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170 Klickitat Trail
.> . t � , , i � . r DAVIE COUNTY HEALTH DEPART'MENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8�60 , Account #: 990001031 Tax PIN/EH#: 5860-31-0963 Billed To: Jwenal Diaz Subdivision Info: I tZQ� Reference Name: Juvenal Diaz LocatiorUAddress: Klickitat Trail-27028 Proposed Facility: Residence Property Size: 8 Acres � ATC Number: 2379 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 WAS , O UC ON I ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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 wi ction satisfactorily for any given period of time. � ,,`A�� (`�N� �..�Y �i� � ! -F� �� �� � �` � ��� 3 ' �� 1 � ��` 22 ST . M. u�,�� ���_ S�T� Septic System Install YJl t—� �� 1 �C-- Environmental Health Sp ' isYs Signature: � �� O DCHD OS/99(Revised) � , � , , � , � DAVIE COUNTY HEALTH DEPARTMENT ���o O ' ; . . Environmental Health Section ��;� ,., � r.o.Bog sasnio x�p�rai sa�t Mocksville,NC 2'7028 (336)751-8760 � ' IMPROVEMENT/OPERATION PERMIT Account #: 990001031 Tax PIN/EH#: 5860-31-0963 Billed To: Jwenal Diaz Subdivision Info: Reference Name: Juvenal Diaz Location/Address: Klickitat Trail-27028 ��roposed Facility: Residence Property Size: 8 Acres ATC Nu ber. 2379 **NOTE** T�iis ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION 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 �• ���iN1G #People � #Bedrooms 3 #Baths Z ✓. Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: �" Basement wlPlumbing: ❑ Basement/No Plumbing: ❑ t Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size �A '��� Type Water Supply ��-- Design Wastewater Flow(GPD)�� Site: New�Repair� System Specifications: Tank Size�D00 GAL. Pump Tank GAL. Trench Width�v�� Rock Depth 2�" Linear Ft.y�0� 2 �1ST��1 lo.� 1 Other: �cc.aS r ��1STal..L L..�...7t.s � o.e. tnti.�r.�� Required Site Modifications/Conditions: 1�S�AtL � ..�T�� �C�,Q pF ,�A� Q �� F-2.p*��-� ' [..1� 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 ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** i2��+���-►��.� 3 W,-�---�— � � �� LpC�TIo•� � � � l (�l �f�OX , ST � ��20�- 1�3� 3s /o �000 a, � o. � o � 3� � _ 6 �k,, x Environmental Health Specialist's Signa e: te:' 1 � ^1O�M�►J. �pp C�� OFG P2-oP.�.trsE DCHD OS/99(Revised) .*, 'j� � .. . � t a . � n(] �r / n.. _ � V � O U � j��s� �i`/ APPLICATION FOR SRE EVAUTATION/IMPROVEMEM PERMIT& 8 . Davie County Heaith Department Environmenta/Hea/ti�Se�ciion � 8 200� �l �?�� P.O. Box 848/210 Hospital Street �P,r� �w Mocksnille, NC 27028 : ENVIRONMENTAL HEALTH � ����� 10 (336)751-8760 DAVIE COUNTY Vn ***I1�ORTANT*** TFIIS APPLICATION CANNQT 8E PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ' Coataat Peraon ��,1�'. �J� Mailing ea 5,�,7� ',/7���D"Yt .�� Home Phone �?�_��7 � ��O City/$£ate�2IPO��IN1 s�a'�,► � �� �� ,J � /�I9 Suainesa Phone � !