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120 Legion Cemetery St , ,-_:.. . ' DAVIE COUNTY ENVIRONMENTAL HEALTH .'t_ , :' , . P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004336 Tax PIN/EH #: 5745-05-5221 Billed To: Cooleemee Civitan Club � Subdivision Infa Reference Name: Location/Address: Legion Cemetery St:27014 Proposed Facitity: Private Building � Property Size: 1.60 Acre ATC Number: 4693 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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� U� System Type: " S.T.Manufacture� �Q Q�Tank Date ` Tank Size ��J �� O Pump Tank Size�:— System Installed By: �� E.H.Specialist:1l0 4��dk�ate: I� � d Z �^ `'� �GN \ 1�"' �� '��4��fi�,�t�d�x � ��k �[ Ch � 9' �' � I� �S �N h � � x �� �� � � .. 7aL � - Q � P . v� � I ' � � ` C��-e�G�2�Ctv /�° a . � ' � DCHD 11/06(Revised) � , '^,r --+ ''• DAVIE COUNTY ENVIRONMENTAL HEALTH �(�S- P.O.Box 848/210 Hospital Street �/�Z/�� Mocksville,NC 27028 < <- (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004336 Tax PIN/EH#: 5745-05-5221 Billed To: Cooleemee Civitan Club Subdivision Info: Reference Name: Location/Address: Legion Cemetery St.-27014 Proposed Facility: Private Building Property Size: 1.60 Acre ATC Number: 4693 Site Type: �ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People Bas�ment❑ Basement plumbing❑ � � Non-Residential Specifications: Facility Type� o i,,,'f" t`'`'��#People�(��eats Square�Footage(or Dimensions of Facility) 'd,ti k�i O Lot Size �• �¢ l t,i i ' Type of Water Supply: £�iCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��Tank Size��AL.Pump Tank��AL. t� I� t� Trench Width�� Max.Trench Depth �� Rock Depth /a Linear Ft. �6Q f Pv�;,, c• ��, 3 6, « Site Modifications/Conditions/Other: �� �tated ir1 15A NCA ys ems may also b� use Contact the Davie County Environmental Health Section for final inspection of this system between 8:30-9:30a.m.on the da of in — � �d� La)3 0'�x 3� s.�P-��� N �..:,�.�� w��'h � �fi��-d�u-''�S `f rc v.�I.t bo'�+o n� rno.X. �� y'l'�� w►�n. i5 36u �A ati� �.�d�����,, , Syst-�o.r: n.,ay . � �-�a,� �n� PQ�k1..5 � Arc•► �� r b�C �`�e-c� �p(.�'E" �x�� �'r�..^T {� v Rd f`�d�-+�-'�'v� �, *+�`'t ^ ``O�`a`�'I.� � ca h /rc YaK�e h r-r`���•`" �'°` d-u,�,--t-c� S Q�� 'y'�►�P� �Y'tvt� ��P��f . Environmental Health Specialist . ����% Date: ��v ' DCHD 11/06(Revised) ' . !. '.1 1� . . .. � � � � . � . . . . . Rug 18 �05 � 1 I {46a daV i e courity envhea l th 336� 751 8786 p, i � �-r.�;;. �� • • ' . . ��. . . ' _ . . . . . _ . :. _ . . . . �. � . .. • . �� � �� . . . . . . � .