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1137 Cornatzer Rd'• , � ti . � ,. . ,, , . , Account #: Billed To: Reference Name: Proposed Facility DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �.� . �� y P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 990002888 Tax PIN/EH #: 5769-21-5016.DA Ignacio Alvarado Subdivision Info: Delia Alvarado Location/Address: Cornatzer Road-27028 Residence Property Size: 112 acres ATC Number: 3833 , � �J����,� i Gc:S,� 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 buildin permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section OE�-Sewag Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTE R-C-A T TION V LI A PERIOD OF FIVE YEARS. .-- Environmental Health SpecialisYs Signatu : Date: Q � CERTIITCATE OF COMPLETION **NOTE** The issuance of this Certificate of Com�letion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance wit Art e o G.S. Cha er 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in N(� be ak a gu an e t t th system will function satisfactorily for any given period of time. � � .; � . $ �- °, z` � � � ,� , ��� � ' �: cw y �i �"--�� � � ,--�15T � `� g�� Qv.J V�dL1l��' , � sa.� �. ��.�-� _ � --��� 1�-�. Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) �,� �a�..�ci� 1 2Q O . � Y , � , . � > DAVIE COUNTY HEALTH DEPARTMENT ' . Environmental Health Section P. O. Boa 848/Z10 Hospital Street Mocksville, NC 27028 (33G)7S1-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002888 Bilied To: Ignacio Alvarado Reference Name: Delia Alvarado Proposed Facility Residence : . C� Tax PIN/EH #: 5769-21-5016.DA Subdivision Info: Location/Address: Cornatzer Road-27028 Property Size: 112 acres ATC Number: 3833 **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 �'��1��� #People % #Bedrooms �D #Baths lG � � Dishwasher: d Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: �Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply ��i— Design Wastewater Flow (GPD) ?z� Site: New � Repair ❑ �o rr ! System Specifications: Tank Size J��GAL. Pump Tank GAL. Trench Width �lv Rock Depth i2 Linear Ft.C%E7� Other i I�1:T r�L-�..1 a'7�.JF, �UV � fAL.�/� Required Site Modifications/Conditions: �'���-i— �� C.���2,�� � Il�'IPROVER'IENT/OPERATION PERMIT FINISHED GRADE. ****NOTICE: Cont� system between 8:30 a.m. to 9:30 a.m. or 1:�1E �}I� '��it�.�� �,�,ti..t�-- � � � �-i�;,S ��^ ISS�'1� Environmental Health Specialist's Signature: yOUT A .rep sen� 0 13Q p, Na2�y � OVED EFF U'N FI T ` the D vi Co n He lth on e da f i st lat n. Te ph \ � :. , � . r :� t�f� R�-�'� R(S) IF C " BELOW \for final inspection �f this I�. (33 C►17_51-87G0. * * * LiJv DCHD OS/99 (Revised) � � . lJ �C� Ll�� . ., �i0/;05/2004 03:06 3369225719 ALANFLETCNER PAGE 02 1 ' � ' Afvarado �..�*� 1 37 Cortwhrer Road n'.�; pAocl�aWe payie NC Z7020-7135 �.� ` Csntr�l Garolh�8ank ' � � 1 i . . = �t !�. -� . . ..1�. _ e� .:.,,;T�_...._.3,.