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2190 Sheffield Rd
i . DAVIE COUNTY HEALTH DEPARTMENT , ' Environmentai Heaith Section � P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003779 Tax PIN/EH#: 4891-79-7625 � Billed To: Marina Blattner Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility Residence Property Size: 1.16 acres ATC Number: 4241 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 WASTEWATER CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. � Environmental Health SpecialisYs Signature: /� Date: �f �,�—� As stated in 1emsNCay�Iso�be use 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. a� 1 �2 � �y �S a�, wod s . 3 , p►-ope�,- lt� ��na,s 1-5 = 4�8 -�1-�eAch ►z � � � �Z �� ��v,�¢, le = 4�4-�� ,, . -t�-a1= �$�I-�t - �o , . o.� s ►a' t 3�j o�tSE S 1�ED �jO Fron-1- ,v'�0� J� �� e�d � Septic System Installed By: �o mm�,��y e� Environmental Health Specialist's Signature: Date: L -7� G DCHD OS/99(Revised) -C o.,�.K� "�P' s��—�o�a � �o u c� qJ.c,1c._ �-4 Skav�daXdl Utia-��✓ � ��'3 \��e s �cd -f I rsk� -}-�e.v� 2"0� se�- � 3 ��w�s �cc� + �. ` DAVIE COUNTY HEALTH DEPARTMENT ��O�D 'r Environmental Health Section �� ,�� � ' . P.O.Boz 848/210 Hospital Street Q y� �'J� , Mceksville,NC 27028 n u,�J` D (336)751-87G0 U IMPROVEMENT/OPERATION PERMIT Account #: 990003779 Tax PIN/EH#: 4891-79-7625 Billed To: Marina Blattner Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility Residence Property Size: 1.16 acres ATC Number: 4241 **NOTE**This ImprovemendOperation 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TI�INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People 7 #Bedrooms�_ #Baths�_ Dishwasher:� Garbage Disposal: ❑ Washing Machin� Basement w/Plumbin� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #PeopleJShift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) Site: New❑ Repair❑ A � System Specifications: Tank Size�(�GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.� As stated in 15A NCAC 18A.1969(5� Other: ��Sg^fe� �� , � �� f. r6c@tT3S^maTcrSv-Qa-a9B Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G"BELOW FINISHED GRADE. ****NOTICE: on c a representative ofthe Davie CountyHealth Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or •0 .to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.**** C�t��� �c�-O�� � �l 5��, Z'S`�d . � ;n�r��w� Environmental Health Specialist's Signature: - ' � Date: ��Iol`�� DCHD OS/99(Revised) s . � n p� , " APl'LICA7lUN FOR SITE CVALUAT[ON/1hII'ItOVL•h1L-NT P � � &�TC(a � U V � , Davie County Health Department • Environmental Healtl�Section • � P.o. soX 848/210 Hospital straeti OCT 2 5 2005 Mocksville, NC 27028 • • (336)751-8760 ' QJVIRONMENfALHEALTN ***ItIPORTIINT*** TIiI3 APPLICATION.CANNOT 13� PROCESSED UNL�SS D INFOR2•S1�TION IS PROVID�D. Ref er to tha I2tFOR2�iATION BULLETIN for inu tructionu. 1. 27ame L•o.bc Dilled IV1��'(1� �(�l� Contact Peraon ���� ` r'� 1•tailing Addrosn _ �,� � ,����1 R(')� Ifomo Phono �� +V h `��a City/3tato/ZIP I'1 Q� MO Y�-I \� � �C)��� Du�DD P!ono' �a.