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429 Rainbow Rd (3) _ : .• , . - � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000880 Tax PIN/EH#: 5851-79-0055 Billed To: Ivan Adams • Subdivision Info: Reference Name: Ivan Adams Location/Address: Rainbow Road-27006 Proposed Facility: Residence Property Size: 9.69 Acres ATC Number: 2429 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 WASTEWA CONSTRUCTION IS VALI F R PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Y�- • Date: �"o�i���YJ CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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 ' atisfactorily for any given period of time. . � , Septic System Installed By: Environmental Health SpecialisYs Signature: Date: ��'=A<�� DCHD OS/99(Revised) ,��1 /2-/v��-�r��� � , �.} , DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section �.�=36-��°e����J� P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000880 Tax PIN/EH#: 5851-79-0055 Billed To: Ivan Adams Subdivision Info: Reference Name: Ivan Adams Location/Address: Rainbow Road-27006 Proposed Facility: Residence Property Size: 9.69 Acres **NOT���iiblmproveme nt/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ,� #People�_ #Bedrooms �` � #Baths 2. Dishwasher: �Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size fi�G Type Water Supply LLl Design Wastewater Flow(GPD)�/� Site: New�Repair❑ < < ,. � " System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width�_ Rock Depth /� Linear Ft._�� ocn�: ��r�,�'� c��Gl�,� U�r Required Site Modifications/Conditions: IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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.**** �� J � � � � Environmental Health Specialist's Signature: Date: - � DCHD OS/99(Revised) � �� � , APPUCATION fOR SRE EVALllAT10N/IMPROVEMEM'PENMR dc ATC r -�� �' ���S' _ Davle County Health Depe,�tment �, � Envfi�nmenta/He�/tfiSe�on � p.o. eox e�e/2�o 8osp�tsl str.et ,; NOV 2 3 1999 . Moc]cstrill�, NC 27028 � • (336)751-8760 � ***S�ORTAI�T?�'�* T�iB 71pM,IC7ITION CaNHOZ � PItOC688aD DN�88 ALL T� R�QIIIRaD IN71'OR�ATIC�i i8 PRCV=DED. R�far to th� Ztil"0�11T=ON BVI.LZTIN !or iastructions. i. �. to b. asu.a .�l�AN Z�ENN j S Adp m S ��t �.�► x�s� �aa=... �Z 9 �n;n�6 aw Rd. ' aa.. a�,. g g�o!�� csht/atat,./ssa /-�c�vANC.�, N,e . 27D0[n a,,.�.,, � 3��j J�3� �. Iias� on �sai!/]1TC ii Di!l�r�at t�t �bon Nailis� ]Iddr��• CitY/S /fi � . �. llppliaatioa I'or: B�Sit� Evalua�tioa �Impio"v� t�� t 11TC 0 8oth a. es�.t,.� to s.=.so.� EYHons� O Mobils Hom� O Bnsin�ss � =ndnstsy � Oth�r a. _� �sid�a�: f B�oplo 2 t 8edzooms Z � Bsthrooms � B�Diabxub�s O Oasl�aq� Di�po�al I�Nasbinq ltaohia� _Q saa�n!/Oltsb.iaq B�Sudm!/1io plm�binq 6. I! swia���/i��ts�y/Ol�rs 6p�cilY tYP� � �opi� f siak� � Coeod�� ; Bhox�s� i IIrinal� � 11abr CoolYr� =a '"OODSSRVZCs: � S�ats sstimat�d Nat�r �aaq�.Q�aon. par a.�t) 7. �p� o! nst�r supply: �Coutitp/Citp � ?�l�T� 0 Commuaity . e. Do yoa anticipste addiNona or e,�panstoas oi t6e facWty thV s}�tem b intendcd to arve? 0 Yea �'Fio If yas,wlwt type? . ***IMPORTAIVT'�'**CLIEN'i'3 MUSTCIOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESfED 1' BEIAW. EiWer a PI.AT or SI'fE PI.AN MI�ST BESUBIKITTED 6y the ellest w�th THI3 APPLICATION. Propetty Dimtusions: �d��l�I./✓�9�L, g, �9�• W1:TfE DIRECflON9(trom Ma1�vtQe)to PROPERTY: Tai 081c�e PIN: # ���I ' � / - 00�...