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144 Sand Clay Ln DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section •� . P.O.Boa 848/210 Hospital Street ' � � . Mocksville,NC 27028 � (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001731 Tax PIN/EH#: 5729-02-2592 Billed To: LaH►rence Cranflll Subdivision Info: Reference Name: Location/Address: Sand Clay Lane-27028 Proposed Facility: Residence Property Size: see map �1TC N b�r: 2840 **N TE** �iis mprovement/Operation Pertmit 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 PERNIIT IS SUBJECT TO REVOCATTON IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT 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 #PeoplelShift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) `l � Site: New�Repair❑ System Specifications: Tank Size,��GAL. Pump Tank GAL. Trench Widtl��� Rock Depth� Linear Ft.� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- ROVED E � T FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a r entative of avie e�artment for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.t 1:30 p. .on ation. Telep one#is(336)751-8760.**** 1 �e�%9"5 �-� �n�e , ��h " �r U� ��d 6 S�� , _ � Environmental Health Specialist's Signature: �� Date: � 1.�'�� DCHD OS/99(Revised) . �� .� � DAVIE COUNTY HEALTH DEPARTMENT ' . Environmental Health Section P.O.Boa 848/210 Hospital Street ` Mocksville,NC 27028 (336)751-8760 Account #: 990001731 Tax PIN/EH#: 5729-02-2592 Billed To: Lawrence Cran�ll Subdivision Info: Reference Name: Location/Address: Sand Clay Lane-27028 - Proposed Facility: Residence Property Size: see map ATC Number: 2840 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 WASTEW R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ��` Date: s �s- a� 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 tak � a tee that the system will function satisfactorily for any given period of time. � �� 5 �� � � Septic System Installed By: �� ..,�� �����1. Environmental Health Specialist's Signature• Date: DCHD OS199(Revised) � ' �pS l�t��z p _ � C� OMC� ' APP ON FON SITE EVALUATION/IRIPROVE]VtEM�PE1tMlT&ATC � M�, Q 2001 Davie County Health Department Envirrvnmenta/Healtfi Section � J P.O. Box 848/210 Hospital Street EDMRONMENT/�!HEAL1}r � Mocksville, NC 27028 UAVIECOUNTY (336)751-8760 ***Il�ORTANT*** THIS APPI,ICATION CANNOT BE PROCESSED UNLESS AI,I, THE REQUIRED INFORI�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nama to be IIilled ' y' � Contact Person Mailinq ,Addreas �� I(a �V(0`��/InI � • Home Phone - "z!, . City/State/ZIP � � � Buainesa Phone 2. Name on Permit/ATC Z Diiferent than AY>ove Mailing Add=eas J(��.Q �5 �p� City/State/Zip 3. Appiication For: ite Evaluation Improvement Permit�ATC �Both 4. Syatem to seL,.i�a: [s�ouse ❑ Mobile Home O Business ❑ Industry O Other s. If Residence: � People �� � Bedxooms � # Bathrooms � l�D�hwasher U Garbaqe Diaposal ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbinq 6. If Bueinesa/Industxy/Other: Specify type � People # Sinka � Coarmodes # Shoxers � Urinala # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallons per a8y) 7. Type oP water supply: County/City ❑ Well ❑ Community s. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Ycs �]-�'� If ycs,what typc? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRLD PROPERTY INFORMATION REQUESTGD BELOW. Eit6er a PLAT or SITE PLAN MUST BESUBMITTED by the clicnt with THIS APPLICATION. Property Dimensions:. .�� /�',�� �VR1TE DIRECTIONS(from Mocicsville)to PROPGRT'Y: Tux Oftice P1N: # �`7a79 -OZ �aJ`9Z �n7/,(� 7U I"�/�C(0/1_( �G�l�(���- �5�/t.C2.'l[� 0�1 K.�T ` �Property Address: Road Name < (1 ���. (� � ��ty,�,p m�n��,(I�. � �- Z7DZ8 � � �� �. If in a Subdivision provide information,as follows: ,,�(.��'lphl �.t .(�, ���..Ln�/1a(i.(J14U ��..�.Q .. , Numc: Sectioa: Block: Lot: Date Property Flagged: � �� � � This is to certify that the information provided is correct to the best of my knotivledge. I wnderstand that any permit(s) issued herCafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed I,also,undersland that I am respotrsible jor al!charges incarred jronr this applicalion. I,hereby,givc consent to the Authorized Representative of the Davie County Hcalth Department to enter upon above described property located in Davie County and owned by to conduct aIl testing procedures as necessary to determine the site suitability. DATE �'�—�� SIGNATURE �{..I: ;:'I'HIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the follo ' g: Eaisting and proposed ��property lines and dimensions, structures, setbacks, and septic locations). � �� Site Revisit Charge � Date(s): �� (�� Client Notification Datc: \} ' EHS: • . ��a ��/ ��� ��� '� Account No. �� � ✓ Revised DCHD(07/99) I,✓� �� _ Invoice No. �� , � �� � /�-��� va-�. � 'e' 'P . -d— �' DAVIE COUNTY HEALTH DEPARTMENT . . � . � u Environmental Health Section � . , � Soil/Site Evaluadon APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001731 Tax PIN/EH#: 5729-02-2592 Billed To: Lawrence Cranfilf Subdivision Info: Reference Name: Location/Address: Sand Clay Lane-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: _S%Y-d� Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring �� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition �L �-- Slo % HORIZON I DEPTH Texture rou Consistence ' Structure Mineralo HORIZON II DEPTH 6 '' .�G "' Texture ou Consistence � / Structure 6/� S / Mineralo . �" HORIZON III DEPTT-I Texture rou Consistence S Wcture Mineralo • HORIZON IV DEPTH Texture ou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON • . SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ♦ , SITE CLASSIFICATION: b� EVALUATION BY: � LONG-TERM ACCEPTANCE RATE: OTNER(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 Teacture 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 Mois 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 t re SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed otes 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) ■��■����■■�■■■����■■�■■�■■�����■■�■■����������■��■■��■■■■������■■ ■�■��■�������■■v■��■������■����■■��■■�■��■■���■■��■�■■�■■�0�■■ ■■■ ■�■��■\��■■i����■�����■■��■■�■�■��■■■����■��e���■���■.0�����■o�■■ ■�■��■■■��■������������■��■■�■�■ ■■��■���■0�����■■��■�■�■���■��■■ ■��■�■��e�■������s■����■■��■■■��■■���■■�����■����■oaes�����■■■��■■ ■■�����■■��■�■����■�s��■■■o■■��■■■��■■■���■��■��000vo■■■■��������■ ■��■��������■■■����■�■o■■■�■oa■�����■�■■�■■��■se�e�o�seo��������■■ ■�■�■■■���■��■■�■��■�■■�■■��■�■��■��■■■■�■■���■��■��■�����■����■■■ ■�■�������oo■��s■s■■■o■■�soo■■■��■■�■■■■��■■�■■��■�■■��o���v��■e�■ ■�■�������■��■■�■■����■��■��■■■��■����■■■■■■�����■��■s�■���������■ ■�����v���■��■■as■�e��■■�■■�■�■��■�avo■v�■■�����o�■■■�e■��s���■■■ ■������■■�■���■�■�■■�■■■■■��■■■■ 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