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118 Cornatzer Rd0 , • Account #: 990002141 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,!�•�� P. O. Boa 848/210 Hospital Street � Mocksville, NC 27028 (336)751-87C►U IMPROVEMENT/OPERATION PERMIT Bilied To: Freedom Baptist Church Reference Name: Proposed Facility: Church/hall Tax PIN/EH #: 5757-79-3341 Subdivision Info: Location/Address: Cornatzer Road-27028 Property Size: 820' x 315' r�- � 2 f� � r� ATC Number: 3265 **NOTE** T'his ImprovemendOperation 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: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type � G9Y`/i #People �a #People/Shift �d #Seats Industrial Waste: ❑ � Lot Size �� Type Water Supply a Design Wastewater Flow (GPD) � Site: New � Repair ❑ System Specifications: Tank Size � GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width c�(�v � Rock Depth lo� �� Linear Ft.�O �� IM11PROVEI�1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis 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 (33G)751-87G0.**** uT s� l; � L�''� dr�c � v��`� ,�-� U �' 6'� --�- Environmental Health SpecialisYs Signature: �� _ '� Date: c��j� �, ✓ DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990002141 Billed To: Freedom Baptist Church Reference Name: Proposed Facility: Church/hall ATC Number: 3265 P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5757-79-3341 Subdivision Info: Location/Address: Cornatzer Road-27028 Property Size: 820' x 315' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA C NST UCTION IS VALID OR A PEWOD OF FIVE YEARS. Environmental Health Specialist's Signature: � _ Date: O'cs�(/ �� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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. ,7,5 � �i'o,,, �u %��' _.J � ��rl�in � Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) L � �Dc� ?oi-p � z�k', Date: _ ��,�- APPI1CATiON FOR SITE EVALUATIiJ�I/IMa+ROVEMEM' 6'ERbfi�T & d Davie County Health Department � Environmenta/Hea/th Section�� P.O. Box 848/210 Hospital Str e�� Mocksville, NC 27028 �j /��„�/��f ��j2 // (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS INFOR2��TION IS PROVIDED. Refer to the INFORNATION BULLETIN f r C, ��C��O�,��[� f� ^, � � �� .. d ,/' �'/`�/j� % THE � QUIRED � instructions. 1. xame to be silled �- r e e� O YY� �a O� �� UrL' (l contact Person (� ��+ a rn C_ a r-l"e.r Mailing Address � b p �(� (- [� � 1 X� V !C U• Home Phone q' q g-�o g o City/State/ZIP ��.� a. � C C� .' 1 V a�!7(J � Business Phone q�� Z� � Y e�� 2. Name on Pesmit/ATC if Different than Above Mailing Address city/state/zip 3. Application For: �ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry b' other l, rC r7 �"/ltil�it�li�! /Y�I /SOJ 5. If Residence: # People # Bedrooms # Bathrooms �-l��r�itw U DishNasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing f.7 Basement/No Plusbing 6. If Business/Industry/Other: Specify type �i People # Sinks � Commodes # Showers # Urinals � jPater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Typa o£ water supply: 0'County/City 0 Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Ycs ❑ No ***IMPORTANT*** CLIENTS MUSTCOMPLETETIiE REQUIRCD PROPIsR'I'Y INFORMA'I'ION REQUESTLD BELOW. Either a PLAT or SITE PLAN MUSTBESUBAlITTED by the client with THIS APPLlCAT10N. Property Dimcnsions: __ , . g�1D�X ,� �JC , Tax Office PIN: ��5'7s 7 79- �3 � I Property Address: Road Name � �n1 a.