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261 Alvarado LnS � '._� . ---1 • Account #: 990003972 Bilied To: Delia Alvarado Reference Name: rces ATC Number: 4394 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street n� Mocksville, NC 27028 �� (336)751-87G0 �I �'' b � Tax PIN/EH #: 5769-20-8995 Subdivision Info: Location/Address: Cornatzer Rd-27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 CONS RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: �� Date: �G��� � CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improverr has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function given period of time. ��� � + �,.., �,- 2� � �r �-I� ��1 �'K ��r� � � T « Pv�P co—�z Septic System Installed By: Environmental Health SpecialisYs Signature : DCHD OS/99 (Revised) � �� �� nt/Operation Permit atment and 'sfactorily for y � ��� � F ����— v � / , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section i�� � '^ P. O. Boa 848/210 Hospital Street Mceksville, NC 27028 (33G)751-87C,0 Account #: 990003972 Billed To: Delia Alvarado Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5769-20-8995 Cornatzer Rd-27028 See map ATC Number: 4394 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHOWZATION 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: � Garbage Disposal: ❑ Washing Machine:.� Basement w/Plumbing:�1 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply r� Design Wastewater Flow (GPD) ��C7 Site:,,riQ w� Repair ❑ System Specifications: Tank Size`� GAL. Pump Tanklc�l5 GAL. Trench Width�'� Rock Dept /}�� Linear FtC�� Required ite Modificat 11�1PR0 Eh1 NT OI FINISH D AD . system twee 8:3 a. . �� � �j� C�r�� � �� Other: (� ... .. . 11/ :RAT[ON PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) �F 6" BELOW ***NOTICE: Contact a representative ofthe Davi County Health Department for final inspection ofthis . to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on he day f installation. Telephone # is (33G)751-87G0.**** �� ��� �,�,/ ,y� l�.l ���� � �� p � ����� �1,� � � ! �� �� �-"�--� �' � � �� �daD�'3� � � ���s�r,� iy .1-�- ' Environmental Health Specialist's Signature: �i%� �"/ 2� DCHD OS/99 (Revised) Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760/ Fax (336) 751-8786 June 29, 2006 Ms. Delia Alvarado 1208 Cornatzer Road Mocksville, NC 27028 Re: Site Evaluation/IP Tax Pin #: 5769-20-8995 Dear Ms. Alvarado, As requested, a representative from this office visited the above site June 20 and 22, 2006 to perform a site evaluation. 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. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Serve: , �LLS� Wastewater Design Flow: ��� System Type: ,❑Conventional �Accepted ❑Innovative System Location: C.F/��%i ��� �d Site Modifications/Permit Conditions: Environmental Health ps-i.p.letter 2/06 ❑Alternative ❑Other Valid: �3'Years ❑No Expiration � � � Date HF�� OR SITE EVALUATION/IIVTPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section �� � � P.O. Box 848/210 Hospital Street ��� % �� �5� ' Mocksville, NC 27028 l J`%v n.� ✓ t�� Gv � (336)751-8760/ Fax (336)751-8786 � f �C � %,`O� �yVIRO �COUt�TI ( '�/ Application . ite Evaluation/Improvement Pernut ❑ Authorization To Construct(ATC) �h� � ***IMPORTAN7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � WiV�/QC{UQ." �QNf �A,�� � 3��}' �j (�D Z �� � �` I 5��.� Name to be Billed _ �� G, �V (` C�,� � Contact Person� �� ��,�,,-� �, � - -� Billing Address n C'_Q�,� ��� Z�:Y R�_ Home Phone ,�'—� - « City/State%ZIP � � N ' "a,'l � Business Phone � ' G�..- `% f ' Cz Name on Permit/ATC if Differe�zt than Above Mailing Address S C?�'mC G.S C�bCv PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. � � 7( (Pernut is valid for 60 months wit site lan, no expiration with com lete plat.) V Street Address 1'��l Qj�� •Sik��Z�� City � � Tax PIN# Subdivision Nam '� �': (��+�.\`.c�.�\vcr,,.