�t , '�+/b�-� 2. Nama on� Parmit/ATC if DilPerent than Above (�. �fC � �3' /�/JGc�� Mailiaq 1�ddreea City/State/Zip • 3. Application For: ❑ Site Evalustion ❑ Improvement Permit/ATC Both 'f. a, sy8t� to sar�►ice: ❑ House 0" Mobile Home ❑ Business ❑ Industry ❑ Other � �-- -��-��� �. s. if Residence: t People � Bedrooms _j���J� #.Bathrooms � �� O Diahrabher ❑ Garbaqe Diapoaal Washinq Machine ❑ Hasement/Plumbinq . ❑ Sasement/No Plumbinq 6. If Buaineae/Znduatzy/Other: Specily type � People �• #'Sinka # Commodes ' � Shoxera � Ur3nals # Water Coolera IF FOODSERVICE: # Se8ts EStimBted WBter Usage (gallona per day) �. Type of water suppiy: ❑ County/City . .B'Well ❑ Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ��Yes �No I!'yes,what�ype? °. ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION ItEQL'ESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. Property Dimensions: U ���e-5 WR1TE DIRECTIONS(from Mceksville)to PROPERTY: ._._ _ • -- �._r --,., TaiOfTice_PIN � ,# y „���D- �T- 17�1�� r Property Address: Road Name �� ! C /� l/��//��- ��i�I'"vr O� /��'�a�'� /��' C`� c;ey�z;p��'<G c���o«� �o�� D Y/h s/�S � �v��`�%� If in a Subdivision provide infocmallon,as follows: /G�i �/32 'L o ,��<',�L � � Name: � ,����L-��-�, ���- �� ��y � ,V�Sici�� . .. � Sections � Block: Lot: Date Property Flagged: `�—��G This is to certify that the information provided is correct to the 6est of my knowledge. I understand that any permit(s) issued 6ereafter are subject to suspension or revocallon,if the site plans or intended use change,or if the iaformation submitted in this applicallon is falsi5ed or cL ged. I,also,understand that I am responsible for all chcuges incurred jrom th�s applicatlon. I,hereby,give consent t e Aut6orized Representative of the Davie County Health Department to enter upon a6ove described prope ceat ' Davie County and owned by fo conduct all testing procedures a ecessa to determine the site suitability. DATE � . r- r SIGNATURE THIS AREA MAY BE �SE O �A OL��T�$ITE PLAN(Include all of the following: E�sting and proposed property lines and dimeaCions, tructu , setbacks, nd:geptic locations). /�/� � Site Revisit Charge /� � ���Z� � % �� y� ate(s): ���U` � �. . �t, ��'�' � � lient Notification Date: t` �,�' %` "- 1'�I HS: i ; � ��� 5��------ J ��� �� � Account No. �� °�;' � �,�,�}t � � . 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Location/Address: Klickitat Trai1-2702,� Proposed Facility: Residence Property Size: 8 Acres Date Evaluated: ��� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ,� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sition t- ' L L G- Slo % ..� � Zo HORIZON I DEPTH 0 - - f0 D ` -2 Texture rou S' S;C `C t� S• �. Consistence :S�p � i S Structure Ik L 5�31C Mineralo 11'1� �'''"t Wu HORIZON II DEPTH -7�3 - - - 12 Texture rou ;C +,,5 ;C � G • G Consistence ' - �: � -;. V -;VS�/ Structure � � 3k i /�31L Mineralo ��c � 2: 1 HORIZON III DEP'TH ., � � } -Z 12-Z Texture rou ' ' _ ?C+-S ;G+ Consistence � - ' J Structure L �1L Mineralo I�n.t Z, � . ��- HORIZON N DEPTH ` ' .s� , -� Texture rou .; Consistence 'Structure � _ Mineraio - SOIL WETNESS _ � . . RESTRICTIVE HORIZON ' � SAPROLITE , . CLASSIFICATION ' � • ' LONG-TERM ACCEPTANCE RAT SIT'E CLASSIFICATION: �S . �� � �C'���� EVALUATION BY: � JG��+�'-P ,. � . LONG-TERM ACCEPTANCE RATE: v�' 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 Mois 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 . tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky � SBK-Subangulaz 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 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) . 