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540 Liberty Church Rd DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • � P.O.Boa 848/210 Hospital Street '�� ' � . � Mocksville,NC 27028 ' � ; (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001755 Tax PIN/EH#: 5811-68-2032.1A Billed To: Kenneth 8�Susan Alexander Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre **NOT�*Tliibgmprov8em8ent/Operation Permit DOES NOT autharize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WAST'EWAT'ER 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 �� #People 2 #Bedrooms� #Baths�_ Dishwasher: � Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply�'� Design Wastewater Flow(GPD)3�� Site: New.� Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width 3�� Rock Depth/�� Linear Ft�� Y>. Other: J. Required Site Modifications/Conditions: Ib'IPROVEMENT/OPERATION PERMtT 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 130 p.m.on the day of installation. Telephone#is(336)751-87G0.**** � r �' ___ i 1i ' i �� .��l1"�l '� Environmental Health Spec a st s S gnature: , Date: DCHD OS/99(Revised) . . � ` r- ' .. � DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section � P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990001755 Tax PIN/EH#: 5811-6&2032.1A Billed To: Kenneth 8�Susan Alexander Subdivision Info: Reference Name: Location/Address: Liberty Chu�Ch Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2858 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED 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 WASTEW R CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � Date: -S 3d�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Pertnit 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 guazantee that the system will function satisfactorily for any given period of time. �" ��a�3 X��`�� Septic System Installed By: � Environmental Health Specialist's Signature: Date: � f��/ L� DCHD OS/99(Revised) 1 �. ��. �. � �..— �-u--`J-'� � 710N FOR SITE EVALUATIOV/IMPROVEMEM PEfiMIT&ATC , . Davie County Heaith Department � MAY I 7 luui i Environmenta/Hea/thse�ction �; �_,�o.�— P.O. Box 848/210 Hospital 3treet � � Mocksville, NC 27028 �,� � _ � � ; ENVIRpA IE COUNn LTH (336)751-8760 ***II�ORTANT*** THIS APPLICATION CANNOT BE PROC,ESSED UNLESS ALL THE REQUIRED INEORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Hillad c...�VSC�.r� � IG��J7U�� Contact Peraon Kenne� �tex�a.nde-�' Mailinq Addresa �`""1\ ) l._.1 L)�f� l��• ��_ Home Phone �� IDQ� � C.itY/State/2IP ��(^-K�j V � 1 �� ( �� d��-�CJ 8uainess Phone 1 �`I" 1�� J 2. Nama on Fermit/ATC if Dilfarent than llbove Mailinq )lddreaa City/State/Zip s. Appiication For: L�Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. syatem to se�ice: ❑ House �'Mobile Home � Business ❑ Industry ❑ Other ' 5. If Residence: � People �_ # Bedrooms �� 1� Bathrooms � O Diahxaaher CI Garbage Diaposal 61�Taahing Machine O Sanement/Plumbing ❑ Basement/No Plumbing _ 6. If Buainess/Induatsy/Other: Specify type �/`T i People M 3inka # Co�ndes / 3hoMera # Vrinals � Water Coolera IF E'OODSERVICE: # Seats 1�1!Ft Estimated Water Usage (gallona Fer aay) __ �y_ 7. Type of water supply: �3/County/City ❑ Well 0 COmmunity e. Do you anticipate additions or eapansions of the facility this system is intended to serve? , ❑Yes n�-�iv If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PLAN MUSTBESUBMI7TED by t6e client with THIS APPLICATION. : Property Dimensions: � � C(p �� '1 WR1TE DIRECTIONS(troro Mocksville)to PROPERTY: � Tax Office PIN: # �� O �c� 030� ' �� e �n�( N ^tf 1 1�.�1 hP� Property Address: Road Name��I l��. �(�_ �Jh • �� • , 1 � �rn 1e-�-�-��-10 c;tyiz;p �n�KSVi ��e, I�IC � i�ri i �E'_ ' �1�,�� C�3 (� r`�� If iu a Subdivision provide information,as follow�� I� I 1 l�� T�JI.d �1 f l dVS� Name: �• . Section: Block: Lot: � Date Properly Flagged: � � This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or c6anged I,also,understand that I am responsible jor all charges incurred jrom this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property Iceated in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE � ` I � 'O � SIGNATURE . THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): (��'��-� _- C6ent NoNfication Date: C/�p�.�-�� "^�_� )v U `" a a EHS• . . . . ��. � �v �� /�� Account Na � Revised DCHD(07/99) G�,.� �� °� Invoice No. `Z- � � � �.SI!�`°' �°"`"� ,�� ,(� � � ��s ,��--� �� , ��- . , . , � - , .-_. , � , , 3 1 fa � T , � f�l'tn t S — � /.. � 1 .; 00000�6 30 . 1682032 . :: o 581 : . : �J3 � . ' / r�o� � , ; a .. . . a , ; 'i �, -� �� ; � ; � � . , . � 53 40 .,,. � ; / , � , ; . / �: . � , .- . i . 4 ,._,�� 5 �..,.� * `•, � � i ,�. i� i � / i � i �� '�, \ �, � ��` � � . ;: , `�.... , � �* � � • DAVIE COUNTY HEALTH DEPARTMENT - � � � � , , � Environmental Health Section � � . . • Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001755 Tax PIN/EH#: 5811-68-2032.1A Biiled To: Kenneth 8 Susan Alexander Subdivision Infa " Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 � 6 7 Landsca e osition Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure • . Mineralo HORIZON III DEPTH Texture rou Consistence Stcvcture 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-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 oist � VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-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 tru ture SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular 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) LTAR-Long-term acceptance rate-gaUday/ft2 DC�ID OS/99(Revised)