�j X�-�(n�t.-�' 3 �CK J 2. Stamo on PermiC/11TC ii Differont than Abovu Mailin� Addroas City/Stata/Zip 3. Application For: W Si.tc �valuation U1 Improvement PermiL/ATC �] I3oth r 4. SyaL•em to sarvice: � IIouao ❑ 2Qobile I�Iomo ❑ Duaine3p ❑ InduDtry ❑ OL-her ` 5. Typa nyntem requoatod: � Conventional ❑ convontional modified ❑ �nnoyat�vo pacCepted 6. If 9to�idenco: It People Z' fl IIedrooms �' 1f IiaL•hrooina � l�Di�litiaaahor ❑Garbago Diapo�al 9ashing t3achino �1D �ement/Plun�ing IidUaaement/2�o Plumbing 7. If IIuninoan/Snduatry /Otlior: verify type � People tE Sinka � Commodoa 1) Showora q Urinala 1! 1•1aLor Coolorn . IF FOODSERVIC�: 4p Seatu �stimated S4ater Uaaga (gailons par day) s. Typo of wator aupply: County/City ❑ Well � Community s. Do �ou anticipato addition� or cxp:msions of tlic facility tliis sy�stc�i�is i�itc►�dcd to sci•vc? Cl 1'cs [�-I�o � If��cs,iti•hat typc? ***IdIPOltT'�INT"�**CLILNTS hlUST COAIP,GE7'L•TII� REQUIRLD PROPGRTY IN1�ORn•IA'I70N RLQULS'f�ll fS1:GOtiV, i:itl�cr a PI,AT or SITC PLA�11►fU.ST IIESUI1hfl77'F.A bti•thc clicnt �vith'i'IIIS APPI.ICATION. 1'roperl��lliu�c�tsions: � r � �D CRC�e.s 1YI21TG DIIiCC7`IONS(trau 11•lod<svillc)to PKOPL•'IZ'['1':� •r�r orr,��i'IN: i� �.��' / 7�1 � l� ��S (� � t,t� -b sh���a t�� I'roperty Adclress: Road Naiuc J`~' �'1 e_(-'-� e_� e1- 1�c�. ���t- p1(� ��.,e�-�a�L�-tcl �� c;iy�z►p M�c-��Sv�1��� NG � g rn�le c-�sk ►�s�.s Y� C.1�.u,rc4, a.`��o a8 If in a Subdi��isiolt providc infor�ualion,as folloSvs: OY� `C�l h�- -�her� 6n fD e-t` �� Namc: Scc(ioii: Blorlc; Lot: Datc lion�c cornct•S n�ss�a,�i D� ��� �� , �• 'I'l�is is to ccrtify tliat tlic iuCor►nation providcd is corrcct to thc bcst of iu}�I.no�vlcdgc. I uncicrstz�id tli:lt aIly peruiit(s) issucd hcrcaftcr are subjcct (o suspcnsion or rcvocation,if tiic sitc pl�ns or intcndcd usc cliaci�c,or if tlic informalion subniiltcd in tt�is apPlic�liuu is falsiGcd or changed. I,nlso,tulrlersta�rcl llrnt I nur respo�lsiLlc fi�r nU clrargcs irrcrrrrcd frunr 1/ris«pplicnliorr. I,l�crcb}�,�givc consci�t to tlic Autliorizccl Itcpresctitati��c of tl�c Davic Counly IIcallli llcpartuici�t to cnlcr upo�t abovc dcscribcd pi•operlJ'IOCSIC(J 1f1 DSti'IC COUI1���and oti�•ncdby to ca�ducl :ill (csling proccdures as ucccssar��(a �ctcrininc thc sitc suitability. i n�t•rL ' � au�5 srcrrt�ruiu; TIiIS ARLA AIAY BI;USI;D FOR Dl�il'4'ING YOUR SiT�PLAN(Ii��nll of liic follo►ring: L.�sc►r�����a nroposcd property lincs�nd Jimensions, structures, sctbacJss, and scptic locations). � Si(c I2cvisit Cl�argc ' ,��. � � •. Datc(s): : .'� e • � �l,��� Clicut Notific:►tion Datc: `�f��" �S O N . __ �I-IS: O �' � � / ' Si�n givcn_� '• �,�lccount No. , � � � n Reviscd llCIID(OS/03 Iii�•oicc No. � ,a � .....,��,.�... __.. _ _ _. . ._._ --. ..__ ._ _.. _ ._. � . �.��.. .��.�.� for recording, S�D TO ID�NTIFY ER5.•SURVEY� Review ❑fficer fLE RE�ORT, ,WHICH ONVEYANCES, TS, OR OTHER Date R 2,Q00,00'. FROM ANY PUBLISHED GR�UND CONTR�L, f� _- , '' - Zl3NED .R-20 WITHIN THE FLD❑D PLAIN. ; George Goforth Bk. 184, Pg, 599 iTAL tation Control Contr Corner N 89°19'39'E Corne 1/2' PiPe \ .. 