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889 Underpass Rd�1 41-00 DAVIE COUNTY HEALTH DEPARTMENT ��J3 Environmental Health Section r P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002848 Tax PIN/EH #: 5881-61-1162 Billed To: Leonard Jones Subdivision Info: Reference Name: Location/Address: Evergreen Lane -27006 Proposed Facility: Residence Property Size: 3.512 acres ATC Number: 3527 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 INSTALVNG SYSTEM. lot Residential Specification: Building Type #People �� #Bedrooms #Baths 2 "� Dishwasher: M' Garbage Disposal: 6d Washing Machine: V Basement w/Plumbing: e Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 3''I� �SType Water Supply QC -LL Design Wastewater Flow (GPD) Site: New 3 Repairer System Specifications: Tank Size 100(%AL. Pump Tank GAL. Trench Width Rock Depth /Z Linear Ft. Other: 7)6Y0 drj ��. �i�lSY4LL tr1 S 9 O•C. f tl4. Required Site Modifications/Conditions: IN /z'FAiv 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.**** 2- � N o. Tou ToT' --0 Xle '• PDX 11A 10 �7 Environmental Health Specialist's Signature: Date p O DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002848 Tax PIN/EH #: 5881-61-1162 Billed To: Leonard Jones Subdivision Info: Reference Name: Location/Address: Evergreen Lane -27006 maize: s.oiz acres ATC Number: 3527 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 CONSTRUC LID F R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate:24 D 03 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. i tO C S 90 Septic System Installed By: h1Ni' 1 l T -&4t9- LPV _ Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) ,► . �1,wD � )Z� . � "Al ��� EIIVIRONNIENTAt HEALTH pAV1EC0UN!•• JN FOR SITE [VALUATION/IMPIIOVBIENT IlEfU11h S ATC Davie County Health Department Eavironmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 -,Tit 9 Ib,. Do ***IMPORTANT*** THIS APPLICATION CANNOT !3L PRVULIS. L;ED U1gLLSS ALL 'i•11L 1tLuu.l.ltLD INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed (UWde�"LP1_�►^►a,J'-3onc-s Mailing Address 19 19 9 (nth c4e r pas— ta City/State/ZIP Advo/-,e.e- NC_ Z-7ODto 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person Leona ✓d j_by1Cs Home Phone 33 6 - Q 9 $ - y 1-7--'-] _ Business Phone S Gt w. [ City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both. P 4. System to Service: 1W House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: R Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People J�-- It Bedrooms L4_ It Bathrooms Z. Mishwasher OGarbage Disposal 2Washing Machine yuBasement/Pltunbing ❑Basement -/No Pluming 7. If Business/Industry /Other: verify type # People It Sinks # Commodes # Showers It Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City Well ❑ Conununity 9. Do you anticipate additions or eXpaliSiolls of the facility this systeill is intended to serve? ❑ Yes If yes, what type? YJ No ***1111P0RTz1NT*** CLIENTS MUSTCOd1PLETL-THE REQUIRED PROPERTY INI,ORNIATION REQU1 STE'D BELOW. Either a PLAT or SITE PLAN eIUST BESU1hUIT-I'GD by the client with 'MIS APPLICATION. Property Dinleusions: 3. rJ Z. Q C YC S Tax Office PIN: # 1 I& Z Property Address: Road Name Ever-4v-een La c1e- City/Zip Adya► c+ e— N(-., If in a Subdivision provide information, as follows: Namc: Section: Block: Lot: WRITE DIRECTIONS (from I1ludisville) to P1ZUI'1?12TY: I" 15Y &z4 W1 . 'To --KL 1117- Vv", lc , 1 e -Pt- O r► u v, 8 e'tj5:- s S �n o►rot.. 3rn'� le., �o EVe✓G Vece-, LG v►.r` on Le -P+ . C- o -ho TJeoJ, C--v,c'I . Date !ionic corners Ilagged: ZL-1 T 5 2003 This is to certify that the information provided is correct to the best of my knowledge. I understand (hat any perulit(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 I am responsible for all charges inctn•,•cd f,•om this application. I, hereby, give consent to the Authorized Representative of the Davie County Iicaltll Departlllcnl to enter upon above described property located in Davie County and owned by Lt �v,e�✓d. Jw,es ____._ __ _ to conduct all testing procedures as necessary to determine the site suitability. DATE `I- Zl- gs SIGNATURE THIS AREA MAYBE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing :old proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): _-- Client Notification Date: EIIS: Sign given Revised DCIIDr5103 I Account No, Invoice No. --1 � • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002848 Tax PIN/EH #: 5881-61-112 Billed To: Clyde Jones Subdivision Info: Reference Name: Location/Address: Evergreen Lane -27006 Proposed Facility: Residence Property Size: 3.512 acres Date Evaluated: r7 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut • •Landscape ©i�i�l0©d0 position Texture group Consistence EMMMMM Mineralogy ����----I Texture group Consistence F502M ff 03W. WN -Am • • • DEPTH �iG''>.TS:►.1�GOWL/I���� group ANNIA 10MM, 11 .Texture Consistence�I iNORA�:tiNtJi S„IWOW MineralogyIT DRUM M 60 Texture - Wrgm Mineralogy 14*14 SAPROLITE CLASSIFICATION SITE CLASSIFICATION: ! �� LONG-TERM ACCEPTANCE RATE:_ A REMARKS: K EVALUATION BY: nn nn OTHER(S) PRESENT: 0-AILLQ 1Z AkIt 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 / J 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 �v^ SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist V 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 \O/ Structure SC - Single grain M - Massive CR - Crumb GR - Granular SBK - Subangular blocky PL - Platy PR - Prismatic ABK - Angular blocky 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) ■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■t■e■■■■Ile■■■■s■■e■■■■■■■■e■■�1■■■■■■■■■■■■■e�■■■■■■■ MENMEMMUiMENNENl' siiiiiiii:iiiiiiiiiiENNEN ■■■■■■■■■II■t■■t■■■t■tet■t■■■■■�1■t■t■■■■t■■■t■t■■■■t■■ ■■■■■e■■■Iles■■■■■■■1�■■■e■■■■■�1■■■■■■■■■t■■■■■■e■■■■■ ■■■■■e■■■II■■■e■■e■■■■■■■■■■■�I■■e■■■■■■■■■■■■e■■■■■■ ■■■■■■e■■Ile■■■■■■■■■■■■■/■■■■■wl■■■■■■■■e■■■■ee■e■■■■■ ■■■■■■■■■Ile■■■■■�r�■■■■■■s■■■■■In■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■■■Ile■■■■■■eee■.-e■eet!�■■�I■■e■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■II■■■■■■��e��!pie■■■�1■■�i■■■■e■■■■■■■■■■■■■■■■■ ■ ■ FF ',w �`x � Y.F. 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