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754 Riverview Rd , , •• �'' DAVIE COUNTY HEALTfI DEPARTMENT , , • Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 — .� (33G)751-8760 Account #: 990003675 Tax PIN/EH#: 5776-24-3587 � Biiled To: Ronald Shoaf Subdivision Info: Reference Name: Location/Address: Riverview Road-27028 Proposed Facility Residence Property Size: 4.75 acres ATC Number: 4141 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 Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON U�ION IS VALID FOR A.PERIOD OF FIVE YEARS. O S Environmental Health SpecialisYs Signature: �' Date:�`'�� � accepted Systems may also�be use 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.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. ��, �� /� tir /G2 � �i2 � � Septic System Installed By: ��/�//��� Environmental Health Specialist's Signature: ��ct'� _ Date:��1� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT , � '' . . Environmental Health Section - P.O.Bog 848/210 Hospital Street �� , /��� • ' Mocksville,NC 27028 ����� (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003675 Tax PIN/EH#: 5776-24-3587 Billed To: Ronald Shoaf Subdivision Info: Reference Name: Location/Address: Riverview Road-27028 Proposed Facility Residence Property Size: 4.75 acres ATC Number: 4141 **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 �' #People #Bedrooms �3 #Baths�_ Dishwasher:Ja Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � � Type Water Supply—l�-b�esign Wastewater Flow(GPD)�_� Site: New�Repair❑ System Specifications: Tank Size,�pGAL. Pump Tank GAL. Trench Widtl�� Rock Depth�'v Linear��� , Other: � CAC 18A.198�5) Required Site Modifications/Conditions: ��R'l�d Sy�tems may also be u�d IA'[PROVEh1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G"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(33C►)751-87G0.**** ��� � 1/�s`�`���rC� ;�. �, . �� ����..����-���� . . � � - . , ' Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � � � , . � ._. ,:..: ,:'�' � l� L'y � V t5 , , � � t � APPLICATION FOR SITE EVALUATION/IhiP1iUVEM11ENT PCIiM111T& , Davie County Health Department • Environmenta/Hea/t/�Section ��� ,� � � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ' � £I'NtRONMENTAI HEAl1H ***IttPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL � INFOR2dATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nama to be Dilled /���✓��C% 5�7�9� Contact Person /�n-yMci �/'�`•'�� Mailing Addresa 2�.� �f/�.�.r,�-� .� Iiome Phone c�/.��G�Z-z'�l City/State/ZIP �/,.�rc'-��^'� �G Z%�Z`� Busineas Phona ��,�— �2Z' 7�f` � 2. Name on Permit/ATC if Difforent than Above Mailing Addreas City/3tate/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC nqth 4. system to service: Fiouse ❑ Mobile Homa ❑ Dusiness ❑ Industry ❑ Other 5. lypo nyntem requeated: Conventional ❑ convantional modified ❑ innovativa p ac�ep te d 6. If itesidence: # People � Bedrooms � � Bathrooms J iahwasher ❑Garbage Dieposal �Washing Machine ❑Hasement/Plua�bing ❑Banement/No Plumbing 7. =E Huainesa/Industry /Other: verity type # People � Sinka � Commociea # Showera A Urinals # WaCor Coolera IF FOODSERVICE: �# Seats Estimated Water Usage (gallons per day) s. Typa ot water aupply: ❑ County/City ❑ Well D Community 9. no You anticipate additions or cxpansions ot thc fncility tliis system is intecided to scrvc? �Ycs ❑No Ity�cs,�vliat typc? ***IAIPORTANT"�**CLIGNTSMUSTCOAIPLETETIIE RLQUII�LD PROPCRTY INrORNiATION 1tEQUGST[:D BGLOW. Eithcr�PLAT or S1TC PLAN 1L1UST BE SUlTAt17TED by thc dlcnt �vith TI IIS APPL1CATiON. Property Dicncnsions: � �� 1VRIT�DIRGCTIONS(from Nlodtsvillc)to PItOPGRTY:` T�,orr,��i'IN: �� s��6 z�f 35�7 �w1 cy �rf- T ,�� �i . . Property Address: Road Namc �` ���e�"`� � � �`'•✓ a �'`� d-'� � G /�,,..