�,�6.ection/Lot# Lot Size llirections To Site: „� F_G�`�� NT'. z r-,n I,c�-�a- n,h ('• c1c��r,-..L �c� � c��fJ:1 � Date House/Facility Corners Flagged J--X �--(� (�� If thc answer to any of the following questions i§ "yes", supporting docunientation must be attacl�ec;. t�-e there an existin wast t t th 't � �' Y �1 ,:-_-_-� --- . �' '„, , � � . d-- ' � ' ��'kf��' rt� �'L�� �, , , '. i . y g ewa er sys ems on e si e. � es o . Does thc site contain jurisdictional wetlands? ❑Yes Cr� •. .' Are there any easements or right-of-ways on the site? ❑Yes C�Io ' :�� °;; ��" Is the site subject to approval by another public agency? ❑Yes �o ' ''� �� Will wastewater other than domestic sewage be generated? OYes C�1P4�o . �'.�'? IF RESID # Feople _ Basement: ---- ----- -- ;d FILL OUT THE BOX BELOW ' L.'� �' � # Bedrooms es ❑No Basement Pl # Bathrooms � GuYde�� Tui ,'�1�'h�. l;, ;c�f 't%�r , :—do � � �'�'es ❑No � i. � � , }`, ' I TF NON-RESIDENCE FII,L OUT THE BOX BELOW ' Type of Facility/Business � Sinks _ # Commodes I�stimated Water Usage (gallons per day) FOODSERVICE ONLY: # Seats Total Square Footage of Building___ _i___ m Pcoplc ____ '_'';,:'' �. ,� �� # Showers # Urinals __ _ _ �- � # (Attach documentation of similar facility �vai��r con.;umpti�nl i, .."-___._._.... _....'.."'_.""-J Type systemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other _ ' Water:>upply'1'�pe: Q�ounty/City Water ❑ New Well ❑Existing Well ❑ Community Wcll Do you anticipate additions or expansions of the facility this system is intended to serve? �s ❑ No If yes, what 1}q;e? _�'y��y�_��Q,M _ _ This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that 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 �ubmitted in this application is falsified or changed. I unclerstancl that I am responsible for all charges incurred fi•om tliis application. i hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to conduct necessary insrectiovs to deternune compliance with applicable laws and ru es on the above described propem� located in Davie County and owned by�� _� � rL�;� ��- � Q.\� L, ��� ��5'� ���i .1 — �� a. _ �� — �owner's or owner's legal representative signature S — C�C>--� �� lla�� ---- – Site Revisit Charge Date(s): Client Notification Date: EHS: Si��n given CiYes No Account # ��qZ�i Revised 2/06 � Invoice # �' � 3_�_ DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section Soil / Site Evaluation APPLICANT INFORMATION Account #: 990003972 Billed To: Delia Alvarado Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5769-20-8995 Subdivision Info: Location/Address: Cornatzer Rd-27028 Property Size: See map Date Evaluated: c�,¢d.��` �� Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit � FACTORS 1 2 3 Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture eroun Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: � 4 Public %� Cut 5 6 �ar���s����■ �il/J�l�1���� �r.1���r�'��.1�i �r�►���r�r�r:�� �'r�'-��r�'��� .FJ'�����.�������� ���ii�����i�.�■ r 1 � 7 _ � � � f-- � - •- � --- � . EVALUATION BY: /!/i!� OTHER(S) PRESENT: ,���'A��"�" (9���'�/t�rd REMARKS: _ CG (` D�l� � D .R� ��`� J�79t� i 1k�� Landscape Position ��•� /� �//�'r�G ��.� LECs��I•-- �///'�1t�-�%�-� R- Ridge S- Shoulder L- Lineaz slope FS - Foot slope N- Nose slope � CC - Concave slope CV - Convex slope T- Tenace FP - Flood plain H- Head slope T�cturg 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 1l�ist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm � NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky , SBK - Subangular blocky PL - Platy PR - Prismatic MineraloQv 1:1, 2:1, Mixed LYQt�S 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 OS/OS (Revised) � (14.26A) 3324 -�_ �li (t1.37A1 5016 ' « i ,.a- I 3546 0 � B477 I s» (5.16A) 5005 , 1.344A \ - 8843 -� � e+� �' ,�J �. � + �,� � � �: � ' �� ,, �� �.} �; _ ,S � � G .�'� � ��� �'��� `� �� �� /% �) (5.34AI •.`� �. 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