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3077 Cornatzer RdAccount #: 990002336 Billed To: Sandra Leroy Reference Name: ATC Number: 3205 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocl�sville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5870-92-6704 Subdivision Info: Z%�� Location/Address: Cornatzer Rd 2ZD28 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �� **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any buiiding permit(s). T'his 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, ction .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT R ONSTRUCTION IS VAL p F R ERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �� v� ?� Date: ,� �� `� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Ceitificate of Completion shall ind has been installed in compliance with Article 11 of G.S. Disposal Systems," but shall in NO WAY be taken as a given period of time. Septic System Installed By: ed on ImprovemendOperation Permit .1900 "Sewage Treatment and m will function satisfactorily for any Environmental Health Specialist's Signature : ��i � v Date: ��'�� DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ,��) . �( - l°�,--c� Z� � ,•' - . y Environmental Health Section � � . • . P. O. Boz 848/210 Hospital Street ''� . Mocksville, NC 27028 . � (33C,)751-87G0 Account #: 990002336 Billed To: Sandra Leroy Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5870-92-6704 Subdivision Info: 2�Q0� Location/Address: Cornatzer Rd-2-�8�8 Property Size: 1.086 acres **NOTEC Th�is Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 REVOCATTON IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _ Dishwasher:� Garbage Disposal: ❑ Commercial Specification: Facility Type � #People � #Bedrooms �_ #Baths �_ Washing Machine:,J� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �A-C, Type Water Supply � Design Wastewater Flow (GPD) � Site: New� Repair ❑ System Specifications: Tank Size �� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width�� Rock Depth 1� Linear Ft.�� Ih1PROVEI�9ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW E'INISHED GRADE. ****NOTICE: Contact a representative ofthe Davie CountyHealth Department for final inspection ofthis � system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33()751-87G0.**** I Environmental Health Specialist's Signature: , �N � '� Date: ��- �Z DCHD OS/99 (Revised) J , 0 : �' . �, ,APPLICATION FOR SI�fE EVALUATION/IMPROVEMENT PEfiMIT & A' • Davie County Heaith Department Environmenta/Hea/th Seci�ion . P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �: �„ I U � ' ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULI,ETIN for instructions. 1. Name to be Billed J� /,/fJ / Mailing Address <� C"�1 City/State/ZIP �__�/1°}✓G G� /(/ �� Z Contact Person Home Phone j' �— S 7 y� Business Phone � � � � �� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Persnit/ATC �oth a. syst� to Service: �B Ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residenca: # People �� # Bedrooms .� p Bathrooms � Dishwasher LI Garbage Disposal Washing Machine I_I Basement/Plumbing 17 Basement/No Plumbing 6. I£ Business/Industry/Other: Specify type # People # Sinks A Commodes # Showers # Urinals # Water Coolers IF I'OODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Typa of water supply: �County/City p Well ❑ Community o. Do you anticipate additions or cxpunsions of thc facility this systcm is intcndcd to scrvc? If yes, what typc? ❑ Ycs ❑ No ***IAIPORTANT*** CLIENTS J�fUSTCOMPLGTETHE REQUIRED PRQPGRTY INFORMATION REQUES'CED 13ELOW. �ither a PLAT or SITE PLAN A�UST BFSUBMI7TED by the client with THIS APPLICATION. • roperty Dimensions: •� �+ d �L �` T:�x Ofticc PIN: #J ?5 /�'� �� C� 7(1 / � Property Address: Road Namc � Q/1 fi /Zl�•�c' �� V City/ZiP __�-�i%, 1��/v `` � lf in a Subdivision providc information, as follows: Namc: WRIT,G AIRGCI'IONS (from Mocksville) to PROPCRTI' � '� � r Ilt �� • ► �u �.! .��;�1 � 1 Scction: I31ock: Lot: Datc Property Flagged: 7" / a- O Z- T'I�is is to ccrtify that the information provided is correct to tl�c best of my lcnowledgc. I understand thnt any permit(s) issued hcrcaftcr are subjcct to suspcnsion or revocation, if the site plans or intended use changc, or if the information submitted in tl�is application is falsified or changecL I, a/so, tutdersluud f/tnt I nm respo�rsible for rtl! clrrrrges incurred fro»t �hi.s applicntioii. I, hereby, give consent to the Authorized Representative of tl�c Davie County Hcalth D partment to cnter upon abovc described property locatcd in Davie County and owned by _ to conduct all testing proccdures as neccssary to dctermine the site su tubility. t �1 DATG ' [- I � - D� SIGNATURC � • TIiIS ARGA MAY I3E US�D FOR DRAWING YOUR SITE PLAN (lncludc all of thc following: I:xisting a d proposeci property lines and dimensions, structures, setbacks, and septic locations). Reviscd DCHD (07/99) Site Revisit Cliargc Datc(s): Clicnt Notification Datc: CHS: Account No. � � 3 �' ,��- _.,,� � Invoice No. � �� f 0 a �� i� n . � - _: jP�CT Lv�E • >,�y � — • _ ._ :a .L ,t A�PLICANT INFORMATION Account #: 990002336 Billed To: Sandra Leroy Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On-Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5870-92-6704 Subdivision Info: Location/Address: Cornatzer Rd-27028 Property Size: 1.086 acres Date Evaluated: �`� �O � Community Public Auger Boring ✓ Pit icx�uic �ivuY 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 SIT'E CLASSIFICATION: �S LONG-TERM ACCEPTANCE RATE: � REMARKS: Cut EVALUATION BY: 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 - Firnt 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 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) ■��■ ■��■ ■ ■ ■■ ■■ ■■ ■�■■�■ ■�■��■ ■■��■ ■��■�■ ■�■��■ ■ ■ ■ ■ ■ ■ ■ ■ ■�■■�■■■ ■��■ ■��■ ■��■■ ■��■■ ■��■■�■ ■��/■ ��■��■ ■��■ ■��■ ■��■ ■��■��■■ ■��■�■ ■��■ ■��■■ ■��■��■■ ■ ■ r��■��■■ ■■��■��■ ■��■ ■■��■ ■��■ ■ ■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■ ■ '"� -�� _ e.isting ..: . � iron 1 . �� _ �_ -_- ___ .. � `- �- ---- ---.._ �_ �+� . . -�"� �_ __� -�� _� __" � � . ... ��, , ' �- C��N'a4 .:N r,n° —� _` —__ . 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PLAT ❑F ;�JRVEY FOk' ��A 1��1� � l,_�� o �� - REVISiONS �CALE� � = 4O' /+PPROVE[� BY� DRAVN BY� �I�E NqNE, �ERO—SAN 40 �� 4U �i� 1�0 qT , 0��09,'02 �LT RHD cpoap. �,�, SANRO'Y1�68 ��— �- '–�—__� Tt1TTEROW SURVEYING COMPANY �—�—��— BEWG 1.08F� ACRES TAKEN FRGM THE CHARLIE lJa7HAM PROPEkTI lC+.B. 181 PG. 661) `.,I.ALE IN f EET� lO? NORTH SALI�B�_�R�Y �T, L_YING IN THE SHADY GRO`✓E TOWNSHIP . DAVIE COUN��r� , NORTH CAROUNA MOC�r vIL�E, N.C. �70�8 (��'E.? 751-561� — TAX MAP REF : i; - F? , r' /C� PARi;EL 1 1 �''AVIN(, NUMBER� 17002— 3