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1819 Ridge Rd (2) � • � �Q � .��-�� . = � , .{ . . DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Heaith Section , ' P.O.Boa 848/Z10 Hospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990003640 Tax PIN/EH#: 4798-60-1430 Billed To: County Line Volunteer Fire Dept. Subdivision Infa Reference Name: Location/Address: 1819 Ridge Road-27028 Proposed Facility Gym Property Size: 1 acre ATC Number: 4100 r 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 Of�ice 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 CONST UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � CERTIFICATE OF COMPLETION **NOTE** T'he 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. 3c stnne � fur -4����� a � o�k}�.a. s P n`�' a,.5��� w'��.�'", � . _... �+�' �w`' �.__. ^_» crFF' Sys 1" ° . cl..� h�� u��.,y P d �� d s a��`'`-,, �'�°� Z l4 . Q _ 3� .r,S�"" �'�5�. �� �`�i• �k�, �o� � ���� S� a!��l ZV��,�.. . - CowlTa'� � �'�v�L Z'S�"'M`k�,�w k �1� ._ • � c,�--�s � `„��z � p�� �.� L � ' - Septic System Installed By: ��.or.. /��Or.w�-Q� \ Environmental Health Specialist's Signature Date:��9'� �i DCHD OS/99(Revised) .,� • DAVIE COUNTY HEALTH DEPARTMENT ; ' ; • Environmental Health Section � . , P.O.Boa 848/210 Hospital Street � , Mocksville,NC 27028 � � / �� v� • (336)751-87(0 IMPROVEMENT/OPERATION PERMIT �l� .a� Account #: 990003640 Tax PIN/EH#: 4798-60-1430 Billed Ta County Line Volunteer Fire Dept. Subdivision Info: Reference Name: Location/Address: 1819 Ridge Road-27028 Proposed Facility Gym Property Size: 1 acre , ATC Number: .4100 **NOTE**This ImprovemendOperation 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: ❑ Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type� #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply� Design Wastewater Flow(GPD)� Site: New� Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widt��Rock Depth��Linear F�� Other: 'Y�.�Sn'!/�D L'S '�/�/� !J<�S' L/'%'��1.� ���%�.�! � `�� v� � _ ��'`�� a`�� Required Site Modifications/Conditions: ��, INIPROVEMENT/OPERATION PERMIT LAYOUT.-. APPROVED EF LUEN R 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 9:3 a.m. . . . . . Telephone#is(33G)751-8760.**** . . ��� ���� �� . � � �0 ,a�- ��D�a'/ .. � � � � � � , -� , � .:�, ':.f�: :., ;...� , .; _. Environmental Health Specialist's Signature: Date: C� DCHD OS/99(Revised) , y, .� �, , �.. � „n � . � (� � U � • • APPLICATION FOR SITE EVALUATION/Ih1PROVEM1iCM PERMI ' ' Davie'County Health Department � �.�05 Environmenta/Nea/th Section ��N � •. P.O. Box 848/210 Hospital Street � Mocksville, NC 27028 MEI`rSA�H�� (336)751-8760 '�pp��,COUN� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to �he INFORMATION BULI,ETIN for inatructions. 1. Namo to be IIilled G��/nT�/ ��n-� tJv,(,,�� T���l.r�R�v�/� Contact Pernon ���� G- /S6onT'L T�^t OWi�c•f�e S — �y�� Mailing Addro3a �g �t°`�,/,-.,t /p� Homa Phone srgy�/_/�� 7� G 1/Z-/ � City/State/ZIP �eal�3✓i�LQ ./�/.C� }7vY� Buainesa Phono 2. Namc on Permit/ATC iE Differont than Above ' Mailing Addres$� � City/State/Zip 3. Application For: ��3ite Evaluation ❑ Improvement Parmit/ATC BoCh 4.. Syatem to service: ❑ House � riobila Home L7 Businest� 0 Industry �Other ��j _ 5. Typo syatem requested: �Conventional ❑ conventional modified ❑ innovativo • 6. If Residence: # People & IIedrooms # Bathrooms ❑Diahwaaher ❑Qarbago Diapoaal OWaeshing Machine ❑Dasemont/Plumbing �IIasomont/No Plumbing 7. If Dusineas/Induatry /Othar: verify types'�q�L ��I��„_ N People 8 Sinkn � � Commodea+� # Showera � � Urinals , �.