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876 Mr Henry Road Lot 5Account #: Billed To: Reference Name: • DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990003228 Tax PIN/EH #: 5716-75-2567 Bob's Home Place Subdivision Info: South River Farms Lot # 5 Location/Address: Mr. Henry Road -27028 Proposed Facility Residence Property Size: 177 x 827 ATC Number: 3897 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 C�O�NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �f(,f ( Date:L/ CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in com with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but II in NOW guarantee that the system will function satisfactorily for any given pyriod of time. COrl Septic System Installed By: Health Specialist's Signature:. DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT/�� A'119 Z)�r Fnvironmenfal Hedlth Section / a. _yl'oY P. O. Boa 848/210 Hospital Street Mockwille, NC 27028 (336)751-8760p IMPROVEMENT(OPERATION PERMIT Account M 990003228 Tax PIN/EH #: 5716-75-2567 Billed To: Bob's Home Place Subdivision Info: South River Farms Lot # 5 Reference Name: Location/Address: Mr. Henry Road -27028 Proposed Facility Residence Property Size: 177 x 827 ATC Number: 3897 **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 constructionlinstallation 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 #Baths Dishwasher -.)?!r Garbage Disposal: ❑ Washing Machinery Basement */Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/ShiB #Seats Industrial Waste: ❑ Lot Size Type Water Supply t� Design Wastewater Flow (GPD) �� a Site: New Repair ❑ t• I• System Specifications: Tank SizeQGAL. Pump Tank _GAL. Trench Width Rock Depth &L Linear Ft. 960 Other: 4e4WAti /lJ a O(? - CQ 10~�--V IMPROVEMENT/OPERATION PERMIT LAYOUT - APP D EFFLUENT FILTER RISER(S) IF 6 u BELOW FINISHEDGRADE. ****NOTICE: Contact arepresen of the vie 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<P�J�meMe day of installation. Telephone # is (336)751-8760.**** Health Specialist's Signature: Date: I/D & b DCHD 05/99 (Revised) • PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT1gC)Z' D Davie County Health Department t 1 2 Z0� Environmental Health Section P.O. Box ,848/210 Hospital Street / Mocksville,"NC 27028- RUNM� FL (336) 751-8760�J') P *** ANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED" FORMATION IS PROO/VI/D/ED. Refer to the�INFORNATION BULLETIN for instructions. - 1.. Name to be Billed DOCS/S Contact Person "Mailing Address J //�G ,r/ IjLS' ',/w �y O/ /'� Rome Phone '.City/State/ZIP / ae l; LUlGe //✓�� -Business Phone 2. .Name on Permit/ATC if Different than Above 1 Q/J��'�� 1jyzlp yli,,,EAd Mailing Addreea 11bj f!/✓d/If-Lv City/State/Zip i 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC lZBoth 4. System to service: ❑ House ,P-90bile Home ❑ Business ❑ Industry ❑ Other - 5. Type system requested: IIi-Conventional- ❑ conventional modified ❑ innovative " s. I£ Residence: # People �� # Bedrooms_ i# Bathrooms Z I M51ahwasher []Garbage Disposal aL9A ehing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type - #People I # Sinks # Commodes # Showers # Urinals #Water Coolers 'IF FOODSERVICE:" # Seats Estimated Water Usage (gallons per day) - 9. Type of water supply: ❑ County/City, LN'Well Cl Community - 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-xr� If yes, what type? I ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION Property Dimensions: 1-77 427 WRITE DIRECTIONS (from iMocksville) to PROPERTY: TaxOfree IN: S7/E•7S2S6 7 D/J��E �1e/rPA�,— y TO T/vt.✓ Property Address: Road Name City/Zip A/JGft_ Su/c( 4,/,.�(� I If in a Subdivision provide information, as follows: Name: SOtti-%!'/ I?/LlrIL- // Section: Block: Lot: �� Date home corners flagged: 1 4 e) 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 aur responsible for all charges incurred frog: this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcaltlt Department to eater upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. _ DATE — Z 7-6 C/ 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). Site Revisit Charge rlV /'/2avT Date(s): —p? ��S Client Notification Date: EHS: Sign given Account No. Revised DCHDA (05/03 i Invoice �C�c G� ✓ ,3No.---_-��L r - 336 7517632 - P.01 May -102-04 011 48PHiarcl Raalty .0 i1 1 i 1039.12 LOT 2 - 101.4 5100 ac. 2 a•.•• «.•. q 74.12I. 8 + 1 i IOBL39 -LOT 3. J 5100 0c, 3 80]Yr0!"W 1090.43 I l 1G 1f �1 - • a W I - ' Iv, LOT q �. WOO ac, i ran]Y_apr � - - �'. F I •_ �._. LOTS SJoO ac. t • n,ao W I i. lat �;. P 84.a+ �I Y68.81 � +I LOT 6 Cdl• 5.100 ac.: a't eaa:,i LOT nn I 5,100 9C, 3=4ow / `V IB7.9'+�^�-- Naso .. 104227 LOT 8 C7 A a nyraa• r I 5.100 ee. t � g9.7a = 1 - 7 . 1074.98 5.100 cc. S / sablrM :89.04 i "„—^•---- N 97.5]'59” N/ wI - e3J5 I RIWR- LOT IO -� - aoMaOrW .5,100 ac. ! ataa 55.K I. f ZONE "C" FLOOD LM! AS SCALFp FROM FEMA J FIRM - �{ _ PANEL N 370309 00038- Q - /�/� - «oavrarW i 497.21 ' OT II'. ....13,160 ac.._ \ h1! CLL � � s•Y 34`5.32 �—L� - 485.09 a!•H I + 5 Bfi•9993' w ••'� N 83.51'0f' W, - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990003228 Tax PIN/EH #: 5716-75-2567' II Billed To: Bob's Home Place Subdivision Info: South River Farms Lot # Reference Name: Location/Address: ,Mr. Henry Road -27028 Proposed Facility: Residence p y e Property Size::177x827 Date Evaluated-. .. - FACTORS ,, 1 2., 3 4 5_ 6 7 Landscape position . Slope % HORIZON I DEPTH Texture group Consistence - Structure Mineralogy HORIZON H DEPTH ri - Texture group Consistence + Structure Mineralogy'! HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOH. WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: ' �� 'EVALUATION BY: �, /i LONG-TERM ACCEPTANCE RATE: 6 OTHER(S) PRESENT: REMARKS: 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 y cla SIC - Silty clay C - Clay CONSISTENCE 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) . 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