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231 Essex Farm Rd Lot 17 ,OPERATION PERMIT or ice se ny Davie County Health Department *CDP File Number, 200211 -1 f � 210 Hospital Street 5870641805 P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753.1680 Township: Applicant: RS Parker Homes Property owner: RS Parker Homes Address: 502 Hickory Ridge Dr Address: 502 Hickory Ridge Dr City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336)362-8970Phone#: (336)362-8970 Property Location & Site lnfonnation - AddressfRoad#: Subdivision: Essex Farm Phase: Lot: 17 231 Essex Farm Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 E. left on Cornatzer Rd. Essex Farm on left #of Bedrooms: 4 #of People: `"Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert 'System Class ificationfDesc ription: .. TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP *CA issued by: 2140.Nations,Robert SaproliteSystem? (' Yes ONo Design Flow: 4 8 0 PUMP TO GRAVITY Pump Required? Distribution Type: (F)Yes QNo Soil Application Rate: 0 a 5 *Pre Treatment: 11, Drain field (N7krificationd 1 9 -2 8 Sq•ft• "System Type: INFILTRATOROUICK4 STANDARD 6 Installer: Frank transou oarencength: 4 8 0 8• Certification#: 2771 Trench Spacing: _ Inches O.C. • Feet O.C. 'EHS, 2140-Nations,Robert Trench Width: 3 Inches - &Feet Date: 0 8 / a 2 / 2 0 1 6 Aggregate Depth: inches _ Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 ApprovatStatus - Inches Maximum Trench Depth: 3 6 ® Approved Disapproved Inches Maximum Soil Cover. 2 4 Inches CDP File Number 200211 ` 1 County ID Number: 5870641805 Septic Tank Manufacturer. Shoal Lat. STB: 760 Long: , Gallons: 1000 Installer. Frank transou Certification#: 2771 Date: 0 5 / 1 5 / x 0 1 6 *EHS: 2140-Nations.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes 0 No Date: 0 8 / a a / 2 0 1 6 Reinforced Tank: ❑ Yes ® No Approval Status 1 PieceTank: ❑ Yes � No ® Approved❑ Dtsappraved -- . Pump Tank Manufacturer ShOaf Installer Frank Transou PT: -42 Certification#: 2771 Gallons: 1250 - 'EHS: 2140-Nations,Robert Date: :0 1 / 0 ,9 / a 0 .1 6 Date: 0 8 / a a / a 0 1 6 RiserSeaied ® Yes ❑ No RiserHeght: 91 Yes - ❑ No (Min.6 in.) "PI) t Status Reinforced Tank: � Yes ❑ No ® Approved❑ Disapproved 1 Piece ® Yes _❑ No - Supply Line Pipe Size: a inch diameter Installer. Frank Transou Pipe Length: 1 0 a feet Certification#: 7771 . 1EHS *Schedule: 40 . 2140-Nations.Robed Pressure Rated ® Yes ❑ No Date: 0 8 / a a / .1 0 1 6 Approved fittings ® .Yes ❑ No Approval Status ® Approved© ;Disapproved a PLimp Requirement Pump Type: Zoeter Installer, Frank Transou Dosing Volume: - Gal Certification#: 2771 Draw Down: Inches *EHS: 2140-Nations,Robert 'Chau: ROPE 0 8 / a a / 2 0 1 6 Date. Valves Accessible 2 Yes ❑ NO Flow Adjustment Valve R Yes ❑ No Check-valve p Yes ❑ No AppwalStatus y. PVC unions p Yes ❑ No ® Approved❑ Disapproved Vent Hole E] Yes ❑ No Anti-siphon Hole Q Yes 0 NO 200211 - 1- 5870641805 CDP File Number County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No - Conduit Sealed ElYes ElNo *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Disapproved ,= Alarm Visible ❑ Yes ❑ No _.. _ 2140»Nations,Robert *Operation Permit completed by: :. Authorized State Agent: Date of Issue: 0 8 / a a / 0 1 6 Owner/Applicant Signature: This system has been installed incompliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for :Sewage Treatment and Disposal,15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by TYPE ui B. sewage septic system. Rule.1961 requires that a Type TYPE III B. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: 5YRS. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCedified Operator. NIA _ Reporting Frequency By Certified Operator.NIA Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywkh a certified operatoror a private certified operator forthe life of the septic system. - Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management eptly prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management ently, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** y OPERATION PERMIT Davie County Health Department CDP File Number: 200211 - 1 210 Hospital Street - County File Number: 5870641805 P.O.Box 848 Mocksville NC 27028 Date: , 0Inch Drawing Drawing Type: Operation Permit Scale: OOrai A k I ej ; -- f CONSTRUCTION For office use only AUTHORIZATION *CDP File Number 2002111 - 1 Davie CountyHealth Department 5870641805 P County ID Number: ` 210 Hospital Street Evaluated For. NEW •�� ,°.