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182 St Matthews Rd (2) � ' DAVIE COUNTY HEALTH DEPARTMENT �'� - Environmental Health Section . . . P.O.Boa 848/Z10 Hospital Street � � � Mocksville,NC 27028 (336)751-87C0 �� y�7�� IMPROVEMENT/OPERATION PERMIT � Account #: 990003081 Tax PIN/EH#: 5707-78-2962 Billed To: Teresa&John Santis Subdivision Info: Reference Name: Location/Address: St. Matthews Road-27028 Proposed Facility: Residence Property Size: 7 +acres **NOTE�*�Th�is�mprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � � #People�_ #Bedrooms � #Baths � Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �•g�S Type Water Supply ��- Design Wastewater Flow(GPD)�_ Site: New�Repair❑ 1 System Specifications: Tank Size �O�GAL. Pump Tank GAL. Trench Width �� Rock Depth �2-� Linear Ft.�� � �h�: �� ��v��oa �,� - � Required Site Modifications/Conditions: j�-�t�- �w coN�-o�?�: � ' �s' �F� �� �a�� ���.. IMPROVEMENT/OPERATION PERMIT LAYOUT- APP FFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative f the Da e County Health Depariment for final inspection of this system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m, n�t�ie�y f installation. Telephone#is(33G)751-87G0.**** 33•x�'x�2" c�`�``' . �33 � � �3y ' ��p � r SQ' � � � ' T L'�'1.3. Q / �F��� ���s ti� ��.� l�°,�s`' s� ��--� ��'ri�r�..�Ss-I,�.�..ot� � ;' � �^'''" 4� (�0� '� .AP�x- 2�b' , � nvironmental Health Specialist's Signature: Date: �, �h'�1��5 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 #: 990003081 Tax PIN/EH#: 5707-78-2962 Billed To: ,Teresa&John Santis Subdivision Info: Reference Name: Location/Address: St. Matthews Road-27028 Pro osed Facilit : Resid n + ATC Number: 3699 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 WASTEWA CO U TION S VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature• Date: �0 (� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Seyvage 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 � ��� ��� ��7 �'�v � I�v�r 19 �ti � ' 2 '� ��� ; 2�' ^j ,. , �'/J �'y f ��j� � �Q�K-��i� • $-2�-�-t Septic System Installed By: � ���''�� Environmental Health Specialist's$ignature: Date: � ' DCHD OS/99(Revised) � _ _ �: � �; � �� � d � _ �., � . D . . � F EB 2 3 2004 ac ior�r-or;sir�rvf�Luar�oN��hinicovensri�rr i�ui��ur s�ni c� � . Davie County Health Department - � Enviro�i»enta/Healfli SecGon ENVIRONPlIENTALHEAl11i p,0. Dox 84II/210 Ho�piLa1 S�ree� � • DAVIECOUNTY biocksville. NC : 2702II _ (33G)751-II760 • --------....._ � ***IMPORTANT*** TIiI5 APPLICATION C1INNOT I3� PROC�SSL•'D U21LLS5.ALL TIIL R�QUI1tLll . INFORMATION IS PROVTD�D. ReEor �o L-ha IIII'ORMATION IIULL�TIN tor in:,L-rucL-ion:r. ••: -- ._/.►f _..._............... ... 