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194 Dublin Road Lot 32DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990000736 Tax PIN/EH #: 5789-72-5991 Billed To: Custom Homes of Advance Subdivision Info: Shamrock Acres Lot # 32 Reference Name: Location/Address: Dublin Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2691 **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 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 #People #Bedrooms #Baths Dishwasher: 21" Garbage Disposal: ❑ Washing Machine: C?`� Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/ShiB #Seeats IndustriJal Waste: Lot Size Type Water Supply Design Wastewater Flow (GPD) CS�V Site: New Mr Repair System Specifications: Tank Size/W GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width.?6N Rock Depth'Linear Ft, �/ 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.**** Environmental Health Specialist's Signature:Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000736 Billed To: Custom Homes of Advance Reference Name: rwNVacu ra�miy. r WQIU=nw ATC Number: 2691 Tax PIN/EH #: 5789.72-5991 Subdivision Info: Shamrock Acres Lot#32 Location/Address: Dublin Road -27006 rl upci Ly OILC. ,= 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`ON/STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: SSL Y�i/� Date: 42 —/7p CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate c has been installed in compliance Disposal Systems," but given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) shall indicate the system described on Improvement/Operation Permit 01 U. Vh2p1er4a,0A, Section .1900 `Sewage Treatment and kea-asa g ent Qha a system will function satisfactorily for any O F Date: 8/�/o / - 2 APPLICATION F01( SIFE EVALUATION/IAIPIiOVEh9EM' f11114HY 5 A1' M Davie County Health Department M pp Dt Environmental Health Section ),% 0,2 P.O. Boa 848/210 Hospital Street JAN 2 5 2001 W °,, =; y • Mocksville, NC 27028 Q (336)751-8760 ENVIRDAUIEECOUN� LTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. c� s tD A` A^ X40 /�}} ,/�U,l 1. Name to be Billed (�V��ConYaat Person / Mailing Address �' I� 60/- Z9 43 Home Phone ptT _ t D - to jO / City/state/ZIP Ll� �/i( V1 � T-7 W (p Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/Stara/Zip s. Application For: ❑ Site Evaluation .9mprovement Permit/ATC ❑ Both a. system to Service: &th�ouse ❑ Mobile Home ❑ Business ❑ Industry 0 Other 5. if//R$Sidence: L7 Diahxaeher :} People ❑ Garbage Disposal # Bedrooms # Bathrooms L aWW ening Maclaine ❑ Basement/Plumbing f3-aasome,:t/No Plumbing 6.If Business/Industry/Other: Specify type # People d Sinks # Commodes 9 Showers 9 Urinals # Wates Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ounty/City', ❑Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: 35ti Zbsi 1D'37t 3(dti Tax Office PIN: # Property Address: Road Name _ pO LJ ( i vv �d City/Zip Aj UnVI6Q, If in a Subdivision provide information, as follows: Name: 5M C1 n,vu—v— Y Yt rc� Section: 4L-1 Block: ut: __G= WRITE DIRECTIONS (from Mocksville) to PROPERTY: _aa fern, l Leek T,19 Th, i�t�srt�. 2d Date Property Flagged: _,— ZO —"Z.00 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 to conduct all testing procedures as necessary to determine the site suitability. DATE—�LS OD SIGNATURE.! I% 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 103 Revised DCHD (07/99) 2 35?D Datc(s): Client Notification Date: EHS: Account No. 1O Invoice No. 0 /0 q9 p0 0 J/ �, o: ?J a 01' J C 1 JJ :O � tiJ Q O'«w a' � Jn O �� o � 41 l /IpQ 41 22BDo i 095 C. J 2�J SHAMROCK ACRES 9G - 3 \ mu" " 0mom � w �i C �(�'.;t/ � �7 p� A�� MAW 0%E4W',J ° 7°i�� f GJ'd r �'y� PLACE 2p' AAVED PEVILE5 cox ROW 2u t I a AIDVAIYAM NC 27006 910 1 940-5064 SHADY GROVE TVIMIWP NORTH CAROiLOU i K'iLL[ M /ST TU7TEROF SURVEYING COWANY 127 UBERTY CHURCH ROAD YOCKSVILLE. NC 27026 17041 432-6616 dos • DAVIE COUNTY HEALTH DEPARTMENT`�� Environmental Health Section Soil/Site Evaluation /� NAME DATE EVALUATED /'n/%e�i ADDRESS �K� OC Fz Awa PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit_ Cut FACTORS 1 2 3 4 Landscape position .7,7 Slope R HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH O'� , Texture group - Consistence Structure / S Mineralogy A' '.9 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 SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: L� OTHER(S)EPR SENT: i 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 <.lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay 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 3C -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(01-901