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206 Speaks Rd � DAVIE COUNTY HEALTH DEPARTMENT , Environmental Health Section , G� / � � � ' ' P.O.Boz 848/210 Hospital Street , `' Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT � Account #: 990002568 Tax PIN/EH#: 5852-51-7289KW Billed To: Kelly Welch Subdivision Info: Reference Name: Location/Address: Speaks Road-27006 Proposed Facility: Residence Property Size: see map **NOAI E�*�ls�mprovemendOperation 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 PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People� #Bedrooms / #Baths� T Dishwasher: � Garbage Disposal:� Washing Machine:� Basement w/Plumbin$,�� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply����- Design Wastewater Flow(GPD)--��-v-� Site: New��Repair❑ System Specifications: Tank Size�GAL. Pump Tank�AL. Trench Width��' Rock Depth�� Linear Ft.� Other: _ —� -U� � fC0<�� Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 9• 0 a,Xr�.)or 1:00 p.m.to 1:30 p.m.on the da llation. Telephone#is(33G)751-87G0.**** . �� �r�Kli►�� � � �JJ� �� ` vz-s-��r��'e. O��p.03 �1r��- � � • � �G,/�-��`Z qr''Q� ��us� � �N� ��� �= Environmental Health SpecialisYs Signature: Date: ��`�� � DCHD OS/99(Revised) , • ' DAVIE COUNTY HEALTH DEPARTMENT ��r , Environmentai Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: _990002568 Tax PIN/EH#: 5852-51-7289KW Billed To: Kelly Welch Subdivision Info: Reference Name: Location/Address: Speaks Road-27006 ATC Number: 3344 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 SpecialisYs Signature: Date: / �D Z 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 taken as a guarantee that the system will function satisfactorily for any given period of time. 1"" �n/ � Septic System Installed By: ' C r ���'I/� Environmental Health SpecialisYs Signature: Date:�—�y l/'� �-- DCHD OS/99(Revised) �. • r .�. ,.....- -� � . . . . . . . . � � . . APPLICATION FOR SITE EI�ALUATION/IMPROVEMENT PERMIT&ATC M Davie County Health Department � � � `� � Environmenta/Hea/th Section D ��}""'�� P.O. Box 848/210 Hospital Street 1 `` .� Mocksville, NC 27028 p�C 3 (336)751-8760 �-*�* b�§' ' . *** T S APPLICATION CAATNOT BE PROCESSED UNLESS ALI, THE REQUIRED ' EpiV yh�,�� ���'� IN�Q��ROVIDED. Refer to e INFORt�TION BULLETIN £or instructions. 1. Name to be Billed L Contact Person /� � , Mailing Address � I��in u'► � Home Phone �'� 3�" S �(J(� 'r� City/State/ZIP L /� 7 ��Business Phone 2. Name on Permit/ATC if Different than Above vi � ir` �j` ?7� ��+ Mai.ling Address / � �C�G1��Gh� �, City/State/2ip .— 3. Application For: � Site Evaluation �Improvement Permit/ATC ❑ Both a. system to service: (� House 0 Mobile Home 0 Business ❑ Industry ❑�Other 5. If Residence: p People L� � Bedrooms �_ # Bathrooms Ci L�Dish�rasher ❑ Garbage Disposal CjDkashing Machine O Basement/Plumbing � Basement/No Plwnbing 6. If Business/Eadustxy/Other: Specify type # People �k Sinks # Commodes 9 ShoNers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water•supply: ❑ County/City �Well ❑ Community e, Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes �No If yes,what type? *.**IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by t6e client with THIS APPLICATION. Property Dimcnsions:` �~�—�, WRITE DIR�GTIONS(from Mocksville)to PROPER'�Y: Tax Office PIN: #�(�c� � �/�����'^' 1 .�r� � � d !