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172 Woodward Rd , DAVIE COt�NTY ENVIRONMENTAL HEALTH 1 ' ` , P.O.Box 848/210 Hospital Street Mocksville;NC 27028 (336)753-6780/Fax#(336)753-1680 � OPERATION PERMIT �ccou�t �: 990005648 T�x F�INiEN#: 5840-22-0121 BiIle;� 70: Helen Krige Su��di�isian In�c�: � Re�er�Etce €�ar��e�: Sam Morgan � Loc�iioniAddr�ss: Woodward Road-27028 �ro�t�s�;c9 F�w�i€ity: Residence . �Eo��c�.y S�iz�: 1 Acre ��'��*�*The�ss8uance of this Operation Permit shall indicate the system described on the ATC 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 taken as a guarantee that the system will function satisfactorily for any given period of time. ' i ,. � System Type: ,c+- S.T.Manufacturer �i0 Tank Date�7`_"_ Tank Size/��✓D Pump Tank Size ' A � �� fW ' System Installed By://Q��(l�.t E.H. Specialist: ' �° ate: � Z41� GPS Coordinate: �� . • �, '3� � �5L � ' ��' ) � � � 9 � r� � � . ��, � � . � � _ � � � � ,� .� ., � �:,. , C� � _ .�,� � � DCHD 11/06(Revised) ��,�� ,• ' , ° i DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax# (336)753-1680 ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �ccour�t #: 990005648 T�x�'I�.%EH#: 5840-22-0121 Bille:r�70: Helen Krige S��E�divi�ior� ir�fa: l��fer�r�ce Nanie:: Sam Morgan LocaiioniAd�lr��s: Woodward Road-27028 � Pro�o�ec9 F;�cility: Residence l�ro��r�y S�iz�: 1 Acre f�TC f�ut�b+�t': 5758 Site Type: 9dNew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental '`'""" Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. �• Residential Specifications: #Bedrooms �#Bathrooms � #People�Basementk7 Basement plumbing❑ � Non-Residential Specifications: Facility Type #People #Seats Square Foot�age(or Dimensions of Facility) Lot Size��_ Type of Water Supply: ❑County/City fy�Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size�G�{) GAL.Pump Tank N/� GAL. Trench Width 3(�` Max.Trench Depth 37"Rock Depth� Linear Ft.�/�0 �it f-� ; �: �C�t�d i7 15f� i`��iC 1��°� 1c;��;j� '�cs��0�1�-�� Site Modifications/Conditions/Other: �r�rrnt�d 5vst�ms m�v �!so � ��s�:� Contact the Davie County Environmental Health Section for final inspection of this system between 8: 0—9:30a.m.on the da of installation. Tele ho e# 336 751-8760. I ��i . �►° �.�� 1 �tio•� , f�1\�� L �� — — � � � �gr�1t5' �4 'I 1�, tY � � . �2�,�� ,n.. ._ __ _ , _ - , , ��°10 �I�Q�`�' �� i , � I�.+�c�� j � 2� /� l c ��,,.�. � � � _ _..� _ � . . � -1. -'�-� .� Environmental Health Sp cia�s Date: DCHD 11/06(Revised) /��l/�LNI� . (� "�-Y �/Z Z!)(I l �-�"� � i . .-� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health � P.O.Boa 848/210 Hospital Street Mocksviite,NC 27028 �' (336)753-6780/Faa(336)753-1680 � �\� Application For: ❑3ite Evaluation/[mprovement Permit [�/I�orizaGon To Construct(A'fC) ❑Both. ,� Type of Application: ONew System ❑Repair to F�cisting System ❑Expansion/Modification of Existing System or Facility v ','l-� +"IMPORTANT""THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED �` �'��C INFORMATION IS PROVIDED. Refer to the INFORMATION BIJLLETIN for instructions. � � APPLICANT INFORMATION