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2466 Liberty Church Rd . __ . DAVIE COUNTY HEALTH DEPARTMENT � , . ' � w • Environmental Heaith Section �� � ,'7�0-� � P.O.Boa 848l210 Hospital Street . Mocksville,NC 27028 (33G)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990002826 Tax PIN/EH#: 5803-78-1516 Billed To: Jerry Gentle Subdivision Info: Reference Name: � Location/Address: Liberty Ch Rd-27028 Proposed Facility: .�es+c#e�ee �1J1'✓) Property Size: 7.74 acres ATC Number: 3509 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION FOR WASTEWAT'ER 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 PERMTI'LS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � #People #Bedrooms_�C�!lLL #Baths �/ Dishwasher: ❑ Garbage Disposal: 0 Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type ' #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) I�� Site: New�Repair❑ System Specifications: Tank Size/bOt7 GAL. Pump Tank GAL. Trench Widtt��Rock Depth � ` ,�Linear Ft./00 Other: Required Site Modifications/Conditions: IMPROVEMEIYT/OPERATION PERMIT LAYOUT- APPROVED EFELUENT 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 .m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** /' _ Environmental Health S ecialist's Si ature: �/ Date: � � � P S� �, � DCHD OS/99(Revised) ". �,• DAVIE COUNTY HEAL1'H DEPARTMENT � Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002826 Tax PIN/EH#: 5803-78-1516 Billed To: Jerry Gentle Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility: Residence Property Size: 7.74 acres ATC Number: 3509 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLIED 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: �� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completio shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be en as a guarantee that the system will function satisfactorily for any given period of time. // , f (' � �� Septic System Installed By: ��r �n' �1 /ry ✓ Environmental Health Specialist's Signature: U U � Date: { / ; f/� DC�ID OS/99(Revised) , • , �''I.. .- � � . . , , t `.� �. ,. �.•'/ � �.� ' ' API'LICATION FOR S1TE L-VALUATION/IMPRUVE11iL-NT PL•lih11T O Q/j Davie County Health Department J� �� � Envi�onmenta/Hea/th Section � ' P.o. soX s4s/Zio xo8�itai s�rae� � �p03 Mocksville, NC 27028 �'Yj �'0l4n� (336)751-8760 �l�j���T4i y�` � ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL TH� R�QU� INFORMATION IS PROVIDED. Refer to the INFORMATION IIULL�TTN for instruction�. I � 1. Name to 'be Billed ��—rE.-,�-y ��(,,.�•�-1�( �'�'�L7��� Contact Per�on �' � � —�� �S� Mailing Address �� � � �, l y�( }�!� 1 �v/y�{�/�.�Home Yhone � . CitY/State/ZIP �� //1 Cr�� /"'`C. �����Business Phone 1�'� —���� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip _ 3. Application For: ite Evaluation �1�Improvement Permit/ATC � Both ' . � � 4. syatem to service: ❑ House ❑ biobile Home ❑ Busine�s ❑ Industry [7 Other ��� 5. Type system requasted: Conventional ❑ conventional modified ❑ innovaL•ive 6. If Residence: # People #� Bedrooms 4� Bathrooms / ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Pluml�ing ❑I3asement/No Plun�ing 7. If Du3iness/Industry /Other: verify type 1{ People � I{ Sinlca • # Coumiodea 1! Showers ' }{ Urinala Ik WaL•er Cooler� , IF FOODSERVICE: # SeaLs Estimated Water Usage (gallons per day) � ' 8. Type of water supply: ❑ County/City ` ❑�l ❑ Community � . �� 9. Do You anticipata additions or exp�nsiolls of t11c facllity tl�is sysc�,��,s�t�c��,a�a c���,•Y�� ❑���s �� Ir ycs,,vliat r��pe2 � , • ***I111PORTANT'°**CLICNTS MUST COAIPLET�TH� lt1iQUIItED PIiOI'�IZ'1'Y 1NFORMA'C10N RGQUI'sS'1'(:I) ii�LOW. �ither a PLAT or S►TE PLAN/LIUSTIIL•SUI3�11ITfED by tl�c clicat �r�ilh'1'11IS r1PPL1CA7'ION. I'ropCrl)'D11AC11S10I1S: (" l�- �{, b � WKITL llIRGC7'lONS(Crum 11lud:si•iUc)lu PROI'I.K7'1': Tax Officc PIN: �� "_��^ / �/ � CQ� � � � �.--� l� C-h- �'"� � , Property Address: Road Namc 2�.