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' . �.�,; . . _t . ... i . . r . �� ��4� `� DAVIE COUNTY HEALTH DEPARTMENT �'.`�' . Environmental Health�SecHon PO Box 848/210 Hospital Street , ocksville,NC 27028 . ' - ,��1"l one: (336)751-8760 � '�..,�:.-�'` � t ON-SITE WASTEWATER CERTIFICATION FO -�WELLING (Check One) REPLACEMENT❑ REMODELING � RECONNECTION ❑ Name: ������ T ��" �//7�.- Phone Number: 1��j 3/z� � � (Home) Mailing Address:��� �i��/t'e�� /!�/' `�i!7- ���.� (Work) �� /� o� �� D tailed Directions To Site: A� [ !f✓ ' OL�` �O�i'���r � , ,fU / I��A� f 1 "�`, �� �' (jt'l�'f�' �} .,,,,� ., Property Address:�' �J1� ��C�! �`} ! / � �// (��/t/�� ' ,. Please Fill In The Following Information About The Existing Dwelling: � J /� /; � � Name System Installed Under: 1���4�� � ��"�`�'' ���2'' Type Of Dwelling: � ` . . Date System Installed(Month/Day/Yeaz): Number Of Bedrooms�Number Of People:� z Is The Dwelling Currenfly Vacant?�Yes�"No❑ Yes,For How Long? • Any Known Problems7 Yes❑ 1Vo�fl" If Yes,Explain: p ����, Please Fill In The Following Information About The New Dwelling: � �`� �i��1����'9 � _. Type Of Dwelling: � ' � �_Number Of Bedrooms: Number Of People: `� � � • • e-�.;. :.-.. �(Requested By:���7 f'� �fL'l� !f' ��r� � ' v Date Requested: � �' �'`(Signature) ' . �, For Enyironmental Health Office Use Only ; ' �{`_ . .; r �' i Approved�Disapproved � � - _ " Comments: -'.�`�3'�1 t ra f,� � ��� j �2�'"-�1 C F . Cr:t�.��--�.,��� � _) �1�(--� �i�i?ti� ..-- f+-�(� � ��+.� r`1 i ��7�s�,�. ���7 r�C_� '' ��%t:.3� L-L. .. -,:--�--"_ -.------�. , Environmental Health Specialist Date � '"`The signing of this form by the Environmental Health Staff is in no way �ded,nor should be taken as a guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash❑ Check❑ Money Order 0 # � Amount: $ Date: Paid By: Received By: . /,r9� � Account #: ���'✓d Invoice #: ,+ _ � .,t.� (� � . - . . � . . .. . ' . . • . "��. . . . ., . .-, ' ..,. \�'_�_ �,,' ....� . �.�YA` ... I . � . i .. . . '. �/��ft � V V r a ��'".:. : , ar �.� � Davie County Health Department � �0�►s j� Environmental Health Section . ,.,� �� ' P.O. Box 848 � . : ,`M � .� -,-.. , � , ,�,, ' 210 Hospital Street • . , O� �'� Courier# : 09-40-06 "• 1911 Mocksville, NC 27028 Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION ""`F�:(336>-753-1680 (Check One) Replacement Remodeling Reconnection Name: 9 t' '� � Phone Number �3� �y0 ����_(Home) , Mail' Address: F� _ T � 3�7��Q� �/�� (Work) �-C�i Email Address: Det iled Directi ns To Site: , P_ Z�/L 1�li►• L—'�'+`� ( i �0 i���� N . S GclOr s - Property Address: � ;K� � �� �v �. �� �s . Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: ��V�/U� � >�t 17i Type Of Facility: (�(,ISPi Date System Installed(Month/Date/Year): �1/ Number Of Bedrooms: �+� Number Of People: � Is The Facility Cunently Vacant? Ye ��Tb��If Yes,For How Long? � Y _.��.. Any Known Problems? Yes No If Yes,Explain: � � f �� t _, ,�� �, _ Please Eill In The Following Inf rmation�b�ut The NEW Facility: Type Of Facility: ' � Gf1 � Number Of Bedrooms: Number of People Pool Size: Garage Siz � .� ' Other: .� �Requested By: ' � �� � Date�R�quested: � 4 .4 : ignature) �r i�S.