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280 Victory Ln� 5 , DAVIE COUNTY I�EEALTH DEPARTMENT Environmental Health Section � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001565 Billed To: Christopher Atkins Reference Name: Proposed Facility: Residence !� � �-2'� a/ Tax PIN/EH #: 5709-68-490$ Subdivision info: Location/Address: Calahan Road-27006 Property Size: 23.735 acres ATC Number: 2731 **NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHOWZATION 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 INT'ENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type C� �(' S k. #People � #Bedrooms �#Baths � Dishwasher: � Garbage Disposal: � Washing Machine: d Basement w/Plumbing: �" BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 23 ��-��-�Type Water Supply �-'U�-� Design Wastewater Flow (GPD) �to� Site: New �Repair ❑ System Specifications: Tank Sizel� GAL. Pump Tank GAL. Trench Width �v� i Rock Depth � 2�� Linear Ft. 3�� Other: � l�� sT� � Tt o� � O =cJ , ��T/�.(L C� � LS �l d• C. til 1!J , Required Site Modifications/Conditions: INIPROVEMENT/OPERATiON PERMtT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED 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. /'Fe.Lephone # is (336)751-87G0.**** �J� Environmental Health Spec� s Signature: DCHD OS/99 (Revised) N o�: ��•C 'rL(1 ti . ; DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mceksville, NC 27028 (336)751-8760 Account #: 990001565 Billed To: Christopher Atkins Reference Name: Proposed Facility: Residence ATC Number: 2731 / `r '�- 2-�.` wl Tax PIN/EH #: 5709-68-4908 Subdivision Info: Location/Address: Calahan Road-27006 Property Size: 23.735 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 e Treatm isposal Systems). THIS AUTHORIZATION FOR WASTE T19 VA FOR A P OD OF F VE ARS. / Environmental Health SpecialisYs Signatur : ate: �� CERTIFICATE OF COMPLETION I**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit I has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and i Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. , W � „ � � S_c, X3� y� 2.� 1 �p' Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) U l5 C�4TION FOR SITE EVALUATION/II�BPROVEINEM� PEiZl��i7 €� tiTC Davie County Health Department Environmenta/ Hea/tfr Section P.O. Box 848/210 Hospital Street Mocksnille, NC 27028 (336) 751-8760 � ***T.MPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �:� 1. Name to be Billed Lyl /` 1 S�d� �'�' �� /-�'D��'� S Contact Person �a.c� /�'Gl�(� S Mailing Addresa � .3 %� ,V ., �. �-� �y � �! � � Home Phone 33 b ' q 9 53 - 9,34s-o ��is��iZ=p A �� .. �.�1/. C_ .L � oo G �9�e9s Phone � 3 6- 3 y�- 3 �// 2. Name on Permit/ATC i£ Different than Above Mailinq Add=eea City/State/Zip 3. Application For: �Site Evaluation 0 Improvement Permit/ATC ❑ Both a. syet� to sa��e: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: � People / A Bedrooms _3 � Bathrooms �_ LN DiahMasher ❑ Garbaqe Diaposal C�I Washi.nq Machine H Basesment/Plumbing ❑ Basement/No Plumbinq 6. If Dusiness/Industry/Other: Specify type # People # Sinka � Co�odes 0 Shoxers # Urinala # Water Coolera IF FOODSERVICE : # Seats Estimated Water Usage (gallona per a8y> �. Type of water supply: ❑ County/City �Well O CQmmunity s. Do you anticipate additions or eapansions of the facility this system is intended to serve? If ycs, what type? ❑ Yes ,�f No ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY IIVFOWI�IATION REQUE�TED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED bv the client with TFiIS APPLICATION. Property Dimensions: � 3� , Tax Ofiice PIN: # s i O�- � g-�% O� G� _o��oo - 6y: e f Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPGRTY: w`"� U�i � r C� L,,G � u,.