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414 Liberty Church Rd
x. r -_- � i.' � �' ( • DAVTE COUNTY HEALTH DEPARTMENT ��.�� '-+ � Environmental Health Section P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 (336)751-8760 Account #: 990003678 Tax PIN/EH#: 5811-76-6775 Billed To: Marcia Lambe � Subdivision Info: Reference Name: Location/Address: 414 Liberty Ch Rd-27028 Proposed Facility Residence Property Size: 7.340 ATC Number: 4149 As stated fn 15A NCAC 18A.1969(5) accepted Systems may also bt ugea 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 eatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE C N V FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa e: Date: �21i J CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion 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 will function satisfactorily for any given period of time. l�p� /�p�� �e �� � /2'' `� � /� •.�11 ( cJ 'i`�t'� ' 'F�-o.,t i Septic System Installed By: ���`� �V'`� � Environmental Health Specialist's Signature: Date: �3�0.5 DC�ID OS/99(Revised) v . DAVIE COUNTY HEALTH DEPARTMENT Z� , Environmental Heaith Section �`'� � P.O.Boa 848/210 Hospital Street � � d � ' �j � ` Mocksville,NC 27028 � (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003678 Tax PIN/EH#: 5811-76-6775 Billed To: Marcia Lambe Subdivision Info: Reference Name: Location/Address: 414 Liberty Ch Rd-27028 Proposed Facility Residence Property Size: 7.340 ATC Number: 4149 **NOTE**This ImprovemendOperation 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 �(. �-�I�KC #People � #Bedrooms 2- #Baths �-' Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size � Q�� Type Water Supply l..V� Design Wastewater Flow(GPD) ��� Site: New��Repair❑ I,�,,n ./ System Specifications: Tank Size�(�/(/ GAL. Pump Tank GAL. Trench Width� Rock Depth_� Linear Ft. ? � As �t�tod ln 15A NCAC 18A.1969(5� Other: 3 �r�;�?fZo-��X.G� taxetrted Systems mav a►se ee us� Required Site Modifications/Conditions: �Sr� 0� � � �`� c�� IN[PROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EF UENT FILTER RISER(S)IF 6��BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe 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.m.on the day of i tallation. Telephone#is(33G)751-87G0.**** � , -- - � 1d' . „ - ,, ��-�` � �.�ati ' .�. �� '�F(�� I..�"1� 1.� ��Z f� . �►�. • ,'� �� � t��ac T¢.�-i'E �+ 34'� S �1,�)M 1� � � . S ��2.��1T °,. � Environmental Health SpecialisYs Signa e:� Date: � Zli 0� � DCHD OS/99(Revised) � u�-���� 2�� � � ti �� �� � � ��� ti r �p ���a��''� ��' �, ��` �o �'�'� I e � „ � .e, • o ,�,� a „ •, , - � � 1 � �" � n �. 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'+ . .. ..,.< �� ��.s� { R. y�%. � � ����u' I y„ ,k� �.. . �l" .�,. . �� t �� � � �✓'� � �„, ,�», µ, � w.� ,� «, : � "�� �' ,�k �� , a« �*a;; I _._ � ,� . �.. ��.' .. _ __,.._� nn� d . � �°..�� � � .� . � , . � ' I � � � 6 �1 � . D :1� , ICATION FOR SITE EVALUATION/Ihf('ROVEhtENT PCRh11T&ATC J�(,., '� 9 2�05 ' Davie County Heaith Department • Environmenta/Hea/th Section " " P.O. Box 848/210 Hospital Street ENVIRONMENTALHEAI.TH MOCksville, NC 27028 DAVIECOUNTY ' , (336)751-8760 ' ***IMPORTANT*** THIS APPLICATION CAIdNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. ` _ � 'A`//�' , l. Namo to be Dilled Contact Peraon ' 1 1[��("Ci�R, �_,nn�Y' Mailing Addrasa �-'�1`� l�t �f�� �►^1 � � Home Phone ,�. �^��—�- �.y� 3� City/State/ZIP i ` 1 �C� �C�✓�\1� `�v � Businesa Phone 1 :��n—�{� �n —�� /�_ _ 2. Name on Permit/ATC if Different than Abova Mailing Address City/Stat /Zip -� � ��- t � 3. Application For: ite Evaluation Impr vement Perm t/A C ❑ Both 4. System to Servicec ❑ HOuse 6d�MObile Iiome ❑ Business � Industry . ❑ Other 5. Typo nyatem requeated: ❑ Conventional ❑ conventional modified ❑ innovativo pgC�ePtecl. � . : , 6. It �tesidence: N People �� # nedrooms � i� Bathrooms� _,�� �iahwasher, ❑Garbage Disposal , Washing Machino �Dasement/Pluml�ing ❑Basement/No Plumbing. ' 7,. If 8uainesa/Industry /Other: verify type # People S Sinka # Commodoa # Showera # Urinals # WaL•er Coolera IF FOODSERVICE: � Seata Estima�ed Wa�er Usage (gaiiona por day) s. Type of