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987 Liberty Church Rd . � �" ��. � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r.o.sog sasmo x�p��i sc��t Mocksville,NC 27028 (336)751-8760 Account #: 990003382 Tax PIN/EH#: 5812-21-9752 Billed To: Sherrill Brinkley Subdivision Info: Reference Name: Location/Address: 987 Liberty Church Road-27028 Pro osed Facilit Residence. Pro ert Size: 64.5 acres � ATC Number: 3903 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 ' n.1900 wage Treatment and Disposal Systems). T�IIS AUTHORIZATION FOR WASTE AfiER CO CTI I ID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signatur : Date: � i ` CERTIFICATE OF COMPLETION *���OTE** The issuance ofthis 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 taken as a guarantee that the system will function satisfactorily for any C�a given period of time. �d , ti ) 4 � . ��L �����' � �lp n�V � `�' �o ` ���,� ; ' .� � S tic S tem Installed B : ���'� ' � � � eP YS Y � Environmental Health SpecialisYs Signa e: Date:�� � DC�-ID OS/99(Revised) � _ • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � 1 P.O.Boz 848/210 Hospital Street ✓ ��� c Mocksville,NC 27028 �� , (336)751-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 990003382 Tax PIN/EH#: 5812-21-9752 Billed To: -Sherrill Brinkley Subdivision Info: Reference Name: Location/Address: 987 Liberty Church Road-27028 Proposed Facility Residence � Property Size: 64.5 acres ATC Nurpber: 3903 **NOTE** Th�s Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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 ��s�. #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 ���'\�'�ype Water Supplyltit�►�i7 Design Wastewater Flow(GPD)��( ei`� Site: New� Repair❑ r� �r �/ � System Specifications: Tank Size��QGAL. Pump Tank GAL. Trench Width � Rock Depth �2 Linear Ft. 7`� Other: � 1/J��T�L���/�G�Gr�� Required Site Modifications/Conditions: /i Vh�'-/� � � �SU� �fl�� '' 11�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G"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 installation. Telephone#is(33G)751-8760.**** T �T� ��� . � , � � '� 3� � � � . � ; . 8 �` p�� �r '��� l.1-�.��1 r� E�� , � \J N � . 3 - ' ���� i Environmental Health Specialist's Signature: '� Date: �� 1 � ; DCHD OS/99(Revised) ` .<<„ ' � � � � � � ; ° , , , � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT �p � �` Davie County Health Department �� � � [�� Environmenta/Hea/thSection U � P.O. Box 848/210 Hospital Street � � : Mocksville, NC 27028 � �CT ��- �i�04 (336)751-8760 ` 1 � . ***IMPORTANT*** THIS APPLICATION CANNOT BE P&OCESSED UNLESS LL TH ��i � �(jH � INFORMATION IS PROVIDED. Refer.to the INFORMATION BIILLETIN for 1. Name to be Billed � � �r��[ / !\ • �U Y'//IP/\. /E� Contact Peraon S AM e : Mailing Addresa P a • L� � � � T � � Home Phone / �/—c>��—�S� d City/State/2IP V d � N S V i ��� _ �V` ��i���Busineas Pho� ?� `�� � � 1 /� �/ ' 2. Name on Permit/ATC if Different than Above .S °` h Q Mailing Addresa City/s�a��� � � /r ' 3. Application For: f� Sits Evaluation L� Improvement ermit/ATC ❑ Both 4. syatem to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requeated: � Conventional ❑ conventional modified ❑ innovative � � 6. =f Residence: # People ot # Bedrooms 3 # Sathrooms 3 �Diahwashar ❑Ciarbage Diaposal ��Washing Machine �Basement/Plumbing ❑easement/No Plumbing 7. If Busineas/Industry /Other: verify type # People # Sinks # Commodes # 3howers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimatad Water IIsage (gallons par day) . e. Type of water supplys � County/City ❑ Well ❑ Community 9. ao you anticipate additions or expansions of the facility this system is intended to serve? �Yes ,�No If yes,what type� ***IMPORTANT''`**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. ' Property Dimensions: � `f �7 � C' rr'S W�ic�E D�R�e I L[�frim Moc�tie)�PRO���Yf LX (p N .