� ,'�G/ , �,�vo� 3 �„ �e 5 v� �,� � r� Date Property Flagged: � �' J ^� � This is to certify that the information provided is correct to the best of my knowledge. I understand thAt uny �crmit(s) issued hereafter are subject to suspensiou or revocation, if the site plans or intended use cl�ange, or if the information submitted in this application is falsified or changed I, also, understaad that I am responsible jor al! charges incurred from this applicalion. 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 suitabili . DATE SIGNAT �� C-• iJIiE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Laisting and proposed property lines and dimensions, structures, setbacks, and septic locations). � , / / 33� ~ 3�y -3 �/ � � 33b ��3� --31yo I Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notificatioa Datc: �HS: Account No. � �fP Invoice No. � � / � � DAVIE COUNTY HEALTH DEPARTMENT - . � ` Environmental Health Section ' Soi]/Site Evaluation APPLICANT INFORMATION Account #: 990001565 Bilted To: Christopher Atkins Reference Name: Proposed Facility: Residence Water Supply; Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5709-68-4908 Subdivision Info: Location/Address: Calahan Road-27006 + Property Size: 23.735 acres Date Evaluated: 7i �� On-Site Well '� Community Auger Boring ✓ Pit FACTORS Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence 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 1: ) �� ,. u�c �- SITE CLASSIFICATION: @5 LONG-TERM ACCEPTANCE RATE: O' �� REMARKS: Public Cut 3 4 5 6 7 C� - r EVALUATION BY: OTHER(S) PRESENT:�Lt�� ' `�1-� 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 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 suitable), U(unsuitable) LTAR - Long-term acceptance rate - gaUday/ft2 DCHD OS/99 (Revised) ■��■ ■�■■ ■�■■ ■��■ ■�■■ ■��■ ■��■ ■��■ ■�■■ ■■■■ ■ ■■ ■■■■ ■��■ ■■�■ ■��■ ■��■ ■��■ ■��■ ■■�■ ■��■ ■��■ ■��■ ■�■■ ■�■■ ■��■ ■ ■■■■ ■�■■ ■■�■ ■��■ ■��■ ■■■ ■�■��■ r�■■■■ ■��■■■ ■��■ ■��■ ■■��■ ■■�■�■ ■�■■�■ ■■■■�■ ■■■■■■ ■�■■■■ ■�■■■■�■■��■��■■■ ■�■■�■��■��■�■■■ ■��■�■��■■��■ ■■�■■■��■■��■��■■ ■■�e■�■�■■■��■■�■■ ■��■�■■��■�■■�■ ■��■■�■��■ ■■�■ ■��■■�■��■■��■�■ ■�■■■■��■��■�■■�■ ■�■��■■■�■■�■■�■ ■�■■�■�■■�■�■■�■■■ ■�■■��■��:::::::::: ■��■■��■�■�■■��■■ ■��■ ■��■■, ■�■■ ■��■�i■��■■��■ ■�■■�■■,�■�■�r��tr�■ ■■�■��i��■■►.�«��■ ■��■■�■i��■��■��■ ■�s��■i��■�■■�■■�■ ■��■■��i■■_...=��=== ■■��■��il��!_.1R C�■ ■�■�■■��■i'�' ..i�l■■ ■■��■■��■��■■ ■�■■�■��■■■��■��■ �J�■■�■��■■��■ ■��■��■■�■�■�■■��■ ■��■■■��■■��■��■ ■��■��■■�■�■�■■��■ ■��■��■■�■��■�■ ii�■��■■��■�■■�■ ■■��■�i■�■�■ ■■■■ ■��■��■��■��■■■ ■��■■�■■�■��■■■■■■ ■ ■��Y■ ■■��■ ■�■■ ■�\�■ ■�■�■ ■■�■■ ■■■�■ ■■■■■■■■■��■■ ■�iO��■�■■��■ ■�■■■�■■■��■ ■��■��■��■ ■��■��■��■��■ ■■��■■■��■ ■��■■■��■ ■■■�■��■■��■ ■■��■��■�■■ ■■■■■■��■�■■ ■■■■■■��■■■��■ ■�■��■■■■�■■��■ ■�■��■■■■��■��■ ■■�■�■�■■■��■■ ■�■■��■�■��■■ ■�■■■■�■�■■��■■ ■��■■■■�■��■■�■ ■��■�■�■■��■ ■��■■��■ ■■��■��■�■ ■■■■■��■■■��■ ■■��■�■��■■��■ ■�■ ■�■ ■�■ ■�■ ■�■ ■■■ ■■■ , -- � - , -G�P., ,.� . .�.� . ) a, v, 'F ��. i �1 � 7 5� - �3�L o '7'�� - 0335 � � �� F� ��, C-�A,�l,,, � �o � � �.,� �..,�,�^ � �l �. �.� ��/ 3 � 5 .� � �1 Q { O w m N N v 0 _f 3 m N A O O � � ♦ F��: !EIti' i k i{�;�J�.}N - � �'`c+`�4 � s i 4 R. � �r� ',, a !!?wtHr ,, � 4 a 5� � ;� ra' $ .L t�'t � � �': . � � � ��`„ �� i 1�>'ro ,. , . �}� ��(1 '?T* A„�;...�y ," . �';' ,, . ; : �. 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