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2682 Liberty Church Rd � � , � � �. '� � DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Heaith Section ��� � u� �� •� P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 (336)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003034 Tax PIN/EH#: 5804-40-3325 Billed To: Joe Caudle Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility Residence Property Size: 2.51 acres ATC Number: 3731 . �� . **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION 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 peimit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERNIIT 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 �Oc�� #People_ �"� #Bedrooms � #Baths 2-��l��� Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: O Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 2•���� Type Water Supply ��tL'll. Design Wastewater Flow(GPD) �� Site: New� Repair❑ 1� ,r � System Specifications: Tank Size�OQD GAL. Pump Tank GAL. Trench Width c Rock Depth �2 Linear Ft. � Other: "i ,��-1�TR,1�JV�i"l01� [�X,V� Required Site Modifications/Conditions: L 9� �-"� I�t� ����"r' F►� �f�� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISNED GRADE. ****NOTiCE: Contact a representative�e Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to : p.m �t e ay o m allation. Telephone#is(33G)751-87G0.**** '7s' ��-`� ����''�-Q°.� �o' . lC�"�'„Kt2" s �t�l� t-1�1� h`j � �S�MIn1. ' ���Mk�• '� - �� ���� �,��� R�=���a�ab � �«s �a�T L'�-t�E � a /'�� Environmental Health Specialist's Signa e: � Date: �� �" �"`'•�,� � DCHD OS/99(Revised) � ��� � 7'p �� � 1 =� j i DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section ,. --.- •. ._„ P.O.Boa 848/210 Hospital 5treet Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003034 Tax PIN/EH#: 5804-40-3325 Billed To: Joe Caudle Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility: Residence Property Size: 3 acres **NOT��*This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AITTHOWZATION 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 C��ANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. `Residential Specification: Building Type ���% #People� #Bedrooms�_ #Baths'�'t'2 �`1-��. Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size L.5 a�SType Water Supply �0.�-- Design Wastewater Flow(GPD) �7 Site: New�Repau❑ �� ,� � System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width� Rock Depth (Z- Linear Ft. L� other: 3 ��`T�.l�t7-t-to•� �xs=S Required Site Modifications/Conditions: �w�T�- �•.� �'J�`�� K�-� �S�c� ���n�,�T: ���O� INIPROVEMENT/OPERATION 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 . . p. . 1:30 p.m.on the day of installation. Telephone#is(33C►)751-8760.**** /� � ',�'O' �F}�"� �� � � !� ��I T � 5'. ��� �--�'JP�S (r� C�' _ �5 -----` _,,U 3 B2 ��' ��: - ��� �� I �2iV►� � ��o� Envi nmen Health Sp ialist's Signature:� � ' '� e: 1 2t� t. ' D OS 99(Revised �.... �_,�-� L ���2.7�? Ct-)ve�-I P_.�� ' � � � �' ' � ' � ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003034 Tax PIN/EH#: 5804-40-3325 Billed To: Joe Caudle Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Pro osed Facili : Residence r ATC Number: 3731 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **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). This Form/Authorization Number should be presented to the.Davie County Building Inspections Of�'ice when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.19 0 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW R V ID FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signature: � Date:_ CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation 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 as a guazantee that the system will function satisfactorily for any given period of time. "�— '?O �` �Z' � �� �� IE�y`'3t,'���yZ�� ig rt•(►' 3 S'�� � � ' �� � �S� �.�w r Septic System Installed By: ������ ��'`� Environmental Health Specialist's Signature: Date: � DC�ID OS/99(Revised) : _, . ^ � , '.._ y . 1�-w' � , ���` �� ��� ��c7��(/�' , . ..... , ,. , _.. .. , ,- - '"�'1' � }� .f .. �- �T ..►o ��:� . �.� � . . �, �� D � � [� fl � � � � v "'"� � � ! ION FOIi SITE CVALUATION/lh1PRUVChIGYf I'L'It�411T I' � Davie County Health Department aPR ' � � zd(� ;, ,��� � fi '� E�vironmeata/Hea/th Section P.O. Dox 84II/210 Ho�pital Street �yy���M��kE�j ' ` riock�ville, NC 2702a - pdVIRONMEMAt HFAI.TN (3 3 6)7 51-B 7 6 0 �VIE COUNiY pAVfE C��1•�r!.. � *IMPORTANT*** TIiI5 71PPLTCATION C1lNNOT F3� PROCESSZ;D U2dLLS5 ALL TlIL R�QUII�Lll~ . I I27FORi3�TI0N IS PROVID�D. Retor �o thn INFORMATION DULL�TIN tor in��rucL•ion_�. 1. Name to be Dilled 1 �C ����11'C- � Conl•ac� Pcrson �m�__.__... t•Sailing Address ��� , J_����pQG \\CA ltomc Plionc �3�_ �'I _1_�.-..�!Z'� ` . City/State/ZIP p[�,��1)j��t, �C Z70Z� _ . Duainc�a I'l�oiic q 'l�� �'1J5� .. , r2.�__��._._..... _. 2. Namo on Permit/ATC iE DiL•terent than 1�bove � Mailing nddress City/Statc 'L'p ---•—•--._..... ...- -.. . � � • a. Application For: �Site �valuation � �Impr" e nnL- Penni�/ATC ❑ ]!oL-li .9. syctem to service:� House ❑ tdobile Home ❑ Du�ine�� ❑ IndusL•ry ❑ OLl�cr _ _ .____ , t., . 5. Type 3ystem reque�ted: ❑ Conventional ❑ conventional modificd ❑ innov�a1Cive 'Z ���) Q�� G. If Rc�idence: 1! Peoplc �! 11 Dedrooul� ' � ��1'! L�itl�ooui:,,2.+ ��2 ��� �Diohwa�her �Gazbage Diapo�al fuyWashing Machino �Ba�emenL-/i'1wnUiiig ❑La::emenL•/2do 1�'liinibin� 7. If Du3incas/Induatry /Other: verify L•ype IF !'coplc " I! :;iiil:a # Commodca IF Shower� If Urinaln III�aCcr Coolura � IF FOODS�RVICE: �� 5eaLa �atimated WaL-er U�age (�ailona per aay) J._ ____ e. Typc oi water �uppiy: ❑ County/City j�l Well ❑ ConununiL'y 3. Do you anticipate addition� or c�jl:ulsiotlS Uf tllc f7Cility t11iS S)'Slctll is iulcl�dcd lu Sct•YC':❑ �'cs �f�u �',Ij.)'CS�11'll�f t)'j)C� ***lAIPORTi1N"1''`**CLILNTS d1UST COAI!'LGTIi•rxc �ui�urltLv��ito��Liz'1'1'INI�OKI1�tA't'lON itl's�Ul'sS'I'I;U � I3CL01V. Eifl�cr a PLA7'orSIT�PLAN�1fUSTdJCSU/3�iII77'ED by thc clicnt n•iU�'1'(iIS A['I'I,ICA7'ION. " 1'roperl��lliiiic�tsiuus: �j A G 1YIZl'TL lllitLC7'IUNS(t'runi p�lud;s��iilc) lu 1'1tUi't;lt'1'1`:': •r:►a orr«rlrr: f� 5 S�d y y�3 3 2 s -1ooJ �. +� Z�6 Lr�.� ��. ��___ Properiy Address: Road Namc�_i 1�t,r�vr C� • �d 3�O g� a. ��� ��dr*,- ��A9k�.� . C1�y�T.1P 1,16c'f�SlS��� � 2,�0� ' �`��fG �11'\G Ol.. �"�• I If iii a Subdivisioii pi•ovidc i►iformalioii,as Tolloivs: ( ha� �� '��.-�- -�-,,— {c,.,� be'�� Natiic: _c�-[�G�r� . Sccliai: Blocic: Lot: D1tc hon�c ca-ucrs llabbccl:_�`� ! _ �� � 0_►..,�r N�2�� Tl�is is tu ccrlify iliat tlic iiifol•matioii p►•ovidcd is corrcct to tl�c bcst of my.lcnutiti�lcdgc. ! uiidcrsl:u�d lluit :iny�ici•�uil(s) issucd Lcrcaftcr are subjcct to suspcnsion or rcvocation,if tltc sitc plans or intcudcd usc cli:wbc,or if Il�c infurnia(iuu SU�IIII��C(I Ifl II11S:ipplicalioii is falsircd or cliatigcd. I,also, iur�lcrslairrl dtat l uur rc�7�u�rsiLlc fur u!1 c/rcub�es iircrrrr•rrl.%runr lhis«ppliculion. I,licrcb)�,gi�•c coiisciit to ilic Autliorizcct Represciita(ivc of tl�c 1)avic Cuiu�t�•Ilc:iltli Dcp:u•fnicii( to cntcr upon abovc dcscribcd properly lucalcd iu Davic Cowity and oiti�ncd 1��� __ tu conduct:ill testing proccdw•cs as ncccssary to dc(crminc tlic silc suitabilily�. � llA'I'L ' � SICNAi'UItI; � TIiIS AItEA MAY I3�USLD TOR ll1ZA.WING YOUR SIT� L (Includc all uf lI►c fullotiviiib: L�islinb aiicl propuscd � property lincs and dimcnsions, structures, sctbacics, and sc `' ocations). : � ,,, • . Sitc ltcvisit Cliar�;c ll:itc(s): . . __ ` . � ��� .. Cliciit No[il7caliai llatc: �r �.���- L��a},� �..�� LITs: Signgivcn AccouutNo. �� � Reti�iacd DCi�iD (OS/03� . • Iiivoicc No. ��`� �. � .. . . .+R;, • . . , . i ,------._..__..--- ��� `� '� Z�7 L� � � -.__._-� -- �� � � � 1025 y '„,,, � 3�,". .� �� _ - . .� � „, „ , ,,.1.-r{ •.•: .': = � ' ��� � '' f r f v 3,��J 3 k 1 �# {'. �,, �37I4�n�1�'�. . .. . �'�. : : , �� y.