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126 Todd Rd• DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksviille, NC 27028 (336)751-8760 Account #: 989900195 Billed To: Richard Poindexter Reference Name: Proposed Facility Barn ATC Number: 4099 Tax PIN/EH #: 5788-33-2851 Subdivision Info: Location/Address: Todd Road -27006 Property Size: 47 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Tr and Disposal Systems). THIS AUTHORIZATION FOR;WA=STE;EvTIO I ALID FO A PERIOD OF FIVE YEARS. Environmental Health Specialist's Si Date: 11 V e57 CERTIFICATE OF COMPLETION ' 106xrx12-1 **NOTE** The issuance of this Certificate of Completion shall indicate the system described onmprovement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .190 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system function satisfactorily for any given period of time. , Cl j 3p r�D �r Q Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) s Date: l��I--/off lio- M DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900195 Tax PIN/EH #: 5788-33-2851 Billed To: Richard Poindexter Reference Name: Proposed Facility: Barn ATC Number: 4099 Subdivision Info: Location/Address: Todd Road -27006 Property Size: 47 acres **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 LJ F� #People I_ #Bedrooms #Baths _ I Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type 13#People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply wt ELL- Design Wastewater Flow (GPD) Site: NewZ-,-Repair ❑ System Specifications: Tank Size =0 GAL. Pump Tank GAL. Trench Width <5-ZRock Depth I V ` Linear Ft. FCX: Other: Required Site Modifications/Conditions: II -IST& — cco 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^.***** ,-PTA tA'� C) -c) s Environmental Health Specialist's Signatur . Date: zl n `111 DCHD 05/99 (Revised) It DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street �-- Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900195 Tax PIN/EH #: 5788-33-2851 Billed To: Richard Poindexter Subdivision Info: Reference Name: Location/Address: Todd Road -27006 Proposed Facility Barn Property Size: 47 acres ATC Number: 4099 **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 �� lj #People I #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 '4 -N -Z Type Water Supply W 1x1..1.— Design Wastewater Flow (GPD) 60-- Site: New Repair ❑ System Specifications: Tank Size AL. Pump Tank �� GAL. Trench Width I Rock Depth If' Linear Ft. Op Other: A ^1 ACc &7—, Z> cJ1Y?STCiy\ rAM A�O �L (� 1 l I � C6 y 1100 Required Site Modifications/Conditions: Of- IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISIIED 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. 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F w�o ., , �. � ... . . .____ — _ . _— �I ATION 1`0I1 SITE EVALUATION/1&1PIIOVE TENT PERMIT & ATC Davie County Health Department 0a Environmenta/Nea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 EI ppb (336) 751-8760 I .►,A*'fIMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROXIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Mailing Address 4,-'"1 City/State/ZIP _ 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person Home Phone Business Phono�li���f� City/State/Zip 3. Application For: ❑ Site Evaluation ❑ ,Improvement Permit/ATC fir Both 4. System to Service: ❑ house ❑ Mobile Home ❑ Business ❑ Industry ❑ other 1�Lt S. Typo system requested: Conventional ❑ conventional modified ❑ innovative 39 6. If Residence: # People # Bedrooms # Bathrooms ❑Dishwasher ❑Qarbago Disposal ❑Washing Machine ❑Basement/Plumbing [Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes' # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City X Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If ycs, what type? J2 No ***1JIIP0RTAN7'k** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INI ORAIATION REQUESTED BELOW. Either a PLAT or SITE PLAN A1UST BE SUBAIITI'ED by (lie client witli TIIIS APPLICATION. Property Dimensions:l�% /'r r r' S 1VRITE DIRECTIONS (from Moc(sville) to PROPER'T'Y: Tax Office PIN: #_SJ3�L Property Address: Road Name7t) ''��n a IJ City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date home corners flagged: This is to certify that the information provided is correct to the best of niy knowledge. I understand that any perinil(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this applicatioii is falsified or changed. 1, also, untlerstand that 1 am responsible for all charges hicurred front thus application. I, hereby, give consent to the Autliorized Representative of the Davie County IIeafIli Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suit.31glity. DATESIGNATURE TIIIS 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). l Sign given V=., C G Revised DCHD (05103 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. e.- ^ /o o �l s Invoice No. 3 uuuv 193 12.000A t "^ 4671 122 3 (810) ©— 322)—ROS 6674 �i ^rye 5599 (3.532A) 3565 2.206A �s 9575 4523 389 b 1178 w001 Z8 47 178131 14 N N 836 rot (1.23A) 827 3399 (1.08A) 5335 0 (4.83A) 428766 (2.83A) 792 rotas 2189 2189 (3.27A) 2042 I 34.38A N 2851 3.665A 2430 554 ry 1800000043 1ao (31.91A) 3.665A 1301 2237 (10.91A) 6006(' a (2.03A) (1.08A) 5791 2643 6g 180000004301 1 H Y ApK1N RSV ER 103 e 1115 (134.32A) 7095 (1.01A) 8804 •- " , - DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION /account #: 989900195 Tax PIN/EH #: 5788-33-2851 Billed To:. Richard Poindexter Sulpdivision Info: Reference Name: Location/Address: Todd Road -27006 _ Proposed Facility: Barn Property Size: V47 acres-!--,- Date Evaluated: ('fr7> Water Supply: On -Site Well >� Community Public Evaluation By: ;: Augcr:$oring ✓ Pit `� 7 Cut ?T—'--7 FACTORS 1 2 3 §t 5 6 7 Landscape position L_ t-- !r Slope % HORIZON I DEPTH O - l - 0�c? O'^ ►�l 0-8 — (;* Texture group C., -#-PnC4C. C S tZL Consistence Fr S'V iFf S I r_ 5 P ( �_ C-1 5.0 Structure ssl .Mineralogy -SEE 1 HORIZON 11 DEPTH 4 00 d " 2 - Texture grou cl<A< 4. Consistence CT T Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON TV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: `� —S� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ir%� OTHER(S) PRESENT: Prim,) 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 loath 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 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(unsuitablc) 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 DCI In 05/99 (Revised) �����■ �����///��/���/��������/��� ������e�/������/�/�/�■ ■ ��� �/ ����■ �/����/��/���������/������ ■ ��/���/ ���/���/��/���� ■■ �� .....�..........................�3�C.......C.............. .�. _. ■ ■�����������������������������s� ■���������������������■ ■ ■ ■ .0.. .. .............................................. ... . .�..C..�..............................................C... 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