� _ # Water Coolers �_ —��r— —��•— IF FOODSERVICE: # Seatu Estimated Watar Usage (gaiiona por day) 8. Type of wator aupply: �County/City ❑ Well � Community 9. Do you anticipate additions or cxpnnsions of tl�c facility tliis s}�stcni is intcndcd to scrvc?0 Ycs �No If ycs,tivl�at typc? ' ***IllIPORTANT"'**CLIENTS AIUSTCOAIPLETETII� IiGQUIItCD PROPCRTY 1N1�ORA7AT10N I2GQUGSTCD B�LOW. G(tl�cr a PLAT orSITI;PLAN AfUST BES[16r1fITPL•D by lhc clicnt witl�TIIIS APPLICATION. Properiy Diuicnsions: / 1VRITL D[RLCTIONS(fran Mocics��illc)to PROI'LR'I'1': T�X om��rirr: f���'S'� G � l�f .� o ,.,�y �y u.�..,�- �1�0-,,��:r�� .���,�,,,;4 Property Address: Road Namc,�8'l9 J�:�,c ��/ Ac.,��, �[°o.c�l G���ie.c ST,f7i o w � . c;cyr�n s���k5�;��- ap�.,� F�,c�/ If in a Subdivision providc ii�formation,as follotivs: Namc: Scction: Blocic Lot: Datc liomc corncrs ilaggcd: � � a � Tbis is to ccrtify tl�at tl�e inforniation provided is correct to tlie Lest of my I:no�vledge. I understand tl�at any perinil(s) issucd licrcaftcr are subjecYto suspcnsion or rcvocation,if tlie site plans or iiitecidcd usc cl�ai�gc,or if tlie iiiformalion subn�itted in tliis application is falsified or cliznged. I,also,rur�(erstn�rd lhat I ani resporrsible jor n11 clrarges i�tcurrerljro�n tbis applicalioir. I,i�crcby,givc conscnt to tlic Authorizcd Represcutativc of thc Davic Counly Iicallh Dcparhucnt to cntcr upon abovc dcscribed propertp locatcd in Da��ic County�and o�i�ncd Uy to coi�duct al!tcsting proccdures as ncccssar��to detcrtiiinc tl�c sitc suit bilit}�. DAT� , ,Jr-�-(�- � � SIG1�iATUIt� . � TIIIS AR�A MAY B�US�D rOR DRAWING YOUR SIT� (Includc all of tlic following: Lxisliug and proposcd property IIncs and dimcnsions, structures, sctbaclts, 1nd p c Iocations). Silc Rcvisit Cliarbc : � , Datc(s): � "/�( �'S Clicnt NotiCc�tiou Dutc: ���Z-� ��: �-�� � � �-� . �HS: . � g a � SIgn given � � d Account No. �-� �f� Rcviscd DCFID(OS/03 Invoicc No. � � 7 � '' . ,�, . DAVIE COUNTY HEALTH DEPARTMENT � . � Environmental Health Section � Soil/Site Evaluation � APPLICANT INFORMATION � PROPERTY INFORMATION Account #: 990003640 Tax PIN/EH#: 4798-60-1430 Billed To: County Line Volunteer Fire Dept. Subdivision Info: Reference Name: Location/Address: 1819 Ridge Road-27028� Proposed Facility: Gym Property Size: 1 acre Date Evaluated: ����`"� � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo e % HORIZON I DEPTH ' //' � !/ Texture grou cL L. Consis[ence Structure - r Mineralo e' � HORIZON II DEPTH '� �/ " Texture rou Consistence Structure / Mineralo . HORIZON III DEPTH '�' Texture rou Consistence � Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: LEGEND T.an s aR,e 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 Textiug � _ 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 . .ON4IST�.N . . II'IQ1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky - SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S r� �r _ SC-Single grain M-Massive . CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed �� 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-gallday/ft2 . 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