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290 Will Boone Rd DAVIE COUNTY HEALTH DEPARTMENT �y�� .?� . ' • • Environmental Health Section / � � P.O.Boz 848/210 Hospital Street /�p`� " Mocksville,NC 27028 (336)7S]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002281 Tax PIN/EH#: 5756-18-0948 Bilied To: Richie&Jill Robertson Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility: Residence Property Size: 6 acres **N(�L�*��iipr�eMent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 �'Y� � #People�� #Bedrooms � #Baths 2 Dishwasher: � Garbage Disposal: 0 Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � G Type Water Supply �ei1 Design Wastewater Flow(GPD) � � Site: New� Repair❑ �, i� System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth'� Linear Ft� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATTON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. '�***NOTICE: Contact a representative ofthe Davie County Health Deparirnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-8760.**** � � Environmental Health Specialist's Signature: Date: ��—� � � DCHD OS/99(Revised) , • . . D � _ DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990002281 Tax PIN/EH#: 5756-18-0948 Billed To: Richie&Jill Robertson Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 ATC Number: 3150 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �� ,� Date: � � � C�RTTFICATE 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 guar ee-that the system will function satisfactorily for any given period of time. � Septic System Installed By: Environmental Health Specialist's Signature: Date: ��-�/�� _ DCHD OS/99(Revised) . ' �- ' �� n� �s � ��« ;' APPIJCATION FOR SI�E EI�ALUATION/IMPROVEh1ENT PER691T&A ��, ``�,_..-"--"'�� Davie County Health Department � � �;-- ; Environmenta/Hea/th Section ��`( � 4 � -- P.O. Box 848/210 Hospital Street � Mocksville, NC 27028 H�LTH (336)751-8760 Er,`JtRD��UNry ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED -� INFOF2MATION IS PROVIDED. Refer to the INFORMATION BULI�ETIN for instructions_ 1. Name to be Billed �� ,�Q dV,�� I}(�{(`��1 Contact Person (.��(�/y��s' __ Mailinq 1�ddress �� 1\�,,��Q � xome Phono 9 Q$ '� �7 Ip,3 City/State/ZIP ��r,��`l� p �_C � a7�� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation p Improvement Permit/ATC 1 Both 4. system to sezvice: ❑ House j$` Mobile Home ❑ Business ❑ Industry ❑ Other 5. Zf Residence: # People �_ # Bedrooms �_ # Bathrooms �_ fl Dishwasher U Garbaqe Disposal j�l Washing Machine U Basement/Plumbing II Basement/No Plumbing 6. Zf Dusiness/Industxy/Other: Specify type # People _ �s # Sinks q Commodes _�_ # Showers ;Z. # Urinals H Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gailons per day) 7. 1�po of water supply: � County/Ci�:y L7 Well� [7 Community e. Do you anticipatc additions or cxpansions of thc facility tBis systcm is intcnded to scrvc? ❑ Ycs �► lf ycs,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHG RGQUIRED PROP�I27'Y[NfORMA'I'ION R[:QUGS'1'l?1� BGLOW. Either a PLAT or SITE PLAN MUST BESUBh1I77'ED by YM�c:icn. with'I'iIIS API'LiCAT10N. � t I'roperty Uimcnsions: � (,�-"�-'��J WRI'fL UIRLC7'IONS(from Mocicsvillc)to PROPIsR'I'1': � �Tax Ofiicc PIN: # �j 7 Jr p f �9 t�� .6 1 ,�c� � �6 C.�?�R� Property Address: Itoad Namc �il� �Od�y�2.� -.�n,�,� �� r�/ � �� :1��a. �. City/Zip � �/ Z * � ' / C If in a Subdivision providc information,as follows: � � Namc: Scction: Block: Lot: Datc Property rlaggcd: ��T(j c� This is to cectify that the information provided is correct to the best of my knowicdge. I undcrstand tl�at any permit(s) ' issucd hcrcaftcr are subjcct to suspcnsion or rcvocation,if tl�c sitc plans or intcndcd usc cl�anfic,or if tl�c inform:ition submittcd in this application is falsificd or cliangecL I, also,understa�td t/�ut l a�n resp��nsiGle for u//c/rurges inc•urrerl.f'rnm 1/ris application. I,hereby,give consent to tl�c Authorized Represcntativc of thc Davic County Ilcultli Dcparti�ac�nt to cntcr upon above dcscribcd property located in Davic County and owncd by _ _._._ _ .. to conduct all testing procedures as necessary to determine the site suitability. llAT�� l,l n�- SIGNATUIt� c THIS AREA MAY BE USED FOR DRAWING YOUR SIT�PLAN(Includc all of tlic Tollowing: �xistiog and proposcd property lincs and dimensions, structures, setbacks, and scptic locations). Sitc ltcvisit Chargc � Datc(s): L ,�In(��- �l�� l V � � �. Clicnt NotiCcation Datc: c�. ( � Io v Io �HS: 5 (� d-� �� C� �— ''�� 8 /� �/ � Account No. ��' � Rcviscd DCHD(07/99) `� . Invoicc No. � '�� - G L� � --- , K, t�� ,�u uo�e>,s ��a�i � / ice o�� flS� . "� J , � Ci' -'"-tJE......._ �- !yeL 5} ' 4� � t�45'3 ��849 `'' � � s�ttrlb s) � �'� 0�9V' �voscG> C��f� �� r' 88� '� ' �—�"'''`� 69� Q 1995 ' .;,,�,, � .... dsz's � t��sv} �t�'bg'�) . �� . r ,;F: 58� . _ : , �.z ' _. _ �� 660D s s '' � �'t�'C'—^ , � ..> � tvoz s) ��NC�tJ`� ` � � - ^ : 59�� , � �� i�166�tJ 09L9 � 3, � a9Z5 `x � > � .��7C5� !trL11�9I a .�.:.A � 5 LG � �+�t �£ v: r � pN 194 �''�. t,f f.4`..�: . . �. �" y�r} '9d56 � . ... ^ . . .� � . Y V� `J94 V .�. � .. 54� I tt6ti 45 � . ... . ..Nl£'ll ' �� 6 II m �' 1 . . .. ... 1n�� . . `� i � .. .. � ,�� . ... � /� �U(.. �. rar�5 ,�ze� � :�tif � � Q�� / `� Vt94`��69 � '�� n��bf��;�c .. /� �• '�p� �'� ' css> �, J &�s2 � �zss _ . � l�.' <, ` tvtvZt �'�� 4t6 , �/ 909C'�. ��:�. .�.C.E � �� . �! ... � � e�e � / : �.. gL�e tvLE ;. 486Z *;' � 8460 � � � �vzc o ` n .. �i = , �t s o., �� , . 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Environmental Health Section � ' ` Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002281 Tax PIN/EH#: 5756-18-0948 Billed To: Richie&Jill Robertson Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility: Residence Property Size: 6 acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain �I-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 Mineralogv 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)