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1821 Cornatzer Rd. � ' � � .,� DAVIE COUNTY IiEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street . Mocksville, NC 27028 (33G)751-87G0 Account #: 990001878 Billed To: Gary Swan Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT .2,-� %�� ,5�/ ` Tax PIN/EH #: 5769-28-9011 Subdivision Info: Location/Address: Comatzer Road-27028 Property Size: see map **NOTE�� Thi b�mprove�ment/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALJTHORIZATION 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 ] 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERNIIT 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 �pI�SE, #People 3 #Bedrooms 3 #Baths � Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size . ��Type Water Supply ��1.. Design Wastewater Flow (GPD) �� Site: New � Repair ❑ System Specifications: Tank Size �C`�Ci:C'AL. Pump Tank GAL. Trench Width � 1 Rock Depth � Linear Ft. �cCL�' � other: CJ� ��L. � SD �F Z`� fl�+`�Jc�'to ,� ��j! t,�. I:JJTEJ� Required Site Modifications/Conditions: Irl�Tn�: • o..� +�.�,'7�� Q � j �� N�, �—� �pp' FQa�v... IMPROVEMENT/OPERATION PERMIT LAYOUT - FINISHED GRADE. ****NOTICE: Contact a represen system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 G�'zr�r 3 �e �a��3� i5� T �L �� Environmental Health Specialist's Signature: DCHD OS/99 (Revised) 7 D EFFLUENT FILTER RISER(S) IF 6" BELOW Davie County Health Department for final inspection of this day of installation. Telephone # is (336)751-8760.**** �, I�`� l�' o� ��.i,Y U-� r-- ///� /Dy .. ,� �- jr� Gk'�rW��' �� 3 �nk�'� �a �G'N - ��1'.4�'T i.�(� n u� � rJ„� "`�" ��-M�i I�(� �Q�� Date: � � ti � � Account #: 990001878 Biiled To: Gary Swan Reference Name: n..,...,.,.,.,� c..,.:i:a... n__:'r__-- � ...f.v.�v.. � uv��a�. �.c.v��v� ATC Number: 2949 DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5769-28-9011 Subdivision Info: LocationlAddress: Cornatzer Road-27028 r�vNciiy vi�c. xc 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 an Disposal Systems). THIS AUTHORIZATION FOR WASTE ER CON UC ID F R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature '.. ��,�� D d: � CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with icle 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO W� taken as a guarantee that the system will function satisfactorily for any given period of time. `2 � fi"L,� %/" � � 2c� +2- �� 1�' � C� T � �1 yy� , ,� LNTt �-��" �P-��.�5 �ST��^.� ,>� Septic System Installed By: Environmental Health SpecialisYs Signature : DCHD OSl99 (Revised) Date: r �%7�iiZ r . � �_lUJ � A� I 4 200f � _ T - ��-�-_ AI PLICATLUN FOR SITE EVALUA770N/Ii9YROVER9EIVT 1 LIiI�f6T &/�8�� -" Davie County Health Department � ��//� Environmenta/Hea/th �ection � P.O. Box 898/210 Hospital Street /� "� Mocksville, NC 27028 ` � `�� (336)751-8760 � ***IMPORTANT***`� THIS APPLICATION CANNOT BE PROCESSED UbIL�SS ALL `.L'HI: I2�QUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions 1. Name to'be IIilled Mailinq Address City/State/ZIP 2. Name on Perm.it/ATC if Different than Above Contact Person �/c.,( � Home Phone � / U �7q�3 ` -r_ -- -- IIusiness Phone �R� �l �— Mailing ]lddress City/State/Zip _�C�S 3. Application For: C� Site Evaluation ❑ Improvement Permit/ATC oth0�l% a. system to service: �t3' House ❑ Mobile Home ❑ Business Il Industry I I Other 5. Ii Residence: # Peo le �_ �-3 �GS �,�17b� � _ P # Bedrooms �� Ba hrooms I41�Dishxasher CI Gazbage Disposal I''�Washing Machine lti�IIasemenL-/Plumbing I I F3asemenC/Lto P�.11IIltilIICJ 6. If Business/Industry/Other: Specify type � Peoplo # SinY.s N Commodes # Showers # Urinals �t Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. �� of water supply: p County/City L�Well I I Coirununity e, Do you anticipatc additions or cxp;�nsions of tl�c facilily this syslcm is inlcudcd to scrvc? Ifycs, wliat typc? I I Ycs lik'Nu ***Id1PORTANT*** CLI�NTS hiUST COAIPLCTCTII� RCQUI/tGD PKOI'LR'CY INI�OIih1A'1'ION RLQUI;S'f'LD I BELOW. Githcr a PLAT or SITG PLAN d1UST 13ESUBMI77'ED by tlic dicnt �vith 'I'IIIS AYI'LICA7'ION. Properly Uimcnsions: �1� ��',�'" �VRI'I'G llIRLC'i'IONS (from �1ucicsvillc) lu Pitt)t'I�;Ii'I'1 : TaxOfficc P1N: # ��C� � lDl � 1�Q�1'�0�.