274.68' � � �- - - - - - - - - - -- - - - - - - - - - - - - - - --1 I � Z❑NED R-20 �, Z � O � o � . ` �.� � Frar�e � 0 0 � Storage 1 , 16 � A c r e s w o � Buitding � cn £ � By C ordinate CoMputation I Ref. k� , , 111 I <a po tion of) • �--- - - - - - - - - - - - - - — — — — — — — - _ � _ `D�. 119.55' 120,23' S 89°19'32'W S 89°19'32'W -20 , � ^ Z❑NED R-20� � � Z�NED R-20 + �orth I , 4 � 1 � � O �. 599 , o , , I 0 . 77 Acre � � 0 ,67 Acre By Coordinate Cor�putation By Coordinate Cor�puta Ref, Bk. 204, Pg. 111 Ref. Bk. 204, Pg. 111 Z Ca portion of> 4 <a portion of) � �0 I I o I � z o W N 4 .�P N � � I 0 -�P o m � � , o� � �1 �! £ .�o, � . I w n' `� `° � � � � ` £ , c*t � � , � :A I I I � I ,-. , � . � I ' � � o � I � � h � � Q � � �, _ . v I I � • i � � / � ' I ,, �- ' � �4ter � � l�- � Coun��-- " !�- .' -_ "_ --- ,2,,`�0 , � "" 6,�cj'0`�"�_ , � __ --'""�� I S 7 1/2 � er ��ne_,_ --- 3551' /' Rebar Wat__-- " �,�9�• � � _ °urty �, �6�� � . � � Q / �?1�2 , . � ► � � � � DAVIE COUNTY HEALTH DEPARTMENT .� ��`• � ' Environmental Health Section ` ' Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003779 Tax PIN/EH#: 4891-79-7625 Billed To: Marina Blattner Subdivision Info: Reference Name: Location/Address: Sheffield Rd.-27028 Proposed Facility: Residence Property Size: 1.16 acres Date Evaluated: l0 �o��`�J Water Supply: On-Site Well Community Public v Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 ! Landsca e sition � Slo e,% HORIZON I DEPTH �• �• : � � Texture grou i Consistence �,/ � Structure !' /� ; Mineralo � '/ � HORIZON II DEPTH r� Texture rou Consistence �` Structure C Mineralo , - HORIZON III DEPTH Texture rou Consistence - Structure Mineralo ' HORIZON IV DEP'TH 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)PRESEIVT: � REMARKS: _ LEGEND , T,�ndscape 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 . T� � ' ; 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 a'I47S� VFR-Very friable FR-Friable FI-Firm VFI-Very furn EFI-Extremely firm 3�t � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky ` NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Str�tur� . _ SC-Single grain M-Massive CR-Crumb . GR-Granulaz ABK-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed LYQt� _ _ _ . 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 fo 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 , DCHD OS/OS(Revised) ■��■���■�■�■■���■■�■o■�■���■■■■■■���s■■■■■■■■■■■■��■■��■■■��.■�■a■ ■■■■■■�o����v��■���■o���■�■�■■■■ ■o■��■■■■■■■■■■■■■■��■�■�������■ ■rs■■■s�e�■s�■�■�.���■��■�■�■�■■ ■■�■■■e■�e■�■�■�s�■■■s■�■�o■�■■■ ■��■.■������■���■�����■■■■■■■����■�■■■���o��■��■��■e�■�■■��������■ ■.�■r■����■�s���■��■■�■■■�■■���s�s���■�■■■��■■■■���������s■�■��■�■ ■�.■re■■�■.�■�■�■�■■■■■■��■�e��■■e����ss�s■■■■■■���■■��■���■�■�■�■ ■■���■��������■��■■■■����������■�■�e■�■�■�■■■�■■■oe■��■■■■�■��es�■ ■�■��■■■■■�■v■■■■��■■■■�■��■■■■■�■■s■�■�■����■■■■■■■■■■■■■■�o�■■�■ 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