1. Nsmc to be� Dilled �e/'PSQ '� VDI7h L C[hGJ$ ConL•acC Pcraon �ChK `_�_,�th�l$ , . Dfailing Addre3a �oG 7 �7 h A�i/ K,k 0�� �Q/T C Iloiac.Pliono �9oC. ` oC._�_�..q . _._ . Ci ty/3 tatc/ZIP /�D C I�$V/ I�C� N C ��OaZ�I Uuaino�a Phouq ��__:,/.9I... D,� �6. : ' 2. Namo on'Pcrmit/nTC if DifEercnt than ]lbovc_ ,�(X/'77e '� ' ` � � Mailing Addras3 : .._: City/StaCc/zip �' 7. Application For: �v^ite �valuation # LY�ImprovrancnL- PenniE/ATC `.Cl DoCli � 4. system to service: 18( House ❑ t3ob.ile Home 0 Du�ine�� ❑ TndusLiy � OCl�cr _ . . . ,�. ' ' _' –.- — 5. Type aystem requested: �Convnntional ❑ conventional modi£icd ❑ innovaLive � • ' 6. Tf Residence: IF People �� 1F I3edroom� '� II .ISaL•liroou�:; .. , oZ,A � LN'biahwasher ❑Garbago Di3po�a1 LT3Washing Machino ❑Ba�emenC/I�lumUinl ❑IIa^emenL•/No l�luiubin� 7. If Duaiaeos/Indu�try /Othor: veriEy type /�/�Q �f Ycople IF SinY.a ._�___, � Commodo� � Showers � Urinala � IEiVaCcr Coolcra __�_� IF FOODSERVICE:. #� Sea�s �Q� Bstimated Water U3c1gC (gallona per.Qny) ___�__ 8. Typo of water supply: 0 County/City . Gd�Well Cl .Communi L-�• . . i . . 9. Do you aaticipatc additiona or ctipa�isious of thc facility this sySlClll 1S 113IC11QCd lU 5l`1'1'c:: ❑ 1'CJ , . 'u Ir)'CS�1}'118t t�'I)C? . ***tnr�onT��v�**.c�iLrc�rs�ilusTconrrL,ezL•r�ic: ruguutLv i�xoi�Lirr��i�roizn-t,��i•iar�����ui.sri�u �-. L3GLOtiV. i;iqura PLA7'orSIT�PLrIN iIfUST!?LSUIlhIl77'GD by tl�c clicnt �ritli'17l1S r1!'i'LICA'I'lO1V. � 1'roperty'D1111CI1S1011S: � T �� 1YR1'tL lllKLC!'lOiVS(fruiu 11•lucics��illc)tu PltOl'I;lt'1'1': '1:ix Officc 1'IN: fE JjU���`�6�'� q � � � Hwv. �� ��o S�a �esvr�/r � �` '. Property Address Road Naiiic_ S�: Ma��/�e W5' I�c�. .�.e t�� �z� C Ct h t�lt P!'' S Y v t C ��Y: (on u ar Ze lacadem y . Rd.� . . Cily/Zip /��ockSVi/�e a270.28 L'ros� 1— 'f� 6ni'cLae — ' II1i1�SLLli(I1Y151031 Pl'OYl(IC 111rU1•niatioii,as fullotivs: �� /rr i�e � b K /�i�o j7� - i�Y v�e I'�3/ , ;' Na,��c: _� C. �. /tre c �� Oe ,rr a � � OG C h � c�C ' S�;./'I L���G Zc1 S �. . _ ��r C�urc�, . Scctioii: Bloclt; Lot: Datc Iiomc corncrs II:ibbcd: �� /�SF�- d � `.: Tbis is to ccriify tuat tlic iiifortuatiou providcd is corrcct to tlic bcst of tiiy lciioSti•lcdba !uiidci•slaud (I�:U:uiy 17ci•iiiit(s) . issucd ucrcaftcr are subjcct to suspciision or i'CYOCA�1011�lI tI1C S1�C nI�I1S OI'111�C11(IC(I USC CIl:l11bC�Ui•if Uic iuforui;�ciuu ' submittcd iu ll�is applicatiou is falsiGcd or chanbcd. I,also,«ndc�rstrrircl lltnt t crn�rc��7�arsiGle jur al1 clrrub�cs i�rcrrrrrd fi•um. � !lris upplicaliar. I,licrcby,gi�•c conscnt to tlic Authorizcd Rcpresciila(ivc of lhc 1)avic Couiily IIcalUi l)cpar(u�cu( lo cutcr. upon abo�•c cicscribcd pi•ui�crty localcd iu Davic Couiity and otiti�iicd by ,Jn{�x � �r e 6lt. �.Gt.k��"S _.: ' �lo conduct alI lcsting pi•occdures as licccssary to dctci•tiiiiic tlic sitc suitabilil��. � � . � DAT'E o2 -�Z�� D '� . ` `� . ' SIGNATUI2�_�/qht,sQ_ - t[�t.�mlr;��. TIiIS AItEA 11'IAY]3E USLD FOR DRAWING YOUR SIT�PLAN(IucIudc alI of llic follotivinb: Lxisliiib:u�d pruposcd , r. property lincs and dimcnsiotis, structw•cs, sctb�cics, and scptic locatious). � - '. ' ,,...� « ...; x......_,.,---__�. 