� (�v �o,lZli o�tl 1 S8' T /�Ri/uUt7tfU �l�C Q� Property Addreas: Road Nam� �g �Ai N�D�al /� ,�F�'� AClL�'SS �f�a ��i c�s�, PJ9SY`-� . � ciryr�ip A��A,���v�.-z'7pa6 �lo�.sFs o.v ,L��t �-il/�� ��rrcTw�y If in�Subdivision prov[de iaformaHon,ss folimvs: ,��9 S� ��.� �/OGtS� .—�f�2.0 ����1- rt.me: �iz��✓,�� D�t Jrt�� s�G�� To .��f zr,�sF secaon: stoc{c: Lot: nnce rrop�rkq r-�ca: //— �2�3-.�� T�ia is to cerHfy that t6e inlormsHon pmvWed is con^e�t to the beat of my ks�anrledga I underadir�d that sny permlt(�) isaned 6eresfter are subject to easpeneion o�revoc�don,Uthe eite plane or intended ase chsn�e,or itt6e Iniorms�ion �"aabm[tted in thia sppUcaHon is falsiBed or chan�ed. I,also,andtrstand tA�at 1 am nspodalblt jor all cha�ges lncarrcd from tbls appllcatton. I,6enby,give consant to tLe Aathortr.�d Reprea�entative oi t6e Davk Connty Halt6lkpaetment to enter npon abave dea�rtbed property toaited in Davie Coanty and mvnal by IvA.v �E',v�!/i S �1c/R�2�t_C' to condact all teating procedara As n�ry to dekrmine We site ndb ty. l DATE // -Z�- ��I�l SIGNATURE 1'�iIS AREA MAY BE USED FOR DRAWIIVG YOUR 3TTE PLAN(Incinde sll oithe folfo�vingi F.iiating and propoeed property Ilaes and dimensione, :tractw�ea, setbacke, �ad repdc locadon�� Slte Revbit Charge D�tete)= w CUent NoHQcatton D�ute: EHS: � �� Aaonat Na ��Q ' Revised DCHD(07/99) � Invotce Na � �J 2- . ���w�-' � •'•� � n �.i•."Ir Y � � �.;•e .:.�r+i � .', �. 'r . : . ��I�'�1.r; w "1 f: .{ ,. .;.L . �� .���`+;��'�!'i. 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I , . . , .�•,�;,1. . , .. . � i;� • .. . , /' . ;)• . . 7' + � , .. , , • ���� f �� � , 'r""���.�...�"� .�. .�.. i . l, i '',;)k T N - _�-=- _�� — --=_�,a � � D - �i � ,,�� x � � . F _ 7 �_�_ - - —- _ � , � — , _ , ! .•. . , � t �' ,l DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation . APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000880 Tax PIN/EH#: 5851-79-0055 Billed To: Ivan Adams Subdivision Info: Reference Name: Ivan Adams Location/Address: Rainbow Road-27006 Proposed Facility: Residence Property Size: 9.69 Acres Date Evaluated: /Z-/-t'� Water Supply: On-Site Well ��_ Community Public Evaluation By: Auger Boring � Pit Cut � FACTORS 1 2 3 4 5 6 7 Landsca osition L Slo %. �j/' HORIZON I DEPTH Texture rou ' Consistence Structure Mineralo HORIZON II DEPTH Q `' (J" Texture rou G Consistence � Structure r / Mineralo HORIZON III DEP'TH Texture rou Consistence Structure Mineralo � HORIZON N DEPTH Texture rou Consistence Swcture Mineralo SOII.WETNESS RESTRICTIVE HORIZON . SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: �C� LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: REMARKS: ��fL�f/z�G�/JiI !f'i`��'`�. � LEGEND Landscape Position R-Ridge S-$houlder 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 tructur SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface 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O. Box 848/210 Hosp�tal Street Courier #09-40-06 . Mocksville, NC 27028 Phone #: (336)751-876� December 2, 1999 Ivan Dennis Adams , 429 Rainbow Road Advance,NC 27006 Re: Site Evaluation/Rainbow Road Tax Office PIN: #5851-79-0055 Dear Mr. Adams: As requested, a representative from this office visited the aforementioned site on December 1, 1999. 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, ,�.�!�t����. Robert B. Hall, Jr., RS. Environmental Health Specialist RH/mp Enclosure(s)