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1078 Wagner Rd � �j d/ , • ' DAVIE COUNTY HEALTH DEPARTMENT U . � Environmental Health Section � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 � (33fi)751-8760 Account #: 990003533 Tax PIN/EH#: 5811-82-8987 Billed To: John James Subdivision �nfo: Reference Name: Location/Address: 1078 Wagner Road-27028 Proposed Facility Residence Property Size: 3.3 acres ATC Number: 4087 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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, Sect' Sewa Treatment and Disposal Systems). THIS AUTHORIZATION FOR WAS ATE RU IO IS�R A PEWOD OF FIVE YEARS. Environmental Health SpecialisYs Signatu • Date: � � CERTIFICATE OF COMPLETION **NOTE** The issuance of this 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 given period of time. � �I . �, No�� � � , � , �� ' �o� . �` �y-�ti �°o• �� ��z.. ���' '���' �',' Ta ►�° •4-- v� ��K � S Septic System Installed By: � Environmental Health Specialist's Signature: Date: ZS � DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT p� , . Environmental Health Section � ��02 �o + P.O.Boz 848/210 Hospital Street � . ; , Mocksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003533 Tax PIN/EH#: 5811-82-8987 Billed To: John James Subdivision Info: Reference Name: Location/Address: 1078 Wagner Road-27028 Proposed Facility Residence Property Size: 3.3 acres ATC Number: 4087 **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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type = #People Z #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 �•��S Type Water Supply��Design Wastewater Flow(GPD) �'� Site: New��Repair❑ System Specifications: Tank Size ��7GAL. Pump Tank GAL. Trench Width �'�� Rock Depth �Z� Linear Ft.y� Other: �����dt��f,h� ��� Required Site Modifications/Conditions: `�?I,t� OrJ �'�f�17�Q, f-�� �{6�hJ�..'��a, �'Y �� �����-+'� I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF f " 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(336)751-87G0.**** •�N�,2c, T(1,;.�rJ�.rl ��►i �2�' � ��p � _ - � �-.�-1�c � �o .�:-�—� .v,1�,r.s�fL. Q--��" � . �,� �,��sS �,� �� � � fi �, � � ,� ►.�Ps�N � � ,.,� �c� , ���o � �� ' � , ,00 ,- ; ,. Environmental Health Specialist's Signature � t"�'; �Date: � S �9 p�`� � DCHD OS/99(Revised) .�p�� . . , . . p � � [� � � � . , � J .' n1�� APPLICATION fOR SITE EVALUATION/IM1iPROVEh1ENT PCRM1UT&AT MAR 1 4 2Q�� ��( � Davie County Health Department C � Environmenta/Hea/th Section j� P.O. Box 848/210 Hospital Street ENVIROh'hiEPJ1ALHEALTH � • Mocksville, NC 27028 DAVIECOUNIY (336)751-8760 ��� � v� �� ***IMPORT1lNZ'*** TFiIS APPLICATION CANNOT BE PROCESSED UNLESS ALI, THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Y': Contact Peraon J��� ��+r3 �l11'1 Y1 � ��i'1'1c�.S � �..�r�a�'ct .lc� �virS Mailing Addresa Q�r, (,� � Fiome Phone �J�-���-�(p �� City/State/ZIP ' � /Y��� U ��� Phone ✓`��1�'` d �j7��/�� 2. Name on Permit/ATC if Different than Above Mailing Address C State/Zip � /�-C � � � 3. Application For: ❑ Site Evaluation ❑ Im rovement Permit/ATC ld�Both 4. system to service: C�ouse ❑ Mobile Iiome ❑ Business ❑ Tndustry ❑ Other 5. Type ayatem requested: L�Y Conventional ❑ conventional modified ❑ innovative • 6. If Residance: # People �Z # nedrooms � �t Bathrooms v2, �ishwasher ❑Garbage Diaposal WWashing Machine ❑Hasement/Plumbing ❑Baaement/No Plumbing 7. If Businesa/Industry /Other: verify typa # People �k Sinks # Commodea � # Showera $ Urinals 1k Wator Coolers IF FOODSERVICE: � Seats Estimated Water Usage (gallona per day) 8. Type of water supply: LJ County/City ❑ Well ❑ Community . 