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194 Redland Rd r.;;,---_..��.,� DAVIE COUNTY HEALTH DEPARTMENT , • Environmental Health Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (33G)751-8760 Account #: 990002706 Tax PIN/EH#: 5861-48-6550 Billed To: Jeff Hayes Subdivision Info: Reference Name: D��}1vt�►� s• ��H�U� Location/Address: off Redland Drive-27006 Proposed Facility Residence Property Size: 175 x 245 ATC Number: 3987 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 Treatm t and Disposal Systems). THIS AUTHORIZATION FOR WASTEW S S VA FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ate: � '�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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 will function satisfactorily for any given period of time. � 3 � Z� ���'��.5 = /��� �° 3 �.'S C–�. A ,�(j.S_ � . ''�` 2'�G�' 1._ , �� . 8 � � 'y`�-l2rs _ � � Eb � � � l3 _! -G—�� �� . ���-P � � C�1C',� �1 �r�c�lp►MP� , ��, ��� ��� ��� -�z��k � � C� �S�Septic System Installed By: � ��� Environmental Health Specialist's Signa Date: �� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ; ` � . � • Environmental Health Section . •�'� ss' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)7S1-87(0 ��� ;��� �ti IMPROVEMENT/OPERATION PERMIT Account #: 990002706 Tax PIN/EH#: 5861-48-6550 Billed To: Jeff Hayes 9,,,, Subdivision Info: Reference Name: �r�yr�,S.�l"a�/�if1, CB�Zy-o7) Location/Address: off Redland Drive-27006 Proposed Facility Residence Property Size: 175 x 245 /�� �,.al��(��7 �Un ATC Number: 3987 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction ofa 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 PERNIIT LS SUBJECT TO REVOCATION IF SITE PLANS OR T�IE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �0��� #People #Bedrooms � #Baths Z Dishwasher: � Garbage Disposai:❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Q�AC-Qi. Type Water Supply��Design Wastewater Flow(GPD)�� Site: New�Repair❑ System Specifications: Tank Size �'�OC)GAL. Pump Tank GAL. Trench Width��� Rock Depth 12�� Linear Ft. �� och�:' 3 '`���T�i�T�� ��.s Required Site Modifications/Conditions: ��� �`FFF �pc'kS�. ��'� �� p�F �E7� l—t�J�. INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISEIED GRADE. ****NOTIC :. Contact a representative ofthe Davie County Health Dep ent 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. Telepho e#is(336)751-87G0.**** �►� A�4 ���x�� � �3S�x�'K+z-'' 3�'.' r�' 1� ' � �ia• � 1°� �� �F',�� 4..�.�.�S �� s%� ���-. , No� � � _��r I ----- !U . - - " _ Environmental Health Specialist's S�, ature: '7D� � , " � Z '� JS"� DCHD OS/99(Revised) �� • � � ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � _ (33�751-8760/Fax(336)751-8786 Application For: 0 Site Evaluation/Improvement Permit �Authorization To Construct(ATC) � Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/1Vlodification of Existing System or Facility ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed��o(�,� �TG�.iI r�}/�� Contact Person �r.Qrj;�y�� �'TC�,�/"� i�',._, Billing Address�;�"� �'j-j-{ �.