Name to be Bille l Contact Person � C� {� QL Billing Address . Home Phone � _. , City/State/ZIP�n��-dyl- , OeiYvL� '�Z Business Phone — '' ' \ Name on PermidA C if �erent than Above {� Q, `� � ��(,( ` Mailing Address � City/ ate/Zip �Z, ,� �J � PROPER'TY INFORMATION *Date House/Facili Comers Fla ed � ( NOTE: A survey plat or site plsn must accompany this application. Included:�Site Plan ' at(to scale) (Permit is ali for 60 on with site plan,no expiration with complete plat.) � � � �l Owner's Name Phone Number 1 Owner's Address � ity/State2ip C.� V �� Property Address 2 ity Z��', �n Lot Size �Q� Ta�qP�IN# (?i �� Subdivision Name(i applicable) 1'r Section/Lot# J ,! Directions To Site: Y4 ��✓� If the answer to any of the following questions is`�es",supporting documentatiop must be attached V �(' q �� Are there any e�cisting wastewater systems on the site? ❑Yes d1Vg ` J ` Does the site contain jurisdictional wetlands7 ❑Yes C33Qo Are there any easements or right-of-ways on the site? �s�N��o i_� r�., tn A n,,�, ,_n 1 Is the site subject to approval by another pub]ic agency? � �Yes I.�o �P• �J �� K�•( l.L�)CJI. WiII wastewater other than domestic sewage be generated? OYes C�Aio IF RESIDENCE FILL OUT THE BOX BELOW #People �_ #Bedrooms �_ #Bathrooms � Gazden Tub/Whirlpool es ❑No $asement: C�Cs ❑No Basement Plumbing: �s ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: nventional OAccepted �Innovative OAltemative ❑Other Water Supply Type:0 County/Ciry Water qytvew Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions ofthe facility this system is intended to serve?0 Yes [�i6 If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter aze subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative ofthe Davie County Health Department to conduct necessaty inspections to detertnine compliance with applicable laws and rules. I understand that I am responsble for the proper identification and labeling of properry lines and comers and 1 ing nd fla ing o t ie house/f i'ty I , tio ,proposed well location and the location of any other amenities. operty owner's or er's leg re sen ahve sip�(ure Site Revisit Charge l% Date(s): � Client Notification Date: Da e EHS: Sign given ❑Yes❑No Account# ��Q Revised 11/06 Invoice� _i/�'"' . . .-... � � STAT£ 40 CURVE TABLE �S� CURV£ RAO/US LENGTH CHORD BRG. CHORD D/ST. o � Cl 66.?0' 1 .04' S1 29' 1d04 � 66 .20' 30. ' SlT 44 30.09 RD �y C3 66.20' J50.49' S.33'S5 4l .N6.�6 Cf /4.T7' 329.86' N7 329.69 ,`AD V�C M/`I/� N.T.S. � �o ' � 2�$'�Z , "E c; 3 N�2�31 2 N � N � 42' ROPos�n `T` s£Pnc z �� ` v -• 45' � N � � � � 3s. � 46� o � � � � � �o� � � _ �,�$ N �mo � �S�' w . � 0 305' S0 � i � •O,��E � / / N W 9, PROPOSED 3 ,3r�"�V �"� �►�� 2• � c� N68� i «, � . � 5 -, � 74 , v � n / / PRNATE ACCESS " 2�8�72 N � AND UT1LlTY EASEMENT Z � � ��' DEVELOPMENT PLAN �o O �T O 4 �'c THIS PLAN !S FOR A PROPOSED LOT ON FOR �O� HELEN B HOOVER S UUVO, A RECORDED MAP NELEN�. HOOYER �O /S BEING PREPARFD, AND AS SOON A5 TNIS MOGKSYILL.