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205 Steeple Chase Lane Lot 12DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001710 Tax PIN/EH #: 5822-89-4209gf Billed To: Gerald Fletcher Subdivision Info: Whip -O -Will Lot # 12 Reference Name: Location/Address: Steeple Chase Lane -27028 Proposed Facility: Residence Property Size: 5 acres ATC Nup� b?r: 2828 **NOTE** Thls mprovement/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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ' oosz #People 2 #Bedrooms `7 #Baths %,s Dishwasher: © Garbage Disposal: ❑ Washing Machine: 11111- Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift /##QSeea�ats Industrial Waste: ❑ Lot Size 504 AORLSType Water Supply Design Wastewater Flow (GPD) ` 11X./ Site: New 21"' Repair ❑ System Specifications: Tank SizJC00GAL. Pump Tank GAL. Trench Width Rock Depth 9 It Linear Ft. �0QQ Other: �%� JYI�T/p� XGS, f� /SLG "^JEj �O.C�. �1�A/ Required Site Modifications/Conditions: � `�j21(.L o") U*J 10LX, ,4- t' IS,OWWCA)S6 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.**** 71��EFJ� U►�s �a ��Q APf L Q, ro o8ag Environment ealth Specialist's Signature: at . 01 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT 64") • Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001710 Tax PIN/EH #: 5822-89-4209gf Billed To: Gerald Fletcher Subdivision Info: Whip -O -Will Lot # 12 Reference Name: Location/Address: Steeple Chase Lane -27028 Proposed Facility: Residence Property Size: 5 acres ATC Number: 2828 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 WAST ATER N IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu e: 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. OL r Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: //—a ��! t ... FOR SITE EVALUATION/IMPROVE6IENT PERMIT & ATC Davie County Health Department Ell wrwmenia/Hea/lft Section .O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed !rP r a/G/ /� �(� // jam, %�' Contact Person �Y'�rr—y/j/oL /C��ij jib• Mailing Address ��-//' O� yy�pS�i�Q(� l( Home Phone City/state/ZIP PDQ- (/O� s9,/f/�( ,2yplf0 Business Phone '%t 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: "ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: #« People 7- t# Bedrooms --!�E— M Bathrooms k'*'Dishwasher LI Garbage Disposal &'Washing Machine ❑ Basement/Plumbing X+19—asement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes A Showers # Urinals A People M Sinks ## Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Irk 0 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: Tax Office PIN: it Property Address: Road Name 4'S'P City/Zip If in a Subdivision provide information, as follows: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPER'T'Y: to -o I Al /-6 ,+a �a . Date Property Flagged: 2`f O 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 to conduct all testing pr/o�cedures as necessary to determine the site suitability. DATE 7 e--7/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). a I� Revised DCHD (07/99) 5- 7-t�a /e O / ay e C i,,31DY 774 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. l —1 ( o Invoice No. APPUCATION FOR SITE EVAu ATION/IMPROvEMENT PERMIT & y Davie County Health Department �g 1 Environmental Health Section P.O. s+K. 200 P.O. Box 848/210 Hospital Street 0 Mocksville, NC �27028/V/RORNT /o (336)751-8760 OAVIfCOUNH LTH V ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDE�D�i. Refer to the INFORMATION BULLETIN for instructions. 