� ����,t � l ��f-`� r Home Phone �(�,� '�/��j�7 City/State/ZIP�6-���� � �f� ')v L �����Business Phone Name on PermidATC if Di r nt than Above ° C'J �� r'1 I` Mailing Address � City/State/Zip „ PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pemut is valid for 0 m nths with site plan,no expiration with complete plat.) Owner's Name �� Phone Number 7-�,"�9'��� Owner's Address �c/1 '�' City/State/Zip��(;� y�. a�j�('�� Property Address n City Lot Size �� Tax PIN#S��=C{�Q'�-�Q Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the sife? ❑Yes �10 Does the site contain jurisdictional wetlands? � ❑Yes Cd'�10 Are there any easements or right-of-ways on the site? OYes f6No Is the site subject to approval by another public agency? �Yes C�No Will wastewater 6ther than domestic sewage be generated? ❑Yes �No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms� Garden Tub/Whirlpool ❑Yes No Basement: ❑ es No Basement Plumbing: ❑Yes No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:. �Conventional f�'Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:j�County/City Water �New Well OExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�No If yes,what Type? i This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pemut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I de tand that I am res onsible for the proper idenrification and labeling of property lines and corners and locating and flagging r s aki g the house/facil loc ' n,propo ed well location and the location of any other amenities. "�' - ' Site Revisit Charge Pro rty owner's or owner's legal repr' entative signature - . . -�/ Date(s): •' ' � Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �L1— Revised 11/06 Invoice# FEB. 4. 2005 1:47PM CBT TRIAD� 998 4492 N0. 1356 P. 2 � , L ' ^ , • � . �/ � • s� � • , - • ' • � �( • At'PLICATION POti SITE[VALtJAT10N/iMP1i0YCh1FM�N171hI1T S�ATC • • . Davte County tteatth Dopartment • � ,EnYirnnmen[a/Nea/thsection. r.o. noa s�o/zio xo�nitiai srs�et � Mockavil.le� xC 27028 � (336)751-4760 � . , trsSFlPOItTRA1T*ts TIIIS 1►PPLSCtITZON CANNOT� PROCL''SSJLD 4NLLSS N+L TIII: I2�4�kL•'D ~_••�I INFotusATzoN Zs rxovzn�D. aoEor to tha 2NFOItrraTZott DULLLrIir for �inatructiono:__ .� � • l. N� co be Dillud�¢�t_� S Or. `u'�����nCacC PCr�oa �_ QC�C Hc�Y�$ r �- ,1 �p 1 Hatlsn7 ndarca� f Z7 �/1�QC�' 1�V A� l�u r� _� __ uoma rLonc ._ ...... ... � � ' City/+"tate/ZSP � 0.�� ��/��0�6 �uD�c9a 7Luua '39_9-4�`�--- ,._._ S. Nawo oa Paraii.C/71IC i.�Li1tCtW6 than Abevc � ._..._.._... • . ga311n9 wdarcas � � City/s ce/z1p ----._...�.._ � � - � - � . � ��!...111��,,,,...►� �-� Z � �, appli.cation For: �Sitc Lwaluatioa J�apzovc�ent Penait/l�TC O n�c�� 1 �� {. . �. Syet�n to Stswice��liou�e C1 2Zo�ile Home ❑ Dusiae9� ❑ Induatsy � OClicr _„� a S. TYpe ay�tem rngueatcd�Coaventlonal. ❑ eameaeloaal mdifled Q iunbvu�lvc � , i. Z! aeniclencee t PQODle � Eeclroom� � ' o Duthroom:: ..Z..__. �altvlahet QCazb3gn OLyoasl �OAing NSebino �SaocnenclPlwebiny OW:mnnnL/Ho ilwd�in� � 7. if Dualaass/Sndn�Ccy/Otllns� �u1I7 Crpe B Ycoplc 1 SinG: . i Comwdeo 4 Shoreze � osiaale 0�aecr ceelorn�___, , IF FOOD3ERVIC�s 4 saate �stimatnd Fiater Uaage (�allona pnr c'wy) �' ' e. zyt�c ot wacar aupply��Cou�ity�City 0 Wb21 ❑ community . �. no you .aciciyuo �aasetoan or exgansions o[ti�c faeililr Uils syslem is iulcudcd lo scrrc?❑a'cs ��u Ifycs,�vhatty�pc? • - • • '"!A!1'O �•CLlENTSdif�C7'COMNIIT,ETF1 RL•'QU!