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343 Cornwallis Drive Lot 21 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,- P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900093 Tax PIN/EH#: 58416-05-1846.21 Billed To: Shelton Construction Services Subdivision'!nfo: Pudding Ridge Lot#21 Reference Name: Location/AddresP-Zomwallis Drive-27028 Proposed Facility: Residence Property Size: 1.009 Acres ATC Number: 2778 **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 #Bedrooms ? #Baths Dishwasher:41 Garbage Disposal: Washing Machine: 21/ 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�� Site: New El'-Repair❑ System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width J`".Rock Depth_ZCS�`Linear Ftae Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)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 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** ,16- Environmental Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900093 Tax PIN/EH#: 5841405-1846.21 Billed To: Shelton Construction Services Subdivision Info: Pudding Ridge Lot#21 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 1.009 Acres ATC Number: 2778 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 WASTEWATERXONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: , . Date: ��`GI CERTIFICATE OF COMPLETION **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.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. Iq i� Septic System Installed By: > Environmental Health Specialist's Signature: Date: 16 DCHD 05/99(Revised) i p P LI TION f0t SITE EVAIl!ATIONjIMPRO!'f.IIENT PERMIT&ATC avie County Health Department nvirmMental Health sawan AR 9 a I Box 848/210 Hospital street ` Mochsville, NC 27028 ENVIRONMENTAL HEALTH (396)751-8760 DAVIE 7n'=1MTXON *IHBGRTAN?*** THIS ION GINNM BE F===D Manes ALL THe ReQUIRaD 18 BROVIDEDL. Refer to/the INIPOR WXCN BULLeTIN for instructions. / 1. fume to be Billed _ TV �o- •1 T-- - Contact Parson Mailing Address /'2 S-7 u S 1 J (,`{ L) Rome vhone City/state/RSP 1'77o c-K s %l�_ . `J.G . Z-7 O Z Business Phone / S - 2. c' 2. Name on Permit/&TC if Different than Above Mailing Address City/state/sip y. Application For'..40111te evaluation Zmprovemaat Permit/= 0 Both 4. system to services M-11ouse O Mobile Homs O Business O Industry 0 Other S. If Residence: # people �_ # Bedrooms 3 Bathrooms tP16L-ehwasher CHNZ3age Disposal 11-MOSing Machine O Basement/Plumbing O BasementMo Plumbing 6. if Business/Industry/Others specify two # People # sinks # Commodes # showers # Urinals # pater Coolers It I'Ot)SZMCR: # Seats estimated Mater usage (gallon. Pw fir) 7. Type of water sugply: EFICO-Unty/City 0 Well 0 Community e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yea D-Adv 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: r U () '7 WRITE DIRECTIONS(from Mocksvllle)to PROPERTY: Taz Office PIN: # t� 6:5 ,:jE7-y e 4-, F—,- ,I. Property Address: Road Name� o r-- ` l &:J �-a -� — , Q •4 City/Zip �'r/1s`Xs�:1Ic 270Z,S' ; _ � .� •� • �� r � If in a Subdivision provide information,as follows: Name: Section: Block: Lot: I Date Property Flagged: 'V C This Is to certify that the Information provided Is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation,If the site pians or Intended use change,or If the Information submitted In this application is falsified or changed. I,also,andernand that I am responsible for all charges incurred from this appiicadom I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property looted In Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 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 Charge Date(s): Client Notification Date: d V ERS: V /'7-7 ' Account No.------------- 3 Revised DCHD(07199) Invoice No. $ V DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME __ /� rDC' DATE EVALUATED ADDRESS PROPERTY SIZE �dIG PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 4- ! Texture group Consistence Structure / 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 SITE CLASSIFICATION: EVALUATED BY: x LONG-TERM ACCEPTANCE RAT OTHER(S) PRESENT: REMARKS: Q N •7 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 Moist VFR-Very friable FR-Friable FI-Firth 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 ,3C-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 DCHD(01-901