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1110 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �� 3/� � ' � / ' _ ,"' , P.O.Boa 848/210 Hospital Street < < - , Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001589 Tax PIN/EH#: 5812-34-8130.gc Billed To: Gary Cleary Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2729 **NOTE** This Improvement/Operation Pecmit 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �7' #People�,� #Bedrooms � #Baths � Dishwasher:� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size U�c Type Water Supply�_ Design Wastewater Flow(GPD) a�o a Site: New❑ Repair❑ ,� � System Specifications: Tank Size l�7�1 GAL. Pump Tank /��GAL. Trench Width�� Rock Depth� Linear Ft.l� oth�: �"s� ;���s ���,� 1,a�-� Required Site Modifications/Conditions: io�/ h�'� �le ` �`Pl� 'l S i /'C ,�h� IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTiCE: Contact a representative ofthe 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�.m da of installation. Telephone#is(336)?51-8760.**** ��/���l,v 6����e� `t ' � ���� ���s � o�P���� �y��- ��� m� �e r , � I1 � ��G� � - . +/ Environmental Health SpecialisYs Signature: Date: c���1`� DCHD OS/99(Revised) �� ' • DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section r.o.Bog sasmo x�p���sh�t Mocksville,NC 27028 (336)751-8760 Account #: 990009589 Tax PIN/EH#: 5812-348130.gc Billed To: Gary Cleary Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2729 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 WASTEWA C NS UCTION IS V D OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �..�J�� 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 talcen as a guarantee that the system will function satisfactorily for any given period of time. i J ���.� � ���-� �lz J - ��>`�- T �� k� � Septic System Installed By: /"'��G�r/'�� Environmental Health SpecialisYs Signature: i���/ --- --- Date:�/��l`�`'r� DCHD OS/99(Revised) . �.� _��', APPLICATION FUR SITE EVALUATION/IMPROVEMENf PERMR&AT . . ' Davie County Heaith Oepartment D � � � � � � Envdronmen�l Heu:/tfi Se+r�ion P.O. Bo: 848/210 8ospital Sts�et , . Mockaville, NC 27028 • ��� I� �I �� (336)751-8760 , ***IMt�ARTAI�IIT*** THIS 718PLZCATION CANNO? 9� PROC688SD VIRa$S 11LL Ha Ra�tRldIENTALHfAI� INFORbATION I$ pRaVIDaD. R�f�r to th� IND'OR�ATIOZt HULLETIN tor fAUN1Y 1. x.a. to b. sill.a n� e ar..oue.oc a.s.on �v-t-�.'C l�.i �CiJL1WJ l�J�^ �� �... 1'1� ��?���; ��a�� �� sa. �. 7�'I -�,o�b ��]r/sc.c./szp 1' L��P 1�Z S�� \,'�i �� d-70a-� su,sA... Phon. _��� 'S t�� D 2. Itas� os► p�sait/71TC i! Di!l�r�t th� ]1bo�� ltailinQ llddr��� CitY/8tiat�/Eip a. !►pplication Sore � Sit� valuation ��s�ezst p�rmit/]1TC � Hoth i a. er.c.� to s.�o.: 8�' ous• � Mobile Hom� O Husiness � Iadua O Oth�r �Y ' s. _! it�sid�ac�: f peopie �' • Hadrooms ,�_ • Sa�throoms � �'as.hwul�r p oarbaq� Di�po�al l9'Nu� �.�sA. o a...�..,c�ai�s� a s.,.�.nc�xo 'ri,�s� 6. It suai��s/I�du�try/Oth�rt 8p�oily typ� ! D�opl� � 81nks ' f Coavod�� � 8ho�r� � Uriaal• * K+tt�r Cool�r� _�' a'OODSLRV=C�: � Ssa►ts aatimated Na�r Osaq� tvuloa. p.r a.Y� 7. �p� o! Kater supply: Couaty/City 0 N�.11 ❑ Community ' e. Do you anHcips�te addltIons or e�analoas of the facWty thts syatem L intended to�erve? O Yes 0 No If yes,w6�t type? **"IMPORTANT"**CLIENTSM[ISTC�OMPLETETHE REQU/RL�DI'ROPERTY INFORMATION REQUFSTED BELAW. E[t6er a PI.AT or SITE PLAN MUST BE SUBMITTED by t6e tUent w�lth TN1S APPL1CATlON. Property Dlmenslon�: �0�3 X � i� X 37a /� Gl�P�` WRITE DIRECTIONS(from Mock�ville)to PROPERT'Y: Tu 08ice PQV: # � ���=3 1 " � �� U• 9'c F • a -F Property Addreas: Road Name e �,� �� � � � G � , Cicy/Zip�uc�C S��L�� �� l��✓ 1 C..