/UiDNll01'L•'!Yl'YINFOIN•L\h'lONltLQUIiSPI'sll I3BI.0 . LTlcbcr a PLnT or SITL J'L.r�f+ •SU IC17LD br thc cGcnt��ilk TkIIS Al'Pl,lC��T{OTV. 3'roperfyUimcnsiuur. �nsxa�� x��sxa4s lYltlTi;DIItECI'10�lS(fYunihlncl:srilic)ful'1tUPlilt'fl': Taz O�ce PiCt: OS��4�-�S-�es"`S(� l54_ E0.5� '� ��s'T O r1 PropertyAddrrss: RoadNuac_(f���l0�t�� 1.)�iV'e. _�c�XG.n� I�naGl. �IC� �nnf� cicy/z�P�c�v, .�C, al�0b �R-�v� . ICin a Subdivisionprovidci�formaUon,as[uiloirs: Nawc: - ' See(ion: D1ocL-: Lot: Datc homc eorncrs IIapbeei: /0 � TL'u ts to eerGfy that the infarmatiou proridcd is carrcct lo Wc 6rst of mr kaotixlutgc.1 wtJcnland lHal anp�tcn„i!(s) issucd Gercaf�cr ara sabjcct to suspeusion or tevoea4on,if t!u stte plans or intenJed use cl�ange,pr iI Ilie tuforaiuliud subtui(ted in tl�is appllCaiiou ts falsili¢A or cLatycd j,clto,.Wu(erstaudlJtall uni trxporisiGlc�ora!!drarga inctrrr�•�l frnm ""' • rbis��pplicr7TG,fr. I�lcrcbp,gisccauscuttolhcAufkortu;clRcprescutatirrotctrc�avicCamq•IIcnitl )cp�rliiic t (o ciuer upon aboti•e dcseribcd property luexlcd iu DavIe Coun�r and otiy�ccd br E,s �.eJj� to cunduc�111 IesGng pr cGd res ns necessary tu dclermine the si[e suitab;litr. �- brl'rL � 6 sIGNATUItE � TIi1SAR�AMAY�USLDTOitDItAWINGYOU.RSITEPLAN(Iud callo[thoLuAo�r;ug: LsLcliugnuJprnposcd . preperty Iincs an�I dimeusioiu, struetures,scWacks,aud septie loeations). , ' . , Sitc ltevisit Chargc ` Dalc{s): � , • � ClicutNolificaUouDutc: . � I�IIS: - . .. Sign givcp ' • A.ccount No.��. '�J'.' . .Rnvian t Tnan rnc�m �n.J � �G � z . . . DAVIE COUNTY HEALTH DEPARTMENT . � - ., . . . - � , - Environmentcal Health Section ' - � : � " '� Soi�/Site Evaluation � _ ; , APPLICANT INFORMATION . -� - PROPERTY INFORMATION Account #: 990002706 � - Tax PIN/EH#: 5861-48-6550 � ' Billed To: Jeff;Hayes � Subdivision Info: - .. Reference Name: Location/Address: off Redland Drive-2700 �.,.: Proposed Facility: Residence Property Size: 175 x 245 Date Evaluated: � : ' ���i. � . , . .. � . ' � . � � '.�i.�,,� � - , . . . . . . . . Water Supply: On-Site Well Community ' Public . � Evaluation By: Auger Boring � � Pit Cut : • � . ' -. FAC"TORS 1 2 3 4 5 6 7 Landsca osition � � ' . Slo % ' HORIZON I DEPTH p— ' —�2 p—�t? Texture rou G� Consistence �S Structure Mineralo • HORIZON II DEP'TH .-C.1-O ') - � � - Texture ou - Consistence ;S ' Structure S ,� , Mineralo ' +'• , HORIZON III DEPT'H .� ': . Texture rou 'Consistence �S "- � Structure -. S ._ ..-;-,.« • . � Mineralo ! . . . HORIZON IV DEPTH Texture rou - Consistence ; � Structure � . • • Mineralo - SOIL WETNESS - RESTRICTIVE HORIZON ` '_ SAPROLITE . CLASSIFICATION ' � LONG-TERM ACCEPTANCE RATE � --a STI'E CLASSIFICATION: _ EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D° � 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-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed ote 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-gaUday/ft2 DCHD OS/99(Revised) , _ - ■��■���■��■��������■�����■���■■��■����■■��■����■��■��■■■����\���■■ ■�������■�����������o�����■����■��■������������■■�■���■��������■�■ ■�■�����■��■������������■��o�■�■�■■■�����������������■����������■ ■�■��■������■■��■��■������■����■ 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