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280 Walt Wilson Road Lot 2Account #: 990002462 Billed To: John Johnstone Reference Name: Residence ATC Number: 3283 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 848/210 Hospital Street Mocksville, NC 27028 j(*11f.V7C.1-Q'7rfi g, 0 viol/ t j I / 5 0, ej Md - Tax PIN/EH #: 5747-30-7046 Subdivision Info: Walt Wilson Estates Lot # 2 Location/Address: Walt Wilson Road -27028 ProDertv Size: see maD 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 I of G.S. Chapter 130A, Wastewater Systems ction .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA R 0 STRUf-TION IS VALID INR A PERIOD OF FIVE YEARS. I /J� r Environmental Health Specialist's Signature: Date: 6,2z /vr? WMIM CERTIFICATE OF CONVLE **NOTE** The issuance of this Certificate of Completion shall indicate the temliescrilfed on Improvernent/Operation Permit i has been installed in compliance with Article I I of G.S. Chapter"" AV,.1900 "Sewage Treatment and 0 t Disposal Systems," but shall in NO WAY be taken as a guarantee tha e= em will function satisfactorily for any given period of time. _0 141. T1 Septic System Installed By: ,gp Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVILE COUNTY ]HEALTH DEPARTMENT Environmental Health Section P. 0. Box 848t210 Hospital Street Mockwille, NC 27028 (336)751-8760 IMPROVEMENTIOPERATION PERMIT Account #: 990002462 Tax PIN/EH #: 5747-30-7046 Billed To: John Johnstone Subdivision Info: Walt Wilson Estates Lot# 2 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3283 **NOTE** This Improvernent/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 I I 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 --A-5 #Baths Dishwasher/E100, Garbage Disposal: 0 Washing MachineefT"' Basement w/Plumbing: Basement/No Plumbing: El Commercial Specification: Facility Type #People _ #People/Shift #Seats Industrial Waste: Lot Size _ Type Water Supply Design Wastewater Flow (GPD) (-P6 0 Site: New-� Repair System Specifications: Tank Size/,QpPGAL. Pump Tank Other: Required Site Modifications/Conditions: J/ 1 .1 GAL. Trench Width Sa� Rock Depth /,.? Linear Ft.,TO IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHEDGRADE. ""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.**** 0113 Environmental Health Specialist's Signature: Date: 2-;,�01? DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE1 11 dri Davie County Health Department E17vironmeftal Health Scwtlw P.O. Box 848/210 Hospital Street Mocksville, KC 27028 SEP 2 4 2. (336) 751-8760 1 ENVM0�,A'1U1JAL �EALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI&EbS-ALL-ik��-!-:;��XE-lj INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed U:� � b, -7;� k 14 fo 21 el Contact Person Mailing Address 'r 0 716 +C I Home Phone City/State/ZIP _ Moe- Iss v'. 4L e f /V e J 7el Business Phone -9 �i- 7 51 � 17 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip f 3. Application For: tte Evaluation Improvement Permit/ATC ith 4. System to Service: House 11 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: # People # Bedrooms # Bathrooms :1 VDishwasher 4-Carbage Disposal Vwashing Machine 11 Basement/Plumbing El Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: P--6ounty/City 0 well 0 Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 440 If yes, what type? 'IMPORTANT' CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS APPLICATION. K, .' ;t Property Dimensions: lqy — 01-90 — 4i.2 1. # S 7 4 73�P 7tf 4L Property Address: RoadNameW&Lf#V W115.0%J TA City/Zip_ 2712 ?" If in a Subdivision provide information, as follows: Name: W W,Lrow 4e,%-eS Section: Block: Lot: 4 'A' WRITE DIRECTIONS (from Mocksville) to PROPERTY: Pt t V V, PL R �':J 01 VI& 0 J� Z rid FA &K 131�0 —WA L tle 1, el W;Lso�, RA le I- a K y 0LfJ4P*-- VeJ4� �11,e�,L �Ojft� '7 - Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(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 responsiblefor all charges incurredfrom this application. 