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7465 Hwy 801S (3). DAVIE COUNTY HEALTH DEPARTMENT Environmental Healtk,Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001225 Billed To: Edgewood Baptist Church Reference Name: Edgewood Baptist Church Proposed Facility: Residence ATC Number. 2551 Tax PIN/EH #: 5745-27-6981 Subdivision Info: Location/Address: Edgewood Circle -27014 Property Size: 1.90 Acres 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 WASTEWA ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: "^ ---�. Date: —%P— 1 d (� 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 1 I 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 p i of time. /L,f R Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 15, Date: —% i DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990001225 Tax PIN/EH #: 5745-27-6981 Billed To: Edgewood Baptist Church Subdivision Info: Reference Name: Edgewood Baptist Church Location/Address: Edgewood Circle -27014 Proposed Facility: Residence Property Size: 1.90 Acres **NOT1E*NiPli1 lmpro5ement/Operation 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 E�o� #People #Bedrooms #Baths 2. Dishwasher: 9!(- Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial) Specification: Facility Type 13/1 #People #People/Shift #Seats Industrial Waste: Lot Size -1 Ae&5 Type Water Supply Cf; Design Wastewater Flow (GPD)c p(� Site: New Repair ❑ 1 System Specifications: Tank Size 1003AL. Pump Tank GAL. Trench Width!;f*i,' Rock Depth 1Z �� Linear Ft X1 IT 0.3 Required Site Modifications/Conditions: I N1_c'r&LL— 0'� e04Tooe.`OFF Foasc'r. Ka., ► ,> Fr- Date: r IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 -BELOW FINISHED GRADE. ****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}p„ on the day of installation. Telephone # is (336)751-8760.**** � f NCS. �XCS Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: f !dZ) ` a APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC n Q U t5 Davie County Health Department U Environmental Health Section — 9 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH nAVIE (M11 Y , ***IMPORTANT+** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED.,. Refer to the INFORMATION BULLETIN for instructions. 1. Nasty to be Billed F. i1--miw Contact Person cov Mailing Address V , �jt �j Hone Phone City/State/ZIP �—,d 6 tk t . 12 8 4 Business Phone 2. Name an Permit/ATC if Different than Above^ K} M [- . Mailing Address City/State/Zip 3. Application For: XSite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to Service: ,House O Mobile Home ❑ Business ❑ Industry n Other 5. If Residence: # People # Bedrooms 3 # Bathrooms a 14 Dishwasher 11 Garbage Disposal washing Machine 11 Basement/Plumbing 11 Basement/No Plumbing 6. If Business/Industry/Other: Specify type i People # Sinks / Commodes showers 6 Urinals / water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 1. Type of water supply: County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client wUh TIiiS APPI.ICAT!0N. Property Dimensions: -� ` YQ Ale S WRITE DIRECTIONS (from Mocksville) to PROPERTY: � Tax Office PIN: # S7 ����?— �� t o� ` I � O HqN t, ONO Property Address: Road NamerW,6Z&11o� L-/ � It -Q �7 JJ n City/Zip �IeeAec- 021 DI XI T b q --,Ac, i� If In a Subdivision provide Information, as follows: C tQG4t�C L� � l d(,( C, �'+l� R.C. N Name: Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County th Depart�nt to enter upon above described property located in Davie County and owned by L t< w O lY--fl.• t � ya,C to conduct all testing procedures as ngFessary to determine the site suitab l . ,, F, E, l9 q SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includehe following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 11 of 200JIA,�,O' Revised DCHD (07/99) k ,--PA y Pao,1 '1a Site Revisit Charge Date(s): I Client Notification Date: I EHS: Account No. .ZaG �I fib Invoice No. 60 3b ` DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001225 Tax PIN/EH #: 5745-27 Billed To: Edgewood Baptist Church Subdivision Info: Reference Name: Edgewood Baptist Church Location/Address: Edgewood Circle -27014 Proposed Facility: Residence Property Size: 1.90 Acres Date Evaluated: Water Supply: On -Site Well /�tommunity % Public Evaluation By: -ger B rin Pit Cut SITE CLASSIFICATION: r LONG-TERM ACCEPTANCE RATE: i REMARKS: 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 - 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) Landscape position HORIZON I DEPTH �A%� Consistence �- _Wjr ROMA���® I�IIe�r7�0 ® MwoWIPMMineralogy ��Nw" Texture group Consistence rMAROMr�u�N�®®� GO �/ IF - E .Mineralogy• .���c�r�r�■�®®® ConsistenceTexturegroup"20 HORIZON IV DEPTH Texture group ConsistenceMineralogy —`�—®-- SOIL WETNESSCLASSIFICATION ®----®— • SITE CLASSIFICATION: r LONG-TERM ACCEPTANCE RATE: i REMARKS: 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 - 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) INDEXED ON 5745.09 (2.83 A) 2668 (I 90A) INDEXED ON 023 5745.06 023 /N Z>l 001p., INDEXED ON .5745.05 INDEXED ON 5745.05 023 8686 1.48A 7528 023 r ,T .DAVIE COIN HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 June 26, 2000 Edgewood Baptist Church Attn: Larry Cox P.O. Box 57 Cooleemee, NC 27014 Re: Site Evaluation/Edgewood Circle Tax Office PIN: # 5745-27-6981 Dear Client: As requested, a representative from this office visited the aforementioned site on June 23, 2000. 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/mobile home location staked off If you have any questions, please feel free to contact this office. Sinc Clint Dorman Environmental Health Specialist CD/mp Enclosure(s)