• P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: - Phone: 336-753-6780 Fax:336-753-1680 0 a / a 4 a 0 a 1 Applicant: RS Parker Homes Property Owner: RS Parker Homes Address: 502 Hickory Ridge Dr Address: 502 Hickory Ridge Dr City: -Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (336)362-8970 Phone#: (336)362-8970 Property Location & Site Information _. Address/Road#: Subdivision: Exxex Farm Phase: Lot: 17 231 Essex Farm Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 E. left on Cornatzer Rd. Essex Farm on left #of Bedrooms: 4 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Ps Shallow Placement Inches Minimum Soil Cover: Saprolite System? O Yes (&No 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 5 Maximum Soil Cover. a 4 Inches *System Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump,Required: (&Yes O No O May Be Required Nitrification Field 1 9 a 0 Sq.ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 6 1-Piece: OYes ®No Total Trench Length: 4 8 0 ft GPM--vs— ft. TDH Trench Spacing: Inches O.C. — 9 Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 O TS-II 7 Septic Tank Installer Grade Level Required: O 1 O II 0111 01V Page 1 of 3 CDP File Number 200211 - 1 County ID Number: 5870641805 ❑ Open Pump System Sheet Repair System Re uiredAYes O No O No, but has Available Space rDesign System Trench Spacing: O Inches O. . ification: Provisionally suitable — 9 ®Feet O.C. Trench Width: Inches w: — 3 Feet Soil Application Rate: 0 5 Aggregate Depth: inches *System Minimum Trench Depth: a 4 Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Maximum Soil Cover. a 4 Nitrification Field 1 9 a 0 Inches Sq.ft. No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 $ 0 ft /Pump Required: ®Yes O No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for stem and repair without approval of Health Department. R- g 9 9 tY� 9 Y P PP P 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. R.�",ng 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps.Signature Required? O Yes O No Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 .1 / a 4 / 2 0 1 6 Authorized State A Malfunction Log OYeS ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 -CONSTRUCTION AUTHORIZATION 200211 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5870641805 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 .2 /..24 / .2016 O Inch Drawing Drawing Type: Construction Authorization Scale: , O Block O N/A .................................r..................................,.................,..................................;................. ..............................................................................................................................,................................... l .... I I I. _i t I I ...... ......I...............I._....- L...... ( _.... 1...... t 1 . .� ! E �. ....... ......._I • 000 i i I I I I. 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I L �..._ r ....... .. ... ........ . . ........... ......... .. .... ... . . . i Page 3 of 3 P1 P2 + r CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 200211 - 1 P.O.Box 848 5870641805 Mocksville NC 27028 County File Number: Date: 12.1 1.2 4 / 2 0 16 Click below to import an image from an external location: Drawing Type: Construction Authorization J h O r< � 44 y - ICP 7 P C- Page 3 of 3 P1 P2 • t APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Bos 848/210 Hospital Street p�jlD Nlocksville,NC 27028 (336)753-6780/Fax(336)753-1680 pate: A n Fo ite Evaluation/Improvement Permit authorization To Construct(ATC) G Both Recalvedb pplication: XNew System 7Repair to Existing System -Expansion/rvlodification of Existing System or Facility ***bIIPORTaNT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed • 5 C 0001-e-IS Contact Persons �` Billing Address .-D � `dC Home Phone, 3 n— City/State/ZIP SCI Business Phone - Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/FacilitZ Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is lid foE 60 months with site plan,no expiration with complete plat.) C Owner's Name j Phone Number 33rP'�4/ Owner's Address I City/Sta /Zi Oro k:C C Property Address Ci Lot Size Tax PIN# Subdivision Name(if applicable) SectlOn/LOt# Directions To Site: 9, 1 5 Vri 11 foi*4A_ } nn r If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? D Yes V10 Does the site contain jurisdictional wetlands? Dyes Are there any easements or right-of-ways on the site? Dyes o Is the site subject to approval by another public agency? 7_1 Yes Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms L4 Bathrooms Garden Tub/Whirlpool X7eTENo Basement: :Yes o Basement Plum ing: ❑Yes No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks •#Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: onventional DAccepted CInnovative CAltemative EOther Water Supply Type:XCounty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?a Yes �No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and riles. I understand that lam responsible for the proper identification and labeling of property lines and comers and Ie'`x' _-rs,-_^^^ •^�^ rt h e' c"u location,proposed well location and the location of any other amenities. Poe own r owner leg 1 representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given -Yes---No Account# Revised 11/06 Invoice# SETBACKS: FRONT: 45' N 07032'00" E