< C h.-f; , V ia A Subdivision provide iuformaHon,as follows: • Name: Section: Block: Lot: Date Property Plaggeds '���"� � This i�to certify tbat t6e intormallon pmvided ia con�ect to t6e best ot my kno�viedga I nnderstand t6�t�ny permit(a) isaaed 6ereafter ere aubject to easpenaton or revceallon,if the eite pl�na or Intended aee e6snge,or if the informeHon � enbmitted!n t61s�ppl[csHon i�faislfted or chunged. l,also,anders�and�hat I ant raporulbl�jor a/l cborges Jxcumd jroni tbls oppltcallo�r. 1,6enby,give conaent to the AnthorFied Repreaentative o!t6e vl Coanty A �16 Depsrtmeat to enter npon abave deacribed property located in Davie Coanty and o�vned bj►� to conduct all teaNng procedara as necessary to determine the dte tnitabW . DATE �1'� � '7 ^D I SIGNATURE e THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include�ll of t6e folto�ving: Ezlating and proposed � property Ilnes and dimena[ons, etractares, eetbacka, �nd sepde Iocallons). Site Revlsit C6a'rge Date(a): , Cllent Notificallon Date: EAS• Account Na !�� Revised DCHD(07/99j Invoice Na �� � `� `'� `_ _ � r°� �b�b9Z ��� t�d06'�) , ,, ,� , , � ; w'� �� ��b80 s�� $ (dfi8'Z) ���. , .�; �- __ ° ..� _ � � : _ �� ;.�; �� � m �, � �a , �:��� �Q ��� � , � � ��0�7�8 L ,,: .,�� _ �� � CdG� E)�, � l � �� � � : ��� � � ��� ��O��O�OOOZa. . ��� -.� ���� . � . . �� _ ,d = ww � � • . _ _ w � �� _� • . �., _ �ow _ S � g� � � � � - � � -� o � . �. ,�� � �_ � �` , �° ', ,�C . :.. .�,. � �o� � APPLICATION FOR SITE EVALUATION/IMPROVEJNENT PERMIT&ATC /� � Davie County Health Department �° 7 � il. Environmenta/Hea/ti�Section �Cr 2 Q � t C�� �•� � P.O. Box 848/210 Hospital Street ���?� u�r rsocxsvi.11e, Nc 27o2s � �, �� (336)751-8760 ***I�ORTANT*** THIS APPLICATION C�IDTNOT BE PROCESSED UNLESS ALI, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions. 1. Name to be Billed j�' /i�G�Gf�[--� (n/� ���'� Contact Person ����� Mailinq Addresa �� / CE���n� C./'�: Home Phone % /�^ � f7 �� City/State/ZIP �(7� /�S�/���/[J �` �•. Busi.nesa Phone �� �'- �O ��� '� 2. Name on Permit/ATC if Different than Above Mailinq Addreas City/State/Zip 3. Application For: B�ite Evaluation ❑ Improvement Permit/ATC ❑ Both a. sYat� to service: �HouSe ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. xf Residence: p People oC A Bedrooms � # Bathrooms -� .I`rDishxasher I:{.Gs�r�bage Diaposal ashing Machine '-�asement/Plumbing ❑ Basement/No Plumbing 6. IP Buaineae/Industry/Other: Specify type A People # Sinka M Co�odes � Showers �1 Urinals * Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (qallona per a8y) �. Z�pe of water supply: ❑ County/City B�ell ❑ Community a. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �o If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with TH[S APPLICATION. Property Dimensions: � ��� """"� WRITE DIREGTIONS(trom Mocksvillc)to PROPGRTY: .� ! �� 3`� " �� 3 � ,J � � ,,, L� �.c�._.�-( Tax Office PIN: # � � � ( � Property Address: Road Name H.Bef�� C�-/� • s�"' ��-✓r'"� �"� ' ^5`~ T�''`"������� ��-^�— � �c.�t�t c..u[acc.F�''�-�- City/Zip a�,ls . �r,!-�,.��.��.:� . . �y.,..�-c ,CA s-L � w� — ���-0�'7 If in a Subdivision provide information,as follows: -e_-1- � o � �-� G-.� � Name: ��' � 7 ` VU /,"C'F R�--`".�'..' `� �, C�d r / / / ryx/t Section: Block: Lot: � Date Property Flagged: ( �j a�J� ° �''="'�` r�66+� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) �!� Lssued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the iaformation ,�.