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262 Smoot Farm Ln _ . • -. : � � ;_,._`. _:;�' " DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003666 Tax PIN/EH#: 5800-64-8711 Billed To: Angela Roberson Subdivision Info: 2l�Z S�ooT�A�rn (�1NE Reference Name: Location/Address: �Ca �� Proposed Facility Residence Property Size: 1 acre � ATC Number: 4195 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWATER CONS RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. " Environmental Health SpecialisYs Signature: Date: � � , � 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 bc-t�e antee that the system will function satisfactorily for any given period of time. ,�"J' �l �lr-- r /v Cil � /DO 00 � � .� �''�� �� Septic System Installed By: c?31/ �� ,���/> �Ir�f �' 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)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003666 Tax PIN/EH#: 5800-64-8711 Billed To: Angela Roberson Subdivision info: C���,h�-�/ � Reference Name: Location/Address: -27028 Proposed Facility: Residence Property Size: 1 acre **NOTE�*-Th�is�mprovemeiit/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION FOR WASTEWAT'ER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/instailation 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 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 '� #Baths�_ Dishwasher: � 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 G�G Design Wastewater Flow(GPD) L � Site: New� Repair❑ �t �/ System Specifications: Tank Size p�GAL. Pump Tank GAL. Trench Width�� Rock Depth� Linear Ft.� Other: As stated in 15A NCAC 18A.1969(5) accepte ystems may a so e use Required Site Modifications/Conditions: IMPROVENIENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth 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)751-87G0.**** � Environmental Health Specialist's Signature: Date:�_���,���_=���J' DCHD OS/99(Revised) . , � , �� �'` �_` . � _ � 1,- � '" �? (� � �11�L1�71 !i 517E L•VALUATION/lM11PIiUVL:1tiiGVI'1'Llii'411T S A'I'C ��� �t� � D l5 �� avie County Healfh Department �� 1 � nyironmeata/Hea/t/�Section �Q � J���� � . Dox 84B/210 Ho�pii:al Stree� 1/ �� 2dock3ville, NC 2702a � (33G)751-£3760 f�ifAlH�� . � *** SPORTANT* ATZON C1INNOT DE PROCESSL•"D UtdLLSS ALL 'i'IIL r�Qusi�Lv . � � ' I I27F ON IS PROVIDED. .Retor to tha INFORMATION DULL�TIN ior in.^,L'rucLion�. ` 1. Namc to be Dilled �U Vl ��1.J� ��� Conl•acL• Per�on _ � �._.__ tiailing Addre3s 1 � �� Itomc Plione J�7�V` �''��� City/State/'LIP I�l���-���le . �w � lO�� Dunine�a Plioiic U 26 ����r`_1`IV� 2. Namo on Permit/ATC if DilEerent than 1lbovc '���C V �'O �7 T��.��� o Mailing nddre33 ' City/statc/Zip ' __._, . ��d"'..•�Q�.