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2798 Cornatzer RdDAVIE COUNTY HEALTH DEPARTMENT ' K Environmental Health Section ,� � P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 , . (336)751-8760 Account #: 990001877 Billed To: Jerry Burris Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5870-63-4053 P(/ �i 3 a'�e l. PG ,,4�i RF`��``'�'� �p. � 3� Subdivision Info: Location/Address: Cornatrer Road-27006 Property Size: see map **NOTE�* Th s-1"mprovemendOperation 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 �. � p 1'✓1�� #People 2- #Bedrooms � #Baths 2 Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �(Oq f-�� Type Water Supply l.A� Design Wastewater Flow (GPD) �� Site: New � Repair ❑ .� �i System Specifications: Tank Size�'�%� GAL. Pump Tank GAL. Trench Widt� Rock Depth � y Linear Ft. �J'�`�� Other: � �1S�l�i`��.J �x, ►��_�3�t.(.- t�l�s � ��.(.', i'►�li�. RequiredSiteModifications/Conditions: I�� �� 0� }�J,�� ,� D11J� O� /�• n. 1�lC-:��U�L�.� I1�IPROVEMENT/OPERAT[ON PERMIT 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 8:30 a.m. to 9:30 a.m. or 1:00 p.m. 0 1:30 p.m. on the day of installation. Telephone # is (33G)751-87G0.**** ' PPcw� � , o Pa.�.-2 (� ►J� �F I ' 120 '`074 L \ � ►o P��-G �y �t.��: � Z- 1&�' To � A � � 3� � 4s` �.I=�� Lt ►-� � � 1 F ►rLS � � �N �- �n�x �e.�►�c� � , +=a�.��;- 32' ` ��C � t�M �-� � � �� � \ �� s� 57 MlN. (pd � � Environmental DCI-ID OS/99 �4�L ,� >t's Signature}��� � �� � �, � �'_ Date: �` Account #: 990001877 Billed To: Jerry Burris Reference Name: Proposed Facility: Residence ATC Number: 2955 �A 8'.�O�DI G� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section p. o. sog sasmo xo�P�t�� st��t Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5870-63-4053 Subdivision Info: Location/Address: Comatrer Road-27006 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 CONS IS V ID FOR A PERIOD OF FIVE ARS. Environmental Health SpecialisYs Signa e: Date: � 2 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemenbOperation 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. � �` �.- �i S ��'��i ., 11._0'�3�0�t� ` ►�k S��`�-�� 6�e.��� eptic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) �o �� ' „ �3�' x�Z Date: � ft, 1 AI'PUCATIUfV rUR SIT[ EVALUATION/1�9PIi0iIC�ENT !'LfiR1[T & ATI; `1� `, Davie County Health Department v Environmenta/Hea/th �ection P.O. Box 84$/210 Hospital Street � Mocksville, NC 27028 � (336) 751-8760 �** ORTANT*** THIS APPLICATION C�NNOT I3E PROCESSED UIJL�SS �L TIiE 12�QUIFt�D INFORMATION IS PROVIDED. Refer to the INFOi2MATION BUI,LETIN for instructions. ------- — r 1. Name to�be Billed ���� . I� Contact Person , renl �(� --._ __... ------ __.. Mailinq Address (�'�� � � -7 Home Phone ��C(J / �p / - /_/ � 3 City/State/ZIP W�/�1��U /� �� /e �1 1 V v� s��� Phone 2. Name on Permit/ATC if Di£ferent than ��; ling Jlddress 3. Application For:�Site Evaluation City/State/Zip ❑ Improvement Permit/ATC a. system to Service: L� House � Mobile Home ❑ Business Il Indus�ry I I Other 5. If Residence: # People � � Bedrooms �_ # Dai:hrooms __ oZJ_ 14I'Dishxasher CI Garbage Disposal l4�Washing Machine U Basement/Plumbing