7 1. Name to be Billed A,,* ee/}ir 7 -y—, -X Contact Person Q �✓ Mailing AddressAll, ��� ��pu'q (L�l��y �Y(�-P Home Phone ! Fe—'F e— 8 City/state/ZIP lN/rif, ^�e7�4, A 'Y X 7120- Business Phone / ozcp 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: Site Evaluationmgrovement Permit/ATC isoth 4. system to service: eHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 'Al # Bedrooms # Bathrooms L+1 Dishwasher Garbage Disposal 14.4ashing Machine �sement/Plumbing IJ 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: fir County/City a. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes "o ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the cl9en::•r':: T"..S APPLICA T A'3N. Property Dimensions: teyxro6y rja,# X,?o x 6 4 k not WRITE DIRECTIONS (from Mocksville) to PROPERTY: -Y ysk 31,- IL / ZS -'r. G 9'} .61 dCoD1 Tax Office PIN: N SkZZall 8209 sow -fio 4'o�.R�/�Gr� •L - Property Address: Road Name.3;4,,.� P•,est� City/Zip /ala rXg--f/!/r /V-A 9pt,7I act �7'z?�.d/1U'�a9a� 7lzs �0 7�.s /g If in a Subdivision provide information, as follows: Name: ti C-10 t <' Section:_ Block: Lot: l2- Date Property Flagged: 7Z/Y/,Oftqz 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 Depart ent to enter upon above described property located in Davie County and owned by �I� frrs d0nof 7b 6-vA4h ra4,4— m to conduct all testing procedures as necessary to determine the site suitability.s�i:!!E �44,x DATE 7 ZZZZ 200 n SIGNATURE(1�-- 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 �1 � U� Date(s): .110 — =v�o L Revised DCHD (07/99) Client Notification Date: EHS• ,X Account No. C) T t Invoice No. r`- rya w t4n-7 7,54 J Ib ,MM ` 0 Q oye 54,E m az 41 1 - 0',� n � yam:► � �--.� Q i ` � ' .rs • �� .�',.�:� �.� `� -. Ad ell SI 01 Ge { 0 � o copM FfN� `, l c04; OP 0 M'y0 Ro,4°'Iz ��i� `fir �• 1,•. , � ��� •r��� r t� 59 G1. '�.� �o l� C A 192. Ur 40 A r AUTHORIZATION NO: " 1 5 8 $A DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section PROPERTY INFORMATION Permittee'sr q- P.O. Box 848 Name, .�1. (21OW4 u�Q Z. Mocksville, NC 27028 Subdivision Narne: YW b 1P-0 - o LL �1� 47 _t ���hone M 336-751-8760 12- Directions t0 property: �� EV � Section: Lot: AUTHORIZATION FOR ! Oeu— i2b WASTEWATER Tax Office PIN:s#SM. SYTF.M CONSTRUCTION / ,,�n ��,J --NW V O+.) *oaa Name:S ]EI-ALZ4U p: Z7v **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits, This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (in compliance with Article I 1)f G.S. Chapter 130A• Wastewater Systems. Section .1900 Sewage Treatment and Disposal Systems) n� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -daviz_ "f "J IS VALID FOR A PERIOD OF FIVE YEARS. FNVIR N TH SP AST DA SUED RESIDENTIAL SPECIFICA77ON: BILI t3 TYPA' � ,, N BATiji , R OCCUPANTS —Z_ GARBAGE DISPOSAL es No COMMERCIAL SPECIFICATION: FACILITY TYPE ,, ,N;, � 0 PEOPLWHIiT 0 SEATS INDYAZRIAL WASTE: Yes or No FLOW NEW SITE LOT SIZES WATER SUPPLY t AT$it (O!D} iE REPAIR SITE + : tt, xK` ;`1�i �I SYSTEM SPECIFICATIONS. TANK SIZB AL... FRlitNC� VV� ROCK DEPTH i IS LINEAR FT.� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT i 'r Q bi �r�ir o t ' **CONTACT A REPRESENTATIVE OF T'H9 BETWEEN 8:30.9:30 A.M. OR 1.00 OPERATION PERMIT SHED Bi AK* LTH DEPA1tTMEi iijI i FINAL INSPECTION O3FgTMS QSYSTEM Y OF INS I' ;r y� "},j'�ELSPHONE * IS (7x1�1(><flll7(N>s' . W�rrrr.r rr,rrrr+#�+lrwur�-'-- - RM INSTALLED BY: AUTHORIZATION NO. OPERATION PBR}►Q'I`>N **THE ISSUANCE OF THIS OPERATION PERMIT SHAI!L.` . WITH ARTICLE I I OF G.S. CHAPTER 130A, SECTIONt900`!"SitW/1 GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT tSPAC tbltll.Y { DCHD 051% (Revised) JD v,5 DATE: ,THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ATMENT AND DISFOSALSYSTEMS". BUT SHALL IN NO WAY BE TAKEN AS A IR ANY GIVEN PERIOD Of TIME. rip. 10 Z - r LV AUTHORIZATION NO: '1 5 8 8A DAVIE COUNTY HEALTH DEPARTMENT /}` • Environmental Health Section PROPERTY INFORMATION Permittee's / P.O. Box 848 Name:xfn�a' it,��^1 i l.E �U Z_ Mocksville, NC 27028 Subdivision Name: "� r 0 • 01 LL, 7p C47Cd S n d Jt e hone # 336-751-8760 Directions to property: Section: Lot: AUTHORIZATION FOR �} WASTEWATER Tax Office PIN:#`2�f/ 2Z - _4a 4 " SYSTEM CONSTRUCTION ��f�'. '��1C -JS 1�`7 v�^►L ck) 1 t�- ('t �.(�► it�� rRo�ad�Name:``TLZALT-I I/KG **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 pf G.S. Chapter 130A, Wastewater Systems, Section :1900 Sewage Treatment and Disposal Systems) t . - - - , - _ K � r �„(.W^'�„�1'��'�,...rti,:,n!"-^'�.-. �,r-++ti�Y.-��•••...�.-`--•f+"-"N�y.,,4y\tir DAME COUNTY HERE I)EPARTMENT�'. i1VIPIRQVEMENT, AND OP9RATION PERMITS PROPERTY INFORMATION 1 ermis { t r T#v�r 7 Name:-- 11, �7 .'y Subdivision Name: �! ('. g , Directions to property Section: Lot: �•G .: tt� ;Tax Office PIN:z # - .� L; Road Name d Imo! 4 + Zip: 2 *!*NOTE** This Improvement Pkruut DOES NOT authorize the'�'sonstruction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM: CONSTRUCTION must be obtained from this'Depamnent prior to the construction/installation of a system or the issuance pf a building permit ; (In coinphance with Article 11' of G.S. Chapter 130A, Waste oLer Systems, Section :1900 Sewage Treatment and Disphsal,Systems) "*NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE a PL. ANS,OR THE INTENDED USE CHANGE. YOUR WASTEWATER' SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE } ENVIRO HEALTH SPI IST DA SSUED INSTALMG TETE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE.AJO%)S& BEDROOMS # BATHS # OCCUPANTS 2._ GARBAGE DISPOSAL No. COMMERCIAL'SPECIFICATION: FAq= TYPE # PEOPLE # PEOPLE/SHIFT # SEATS IND WASTE: Yes or No ` .LOT SIZED, -I TYP&WATER SUPPL ESIGN WASTEWATER FLOW.(GPD) ' NEW'SrfE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 'L° GAL. PUMP TANK OOOGAL..TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER ! 1.), sTet 1&v)"' C •.