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140 Walt Wilson Road Lot 11DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section p.Q P. O. Boa 848/210 Hospital Street Q Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003543 Tax PIN/EH #: 5747-31-4872 Billed To: Samuel Bailey Subdivision Info: South Arbor Lot # 11 Reference Name: Location/Address: 140 Walt Wilson Road -27028 Proposed Facility Residence Property Size: 3/4 + acres ATC Number: 4043 **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 /J / #People #Bedrooms k,, #Baths Dishwashen .4eicGarbage Disposal: ❑ Washing Machine: 121"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industria13V V4—ACI Waste: Lot Size AG Type Water Supply _ Design Wastewater Flow (GPD) —S= Site: New RfalRepair ❑ System Specifications: Tank Size,oe"GAL. Pump Tank GAL. Trench WidthZ�f Rock Depth Linear Ft. c?Ol3 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF `° BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe D County Health Department for final inspection of this system between 8:30 a.m. to 9:30 am. or 1:00 p.m. to 1:30 p.m. a day9€installation. 'Telephone # is (336)751-8760.**** Ott Ppo�. ,�iYll�S Environmental Health Health Specialist's Signature: DCHD 05/99 (Revised) Date: Account #: 990003543 Billed To: Samuel Bailey Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5747-31-4872 Subdivision Info: South Arbor Lot # 11 Location/Address: 140 Walt Wilson Road -27028 Proposed Facility Residence Property Size: 3/4 + acres ATC Number: 4043 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 I1 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 Specialist's Signature:// Date: CERTIFICATE 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 guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialists Signature: DCHD 05/99 (Revised) Date: APPLIa TION FOR SITE EVALUATION/INIPROVEAIENT PER If C , Davie County Health Department t/ Environmental Health Section i P.O. Box 848/210 Hospital Street 2 4 2005 � Mocicsville, NC 27028 n (336)751-8760, ENV1R'ONM DA EYTAt N * PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE R' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. J1. Name to be Billed d411ma-�. // h Contact Person H41W Mailing Address %/i d (-UPAIALIZE,Q A3040 Home Phone City/State/ZIP Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/zip - 3. Application For: ❑ Site Evaluation Improvement Permit/ATC - ❑ Both a. system to service: jq House E3Mobile Home 13Business ❑ Industry ❑ Other S. Type system requested: 0 Conventional ❑ conventional modified ❑ innovative ' 6. If Residence: # People # Bedrooms 3 N Bathrooms XDishwasher ❑Garbage Disposal *aching Machine '❑Basement/Plumbing ❑Basement/No Plumbing 7. 'If Dusiness/Industry /Other; verify type # People "'O Sinks # Commodes # Showers - # Urinals O Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) S. Type of water supply: g County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes WNO •- _ If yes, what type? ***1AI1'0RTANT*** CLIENTS AIUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN AMSTBESUBAfITTED by the client with THIS APPLICATION. Property Dimensions: 7- ' WRITE DIRECTION (fr In Muc(sville) to PROPER'T'Y: Tax Office PIN: it 6-2!/7 5/f�1 � 72 - Property Address: Road Name City/Zip I _� If in a Subdivision provide information, as follows: Section: Block: Lot: Date home corners flagged: 5 This is to certify that the information provided is correct to the best of my knowledge. I understand Ilia( any perniit(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 l slit responsible for all Charges incurred frani this application. I, hereby, give consent to the Authorized Representative of the Davie Courtly IIealth Department to enter upon above described properly located in Davie County andowned to conduct all.testing procedures as necessary to determine. the site suitabil' DATE �, Z IS SIGNAT TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following." Misting and proposed nrnnnrty Onnc and dimnnsinnc. structures. setbacks. and seAtic locations). - Sign given ,v Revised DCHD (05103 Account No. ` Invoice No. Z 7G 6 �� ` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department i� r� I� Q�t� Environmental Health Section I �� E E P. o. Box 665 NOV 2 81994 Mocksville, NC 27026 1: Application/Permit Requested By Mailing Address 3> IS, Home Phone MCC sI/!//r Business Phone 20 eel -1, 2222- 2. Name on Permit if Different than Above 3. Application for: 4. System to Serve: Evaluation ❑ Septic Tank Installation Permit ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑/ Other ❑ Unknown 5. If house, mobile home: Subdivision SOU4 a lnr)!i2 Section = Lot # No. of People ✓�� No. of Bedrooms =2 No. of Bathrooms^- Dwelling Dimensions Aamlz /�6a 6. If business, Industry, place of public assembly, other: Specify type No. of People Served 442- No. of Sinks 0 Basement/Plumbing ❑ Base lent/No Plumbing ashing Machine . Dishwasher ❑ Garbage Disposal No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions �SJZ /?&rg Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes No If yes, what type? -NOTE: Improvements Permits shall be valid for a period of 5 years from date Issued. Improvements Permits are subject to revocation, If site plans or the intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the Information provided is correct to the best of Incurred from this app'catio . — Sl AT I am responsible for all charges MUST CHECK ONE: ❑ 1, 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCMD (1103) ?w , • DAVIE COUNTY HEALTH DEPARTMENT I Environmental Health Section - Soil/Site Evaluation. - 1 f / �+ NAME �' ��f \2 S W t e e e oO ci DATE EVALUATED r ^�� /�l�i ADDRESS \rn' - : PROPERTY SIZE CQ 6 PROPOSED FACIILTY O S 2 LOCATION OF SITE wino Water Supply: _ On -Site Well _ Community - Publicy Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 2 3 4 Landscape position Slope Z o ° 8° HORIZON I DEPTH -(lt1 IZf Texture group C L. Consistence H Structure Z 2 Mineralogy\ 1 HORIZON II DEPTH Texture groupC Consistence -� Structure G Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS S RESTRICTIVE HORIZON r SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: Q ' S- EVALUATED BY: p LANG -TERM ACCEPTANCE RATE: y OTHER(S) PRESENT: REMARKS: �- �•1 ri5\ LEGPND 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 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