��� ,� ,`:���� '4 ����� ;� � For Environmental Health Office Use Only � � � Approved Disapproved ents: ' . Environmental Health Specialist ' � (�� Date: C���� *The signing of this form by the Environmental Health Staff i� in no way int� ded,nor should be taken as a guarantee - ._..,� �..: (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ 10�. Date: Z � � 2'/� Paid By: ��i� 21 Received By: /.�,�(// � Account#: ���/ Invoice#: ��7�/ `" . . ���V LJ �' . . . , . ' .• �_:.Y�` .. . . . . . .,. , . . .. . , �_. � DAVIE COUNTY EN V�tONMENTAL I-��.LTF-I P.O. Box 848/210 Hospital �t�eet Moc;ksville,NC 27028 (336)751-8760 Fa�c#(336)751-8786 OPERATION PE1t1VY�T Account #: 990004001 Tax PIN/EH #: 5860-31-0963 Billed To: Juvenal Diaz Subdivision Info: Reference Name: ` Location/Address: Klickitat Trail-27006 Proposed Facility: Residence � � Property Size: 8 acres � � ATC Number: 4646 **NOTE**The issuance of tlus Operation Permit shall indicate the system described csn the ATC has�een irastalled in compliance witt�Article 11 of G.S. Chapter 130A, Section.1900"Sewage Treatment and I)isposal Systeans," but shall in NO WAY be taken as a guarantee t�iat the system will function satzsfactoraly for any given period af rime. � System Type: �� S.T. Manufacturer J�l�a� Tank Date� ( + (Tank Size I �0 O Pump Tank Size G�� 1" �� 1r./ct►n ' _Q l �,��'V l � � � S y s t e m I n s t a ll e d B y: U f y E.H. S p e c t a l�s t. a t e: � O� N' 3�° SC. . � 7�t � l,t/6����& • S T�i` �� � � � � � � �q fl Ou � � �n'.f'�t u -t� 'v �� a c , s. � " 1 � r � I � � � CI� .� –� � � � � � J � � s r r s � h i Q �� I � � � Q ^ ^� /`� � � � P�� r J' ._'� I �� . �� �- — ---. � d � '��i`J e wQ/ _ � �— - '� s� �c� , fOr-�ln �o� � -6 �,' a — n��-m i�m� rR��;.���� � SY y� , � . �� � l.� ��� '�c-�� � �1 -� � '.�' � � � � � �p�s � _ � . � � 5 F�`� . � - � �� , �fi 1 �L . � l-- � GK 1 � a � � � 1 � � � � . . ���� � A � . � , . � , �� . � � . . . . , . . . � , � • . • � ' • '�'. DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital.Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERNYIT Account #: 990004001 Tax PIN/EH#: 5860-3'1-0963 ' Billed To: Juvenal Diaz � Subdivision Infa Reference Name: \ ` L'ocation/Address: Klickitat Trail-27006 . � ( Proposed Facility: Residence_ Property Size: 8 acres ATC Number: 4646 **NOTE**The issuauce of this Operation Permit shall indicate the system described on the ATC has been installed in compliance witl�Article 11 of G.S.Chapter 130A,Sectinn.1900"Sewage Treatment and Disposal Systems," but sliall in NO WAY be taken as a guarantee that the system will functian satisfactorily for any given period of tune. ' ' oO O System Type:�,_�S.T.Manufacturer J n�a� Tank Data� ` � `Tank Size , Pump Tank Size (� �/�� (� ,-Q� -a �' � System Installed By: Ui"+{tev� j" "' `' `t'�` E.H. Specialist: ate:�_ � �j 3�° Sc.. �7� � w6�o��� . ST r� �� � � a� � / i ��l Ou� . p,-.�u ...�� r^, V � f� � ' ^ \ ' 1 � I Si .J � � � � � s rss � � J� � � � q h ..-b 1 %- �- � o ' ���� � � � P//. s- r'�� . � ' ��. , - �— ---„ — .�, /� � y / d � u/'i J 2 �cJa _ — .. ,_ `—_ f _ 'f' s� �or��^ . �o� ..