�- L ���o SS � C� �' City/Zip �- ��f`-t� C�K., If in a Subdivision providc information,as follotirs: Nacnc: Scction: Blockc Lot: D�tc honic corucrs IIaggcd:_ //� ,��3 Tliis is to ccrtify that tlie information providcd is corrcct to tl�c bcst of iny luio�ti�lcdbc. I uiidcrsland lliat any pern�it(s) : issued l�ereafter are subject to suspension or revocation,if tlie site plans or intendcd use change,or if tl�c inforinalion sub►nitted in tliis applicatioii is falsilicd or cliangcd. I,also,tutdersland t11at I urn res1�uusiGlc�fur•RII clrrnb�es iucrn•rcd fi•om ' �his applicatio�r. I,hercby,give couscnt to tlie Authorizcd Representativc of thc Davic County IIcaltli llcpartu�cnl to cntcr upon abovc describcd property locztcd iu Davic Coui�ty and o�vncd by . to conduct all testing proccdures as neccssa�y to dctcrtninc tlie sitc suitabilil}�. DATE T,f� � � SIGNATUI2� THIS AItEA MAY BE US�D TOR DRAtiYING YOUR SITE PLAN(Includc all of tlic follotivii�b: Lxislinb aud proposcd property lines and dimensions, structures, setbacks, and septic locations). , Sitc Rcvisit Cl�:u•bc _ Datc(s): . • Clicnt Notircation llatc: EfIS: i n 'ven �� "` — � cc it No � s� �� �l A ou� . o�-t� Revised DCHD !03 /��� < Livoicc No. �--� 7 3 � b �--�-- � . s ���` -F �"7' � �.�°��a.�"�.��aq°Pw .�+�, k .. � �a a�' y,•;-:. ��'"T°�� �� �A,s�"�r��'� ��, ��,�, � �����::- �� �� � � u �t��.� '��.ffa��+��. ��x .��`, ,;, ,��3� � F �,�. �.xa5. ���1���N� .�� ..�i ;� � ✓/ 4� f,� P,,. /�"� a�s+ c�y � � x . ��✓,�� t ��n� � � & d� e ,��;` ��� ��Cgr �t � e, .. i ' �}�xw��, ��s g �s�s.,&`�' �^ �,�,¢ , ���r��-; "�� ��� � ,� °e� a�„�,�+,�� ��S��a��a� � ,k �$ . � ����.�.€«� .�* ����. �zd``s .� 3` s��� «a� ,� x ���� -,r r� � � �z w � ,A' �, � f�x.�,3����;�� '� �� �; � � �"� r,�s� .�� ca n�� � �: �e u�:�.4.�'��^ � mA�..; � +.� � d,� y �� � '4... �, ` "�� 3, "'�`� - n� .� $"� ;;.�`" `�?`�� �. e �� �i, � � y ,t'�: d a�'.� E� r� e^* -. � pj a�' "�Z �"a���� �n'�m- .q�, '��� �'� £ s�.:�`'� '�e. ���-a�,•.: g� w �'� � d'�r PW � :� �'��i-� �'` c� � � a z�.. as, � €�. � r�� �y� ,y @ x� �",, .%;,, f�"�� H' ` � w '' `"M.� :� .a��; °a.� �"�:�a s`� t 4'� `���, y����r,��Y� �. �r� <�1 � C ' ,« �2.� ,.� - 34°;� �« x' � �'� ` �� z �,.`<'�#r a�k C; � � n �y�,` ,� �a$� � k s�"�a � �".�va,' � g� &� .r ,�"�W x" �'�� �,�a�. 3 � a �: yg k"�'"�f'w�y fq .. k � �` ,✓�� # A',�� ',A���'�..s; �3 f` �`� Y� � u ���' � �� .;�A 9..��-��.. 7 �r�,.µ�.,. «�� v � s� s� +���.� "��� � „ i a , � ` � s� S ._ � �' � t , . � � r�'���.�� �� a� 'k.�n k ��� "4 St,r� �y� � '�� s �,�t � ._ -P`��&, `'' .w a� 4 ��, r��� s �� � i� a & � �li,s,$�f � � F4 � � '. � r � ��§q r��� � �� ,� .:��� �a � � a � , �;„��, �- g� �-� � .<a �� ,. � f f r�. �' - �� . °�� a�7 �'��^� � � � �c ;. �„z"'�,.d,�,�t k �,,q .� .:� '.3�y. .; ��e� �m 2 �` ..�r �'. �'����.�. ��� §� p�� f r� g � �'� a` ��� �. a L,�$``� °�#� � *� 3 r±e � �:i 9�� �� "'� �::� , � ... � - �c - c 6 a' v � . ��"' ����k� � �;.� „� - � E a ` � y ' �n f s � w..� � �.� � �x ,� . �,� e �n� .,,;;�� � � �da ��j�`�z 2 � .�.� .�';,�° y" ,�' � "e � � , �` p ���. ,, / ,e ; 5 .�. 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S.�-f- r G Please Fill In The Following Information About The Existing Dwelling. �Name System Installed Under: Type Of Dwelling: / D�te System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People: \Is The Dwelling Currently Vacant? Yes❑ No❑ If Yes,For How Long? Any Known Problems7 Yes❑ No� If Yes,Explain: o � .r- C�e.a►�1� N �``� � �-r�'' � + Please Fill In The Following Information About�'he New Dwelling. ��C� c --f'i �-�^-J Type Of Dwelling: ���- /" � nF--� 3 cz—'7�� Number Of People: � Requested By: G� Date Requested: ��U�� ��. ignature) �G�S.S/!✓/�_. 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. 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I�'�� � o� / .. 3 , ., .���d9�� „�,_..,,�,�rs%', � t / � ��.;� F/ ���� /����� �� �, ��' T�� � .� ����: �� �� . �i�.r � � '. / _ � 1H � '��E �' y f 1���/� � �g x �i�'y�'�' . �� ��.v` �. /„'�y .,»�r,��� � � „��«, ...,.»..,n.>.,..,..,.. ,�,,,,��...�i,x;�.r"'�''�.��.,�,_. �.,a»u 3.�.. � e Ja . . . . . . . � .. � . . . . � . . , : '•, , ` DAVIE COiJNTY HEALTH DEPART'MENT ' � � � Environmental Health Section . Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002826 � Tax PIN/EH#: 5803-78-1516 Billed To: Jerry Gentle � Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility: Residence Property Size: 7.74 acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit - Cut FACTORS 1 2 '3 .. 4 5 , 6 7 Landsca e osition Slo e% _ . .._ . HORIZON I DEPTH Texture rou Consistence Swcture Mineralo HORIZON II DEPTH , Texture rou Consistence Structure 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 Moist _ _ VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm . _ Wef NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic tructure 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-gaUday/ft2 DC�ID OS/99(Revised)