� )C ` REQUIRED SITE MODIFICATIONS/CONDITIONS: WSTAL JI 0,J -SVSMLA w i40:> fQOI IMPROVEMENT PERMIT LAYOUT • Q, +APPROVED;EFFLUENT FILTER* -*RISER( IF 6+9 BELOW INISFR;D GRADE ro . "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 9:30- 9:30.A.M. OR 1:00; 1:30 P.M. ON THE DAY OF INSTALLATION: TELEPHONE # IS ( >� 7 4tx �A, A DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS 1'' z' `"' PROPERTY INFORMATION Permittee's,� Nameo`: '!',';, : " ! Subdivision Name: Directions to property:' { II' ~+' iJ" x` Section: Lot: ' IMPROVEMENT t t PERMIT Tax Office PIN:# r lis t"3. t. � # ; :' '} Road Name: t .. L dip. **NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the constructionrnstallation 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) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE j j 1 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE I I G, # BEDROOMS __q__ # BATHS `'` # OCCUPANTS 21 GARBAGE DISPOSAL(Yes'or No COMMERCIAL SPECIFICATION: FACILITY TYPE_ �# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE_? 1=��L� TYPE WATER SUPPLY.--� 4�-DESIGN WASTEWATER FLOW (GPD) v NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZELa. GAL. PUMP TANK 0 V0'GAL. TRENCH WIDTH ROCK DEPTH 1 LINEAR FTc" OTHER •J REQUIRED SITE MODIFICATIONS/CONDITIONS: W 71 ALL, Ur/ 6CP170 dko "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS(3N) q4,j W1,6 1'751 .—T�7t.s�t OPERATION PERMIT SYSTEM INSTALLED BY: 1 r AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 05/96 (Revised) tt IMPROVEMENT PERMIT LAYOUT `^ FFt *RPPROVED EL1,.f = 4T FILTER* *RIFER{�,1 IF G� � PELM �INI''mil- !+C1:ADC `w t I.G.. Ile .I "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS(3N) q4,j W1,6 1'751 .—T�7t.s�t OPERATION PERMIT SYSTEM INSTALLED BY: 1 r AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 05/96 (Revised) 1 'APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED ALL THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed • LA ,S (.i_n (�_✓►r% (_s <'c� L/C -i1 /oo Z Contact Person Mailing Address / Sg� a & Home Phone City/State/Zip �Pn� �s �� 1/P, /� C . oC 9122IV Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: E " Site Evaluation 4. System to Serve: GY <ouse ❑ Mobile Home 5. IIf Residence: 0 Dishwasher 6. If Business/Other: # Commodes If Foodservice: 7. Type of water supply: # People o1 City/State/Zip Improvement Permit & ATC Ul-�oth ❑ Business ❑ Industry ❑ Other # Bedrooms # Bathrooms Ll/G'arbage Disposal Q4ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing Specify type # People # Showers # Urinals # Seats Estimated Water Usage (gallons per day) ❑ County/City U4611 # Sinks # Water Coolers ❑ Community 8. Do you anticipate additions or expansions of the facility this system /is intended to serve? Yes ❑ No Ifyes, what type? O u e5- J— .L�) u 5 �' / / PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Q WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # r2g -� - o! y, 1 fo�-o Property Address: Road Name & e&_D1@ Gkd 0.__LAne ` o City/Zip AoC.1 s s { &.-�i 1 Sa21 �-e,e If in Subdivision provide information, as follows: ; RA Name: —lam 1 fl 1 k. Section: Lot #: a 1 1 1 4 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 as necessary to determine the site suitability. DATE o�(� �/� SIGNATURE Revised DCHD (06-96) WE conduct all testing procedures ;'T Iq v 'a ; Ms , Ilr ;rk! 4 soon rA A, '441 ;rk! 4 soon '441 " DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section SECTION LOT 12 Soil/Site Evaluation APPLICANT'S NAME C���Sad �IE3�%A^�� l.