�. .. . .. . . : � � � A 1 ';ION �O[i 51 �EVALUATION/Ih[f�R WEM1IFNT PCiih11T&ATC � C , Davi County Health OeF ;rtment � 20d� E�tv onmenta/Hea/t/i� i��tfon . - � � Z. � P.O, �o�s 8A8/210'Hospil �1 3�zee� � �> pQ Ma�akaville, NC 2:1)28 . . , �pNME��N�1.St1 . (336)751-876�:... � +�**It!!� *** THI3 AP�'LTCATION iCAMY01' �E PROCE;. :IED<'UN7,ESS hLL'THL'�QUTRED, . � TZQ11 IS PR�VIDLD. : Ra�er o the TNFOIi2�iA II :[ BUI,LETTN for inatruct3.One. i----- • �_ ` � 1. Name L•o bo Dillad Q,�("��G.� ✓!/� ""V.Conbaat Poraon � � �� � Mailing Addrese � .��� 7ioma Phone 33� 0�0 `(�'�.�!�G� City/8ta4to/ZIP �i �DI eueinass Phone�3�� ��Z^ �� / 7� � 1. Hams .on;Yez+',ntt/nTC if,DiEforenr.than Above ��C..� , . Ms�ling;AddXoss CitY/ ute/Zip � ._._._.._.,.._ 3. Appl�ca�ion For� �zta: Esvalua��ou m� :•ovemen� Yermi�/ATC Both fG . � �`CX'�1 4. Sy�tem Co S;eL�vlcoi ❑ HOli80 - ❑ MOb�;7.'B Home Cl Due ;neaa - � InduAtry : C9'Other eG.. . aw �, � ��c.� . . 5. Typa uysteaq zequeebedi L:t'�Con•+oational � aonventional iid3Pied• ❑ liutovaL•lv6 pgCCepted 6. I� Reaides�ce� � Peoplu � Beclro •�ns - � Hathroome . ❑Diahwaahojr �Qnrbage Diepasal. CIWu�hin� Machino C iaegment/Plwnbing QDase anC/No Plumbing . 7. if auaine,�a/Industry /Othors verify type�U�bu� V�'`��`p eaple.v/�b'�'��' 1!,Binka _„� N Coacnoclea ,�� � tihoweza �_� p. Ur1. l�la M WaL•nr Coolera T� FOO�SE�tVICEs $ 8eate ' Eatfutated ` �.�er U9age (gallona per da�y) s. Type ot watar oupplys IJYCOu::►Cy/city � w� :t]: � 0�'Communi.ty 9. .Do you antipipato adalitioar� on ezpunston�olf tl�e CucJlity tt�is sy �cin ts Intcudcd tuserve?O Ycs - [�IVa . iC��cs,tiulinE typ4? . _ . � ***}IIIP 1�T'�6LILsN":SMUSTCO+lPL�7'GTI�[� R,CQUII �'D PROPCRTY it�iFORMATIOIY Rf:QUIiSTGD [3� �fllY. Cithcr n PI.AT or Sil'C PLAN MI�ST/1GSU1111fITTBD b� ;hc cl�cnt �vili►TIIIS APPLICATION. __ , , f � • . I'roperly I�Iwa�islous: ,f�,�4� \YRl' L DIRCCTiONS(from Nlocicsvlllc)tu PIZO•G(iTY:,� Tax Of(Ice 1'IN': �. V 7'�-��G�,S ��2 � . .SQC?� ��—`f'�� �' c p-/�.��vv � ��n c.�� �c.J tJ ��i�) -� �. b/ Prorcrty Addr�Ess: Road Numc _���6� c � �I p --�- j�,ton'' � /�� _ . c�ty�z�r ,� � ,sz- ���:� Lo� Zr.�s If(u u Suucllvis�o�t pXovidcittfori»a'.lo�a�:s►s follotivs: . . � �" . F� �.�ct -t av�u �'' Namc: _ ���l�����`Ut �f�'�,�-�-r��. 5cctiont � IIlocic ___,: . Lut: Datc J�omo cornccs Iluggecl: ' . - ;. . Tiiis ts to ccr'ttfy �I�at f l�e luformullon provldc�is arrect to ti�c best of� •v knowlc�gc. I unilcrstAud tliat uny permil(s) issucd l�crca ter re suvjeci to suspen�toii or revo Ation,if tue slte plun: �r tntende�i use cl�Angc,or,if lUo h�formAtfon . \ subu�ilted tu fl�Is applicatiuu Is[ulsfticd or cl��ngc . I,also,un�lcrstrr�irl iat I nm responsiL(c for a!!chargcs incrirred fru�n 1lrls applicali n: ,licrcby,�gtvc consciit.to tltc Aut��orIzcct Represcntath nt'tbc D vIc C w�ty IIcnIIG cpurtu� �t � \ lo enler upo��abc ve describeJ pro�urt•y foc�led ii�DnvIc County und ov: ied by .2.e " / to conduct all tcs�iug proccduccs as nr.cessary fo detcrminc tl�c sltc suits �ilit.