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2111 Cana RdAccount #: 990002692 Bilied To: James Latham Reference Name: Proposed Facility: Residence ATC Number: 3435 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mceksvilte, NC 27028 (336)751-8760 Tax PIN/EH #: 5832-33-2689 Subdivision Info: Location/Address: Cana Road-27028 Property Size: see map 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: G/ 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. / �� �/,--� C��` G���� ��� x��{'�� d� Septic System Installed By: �; o ' �r:� c l� � �" �i�"!/J'Jor-�' Environmental Health Specialist's Signature : �]//� Date: �J`�� �'� �— DCHD OS/99 (Revised) �� • DAVIE COUNTY HEALTH DEPARTMENT `�• ' � Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33fi)75 ] -8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002692 Billed To: James Latham Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5832-33-2689 Subdivision Info: Location/Address: Cana Road-27028 Property Size: see map / �`2 ,�� U� `� ATC Number: 3435 **NOTE** T'his ImprovemendOperation 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 vZ�s Dishwasher: 1a Garbage Disposal: ❑ Washing Machine:.� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size Type Water Supply �,{��� // Design Wastewater Flow (GPD) c��i � System Specifications: Tank Siz% GAL. Pump Tank Other: Required Site Modifications/Conditions: Industrial Waste: ❑ Site: New.O�Repair ❑ GAL. Trench Width��� Rock Depth �XLinear FtSJUv IMPROVEIV1ENT/OPERATION PERI�'IIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33()751-87G0.**** Environmental Health Specialist's Signature: Date: ✓ � DCHD OS/99 (Revised) ';.:��c��d�]� ,��r , ' APA 4 2003 :J ►- ENVIRONMENTAL HFALTH DAVIE COUNn �x,�� � I� ish�� � C������ IN FOR SITE�EVALUATION IMPROVEMENT PEIiMIT & ATC�� ��~t r� Davie County Heal h Department ,33�� ��� zU 3 l Envi�nnmenta/Hea/th Section P.O. Box 848/210 Hospital Street �' Mocksville, NC 27028 )"� l � (336) 751-8760 �� ��'� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFOR2�ITION BUI,LETIN for instructions. i. xame to be silled J�!Y1 cs ,f�'J • /� a�^ � h�( Mailinq Address /� 9 �c.S /-a c� ���"� �� City/State/ZIP �6 �,.rY, f �i� �l�G � 70�8' 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person Home Phone �.5� Sy-?.3 Business Phone City/State/Zip 3. Application For: IK �ite Evaluation ❑ Improvement Permit/ATC �Both 4. system to service: �House ❑ Mobile Home p Business p Industry ❑ Other 5. If Residence: # People �_ # Bedrooms ,� Cy'DishWasher C3�Garbage Disposal P�Washing Machine C+t�Basement/Plumbing # Bathrooms � fJ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks k Commodes N Showers # Urinals # Water Coolers IF FOODSERVICE : # Seats Estimated Water Usage �gallons per day) 7. Type o£ watar supply: ❑ County/City 17 Well ❑ Community e. Do you anticipatc additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Yes 6'l�io ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the clicnt wit6 THIS APPLICATION. Property Dimensions: 5 � � �h �� Tax Office PIN: # ss 3.� 3�a� 89 Property Address: Road Name C� /�dl�- City/Zip If in a Subdivision provide information, as follows: lYame: Section: Biock: Lot: WRITE DIREC'I'IONS (from Mocksvill�) to PILUPGRTI': �a'/ /Y f� G� r!w /2 � � /r�.�/el o h L�n�. �� %I-o�}je.K 7" y iS � Si�- f� o/ 0 � ot/r Gh : �3 o h �� Datc Property Fiagged: T6is is to certify t6at t6e 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 intendcd usc change, or if the information submitted in this application is falsified or changed. I, a[so, understa�td tlrat I am responsible for a!1 clrarges iircurred fro�n this application. I, hereby, give consent to the Authorized Representative of the qavic County �calth Department to enter upon above described property located in Davic County and owned by� /L�.+-�.Q .S t.-� :�C n-� to conduct all testing procedures as necessary to determine the site suitability. DATE � �� l/3 SIGNATURE • 0 THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Siic 12evisit Charge Date(s): Clieni Notification Date: GHS: Revised DCHD (07/99) Account No. � `- � Z- Invoicc No. � � Z � ��� ::`��� .. � � k. ..� � �� � i '� L,���;���±j�` � �� �y�y'�`� Le a, �. 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'�...fi, (2.67A) 2911 � APPLICANT INFORMATION Account #: 990002692 Billed To: James Latham Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5832-33-2689 Subdivision Info: Location/Address: Cana Road-27028 L Property Size: see map Date Evaluated: !�L� �3 Water Supply: On-Site Well �/' Community Evaluation By: Auger Boring ' V Pit FACTORS Landscape position Slope % HORIZON I DEPTH Texture group Consistence Swcture Mineralogy HORIZON II DEPTH 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 �� ��� '� �/!!�J LONG-TERM ACCEPTANCE RATE I -'� I � SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: � REMARKS: Public Cut 3 4 5 6 7 EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position R- Ridge S- Shoulder L- Lineaz 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineralogv 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 OS/99 (Revised) ■ ■ ■■■ ■�■ ��■ ■�■ ■�■ ■�■ ■�■ ■�■ ■■■ ■■■ ■■■ ■�■ ■�■ ■■■ ■�■ ■�����■■�■��■�■����■ ■��■���■�■■���■■�■�■ ■�������■�■��■������ ■■��������������■��■ ■�O■�■■■�■��■��■�■�■ ■�����H■���■�IH■ ■�■■�■���■����I■�■ ■���■����■�■�11��■ ■���■■�■��■�■11��■ ■■���■����■���.:■ ■��■��■������■��■ ■���������������■ ■��■���■��■��■■�■ ■������������■��■ ■���■����■o■��■�■ ■�■■�����■����■�■ ■��■N����■�����■ ■�■■■�■��■�■■�■�■ ■��■���■������■�■ ■���������������■ ■�■■��■�■■���■��■ ■�■�■�■�����■���■ ■���������������■ ■ ■■�■ ■�■■ ■��■ ■��■ ■■�■ ■��■ ■���■ ■ ■ ■���■��■�■�■ i■��■■����■■ ■����■��■��■ ■���■�����■■ ■�����■����■ ■�■ ■��■�■ ■����■����� ■��■�������■ ■�������■�■■ ■��■�■�����■ ■����■■����■ ■■��■������■ ■�������■��■ ■��■�������■ ■����������■ ■■��■■��■��■ ■����������■ ■��■�������■ ■���■��■■��■ ■■��■��t���■ ■����������■ ■���■��■���■ ■����������■ ■��t■��■■��■ ■������t���■ ■��■■������■ ■���■������■ ■���■�■■��■■ ■������■��t■ ■�����■����■ ■■��■���■��■ ■������■��■■ ■���������■■ ■���■���■�■■ ■������■■��■ ■■���■■■■�■■ ■�■ �� ■■■ ■�■ ■�■ ■�����■ ■�����■ ■�����■ ■����■■ ■�■���■ ■�����■ ■���■�■ ■■�■��`i ■�■■��■ ■���■■■ ■�����s ■��■��■ ■��■�■■ ■�■���■ ■�����■ ■��■��■ ■�����■ ■�����■ ■��■��■ ■�����■ ■ i i ■ i ■ ■ ■ ■ ■ ■