water supply: �,YLounty/City ❑ Well ❑ Community 9. Do you anticipate additiona or expansions of tl�c facility tliis systcm is intcnded to scrvc? C]Ycs �7-�'O If ycs,i��l��t typc? � ***I111PORT T"`**C IGNTS MUST CObfPLETL•TIIE REQUIRED PROPCRTY INfORMATION REQUGSTLD I3ELOW. �ith r a PL o SITG PLAN MUST BESUIIMITTED by thc clicnt with TIfIS APPLICATiON. Property Dimcnsions: �• J � � ` ��� �VRIT�DIRGCTIONS(from Nlodcsvillc)to PROPGRTY:` Tax OfGcc PIN: # J /� 7 (o�c��� ��l I Va�� TC� 1-,�L��C'�v �� Property Address: Road Namc��L� �1 C,�t����� �() h�l� 1� O�1 �,�9'�_ c,cy�z;n �r��csv���� �C l.c��c1., Qe�r-,:n� '�e� r�,a����� �1dr�� / �) r � I' � � If in a Subdivision providc informatiou,as follotvs: �(1 �S)/I e �(',K�I� 'LIi m �e Namc: f�1'� �n Ot N�I� �Y��� �� POt��'f �o� I Section: Blocic: Lot: Datc home corners flagged: 23 O s This is to ccrtify tliat tl�e informatioti providcd is corrcct to tlic best of my l:nowledgc. I undcrstaud tti�t any per�nil(s) issucd hcrcaftcr are subjcct to suspcnsion or revocation,if thc sitc plans or intended use changc,or if thc information submitted in tliis application is falsified or clianged. I,a1so,rurderstairrl tliat 1 ani respo�isiGlc for n![cliarges inc�rrr•ed fruur tlris npplicntio�r. I,I�creUy,give consent to tlic AutUoriud Represcntativc of tl�e Davic County Iicaltli Deparhncut to enter upon abovc describcd property located in Davic County and owncd by to conduct all t�stiug procedw•es as necessary to determine tl�e sitc suitlbility, - � DAT� — 7 "'C� S SIGNATUIt� ^.��' ,(Y/I��, ./.l✓1 i-2� � THIS AR�A MAY B�US�D rOR DRAWING YOUR SITE PLAN(Include all of tLc follo�ving: Existing and proposcd property lines and dimensions; structures, setbacks, and septic locations). �- Z� .. U s Sitc Rcvisit Cl�argc . ,;/�� C (��� � . Datc(s): !/ a a : � � Clicnt Notification Datc: � C �_ �IiS. n Account Na y�P 7� Sign grvc ___�� - � / / � ✓ Reviscd DCHD(OS/03 _ / Invoicc No. j � ���/t�_«_�." ����,� ���� � - iuu Y � •`(1.34A) �• ' N N , � 2��0 " " �- � ; � � �n 75 � 143 ; 2a 51 6.482A 6363 � � � • N 6� ^ 24 ; 387 M 2�7 � (2.33A) ' 5282 ^ ry (1.80A) 4917 �, � � �� � � ^ �°� ` � `° 7.336A m~. . � 491.43 . ,� (1.o6A) 6775 .. � "i 721 � o �� 1 � � � � � �� �-� ��� � � ��� M 1507 � N ��Q 4.22A ,�6 _ �� v�;�.' 1553 ?� �` � � 2424 � �.� ^ �� � � � �S '� � 'oo. �� r�7 J � 7243 � c�� 4.24A �p� 0199 `� ��' `�° J v l`Lg9� N (1.78A) (1.12A) 4084 �� 9034 09� �s N ..,a\ ��� �'�O / � � " DAVIE COUNTY HEALTH DEP�IRTMENT y � Environmental Health Section - ' ' '�' Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION " Account #: 990003678 Tax PIN/EH#: 5811-76-6775 • Billed To: Marcia Lambe Subdivision Info: Reference Name: Location/Address: 414 Liberty Ch Rd- 7028 " Proposed Facility: Residence Property Size: 7.340 Date Evaluated: � Z� � . Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring � Pit Cut . � �FACTORS 1 . 2 , 3 4 , 5, 6 � Landsca e sition . L, c Slo % r' 3 � HORIZON I DEPTH�. � O-ID a - '� Texture rou ` S�Gt� G.� S►C+.— • � . Consistence - �S �r Sg 5 S� . , Structure , � ,�Mineralo � _ . , ` HORIZON II DEPTH . �p � ;'Texture rou � L •G •G Consistence _s � Structure Q � � .Mineralo l � . `` HORIZON III DEPTH . , � - p- - Texture rou S'�G,a Gonsistence : s . ' Structure �" ' Mineralo t� `:HORIZON IV DEPTH . Texture rou � . ' Consistence � Stntcture . Mineralo . � . _ SOIL WETNESS � RESTRICTIVE HORIZON SAPROLITE � CLASSIFICATION �" . LONG-TERM ACCEPTANCE RAT . 2 , _, SITE CLASSIFICATION: ' EVALUATION BY: ��F � � f LONG-TERM ACCEPTANCE RATE: •��'� � OTHER(S)PRESENT: ' . ,REMARKS• " LEGEND . T,an 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 . Ts�ctiu� . : � 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 D�1S� . VFR-Very friable FR-Friable FI-Firm VFI-Very firm. EFI-Extremely firm _ � 3�'e.� � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure ' - , 1 SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic � Minera�°� , . 1:1,2:1,Mixed lYOi� Horizon depth-In inches - Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil wetriess-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 . 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