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660 Ijames Church RdAccount #: 990003408 Billed To: Vauda Ellis Reference Name: ATC Number: 4383 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5810-81-2271.CC Subdivision Info: Location/Address: 660 Ijames Church Road -27028 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 WASTEWATER CONSTRIXTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ay Date: 411,1;� �/(j 4 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 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. ,.r ��//yjlp✓ sC'Jwnn Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEtARTMENT Environmental Health S ction P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003408 Tax PIN/EH #: 5810-81-2271.CC Billed To: Vauda Ellis Subdivision Info: Reference Name: Location/Address: 660 Ijames Church Road -27028 Proposed Facility: Community Center Property Size: 14 acres **NOTES.%Islmprovement/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 _ �`/' #People#B _ edrooms ////� #Baths l Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size,/W GAL. Pump Tank GA/L. Trench Width( Rock Depth., -44' Linear Ft. Other: zs�! �!� • �� 2( Required Site Modifications/Conditions: IMPROVEMENT/OPERA FINISHED GRADE. ****] system between 8:30 a.m. PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW iE: Contact a representative of the Davie County Health Department for final inspection of this p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: / Date:�� DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department e C r, O W E Environmental Health Section D P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ' APR 1 ) 2006 (336)751-8760/ Fax (336)751-8786 or: IG�S�r�F�a>»a inAmpro�ement Permit ❑Authorization To Construct(ATC) Q'Both ENVIRONMENTAL HEALTH **FIAAPnRTeALI=*4rzx19 ,W h4'ftk1N CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Va tta 15 Contact Person _Vou\A 8 E I 115 Billing Address �" me,5- C11 IM Home Phone 4-q a— 5 a r7 Y7 City/State/ZIP Q Business Phone Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/S NOTE: A survey plat or site plan must accompany this application. 5-910-91-7,Z71 (Permit is valid for 60 months with site plan, no expiration with co Tete plat.) Street Address (o (p D �i Q m,eS City ;UG' i%1,6 Tax PIN# _ 0-4-3 O DODDDD`7 Subdivision Name S ction/Lot# Lot Size Directions To Site: I o 151 AAA r �.,� Z I � r r m p.C!" J, , P , I ,, t,-, , Date House/Facility Corners Flagged "a p o 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? Dyes Cho Does the site contain jurisdictional wetlands? Dyes CKo Are there any easements or right-of-ways on the site? 216s ❑No Is the site subject to approval by another public agency? Dyes 9No Will wastewater other than domestic sewage be generated? ❑Yes p -W66 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: Dyes ❑No Basement Plumbing: Dyes ❑No 1 IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business p * h, rTotal Square Footage of Building F qU # People # Sinks _(# Commodes I # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats iJ Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other �j Water Supply Type: fd'County/City Water ❑ New Well ❑Existing Well ❑ Community Well �J Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes "-0 ah If yes, what type? VV 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections determine com lianc with ap}�1)"cable laws and rules on the above described property located in Davie County and owned by o r� (tom(� / f: )(I Al 1 I��_X ,JAIL Site Revisit Charge Property owner's or owner's legal representative signature Date(s): U� Client Notification Date: Date EHS: Sign given ❑Yes Account # ��6� Revised 2/06 Invoice # r v a 5, „nom r, vx i$x is • }°. � ',y: . ' r , y e AW d fir{ Y_ d • 1 � r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003408 Tax PIN/EH #: 5810-81-2271.CC Billed To: Vauda Ellis Subdivision Info: Reference Name: Location/Address: 660 Ijames ChurchRad- 7028 Proposed Facility: Community Center Property Size: 14 acres Date Evaluated: Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group I - Consistence Structure Mineralogy HORIZON H DEPTH G �� Texture group Consistence,/ C, Structure s;. e. Mineralogy -1 HORIZON III DEPTH Texture grouplr . Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence - Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE. r OTH R(S) PRESENT: REMARKS: LEGEND j nndscape 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 lY.oteS 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 chroina 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) _'+_ I 1....�.1..,.- !_. I i i j: I ! _ I I i r i { 1 _ i _ ' __ I ` .. ! � ! � •-/ �- I ..� 1. r 4. 4 _ r _..:. i 771 ., � I ( l I I ' I _ I I l i f I C � f ; I 11 � � 1 l ► � i I f 1 i � f + l ! IT; ........ ...__ __.... _71 Ll L. { .L........ _._... _-.__L ... ..__!; ,.I �... __ 4 I f ! .... Melf {_ I r I f t _i Davie County. Health Department Environmental Health Section P.O. Box 848/210 HospitalStreet Mocksville, NC 27028' (336) 751-8760/ Fax (336) 751-8786 April 24, 2006 Mrs. Vauda Ellis 660 Ijames Church Road Mocksville, NC 27006 Re: Community Center, Ijames Church Road Tax Pin #: 5810-81-2271 Dear Mrs. Ellis As requested, a representative from this office visited the above site April 20, 2006, to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. This Improvement Permit DOES NOT authorize the construction of a wastewater systema 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 or the intended use change. Improvement Permit t LL System To Serve: ��97�Ya�r _6 �� e�' Wastewater Design Flow: System Type: ❑Conventional „2Accepted ❑lIInnnoovative OAltemative ❑Other System Location: Valid: Years ❑No Expiration Site Modifications/Permit Conditions: 41'i a-7 Env' onmental H th Specialist Date I ps-i.p.letter 2/06