�� " �,,�e �. � > Property Address: Road Namc �� \ Q,�`.(Q�� i��-`Q�S .�� City/Zip��4 5�:11 � , �� %,1'�.T�C'� -r , If in a Subdivision providc information, as follows: Namc: Scction: I31ock: Lot: Datc I'roperty I�lagbcd: This is to ccrtify that thc information providcd is corrcct to thc bcst of my knoivlcdgc. I undcrstand tliat :�ny permit(s) issucd hcrcaftcr are subjcct to suspcnsion or rcvocation, if tl�c sitc plans or inlcndcd usc chu��c, or if thc informalion submitted in ti�is application is falsified or cl►aabcd. I, nlso, rutderstnird 1/tat I rrm respurrsiGle fr�r rr!/ cltur�e.s iircurred frum ri„s annr,�utr�,,. I, hereby, give consent to the Authoriud Representative of the �;ivie Cou� � Flcl►Ilh •parUncnl tu cntcr upon abovc dcscribed property locatcd in Davic County and u�vncd by (,��L�n ----.._ . --_ to conduct all tcsting proccdures as ncccssary tu dctcrminc thc sitc s itaUility. llATL SIGNA'I'URG , � THIS AIZ�A MAY BE US�D P'OR DRAWING YOUR SIT� PLAN (Includc all of tlac follu�viug: �xistin�; an� proposc�l property lincs and dimcnsions, structures, setbacks, and scptic locations). Rcviscd DCHD (07/99) Siti Rcvisit Cl�.�r�c I llatc(s): Clicnt Noiificatiou llalc: �HS: Accouat No. �Z8 Invoicc No. � 7 0 � � 6.34A 4090 (16.63A) 3263 ,z,s (10.56A) 5664 � rn v G70000004501 4.64A 9011 ��, 0 773 (13.72A) 2456 (11.32A) 6504 (1200) (3.82A) 0687 ��8 % � �� (1.37A) 9520 �9J w � � ,L66 �6�6 5R . �� a M� � v .� �` , « tl��{��: � •� • i Davie County assumes no responsibility for the data contained in or the accuracy of this map. N W E S 200 0 200 400 Feet Davie County Tax Mapping . ' ' '' y APPLICANT INFORMATION Account #: 990001878 Bilied To: Gary Swan Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Landscape position Slope % HORIZON I DEPTH Texture group 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 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5769-28-9011 Subdivision Info: Location/Address: Cornatzer Road-2702 Property Size: see map Date Evaluated: � 1'� On-Site Well l Community Auger Boring � Pit 1 2 L L /� � �� — `!i - (0 0- O� s c..i. C� SC� C � C r SSS Sc,� SS (-r S� < SOIL WETNESS RESTRICTIVE HORIZON CLASSIFICATION LONG-TERM ACCEPTANCE RA SIT'E CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: � � � EVALUATION BY: Public Cut 5 6 7 OTHER(S) PRESENT: ��-`� `—'W �-'J REMARKS: LEGEND Landscape Position R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope CC - Concave slope CV - Conve�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 �rm 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 Mineraloev � 1:1, 2:1, Mixed Notes � Horizon depth - In inches � Depth of fill - In inches � Restrictive horizon - Thickness and inches from land surface �1 p 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 - gaUday/ft2 DCHD OS/99 (Revised) ■■ ■ ■■■■ ■��■ ■��■ ■■�■ ■��■ ■��■ ■■�■ . . ■AL UMI I�� ■■�■■ ■��■ ■��■■ ■■■�■ ■�■�■ ■��■ ■��■ ■�■�■ ■�■�■ ■��■ ■■��■ ■��■■ ■�■■■ ■��■ ■■��■ ■■��■ ■��■■ C■�■■ .... ..... .......................��... .......................■�... ........................�... ........................... ■■■■�■��■�■�■��■��■��■■ ■��■��■��■��■■��■�■�i��■ ■��i�■■ ■��■��■��■■��■��■■ ■��■■��■��■��■��■��■ ■��■��■��■�■■■ ■■��■■ ■\��■ ■��■ ■��■��■ ■��■ ■�■��■ ■��■ ■■��■ ■�■�■�■ ■�■��■ ■��■�■ ■��■ ■��■��■ ■��■��■ ■■�■ ■��■■ ■��■ ■��■■ ■■■�■ ■��■ ■�■■■ ■��■ ■■��■ ■��■■ ■�l■ �� ■ ■ ■■�■ ■■�■ ■■�■ ■��■ ■��■ ■■�■ ■ ■ ■■