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211 Ridenhour Rd DAVIE COUNTY HEALTH DEPARTMENT n� 3 J �-`� a 1 . ' Environmental Health Section ! � 1S , � - �- ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001575 Tax PIN/EH#: 5754-95-5315 Billed To: Dennis Adams Subdivision Info: Reference Name: Danny Ridenhour Location/Address Ridenhour Road-27028 Proposed Facility: Residence Property Size: apprx.7 acres **N��*��tiis�ImprovemenbOperation Pecmit DOES NOT authorize the construction of a septic tank system or any wastewater -system. An ALJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building perrrtit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERNIIT 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 l� #Baths�_ Dishwasher: � Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size c 7AC Type Water Supply� Design Wastewater Flow(GPD)�� Site: New�Repair❑ System Specifications: Tank Size/'�GAL. Pump Tank GAL. Trench Width c'����Rock Depth��Linear Ft�/ Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATTON 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 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.**** 1" Environmental Health Specialist's Signature: Date:���`'�l DCHD OS/99(Revised) � �� � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 Account #: 990001575 (336)751-876(l�ax PIN/EH#: 5754-95-5315 Billed To: Dennis Adams Subdivision Info: Reference Name: Danny Ridenhour Location/Address: Ridenhour Road-27028 Proposed Facility: Residence Property Size: apprx. 7 acres ATC Number: 2718 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ��%�C Date: � �O �� � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S Cha ter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee t ia system will function satisfactorily for any given period of time. �aa $� � f � Septic System Installed By:S- 0 ��/1��/ Environmental Health SpecialisYs Signature: �1'�� Date: 'L�`�- /��U DCHD OS/99(Revised) . _..�.�.r..�.�. 1 - . p [� t� � � N1t� � � • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A Davie County Health Depa�tment �kd 1 3 2��� Environmenta/Hea/th Secbon P.O. Box 848/210 Hospital Street . Mocksnille, NC 27028 (336)751-8760 EI�MRONMEMAl HEALiH DAVIECOUNiY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE.REQUIRED INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for ins�ructions. 1. Name to be Billed D���v�5 Adp m s Contact Peraon �N/�/�� ��q� Mailinq Addrees ��7 "A�N�dw �—'Ti` • 8ome Phone / ]�����/ City/State/ZIP � Y��(�C� /y J,.�� 2� v�W Busineas Phone �/T�/ �� � � 2. Name on Permit/ATC i! Ditferent than Above �AN��/ �/L/ENY11��� Mailing Addresa o����%,G�/�//Ul(i�• �4l�� City/State/Zip //��G�,1LJ���C�Ne• p�/��0 3. Appiication For: Cr�Site Evaluation ❑ Improvement Permit/ATC �Both a. syst� to seZ,►3�e: ❑ House f�'Mobile Home ❑ Business 0 Industry ❑ Other s. if Residence: # People � � Bedrooms �_ � Bathrooms �- ❑ Dishxasher O Garbage Disposal Q�washing Machi.ne ❑ Hasement/Plumbing ❑ Basement/No Plumbing 6. If Buainesa/Induatry/Other: Specify type # People � Sinka � Commodea � Showera # Urinals � Water Coolara IF FOODSERVICE: # Seats Estimated Water Usage (gallona pe= a�y� �. Type of water supply: ❑ Couaty/City " �Well ❑ Community a. Do you anticipate additions or eapansions of tLe facility this system is intended to serve? ❑Yes B'No If yes,w6at type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wit6 THIS APPLICATION. Properiy Dimensions: A�U D. ? A�n�`S WR1TE DIRECTIONS(from Mocksville)to PROPERTY: TaxOfficePIN: # S'�Sf�gS=S"3I5— Saa.9��, �DI �o �C���- o�.� Property Address: Road Name o2r//��c��J��OLC,� /4�� �/���fiLr /1��Z �o ✓L'�y'/l7" O/'✓f 2i/��� City/Zip �O G/1 S t�j�/�j Ne.Z70i-S l�iC. .LL�'� a�l! /G,��X�i�/�L'L�UiC� �' If in a Subdivision provide information,as follows: Name: ' Section: Block: Lo�t: Date Property Flagged: � /�3 / a/ 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 applicatioa is falsified or changed. I,also,understand lhat I am responsible jor all charges incurred from this application. I,hereby,give consent to the Authorized RepresentaHve of the Davie County Health Depar ment to enter upon above described property located in Davie County and a»ved by .,; ,� to conduct all testing procedures as necessary to determine the site suitability. r DATE Z�-' I� '' � I SIGNATURE y�+,�;�L�it,c� /,�L� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include alt of the fopowing: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): '�•-- Client Notification Date: _, �, - �_.. - .. - �-- _.._._ _ -.. � EHS• . .�__ ._ . 4 ��� 7 � 1�7 5 _ _ _. Account Na Revised DCHD(07/99) � Invoice No. � � ! � � --- _- - - - _ _ ,,�4 --- - - � 211 060000006801 � w '� (7.58A) � , E„l _ (,Wj � i� 5754955315 t��-,� � II 5315 �� � ��"�' S��f � i I _ � - � � W �; P C I ' \� INDEXED ON 5754 \ \ �I RISIN� STAR MISSIONARY BAPTIST ) / ^ , i I (15.69A) � 4832 �`��� , ,_,, �' , , 123 % ���s� � , � _\ (58�� � j� � ` p�t� .� �� 5� , . - DAVIE COUNTY HEALTH DEPART'MENT � � • • ' Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001575 Tax PIN/EH#: 5754-95-5315 Billed To: Dennis Adams Subdivision Info: Reference Name: Danny Ridenhour Location/Address: Ridenhour Road-27028 Proposed Facility: Residence Property Size: apprx.7 acres Date Evaluated: �2'��✓ Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring s� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition ,L_. �= Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �� ' " Texture ou Consistence �r Swcture G Mineralo -� � HORIZON III DEP"TH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTI-I Texture ou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE _ CLASSIFICATION � LONG-TERM ACCEPTANCE RATE ,. t SITE CLASSIFICATION: v-, EVALUATION BY: G`-���j LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Lineaz 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 tru tur 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 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 DC�ID OS/99(Revised) ■■■����■���■■■�■■�■■���■�■■����■��■■��■■O�■�■■�■■�■�■��■����■��■�■ ■��■■���■■■�■�����■■�■■■�■■�■�■■ ■���■■���������■■�v��■■■���■���■ ■■■■■���■■■■�■����■���■���■�■�■■�■�\��■����■■���■�����������■���■ ■�■■■��■■■■■■■�■■�■■�����■■���■■�■■����■��■����■��■�■��������■�■�■ 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