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136 Lera Ln f;�'°, DAVIE COUNTY HEALTH_DEPARTMENT � � �/�� � "`� Environmentai Health Section / _ . , _ � � P.O.Boa 848/210 Hospital Street ` -- /� Mocksville,NC 27028 �r �v (336)7S1-87C►0 v- IMPROVEMENT/OPERATION PERMIT Account #: 990002508 Tax PIN/EH#: 5860-16-1973 Billed To: Christopher&Paula Marshall Subdivision Info: Reference Name: Location/Address: off Lera Lane-27028 Proposed Facility: Residence Property Size: see map **N()TE�'�"I'liisgmprovement/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 PERNIIT LS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE C GE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INS LING SYSTEM. Residential Specification: Building Type � #People� #Bedrooms #Baths� Dishwasher:�Garbage Disposal:� Washing Machine:lQ Basement w/Plumbing: � Basement/No Plumbing: ❑ �Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply ✓ / Design Wastewater,Flow(GPD) ��� Site: New�Repair� , �v� System Specifications: Tank Size,�n2�v GAL. Pump Tank GAL. Trench Widthc�C��Rock Depth���Linear Ft:�" Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a represent ive ofthe Davie County Health Department for final inspection ofthis system between 8:3�a.m.to 9:30 a.m,or 1:00 p.m.to 1:3 p. on the day of installation. Telephone#is(336)751-87G0.**** S�, �e��.re�� 0✓° , 'f � 3�(J",Peorn.. 6� � j� �' � �/ lQ1Z/{'Aa/O D�N � r�U� �� n� �,�.2 � � `� CaS _ .�/�"�s ` �� , � � l°`� � �' /�P �`�G ��� �/a ��p �pv!`G�� I �� /��i Environmental Health Specialist's Signature: Date:��/;�-2 l/�� DCHD OS/99(Revised) � � � ,• �.. �• ' DAVIE COUNTY HEALTH DEPARTMENT � •` Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002508 Tax PIN/EH#: 5860-16-1973 Billed To: Christopher&Paula Marshall Subdivision Info: Reference Name: Location/Address: off Lera Lane-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3320 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: ,�i�� Date: J/_ �!�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Complet hal ' icate the system described on Improvement/Operation Permit has been installed in compliance with ' le 11 0 .S. ter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO AY be as ara that the system will function satisfactorily for any given period of time. - ���1 � � Septic System Installed By: Environmental Health Specialist's Signature: 4 V L����1 Date: � �� `� DC�ID OS/99(Revised) � .� . o . . � . � �o. � , . .- � _,.. • APPLICATION FOR SITE EVALUATION/IMPROVEMENT FliMl &A�'��j � � , Davie County Health Departmen i 2 > _ �� Envirnnmenta/Hea/th Sectio �� ZOp1' � � l P.O. Box 898/210 Hospital 5treet RO�y� � � �, /� Mocksville, NC 27028 �q�iF�Tqly oSS�b l-c� — pv-1''� . E�"l� w'v'1K (336)751-8760 �UNry� ***I2�ORTANT*** THIS APPLICATION GANNOT BE PROCESSED UNLESS AI,L TH� REQU �D . INFORMATION IS PROVIDED. Refer to the INFOFiMFITION BULLETIN for insi:ructions. 1. Name to be Billed ������� �,c��. / I�W�'µ+�ontact PQrson ,,d� _ Mailing Address OT� �ti'C:'l�(,•t[/��-I/LYl'�l.v Home Phone �d��� 1��� City/Stata/ZIP I )lA�,l(,�j V1�'.Q, �� �I�O�U Business Phone 1�� 1����`1 8 l,�U.��/ __ , 2. Name on Permit/ATC if Di£ferent than Above Mailing Address City/State/Zip 3. Application For: � Site Evaluation ❑ Improvement Permi.t/ATC Both a. system to sarvice: 0 House I�Mobile Home ❑ Business ❑ Industry IJ Other , 5. If Residence: # People � # Bedrooms __� H Bathrooms � ;, . "C1 Dishxasher : :4�Garbage Disposal , s 'ng Machine C1 Hasement/Plumbing I:I IIasement/No Plwabiny 6. If Business/Industry/Other: Specify type # People il Sinks N Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (galions per day) 7. Type of water supply: fJ County/City /�7e11 l_I Community a, Do you anticipatc additions or expnnsions of tl�c facility this system is intendcd to scrvc? ❑ Ycs �No lfycs,wliat typc? . ***IMPORTANT***CLIENTS MUSTCOMPLCTETHG REQUlRCD PROPCRTY INI�ORMATION RGQUGS'I'LU I3F.LOW. Eithcr a I'LAT or SITE PLAN MUST BLSUBMI7TED by thc clicnt with TIiIS API'LICATION. Property Dimcnsions: , D D �--�pQJ �VRITL UIRGCTIONS(from Mocicsvillc)to PKOPI;It'I'1': Tax Officc PIIY: # 5�����0�`1�� � ��� � � p�'� Lc.(�-- F-n-.n.t- — Property Addressc Road Name�13 S � d�� _7-�. � ��-� ~-o'�fi°`` �—a—^� City/Zip �� �-� �� �n- �/'� If in a Subdivision providc information,as follotivs: pQ�it � 1 $'�"" � Namc: _ Section: Biock: Lot: Datc Property Flaggcd: l . �� O Z This is to certify that the information provided is corrcct to the best of my Icnowlcdgc. I undcrstand tl�at any permit(s) . issucd hcrcaftcr are subjcct to suspcnsion or rcvocation,if thc sitc plans or iutcndcd usc cl�angc,or if thc intormatiou submitted in this application is falsificd or ciianged. I,also,�rrrderstaud thirt 1 m�r respvnsiGle for n//chrrrges iuc�rrrc�/frnm t/�is applicatiou:'I, I�creby,give consent to tlie Authorized Representative of tlie llavie County I-iealtl� Departmciit lo cntcr upon abovc dcscribcd property locatcd in Davic County and o�vncd by ._ to conduct all tcsting proccdures as ncccssary to dcicrminc thc sit ' w ity. DATE � UZ' SIGNATU . . � . . . . . . . . . . .. . . . - . . . . .. . . . . . . ..J _ . .. THIS AR.EA MAY BE USED FOR DRA.WING YOUR SIT�PLAN(Includc all of tlic fotlowing: �xistiug and proposcd property Iincs and dimensions, structures, setbacks, and septic locations). � � Sitc Rcvisit Ch.trgc � � �2 : D1t��s,: — � � - Clicnt Notification Datc: ��9 � �1-iS: � t �'-�'r� � _'1 � �. 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Residence Property Size: see map Date Evaluated: /1`'.7n `dZ Water Supply: On-Site Well �� Community Public : Evaluation By: Auger Boring f/ Pit Cut FACTORS 1 2 3 ' 4 5 6 7 Landsca osition �- Slo e% • HORIZON I DEPTH '� -�' Texture rou Consistence Stntcture Mineralo HORIZON II DEPTH �� % Texture rou Consistence � Structure c� Mineralo > -- HORIZON III DEPTH Texture rou Consistence Structure Mineralo � ' HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE - CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: `/ LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT: _ � REMARKS: LEGEND • Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 Mois _ 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