��s 3. Application For: �1 Site �valuation ❑ Impz�ovemcnL Yei�ni�/�TC ' ❑ 2�oLli . . � 4. Syatem to Service: � xouse ❑ 2dobile FIome ❑ Du�ine�3 � Indu:,try ❑ OL•llcr _ __ _ _ �� 5. Type �ystem requested: �Conventional ❑ conventional modificd ❑ iunovaL•ivc G. If Residence: i! Peoplc � II IIcdroom� �. II L'aL'hioouiu ✓ _ �Di3hwa�her �Garbage Diaposal �Washing Diachino �Ba�emenl•/Plwnbin� ❑Da;,ecnenL•/tlo 1�lu�uUi�i� 7. If Du3ineas/Zndu3try /Other: verify Cype 11 Peoplc I! Sinl;a ___ _ _ t� Commodc� 11 Showcr� 1{ Urinaln � If WaLcr Coolcr� IF FOODS�RVICE: �k SeaL-u �atimated Water U.^,age (gallona per �Iay) _ __,__ __ 8. Typc of wat-cr �upply: ❑ County/Ci�y �WCll ❑ ComntuniLy 9. Do you anticipatc addition� or eXj):tllsiollS Uf tllc f7Cility tltiS S)'Slctll iS it1lc11cIL'd lu sG'YCZ 0 YcJ �f�u lf��cs,ti��l�at t��pc? � ***tnrron•r,i�vr�**cc.�Lrc'fS DIUSTCOAI!'LGTt TfiL: l��U!/tGU PKOI'Lli'1'Y lNI�O1tNiA'1'1pN It[s�U1:5"I'I;U I I3GL0\V. I,ithcr a PLAT or SIT�PLr1N r11UST IICSUI3AtIT7'ED by thc clicnt n•ith'1'1IIS API'1,ICA'I'ION. I'ropert�'Di111ct1siultS: ` ��v� �-�t���/ � 11�R1'fL llIIZLC7'IUNS(frau 141ucl:si•illc)lii I'1ZUl'1:1('1'1': i:►x ocr«rlrr: � 5�"�(��rT 11 l� 4- �-b She��,�C� ��.�_ Pro�icrtyAddress: RoadNanic l�e��,��i1fAY_l I�E�t. �(-t. � DYY�'� ������ �� `� ��01f�1 city/z;p �((X,�5Vt1��,hiL 270 2� -�c�Ir (;�'.�pr�x• 2 rn��1es -{-t�x1� �v�n� If iu a Subdivision providc informalion,as fullotivs: CG��1� +�(i1 mLl�(,Q Gl �I[TT bYl� nT�,►��: � Smda-I� �m �d q o a.r�vvtnc. /m m7edmwn ��T Scction: Blocl.: Lot: Datc l�omc corncrs llabbcd: / � —� S 51(�-�' : G�1Y�(' 1/J�11 � 5� on 1��j�t • Tliis is tu ccrtify tliat tlic iiiformatioii pi•ovidcd is corrcct to tl�c bcst of my luiotiti�lcd�;c. I uiidcrs(aiid lli:it:u�y per»iil(s) issucd l�crcaftci•are subjcct to suspcusion oi•i•cvocation,if tlic sitc plaiis or ic�tcudcd usc clia�ibc,ur if tlic iiifo►•nuilioii submi(ted in il�is:ipplication is falsired or changed. I,also,«nrlerslrrnd tlrall uut r•e�f�unsiLlc jur al!chn���es iircrrrrrrl./�•unr tlris rrpplicutiv�r. I,licrcby,bi�'c cot�scnt to lt�c Au(liorizcd Rcpresciitalivc of tltc Ih�vic Cuu�il}•Ilc:ilUi 1)cpar(uici�( � �U CIIIG'lij)OIl abo�•c dcscribcd pruperly focatcd iu llavic County and on•nccl by _ __ lu cunducl :III lC5I111�OI'UCC(IUl'CS 8S JICCCSSary to dctcriniuc ll�c silc suita�ilil��. llA1'L � � (�S SIGNATURI; TIiIS A.REA MAY 13�USLD rOR DRA.tiVING YOUR SIT�PLAN(Iiiclu c all of tlic fullotivit�b: I;sisliiib:uul propusccl � property lincs and dimctisiol�s, structures, sctbacIts, and scptic locations). � . � �`o"— � Sifc Kc��isif Cliargc llatc(s): _----� ' • Clicut Nolilicaliai ll:itc: G�� . l/ . � C� � �-� .Z �"' 1:IIs: l ��' , � Sign gi��cn �� r�--� Accow�t n'c�. � � � � ltc��isccl llCI�ID ( 5/03 � ' Iuvoicc No. �o?.�o � c. /��J �' ��// „' �— ��.A, i�,�,�,_— 9?4 � � � 2.38A �° • 0827 zz0 . � � , . aos � 2�4 1.00OA • 8549 ,. (1.351A) � N 0533 � � �� s s�p 48q 0 301 0 � �1 s@ �9ry (2.90A) 5281 ° � ; 59.962A , � 5153 � � S � -t, . ---z_ �� . � 2,s ,� � .- ^ � � N 1p.00OA � N y . ` V7�� . ._N ��' � . `'�. 2�6 � . ��� , _ 1 . ��� � 1 . � • , N t �8 � � h ao �.