9. no you anticipate additions or cxpansions of tlle facility tliis systcm is intcndcd to scrvc? �Ycs C3'I�io , _ _ If��es,�vl�at typc? ***IhIPORTAN7"'**CLIENTS A1UST C0�11PLETE TIIG REQUIIZL•D PROP�RTY INFORII�IATION REQUGSTGD BELOW. Githcr a PLAT or SITE PLAN h1UST BESUBMITTED Uy thc clicnt �viti�T111S APPLICt1TION. Property Dimcnsions: �, 3 _�C'_-��'`� IVRITE DIR�CTIONS(from Mocicsvillc)to PROPGRTY: � T�a ocr,��rirr: �� � 5�11 — �'�- �g�'� L�Q% �/. /��'��>;� /_.�-��� C'l. /�U�; Property Address: Road Namc � � �� L�'��-`�'� �� �F�i` �a�� l_��=�i1r�' /�✓�,-�-�/i O��/�Y', . , � _ City/zip ���U t t..�.� ��c� �/ ��r�n��L��=��-f _33l 9C�%-l-?r�.�`��� If in�Subdivision providc information,as follo�vs: Namc: Scction: Blocic: Lot: Datc liomc corncrs Aaggcd: e� '/��S Tl�is is to ccrtify ttiat tlie information providcd is correct to tlic best of my knowlcdge. I undcrsta�id tl�at any permit(s) issucd hereafter are suUject to suspension or revocation,if the site plans or intended use cl�arige,or if tlic information ` subn�itted in tliis application is falsified or cl�anged. I, nlso,tiuderstand tliat I nur resf�ousrGle for nl!clrarges inctrrrc.�r1 frunr t/ris application. I,l�creby,givc consent to thc Autl�orized Rcpresentativc of tl�c Davic Cowity IIcalth Dcpartmcut to cntcr upon aUovc describcd property locatcd in Davic County and o�vncd by to conduct all tcsting procedures as ncccssary to dctcrmine.thc sitc suitabilitJ,, ' DAT� ���/`� / C�.� SIGNATUI2� i���. :� � _ � -.-, ,� ,� z/�t�' . . � . TIiIS AIZ�A MAY BE US�D rOR DRAWING YOUR SIT�PLAN(Includc all of tl�c follo���ing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). i Sitc Revisit Chargc ��3 , Datc(s): (;�t�.L fti,�,`L'�" C� -�.�' � � ��� ` � n ! �' � Clicnt NotiIIcation Date: �,, � � ��n�,��; �Z �IiS: l0�0 NG H�`t'k'0j"� Sign givcn �-��llt%`�C,v Account No. ��3 3 Rcviscd DCHD(OS/03 Livoicc No. - / �7� 3 ,_.�c.�-� ;��F �l �t'1� �f� � �;�.-�- ��—°.,.,Q'� - •� .r�.,P,.w �vr �c�c rra�r�1T . � � • 'EO Ih r�cE �aetinn5tQ1 • N b t tf�T ME M27�(E�1f _AO'Q/"� � �� - :� C�w��tt1'. ��'A4L�!� � � , • �t� o�c,��E xu, sfi�E'rs. 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CONSISTLNCI: l!'Ioist ' VFR-Very friablc FR-r'riable FI-Firm VPl-Vcry firm EFI-Extrcmely Crm .� � NS-Non sticky SS-Slightly sticky S-S�icky VS-Vcry Sticky � NP-Non plaslic SP-SlighQy plas�ic Y-Plastic Vl'-Vcry plastic 't r c rc ' . 'SC-Single grain M-Massivc CR-Crumb GR-Granular ABK-Angular Ulocky SIIK-Subangular blocky PL-Platy PR-Prisq�atic �incr�loev 1:1,2:1.Mixcd � Notes ' Horizon depth-In inchcs Dcpth of fill-In inchcs . Rcstrictivc horizon-Thickncss and inchcs from land surfacc Saprolitc-S(suitablc),U(unsuitablc) ' � � Soi[wctness-Inchcs from land surface to free watcr or inchcs from land surfacc to soil colors with cl�roma 2 or lcss ■ ■ ■ ���/��������/� ■�������������\������������i . 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Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally,please have this parcel surveyed and locate the property corners prior to making this request. If you have any questions, feel free to contact this office at 751-8760. Sincerely, - Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s)