� �7�-4-�� b o--J Property Address: Road Name—�t�e a-,�S' � . �� • ��O �.1 S "Z�s . �— City/Zip tis� a ,✓ If in a Subdivisioa provide information,as follows: Name: � � Scction: Block: Lot: Date Property Flagged: // �� 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 falsified or changed I,a/so,understand that I am responsible for a/[clrarges i�rcur�erl from this 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 owned by to conduct all testing procedures as necessary to determinc the site suitability. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locatioas). Site Revisit Charge ,/�: Date(s): /� J� f� � 3 Client Notification Date: U�-- � � � 1F�` �� � J� EHS: fQ � Account No. ���� 1'_' � Revised DCHD(07/99) Invoice No. a f 0 � . 73� , \o`�'�� (4�.1�,4) 198 1242 2�e �g0\ 29� 2 / L �' � . � � o� ry C`i (' 1 J � L , V� ,n 138fi \g0 24d `� \� (1673 A) �zss P�� ,�--�- n � �_� s, � 0� 2 6 „90�,d s �-D �q6 (3gZ� � P� ' �O ' ,�5 9/ (as.e�,a> p. � 8646 gQ� y-' 310 � ryn (924A) m � 24$0 '. .` • � �'�l (1.06 �) (23.60A) -'"' ' I ---------------------------� t, 522� ;,,, 8257 . „�, ' 3�03 5� �9 ti�� . . 36 � _19A) '920 � + Pozo � ass i�;� _ . a, Oct 02 02 10:51a davie count envhealth 336 751 8786 P• 1,�Qq /a�� r . • �e _ ,...�� _ Ca/�G'�io-�-DZ � �L-- �`� �,�'!�!�' � -. 0 - y.� ,� � ll�� MPUCATION FOR SIiE EVAWATION/IMPROYEMEN f PERMIT&ATC ��� /� 6�� s(� Davie County Heaith DepaRment G/ n/� � � t' � � l� Environmenta/Hea/thSection Q �'.% D �~ � P_o. Sox 848/210 Hospital street Li � ,: Mocksville, NC 27028 � � �. , ��^ (336)751-B760 �� ,� J � OCT - �• ,� � . ;� ' *t*ZbIl�ORT * THIS APPLICATION CANNOT BE PROCESSED UNLE33 AL2. TAE REQUI Q�� F/fi ' iNFORt4►TI N IS ROdIDED. Refer to the INEORt�.TION BIILLETIN for iastructions. ��Fc^nT� irc;, €P�Y�?���� � l.c�P_ c�.. ��.A-� 4k/ � �"y���, , � ailled ContacL Per3on ,,��.� �Q,�as$ .� . �C.p.k o ����� 7GG- o!o s"(o ���,�s�to�Z=P�I�.,�,�oNs;n�c. atie��.�s���T�- �'�� 7 � 2. Namo on Pormit/ATC ir DilPerent than Above Mailing Addzess City/State/Zip . 3. Application For: �te Evaluation ❑ Improvement Pexa�S.t/ATC [� Both �. Syaiem to servica: �"fiousa ❑ Mobile Home ❑ Business ❑ Industry ❑ Other , s. if Residence: � Poop2e _�_ / Hedrooms �_ � Bathrooms � - �bieh.raehar U carbaqe Disposai I�hinq Machina fl Basemnnt/Yl�bing Il eaeenant/No P1umbing � � . ., 6. IP 8usinesa/Znduatry/Othar: 6paci£Y tY?e � Peopla + Sinks - � . �� � ! Co�odaa Y Shorern � Urinals t Water Coolera - IF FOODSERVICE: # Seats Estimated Watar Usage (qalions per day) �. iype of water supply: Q County/City ell q Community s. Do you anticipate additioos or expaasions of the facility t6is system is intcnded to urve? ❑Yes ❑No Ifyes,wLat type? „ • *'=IMPORTAN7''**CLIENTSANSTCpMPLETETHE REQUIREAPROPERTYINFORMAT[ONREQUFSTED , � BELOW. Either a PI.AT or SC['E PI.AN MUST BESUBM/7TED by fhe clieat with THIS APPLICA770N. r� ///��) Q� �e � •Properfy DiminSions:'��:'(.i' ` -/ �! �� �/ �RITE �RE NS(from Mocksvilic)to PROPEItTY: .Taz OfficewPlN: �J 3 S.2.r11 ! � d ! !���/ ��� � . l�-� �"t O� �P��3'Addras: Road Name ����L�� /`a.�Q//��Gl V Lt.� !C�. L.� �� D� c;��z�p A�UC�cNC{,a7onLc��e�ks ,�c1. �t4s c e�J k�" lfia a Subdivisioo providc information,as follows: �D��jd.�e�� �Q n�1.