5ilc Rcti�isit C(uu•�;c �, . f - � �� llatc(s): .. ��=� . _ . , . • � ' Clicnt Nolilicalioii Datc: ,�- . . , ; TIIS: � . . ,' _ ���",W�, • ' Sign given L • Accowit Na �_� ,� 1 �� / �3Z . Rc��iscdDC (05I03 `��'c'�?,�� T„��;���x�. `� " � � � � � � I� � � � � , � � , r, � , , ... , � �.-� ;� � IND��"�ED t�N ; � . � '�� ' �� , , � � ' � , ss ' � 5708 I � ' � 4�,54 f �� � , ;. ,, , ; �, ; , , , 8� , � F369) ; � `--=�... (30 , � ,r � � ��' -�__ .""'-�,.�� � ! ' ' ' R � � � , � � , � ��. � ' c � � , �. � � _ _ _ _ -� r i ; � , �4� i � � �� � ; � ��� �8 ; i � � � � ' � � , , , �. ' � " � � � ( I � � ' � � (3.2�. " ('i.464A} � <'26) ' �., ��. ' . , . �M ry � .. � � 66� �: � �� r � ��'��+ .�..r 3'� � �M , � � 2� � � , � � , � ,; , � , � � 29 330 � 6556 rn I , �. � �- � , 27 � 359 I: 4 ,. � � � � � � ,� ' - 1 , _ 39 - ______ , ____________ � L� , , , � � . , , � � � CL � � �� �.09 A) ;' ,< � , � , � � , i � (9.46A) � � � ` � ' � � 7009 , 7.8A � � � ) � 2962 i � , � �' � � r-,�..��� j �".. �I �'"'--- Qo0 M � I c�• � � 1`- , � 'y � i ti- � P � I y � � ti• �y.3 ��� .:� 3 �� a,o c.� , �� I � � � ' i � I h� '" ` � � � I � �i ' � . I �.--' .� � � . . 903.93 142 ,�' •`� � �� � 1033 , ,. ., ��4 "�-�-._.,, � .' � � 10 __ _ _ � � 2 214 � ��� 22g .._� � � � (18.22A) � 6094 � (15.86A) � I ,�-, � 6971 283 �O II � 155 �p�, . � r , '7 � ... . :.. � ... . . . . . ... . . ....._............... . � . . . . s, �'� ' � . �. . . . . . . . LJ�I c..+*l�; . � .N � . . .. . ... .. , . j� .... � . , . '�. �'�. ..- �— �-- .___.. . .. _. . . � . . � �� � � :� --- — --JI � , DAVIE COUNTY HEALTH DEPARTMENT J = . Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003081 Tax'PIN/EH#: 5707-78-2962 ' Billed To: Teresa&John Santis Subdivision Infa Reference Name: Location/Address St: Matthews Road-27028 � � ) Proposed Facility: ,Residence Property Size: 7 +acres Date Evaluated: � y ,c�7 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 E��-' lr,, ` Texture rou AiO.�,'�O'� Consistence (�7Cc�d,T� � Structure Mineralo HORIZON II DEPTH �- �'2.� ` Texture rou 'P �' C-r Consistence � '-' �.1 �; S Structure � �� Mineralo ; (` � HORIZON III DEPTH ,� - � �£2—6} Texture rou L ��• Consistence .�S Structure Mineralo � HORIZON IV DEPTH Texture rou ' , �� , Consistence �r 5S P Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION � LONG-TERM ACCEPTANCE RATE . p. SITE CLASSIFICATION: � EVALUATION BY:C�- �� � � �.�,._.�J LONG-TERM ACCEPTANCE RATE: , OTHER(S)PRESENT: ��'-` � 't'1� REMARKS: 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-Very plastic Structure SC-Single grain ' M-Massive CR-Crumb GR-Granular ABK=Angular blocky SBK-Subangulaz 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) ■�����������■■■��O■0■���■�����■���■��■��■����lO■f�����■�■����e��■�■ ■�■������������■�■■■���■����■��■�����■�■�����i�■I■�■■��■5������■�■■ ■������■eo�a���■���■���������■o■��■■����■■��■��i■�■���■�■■■■��■�■■ ■������������■■����■�■�e■■�����■ 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