� � a DCHD 11/06(Revised) , , ,� � . � . ' ' � DAVIE COUNTY ENVIRONMENTAL HEALTH , P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 O (336)751-8760 Fax#(336)751-8786 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION a. Account #: 990004001 � Tax PIN/EH#: 5860-31-0963 ' Billed To: Juvenal Diaz � Subdivision Info: Reference Name: ' Location/Address: Klickitat Trail-27006 , Proposed Facility: Residence_ Property Size: 8 acres ATC Number: 4646 Site Type: CC�2�ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pemut(s), (in compliance with Article 11 of G:S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intencled use change. Residential Specifications: #Bedrooms � #Bathrooms�,�#People�Basementf�Basement plumbing� � Non-Residential Specifications: Facility Type #People #Seats � Square Footage(or D'unensions of Facility) { L Lot Size Q /` aj Type of Water Supply: ❑County/City �ell ❑Community Well �" System Specifications: Design Wastewater Flow(GPD)�Tank Size l�d O�GAL.Pump Tank �1 dd6GAL. �� �� �. Trench Width� Max.Trench Depth�G Rock Depth �� Linear Ft. �t�Q . � Site Modifications/Conditions/Other. tig gtated in 25,A NCf,C 13A.i.969(5) �' �ep�ted-Syst� rnay a so � use Contact the Davie County Environmental Health Section for final inspection of this system between " 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. � Cav��Ta�� r�u-s�""s�k-�d�l� d�PocrY�'f ,,,r,-t�, ;rsQ,����r priar r.a _ , S��ul;v.�, ;�s�«.11w�Ta�, � // � S�'.7'-� •� Pro�!'�'a�c �'.��/ Ca n no 7� b� �� t+ Pt,�-rir�Q �rK G�%� r � � �! ��,SJ'���,��� �t a`w.nn. � � r, / �S'� �G'r g---� � � .. Q � � , , y � ,� . 9�� s"` y„� ��� \ ,p � � l���r.f,�' � �' ��'r 11 �' ,' � � . ���Q �' ° 4': �t 'y � � I � -t e... k , � �� Co tic.nc'E t l�p ,qba•c� . '�v � � _�-- . •�,� r � ,� \� � �� �J � � � i �. Environmental Health Specialist Date: �—�`��� nCHD 11/06(Revisedl �� i � . . � � Davie County Environmental Health P.O.Boz`848/210 I3ospital Street, �'�.Mocksville,��NC 27028- � � (336)751-876,0/Fax(336)751-8786 << IMPROVEMENT PERMIT ' Account #: 990004001 Tax PIN/EH#: 5860-31-0963 Billed To: Juvenal Diaz Subdivision Info: Address: P.O. Box 96 � . Location/Address: Klickitat Trail-27006 City: Advance Property Size: 8 acres Reference Name: 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: 1�Tew ❑Repair ❑Expansion Permit Valid for: �Years ❑No Expiration / i Residential Specifications: #Bedrooms�#Bathrooms��#People�_Basement�asement plumbing8� Non-Residential SpeciCcations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):��� ' Type of Water Supply: ❑County/City C�'Well ❑Community Well � Site Modifications/Permit Conditions: �.s stated ir+ 15A NCAC �.8�1.1969(.�i� � ��C�St�u�ysrte�rrs�Tra?-�G-r��-us- S stem T e LTAR � Initial 1�e D . '�. � Re air . Z Site Plan , � � �G �l 3 -o � � ` 4� o � �' +�`. �� � � � � �� �� ��, �� �'� � ti � s � � � ' T: a o � � ,��x;� � � Y � � _ y N � k �"`' � � J � M � � � � �� 3v� � �� ., � --�' � ., � _ . � � ���. � f;�-- _ _ � _ " T��r�i��^ . / 6 ' Environmental Health Specialist Date '�l 3�� � i.p.l l-06 � . . . , , t ..4 , �_. � ; . P_PI,,ICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �..R� }�.. � J . ."�..a4.,. : . . . . ��� �, � +:'� ,� � F� Davie County Environmental Health " � "�"--�- �s- -'` � P.O.Box 848/210 Hospital Street y,e ,.... � .�, :, �{"f,.: �1 a�Z 2� �� , # Mocksville,NC 27028. u.