�, I1�G Q � LOT PASSES, W1LL BE RECORDED. D�4NlFL L. 5TANLFY, Lr4ND SURYFYOR ZON/NG: R-A rvixs ori s.at�r�i,rr�Krt�c�ounr�a THIS MAP /S NOT A CERAFIEO SURVEY AND 336-768-5142 !S NOT FOR RECORDAAON CONVEYANC£S 6J?�4PH/G 5G14LE �-�, f' = 6Q' . . . Dar�f. . v�. !►�w?.1.�. (_prs�PRP.�LOT f p�y�.AG4 . .�. . . . . . 60 30 O 60 /20 OF, . . . . . . � . . . . . . . . . �4 . . . RAT BOIOK . . ./VA . . . . . . . . f'�. .KA. . / /NGH = 6�T � ''K. . 38� . . PAF,�. 229 , T�P�a � 5�!�P�201�21 . � ' Davie County Environmental Health � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005648 Tax PIN/EH #: 5840-22-0121 Billed To: Helen Krige Subdivision Info: Address: 423 Burkewood Drive Location/Address: Woodward Road-27028 City: Winston-Salem Property Size: 1 Acre Reference Name: Sam Morgan Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of.G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permrt T e:__._....._.�..._...�.�......_�.._.�._._._._._..____.....�._�__..��.__�._ �.._._..�_ ._.__._.___._..._._. .. ._____ _....... . .........._.___-- yp [�Tew ORepair ❑Expansion Permit Valid for: �Years ❑No Expiration Residential Specifications: #Bedrooms�#Bathrooms� #People�Basement�--Basement plumbingBl Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_.i`�'� Type of Water Supply: ❑County/City �Vell ❑Community Well Site Modifications/Permit Conditions:- � /� � s��i��',� S stem T LTAR Initial 2 S Re air �2 Site Plan ✓ � � t , � �� ,ao�' �, .� . . � '� ('� � . � o � N � , ��I`�1i a . lZ5 � �� : Environmental Health Specialist Date_�� i.p.l 1-06 ' � � �' C��.CJ�-- ��'��'-07X—� G,�t��'�-� , e U� ti • , . ��r TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health � �(��`� P.O.Box 848/210 Hospital Street :� M�� c. Mocksville,NC 27028 (33�753-6780/Fax(336)753-1680 ��j pp icaGon For: ❑Site Evaluation/Improvement Permit 0 Authorization To Construct(ATC) oth Type of Application: C�2�ew System ❑Repair to Facisting System ❑E�cpansion/Modification of�xisting System or Facility **f1MPORTANT"'THIS APPLICA"I70N CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BIJL,LETIN for instructions. APPLICANT INFORMATION .r�' �0�"`'ft � � �ZGZS•S� Name to be Billed i � 1�1�Qi Contact Person �"1 � 4'I G+L BillingAddress -► ' � � HomePhone � ��I��L��- City/State/ZIP C� . U Business Phone��Qyy�, Name on PermidATC ifD�erent than AboveC 'v" Mailing Address City/State/Zip yYl�� PROPERTY INFORMATION *Date House/Facili Comers Fla ed � NOTE: A survey plat or site plan must accompany this application. Inctuded: ue Plan ❑Plat(to scale) (Permit is v id for 60 mo ths w'th site plan,no expiration with complete plat.) Owner's Name +Q,4� Phone Number � ��L'�i Owner's Address � � (,(lCCk. � • City/State/Zip�Q� �,�� Property Address t1C- ' �' ity 5 7 (, Lot Size Tax P N# "'' r,'1 Subdivision Name(if applicable) Secf on/Lot# irections To Site: ! /1 Y��L LtO� G � If the answer to any of the following questions is"yes",supporting docum�tation m be attached. Are there any e�cisting wastewater systems on the site? C9�Yes ONo Does the site contain jurisdictional wetlands7 ❑Yes C�o Are there arry easemerrts or riglrt-of-ways on the site? Ch3res ONo Is the site subject to