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104 Shuler Rd ,_ ��' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street ' . � Mocksville,NC 27028 � Q � (336)753-6780/Fax#(336)753-1680 �� REPAIR OPERATION PERMIT �� �c��u�t #; 990005621 T�x PIP�€.%EH#: 5728-28-4879 Biilcd 7a: Ethel Suler Su�idi�risior� lnfo: � Refer�r�ce N��ie: Repair Permit LocaiionrAdde�ss: 104 Shuler Rd-27028 , Propasec9 Facility: Residental Repair Prop�r�y Size: 4:696 Acres E,T�'`���The��i�ance of this Operation Permit shall indicate the system described on the ATC 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. . . $ystem Type:�Q`� S.T.Manufacturer $}�oa F Tank Date Tank Size 1 Do D Pump Tank Size System Installed By:Lo►K.tw�a.c�Cl�� E.H.Specialist:�i Date: l- ��'<< GPS Coordinate: U 342 � �\ �ot 32�`�rQ.�► � � $ZG �� � � 1.�.�a \:� � � � �, N 0� ,M .�� �n 'a _ L � � � N . C � \ � � � . . 'C . • '� _ \ �7' �l I � � � �z , � � — — �� � � �o — -- — — 5� — — �•I-�� �. ca�, _ ` �?� �.,�, �_. �... �— �} �� � � � ; . _. 3 iv� �go� , . +. DCHD 11/06(Revised) � � . �Nuoic�`� �5� r ' j� � � DAVIE COUNTY ENVIRONMENTAL HEALTH � . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 . � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION � Accou�t #: 990005621 'T�x PINiEH#: 5728-28-4879 8iEle� Ta: Ethel Suler : SuE�divisiort Infc�: Refer�r�ce Na��e: . �LocaiioniAddr�ss: 104 Shuler Rd-27028 , _ . � Pro�used FaciEity: Residental Re_�r . . � Prap�r#y Six�:�� ��1:696 Acres , Site Type: ❑New �Repair ❑Expansion �TC Nurnb�r: 5726 , � � _ **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to.issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat or the intended use chaage. Residential Specifications: #Bedrooms 3 #Bathrooms � #People � Basement❑ Basement plumbing❑ � Non-Residential Specifications: Facility Type #People #Seats • Square Footage(or Dimensions of Facility)� � Lot Size Type of Water Supply: �County/City OWell ❑Community Well System Specifications: Design Wastewater Flow(GPD)3�v Tank Size GAL.Pump Tank�GAL. 1a �� ^ f Trench Width 3 G Max.Trench Depth 3 4 Rock Depth�-Linear Ft. 3 d�? ��g siate� in 1��1 hC��(,��_£3�.1�uai�5-�s �eeQc.�`r, Site Modifications/Conditions/Other: �r�P�tP� SvstemS may also b� us Gp }�y� Contact the Davie County Environmental He�lth Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. , - Gr�� � � 1H`�. ° � . � Y �. . � l ��` � `� � ` � ` +�' � 5� - ' ��i5�� ' � � �� �' � ----- � �'� k�� � 3$� ` � /S �` ,.� l � s� � � 0 "'� ��,� � � � � p }� y/`�'P � ,�►,1_ �—�' Car' . ! � ---�-��,_. ._.,--��_--._ ,�- — � Po�-� . r _ _. _ o��Y � � ` —�--� � �h� � �� � 3�o � � , . � �Environmental Health Specialist :%i� Date: � �� �� , �, � ' DCHD 11/06(Revised) /�b /� /� �u'�� �'- '`� (07'� ��t � !� � . Q'C!`dS 5 F/`vw� S�l•t� � , '�N � � ' , �J' �l't�C.� „ - • . � �Ce��l.�2� .. �, �.` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION �f�►.¢ � J {ti�.�-� r� ,���� �� $-� � �� � C�41 -�'j l�►.v� l..►,r �e! - � , (,� `�G. c�c.r.�. �p bGkSJ � �`�. N�, �.Z 02�, / '' Water Supply: On-Site Well Community Public �/ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 � 3 4 5 6 7 Landsca e sition L Slo e% , HORIZON I DEPTH � Texture rou ('i _ Consistence �j Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence - Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure ' Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION > LONG-TERM ACCEPTANCE RATE % i'�• - SITE CLASSIFICATION: �D��7! EVALUATION BY: �/✓"���'�� � ��QH`��� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: . LEGEND i.an s ane 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 TeSturg ' _ 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 � � . .ONSIST ,N , �1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-Extremely firm 3Y�t __ : � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky , NP-Non plastic SP-Slightly plastic : P-Plastic VP-Very plastic S i ir - , SC-Single grain _ M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic : _ Mineralo�v - 1:1,2:1,Mixed LYntes ` 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 , DCHD OS/OS(Revised) .,, .. ., :.. .., .� '_ =--. . . _ , . �GV`�.Q C� ,� .,. � . ' DAVIE COUNTY ENVIRONMENTAL HEALTH ECTION ' APPUCATION FOR IMPROVEMENT PERMIT(REPAIR) � NAME ���-Q l c� I/�.c��-2� PHONE NUMBER ADDRESS ,!C� �"'t S�c��..F r` �Cx CJI SUBDIVISION NAME / LOT# � � DIRECTIONS TO SITE�a � W � ' I � S�1 t.� ��¢i'r` A Q c,� �•,�,fs_�'ry� S T�Lt£Yl�_ /'-e-c N lt .� � � f Is�t.�. �..��\/ v. DATE SYSTEM INSTALLED �y� NAME SYSTEM INSTALLED UNDER Sh��`Q� TYPE FACILITY � � NUMBER BEDROOMS _NUMBER PEOPLE SERVED 1 � TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING �'l� 1'Tac�r�e+� �_ � o.�.k a.�.� -Q� � f.�•.���1 DATE REQUESTED � '" ` � � l INFORMATION TAKEN BY_�=���1 I �� �j This is to c�rtify that th�iniormaoon provided is eoneet to the best of my knowledys,and that I understand�am nsponaible lor all charpss incurced from this applicatio�. SIGNATURE OF OWNER OR AUTHORIZED AGENT Fim,,,�93