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275 Brangus Way Lot 27DAVIE COUNTY HEALTH DEPARTMENT t Environmental Health Section ' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000847 Tax PIN/EH #: 5832-07-9890.27 Billed To: Douglas & Margaret Bordner Subdivision Info: Whip -O -Will Lot#27 Reference Name: Margaret Bordner Location/Address: Brangus Way -27028 Proposed Facility: Residence Property Size: 6 Acres ATC Number: 2250 **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 1-4 QL)f>Z #People _ #Bedrooms ZI #Baths �• Dishwasher: ®"�- Garbage Disposal: ET Washing Machine: Er' Basement w/Plumbing: l2r'�­Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift ##Seats Industrial Waste: ❑ Lot Size (O • C42 4!L&?SType Water Supply —eowy Design Wastewater Flow (GPD) LRO Site: New ET Repair ❑ System Specifications: Tank Size kwGAL. Pump Tank GAL. Trench Width Rock Depth /2 Linear Ft. Other: 3 -P1ST£?1boT1,o 6oxe-5-, • WSTQUL UtUeS 9O.C. Required Site Modifications/Conditions: Ir"STALL.yr�, CA,4w tie. L-4--p►-y IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW FINISHED GRADE. ****NOT CE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30A.m4 A3R.�. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** •moi - �, �, I-IS'Mva 90.e T LP Environmental Health Specialist's Signature: Date: — 11�IsAl DCHD 05/99 (Revised) F.e- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000847 Tax PIN/EH #: 5832-07-9890.27 Billed To: Douglas & Margaret Bordner Subdivision Info: Whip -O -Will Lot # 27 Reference Name: Margaret Bordner Location/Address: Brangus Way -27028 Proposed Facility: Residence Property Size: 6 Acres ATC Number: 2250 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 WASTEWA MON IS YALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature- Date: �S CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicag the s tem described on Improvement/Operation Permit has been installed in compliance with Article 11 of . . Chaff ter 1 OA, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as uar tee t t the system will function satisfactorily for any given period of time. -5- X _ k 0 4 8 p? -0 —3 1 Septic System Installed By: Environmental Health Specialist's DCHD 05/99 (Revised) Date: APPI (CATION FOR SIFE EVA: UATi0N/IMPROVEMENT PERM A ATC C �O Davie County Health Department ' Envfissnmehta/ Health Section �G! 2 P.O. Box 848/210 Hospital 8tant Mockaville, VC 27020 (336) 751-8760 r_ -,o HEALTH ***ZWCRTlltt?*** TRIO APPLICIITICRB CAMWT 8B (?ROC SgZD UNLZ88 AIX QOIAED IN1"Of4rD1TI0N I8 PROVIDW. Refer to the IN>t'ORIMATION SULLZTIH for instructions. 1. now to be Killed Dou.alAn, E 4AArn' 1041 rA ner Contact person j1ArMAeI Hailing Address son• wone ciht/stat•/s=p �,�' 02 I o1 owls••• p!►oM* 5/Am e, a. 1Kar on P•snit/A= IS DUterent than lbo�� S a rv4 V@414g Address Ci state/lip �ie,� 3. Application For: 13 Sito =valuation Improveamat I?w mit/IITC of h 4. system to service: V' House 0 Mobile Rome O Business 0 industrr 0 other S. i! sidenoe: i people _ f Bedrooms f Satbrooms , rDi•hxa•her garbage Di•po•el 1:ashing Naobine sa•em•nt/plumbing a sa••ment/k:a Plumbing 6. Zt swine••/Zadu•tsr/otber: opacity type I people i sinks commodes i Shows= Orinals f Yater Coolers IF V=8ZRVICZ: # seats Zatimated Vater Usage (gallon• per day) 7. Type of Mater supply: 11K County/City Moll 13 Ca mmaity a. Do you anticipate addition or expansions of the facMty this system Is Intended to serve? 0 Vas JIio U yes, ►hat type? ***IMPORTANT*** CUEMHIMTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BER --Awe V!her e P1-IkT _s MTc PIAN p.- rnvuC'm"I7-1SV 67 Qe cuent wild t�5 API LGATION. 