�'�G R�4� Na��: �s�rr1'� S��n� ;�v Tg rd. Scction: Block: Lot: Date Property Flaggetl: `D-���� •`This i4 to certify thnt t6e informatiou provided is correct to lde best of my knowledga 1 understaad that any permil(s) issued hereaftcr are subject to suspension or rcvocation,if the site plans or intendcd usc changc,o�if the information : submitted in this application is falsified or c6aaged I,also,uxdersland[hal l am r¢sponsfble jur al!charges incnrred jrom this appllcation l,hereby,give coasent to the Authorized Represenlalive of the Davie County Health Dcpartmc�t to eute�upon above described property located in Davie County aad owned by to eooduct sll testing procedares as necessary to determine the site snitability. DATE IO - p� - D� SICNATURE � �'��""'-' THIS AREA MAY BE USEDFOR DRAWING YOUR SITE PLAN(Inclu ail of the foliowing: Exi mg and proposed property liaes and dimensions, structures, setbacks, and septic locations). 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SAPROLITE . CLASSIFICATION LONG-TERM ACCEPTANCE RATE 2 - 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 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 tructure 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 ' 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 Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DC�ID OS/99(Revised) ■���■���■������■�■��■��■o�■��■e��■�����o����■s■■��■��■■������■���■ ■����■�������■�■��������■�■��■�■���������■��■��■■��■��■����������i ■������������■����■�����■���������■■����■���■■�■��■e�■��e�������■ ■��������■���■�����■��■��■��■�■■ ■�■�����■����■����■�■��■������■■ ■��■����������■��■����■�����■����■■■���■���■������■���■���������■■ ■�����������■����■�����■��■�■��■����s��■■���������■��■■���■��■�■�■ ■��o��������a����������������������������������������������o�����■ ■����■��■�■��■���■�■■�■��■■������■■����■�■���■��■��■■���■�■������■ ■��■����■■�■��■�■■��■��■��■���■��■■■���■����■����■■�■�■�����■����■ ■��■s�o�����■��■�■��■�■���■���■■���■�■��■■�����■■�■�■■�������t■■�■ ■����������■���■�■��■����■■����■��■■����■�����■��■��������������■ ■�■��■■����■�■�■■�■�����■■�����■ 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■��������������������������������i���■t���������������������������■ ■t�����■���■■�■�■����■■������■■■�■■���■■■�■��■��■������■■■�■�■■■�■ � , I . . , r . � � . � . . . . ♦ � •� � y � . . . ' � .. . . , . "�3�����Cf�U��I�LT�I }�����T1��N`�T ,�� _.� ..._ . .�_.., .. ,.. , _.. ._......� ...a . oti,� _ �_ .__. _.,. . �....�.v...,. �..�,�� ENVIRONMENTAL HEALTH SECTION� P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksvilie, NC 27028 �::��.,.�c�u.�u�..__� ����....�..___--�- pPhone��#, (336,751 8760.�.._�Ay� ._._�..,.:�.r.,�..��� .a.N�.,.»a���aa� October 8, 2002 Edgar Welch 3715 N. Lakeshore Drive � Clemmons,NC 27012 Re: Site Evaluation/Speaks Road Tax Office PIN: #5852-51-7289 Dear Client(s): � , As requested, a representative from this office visited the aforementioned site on October 7, 2002. Based on information provided on the Applications for Site Evaluations and after the evaluation was completed this site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Aasthorization(s) to Construct can be issued the appropriate application(s)must be filled out and the house/mobile home location staked on each site. If you have any questions,please feel free to contact this office. .�incerely, � �:�����. Robert B. Hall,Jr.,R.S. Environmental Health Specialist RH/df � Enclosure(s)