III3asemenl/Nu Pliunving 6. If Dusiness/Industry/Other: Specify type # People N Sinks H Commodes }k Showers # Urinals !i Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallons Per day) 7. Type of water supply: C�"County/City ❑ Well Il Community e, Do you anticipatc additions or cxpansiuns of thc faci(ity ttiis syslcm is intcndcd lo scrvc? �ry�s,.y��ac cy���� Il Ycs I I�i ***Ih1PORTANT*** CLIENTS BfUSTC0,11PLETGTHC REQUIRCD PKOI'I;R'CY 1NI�OIt111A770N R[iQUES'I7?D BELOW. Githcr a I'LAT or SITL PLAN h1UST 13ESUBA�I7TED by tLc dicnt �vitL 'I'!!IS API'LICA`I'ION. Property Uimcnsions: S� ��(,(,(> �VRI"1'L UIRGC('IONS (frou� Alocl:svilic) lo PKO1'I�:12'I'1': ax Ofticc PIN: .�(f "%(� Q,3 � � J� � �� fU crSd / .-�X � � -�U j �a � I'roperty Address: Road Namc�ilY'N�t��r 8a I���v��c� Tu v�N '�n �G il� � c��y�z�P , o rv C� r��z� r;, � r�, ��— lf in a Subdivision providc information, as follo�vs: U1�) ���'/ CL�Q(,�� � i7 � �e. LC� Namc: �/lf' r'OQ,� bP�'iC��' � �16LLSP_S Scction: I31ock: Lot: Datc I'roperty Flabecd: a .z- � I 11 ��• This is to ccrtity that thc information providcd is corrcct to tlic bcst of my lcnuivlcdgc. I undcrstand Uint :eny permil(s) issucd hcrcaftcr are subjcct to suspension or rcvocation, if tlic sitc plans or intcndcd usc cl►angc, or if tl�c infc�rivation. submittcd in tl�is applicatiun is falsi6cd or cl�angcd. 1, also, «nderslaitt! t/rul I�r»t responsiLlc fi�r a!/ drur�es i�rcrrrrcd f'run� tlris applicution. [, hcreby, givc conscnt to tlic Authorizcd Rcprescntativc of llic Uavic County Ilcalth Dcpartnicut to cntcr upon abovc dcscribcd property locatcd in llavic County and u�vncd by . ------ - _ _ _ .--�-- to conduct all tcsting proccdures us ncccssary to dctcrminc tt�c sitc suital�ility. UA1'E S[CNA'I'Ult� �-E' �n (�Q ,J� � ' THIS AR�A MAY BE US�D rOR DRAWING YOUlt S1T� PLAN (Includc all of tGc follo�ving: Lxistin�; au� pruposcJ propecty lines and dimensions, structures, setUacics, und septic locations). �% �� � �L�_ �`� �-✓ �' / [l, �J � �� 0 % -° �'l�v o ,l �� _ --�-,[�,� r 1`" 5 /--�-- ��� �� SS/b/ �, � ���k � �� ( � � L�� U Reviscd DCHD (07/99) C�C �_ Sitc Rcvisit Cliar�;c Uatc(s): Clicnt Notification llatc: ���5: Account No. � ( � Invoicc No. � I � � 6_I�� 1 Z`N � � ��r��, ��a� r� ,a � xa� .�. /� d . ; . � = a��✓�' � ,. ,mM . ; , � . �,.�oc1���� h2 � � � ._..-�. - _. .... Y � V �.��,.•,, . , , 5 ��� �3 c�.,,o� 3a 4- � �'�c \ �' \ � �� � � w. � � ��s : 'o• �o \ 30 � �.�� j G^� \ . -.J o H nL N. �D O T S, QiaL - \ �D .8. I Ce 2. f� 4-B 1 p.8.�,'PF� 49 PRELIMINARY PLAT Not for recordation, conveyances,orsales. C orz � �T Z 338.8-��,. ,.� 5.8�� S -� \ � 4� Tti \ I certify that this inap was drawn from an �.��`�'�������'�i, T actual field survey made under n{y supervision; ��.���'�'K C,gR �'�'� recision is 1:10, 000+. ` Q •••• •• �'� that the ratio of p ` • • � �� r G1 S iFR . l/2 • This �, daY of ����, �992• O. i�,• � � Q� F ' : � SEAI, : - • . : � • - • � -]5,�� : c c�` , : � � 9y0 p�;• �__�� : � �'•.SL/RV��•� ��` -,,9q�.1••......••�5��,,. 4.� ,,�`''���E „� ��`'���` This map does not meet N.C.C.S. 4�-30 standards and is not for recording. �: .: . y. „ � � � � S. 84= 3 i��+ �, \ _ . c� Ftia< 13Z 3�• y S�9\� \ 'r E 7a.7�4 F�S•72: � �w. `59qo1 � 84. S 77.