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540 Liberty Church Rd (2) ; . DAVIE COUNTY HEALTH DEPARTMENT . , Environmental Health Section • ' ' P.O.Boz 848/Z10 Hospital Street . - . Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001755 Tax PIN/EH#: 5811-68-2032.16 Bilied To: Kenneth S Susan Alexander Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: ResidenCe Property Size: 1 aCre **NO'I'�**'This�mprov8em9ent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AITTHORIZATION 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 PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type� #People� #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)_�� Site: New� Repair❑ „ s� System Specifications: Tank Size , v GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FTNiSHED GRADE. ****NOTICE: Contact a representative of the 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 installation. Telephone#is(336)751-87G0.**** � ! Environmental Health Specialist's Signature: Date: �c�l��/ v DCHD OS/99(Revised) • _ ' �dL� , , . • DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001755 Tax PIN/EH#: 5811-68-2032.1B Billed To: Kenneth 8�Susan Alexander Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 2859 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewatet System Construction MUST 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � ^� Date: .�3�� CERTIFICATE OF COMPLETION � **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation 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. ` r � pa��rG'� � Septic System Installed By: Environmental Health Specialist's Signature: ii� Y c� Date: � �9'�� DCHD OS/99(Revised) � �..._._.._.— . ,.4._._� _-�,._".' M r D _ �� � � WP�1 R SITE EVALUATION/IMPROVEMFM PERMIT&ATC Davie County Health Department Environmenta/Hea/tlt Section MAY � 7 2�� . Box 848/210 Hospital Street Mocxsville, xc 27oz9 ENVIRDAVIEECOUNTY LTH (336)751-8760 ***II�ORTANT*** THIS APPLICATION CAPTNOT BE PROCESSED UNLESS ALL THE REQUIRFn INFORt�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed � �S(�y ,. �I P_l���l_�C� Contact Person �P�,,�e-�h �4 le_xa,nde.r Mailinq Addrea e �y(� L� ����� �� ��• Home Phone '�'1`-'!O�' �l.(��V � City/State/2IP M�c ksv� I l�,Nc ��oa8 �S�esa Phone � ��" � �� � 2. Namo on Permit/ATC if Dilferent than Above Mailinq Addresa City/State/2ip s. Appiication For: Q�Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. syatem to sez,.ice: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People `-1 � Bedrooms �_ t Bathrooms ,�_ ❑ Dishnasher O Garbage Disposal �Waahing Machine 0 Haaement/Plumbing ❑ Basement/No Plumbing 6. If Sue3neas/Iaduatry/Other: Speci£y type ��j-t Y People � Sinks / Co�dea # ShoKera � Vrinala � Water Coolers IF FOODSERVICE: # Seats �� Estimated Water Usage (gallona per aay) �. Type of water suppiy: L4�County/City 0 Well ❑ Community e. Do you anticipate additions or eapansioas of the facility this system is intended to serve? ❑Yes C�'No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �Cl G(L i G � WRITE D1RECfIONS(from Mocksville)to PROPERTY: TaxOfficePIN: # � � I 1(a��O3�- � g -��KP (�OI ►�I -1-� �� b�r-I-,r Properly Address: Road Name I,��I ,'�(��d. � �'1 U i'C�'1 � C_� ��'v r n 1P�-� City/Zip M C►�C�SV 1 ( �P ,�C��(,�S C',t cZ � m i �e . L'�r�3 pe,��v lf in a Subdivision provide information,as follows: e h Y 1 r�h-��b�a,h�-I� �('r�✓m , Name: h �e Section: Blocke I.ot: � Date Property 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 revocatiou,if the site plans or intended use change,or if the information submitted in this application is falsified or chaaged I,also,understand that I am responsible jor al!charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davic County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE �� " (�" � I SIGNAT'URE���,� ,t \ -�►1��(��.�r`��.C�-�Jt� �J 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): . � Client Notification Date: � � � a � EHS: . �, � �- �� / �U �S � Account No. / � Revised DCHD(07/99) � Invoice No. �3�`� ��� ��.� Z� I � - �. . � � , �-_i �_� � � � �� a-e,,�-� �� .�` , .` ; `'�, ;� � t i� t I i C J ' t 3 � � . ' . . � � � . �i � \ �Xy / �� � . . - /! . . �. � . . � '''7 � � � �. � / \. / . . j' J �\ ). •`\ /�'� % � / / �/ . . / / `\ . � t\ , . � ���� . � . . . \ . . ;, ;, o� � ; i , �� ., � � . , . ,. . a. , : . : , , _ K _ , ; , � :. _ _ _ , , _ ;, � ��0� ,.. i, s � o��J : . Z�OZ89 � �8� ; � f 90000000� t � } � � g � �. . _ _ ___.� `�+ .. �V7'�./ � . . . � � . � . T i . - ' _ �. � . . � � . . . f . . � � V ' . . . . . • � � '�,�,,a� � - , , DAVIE COUNTY HEALTH DEPARTMENT • l��� `' � • Environmental Health Section � Soil/Site Evaluation APPLICANI'INFORMATION PROPERTY INFORMATION ,. Account #: 990001755 Tax PIN/EH#: 5811-68-2032.1B Billed To: Kenneth&Susan Alexander Subdivision Info: 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 SWcture Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo , HORIZON IV DEPTH Texture rou � Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLTTE 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 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed ote 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)