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134 Terrace Ln (2)DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000838 Tax PIN/EH #: 5860-05-6110 Billed To: Barbara Jackson Subdivision Info: Reference Name: Barbara Jackson Location/Address: Terrace Lane -27028 Proposed Facility: Residence Property Size: 3.4 Acres ATC Number: 2246 **NOTE** This Improvement/Operation 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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type M. 1- DMV, #People 4�P / #Bedrooms Z #Baths –7— Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size -J SAC66 Type Water Supply (niL.l.L_ Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size �—)D�AL. Pump Tank GAL. Trench Width -L. Rock Depth I Z Linear Ft. 270 Other: 2 '�1STP�+g�Tt�-� � IrJSTAt_t_. t_�•,�5 9Ic>.C,- Required Site Modifications/Conditions -SI 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.**** f- -� jf� APPQvw.l,sb h r go•.�� o.., 90' x3ce"xiz" - - -�( /, -_ Environmental Health Specialist's Signature: �. Date: ////S DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000838 Billed To: Barbara Jackson Reference Name: Barbara Jackson Proposed Facility: Residence ATC Number: 2246 Tax PIN/EH #: 5860-05-6110 Subdivision Info: Location/Address: Terrace Lane -27028 Property Size: 3.4 Acres 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). THIS AUTHORIZATION FOR WASTE W CONST IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa e: Date: / /Ji 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 guarantee that the system will function satisfactorily for any given period of time. Srrc. Septic System Installed By: n L,LAI� Environmental Health Specialist's Signatur ----QAVMDate: hq DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �]I Davie County Health Department Env/mnmeafa/ Health Secffon P.O. Box 848/210 Hospital Street OCT 2 5 1999 Mockaville, NC 27028 (336) 751-8760 _..... .,..�.TA:JCAITU ***XMPCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE-MQUIRED INVOMaTION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nems to be Billed Contact Person Mailing Address '7—Q/�1/fit'sy Home Phone city/stat./SIP , 2. Name on Perait/ATC if Different than Mailing Address Q -&4-2A-1 3. Application For: ❑ Site Evaluation 4. system to service: ❑ House Mobile Home City/state/Sip ❑ Improvement Permit/ATC Both ❑ Business ❑ Industry ❑ Other a. If Residence: # People # Bedrooms 47( # Bathrooms 0 Dishwasher 0 Garbage Disposal VVAshing Machias 0 Basament/Plumbing 0 Basement/No Plumbing 6. If Businecs/Industry/Others Specify type # People # sinks # Commodes # showers # urinals # Yater Coolers Ir FOODSERVICE: # Seats Estimated Water AUsage (gallons per day) 7. Type of water supp,�:sy: ❑ County/City well bo f ❑ Community S. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Y� ANo If yes, V"t type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either* PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �� ; '7 C yWRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # vs Property Address: Road Name City/Zip A If in a Subdivision provide information, as follows: Name: Section: 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. 1, also, understand that I am responsible for all charges incumd frons 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 determine the site suitability. dLA- - , WmW m- �— THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbac ons). A"1 � Site Revisit Charge Date(s): j� Client Notification Date: 40—e e 4 r 4 "T EHS: x�L Account No. 0 6 Revised DCHD (07/99) Invoice No. Ao 5 , � �� . , � ��,�,, ,� .�.f °�� . �i'�''+����/ , ��� ',� ; �,� .�,, . � "„ ,�` �' �t " � ' a ��s �} �r�q"��w� k«���'F{'�y��,s��"� 1r' ��g �u,< ,�y , . + , . . � a �, � ��,� �� ` �, �e �'�.� �`� ,�.c '� � sj� � � . _�� � 4�a ��` .� . 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'" k . � � ,� ''s� � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000838 Tax PIN/EH #: 5860-05-6110 Billed To: Barbara Jackson Subdivision Info: Reference Name: Barbara Jackson Location/Address: Terrace Lane - Proposed Facility: Residence Property Size: 3.4 Acres Date Evaluated: f O Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH tg Texture group GL— 0-yu Gi Consistence - e r Structure Mineralogy HORIZON II DEPTH 1� Texture groupt.eG Consistence C=; S - Structure t Mineralogy t V-60 HORIZON III DEPTHc) Texture group Consistence r Structure 5 Mineralogy�i�►y HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: VIS LONG-TERM ACCEPTANCE RATE: I EVALUATION BY: _ tpr—Ct4 d7— ++f OTHER(S) PRESENT: �>�,01, "' REMARKS: � 4 2 MiSG. 40&5# ow Caeov-jP `c,1301laO-44"/aSSI g/,}' gy 6,4406.7C, .ne-7,o� r, �}(�,SA�L 7b 8� G�u-� �S t [_LEGEND Landscape Position W 3ke C�Q4p i . p,J (.QwhX— ! , p4 oC Psi cry 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 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 Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 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 - gal/day/ft2 DCHD 05/99 (Revised) i ON ON on ■■ ■ ■ SEEM NONE ■E■■ ■E■■ ■E■■ ■M■■ ■■E■ ■■E■ NEON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS ■E■■■■■EN■■■■■Ea■M■■■■■ ■■■■r�iS■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NONE ■■■■■■■■■■■■■■■■■■■■■■■ ■Mmeeo■■■■■■■■ ■■■■■ME■■■EMM■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■■Eu.■■■■ ■■■■■■�i��■■■■■■■■■■ ■■■■■SSSS■■L■■��C������:!i�Je■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■N■■■■■■ ■■■■NEEM ■■■■N■■■ ■■■■■■■■ ■■■e■■■■ ■■■■■■■■ ■■■m■■■■ ■■■m■e■■ ■■■■■e■■ ■■■■■■■■ ■■■mono■ ■■■EEE■■ ■M■■MM■■ MEMO■■■■ ■MM■■■■■ ■■■M■■■■ ■■■■mom■ MOMS■■■■ NEEM■■■■ ■MSE■■■■ ■■■m■■■■ ■■m■m■m■ ■■NESE■■ ■ENNEM■■■■■NE■ ■■m■■m■■■■■■m■ ■E■■EEM■M■■■E■ ■EN■■MEMM■■■E■ ■■M■NEEMEN■■■■ ■■ME■MEMENE■E■ ■■■■m■■m■■m■■■ ■■E■■MEMEMENM■ ■■E■■OMMOME■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■EEE■■■■■■■■■■EEE■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■■EEE■■■■■■■■■■■■■■■■■■■E■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■