� S, \ ,`''�'M 'l�'2o��t5 � E, � �3•=�cw + S.83 �3 � `a.�. � � ; � � � \ � � � ����vq� • .\ 7,2rq.� \ � . � I \ � � � � ' LoGq-f' i0 N MAQ - ►ao s c�s�r: - 'L �G.IQ.KD ^ CH - G Ho¢.p D�}: Ps�NT � — c.icr.a�cr.�u �.t E A� qQ-tsP.s A2.� S� GOOQD��.IATErS C�R.�.IATLEQ„ 'Rl�fiD 0 � • �" . '2olE. cf, ` Q � � Co -r zE R —�a� JO'GH- S.B�jS 4'S �' . . 338 87u,. ,,,�, S.B�= l+'Zo"E. 5.�=35 20� �. �. �� (�p ' a • _�. S. 86=4-0'2 --._ \� SZ.7044 II..! �,L• S.B%'�q'40�.� �j 8 S' �'�5���. � � . � 'W�a/ct I laj,leG'cM. P �oczo CFI. -� 79.66�H� �wr �e•,!-cbtc svc� _ 8 0. iz 7- 3 Z•zo'IE. -.� 1—+- �-s 3.2�•-r. \ , �. p..uc,t/PF►.rt L...vu Vbccn ICoS.0 �H �'� �.: #t P- , f� � �j `303 � - �J — •n � � �Q' � � ; � r N \� \ ' � � � 6� h ^, . �, � • m � �" � / � �s' �a. ' � Z - i.o� ac�` - .a N w • .. \ 3 0 .� �� ^ ,q� (V Q � �' � b�'� � "'a� M -I.oSAcj - N M � , I.c2 i G_�i � � o��, � � \ Z - / J , - JoH� H. Neots, e�. - � Q o � N - I.ol Acr- � v.a. ic� c. � a�e, v � ��, N " ' P-3-L:� �� � �T�y 2�O•o' "v �°`�� . Z M / i : G-8 , � � � N \ �j . . �J � �. - S�aNsw �. KoaTSr \ � � - a.8. i V2, i�.4T! � ` 'A ,` � ,>a o � nb�� � .. p.B.L .P�a9 `, I \ � � .. _. . . . . . �` �� V .� Yk� . - ; \ \ � � '�.�.� �� 'R~ \ � . 30 \ � . Gc� - . ♦ � � oi��N ^ I certify that this map was drawn i'rom an actual field survey made under �p supervisioni that the ratio of preciaion is 1:10,000+. This � day of ���`�1 , 1992• � � `-l�c C. ,,,�����u��r����,'I .-•'� 4��� . �qRp�'•-, ,� �� Q��is rF�. �i2 ; : FO : � : • S • . EA(, • = • � • "s ;s � '�540 : : -e� : ti Q r = �,: o ,�o: : . : �'•.SfJRVE�.� �. -.,'�9 ••.......• � �. '�.:'1 E. G�ti��S•`'� , �����/tt1�NN��a Thia aap doea not Qeet lt.C.G.S. 4y-30 atandarda and ia nat for recording. 4.81 Ac�.Es �' . --- J oN N �I . �oo-� s, e� � SHADY C�QovE TCw�.15H1P � '� AK �� C oU N'N� t�( .G . f3Et�.1S Pa2-Cier.15 QF LpT t.02 OF TAIC (V�(�P N0. G-8 ocZ p.�3. Co, �G. 4�j , SE� o.s. Ito2, t��. 48� � ScAc..E- �"=�o�� � 5e �o� Jul..�l, 1�19Z G,�z.i..is�1 S�R�[EYi�G co. 727 GAc�s Av�. k[�..tsTa�.t SA�JENi, NC. 2T1o3 7Z2-oSS4- ,,,, APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation PROPERTY INFORMATION Account #: 990001877 Tax PIN/EH #: 5870-63-4053 Bitled To: Jerry Burris Subdivision Info: Reference Name: Location/Address: Comatrer Road-2700 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply:. On-Site Well Community Public Evaluation By: Auger Boring Pit Cut SOIL WETNESS SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: v'� OTHER(S) PRESENT: 2 i� REMARKS: M�,� � � ����'� �J� � 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 - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralo�v 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) iii ■�■ ■ ■ ■ ■■ ■■ ■�■ ■�■ ■�■ ■�■ ■■■ ■■■ ��■ ■■■�■ ■■��■ ■■��■ ■�■�■ ■���■ ■���■ ■���■■ ■��o�■ ■■�■■■ ■����■ ■��■�■ ■��■�■ ■■�■ ■■��■����■ ■���■��U�■ ■��■��l��■ ■��������■ ■���■��e�■ ■��������■ ■��������■ ■��■���■�■ ■����■�■�■ au�r,��■��■ �r��r�■����■ ���r������■ d���ri■��■��■ �i�a������■ ■ ■ ■ ■����■��■ ■�������■ ■����■��■ ■�������■ ■�������■ ■��■����■ ■ ■ ■■�■ ■■ ■ ■ ■ ■