�,� ���'�,� "� � ��.;�' "{. �''� (33�751-8760/Fax(336)751=8786 , � u w�;���. , , Ap r:--Q.Site.F,y�uat��mprovement Permit ❑ Authorization To Construct(ATC) oth Type o ��%c�t}ori�'C�T�fiew Sysiem ❑Repair to Existing System ❑Expansion/Modification ofExisting 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 Name to be Billed�,�,,,�.��( ��,�r (� ��'L Contact Person��;�,n 2 . Billing Address �'f� l�aX �j 6 Home Phone ��� �cy� ���� City/State/ZIP_��„/���H c� ��� 7� c c � Business Phone '3 3 � t(t�� �'j',�S` Name on PermidATC if Different than Above Mailing Address ' City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Permit is valid far 60 months with site plan,no expiration with complete plat.) Owner's Name .,�ra t � � �, Phone Number Owner's Address o ��x c�%( fl 1Zj�t yt c c� �v2-c_ City/State/Zip ? ��o� Property Address_1 L�� k L i G �'1 %!��� '�!�i L City ,9,0 v�7-r,�LC L,ot size__ g�i2�S TaX P1N# 5 te 0 -3/-0g 63 Subdivision Name(if applicable) Sect'on/L t# "� Di c ions T ite: t � � N � r L i If the answer to any of the following questions is"yes",supporting documentation m st be ached. Are there any existing wastewater systems on the site? �Yes @No Does the site contain jurisdictional wetlands? ❑Yes C�No Are there any easements or right-of-ways on the site? ❑Yes @1�fo Is the site subject to approval by another public agency? ❑Yes [J�No Will wastewater other than domestic sewage be generated? ❑Yes 6No IF RESIDENCE FILL OUT THE BOX BELOW #People �� #Bedrooms � #Bathrooms � �_ Garden Tub/Whirlpool ❑Yes ❑No - Basement: F�'`i'es ❑No Basement Plumbing: C�'es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 � Typesystemrequested:, onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water C�Y1Qew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes � If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my lrnowledge. I understand that any pernvt(s)or ATC(s)issued hereafter are subject to suspension d�evocation 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 Deparhrient 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 corners and locating and flagging or staking the house/facility location,proposed well location and the locarion of any other amenities. i �' �L � �� '�— Site Revisit Charge operty owner's or owner's legal representative signature Date(s): `� �Z� �77 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# "� � "�+ Revised 11/06 . 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V. , Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit Cut � FACTORS 1 2 3 4 5 6 L!/ L. 7 Landsca e sition t_L L/� _.- v�i L -5 Slo % ;� - _. HORIZON I DEPTH p--`l —3 O �i— � �'K Texture rou G � cr � Consistence` , �� - � < < r Structure {� �q- Mineralo �', r � � �/ HORIZON II DEPTH 3 0 7 Texture rou �, � �� Consistence Structure , Mineralo HORIZON III DEPTH Texture rou Consistence - Structure Mineralo .. _ HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE • 2 G. SITE CLASSIFICATION: �6�1 '. J k-1� ���f' � EVALUATION BY: �n�.,„ 1a`�YJL� � � Q'T � -�- LONG-TERM ACCEPTANCE RATE: . � � OTHER(S)PRESENT: ,�"_Y ��� Z ,REMARKS: LEGEND � T, n s �e 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 Texturg . 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