm Loa' Name an aatLLt/aTC Le DLtlatnaat than ALew . --rbAL&&UW Add.*.. city/st:at:e/xiP 7jpa1LmtL&n row: 0/8ito Evaluation 0 Xsq2wcrvazqent Pesmft/ATC Roth —^'af Systaft to fesvACO: 0 House gi Mobs2a Home 0 ausaaimes O Znduntiy 0 other zlfaooidence: a People • nedso nen _ Al • Bathrooms �� w Olehnaahar to OaCbag4 DLIDO/�7. Kraahinp t�iea CI Daearez.t/Dl�s�isq 11 e,.aeelent/fere D1umLled 6. xr tlurin.ee/zoduetey/Othac: apbalz r yya _ a reop4A • t11.0ata A caraedaa A 9hoe.ee a v�iaai. a mater coolers c, I? WO DG=RVZ13S: It Gelato Estimated watar lusage (Qantas par d yl 0.17- Type of water supply: O Cotafty/City wr l] o caomaanst,//fir ��.a. Do you anticipate addidons; or cipaashams or the 4cUlly this system Is Intended to serve? 0 Yes lrno • tf yet; what type? •••IAfPORTANT•••?Earls MOTrCOMPLEMTHE NEOMNED PROPEAW INFORMATION REQUU-VMD • BELOW. 1tbar • PLAT a► SIbythee3lcai with THIS APPWCA`n0K (,Property Dimeeaionr. Q �/ 2 -wIa4E DIREcTioNiS ((tem Modavitie) to PROPERTY: «Tax Office PIN,. 3 '1 # Sr/ 711 C/ j,� R `,eeaperty Address: Road Naato(oZ17J OiQr01 he City/Zip vek5viil f�frne�u�1 �irla as�ci�l Provide information, as fdllows: (0 ^ f?f"i�%1!/Q Pli Ao /Ih% • Name.- Section: ame:Section: Block: Lot: _ r/)TrDte Property Flagged: a? a$ 0 This is to eorti& that the information provided Is correct to the best of my knowledge. t understand that any permit(s) L. and hereafter are sbbjeet to suspension or revocation. ifthe site plans or Intended rase change, or if ibc information r6ubmitlod in this applkation Is tbtaltled er changed 1, a4a. undrrsland aha/ law responsible jar aN charges lncar d from lb,ls application. 1, hereby. give eonsent to the Authorized Repremstadve of the Davie County -Health Department to enter upon above described properly located in Davie County and owned by to eaaduce all1"iting Procedures as nccc=ary to dm ctcrtnt the sites . bili C� � �✓ DATE. �! 1 /O a 4/SIGNATURE t� THIS AREA MAY BE USED FOR DRAWING YOUR S M PLAN (lneiade au of tlic following: Existing and proposed property lines and dimensions. stroetoee& setbacks, and septic locations). Site Revisit Charge Dete(s): Client Notilleation Date: ENS. Aeooant No. Revised DCHD (07/99) / Invoice No. d r e P ti - r 41, cc, 7 o 4— S 9' 3- i `� APPLICANT INFORMATION Account #: 990002053 Billed To: Ralee Ross Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5813-79-4399.RR Subdivision Info: Location/Address: 217 Pratt Farm Lane -27028 Property Size: 5.10 acres Date Evaluated: I?".:;, -D2, Water Supply: On -Site Well 1/ Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH �< r Texture group L Consistence Structure Mineralogy HORIZON II DEPTH .� Texture group Consistence r / 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: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: 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 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 `Q (� SBK - Subangular blocky PL - Platy PR - Prismatic lV) " Mineralota 1:1, 2:1, Mixed Notes 1 Horizon depth - In inches 1 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) ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■M■ ■MMMMMMMMMMM■M■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■E■ ■■■■OMEN ■OEM■■E■ ■E■EM■E■ ■EEMM■■■ ■ME■■EE■ ■■EMMME■ ■E■■ ■EO■ ■■M■ ■OM■ ■ME■MEME■■M■■ME■ ■MEME■EMME■■E■E■ ■EMMEMEMEME■E■E■ ■■M■ ■■■■ ■ ■■■ ■E■■■■ ■EMME■ ■■EME■ ■EMEM■ ■ ■ ■ ■ ■