���Y submitted in this application is falsitied or changed. I,also,understand that I am responsible jor al!charges incurred jrom thls application. I,hereby,give consent to the Authorized Representative of the Davie County Healt6 Department r'r v- to cater upon above described property located in Davie County aad owned by to conduct alI testing procedures as�necessary to determine the site suitability. , DATE � l � Z��� SIGNATURE i��� L.✓C�%« �--- TfIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Egisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge � 6 �✓'r✓�- Date(s): Client Notification Date: EHS• . Account No. l � �. Revised DCHD(07/99) Invoice No. J /,j.� �p/�-�/o 0 . . . . vl� � . . l: �� �b�b9 Z td06'S) � _... � w'�1 ' �w .� } ��b80 . s�,� (d�s�z) ��� . � '..l � .. . �sh� �'A7� `V V ��� DE �S . � �`d��b'E) =�^-�Y � � � ��� �� >>�ro�� ��� ., � � � ���� ��� ww ` � � � ,� _��--c ��� r`.�'"� -� C.__. _> ww .� . ti , , . � . . . . r! h • . - � r ' �r `- t � , � , M , '.k' DAVIE COUNTY HEALTH DEPARTMENT . � � �° ' ' • � ' Environmental Health Section . � � . � Soil/Site Evaluation APPLICANT INFORMATION - PROPERTY INFORMATION Account #: 990001464 Tax PIN/EH#: 5812-348130 Billed To: Michael Wallace Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence. Property Size: 3.41 acres Date Evaluated: /Y�'�.Z��l� Water Supply; On-Site Well Community Public Evaluation By: Auger Boring �/ Pit Cut _ „ -b FACTORS 1 2 3 4 5 6 7 Landsca osition Slo e% HORIZON I DEPTH '� �� Texture rou � l''i!i (% S"G Consistence Structure Mineralo ' HORIZON II DEPTH `� `� � �. Texture rou �' � Consistence � I -f Structure ��- Mineralo -� c� HORIZON III DEPT'H Texture rou ` Consistence Structure Mineralo ' HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � � SITE CLASSIFICATION: �/"\S - EVALUATION BY: �/ LONG-TERM ACCEPTA CE ATE: c- ' � ��v� OTHER(S)PRESENT: � J �, m� , REMARKS: � `� ��y 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 oi 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 truct re SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloav 1:1,2:1,Mixed 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 chroma 2 or less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DC�ID OS/99(Revised) ■�������■■�■■��■��■�■�■��■■�■■■����■■0�0�■��■�■�■����■■����■�■���■ ■■�������■■■■■�■��■�■�■��■■���■■■■����������■�■■����■■■�����■■���■ ■��■���■��■■O■�■�■■����■��■�■■■����■����■���■������■■■����■�■��■■ ■����■�■�■■�■■■■■�■�■�■■��■�■■■■ ■■■����■�■■�■��■��■■��■��■■��■�■ ■����■�■■■■■�■■■■�■�■�■■�■■�■■■�a��■■���■��■■�■��■■■e■���■■s�����■ 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■■�■��■��■�■��■�■�■■■e■■�■�■���■��■■■■�■■■�■��■���■��■■■■■�■■����■ ■■■�■■��■����■■�■■�������■�����■■■■�■�■����■���■■�■��■■■■■�■��■■�■ ■�■�■■������■■����■���■�■�■�■��■■�������■�■����■■�■�■■■�■��■���■■■ ■e■■■�■■■�■����■�■■■�■■�■�■��■�■ ■����■■�■����e■����■■�������■■■■ ■��■��■�■�■��■■■���■■■■�■�■■�■■��i�■■■�■■����■�■■■■�■�■■■�����■��■ ■■����������■■■�■��������■■�■■��■����■��■■�e■�■■�■�■���■�����■■�■■ w " . . : i ♦ � , � . ... . . . . . ' t., r» ..�.: �i._... . �.ir.-.n� ....�-_.......�..�. .......... .i....�:. n..�...- .. ....�..r...-.. ��.u.��r-.. rw...e�. . . .... . . . . . '- ..+-� y-+-� . • ' D��I��OUIJTY�I�cI�Tii D��'��'I'hrI�IVT . .� . :, . . ... : _ _ . . ,.._:_ ,.._�.�.= ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street • Courier #09-40-06 � Mocksville, NC 27028 Phone #: (336)751-8760 October 27, 2000 Michael Wallace 199 Leanne Lane � ' Mocksville,NC 27028 Re: Site Evaluation/Liberty Church Road . Tax Office PIN: #5812-34-8130 - Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 26, 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. Sincerely, . �k������• Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di � Enclosure(s)