�}f�; � �,"•; •t. , ' ' . ., • , ;';° `r � -• ' ' � � � . . , . � � ' .ij+ � ! + ir�� ` �• � ' , • I r' � ,. . h�s ►� � ,;� � . nji �� -Tp ��P � il�} � � _ � 2)2J i * � . � � � , tr`� � r.-- —ii;;�^.--..�..��.. . . i�, t � • .I 1 � ' � � ' � � �J � i � .�. ,l�i � l�I . l,�i'' , • � + �(►t . ' 'if `+. 8 � 1��• lt,�� ;:.; .' ��. � �� �- :� • ' N� ' l r��.f ���,; • �,%�?�� ��t� r 1` .: ••... � " . •� -... .'�G�.,n -'.r• � . . . . '�� r� _ � . . . .f" . _. � „ �. �. � = �•Un/ '�,. �� �JS� » ��, - �s;� ,� ..., ,. ., ��.�� A' , !. . . i .�� /u.��f:�=" � '"+. , c';+ e�U(rtu . . ������ •l.i� , ti. ' t`�` . „ ;,.j�-, ..r�• .; �.. . ^ �r 0 DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section � �" �/� � P. O. Boz 848/210 Hospital Street � Mocksville, NC 27028 ^ _;/ � �, -Z �., (336)7S l -8760 �-�`'" IMPROVEMENT/OPERATION PERMIT Account #: 990002888 Bilied To: Ignacio Alvarado Reference Name: Delia Alvarado Proposed Facility Residence Tax PIN/EH #: 5769-21-5016.DA Subdivision Info: Location/Address: Cornatzer Road-27028 Property Size: 112 acres ATC Number: 3833 **NOTE** This Improvementl0peration 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ' l�l�— #People ? #Bedrooms lo #Baths �D� � Dishwasher: � Garbage Disposal: ❑ Washing Machine: u Basement w/Plumbing: u BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �- ' � Design Wastewater Flow (GPD) �� Site: New � Repair ❑ System Specifications: Tank Size �c��',AL. Pump Tank �-J``�'iAL. Trench Width �� � Rock Depth ���� Linear Ft. -1 �t other: ���SSI�' % r�,.! iG�'� , Required Site Modifications/Conditions: �*-SS I1�IPROVEh1ENT/OPERATION PER1191T FINISHED GRADE. ****NOTICE: C� system between 8:30 a.m. to 9:30 a.m. or 00 Ci7 P���C. MAa ��-��% %..�•� �S '�i (�(' �11��J � Environmenta Healt�h Specialist's Signature: _ C���2 1�..=� � 5 C,. IL,..�-� 1 C,27 LQO1w�.+',L�! PPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW ja�e��f'i1'I�D�ie.C�unty Health Department for final inspection of this �e�e-day�installation. Telephone # is (33(►)751-87(0.**** � " i' ' � � � �� �� ��� � � f DCHD OS/99 (Revised) �� Te 1.�%0�� Lt.�L �4�'T� �.�� ��►.��' � ' '. � � 1 •. • • • • � � O �.I . � PP D 2 g �� ��j� FS��DAV1�� � D� n FOR SITE EVALUATION/IMPROVEM1tENT PERM1IIT & ATC Davie County Health Department Environmenta/ Hea/th Section 0. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 *+��ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. l /1 � 1 1. xame to be Hilled �-Q, V Cl �,,VC�—Y" C•. d0 Contact Person �`.�i c. '� � V CMr'�..c� � t v /� Mailing Addreas��I l C'�,i�1�711 �V'� � Home Phone , _��n—�� % � —tc��� � City/State/ZIP �('� J'�(�U 1� 1TNSo �/�.� .l Busineas Phone ,"��Q—� g� —��� �� 2. Name on Pesmit/ATC if Different than Above Mailing Addresa ���vn�r,p G, S('„�jllQ City/State/21p 3. Application For:��,,,Site Evaluation Zfiprovement Permit/ATC ❑ Both 4. syatem to service: y�r rsouse ❑ Mobile Home ❑ Business ❑ Industry � Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ! # Bedrooms �_ # Bathrooms � —T — 19�Diahwasher ❑Garbage Diaposal ��shing Machine 7. If Buaineas/Industry /Other: verify type # Commodas # Showers IF FOODSERVICE: # Seats L7Basement/Plumbing # People # Urinals ❑Basement/No Plumbing # Sinks # Water Coolers Estimated Water Usage (gallons per aay) s. xype of water supply: ❑ County/City f� ell ❑ Community 9. ao you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes .❑ No If ycs, �vhat typc? ***IMPORTANT'�** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED F3ELO�V. Either a PLAT or StTE PLAN �YiUST BG SUBMITTED by ti�e client with THIS APPLICATION. Property Dimensions: �\� i� (� C/�-'L � WRITE DIRECTIONS (from Mocksviltc) to PROI'ERTY: Tax Office PIN: # S� �+J !- v2�—�O/ �o< � A Property Address: Road Name �(`�Y'� �(1(',; �Z f'N,�{�; �.. 6 n C o(' 2-22 1�� - n�' /t� �.e� � . City/Zip K��C'N�rn C�, . ��SS �' /u.��o� ' � e E.� ('�e �1 e� s � If in a SuUdivision provide inforniation, as follo�vs: C l` c,��-. Name: Section: Block: Lot: Date home corncrs flagged: l 3� d Tl�is is to certify ihat the information provided is correct to tite best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if tlie site plans or intended use change, or if ttie information submitted in this application is falsified or changed. I, also, ru:dersfand tltat I am responsiGle for a[l c/iarges i�icurred fruui tlris application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth De{;artme �t to enter upon above described property located in Davie Cowity and owned by �;y�C�(�,� ���f I�r� ,`)��Ja�Y'C1�� to conduct all testing procedures as necessary to deternune the site suitability. DATE � — c� C'1—�'� �1 SIGNATURE �i`� � THIS AI2EA MAY BE US�D FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locatio�is). . \` Ib�o� ���►.�io� �n✓.� ��-G ��r�-�Qs ��� z�h��;� . /� �-1 � S, p�, +. � (/q`/�r�,l°"i�- o� �,���� \ ` , a� �� 2��,,�. v �, �/ ��,,-' �� o�, .�,�j�`.. �.�`6 � . . � . � ��' . � � r, C� Sign given � `� r n `J � Account No. � � � �, /1 � � � � Revised DCHD (OS/03 � Invoice No. ' vi �� , O� � Date(s): �''�- ' . , fr f,., . . . ',�,;f; ; .. r.. � �,- .. • ', � ,. � ,t ,..' '�. , . f�' , � � � ;�M1M1 . f ,y ,�' }; . �, _ {� 4..T 4 rsyM�� , ''; � .; i �' � > - , ;' � � __ ���..:.. . �, - %, _ ; � _ � � ��� ' 8�� ' 9�� ' «.,, � ; ., . � � � � � � '�_ � �. � � � �--�_. _ � � II� ' I5� � `, � `� � � �. �s��,. 9�z� .�. ��z� . . . . \�. ��. \ w V ��\* _� \ �� � � "'" `V� � V � � /� ry � . . � � ; �v ���(.���`~�'. . � � � �6�� gg , - f.�...� y - � -�,., Z..,.� v /����._,� �;=�s�z� - -- � �� �, �8z���ds8z � - c� ,��, i lY �� . . .. S � �M. , - 1 v`QS'c, . �`�� , `�. , ,� : 0£E4.` _.�_. i ', . • .��c� .: f , . . 1 ,� M��'` � ,p ' �l, � . . �� � ;� V 5" "3 � �� l �i � �► 5 . ��,� '1�1 �,� �� APPLICATION FOR SlTE [VALUATIUN/Ih1PItOVEhILNT I�LIiitilfl' �ic �� Davie County Health Department Enviro�menta/Hea/t/� Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 1 2 ����� A!!G 2 1 t�i�� ENVIRONMEPITAL HFlU.TH DAVIE COUNTY (336) 75�.