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110 Summer Sweet Dr Lot 6 DAVIE COUNTY HEALTH DEPARTMENT Environmental'Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 . I Account #: 989900093 Tax PIN/EH#: 5880-51-5031.06 Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#6 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility: Residence Property Size: .89 Ac ATC Number: 4480 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:�/ Date: "L S CERTIFICATE OF COMPLETION 1-7 "NOTE" The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.C} A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be tal a the system will function satisfactorily for any given period of time. C 15 o 4 s Vlcus �) VIE c Septic Syster i Installed By Environmental Health Specialist's Signature. Date: 1?1 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT .� Environmental Health Section Pill • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900093 Tax PIN/EH#: 5880-51-5031.06 Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#6 Reference Name: Location/Address: Summer Sweet Drive-27006 Proposed Facility: Residence Property Size: .89 Ac ATC Number: 4480 **NOTE**This Improvement/Operation 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 CO CTOR MUST SEE THIS PERMIT BEFORE IN,,�S/TALLING SYSTEM. Residential Specification: Building Type �S #People T #Bedrooms T #Baths -f-2/ Dishwasher: Garbage Disposal:l" Washing Machine: u Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) 'yffy Site: New®R pair❑ System Specifications: Tank Size A)4D GAL. Pump Tank GAL. Trench Width 34 Rock Depth jZ Linear Ft.-�W' Other: As stated in 15A NCAC 18A.1969(5) accepted Systems may also De use Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED 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 1:0 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** F Environmental Health Specialist's Signature: Date: 9✓/ir/d DCHD 05/99(Revised) _ yy td TI R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County-Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville NC 27028 • ONM�F�"��; T � � ppV1E� (336)751-8760/;Fax 6)751-8786 Applicaion F� or: ❑ Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Sfi - /)-__ _ , L _ __/'. Contact Person Billing Address Home Phone City/State/ZIP /7-7- �, -: I I� , �.�. C , z� 2 Business Phone 3 S- 2 u v Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Pernut is valid for 60 months with site plan,no ex iration with complete plat.) Street Address 11 � S ,, City. A-1. . _ � c Tax PIN# o .S/ O-A Subdivision Name /0 n A, Section/Lot# Lot Size . X 7 Directior}s To Site: �'L 1 5 L -d 1 — / c - IC �-Q, L Date House/Facility Corners Flagged If the answer to any of the following questions is yes6,supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes RX0 Does the site contain jurisdictional wetlands? ❑Yes D1' 0__ Are there any easements or right-of-ways on the site? ❑Yes [ Ito Is the site subject to approval by another public agency? ❑Yes UNC Will wastewater othet than domestic sewage be generated? ❑Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People Z-/ #Bedrooms L_/ #Bathrooms -3. Garden Tub/Whirlpool 2ffes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY:#Seats Type system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 4-e6u-n-ty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Z_ ems' If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determinj compliance with applicable laws and rules on the above described property located in Davie County and owned by S / . —_ Site Revisit Charge Property owner's or owner's legal representatiyq signature Date(s): G Client Notification Date: Date EHS: Sign given ❑Yes ❑No f Account# Revised 2/06 Invoice# a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION___L_LOT Soil/Site Evaluation APPLICANT'S NAME —b'2//I� DATE EVALUATED PROPOSED FACILITY IV PROPERTY SIZE SUBDIVISION �,��llo-T& 4C ROAD NAME Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH yO>• br Texture group Consistence r Structure K, (� Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: c OTHER(S)PRESENT:_ REMARKS: /¢ d✓ /�C / � � M L 4)9 P, LEGEND Landscape 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 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 M is 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 Mineralogy 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-gal/day/ft2 i DCHD(O1-90) A