1, 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 suitability. A DATE -'r 1 'X ej!w- .1 47 y- SIGNATURE "�' F. -- THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLA4 �nclude all of tli��fo/llowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. '�� (.& Revised DCHD (07/99) Invoice No. 0-1�177 LO N 11 0692 (V99, 0 VK9 z APPLICATION FOR SITE EVALUATIONAMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. NametobeBilled wit -L -[Am L Pbwk%jD Mailing Address 6,80 E. lgo�L-L P- I- --,) - City/State/Zip M1-4'6306 2. Name on Permit/ATC if Different than Above Mailing Address ContactPerson X-420-QAM Home Phone P� (0- 6,:S- '1 (-7 (t' Business Phone City/State/Zip 3. Application For: [A Site Evaluation [ J Improvement Permit & ATC 4. System to Serve: [A House [ I Mobile Home [ I Business [ ] Industry [ ] Other [ ] Both 5. If Residence: # People ---5' # Bedrooms # Bathrooms Dishwasher N Garbage Disposal (7) [,4 Washing Machine Basement/Plumbing Basement/No Plumbing 6. If Business/Other: Specify type # People_ #Sinks # Commodes— # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [A County/City [ I Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes NJ No If yes, what type? r4rq�rWAMTVA PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** Aft,161-OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. 4 Property Dimensions: ?An�7r WRITE DIRECTH ocksvflle) TO PROPERTY: TaxVSfF,cTPTNK #—T7, ')r aq a -me 'Fp- o t, A I N -% Y--� �SQ c�r e > w C Property Address: Road Name WAi-T VJIL-Sow P-0 DrrAoMn�-) ep Aqjo Wlkt-T WILGoLj City/Zip M0Cr-G V I L�L G 2- 702- tZQAr> !S0,L>r1-A AeOO-C If in Subdivision provide information, as follows: V Name: UjAi--r VoL--:z�tj eo.4'pi' Section: Lot #: :56-M HAI -L V -)(L.(- EL -66, Lcrr fbf?- PEZ�� TL-!� -r 1"5Y 4 - (e-97— This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(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 incurred from this application. 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 F�P L -a 00%> rA"i L-�-C 'f-kVG'V to conduct all testing procedures as necessary to determine the site suitability. DATE �4 - ti- 9 7 SIGNATURE 71(1A&-V4t4- r&&LA Revised DCHD (06-96) FA -64 L Ir T7ZOST TRIS AREA AfAy BE USED FOR I)RAWINC7 YOUR SITE PLAN: 65e I FOS-) 4L vjAi--r FSTATEE'4 N APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION \_Q Q� \43 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation DATEEVALUATED T1 PROPERTY SIZE ju Q­A� ROAD NAME \33 �'_A \N�Q J&u� Water Supply: On -Site Well Community Public Evaluation By-'�_'�6- Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position _,:I S Slope % HORIZON I DEPTH Texture group L r— L I Consistence S F X Structure V_ Ic IK 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 sle RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 1 -4 SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT. REMARKS: Q LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Ter -race 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(01-90) ME ME NONE NOME NOME MEMO EMEN MEMMEMEMEMENNE MEMEMEMENOMMU MENNEMEMEMEM MEMEMENEEMMEME EMMEMENMEMEMEM MEMMENNEMEMEEM MEMMENUMMEMENS MMEMMEMMEMEMME MEENNEEMMMEMME MENOMEMEMEMOU EMMEMMEEMMEM NOMMENOMEMEMEM MEMEMEMEMOMENS MEMMEMMEEMMEEM COENNUMM _qmlm6lbmmm slimmolism MWENOWEE HEMMOMEM ON MENNEN MENNEN ONEMEN MENEM WOMEN MENEM EMMEM MENEM MEN MENEM MENEM MOMME MEMENMEM MEMENMEM ommomomm MEMEMMEN sommomom EMMEMEME MEMEMMEM MEEMMEME ONE MEN mom mom MENEMEMMENNOMM ONMEMMEMEMEMME MOMMEMMEMEMMEM ENMEMEMENMEMEM MEMEMMEMOMMOMM MEMEMMOMMEMENN EMOMMEMMENNEME MOMMEMEMMMEMEM MMEEMMEMEMEMME MEMMEMEMEEMMEM EMEMEEMEMEMEME ONEMMEMMEMEMEM MEMMEMMEMEMEME MEMMEMEMEMEMME 0 mom MEN mom EMEMEMMEM EMEMEMMEN MEMENMEME mom"EMEM Emm"Emom MENOMONEE MEMENNEME MEMEMEMEM EMEMOMMEM OMMEMEMEN MEMMEM ONSOME MEMMEM MENNEN MEMNON MEMEME NEON MEME ONES NEON