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227 Pratt Farm LnAccount #: 990002522 Billed To: William Pratt Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5813-69-7210 Subdivision Info: Location/Address: Pratt Farm Lane -27028 Property Size: 9.71 acres ATC Number: 3332 **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 E)QSC - #People #Bedrooms #Baths Dishwasher: GTO"' Garbage Disposal: 0 Washing Machine: Basement w/Plumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size .-71 ��-�SType Water Supply OeLl— Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size I ©` Q, -AL. Pump Tank GAL. Trench Width - P"Rock Depth 12 1 Linear Ft. q00, ' Other: Ii�'�Al L� t { C). C— . K,-1 (-! �Sl �1 �ti 1 �O� t — � Required Site Modifications/Conditions: 1l I �it�19U ©+� C � . 1�' ��f fX ?J�c-Me--3T, &77Q 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.**** O `�� S� FAV -.. Environmental Health Specialist's DCHD 05/99 (Revised) 54C ��)� LA oai— Account #: Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT y Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990002522 Tax PIN/EH #: 5813-69-7210 William Pratt Subdivision Info: Location/Address: Pratt Farm Lane -27028 Residence Property Size: 9.71 acres ATC Number: 3332 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. PQO Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW NON IS V LID FOR A PERIOD OF FIVE 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, 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. l,fig T1 a7' IV � L 00 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) ID 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Healtly Section _ P.O. Box 848/210 Hospital Street E��',;; ;;`:r, G',i. HEP0H Mocksville, NC 27028 "X.`J E G)[J; "'TY (336) 751-8760 _�C rt17,' ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refers to the INFORMATION BULLETIN for instructions. 1. Name to be Billed \Ih1.1. /%Qt�7 �l'L(I t Contact Person Ff'-eel Mailing Address /067 Qyi!ySt107 Rel Home Phone '7 9 4, City/State/ZIP 7AlX tfL 3Z Z t Business Phone 1A 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For:Site Evaluation Improvement Permit/ATC ❑ Both � I��V III 4. System to Service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People - # Bedrooms # Bathrooms .2- Z2 M/Dishwasher PGarbage Disposal 6'washing Machine Id'Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers e IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ewell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes RIZO If yes, what type? 'IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 7, 7 / A Tax Office PIN: # 6 $1 31 rf,7 Z / O Property Address: Road Name 0."ttt 'r'dr'm tape City/Zip C lurksv,'At /oN7n4SA,P If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: bc,a,J- / r„► lc pus t- $G / eA, l"r is % c "-04W rx�" opt 'end - Date Property Flagged: 1 2� 8 �� 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. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitabilI y. DATE 1,2Z&17-e0n 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). Z�, w4-ru--"N I—� s t - Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. � 2 - Invoice No. G �! to c o 84• 132 89 666.21 193 /h�1 ti 5.030A 6.83A 8744 p 4735 0 C) rn� 647 ss �t r` 630000000617 2�9 5813697210, 9.71A 721 0 (5.313A) � U �- 4399 - C (35.54A) 2564 APPLICANT INFORMATION Account #: 990002522 Billed To: William Pratt Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5813-69-7210 Subdivision Info: - Location/Address: Pratt Farm Lane -27028 " Property Size: 9.71 acres Date Evaluated: C� On -Site Well — Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Sloe % 7,, 13 t7vG HORIZON I DEPTH i- ) — 0 -1 Texture group C L I[ L. Consistence Structure t! ' Mineralogy HORIZON II DEPTH 10 2 y ' ^ 74, 2 - Texture group Consistence ,` , — 71 Structure IC `' ve Mineralogyt �L HORIZON III DEPTH - f(. Texture group C C -t Consistence 177,3 Structure MineralogyG !v HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE , CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:_ LONG-TERM ACCEPTANCE RATE: v 'rr }REMARKS: Q; (( tM TF b � # { �� � ` r - LEGEND Landscape Position EVALUATION BY: OTHER(S) PRESENT: a ori ' 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 - 5and 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=s 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 Mineraloey 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) ME ME ME ME ■■MENU■■E■ ■EEE■■MEM■ ■■■■■EM■a■ MEMEMMEMME ■■ME■■MMM■ ■■ 0 ■E■E■ ■■EM■ ■o■m■ DIO■O■ ME■E■ MESON ■oso■ SEEMS ■O■RE ■EEEM ME■EM MEMO SOME MOSES ■■rjWE M■OOJ somas ■E■a■ ■■■E■ ■■■■■ ■ ■ EMMEMEMME MEMEMEMME ■EMOM■O■■ ■■M■MEMM■ ■■MEM■ ■ ■EMOM■ ■ ■E■■MEM■■ ■M■■M■EM■ EMEMMEMEM ■■O■■o«"m mmmmm mmm MEMMEMMEN ■■M■MMU■ MM■MME M MEMMAMMEM MMMEwwwMM ■■■ar.:NINTAIvi ■■ ■ ■MM■■ ■EM■■ ■ ■Aw ■E■M■■ ■M■MM■ MEMO■■ ■E■NO■ ■MMEM■ ■■MEM■ ■■■mo■ ■EMME■ ■MMO■■ ■M■ME■ ME■NE■ ME■■E■ ;■■■■■ EMMEM no ME ■■ ME ■ @I MINE