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2363 Liberty Church Rd
I • � � ' DAVIE COUNTY HEALTH DEPARTMENT . -�.._.- Environmental Health Section � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002383 Tax PIN/EH#: 5803-67-1746 Billed To: Valerie Nichols Subdivision Info: a3(Q 3 Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3228 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWAT C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �— �i�'►y Date: ����. �. `� CERTIFIC TE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completi n shall in�h'cate the system described on Improvement/Operation Permit has been installed in compliance with icl 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO W Y be aken as a guarante�s�at the system will function satisfactorily for any given period of time. � � /oo,� � �� �G,, � -t�� , � ��' � , Lrni�;�vo r �'D o��`7�G A�r-�.+Js�c.rcx/v.J 7 ss �-ir�1� � 1� � �� �N��' � ��r i+�� L�.� s-i� Septic System Installed By: vi���'�'� �T�- �'.l''��� � Environmental Health Specialist's Signature: e: �-S � , DCI-ID OS/99(Revised) �,�v DAVIE COUNTY HEALTH DEPARTMENT � �//�'�v • `�, � , Environmental Health Section / • P.O.Boa 848/210 Hospital Street ` . - Mocksville,NC 27028 ' " -- (336)7S1-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002383 Tax PIN/EH#: 5803-67-1746 Billed To: Valerie Nichols Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 3228 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An Ai7THORIZATION 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 PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �� #People�O _ #Bedrooms � #Baths� Dishwasher� Gazbage Disposal: ❑ Washing Machin�Basement w/Plumbing: � Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply e� Design Wastewater Flow(GPD) ��C Site: New�Repair❑ System Specifications: Tank Sizei�fL/11 GAL. Pump Tank GAL. Trench Width��Rock Deptl� �� Linear Ft.c��� Other: Required Site Modifications/Conditions: � INIPROVEMENT/OPERAT(ON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a repres tah fthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m. 1:30 p. on t ay of installation. Telephone#is(336)751-87G0.**** �� Environmental Health S ecialist's Si ature: �i�:vJ� S�� Date: �` '��-✓ P � DC�ID OS/99(Revised) .,;, � . -�� , �G� APPLICATION FOR SITE El/ALUATION/IMPROVEMENT PEIiMIT&AT � � .� ' I� Davie Count y Health De partment ��S /� • Environmenta/Hea/th Section . �� a� ti P.O. Box 848/210 Hospital Street Mocksville, NC ' 27028 �U� ,�Z (336)751-8760 �,� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROC'ESSED UNLESS ALL Z' HFa��_ INFORMATION IS PROVIDED. Refer to the INFORI�TION BULLETIN for instruct ��"r� 1. Name to be Billed j,�ler�e Y �1),G�'1 O/S contact Person .�'ti/C J^� --�;° ' Mailinq Address ' Home Phone � �:��L c ' L � City/State/ZZP - Q Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/2ip � . . � . .� :� . � .. r� �. -r� +�-- .�o�-�� . . 3. Application Eor: Site Evaluation� lrlmprove�.m,ent Permi.t/ATC ❑ Both a. syatem to service: ❑ House fcl�Mobile Home ❑ Business ❑ Industry ❑ Other. 5. If Residence: # People �_, # Bedrooms _� � Bathrooms � � G.(Dishwashei I_I Garbage Disposal Hf Washing Machine fJ Basement/Plumbing ❑ Basement/No Plumbing Y 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Typo of water supply: ❑ County/City �ell ❑ Co�unity fl. Do you anticipate additions or cxpAnsions of the facility this system is intended to serve? ❑ Yes 6'No If yes,�vhat typc? ***IMPORTANT***CLIENTS hIUST COMPLETETHE REQUIRED PRQPERTY INFORMATION REQUESTED QELOW. EitLer a PLAT or SlTE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. � f Properly Dimcnsions: G WRITC DIRGCTIONS(from Mocksvillc)to PROPGRTY: � G� T�x Oftice PM,1: # � �� o �'- �� ,� T Property Address: Road lYamcl.�b2,r`�c., �.'Q� l�.v � � C3,�,� �-. G�-� . c�tyiz�n.V����.�;ll� a�oaR ,�"--�r — b��r -� If in a Subdivision providc information,as folto�vs: L—� �3 • C �.�-L Namc: �' •Scction: Block: Lot: Datc Property Fiagged: � � Z/ v � This is to certify tl�at the information provided is correct to the best of my knowledge. 1 understand that any permit(s) issued I�crcaftcr are subject to sus�ension or revocation,if the sitc plans or intendcd use changc,or if thc information submittcd in tl�is application is falsified or changed I, also,understa�rd tknt I nn:respnusible jor all clr�rrges i�rcurred frun� , lhis applicniioit. I, hcreby,give consent to tl�e Authorizcd Representative of thc Davie County Hcaltl� Depnrtment '�, to cnter upon above dcscribed property locatcd in Davie County and owncd by to conduct all testing procedures as neccssary to dctermine the site suit ility. DATC SIGNATURE � TIiIS ARCA MAY BE USCD FOR DRAWINC YOUR SITE PLA (Includc I of thc following: Cxisting and proposed property lines and dimcnsions, structures, sctbacks, and septic loca ' Site Rcvisit Chargc Datc(s): Clicnt Notification Datc: EHS: Account No. ,���� , . , • , , �'.: .. . . / Reviscd DCHD(07/99) Invoicc No. ����_v . ,. e.• �" . � . � � � . ..', , • DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � � ; ' ' Soil/Site EvaluaHon APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002383 � Tax PIN/EH#: 5803-67-1746 Billed To: Valerie Nichols Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: �'��'�?)Z Water Supply: On-Site Well Community Public Evaluation By: Auger Boring v Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% � HORIZON I DEPTH � �� " Texture rou S Consistence � Structure Mineralo HORIZON II DEPTH '� li Textwe rou Consistence � Structure /L 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 SITE CLASSIFICATION:_�;� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ' � OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Lineaz 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-Subangulaz blocky PL-Platy PR-Prismatic Mineralo�v 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-gaUday/ft2 DCHD OS/99(Revised) � ■�������■�■�����■��■�■��■��■s���s��■����■������■����■����������■■ ■■���■��■�■�■�■������■��■■������■���■■�����■��■��■■�����■�■ ■�■��■ ■■�����o���■o�������■����■�■■����������������������■��■���■�����■ ■■���■�������■�����e��■�■■■�■��■ ■���■��■■����■■����■o■�����■■■�■ ■����■�■���■�■�■�������■��■�■����■■����■��������■����■�■���������■ ■��■�����■���■�■��r���������■�����■��������■�■■���■■■�■������■■��■■ ■�■���■■■■■�����■�i��■■��o�■�■������■■��■���■���■■����■������■��■■ ■�������■■■������m�■��■��■o�■����■������■■�■■s���■�■■■s■�■��■���■■ ■�■��■��■�■■■��.���■�■■��■�■���■�■�■�■■�■■�■■�■��■�■■■■■■■���■■�■■ 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