3 00 • )( 978'•«+10v -c -b Property Dimensions: 1 �� ��'�S, WRITE DIRECTIONS (11na Mockn1lee)) to PROPERTY: TaxOMeePIN: taho'IA'o Property Address: Road Name a � AQv /b+ 27 / to Uv CitytLIpiaoc�sL)'Jte_ A)( 110 U in a Subdivision provide Information, as follows: Name. Section: J3 d Blocks Lott 2 _ Date Property Flagged: 11 -,2 - 9 Q This Is to certify that the Information provided Is correct to the best of my knowledge. I understand that any permit(i) 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 shat I an responsible for all charges Incurredftom this appHeadom 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located In Dsvfe County and owned by to conduct all testing procedures as necessary to determine theslte EalWty. ,� DATE I-.3 TMS AREA MAY BE USED FOR DRAWING YOUR SffE PLAN (Inchk property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) of the following: Existing and proposed Date(s): 1EHS: Site Revisit Charge Notification Date: Account No. F11-17 Invoice No. /� ��7 It t p6� \� n •�i0 �.t2Fi \ �O ltr� ," Q y 52 E9'T4T 3 �� "� a ; I.t , z� t f �'< J mss. s O • ol ,O - u�"SVho� or 00 Tv- �,F�. IoM \ �� V �1{ 10 I\ 40 G J 6a 9ae ��ti •� � � a 'J '� •6e.4b,ps as � : o� PI9,1 Oa � X51 \\. ��00 •9S81Ad CO �• �� J•69 N rp / —~ or 61 ru In . � Ob� z. D CO -v •7 ,n of pH 6, .� .9� •6� /� s n 90 1 s S t" ` \ ` r' r - � -,�-•-- Lv� . APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE rATC �/�� ireDavie County Health Department C �F C`,7'F ; ""IEnvironmen.al Health Section �--- - f P. O. Box 848 Mocksville, NC 27028 AN Q I; (704) 634-8760 0-1 ****IMPORTANT**** THIS APPLICATION CANNOT BE PRO ESSED UNLESS ALL THE REQUIRED INFO ATION IS PROVIDED. 1. Name to be Billed Idl, �•--�-��1�Contact Person K1 i� Mailing Address r I Home Phone L City/State/Zip [ l 1 & Business Phone 20q q 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. 6. Site Evaluation House ❑ Mobile Home City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry If Residence: #People 10 -to r� ,,_# .�Bye�,rq�om�s �"� ❑ ' Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing, If Business/Other:J�Oecify ty e # People _ # Commodes # Showers # Urinals If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply:County/City ❑ Well ❑ Both ❑ Other # Bathrooms ❑ Basement/No Plumbing # # Water Coolers 8. Do you anticipateladditions or expansions of the facility this system is intended to sgrve? If yes, what type? ❑ Community ElYes j No PROPERTY INFORMATI N REQUIRED} *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �"�' l'- tz- e . WRITE DIRECTIONS (from 0Q� 1 Mocksville) TO PROPERTY: Tax Office PIN: # 1 Property Address: Road Name &rj S ,� 4i4(0 t City/Zip �� �� •J i :--iz If in Subdivision provide information, as follows: 1 Name:?1 q5`►v�.`` U i 1v' �v "t'7� C 7 f' Section: ��[-tL[1si IZC,rl Lot #: 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 1, ! to conduct all testing procedures as necessary tetermi a the site suitability. o d DATE + 1, ! _ SIGNATURE � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME " 6 PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well ,--myr- Community. Evaluation By: Auger Boring Pit SECTION_/- LOT'! DATE EVALUATED PROPERTY SIZE 15' ROAD NAME X/ d�?_Va ( f 6:2 e_v 41W Public /_,-1 Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group C,- G Consistence Structure 6 /� Mineralogy. Y 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: LONG-TERM ACCEPTANCE RATE: '13 EVALUATION BY: A '� 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) ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ice■■■■■■■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■E■■■■ ■■MME■ ■■MME■ ■E■ME■ ■■■■■■■■■■■■■■■■■■■■■■■tri■■■■■■■■■■■■■ ■ ■■■■■■■ MEMO■■■ ■■M■■M■ ■OMMEM■ ■E■■M■■ ■■■M■E■ ■■MEMS■ ■E■MEM■ ■■■■■M■ ■■M■■E■ ■M■■E■■