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545 Todd RdDAVIE COUNTY HEALTH DEPARTMENT'�� Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 30 IMPROVEMENT/OPERATION PERMIT Account #: 990002832 Tax PIN/EH #: 5788-48-0296 Billed To: John Idol Subdivision Info: Reference Name: Location/Address: 545 Todd Road -27006 Proposed Facility: Residence Property Size: 12.53 acres ATC Number: 3511 **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 #People �_ #Bedrooms .21 #Baths %. Dishwasher:,, Garbage Disposal: ❑ Washing Machinelf�Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � Type Water Supply Design Wastewater Flow (GPD) �L Site: NewZ2-1Repair ❑ System Specifications: Tank Size O GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.� Other: Required Site Modifications/Conditions: 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. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990002832 Billed To: John Idol Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5788-48-0296 Subdivision Info: Location/Address: 545 Todd Road -27006 Pro osed Facility: Residence Property Size: 12.53 acres ATC Number: 3511 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 WASTEWATER TTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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. Septic System Installed By: (rf)!1 n c-4 Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) D JUL - 3 2003 El,VRONMENTAL HEALTH DAVIE COUNTY TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC AV s� Davie County Health Department B=11-0nmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 L �` (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �p r` L[1� l Contact Person n =-JO...�___.. Mailing Address �+ I� O • ettY,L4f) P Home Phone 3�' %l✓G /3_��4//, = City/State/ZIP C M a,n'S /y-_ ,x.70,12 Business Phone 36 -7%I - y.2Y-Z 2. Name on Permit/ATC if Different than Above 'rr.rn Mailing Address City/State/Zip _. 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC th 4. system to service: P House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: ❑ Conventional El conventional modified ❑ innovative 6. If Residence: It People 8 Bedrooms pZ 11 Bathrooms .Dishwasher ❑Garbage Disposal 96ashing Machine asement/Plumbing kf ascment/No Plumbing 7. If Business/Industry /other: verify type 11 People 11 Sinks _ It Commodes 11 Showers 11 Urinals 11 Water Coolers IF FOODSERVICE: #1 Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ANo If yes, what type? 'IMPORTANT" CLIENTS AIUSTCOAIPLETL• THE REQUIRED PROPERTY INFORMA'T'ION REQUESTED BELOW. Either a PLAT or SITE PLAN /11UST BESUB111ITTED by the elicit ivitli THIS APPLICATION. Properly Dimensions: /,T, 5 5 a , Tax Office PIN: 1/ 1//8 ' ao'Z R G Property Address: Road Namej yS Tp dd. Pd City/Zip '40ba Ace '27W& If in a Subdivision provide information, as follows: Nantc: Section: Block: Lot: WRITE DIRECTIONS (from Nloclo%ille) to PROPER T'1': C elb --4. F0! s (a) 16,x,,1 7-- d d (e✓ a�G "d en 4. e oT %: )) to J'dfne rl'4e Date !Ionic corners flagged: 7 -5- 05 This is to certify that the information provided is correct to the best of my knowledge. I understand that :Illy pernlil(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, also, understand that 1 am responsible for all charges incurred fi-oln this application. I, hereby, give consent to the Authorized Representative of the Davie County I1calth Department to enter upon above described property located in Davie County and owned by ------ to conduct all testing procedures as necessary to determine the sit 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 locations). C.��eA )/r:? Sign given Revised DCF (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. '7'-0 Invoice No. cT �, eL�e ss IN .w daM+»w°a, rev£ ,. dp j ak k �ll i r Kri ra+ ..< � ..,•BSL .a l aA n r,�Y' C L .1 l 1 L eoe sozE ^� y� 1 ♦ ezz osz 86z 61 q �...._...,.. -.♦ ...,--.»».. W -. YY fi 6,92 t la Nss.`ez�e � Gly .-• � � @qs ..s le r ; N It 1 It � si cL Lb\ i 1 I I 1 t !FPZ�,� jflO JIN.. _ p9L4z ZLGL if101 BL r ZLts G r4 _I ^- F . .♦ _ _ 9Zy. �. Z4♦- Lc fi _ ;. ,.,. s i ♦ 994♦ � t i • l - _ '� ZL Sf 961.► �,,,, .. f r a, re e3 te - Kz eat rocy♦ '` - ResL` —� __ ._ r APPLICANT INFORMATION Account #: 990002832 Billed To: John Idol Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5788-48-0296 Subdivision Info: Location/Address: 545 Todd Road -27006 Property Size: 12.53 acres Date Evaluated: 7 -`�- i Water Supply: On -Site Well Community Public Evaluation By: Auger Boring C/ Pit Cut FACTORS 1 2 1 3 4 5 6 7 Landscape position IL I Sloe % HORIZON I DEPTH z Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence l Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 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) ■ NONE ■E■■ ■■■■ MEMO NONE ■■N■ ONES ■EE■ MEMO NEON NEON NONE ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SOME ■■■■ NONE OMEN MEMO NONE ■M■■ NOME ■EE■ NONE NOME ■E■■ ■ME■ MONO NEON ■E■■ ■O■M■ ■E■E■ ■MEN■ ■ENE■ ■■ ■ ■ SEEM NONE NONE MOON ■iNE ■■ ■E■■ ■ME■ NONE ■■■■ MONO ■■E■ ■O■■ ■O■■ ■■N■ ■EE■ MEMO MOON NEON NONE ■■■■ MOON ■■■■■■■/■■■■/■■■■/■■/■■■■■/■■/SSSS/■■■/■�I■■11■■■■■�■/SSSS SSSS■/■/■■■■■■■■■■■■■■■■■ ■■■■■■■■■■/■■�I■■It■■■//SSSS■■■ ■■/■////■///////////////■■■/SSSS/■■/■■/■�!/■It//■///■/■/■■ ■■■■■■■N■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�I■■It■■■■/SSSS■■■ ■■■■■■■■■■■■■■■/■■■■■■■■■■■■■■/SSSS■■■/■tl/■11■■■■■■■//■/■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■III■■■■■■■■■■■■■■■ ■EM■■EM■■E■M■EMEM■