�t7Z DATE EVALUATED 25--k h, PROPOSED FACILITY t ,�tOVs� PROPERTY SIZE SUBDIVISION ROAD NAME C>1Lwp L+•-� Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public c� Cut SITE CLASSIFICATION: V S DQL, 16 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D. 2- 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 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) Landscape position HORIZON I DEPTH Texture group Consistence OEM • : Ld 6• ti[ �L O' AML] -- HORIZON II DEPTH - Consistence Mineralogy Texture group Consistence - • _ �f/11�� i�/�a .-./,;�� .moi t,�.a�i►'��I��-� HORIZON IV DEPTH Texture group Consistence ff=4F SOIL WETNESS -�-- CLASSIFICATION Romm'I'Virm • '��'_7----- SITE CLASSIFICATION: V S DQL, 16 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: D. 2- 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 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 - 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ii.a __. �.lt�.�rrrrrrrrr������ ��■■■■■■■e■MI■MISI■■■■■■■■■■MISI■■■■MI■■■■■■■■■■■■■11■ecce■ ■■■■■■■■■��I■■►�■e■■■■e■■e■■��n�1�■1�■■■■■e■■Mee■e�llee■■e■ ■■■■■■■■ws�■■IN■■■w■■SI■■■■Mer. �■■■■■■■■■■■■■■■■■I�G1■■■■■ ■■■■■■■■�►�■■■■■■■_■■■■■■■■�■■■■■■■■■■■■IN■■■■elle■■■■■ ■■■■Mee■\I■■■■■■e,iMI■■■■■\1\►I■■■■■el�r1�']e�■■■er■11■■■■■■ ■■■■■■■■►■■■■■■■l\7■■■■■■Eli■■�■■■,L� V■SIe'■■■■\��'�i■■■■■ ■■■■eee■■■■■■■■w■:�■•_.■e■■e■■'■■■■■■■■■e■■■e■e■eu■■■e■ ■■■■■■■■■■■MI■SI■MI■■■SIMI■■■MI■■■SI■MI■■MISI■■■■Mee■■SI■■��■■■ ■■SI■■■■■■■■■■■■■■■■■■■eMI■■MIMISIMI■■MI■■■MINIMI■MI■■MIe�IN■■■■■ Mee■■■■■■■■■■■MI■■MI■■SIMI■■■■■eee■■SI■■■■eMI■■■■■■■■■■■■■ ■elN■EE■■IN ■■IN■■■■■■ ■■It■■■■■■ ■■It■■■■■■ ■■II■■■■■■ ■■11■■■■■■ ■MIU■■■■■■ Wi■■■e■■■ R■■■■■■■■ MIME■■■■■■ ■■■■■■■■■ ■MINI■■■■■■ ■■■■■■MIEN ■■■MINI■■■■ ■■■■■■EMI■ ■MINI■■■■■■ ■■■SIMM■■■ MINIM■■■MINI■ ■■MIME■■■■ ■MINI■■■■■■ ■ ■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900577 Tax PIN/EH M 5822-89-4209.0012P Billed To: Susan & Giovanni Looz Subdivision Info: Whip -O -Will Lot # 12 Reference Name: Cynthia Toth Location/Address: Steeplecase Lane -27208 Proposed Facility: Residence Property Size: 5.694 acres ATC Number: 1588A **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 MoLn-r #People 2 #Bedrooms 1-1 #Baths Dishwasher: l" Garbage Disposal: r Washing Machine: e Basement w/Plumbing: 131" Basement/No Plumbing: ❑ Commercial Specification: Facility Type#People #People/Shift #Seats Industrial 11al Waste: Lot Size 5- cR4 A &SType Water Supply `- ��11 VLW Y Design Wastewater Flow (GPD) Site: New 12 Repair ❑ System Specifications: Tank Size I OCO GAL. Pump Tank GAL. Trench Width Rock Depth �$�� Linear Ft. (GCO' Other: J g�(GS , WSTA U. L1+JE_S T O . C . M Id Required Site Modifications/Conditions: -kN ,�T�� Un1 +Gt �dt)�i Iti�=P t5' OCC 14003.E ('C&.S 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.**** Nom Ey .LPA.-sT C� ,4 fi +, I2p+ Environmental Health Specialist's Signature: 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 #: 989900577 Billed To: Susan & Giovanni Looz Reference Name: Cynthia Toth Proposed Facility: Residence ATC Number: 1588A Tax PIN/EH #: 5822-89-4209.0012P Subdivision Info: Whip -O -Will Lot # 12 Location/Address: Steeplecase Lane -27208 Property Size: 5.694 acres 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 Treatme and Disposal Systems). THIS AUTHORIZATION FOR WASTE ONS IS VA FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu e: A5�o) 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 Specialist's Signature: DCHD 05/99 (Revised) Date: