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273 Orrell Trail � � . DAVIE COUNTY HEALTH DEPARTMENT ' ' Environmental Health Section r.o.sog sasnio x�P���sr��t Mceksville,NC 27028 (33(,)751-87G0 Account #: 990001852 Tax PIN/EH#: 5870-70-8397 Billed To: Jeanette Cornatzer Subdivision Info: Reference Name: Location/Address: 273 Orrell Trail-27006 Proposed Facility Residence Property Size: 5 acres ATC Number: 4108 As stated in 15A NCAC 18A.1969(5) accepted Systams may also be used 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 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 WASTEW ONS IS VA FOR A PERIOD OF FIVE YEARS. ? � Environmental Health Specialist's Sigr�at re: ate: �` � J `�a�� ��e,w-�;� aM r CE TIFICATE OF COMPLETION ���C► ���,,��P�C''�'"� 1- / '�*��(�.i�The i'ssu�ance�ofthis Cert'i�icate Completion shall indicate the system d cri d on ImprovemendOperation Permit ��_ has been installed in co�pliar e with Article 11 of G.S.Chapter 130A, S ti .1900"Sewage Treatment and � L Disposal Systems,"but�hall m N�WAY be taken as a guarantee th the ys will function sati'sfa�torily for any given period of time. ; 6 • � G,,,�•W S3• x ��'� _ to��nK y-�?-o�' / � � ��� ; �.( S�P w�K Rs hor+�cw�- � -� �' �c,� �' R�b o���*��- � � , ���j N�w _� � � l \ o\ a ���, � ��.G � �� :� � / ��' � � _ �z' 2 ` f� d��'-'� i �. �. � � �« �,I , ` -q �3� � ��`� ( � ` 1 ��% �'� � �v� S•� � ( , � ,_ ,� � i - �_" �'�� W o'vY.? C,..�_ . ...._� � � +, � C,n e c.4t ,,,_�. Septic System Installed By: �GtK � �._ �y _� -D Environmental Health Specialist's Signature: - Date: DCHD OS/99(Revised) ' DAVIE COUNTY HEALTH DEPARTMENT ` ' Environmental Health Section /�� �/�/�- ,�� �.... � ..,� P.O.Boz 848/210 Hospital Street ✓% J Mocksville,NC 27028 (33G)7S1:8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001852 Tax PIN/EH#: 5870-70-8397 Billed To: Jeanette Cornatzer Subdivision Info: Reference Name: Location/Address: 273 Orrell Trail-27006 Proposed Facility Residence Property Size: 5 acres ATC Number: 4108 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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 THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type L`(�',�G #People � #Bedrooms 3 #Baths�_ � Dishwasher: � Garbage Disposal: � Washing Machine: �/Basement w/Plumbing: � Basement/No Plumbing: ❑ � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 �" Lot Size 5�el� Type Water Supply ��L-1..4r Design Wastewater Flow(GPD) �� Site: New�" Repair❑ � System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�1'� Rock Depth �1��� Linear Ft.�� I';.� �;�o�� Ia 15A P:CaC 1�9.13 a�'�5�) � Other: � ��5���� rt"�cyc,�.�g ��_��_� �yr.tcmr, m�y ��s� C� u��d 1 r� Required Site Modifications/Conditions: �'�`��'"�'�— � �-a-'�'b��'t?2 �� ��,FQcN•, CQ,�� � �tY� �72aw� �,3,:.�L ti � 11�9PROVEMENT/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 a.m. or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** �� + D� �tica.5`+ y'� � ��y"�' ���,Q.�—,�..a�'��9 �,�_32 � ��� � 00 � � �� � �C��a��e- A�. — � � � �� �� � ' ��°7 , v' �'��.5 c�e� �-►.�� �, � �P�^ '�,�� �C�►-��� �s�--���o.� �' ��-�'^,� � ��`� c,; s�sz.-,�- r�-`''''�t �"� �,� �``-� ,, „ �j��Uw � t1 v Q-� �33'�.3c� ��Z (� �v�.