SIDE: 15' 100.00' REAR: 30' +�•'°"' SETBACK I I I 1 I I >a I I I 18.0' _ O � N N 26.6' 5.7' o "- W 20.0' 4.7' 00 C 0 cc o N O I I 04 N 04 Cy)co � M z I I N PROPOSED 4.0- N RESIDENCE 4.0' 15.50' y PROPOSED I N RESIDENCE I 15.4' 19'7 N 21.9' 15.50' I . CK 27L46' 0 IQ I 10' UTILITY EASEMENT HOME DIMENSIONS NTS S 07032'00"W 100.00' PRELIMINARY PLOT PLAN FOR: RSP ESSEX FARM ROAD LOT B7 OFERS ESSEX FARMS, PHASE 1 50' R/W (PUBLIC) P.B. 9 PC. 290 GRAPHIC SCALE ao Fiming69'1'nfhfm*og, enc. 8518 Triad Drive,NC 27235 IN FUT ) Phone:336.852.9797 «Fax: 336852.9766 1 inch = 40 & NCBELS C-0950 DATE 02-16-2016 REF: PROJ\1831-01\dwg\ESSEXFARM.dwg SETBACKS: FRONT: 45' N 07032'00" E SIDE: 15' 100.00' REAR: 30' "°'°° TSETBACK I I ' 76 18.0' � N O � N oN 26,6' 5.7' J LLl 20.0' 4.7' OO O io O p I p o 'a n N I 00 (N N 'r- 0 CDN CO N M z I I 0 PROPOSED a.o' N RESIDENCE 4.0' I 15.50' DED I N I 15.4' 19'7 N 21.s' 15.50' I 2446' 0 ui LO 10' UTILITY EASEMENT HOME DIMENSIONS — NTS S 07032'00"W 100.00' PRELIMINARY PLOT PLAN FOR: RSP ESSEX FARM ROAD LOT BRS 7 OFEESSEX FARMS, PHASE 1 50' R/W (PUBLIC) i P.B. 9 PG. 290 I 40 0 20 40 GRAPHIC SCALE 80 ! Fleming69imaenng, Inc. 8518 Triad Drive,NC 27235 ( IN FEET ) I Phone:336.852-9797 Fax: 336.852.9766 1 inch = 40 fL i NCBELS C-0950 DATE: 02-16-2016 REF: PR0J\1831-01\dwg\ESS0(FARM.dwg �APPLI N FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC --11 Davie County Environmental Health D 3 `tQQI P.O.Box 848/210 Hospital Street P�G 2 Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 1T� / Rl lv'� or: Q' uation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both Ej1V�Rp�6� ion: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT•**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION '7< .73 Name to be Billed .dSC IACyGGo�KaNT mat./.•� Contact Person ZcsrRkY Jcen v,C Billing Address A.*•49.;c 3f0 Home Phone City/State/ZIP_Cfocrsui r+G Z 7oZ 8 Business Phone 7,5'/- 730c Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name_AT,-- oprsSNi c A Phone Number 7S/-734;,0 Owner's Address ,,±oCity/State/Ziprr.+�ca.r f�G 27oL8 Property Addre City Lot Size &IT Tax PIN# Subdivision Name(iflicable) ES = Sectiio�ot# I)irections To : ap &115f e fi S r? Gt i f the answer to any of the following uestions is`ryes",supporting documentatiogg must be a hed. Are there any existing wastewater systems on the site? Dyes C31�1 Does the site contain jurisdictional wetlands? Dyes❑No Are there any easements or right-of-ways on the site? Y3 es❑No Is the site subject to approval by another public agency? Dyes D� Will wastewater other than domestic sewage be generated? Dyes C31ko IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms :14— #Bathrooms Garden Tub/Whirlpool❑Yes ❑No Basement: Dyes ONo Basement Plumbing: ❑Yes ONo t IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY#Seats Type system requested: 616onventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:C316ounty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes ❑No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand ' that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locatingan ging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Propema r oro er's legal representa re Date(s): 7 Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# Revised 11/06 Invoice# ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH#: 5870-64-2265.17 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot# 17 Reference Name: Brad Coe Location/Address: Cornatzer Rd-2700 Proposed Facility: Residence Property Size: 0.691 Ac. Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring_ Pit / Cut FACTORS 6 ZS 23 0 24 4 5 6 7 Landscape position Slope % HORIZON I DEPTH - -L.3 Texture group 0 Consistence T.`S F Structure Mineralogy _ .v HORIZON II DEPTH Texture group 'Consistence. .�5 F Structure INV Mineralogy , HORIZON III DEPTH Texture groupG{ Consistence. [: Structure Mineralogy HORIZON IV DEPTH Texturegroup Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON — v �- SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE O •Li O, SITE CLASSIFICATION: '1 S EVALUATION BY' LONG-TERM ACCEPTANCE RATE: 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 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 05/05 (Revi&ed) Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990004425 IMPROVEMENT PERT1ffifIN/EH#: 5870-64-2265.17 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot# 17 Address: PO Box 340 Location/Address: Cornatzer Rd-27006 City: Mocksville Property Size: 0.691 acre Reference Name: Brad Coe Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: ew ❑Repair. ❑Expansion Permit Valid for: 05 Years,,2Ko Expiration Residential Specifications: #Bedrooms 4 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply./County/City ❑Well ❑Community Well Site Modifications/Permit Conditions.: Sy stem Type LTAR Initial c:.25 Repair O- site Plan CAf LC Environmental Health Specialist Date l D7