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253 Singleton Rd - •. . • DAVIE COUNTY HEALTH DEPARTMENT " � Environmental Health Section P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003329 Tax PIN/EH#: 5755-80-7673 Billed To: Terry Bates Subdivision Info: Reference Name: Location/Address: Singleton Road-27028 Proposed Facility Residence Property Size: 300'x 600' ATC Number: 3853 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). T'E�S AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� /� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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. � � �s �5� ,- � ��Septic System Installed By: _�,� � ✓i �� Environmental Health Specialist's Signature: � l� Date: // /��� ��' ^Z�— DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT . ,� � Environmental Health Section d � 2 �D � . ' P.O.Boz 848/210 Hospital Street � � Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003329 Tax PIN/EH#: 5755-80-7673 Billed To: Terry Bates Subdivision Info: Reference Name: Location/Address: Singleton Road-27028 Proposed Facility Residence Property Size: 300'x 600' ATC Number: 3853 **NOTE** This ImprovemendOperation 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 �f #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�i,/l Design Wastewater Flow(GPD)��� Site: Ne�Repair❑ ,, �� System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width���tock Depth� Linear F�SD� Other: Required Site Modifications/Conditions: I1�IPROVEi19ENT/OPERATION PERMiT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISt1ED 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(336)751-8760.**** � Environmental Health SpecialisYs Signature: Date: � � DCHD OS/99(Revised) �' `�-,�.!".r�"�"...�""'' . . �. . . . .. . .. . .. . .� �- . .� �. � : . �. �.� � .. . . � � � � CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC , Dc' l�1 . Davie County Health Department Environmenta/Hea/th Section A�G 1 9 �" p.o. soX 848/210 Hospital streat Mocksville, NC 27028 ROtyMENip1.lIEA1� (336)751-8760 ***I *** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED NFORMATION IS PROVIDED. Refer�to the INFORMATION BUI,LETIN for instructions. t.. /' i. x�e to be Billed I���r({� '��'�{'S cont8ct Parson S�me vc P�pr�n�� '�t��eS . Mailing Address _o�`� 3 S�tlq e�O 1.�} C`� Home Phona 3�6� ���--c���� City/3tate/ZIP m�C�(s�?i��� �L, c���cl� Buaineas Phone ��(�" � / j "'�a�� 2. Name on Permit/ATC if Different than Above Mailing Addreas City/State/Zip , 3. Application For: � Site Evaluation ❑ Improvement Permit/ATC 0 Both - 4. syatem to service: �3"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other `5. Type syatem requested: LI Conventional ❑ conventional modified ❑ innovative 6. 2f Residence: # People ,�_ # Bedrooms � # Bathrooms �_ L Dishwasher ❑Garbage Disposal �Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Susiness/Induatry /Other: verify type # People # Sinks # Coa�odes # Showera # Urinala # Water Coolers IF FOODSERVICE: # Sests Estimated Water IIsage (gallona per day) 8. Type of water aupplys 0 County/City 0 Well ❑ COmmutiity 9. ao Yon anticipate additiona or expansions of the facility this system is intended to serve? O Yes 0 No If yes,what type? ***IMPORTANT'k**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. i Property Dimensions: 3Q�� � � Da WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: � # �� J�� ���h / � �Dl So�l7Li �b Jc7� �O � , dor Property Address: Road Name ,��`/tJc� %�tJ� ►�� C�n�'',tIG(� S�c1�l y� C�i�t?�2✓J �� City/Zip/�cC�C d��/% a���� /�� iPc.� �c112n1 �,P«- ;�O �v . If in a Subdivision provide information,as follows: S�r��,�P�� l�n� �Lll�N k"���/�� Name: � r� /�vtl S� c9 itl ����{' /��20S S �r�n r�-� r�o i�d. Section: Block: Lot: Date home corners flagged: ��2 0:�o y 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 application is falsi6ed or changed. I,also,understand tliat I am respoirsible for all cfiarges incrrrred from tl:is application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and o�vned by '`� - S to�conduct all testing procedures as necessary to determine the site suitability. DATE B� I SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include a 1 of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge • Date(s): Client Notification Date: : EHS: Sign given �/ Account No. �� �� Revised DCH (OS/03 Invoice No. _��s� i/ a � . 23 � � p� D w � i_. . 'x�sf,,,�, or.., . µ w --, -_-. 5� o � D � a�` ' ...... ..,, .. . . �. �i,�..� v v �i W �, . : � � - ;� _ � ����`..o ' d�..:�-�_ 711 N j � ��\ �/ N � 1 N _ . _..., �_ �� . 9 --- W-0-- 969 � � PA � 5�9.� W , W LI� . � � ' _...- � D �� �� . _ . 30.� � - w . - � ' „^ . , DAVIE COUNTY HEALTH DEPARTMENT ' ." - Environmental Health Section ~ Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003329 Tax PIN/EH#: 5755-80-7673 Billed To: Terry Bates Subdivision Info: Reference Name: Location/Address: Singleton Road-270 8 � Proposed Facility: Residence Property Size: 300'x 600' 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 osition Slo % HORIZON I DEPTH !/ �"y Texture rou L �� � Consistence Structure � Mineralo HORIZON II DEPTH '� Texture rou Consistence � Structure Mineralo � .` HORIZON III DEP'TH � 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 � 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 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 ois 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 truct re 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 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 DCHD OS/99(Revised) ■�����■■��■��■��■��■■������■■��■■�e■■��s■���■��■■�■■�■�■■���v■■�■■ ■�������■���■��������■■��■�������■��������������■�■■����■������■�■ ■����������■���■�����■�■�■s������■���■■��■������■�■����■���■■���■ ■����■���������■����■��■������■■ ■����■���■o�■■�����■■��■���■���■ ■����■�����■�����������������■�■�����■��■��■���■�■���■�■����■�■�■■ ■■��������■��������■�������■����■��������������■��■���■■�����■■��■ ■��■������■��������■�����■�■■���■■�■■�■�����������■■��■■���������■ ■����e�■■�������������■��■■�■�■��■■�■■■��■■��■��■■�■�■�■■�����■�■■ ■������■�■�■���■�■�����■���������■■���■■��■��v■�■��■■���■��■�■■■■■ ■����������■���■����■�■■�■■�■�■��■■���■���■�����■■�■■���■■��■■�■�■ 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