�.. � , 6 3:�:��� ������, a� �; ' �3 , ,_,,,, , � ���. .. ; • 33 , � - ,._ , , ; , . y. H. ����. 3:d• �a � _ �. . .. , ; � . � ' . . , . ,+ ,.' ,.�,, �x�:.. �: , . � .. " . .�.,' ..: . • , � : , _ _ • ' � ' . .:j .�. .'r " � t� . . � .y3.�'e � . - �.�. ; :. �'.. , . r ;: .T -�. , �. �.' �. � . , ; . , a�. .....� _ L �. ,,. ..�__ . �'� -, � ;. ,. .:_ ..,���. . . .. -.... . - -�� . �fl < ._. , � , � , , , .. ."'' . . - . ,, 3., ; . . -_ � . , g� . .,,,, •• ��� . ::���.:. ,, •���. � . . 3 �,U.�'�. � ��. . .. ,. �' � �.. 3�75i'�33 3 � � r i � �"""`�... ; � 3 . � . �.� �� , � � . .. ;� , A�..° _ , �. � 3 �'� � "d f Ln (2:51A) . 3" �, Y3 � � ����� ,�3332��5 , �3 � �� 3 � �- -�� c�`b�,. , � 0� r 3, .81 A) 'r 3 � ) .- ' 267 , � a � . � � � . � - -� � , : � . . ,. , 3 � � . s , � . - �'I . . ....3 . � � � ���;�... . / '� � , / � -: :, _�'�� /� ���� '- �i �, � ��I / / / / �.S-� V ��10 ' . ;' . i ; i � � i i 1 , � , i O i � i � � � i � � � � � � � � ' ' � � � i � O ' � ' � 1 i � - a , , , , , , , , ; . , ,- , . : (3.93A) � ; , , . . , , 0882 ' '" ; ;- , , , , . � � .- ., .� , ��- DAVIE COUNTY HEALTH DEPARTMENT ' '��' ` " � � � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003034 Tax PIN/EH#: 5804-40-3325 Billed To: Joe Caudle Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility: Residence Property Size: 3 acres Date Evaluated: _ j ����� Water Supply: ; : On-Site Well Community Public Evaluation By: � y , Auger Boring Pit Cut ,:3.; FACTORS 1 2 3 4 5 6 7 Landsca e osition � " � 1.L. Slo % .5 �>I HORIZON I DEPTH S; (.�. � (� � L`� .—�a .- � Texture rou" ,�� `S�L �C i S� Clr S; l� Consistence � � � r• 5 Structure •, I G c.< � Mineralo . �� • � �, � HORIZON II DEPTH - — L. . Texture rou �; 1 � ; t Consistence - !� � ' ' S ' Structure • ,= � Mineralo 1� I � � l HORIZON III DEPTH �C. t� � �'� Texture rou -_ �� � S i G C �*� Consistence � j- Structure Mineralo '• I ' HORIZON IV DEPTH Texture rou Consistence Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON - SAPROLITE CLASSIFICATION I`.5 LONG-TERM ACCEPTANCE RATE " -0� D• 5 SITE CLASSIFICATION: ��J EVALUATION BY: ��� '"� LONG-TERM ACCEPTANCE RATE: �• S`�•�� OTHER(S)PRESENT: 1 J_ REMARKS: s � � " �t � v w`v %���KZ a� 1s,��. . C� � �w�;t nJ , " 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-Veryplastic Structure SG-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloav . 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) LTt�R`='Lorig-term acceptance rate-gaUday/ft2 DCHD OS/99(Revised) " ,. � ,: ■■��������a■�■�■��■����■��■■��■■�����a�■■■������■��■��a�����s�■��■ 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'� „v; ` .. � ¢,��:��._ . =� �r k � � ��� ���� x. �� � } , � a . , . �a .?i°d � ' , - � , �, ,� w„� 's �_s...., _�o-.a�m�,, 4� , ,.. �. „..o � ., . . ��r..�. : ' ..w�.„_.. �: � � + � - . ,. ' . . • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 /Fax: (336)751-8786 January 26, 2004 Mr. Joe Caudle 240 Jack Booe Rd Mocksville,NC 27028 Re: Site Evaluation- 2.51 Acre Tract/Liberty Church Rd Tax PIN#: 5804-40-3325 Deaz Mr. Caudle: As requested, a representative from this office visited the above site January 23, 2004 to perfortn a site evaluation. Based on the information provided on the Application for.Site Evaluation and after the evaluation was completed;the site was found to be provisionally suitable for the installation of an on-site sewage disposa.l system It should be noted that due available space,house location and complex topography on the site, an innovative system that meets the�25%reduction requirements of Rule .1956 will be specified for the initial installation. Additionally, a pump station may be required at such time that a repair of this system is necessary. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct,the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at 751-8760. Sincere� � Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s)