��DA � - . � . DAVIE COUNTY HEALTH DEPARTMENT _ � � Environmental Health Section • � � �� Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003666 Tax PIN/EH#: 5800-64-8711 Billed To: Angela Roberson Subdivision Info: Reference Name: Location/Address: Calahaln Road-27028 . � Proposed Facility: Residence Property Size: 1 acre Date Evaluated: ��,�,��S Water Supply: On-Site Well f� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo % HORIZON I DEPTH �> �/ Texture rou ' Consistence Structure f � '. Mineralo - � HORIZON II DEPTH '' I �• - Texture rou Consistence . Structure � Mineralo .' �. HORIZON III DEPTH � . Texture rou Consistence ' Structure . �, Mineralo ! HORIZON N DEPTH • i Texture rou Consistence 1 Structure Mineralo SOIL WETNESS � RESTRIGTIVE HORIZON SAPROLITE � CLASSIFICATION � LONG-TERM ACCEPTANCE RATE , ,} SITE CLASSIFICATION: � EVALUATION BY:�/� � LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: ' REMARKS: , . _ LEGEND Jj T, n s ne Position • R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-F1ood plain H-Head slope T�at�g . � 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-Silry clay C-Clay CON4I4T�.N , "' 1?�1SY �.. VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 1� � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very.Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic StLu�.tIITg . , .. . SC-Single grain M-Massive CR-Crumb . GR-Granular ABK-Angular blocky SBK-Subangular blocky ' PL-Platy PR-Prismatic � '� Mineralo�v 1:1,2:1,Mixed .'lYo�S , 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) ■��■����■■��■�■��■��������■■■■�■��e■�■�■����■�■���■�■■���■�■■��■�■ ■��■�■��■���■����■�■�������■■■�■ ■��■��■■■■■�■�������■��■�■■■���■ ■�■■�■■■��■�a��■�■�■�■��■■�■�■���i■���■■�■■■�os���■����■�■�■��o■�■ ■��■■■■■■■���������■�■■����■�■■s■�■�����■�■■��■■�■�����■■■���■■■�■ ■■■��■�■■■■�■■■■���■������■■�■■■��o���■�■�■�������■��■����■���■��■ ■s■■�s�■■■�■■■■���s���■■■■�■�■�����■���■��■�■■���■■�■■�■��■■���■■■ ■��■■■���■�■■����■������■��■■■o■■������■��■��■■������■�������■s�.■ 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Box 848/210 Hospital Street Courier 09-40-06 ' Mocksville, NC 27028 � ��. ° � �; ��, �° ;� _ (336)751-8760 � �.' ���' � �, � � ���-�-� �, i # 5 � � S. � ��.t�' i $ � '� i�. d{ >*l . � } LA g'U'�,'�... � ;,i .k .»E d�,!_ �'.' . a° v , .� Jf� k, �. S � 1 ..:.- � 'S ` "�'9 (f 1 4 �y � J .. t't 'M ¢ F�{� 3' � � r f k�� Y�k�k S�. � r�- } ;�, S d. �ssur_ � fi " rk�'ibcE� y'�L *t 3Y r..rY �4.4�! 4�4),�' � r* :%,. ., . July 11,2005 Angela A.Roberson 138 Roberson Drive Mocksville,NC 27028 Re: Site Evaluation/ Calahan Road Tax O�ce PIN: #5800-64-8711 � Dear Client(s): As requested, a representative from our office visited the aforementioned site on July 11,2005. Based on the information provided on the Application for Site Evaluation and after an evaluation was completed on the site,it was found to be provisionally suitable for the installation of an on-site sewage system. Before and ImprovemendAuthorization 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, /�o�'�t��/�a�,• Robert B. Hall,Jr.,R.S. Environmental Health Specialist RBH/dlf