✓e� ��`� I � 9�,�"� ��' � ii �,�, P�,,,,�,�M • Env ri onme�t�HealtL Specia ist's Signature: e: �JO� M �!c � �7 �� DCHD OS/99(Revised) Y �� _ . 3 : � v � � � �I � . : , �� , � - � � , _ ,� � � � � � t _ _ � � � - � '" � � 1' . � � , � �� _ � � a t, 3� . ' . y . � d«, Y+ ._ - ,i a ,: �. .__ . y », _ m � � _ E-' _%� F �_ :�` �, �kS �-«�,w. � g� i � ^;�, � i . ` � �� � � � � O � � � � � � -� � � .y: ��, ,�� - � � ,-1 , . 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' � . .. . • _w„ .:- -z" ,. c . � `.�_ . ,� � ...� � r� „ � , , . - ._.__._-___. __ _ __ __. _..__ _ _ _ __.__ . . . _ .. . . _ . . .. . _ ._ . . _._ _ -_ ._ .__-.- __—_._ _- .— __—__-__--_._. _ .__. �I , • . � '/.��1� a�� � � � �� A LICATION FOR SITE EVALUATION/IMPROVEMENT PERM1IIT&ATC O�� � �� ��j? Davie County Health Department 1�l / -�� Q �' Environmenta/Hea/th Section ��- yL � ���� �- � P.O. Box 848/210 Hospital Street � , J � ��I� �- �� v� , N Mocksville, NC 27028 � �`�Z��� (336)751-8760 „�,� ,�l _� 4 �� v ' ��, � ***IM TANT*** TFiIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED � I TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. _ � 1. Name to be Billed 'JC.;.G✓lG��� UDirl'�O1�ZCf Contact Peraon Je�ne�� �D(�Y1Q1 Zef- Mailing Addresa �7� /�)y'y"� �� �y"Q� I Home Phone 7 7 d - "/lv� I City/State/ZIP � �Ja�ee /v t_, r,7 /Q��: Buainesa Phone l, ��I - �/,�� ��"7"� 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zip 3. Application For: �Site Evaluation LU" Improvement Permit/ATC � Both _ � 4. System to servtce: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type aystem requestad: LY Conventional ❑ convantional modified ❑ innovative 6. If Residence: # People _�_ # Bedrooms � # Bathrooms �_ Diahwasher Garbage Disposal �shing Machine Basement/Plumbing ❑Basement/No Plumbing 7. If Buainess/Induatry /Other: verify type # People # Sinks # Commodea # Showera # Uzinala # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallona per day) e. Type of water aupply: ❑ County/City . W'well ❑ Community 9. no You anticipata additiona or expansions of the facility ttiis system is intended to serve? ❑Yes ,�No If yes,�vliat type? ' ***IMPORTANT'"**CLIENTS MUST COMPLETE THE RLQUIRED PROPGRTY INrORMATION RGQUEST�D I3ELOVV. Eithcr a PLAT or SITE PLAN MUST BE SUBA7ITTED by the client witl�THIS APPLICATION. Property Din�ensions: � �e r�S WRITE DIRECTIONS(from Niocksvillc)to PROP�RTY: Tax Office PIN: D�f�l 'I►�Dm �N� �w� g61. fa K� �arna�ze r Property Address: Road Name ,�73 !�rr-�1 J Tr', �C�, �QS� ���'�U D t� ���� , s�p0� Dn c�tYiz;r �v'r� n�e_, ,�17�U� ri a hf, F;rs-� road s a n ,�✓� ,C e��-, If in a Subdivision provide information,as follows: Dfrel� Tr'a��� e rDSS 1-'G i�r�QO�, jJ C'� r Namc: �� � a-'�(7 " �3 6 / ti ►� �' r1�L Y1C�1C (" DYl 1 c�,��": ��._�_. ' Dt.l '�'o �Dmesi�'C�. Section: � Blocic: Lot: nte home corners ilaggedc y �, S �J ,,,� —1i cc� S���/ � S s�� Tl�is is to certify tliat tlie information provided is correct to tl�e best of my lcnowledge. I understan�tl�at any permit(s) issucd I�ereafter are subject to suspension or revocation,if the site plans or intendcd use changc,or if thc information �J" submitted in this application is falsiCed or