approval by another public agency? CTi'4es ONo Will wastewater other than domestic sewage be generated? ❑Yes�.Ad6 IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms � #Bathrooms�_ Garden Tub/Whirlpool es �No Basement: es ❑No Basement Plumbing: B'ires ONo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness � Total Square Footage of Building #People #Sinks #Commodes #,Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seais Type system requested: �ventional �Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:O County/City Water �i✓1�Iew Weli ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes �.2do If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted i�this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and niles. I understand that I am responsible for the proper identification and labeling of property lines arid comers and locya,ti�ng a d flagging or sta�k' the house/facility lo tion,proposed well tocation and the location of any other amenities. ' -�4-Y��''"^-� ��'^-'�i� Site Revisit Charge r Prope owner's o ner's legal representative s�gnature Date(s): � �—3 �-- /� Ciient Notification Date: Aate EHS: Sign given ❑Yes ONo gg Account# ✓�� • Revised 11/06 ,1� Invoice# •`�1/_, �� v'; �� v� , : � . , , MFIPSTAlE IO , �$/� CURVE TABLE CURVE R40/US L£NGTN CNORD BRC CHORD D/ST. o � Cf 666.20' 1Q.04' S13'?933 1�� C2 666.20' 30.09' S1TJ3'44'E .30.09 �� q0 fy � 666.20' 350.49' S5 411r .�� C4 2914.79' 329.86' N1 31 .�� /� �/�p �l� IY/H!" N.T.S. �� o ' i Z�$'�2 , "E N 3 , N�2'3� 2 v, N � N � /�2' ROPOSED m sEnnc z �� \ � , 45' i N CA � � 46� w � 36r O . � �= � A CA � �No � N �mv \ �S j� W � � 0 305' S0 . r , `� 68.0,�1 j i / / o � 9, PROPOSED S'�. 32"yV .-, �,, �►� 31 � n j � / �, � 74, �r � � � � N / / PRNATE ACCESS �-% 208-�2 � AND UTlUTY EASEMENT � � � ��' DEVELOPMENT PLAN �o O ��, O 4 yc THlS PLAN lS FOR A PROPOSED LOT ON FOR �Q� HELEN B HDOVER S LAND, A RECORD£D Ab4P H�LEN$ HO�VER �Q IS 8ElNG PREPARED, AND AS SOON AS TH/S MOGI�SYILLE, NG Q � LOT PASSES, WILL BE RECOROED. D�4NlEL L. ST�NL�Y, L.fiND SUR1/EYOR 26l3 WYNBROiOK DRIVP ZON/NG: R A �urisron►s,4cFr�r, r�oun-i c,aRounr.4 7HIS MAP IS NOT A CfRT1f1ED SURVE'Y AND 336-768-�142 lS NOT FOR RECORQAAON CONVEYANCES 6R�PKlG 5Gr4LE sGa�e. �" = sq' . . . Da�f. . .o,�. M�v?.�.�. �,pT�PRP_�LOT 1 q�y,�.NA . .MAP. . . . . . 60 30 O FO /20 G1F . . . . . . . Nf1 . . . . . . . . . . �64 . . . Pl./tiT BG1'�I!r . . .� . . . . . . . . r'�4F�. .K�. . / /NGH = 6l�T �ea.�. . 38 . . r'.a�SE. 229 , TAX P/4RG�L ?� ,S�B:¢01��1�1 . , , . DAVIE COUNTY HEALTH DEPARTMENT ��r • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005648 Tax PIN/EH#: 5840-22-0121 Billed To: Helen Krige Subdivision Info: Reference Name: Sam Morgan Location/Address: Woodward Road- 7028 Proposed Facility: Residence PropertySize: 1 Acre Date Evaluated: ��___ Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit �� Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% �,� % HORIZON I DEPTH -� Z - S/ .,� � Texture grou �' Consistence . � Structure ,� Mineralo J HORIZON II DEPTH 2-�/p Texture rou s C Consistence �C'� Structure � Mineralo HORIZON III DEPTH Texture rou ( Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE L � CLASSIFICATION LONG-TERM ACCEPTANCE RATE . 