-8760 �D��{��� ���� �'I/(c%��/L -- - - -�r ,_.r ***IMPORTANT*** TiIIS APPLICATION CANNOT BE PROCESSED UNLLSS ALL '1'IIL R�QUII2Lll 3}(�7-5-11 �"`� INFORMATION IS PROVID�D. Rei-er to the INFORtdATION IIULL�TIN for ins�ruction�. \ (� \ � 1 , 1 Name to be Dille�,��� (1C-c.�c� T t \`./��'�ix_(1i�1 Contact Pet�ot� ��C.,y� V �=t.-��G-��'� ���� i \ � " / Mailing Address �� � � c�t/' �`t ,��- F) t� {aC� (� �_ FIome Phone � '7�� -- �fs �C�-�- �n � j f City/State/ZIP � (�il,c�,� ( � �/ � `. �'� , � 1 f� 1 ��li9ine�� Pt3one ,� � � ^_�j_-=.�� �ir� Namo on Pennit/ATC if Different than Above • r�', _____________ Mailing Address City/State/Zip ___�___ 3. Application For: Site Evaluation ❑ Improvement Pennit/ATC ❑ I3oL-li . r 4. Syatem to service: El House ❑ Mobile Home ❑ Bu3ines� ❑ Indust:ry ❑ Other __,_� 5. Type system requested: �Conventional ❑ conventional modificd ❑ innovaL-ivc 6. I Residence: I{ People , IF Bedroo s�_ . 1E Bathrooms _� ___ �Dishwasher ❑Garbage Disposal Washing Machino �Basement/P1iunUiny ❑Basement/No Plun�ing 7. If F3u3iness/Industry /Otherd verify type �t Pcople 11 �inl:� _ ___ # Commodes 1� Showera �� UrinalD IESvaI-cr Coolcr� IF FOODSERVICE: �# SeatB �atimated Water Usage (galions per aay) ____ ____ 8. xype of waeer supply: ❑ County/City � Well ❑ Conununity 9. Do you anticipate additions or CXp:uisious of thc facility tliis s�'SlGll 1S IIIlC11lICd lU SCI'VC7 ❑ YCS ❑ I�'o Irj'CS� l�'�la� fj'i)C� � ***I1IIPORTAN7'�** CLILNTSMUSTCOdIPLGTL• 'TIIG 1Z�QUIIZEU !'KOPLK'1'Y 1NI�ORIYtA'1'lON K[:QU1.S'1'l:U I3�LOW. I:ithcr a PLAT orS(T� PLt1N DIUSTBGSU/l�1fITTGD by tl�c clicnt �t•ilii'1'1(IS r1P!'LICA7'IO1V. J � Pt � (C S'rr�'s 1 - Propert}' DIIIIClISI011S: / � �- �%�c-,� � ���`\�- 1 ' tiV121'I'L DIRGC7'lONS (from 1llocl:s��illc) [u 1'1ZU1'I(IZ"1'1': ' , _ ` � ��•:�a orr�� i Ix: � � � � � � � � j � � � f,v t� C � %�....��-r�� �-.�__ "`> Property Address: Road Namc ��� 2.�.4-C �c./> �r��-� �:� �i� �- �., � pv„ �!1 .c.<h �, j� ,n\ ���,-,Z�n c� �.f.(�5�; rr� r��`����� �4��:� ��,� C���, �-� e If i►i a Subdivisioci pi•ovidc informalion, as follo�vs: Namc: Scction: Blocl.: Lot: llatc I�omc cor►�cc•s ll:ibbcd: 1.�� l�� ��- Tl�is is to certify ttiat tlie iuformatiai provided is correct to tlie best of nry Icuotii�ledbe. I understand tLal any permif(s) issued hereafler are subject to suspeusion or revocation, if the site plans or intended use chanbe, or if lhe infa•matiou submittcd in tl�is applicatiou is falsificd or cliangcd. I, a1so, «ndersla�id t/rat 1 rrnr rc���o�esiGlc for nl! clrrr�b cs incnrrcd frun, !/�is npplicalion. I, l�ereb��, give consent to t(ie Authorized Represei�tative of tl�e 1)avie Cowity Iie:ilU� lle��:u•(u�cut to cnicr upon abo�•c describcd property locatcd in Davic Cou►ity and o�viicd by _____ _ to conduct all icstinb pi•occdures as ncccss:try to dctcrmi�ic tlic sitc suitabilitJ;. � - �� -� � l j ; . DATE SIGNATURl; - �� �=-� - . � ; �� f ���-�-- ,�- "<" _ / � TIiIS AIZEA MAY BE US�D TOR DRAtiVING YOUR SIT� PLAN (Licludc all of tlic follo�vil�b: L:�istii�b :iiid pi•oposcd property lines and dimcusions, structures, sctbacks, and scptic locations). s�sn s►��t� Reviscd DC�ID (OSl03 Sitc Rcvisil CLarbc llatc(s): Clic►it Notil'ic�tio�i Datc: �IIS: Accowit No. � 0 0 O � Itivoicc No. �7 �`� � � •�. . : „ � .� . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002888 Billed To: Ignacio Alvarado Reference Name: Proposed Facility: Residential Water Supply: Evaluation By: FACTORS Slope % HORIZON I DEPTH Texture group Consistence Structure HORIZON II DEPTH Texture group Consistence Structure Texture gro� Consistence Stivcture IV DEPTH Consistence PROPERTY INFORMATION Tax PIN/EH #: 5769-21-5016 Subdivision Info: Location/Address: Cornatzer Road-2702 � Property Size: 112 acres Date Evaluated: �J On-Site Well Community Auger Boring Pit '� SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTAr SITE CLASSIFICATION: Public Cut ___ ��� �Q��oao� ����----� �����+'�----� Si��i�l������ RATEIO�SS- LONG-TERM ACCEPTANCE RATE: D��'�� 3�� REMARKS: EVALUATION BY: OTHER(S) PRESENT: •��� ��t �; C' J1Q� 1 �L 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 - 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 ' SC - Single grain M- Massive CR - C�:�'mb•" � GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic MineraloQv 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 - gaUday/ft2 DCHD OS/99 (Revised) # � ; � F• �� . � ei-� � .. t �� ��T i�� �'� �b �+�:�>�J �d . 7�'• ��.�., fi— ,�' - � - - . .. _ .. .1.: � . � : T ' � �� � - ' -:. ., . 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BOX 8�I�H 210 Hospital Street Courier # : 09-40-06 Mocl:sville, NC 27028 ON-SITE WASTEWATER CERTIFICATION FOR DWELI,ING (Check One) Replacement Remodeling Reconnection s�' �a"� S�Z,�a � P'�vc: (336) — 753-1f80 Name:_j �� �( � �t��d (�� �'C�.� Phone Number� �%:• w�- � �j� � �� ��� (Home) F'� ~� P / �,�� ������ � �WOiIC MailingAddress�,��:,� C�Y }'l�y`� 2�\( ��\ �Z�C?-- ti- y ) � "t � � j� , � --o,��D � (11�� '�,SV i l�� �`s �-�..-z.— `� � � Detailed Directions To Site: �� Property �� 0 Please Fill In The Following Information About The EXISTING Facility: l "1 Name System Installed Under: 1� ��(t_�` � j' �. Y(`�.� C� Type Of Facility:�lL;� �~�'�'�`{' �` ��' �� N" � Date System Installed (Month/Date/Yeaz): � ��, .,-�`� ` L` �� Number Of Bedroom.._ __ ilumber Of People: Is The Facility Currently Vacant? Yes No � If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: ��"�C ��� ` �.-�'1 Number Of Bedrooms: �' Number of People � � —1 —1 > Requested By:_,( ,x� :1 �'�,,� Date Requested: (�gnature) � For Environmental Health Office Use Only Approved Disapproved �/� n �i � ��%/ / /� omments: .(�pc� l ��%%��l �!l(i% .nl ,l`"fN[.� �7` �( f7/ri%C1�1 ��� , Environmental Health Specialist. Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash �(,�("heck Money Order # Date: ��-���'�- ( U Paid By: � • �CLf��; 'l1, Received By: _ Q-�= � Account #: .� d (�' iVAL'�tte� �- giiv�� 3 �'�.2 Invoice #: '%2 �� _ � 1 ' �, rl�.�..,, �.n.... .�rl �i-ilti � �� . . . 1..�.,,