changed. I,nlso, rrrrderstand tliat I nni respo�isiGle for n!!cliarges i��cttrred fra1� ri,�s Rrrrt��,r��,�. I,licreby,give consent to the Authorized Representative of tlie Davic County�Hcaltli Dc artment1 to enter upon above described property located in Davie County and owned by .,J�eQ►1 C���� �D T'Y�Q 1 Z� �" to conduct all testing procedures as necessary to deterniine tlie site suitaUility. DATE � -/g-Q�J' � SIGNATU � THIS AREA MAY BE USED rOR DRAWING YOUR SITE PLAN(Include all of the follo�ving: �xisting and proposed property lincs�nd dimensions, structures, setbacks, and septic locations). � � Site Revisit Cliarge `. . 6o Datc(s): �/�- ���� Clicnt Notification Date: �//�� G!_� � �5�� EHS• . Sign given ~ I CCAS� ��1 �� � e� �� L!�VY� i►'�a , Account No. � Z .�1 Revised DCIID(OS/03 �" � �L� �J b � �� S� �� � Invoicc No. � � �k'e�r�� � ���q �,�� � 5 .tr _ ' — � . . � �/ - Q � � �� � � � � 2.t � 36: � ( � � 76.74A � 0361 � 113.80A . 198 ' �� � g � J I "� W / � . � O 1 / / I / / ' � .:.471.p$ � � 273 � . � �� 5.00A . . J � � ''��8397 �-.�. .. .. � � � 27a � / / � ' �.�ti / / / • � � / / / / � � `/ / � / � / � / � � I / � � / 1 � , � I � / � \ ca.ean� ��1 � � � � 1 / ( � � � � �io.aen� � esa� � � � � , - DAVI� COUNTY HLAL'Tli DCI'ARTM.CNT i � � � Environmental Health Section Soi�/Sitc Evaluation API'I.ICANT 1NFORMATI0IY I'ItOPER'I'Y INrORMATION Account #: 990001852 Tax PIN/EH#: 5870-70-8397 �Billed To:. Jeanette Cornatzer Su�division Info: Reference Name: � � Location/Address: 273 Orrell Trail-27006 Proposed Facility: Residence Property Size: 5 acres Date Evaluated: V '� � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut ' rACTORS 1 2 3 � 5 6 7 Landsca e osition L �— � Slo e% a o �C HORtZON I DEPTH Q r`f ti� • O'SY' Texture rou 5�-�- C-�— S CL Consistence G-S5 "j(� � j Sn Swcture C G�'^'- C-i Mineralo S--'YP S�k.P HORIZON I[ DEf'TH - (c�-1{ b - ��L.- Tcxture rou �;C- -C_ �-' Consistcncc - TS ��S �'� Structure ' �'It- l�.- Mineralo � '' � HORIZON I(I DEPTH 2c'- � -r •-3 � Texturc rou �c� �}� C=+ �, Consistcnce � � s5 S Swcture - '`�, Mineralo ��% �% � HORIZON TV DEPTH � f-F • Texture rou ` - Consistence Structurc Mineralo SOIL WETNESS RL'STlZ1CTIVG HORIZON SAPROI_IT� CLASSIFICATION - �5 LONG-TERM ACCCPTANCE RATE �,�S , � S1TE CLASSIf1CATI0N: �VALUATION BY:C_ — � t�(` !/.�v�✓ � , � ✓ - LONG-TERM ACCEPTANCE RATE: O�� OTHER(S)PRESENT��`� ��� `��l��IC. RLMARKS: LLGEND ' • L�ndsca�c Position R-Ridge S-Shouldcr L-Lincar slope FS-Foot slope N-Nose slope CC-Concave slopc CV-Convex slope T-Terrace FP-Flood plain H-Hcad slope � Tcxtt�rc 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 S1C-Silty clay C-Cla"y ' CONSISTENCE ois VFR-Vcry friable FR-Friable FI-Firm VFI-Vcry firm �FI-Extremely Crm Wet ' ' , NS-Non sticky SS-Slightly sticky S-Sticky VS-Vcry Sticky � NP-Non plastic SP-Slightly plastic P-Plastic VI'-Vcry plastic � ' ru t �rc _ , 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky . SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�y ; � 1;1,2:1,Mixed_ ' oe �' . Horizon depth-In inches - ' Dcpth of fill-In inches Restrictive horizon-Thickness and inches frott�land surface `. 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