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298 St Matthews Rd � - ^ DAVIE COUNTY HEALTH DEPARTMENT 3 �� ,- Environmental Health Section , ,' � �'+ P.O.Boz 848/210 Hospital Street � ,a 9 ' v� _ Mocksville NC 27028 � � � (336)751-87G0 . IMPROVEMENT/OPERATION PERMIT Account #: 990002744 Tax PIN/EH#: 5707-67-8297 Billed To: Ronnie&Susan Miller Subdivision Info: Reference Name: Location/Address: St. Matthews Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3465 **NOTE** This 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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type (�l' � #People �t #Bedrooms � #Baths � Dishwasher: � Garbage Disposal: �d Washing Machine: �" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ � Lot Size I n � ���Type Water Supply �E�- Design Wastewater Flow(GPD) � Site: New� Repair❑ �� �� � System Specifications: Tank Size ���GAL. Pump Tank GAL. Trench Width �(i Rock Depth {Z Linear Ft.� Other: J� �1 g'121 gc}�i.ca.) �J�.�'. 1 t1S'Ta-1- U a�S 1�fl.C. t�..t�s. Required Site Modifications/Conditions: _ �ti1�� c9� C.A-JTOt�2, �� ���Qc�, (�Jc-=-7�,�G�Q .5� C��-� INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISI�ED 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)751-87G0.**** — � � '�Q�Ji --�� �����L�r�S lcJ 0�,� I :� Llp�'h�'�" (oo � (� /�R�c,, �Is' � ,. � ;��ti 1� � �-� L � �d' S ° . -� , � �� $� ?� �i v � Q Environmental Health SpecialisYs Signature: Date: `� 2� � � • 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 #: 990002744 Tax PIN/EH#: 5707-67-8297 Billed To: Ronnie&Susan Miller Subdivision Info: Reference Name: Location/Address: St. Matthews Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3465 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 Tr ent and Disposal Systems). THIS AUTHORIZATION FOR WAS N IS ALID FOR A PERIOD OF FIVE YEARS. � � � Environmental Health Specialist's Signa e: / Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. `�����A:t-� ��1 �c`�S`=' P..�r �s' S H� ��j/ /� fi�.. � kj2,� ��v i `1�� ^�n�-� �--� G�"',��sP`�'�'� � Septic System Installed By: ��D �'�'-�� Environmental Health Specialist's Signature: D DCHD OS/99(Revised) � \ . . . { .. � _ � � � � ll � ' � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& � Davie County Health Department Environmenta/Hea/th Section � P.O. Box 848/210 Hospital Street EOOZ z � ��W Mocksville, NC 27028 (336)751-8760 Et+MRONMENTAI HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL INFORMATION IS PROVIDED. . Refer to the INFORMATION BULLETIN for instructions. i. xame to be aiiiea 1�p'1✓1i� �1Si,cScka. III�f Contact Person �t�niG �- .St1.SQt-� Mailing Addreas' / � LL GCi Home Phone ��31o) 7/p— ���7 City/3tate/ZIP �UQ.h�'e �I� p�/ D� Business Phone [���5''7 7'�D 2. Name on Permit/ATC if Diffarent' than Above Mailing Addresa City/State/Zip �— 3. Application For: Site Evaluation Improvement Permit/ATC Both 4. syatem to service: House Mobile Home Business Industry Other 5. If Residence: # People Lt # Bedrooms � # Bathrooms 3 Diahwaeher Garbage Disposal Washing Machine 8asement/Plumbing Basement/No Plumbing 6. If Susiness/Industry/Other: Spacify type # People # Sinks # Commodes # 3howers # Urinals # Water.Coolera IF FOODSERVICE: # Seats Estimated Water IIsage (gallons per day) 7. Type of water supply: County/City Well Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No ' If yes,what type? ***IMPORTANT'"°**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �� � C�C1"�S WRITE DIRECT[ONS(from Mocksville)to PROPGRTY: Tax Office PIN: # .�/�7— ��" d a 97 l.t..� Cc�t l,c'e5� �d �0.v�e- Property Address: Road Name��, ��e�JS' /C4 e aU�� - . � J , c�ty�z;p,�Yl oc�sv�Il�. �7D�8 e . � cs If in a Subdivision provide information,as follows: �a .s-�. ma- �Qc�.�S /�Gt, or. ��.� l Name: Y'%_ al�ra��� ►ni. oh �14�n� Section: Block: Lot: Date home corncrs flagged: 2u �3. 0700� ` This is to certify that the information provided is correct to the best of my knowledge. I understand tl�at any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use cl�ange,or if tlie information submitted in this application is falsiGed or changed. I,also,understand that l ain responsible for all cliarges incr�rred fi�o�u t1:is app[icatio�:. 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 (2�n r�iQ �- S�SaY, ��e� to conduct all testing procedures as necessary to determine the site suitability. � ���Q.�lZ DATE IY�Qv I o2. �OQ3 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 locations). Site Revisit Charge Date(s): . Client Notification Date: �HS: \ � �! Sign given� Account No. Revised DCAD 07/99 Invoicc Na � �� '. � ) ` - , � . , LEONARD G. _ _ _ _ _ _ ` _ _ _ : _ D•B. »8, , r '� -DA VID J '� . D�� 83' �'G�'�`YAL T �i r i A � �4> v� � . �� �� � �� , . � ,� �I � Z- 7i�c� _ . �' �. . . �� ; � �. �: � �'h�r��- �, ,� �. Y :; . NE W , (� , �RON 1j I (�'w i S�TA�` 349,73 `� / 329,7q 9' E _ � / , , i �� ,:,h ; 'Nc,ti,19.9 .� � � � 1 . . . . � . . . � .. .. . . . , . N v � � �� ` � � v N �' j� � � o . � ;, -. ��' �, ,�._,� �/� �� 2 , r . P . ... i y A-= _1.59 4_ �-C. / i� �.� �ra --- -' UB.IECT 0 S.R. 1155 /W . . � . . � V\ . � ' � . . . .l � . . . . ' ' l/ 1 v . . . . ' .// . . . . � . / . . � . •. . � � � . . � . � . . ,, I . �.- -`� � NFW � W- � � �RON I �'`_ � , / ¢�o ? � � �^ � �,� ... �j � -. � � ' . � � . � `;----*� � . . . y . � . � . 3'�48___. �_... � N 80• - 3 . TOTq�� 350!13 � .s ,;,. �� r�, � ,�r.v 20.5$ . Dn4 VID .T n . ,._ � . ' DAVIE COUNTY HEALTH DEPARTMENT . � ,' Y ` ' ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002744 Tax PIN/EH#: 5707-67-8297 Billed To: Ronnie&Susan Miller Subdivision Info: Reference Name: Location/Address: St. Matthews Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: �` ��'�3 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 e% a HORIZON I DEPTH � � p—�1 Texture rou L Consistence � � S SS Structure C C� Mineralo 1; � HORIZON II DEPTH � . '7 � Texture rou 1� Consistence Structure Mineralo � � HORIZON III DEPTH Texture rou � G� Consistence C $� Structure S Mineralo i � � ' HORIZON IV DEPTH Texture rou .Consistence Structure Mineralo " SOIL WETNESS " RESTRICTIYE HORIZON ' SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION B : ' `'�� LONG-TERM ACCEPTANCE RATE: - "_1 OTHER(S)PRESENT: REMARKS: . LEGEND � Landscape Position r,: 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 � Moist 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-Subangulaz 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 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