� Tax Office PIN: #�g � ��o� � '— � '7 S' � 2 f'��le C r.J �.e� Property Address: Road Name / g � L >,�,r.� � � � r� � City/Zip /vI C� �l�.s U i�ff. , /I/ ' � '� d � � If in a Subdivision:provide information,as follows: Name: ��� Section: Block: Lot: Date home corners t]agged: �� l. sJ � y This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) 'issued here�fter 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 changed. I,also,u�iderstaiid t/iat I am responsible for al[cllarges incurred from t/iis application. I,hereby,give consent to the Authorized Representative of the Davi County Healt epartment ,/ to enter upon above described property located in Davie County and owned by 5 e rYi �� �• Q Y I N I�[ � ' � to conduct all testing procedures as necessary to determine the site suitability. � i � � '. DATE �D C.�'a b�� I I .Z� � � SIGNATURE,� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed � property lines and dimensions, structures, setbacks, and septic locations). . Site Revisit Chargc ' Date(s): Client Notification Date: , _ EHS: `�. �3 � � : Sign given - �� Account No. Revised DCHD 05/03 � � Invoice No. � , �n �e� � �. , , �d� ,�° i � , � fi� � � ����'�i��u9���� I � � ( v � �1., ,��p!)�7��f � �� , , �� i D�i �W4� . � �N �,� '�' �4 Niii ii����� ���, �. �h��'�fl��i�lii��� � . . �,,tiav� �04�8� �, a � `� � � as n '� wn i. �� „ .. ss � y'^ d����� �Id�� �Ii��qp4� �( �� � � I � � y'�"��'�+1 iY f 9� �ilii f M` F . . . Iw��� � �I�;�y � . � �a��� � � ���'z z! �����` � � � �-� � ��u� �� � � . ��ITyrlB��� �}I.t ' � . 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I . �rcon�a;��^� 1� . � �OYLS � � � � I � . . � � (V9>"ZZ) .. � �� ' � "" . _ _'_�__"_ � -""" ��� �_---� � l��� �` � \�� , 'a° ��- � '; � V �' �� O .,' �� � � 1 zeee � ���� `� � 0 � � y- y� A > Q�VO �sZ \ (tieo z) Z! � � fr `. . �& �����N'��� � '��� ��`'°��"��.������. orosZ • I i I . , � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � _ Soil/Site Evaluation .�___ APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003382 Tax PIN/EH#: 5812-21-9752 : Billed To: Sherrill Brinkley Subdivision Info: . - Reference Name: - Location/Address: 987 Liberty Church Road-27028 Proposed Facility: Residence, Property Size: 64.5 acres Date Evaluated: �� 1 f� � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit , Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo e% ,� HORIZON I DEPTH � r ( - (2 �� Texture rou . iGL 5;C.c..- i CE, �GL Consistence � .r � < S Structure 1t Mineralo HORIZON II DEPTH �� '" �� ( —?jp 2� Texture rou :C., 'C.. 'C � 4 Consistence ;S � ; SWcture � � Mineralo %k �.�3X, � HORIZON III DEPTH �'�" -� Q — Texture rou G� • {- Consistence �� Structure _ ,� c� Mineralo L� � HORIZON IV DEPTH -- Texture ou .�, (� Consistence C S S Structure � Mineralo S SOIL WETNESS RESTRICTIVE HORIZON ' � SAPROLITE CLASSIFICATION .' LONG-TERM ACCEPTANCE RATE O� . a•Z�' � . SITE CLASSIFICATION: PS EVALUATION BY: ����]�c1C%i't''�'V LONG-TERM ACCEPTANCE RATE: ����' O�3 OTHER(S)PRESENT: Q� 1.., ` , �K� � .� _' ', . �, fi n,�� �1 . '1 REMARKS: �` tt LEGEN � Landscape Position R-Ridge S-Shoulder L-Lineaz 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 Moist _ CONSISTENCE 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-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fi11-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) ' ■■�■�����■■�e��■e�■�■��■��■������■■�■1�■II►!I■�����■�■��■�■�■����■ ■■ 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