}. � DAT��'���"� ` . SICNATURI:��-�• ( � TI-IIS AIi�A�M�II�U5�D TOR D:RA,WI.NG Y,}DUIt SI'F�PLAN(In :udc u!1 of d�c follo�vL�gs �sistlns stnJ proposed proper 11ucs an ctlmensfous, struchires, setUacks, and septic locatio: t). , _ Silo Rcvlsit Cl�urgc . • . . Dntc(s): . , \ Cltent Nolfticattm�Dutc: • 1� . _ , . - . . 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S L�- . Consistence � � t° p J c Structure �' �..}'V Mineralo l; ) ` � 1 l HORIZON II DEPTH — I � h p— 7 Texture mu C L`� C iZs � Consistence �,r- Structure y l Mineralo � ��r HORIZON III DEPTH '1l— ( S �C Texture rou � `L — Consistence p , v • „�c Structure S � Mineralo M. � HORIZON IV DEF'TH � — ' �- Texture rou I... - SL Consistence ' 1, � Structure Mineralo l a� ' � SOIL WETNESS RESTRICTNE HORIZON ���� �•'" SAPROLITE � — — —li0 '7— — CLASSIFICATION LONG-TERM ACCEPTANCE RATE . SITE CLASSIFICATION: �Ct1 U. � �y c�� �Q EVALUATION BY: � �� �. ' LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: � ��U�S ti Q _ REMARKS: SJ�'�— �'3G�•�M��IC�:`1r�� �c+ �.;�J`uv� S LEGEND i, n c ,pe 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 Texturg _ 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 . ' ONSIST ,N . �ulS� _ . 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 S r' �r SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Miner�o�v . 1:1,2:1,Mixed ' . 1Y�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-gaUday/ft2 DCHD OS/OS(Revised) �� � _ __ _ _ -, �1`�`�U �) � � �" � � � " � ,;� � a' '� � �� { ",� F (`c/�£' �) ; ��,. : , w, . _ � ;o � - o�� �-�. o�� 8 _ � � � � � � os�� . '0 ��V � ������ � � � _ � � � �� � o.� _ � �� �;� 9�� 0 �� �# = �� ; , ,� . c�, ; � � -� �� � sol ���� � � ��� � � � 9 � . � ��� , ���� �. � so� � �w � � � �� �-�� � � L�o� L �. 5 i : � � ��s � �-�' �tiw `� 8 �9 � . �,� , �,. �� g�� � =�� 9LZ ��� � � � ; '' � ��� p� � � ;-,� ��,:` �� o � �,,�' '�,, � � � �p � � � _ ��. ` `�`"� '� � � � , = �. P � _ _ � ,. a � /�� , � ���1� �� � . � � " �: �l"r� ��Z �����, _ .,_ �.�-�� � ��_ � ,� . � �:� � = ,���-�-.� ' 0�.� � I r �, �,� {d09 � �� � �� �ri�,� � ti �_ � z � . '�o��, . o�,� � ��� �� . ;��, � �� � a� � �� � _ > �, � , _ � f � : r . � , � � � � a��� t � x �� �� � ;� - � _ �=��.� �� �� �� � ,�� � � � � - ��., _ � ���� � ,��� ������ z F.� � - �� � ,� , o a. EZ�8 = �_ � 5 �b0 E , . : � � a r �i. �., .., '����� �� � „������� i - � �t Davie County Environmental Health P.O.Box.8481210 Hospital Street �` Mocksville,NC 27028 (336)751=8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004336 Tax PIN/EH#: 5745-05-5221 Billed To: Cooleemee Civitan Club Subdivision Info: Address: Attn:William Davie Location/Address: Legion Cemetery St.-27014 City: Cooleemee Property Size: 1.60 Acre Reference Name: Proposed Facility: Private Building **NOTE**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,plat or the intended use change. Permit Type: f�Tew �Repair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ �+ � `"°"�G` Non-Residential Specitications: Facility Type l,(5o w'"�' ��tPeople ad #Seats Square Footage(or Dime sions of Facility) �y Y(�a DesigriFlow(GPD):�� Type of Water Supply: �ounty/City �Well ❑Community Well d�s statc:d in 15A �VCAC 18A.1963(5� Site Modifications/Permit Conditions: t�sse�ed �,s�ems r���;�Iss �� ds� S stem T e LTAR Initial 1 � • Re air c ( 5 � Site Plan '7l,�`J ' . . � v n y v � � Co . � � � pr�s��. �,���`+'��`e-a � �v,:ttio.CS�ps';tQ ��� ��� Environmental Health Specialist Date — ^'Q � i.p.l l-06 • ` ' � � � ' ' F.:y � Davie County Health Departmen (� � �,;:� �,��F. ri> ��T � ��, 1� ���«� ��';�� ,�,� �� Environmental Hea c�� � � �q `���� t, ��'� � P.O. Box 84 ;' ����3� , �s�� , G . �� �-�� . � ��,� � �`�P�'� �� P� 21�0 Hospital St�- 2 3 201� �� �'��F�`������. r� r � � �,���� �a�j Z(�"�u O Courier# : 09-40- DEC _� ���� ���..��p• A � Mocksville, NC 27 Ep�jN r �,�..�,��,�-� � '� �ViRONM�N��t� � �� C� Plione:(33G)-753-678� �pv�� F�.�c:(336)-753-1 G80 B � ON-SITE WASTEWATER CERTIFICA OR DWELLING (Check One) Replacement Remodeling Reconnection ��. C.ft'�Rl��-- Name: ��Q` �+� �I�� �J V 1 ��f�j���'-L 1„��Phone Number � 3 �o ^�'y"� �1�iome) Mailing Address: �, U , �� r7 �� ,�i ai � ~al�q - � � �i�('��Q . f, Gmo C. e-�m�E'�, C. �-�oi� Detailed Directions To Site: ��( t�vr� �'hD��'il/ I �t�' , � � �. `� ��/ "� �� J J � C�pL, ��y►-i�-� 1 �G,� C �rr•��� ST 15 0�� L�F�' ,�-S V �� ��7�(� C'o�L�'�7►��' �-r Si7'E v 5 oN �m�l�T� 7�e �I� Property Address: � � L L��'rf O/� C�'�1tit'�'�1�7� 57'� � P7s L����L�` Please Fill In The Following Information About The EXISTIIVG Facility:TA x�5��� tr-�5 � � l Name System Installed Under: C.�c�t�LL-�E,Iy)�� C I(/��A/�(�ype Of Facility: ' Date System Installed(Month/Date/Year): �i� � J� ��� Number Of Bedrooms:�Number 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: ��'p��-�- _ _�`� . Number Of Bedroorns: � Number of People�_ � Pool Size: Garage Size: Other: Requested By: � �'./.G, ' Date Requested: /;)-/ 7-7� J/"a (S ignature) , For Environmental Health Office Use Only Approved Disapproved ♦ . Comments: .�� � 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 Check Money Order # 'Amount:$ I Date: « 3 I� Paid By: �(,Y � �,(-�.�_j Received By: C�.; Account#: �lp �� Invoice#: I S�-1