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271 CV Smoot Ln (3)Account #: 990003488 Billed To: Lauren Coley Reference Name: Proposed Facility Residence ATC Number: 3990 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87(►0 Tax PIN/EH #: 5801-77-9122 Subdivision Info: P�_ Location/Address: CV Smoot Lane-27028 Property Size: 29 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental ' Health Section prior to issuance of any building permit(s). T'his 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 IG.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS , AUTHORIZATION FOR WASTEW ON IS A OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : Date: zu ` **NOTE** T'he issuance ofthis has been installed in Disposal Systems," b given period of time. CERTIFICATE OF COMPLETION �e of Completion shall indicate the system described on Improvement/Operation Permit nce with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and in NO WAY be taken as a guarantee that the system will function satisfactorily for any ��� � ��°� .J� � Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) 0 0 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street / ��_ �� Sf Mceksville, NC 27028 � (336)75]-8760 Account #: 990003488 Billed To: Lauren Coley Reference Name: Proposed Facility Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5801-77-9122 Subdivision Info: Location/Address: CV Smoot Lane-27028 Property Size: 29 Acres ATC Number: 3990 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 T�IIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �� #People Z #Bedrooms 3 #Baths � Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � Q�S Type Water Supply ��— Design Wastewater Flow (GPD) �m Site: New � Repair ❑ 1� il � System Specifications: Tank Size�OC.,O GAL. Pump Tank GAL. Trench Width�� Rock Depth �Z Linear Ft. � Other: Z. � � t�.i �� 15 • E`�¢''k� , • � ,� r Required Site Modifications/Conditions: �rJS'j' t„r C�`� t-r�� �� �Q�-�-' �J�-- � -� C'� t-(o�-'� PROVEh1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) 11SHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for i rem 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 (3: ��,� I���S la � ��.X --�t�.��%�-1 .32' � '2��x���xlZ " ��_► �C�41 � � Environmental Health Specialist's Signature: DCHD OS/99 (Revised) ��-�. -�.� '6 �� BELOW �l 'nspection of this 75 -8760.**** , Y ' � '{ APPLICA710N FOR SITC EVALUA710N/lh1PROVEM1IFNT PCRMlT Davie County Health Department Environmenta/Hea/ih Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 F��EB - �' �}�'�� ___ ��p��_ J ( rnnllD!'���li[17�T1, I ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INrORMATION I5 PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Namo to bo Silled 2. 3. 4. 5. Contact Peraon CI)U�VIY Mailing Addresa �� I l,U (�Yi7V� /%� Home Phone l'j� ,)�`� � , City/State/ZIP ' �+�K�SV 1(�l, ��( ��U� O Buainoss Phone �rT,:.) '�1 J�U Name on Permit/ATC if Different than Above _�tLyY7n s. r�1�� � // t i /, ' � Mailing Addresa City/State/Zip Applica�ion For: �te Evalua�ion �1 Improvement Permit/ATC ❑ Iioth system to sorvice: �iiousQ ❑ Mobile Home ❑ Business � Industry ❑ Other Tj�pe sy�tem raquested: lL� Conventional ❑ convantional modified ❑ innovative 6. If Residence: # People O� # Bedrooma 3 t� Bathrooms � �Aishwa3her ❑Garbage Disposal �Washing Machine ❑Sasement/Plumbing ❑Basement/No Plumbing 7. If Buainess/Industry /Othor: verify type " $ Peoplo r # Sinks � # Commodas �`" # Showera � # Urinals '� # Water Coolers IF FOODSERVICE: # Seats ^ 8. Type o£ water aupply: ❑ County/City Estimated Water Usage (gallona per day) �We 11 � Communi ty 9. Do You anticipate additions or cxpansions of tl�c facility tl�is systcni is intcndcd to scrve? O 1'cs �No � If ycs, ivbat typc? '—" ---- '-- ***IAIPORTANT''°** CLI�NTS �11UST COD11'L�TE TIII's .liEQUIRED PROPCRTY INI�ORMATION R�QUGSTCD BELO�V. �ithcr a PLAT or SITE PLAN MUST 6Ii SUBA/ITTL•'D by tlic clicnt tivitl� TIIJS APPLICATION. Proper(y Dicncnsious: �a ���i1 �g�� �q -�f Tax Officc PIIY: �� ,r�%� ,�,,:���, � a•� Property Address: Road Namc 1'v �1'Y100�- ��1 Yl �' c�tyiz�l� m�tSU'� I le a7c�� � If in a Subdivision providc ii�formation, as follotivs: Namc: � Scction: Block: Lot: tiVItITE DIRGC�IO� (froi�i Mocicsvillc) to I'ItOI'GRTI': �J � 0 l� ���, L; h� rfi� E u rc��� � o� I�� C�eP� ��u��h ��I , '� �n �',li �,v�nDo� �a�c�, . Datc liomc coriicrs flaggcd: _ p11 J�/r�(�'� � Tliis is to ccr(ify tliat tlic infor►nation pruvidcd is corrcct to thc bcst of my Ic�io�vledgc. I undcrstand tliat al�y permit(s) issued l�creafter are subject to suspension or revocation, if tlie site plans or intended use cliange, or if tl�e information subn�itted in tl�is application is falsificd or cl�angeJ. I, also, rurrlerstau�! tllnt I artr resparsiLle for a11 c1lar�es inctrrrerl jroni lhis application. I, hereby, give consent to tlie Authorized Representative of the Dav' County IIcalth Deplrtment to cntcr upon abovc describcd property lacatcd in Davic County :►nd otivned by �Q I.1 �P,q �,n � 1/ tu conduct all (estiu� procedures as uccessary to determine tlie site sui :ibility. DAT1; _ �I7 I a1Ci�� SIGNATUI2� TIiIS AItEA MAY BE US�D FOR DRAWING YOUIt SIT� PLAN (Iiicludc all af tlie follotiviiig: Existing and proposcd property lines and dimensions, structures, setbacks, and septic tocations). . � Sign givcn � " v Rcvised DCIiD (OS/03 � Sitc Revisit Cliargc Datc(s): Clicnt Notification Datc: ' �fIS: Accouiit No. � �� � Iiivo➢cc No. '�(�� � J � n�s� . i ¢€' � : ;� fUU�Y , ' � � ( Ei ii i F ` .. � � �' I p j(� ��, "•� " � �� i i i f� Ir� t �i I �� ' �^,j�^�' �q� �� � � I �Id , ��i ; � : � � h�ii - ' � ' i -���, t � �� ����I ti ' . i i � t � � j0 �E � ( � (�„ . . . . � �. 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' � \��� , � � i� , � ,-- �-" APPI,ICAN'1' INFORMATION Account #: �90003488 Billed To: Lauren Coley Reference Name: Proposed Facilit�: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY [NFORMATION Tax PIN/EH #: 5801-77-9122 Subdivision Info: Location/Address: CV Smoot Lane-270 8 Property Size: see map Date Evaluated: �/ �/c'�'.�� __ Water Supply: On-Site Well � Community Evaluation By: Auger Boring � Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition C",= Slo e % � � HORIZON I DEPTH �-' � - I Z- -- � Z Texture rou j' C�- 5 i�� i(-�— Consistence F!- � S S'S Structure t gj� c Mineralo - �? � HORIZON II DEPTH l;o� � _' (v ; Texture rou S; �= 5' �- ��'L Consistence �' - Structure la. -- Mineralo � HORIZON III DEPTH - 2(,, - � �� - Texture rou � C fi- � 'L �C- Consistence ; S • " S � . 5 Structure � ', � Mineralo , % ;1 S .r HORIZON IV DEPTH l-1 ' Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ► ,% LONG-TERM ACCEPTANCE RATE - O• SITE CLASSIFICATION: �� EVALUATION BY: v t=����`�'`� LONG-TERM ACCEPTANCE RATE: �•� OTHER(S) PRESENT: REMARKS: ��� �L'4�`�=-� -`�" + 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 Mineraloev 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) I _� ■■ ■■ ■■�■■■�■��■■■■■■ ■����■���■�■�■■■ ■■��■��■��■■�■■■ ■�����■��■�■■■■■ ■■ � ■■ ■�■lQ1�■■ ■■���J�■■ ��� ■��■ ■�1� ■�■ �■■ ■■■ ■■�■■ ■�\■■ ■■■ ■■■ ■■■ ■�■ ■■■■■ ■■�■■ ■■■■�■ ■■■��■ ■■■��■ ■■���■ ■■■■■■ ■�■■■■���■■�■■ ■■■�■��■��■�■■ ■�■���������■■ ■■■�■■■����■■■ ■■■■������■■■■ ■���■�����■■■■ ■�■��■�■■■■■�■ ■■�■�■■■■■■■�■ ■��■■■■■■■��\■ ■ ■ 29.048A ��a �- - � :.a ��p „�� . r�.-. �� � � � ��� , . 1049 �es 3114 � ie k �� � ' "� � � �� ' �� I . . ... ��i , 5.820A � a ' , � , " i �� ��� ���� � rr ,, . . � .. . � . . � �� ts2 �. � .., , ����. 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