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187 Shore Ln . - . DAVIE COUNTY HEALTH DEPARTMENT � I�--a,b ��� � Environmental Health Section � • � P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001467 Tax PIN/EH#: 5803-39-4724 Billed To: Danny Shore Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27055 Proposed Facility: Residence Property Size: 2.064 acres i4TC Nurr�ber: 2626 **NUTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a 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 PERMIT 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 V #Baths�_ Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: � BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��C Type Water Supply� Design Wastewater Flow(GPD)_<'� Site: New�Repair❑� ,, ��;' 2 System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width;��i Rock Deptn� Linear Ft.�' Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION 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 of this 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.**** � ! ` Environmental Health Specialist's Signature: Date:,���8'!�� L/ DCHD OS/99(Revised) • a /J d� • DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001467 Tax PIN/EH#: 580�39-4724 Biiled To: Danny Shore Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27055 Proposed Facility: Residence Property Size: 2.064 acres ATC Number: 2626 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signahue: „��� Date: /6 ��"� CERTIFICATE OF COMPLETION **NOTE** The issuance of this 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 uarantee that the system will function satisfactorily for any given period of time. /��X� �,a y���,,�� � �- S tic S tem Installed B : � eP YS Y � Environmental Health Specialist's Signature: ��,� Date: s %3(��(�� DCHD OS/99(Revised) - ` � ' �� `� a,�en-� ���� ��o�- 3�- ��a� p � �o a ,nl �fAPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC � Davie County Heaith Department QCj � 1'CJ Environmenia/Kea/th Section 2`5 Z��� � P.O. Box 848/210 Hospital Street � Mocksnille, NC 27028 ����ONMENTAL HEq (336)751-8760 �A�IECOUNTY � ***Il�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALI, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORt�TION BU7�LETIN for instructions. 1. Name to be Billed n �� r � Contact Peraon 1 � Mailing Addresa � �f[."'( �r VV i ��,Some Phone riTJ(fJJ �/Y0� l �W 7 ��, City/State/ZZP � , IY Business Phone O / � / � 1 ��i n �T ta . Name on Permit/ATC f Dilferent than Above �'� � �- G�' n Mailinq Addresa City/State/Zip �CQ�,�S�G.� /o�3 u�a° 3. Application For: �Site Evaluation ' �Improvement Permit/ATC ❑ Both a. sy�et� to se�ioe: l[�iouse ❑ Mobile Home � Business � Industry ❑ Other s. If Residence: t People � � Bedrooms � i Bathrooms � �ishxasher 17 Garbage Diaposal [1/�7ashing Mschine O Bssement/Pluaibing ❑ Basement/No Plumbing 6. I£ Hueineea/Industry/Other: Speci£y type i People M Sinks # Co�des � Shoxera � Urinals * Water Coolera IF E'OODSERVICE: # Seats Estimated Water Usage (gallona �r aay) �. Ty�e of water supply: � County/City �Well � ❑ Community e. Do you anticipate additioas or eapansions of the facility this system is intended to serve? 0 Yes '�o If yes,what typc? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTGD BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client wit6 THIS APPLICATION. Property Dimensions: ��v� T �� WRITE DIRECTIONS(trom Mocksville)to PROPERTY: � i� Tax O�ce PIN: # 58b3 -39- �f�'a� tOC�� � fi0 U ��� G�'1C-�-� Property Address: Road Name , '�• 'C�• �� J tI2 m� 1 e ��'S� �'`�j c;��z�p �la��n����I�Nc.. _� �'cr�ew a.�-� on I��f— If in a Subdivision provide information,as follows: Z��`� �t' r� , �-1 �• 'C� • Name: Section: Block: Lot: Date Property Flagged: D 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 revocatioa,if the site plans or intended use change,or if the information submitted ia this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from !h!s app/ication. I,hereby,give coasent to the Aut6orized Representative of the Duvie County Health Departmcot to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suit i DATE IO `7 � SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge � Date(s): �e..w� � Client Notification Date: ,C,�jL`L_cL.e.'''�'� EHS: , lJ Account No. ��o� " �Ivl���,�a 1 ��`J�-. Revised DCHD(07/99) nvoice No. � !N✓.� �r.S L�f-.e / �1-7/o 0 � ��- l�z 3 ' ' � � - ' � DAVIE COUNTY HEALTH DEPARTMENT ' • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION -' Account #: �9Q001467 Tax PIN/EH#: 5803-39-4724 • Billed To:��anny Shore Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27055 Proposed Facility: Re�E� Property Size: 2.064 acres Date Evaluated: _ /�j d� f�a 'Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �� Pit Cut L� � FACTORS 1 2, 3 4 5 6 7 Landsca e osition 1L L Slo e% � HORIZON I DEPTH Texture rou Consistence Structure Mineralo 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: � �S EVALUATION BY: ` LONG-TERM ACCEPTANCE RATE: 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-Tenace 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 Moist _ CONSISTENCE VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-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 Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic ' Mineraloav 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 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D��IE;��UIV'1'Y��I.T�I I}}���Tbi�NT._.._._ . ._... �_ . �., _:..,.; � ' ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street � Courier #09-40-06 Mocksviile, NC 27028 Phone #: (336)751-8760 October 27, 2000 Danny L. Shore 2669 Liberty Church Road Yadkinville,N. C. 27055 Re: Site Evaluation/Liberty Church Road Tax Office PIN: #5803-39-4724 Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 26,2000. Based upon the information provided on the Application for Site Evalurrtion and after an evaluation was completed on the site,the site was found to be provisiori�lly suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, ��'�`����• . Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s)