2 SITE CLASSIFICA ION: a'� EVALUATION BY: � � LONG-TERM AC EPTANCE RATfi: `�� J � OTHER(S)PRESENT: O /' , ,t.� iC _ REMARKS: -� LEGEND i.anda sca�e 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 CONSISTFNCF. 1?�is� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-Extremely firm � ;k , NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky -. NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ; S r� �r SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed L1o3.�S �orizon depth-In inches epth 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) TTAR -i.�no_tPrm art�t�ntan�a ratP_ oal/rla�i/ft� Tl+7iT hC�AG m__.___�� ■��/��/��/��■ ■��/��■��■��■��■��■�■ ■��/��/��/��/��■ ■��■ ■��■��\��■ /��■��■��\��/��/��■ ■��■��■■��■��■��■�■��■��■ ■��/��/��■ ■��■��i��■��■��■ ■��/��Oe��■ ■�■��o��■��■ ■��/��■ ■��0��/��\��■ ■��■��■��■��i■��■ ■��/��0/��/��/��\�� ■��■��■ ■��/��■��■��■��o��■��\��i��■ ■��■��■��■��■��■��■ ■��■��i��e��■��■/■��■��0��■ ■��■��/■��■��■��■��■ ■��■��■��■��■��■ ■��e��o��■��■ ■��s��o��s�o��■ iiiiiii�iiiiiiiiiiiiiiii:::��■�■��■��■��■��■��■ __�� ■��■■��■��i��s��■��■��■��■ ■��■��t��i��t�■ ■��■��■��u��i��e��■��s��■ ■��n��i��■ ■�■��■��i��■ ■��s��■ ��i��■ ■��i��o��v��■ ■��n��i��o��s��■ ■��■■�i��n�■��■�■��■��■��■��■ ■��i��o��i��s��■ ■��i��■�■��■ ■��::� .�:�:�� ■��:�■��i�■��:.�n��■��■ ��o��i��■ ■�■��■��■��s�n��■o��■ ■��■��,��n��■��■ ■��■�■��i�■��■��■��■�■��■ ■��i�s��■��■�o��i��■��■ ■��■�i��■�■��■��t��i��■ ■�e��■ ■��■ ■�i��■ ■��■�■ ■��■ ■��■ ■��■ ■��■ ' ■��■ ■�u��io��i��o��n��i�� ■�■��■■o■■��s��■�_.�■�■��::��i��■��■��■ ■e■��,��■��!�:t��:��■ ■��■��■■��i��.��!n�;��n��■��■ ■��i��a��r.:;,i��►��t��■ ■��■��i��■��n.��■�■��■��■��■��■■�■ ■��e��;��z��>:�=,��i��■ ■��i��e��.•_�-_;��;��rrn��i��■ ■��i��cr.��i�s��u��i��■ ■��■��■�iis�_rs,::��i��i��n��a��■■ ■��i��:i��n��■ ■�■e��rru��■ ■��f��t��■ ■■■��■��I��E:!Ii,��■��ll�■��■��■ ��f■��f11��/��il��/��■ ■��!■��tuii��/��11��■■ ■��L!!=�o��r_ ■��r��1��/�/■ ■��Y��■��■ ■�/��l��l��/��/��0�/ ■��■��■��■��■■ ■��■��■ ■��■��■��■��■■��■��■ ■��\��/��■ ■��■��■��■��■ ■��a��■��o��■ ■��■��■��■��■■��■��■��■��o��t��■�■ ■��■��■��■��o��■��t��■ ■�■��■�■��■��■��■ ■��■��■��■��■��■��■ ■�■��■��■�■��■�■��■��■��■ ■��■��■ ■t��■��■��■��■��■ ■��■ ■��t�� ■��■��■��■��■��■��■ ■��o��■ ■��■��■��■�■ ■��e�� ■��o��■��■��v■��■��o��■ ■��■ ■��tv�� ■��■��■ ■��■ ■��■��■��■��e��■��■ ��v��■ ♦ • _ y . " � � � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005648 Tax PIN/EH#: 5840-22-0121 Billed To: Helen Krige Subdivision Info: Address: 423 Burkewood Drive Location/Address: Woodward Road-27028 City: Winston-Salem Property Size: 1 Acre Reference Name: Sam Morgan Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: ONew ❑Repair ❑Expansion Permit Valid for: ❑5 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: ❑County/City OWell ❑Community Well Site Modifications/Permit Conditions: S stem T e LTAR Initial Re air Site Plan Environmental Health Specialist Date i.p.l 1-06