�Z�i �'� �w�• (� � city/Z;p z ? o -,2 � If in a Subdivision provide ioformation, as fol(ows: Name: Section: Block: Lot: WRITL DII:LC7'ION� (fro�n Mocksvillc) to 1'1201'LR7'1': �t�'U rh I�l U C�S 1% 1 l ��, � `� E• C.r vss ��s��marJ �c��K �. / rn i l� o l� f e�"C Date Property Flaggcd: �� - d o�-� This is to certify that the information provided is correct to ttic best of my kn�wledge. I understand that uny permit(s) issued hereafter are subject to suspension or revocation, if tl�e site plans or intendcd use change, or if thc information submitted in this application is falsified or changed. I, also, ru:dersta�rd diat I an: respoarsible for a11 cl:arges iuci�rred from this application. I, hereby, give conscnt to the Authorized Representativc of thc Davic �ounty Health Department to enter upon above dcscribed property located in Davie County and owncd by to conduct all testing procedures as necessary to determine ths site suitability. DATE / - �� - � � SIGNATURE ,iC.C��.-rr�-rtJ � �� THIS AREA MAY BE USED FOR DRAVVING YOUR SITE PLAN (Include all of the follo�ving: Existing and proposed property lines and dimensions, structures, setbacks, and scptic locations). .L"1 � Site Revisit Ci�arge Datc(s): Clicnt 111atification IDate: EHS: ,-'� � l Account No. � � Revised DCHD (, Invoi e No. v� � � S=L (e, 2 J�L.S 1� • " ,� � ��;� � L � N � 0 � � 39� 66 0 0 671 (4.98 A) �NDEXED ON 57 8.20 3849 � 718 (5.05 A) 3508 Tg9 Fal��`�J60000005408 �,� ��q�`�,1 3341 � � �h�� i �� 3� �30 /�1� �31 (3.20A) 5899 0 0 N � � 5.94A 8391 139�1 6p0 (5.OA) 9833 � "--' �� 03L! 3326 • 6.33A �� pP� 1229 0 �18 ° . 68 'Lt SR 1693 � o � 28 , 2�� 1� . �� g ,� 4q . o „ r. ' 815� 225 o Z�� 6114 � 7145 3089 ` � ' N �p0 1� p0 6053 � 0 4906 o Zoo �� 1�1 � 8914 w o �L � 6970 0 � 0 4827 � � � 200 , o � w��E� ME �� o 4747 � Z P �o0 10 20o m g2 . 0 4 N 7780 0$ 4667 N6697 a J60000005411 Zoo p 4.98 A � � � ) 4597 �' �11 0545 �c,� 1203$' (2.50A) 8030 N oMi � Q 64 �q55 ' DAVIE COUNTY HEALTH DEPART'MENT ' ' ' " Environmental Health Secfion � ` � Soil/Site Evaluation A�PLICANT INFORMATION PROPERTY INFORMATION Account #: 990002141 Tax PIN/EH #: 5757-79-3341 Billed To: �reedom Baptist Church Subdivision Info: Reference Name: Location/Address: Comatzer Road-27028 Proposed Facility: Church/hall Property Size: 820' x 315' Date Evaluated: 07 l� l� Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit icA�uic �ivuY Consis[ence 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 SITE CLASSIFICATION: � LONG-TERM ACCEPTANCE RATE: ' REMARKS: �] %��_ _��i�l� I Public j� Cut EVALUATION BY: OTHER(S) PRESENT: �,��v2(i�� 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely �rm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineralo�v 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 OS/99 (Revised) ■�■ ■�■ ■�■ ■0■ ■�■ ■�■ ■�■ ■�■ ■�■ ■■■ ■�■ ■�■ ■■■ iii ■■■ ■�■■ ■■�■ ■��■ ■■■■ i ■ ■■��■ ■��■�■ ■��■ ■■�■�■ ■�■��■ ■��■ ■��■■■ ■��■�■ ■�■ ■�■ ■ ■ ■ ■■■��■■ ■��■ ■■�■��■ ■��■ ■��■ ■��■��■ ■��,m��■ ■��r��■ ■■��■ ■��■�■�■ ■��■��■ ■■��■��■ ■��■�■ ■■��■�■ ■��:�■_■ _��■��■, ��■��■ ■■��■�■ ■■��■��■ ■�■�■��■ ■��■��■�■ ■�i��■ ■��■�■��■■ ■�� ■��■��-- ■��■ ■��■ ■��■ ■ ■��■ ■��■ ■��r ■��■ ■■ ■■ ■■ ■■ ■■ ■■ ■�■■�■�■��■��■■ ■��■��■■�■■��■ ■��■��e��■ ■��■��■��■ ■�■■��■��■■■ ■��■��■��■ ■��■ ■■��■■��■ ■■��■��■■■■ ■��■��■��■��■�■ ■��■��■ ■■�■��■■�■■��■ ■��■��■��■ ■��■��■��■ ■��■ ■��■■��■��■ ■��■��■ ■��■��■��■��■ ■■��■■��■��■��■ ■■��■��■��■ ■�■��■■��■■��■ ■��■ ■��■ ■■ ■��■ ■�■�t■ ■■ ■■�■■■��■��■■ ■t��■��■��■ ■ ■��■■�■��■�■��■ ■��■�■■■��■■ ■■��■■��■��■�■��■ ■��■��■��■��■■��■ ■�■■■��■��■��■ ■��■■��■�■��■ ■■■ ■ ■ � . . • ��.o�__.�,y.__ �?� .. _�_ .D�'f�I� �OUNTY�I�LTi� D��'��T14I�N'T . .._ . . ., _. . ��.�yr � � ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street - Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 February 12,2002 .,• _ Freedom Baptist Church 388 Fork Bixby Road Advance, NC 27006 Re: Site Evaluation/ Cornatzer Rd./ 64 Tax Office Pin : # 5757-79-3341 Dear Client(s): As requested, a representative from this office visited the aforementioned site on February 11, 2002. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/m�bile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, ,��2!�t� ��d�,. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df