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208 Fred Lanier RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002375 Tax PIN/EH #: 5709-95-5372 Billed To: Thomas Wright Subdivision Info: Reference Name: Location/Address: Fred Lanier Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3229 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 ,/� r/ #People Q - j' #Bedrooms #Baths o _S Dishwasher: F� Garbage Disposal: ❑ Washing Machine: K Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �— Design Wastewater Flow (GPD) -�16� Site: New Repair ❑ System Specifications: Tank Size Zaa GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width ZZ Rock Depth .1,2 " Linear Ft,,DO I IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FI N I S H E D G RADE. ""NOTICE: * *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. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002375 Tax PIN/EH #: 5709-95-5372 Billed To: Thomas Wright Subdivision Info: Reference Name: Location/Address: Fred Lanier Road -27028 Pro osed Facility: Residence Property Size: see ma ATC Number: 3229 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 WASTE WAT C�N�STTRRUCTION 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 Specialist's Signature: Date: DCHD 05/99 (Revised) • APPLICATION F013 SITE EVALUATION/16IP110VEMENT PERNII7 ' Davie County Health Department /jam Envirorlmenta/Health Section P.O. Box 848/210 Hospital Street ) 8 Mocksville, NC 27028 F, ZQ (336) 751-8760 tij� oe G. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers if Urinals # Water Coolers IF FOODSERVICE: 4 Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City C1 Well 11 Community n. Do you anticipate additions or expansions of the facility this systan is intended to serve? ❑ Yes �rNo Ifyes, what type? ***h1f1'0R7ANT*** CLIENTS A/USTCOAM'LETETHE REQUIRED I'ROPER'I'Y INFORMATION REQIJESTE'D 111?LOW. Either a PLAT or SITE PLAN AMST BESUBARTTED by the client with TIIIS APPLICATION. ti 1'roperly Dimensions: _ S'e �'" WRITE DIRECTIONS (from Mocksville) to 1'R01'ER'1'1': 11 _ Tax Unice PIN: 11 1-79 1- 5S -S3 7 2-- 31 T 1,vifk Properly Address: Road City/zia' P -02r Y D If in a Subdivision provide information, as follows: Name: .Section: Block: Lot: Date Properly Flagged:—� —� This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the infornm(ion submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred front this application. 1, 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.4u. _y 1 e to conduct all testing procedures as necessary to determine the site suitabilit . 1)A'1'l.� y %4 oO SIGNATURE TI IIS AREA MAY 13E 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 Daic(s): Client Notification Date: EI -IS: Account No. cc No. c1 C1 M ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEIFit'rb v PROVIDED. Refer to the INFORMATION BULLETIN for instructi 1 . Name to be Billed / p� A S �t, Lj � / Contact Person / ZII p S L✓�,�� Mailing Address ��j'� �Z�� /� N �/� �C 11ome Phone City/State/ZIP Business Phone 2. llama on Permit/ATC if Different than Above Mailing Address 2 City/State/Zip 3. Application For:mite Evaluati n Improvement Permit/ATC P Both L cQZJ 4. System to Service: f_l House Jif Mobile Home ❑ Business ❑ Industry 0 Other 5. If Residence: # People # Bedrooms 3 # Bathrooms SAL. ' Dishwasher 11 Garbage Disposal Ar Washing Machine 11 Basement/Plumbing 11 Basement/No Plumbing G. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers if Urinals # Water Coolers IF FOODSERVICE: 4 Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City C1 Well 11 Community n. Do you anticipate additions or expansions of the facility this systan is intended to serve? ❑ Yes �rNo Ifyes, what type? ***h1f1'0R7ANT*** CLIENTS A/USTCOAM'LETETHE REQUIRED I'ROPER'I'Y INFORMATION REQIJESTE'D 111?LOW. Either a PLAT or SITE PLAN AMST BESUBARTTED by the client with TIIIS APPLICATION. ti 1'roperly Dimensions: _ S'e �'" WRITE DIRECTIONS (from Mocksville) to 1'R01'ER'1'1': 11 _ Tax Unice PIN: 11 1-79 1- 5S -S3 7 2-- 31 T 1,vifk Properly Address: Road City/zia' P -02r Y D If in a Subdivision provide information, as follows: Name: .Section: Block: Lot: Date Properly Flagged:—� —� This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the infornm(ion submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred front this application. 1, 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.4u. _y 1 e to conduct all testing procedures as necessary to determine the site suitabilit . 1)A'1'l.� y %4 oO SIGNATURE TI IIS AREA MAY 13E 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 Daic(s): Client Notification Date: EI -IS: Account No. cc No. c1 C1 M W L89ti Z8L9 9 69' (Vzo z k ZL£9 (dssz ) L89ti Z8L9 9 69' (Vzo (d£S Z£) W (t9L) term %i DAVIE COUNTY HEALTH DEPARTMENT - •' :� ' 1 Environmental Health Section Landscape position 27 Soiil/Site Evaluation ° ~� , APPLICANT INFORMATION HORIZON I DEPTH PROPERTY INFORMATION Account #: 990002375 Tax PIN/EH #: 5709-95-5372 Billed To: Thomas Wright Subdivision Info: Structure Reference Name: Location/Address: Fred Lanier Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 7�Zg`L Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 27 Sloe % , HORIZON I DEPTH l Texture group X_' P J X4- Consistence Structure Mineralogy HORIZON II DEPTH « Texture group Consistence Structure Mineralogy 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 L SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:rl // 'T OTHER(S) PRESENT: 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 05/99 (Revised) ■ ■ ■ ■ ■■ ■EM■ME■■MEMM■M■ ■MEM■MMEMEM■EM■ ■EME■■MEM■NEME■ ■M■M■MN■■N■■M■■ ■■M■EM■■EMM■MO■ ■MMEMMEMMEM■ME■ ■EME■E■EME■■EM■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■E■■■■■■■■EOE■■■■E■e■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■S■■E■■EM■■■■■■■ ■E■■■E■■■■■MME■■ ■■■■■EE■■■■■■■■■ME■■E■E■E■E■■EOE■■■ ■■■■■E■E■EE■■■■■■E■■■EEE■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■Ott■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■Ott■■■��ii■■\■■■■ ■��tt��E■mo■s Mons■n■■mmins� ■■■■■■■■■■■■■■■■Ott■■■■■■■■■■■�i■■■■ ■■■■■■■EOE,■■E■E■■E■EE■U■EE■■t■�it■■■ ■■■N■■■■E■(■E■MM■■ ■■EM■■E■■■■AIMMEN ■■■E■■■EME■■M■■M■ ■M■MMMM■■■■MMMM■ ■■■ME■■M■■M■■M■ MENU■M■M■■M■M■M■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■M■■ME■■MMM■■MEM■ ■M■■MM■■ME■■■■MME■ ■■M■M■■MEMEMEM■■M■ i ■Mt■■■■■ ■■■■■■■■ MONSOONS ■■EEE■■■ ■■■M■■■■ ■■■S■■■■ ■EM■■■E■ motto■■■ ■ENE■■■■ ■ME■■■M■ ME ■M■ ■M■■ ■■■ ■E ■■ME■■ ■E■■M■M■ ON ■I■■E■■■ ■ ■■■■■■ MEMME■■■ ■EN■t■■■ ■■t■■■M■ ■■E■■■■■