�.. City/Zip ` ��:�-�cc�i�.-✓ �-� �-� si� �/ If in a Subdivision providc inforniation,as follotivs: � •�•�/� o-.� ���/-�. Namc: . Scction: Blocic: Lot: llatc lionic corncrs tlaggcd: � ; 1'his is to ccrtify tl�nt tl�c iuformation providcd is correct to tlic bcst of ii�y knowlcdgc. I undcrstand tl►at any permit(s) � issucd l�crcafter are subjcct to suspension or revocation,if tI�c site plans or intendcd usc cl�angc,or if tlic information subnutted in tl�is applicatiou is falsiGed or cl�anged. I,also,rurdersta�id 11iat I a»i responsible for al!cJlarges incrrrred froui tlris applicntiu�i. I,hcreby,givc conscnt to tlic Autl�orizcd Representativc of tlic Davic County Iicallh Departmcnt to enter upon above described property Iocated in Davic County and otivned by to conduct all tcsliiig proccdures as iicccssary to detcrminc tl�c sitc suitability. �/' /� .�,f' : DAT� /� SIGNATUIZ� ���� , , THIS AI2�A AZAY B�US�D TOR DRAWING YOiJIt SIT�PLAN(Inclucic all of tlic follo�ving: Existing a�id proposcd property lines and dimensions, structures, setbacks, and septic locations). � Sitc Revisit Cl�argc . Datc(s): Clicnt NotiGcation Datc: �HS: � � � �7s Sign given . Account No. . . �9,� 9 Reviscd DCHD(OS/03 Invoicc No. . , ; . :z . ,� , :' ��g �� (3.39A) w ������ ..�.�'. ��t� �M 3587 � .- � �'�°" j � � � 7 (1316) 1p4.3 � -� �' � � C3� 6.27A ,� M 3120 � `'� �`5290 0 ^ � . . DAVIE COUNTY HEALTH DEPARTMENT . ��� N�` Environmental Health Section M � � � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003675 Tax PIN/EH#: 5776-24-3587 Bilied To: Ronaid Shoaf Subdivision Info: Reference Name: Location/Address: Riverview Road-27028 Pro e Size: 4.75 acres Date Evaluated: f�� �roposed Facility: Resi�ence r rtY Water Supply: On-Site Well Community Public % Evaluation By: Auger Boring Pit ✓ Cut L/ FACTORS 1 2 3 4 S 6 7 Landsca sition L� L Slo % HORIZON I DEPTH -�� �/ Texture rou � _ Consistence � (/— Structure ' �-- Mineralo r ' � �' HORIZON II DEPTH � ' Texture rou Consistence � r' _ Structure Mineralo � `/ ` HORIZON III DEPTH ' Texture mu 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: i REMARKS: LEGEND . , T. n cca=e 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 T� . , 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 ('ONSISTF.N . a. a'1415� - VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 33..�.' t • NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic . P-Plastic VP-Very plastic . r> >r SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv -1:1,2:1,Mixed ZIO� 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/OS(Revised) ■��■�■��■�■■��■�����■��■�■����■��■�■�■����■��■�■■■�����■�so��ses■■ ■�■■o��o■�■���������■���■■�■�■■�����■�■■�■����■■������■■■�■■■��■■ ■�■■�■■�■■■���■�����■■■�■■����■■ ■■���■�■■��■�■■��a��■■���■�o■�■■ ■��■��■■■■�■■����■�■■�■■■■■��■��■�■■■��■■����■■�■��■��■■�■�■�■■■■■ ■■�■�■t������■�■�����■■�■�■��■■■■�■■�■�■���■�■■�■■�■���■■■���■���■ a�■���■■s��■�■��e��■�����■■����■��■��■�■�■��■�■���■�■��■■■■������■ ■■■����■�■�■■��■��■■���■■�■�■��■■�■�■��■���■■■s����■�■■�■��■�■�s■■ ■�■��■�■■�■�■��■■��■���■�■■�■���■�■�■��■■■��■�■��■�■�����■���■���■ ■�■■�■����■��■■�■��■■■���■����■��■■�r�������■��■�■■��■��■■���■���■ 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