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348 Cornwallis Drive Lot 11 NORTH GAR01INA Davie County Health Department 336.753.6750 April 21, 2016 John Maines 348 Cornwallis Drive Mocksville,NC 27028 Dear Mr. Maines � "` e Lof, After receiving your application for expansion of the septic system at 348 Cornwallis Drive, the permit was pulled and reviewed. A site visit on April 20, 2016 revealed a well functioning septic system. The original permit was written for 3 bedrooms with 500 feet of septic line with 18 inches of gravel. The original soil LTAR(long term acceptance rate) was 0.3 gal/day. The soil conditions do not appear to have changed. Considering that a 4 bedroom house is designed for 480 gallons of flow, divide the 480 gal/day by the 0.3 loading rate and you have 1600 square feet of septic. Divide the 1600 SF by 3 feet to septic line length of 533 feet. The current septic is equates to 750 of line based of 18 inches of stone. After reviewing the site,permit, and consulting with our regional state soil scientist, the current system is sufficient to support a 4 bedroom system. Sincerely, n /- �7 - Robert M.Nations, REHS CPO Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville,NC 27028 (336)753-6780 mations@daviecountync.gov q 11836 IC�' C� 4 0UN� 210 Hospital Street I Mocksville, NC 27028 www.DavieCountyNC.gov •t r cvitpION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC ' Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: 7 Site Evaluation/Improvement Permit C Authorization To Construct(ATC) ❑Both Type of Application: ❑New System ❑Repair to Existing System qurr�xpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name �� C�^ /,VG Contact Person Address G o/ =vi*/b 5 V.- Home Phone 3 L 9/Sf G 7 City/State IP /y e- -7-7;ASr Business Phone Email J»A;Aj 61-/1" QZ2 2 MAo/. ZUrL.Email: Name on Permit/ATC if Different than Ab ve Mailing Address • City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# 1 (� U 0/ 1 Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes No Does the site contain jurisdictional wetlands? _Yes r6 No a A1 UP 9 Are there any easements or right-of-ways on the site? _Yes No Is the site subject to approval by another public agency? _Yes No Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool I IYes INo Basement: :]Yes ❑No Basement Plumbing: IYes DNo 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: Xonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:-WCCoumy/City Water ❑New Well ❑Existing Well 7 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes ❑No 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 f 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I unders iat I am responsible for the proper identification and labeling of property lines and corners and locating and flagging ors mgt ou /faci ity location,proposed well location and the location of any other amenities. P o or wner's egal representative signature Site Revisit Charge py Date(s): Client Notification Date: Date EHS: Sign given I Yes❑No Account# � Revised 11/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section U P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001219 Tax PIN/EH#: 5841-05-7725 Billed To: Jimmy Summers Subdivision Info: Pudding Ridge Lot# 11 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3177 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 WASTEWATE ONSTRnUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ,�j 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. t/ elf S Avg Septic Syst Installed By: Environmental Health Specialist's Signature: �Gy � Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 1 l z 3 tl (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001219 Tax PIN/EH#: 5841-05-7725J�� Billed To: Jimmy Summers Subdivision Info: Pudding Ridge Lot# 11 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3177 **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 c� Dishwasher:RK Garbage Disposal: ❑ Washing Machine-2"" 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-121'*�Repair❑ System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width,;�_'y&_ Rock Depth J9 Linear Ft�PO Other: Required Site Modifications/Conditions:c_� 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 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: �� Date: ` P � DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department O Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 J�N Anlm ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLE ALL Zp QUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN ink "� ns. 1. Name to be Billed GY Contact Person � Mailing Address 0 C._ Home Phone /�j%(JQ- Vp' City/State/ZIP (y 4' 6 � Business Phone c.J 9/"- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation mprovement Permit/ATC ❑ Both 4. System to Service: -use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People _�� # Bedrooms # Bathrooms _ Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes o If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. ) Property Dimensions: ,�/./r tr r- WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # Property Address: Road Name CyG'-N w /��L Dr 0 c. city/zip d If in a Subdivision``provide information,as follows: Name: V eJ VLL Section: Block: Lot: —L� Date Property Flagged: 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 plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davi County Health Department to enter upon above described property located in Davie County and ` to conduct all testing rocedures as necessary to determine the A a suitab i DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PL (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and se locations). -Site Revisit Charge !-::D Date(s): Client Notification Date: EHS: Account No.: 1 2 Revised DCHD(07/99) Invoice No. � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ro e DATE EVALUATED fe ADDRESS PROPERTY SIZE /Iff e PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit c/ Cut FACTORS 1 2 3 4 Landscape position Sloe % •t/ HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC Consistence r Structure 'T 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 RATEI SITE CLASSIFICATION: �'/� EVALUATED BY: //Z LONG-TERM ACCEP ANCE RATE: �� OTHER(S) PRESENT: REMARKS: EGEND 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 r:lay 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-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 ;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 i • vfi r � � �'4, • � �' ,X ..t is, 4�A ,irk-; �• i ., a V a 1' s` , c aM \"Y� S": •ate � '/ � n�i `� ,� F> / isv. y '``'�.