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153 Cornwallis Drive Lot 32 DAVIE COUNTY HEALTH DEPARTMENT /���5=2.�-o d Environmental Health Section 7;a°,. P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000673 Tax PIN/EH#: 5831-98-8052.32 Billed To: Jerry Kapp Subdivision Info: Pudding Ridge Lot#32 Reference Name: Jerry Kapp Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 1.010 Acres **N07"I'✓*'�` iisbgmprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION 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 q: #People Z #Bedrooms #Baths Dishwasher: Zr' Garbage Disposal: Cdr Washing Machine: Ef Basement w/Plumbing: ❑ Basement/No Plumbing: 173" Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ . Lot Size Type Water Suppl j�� Design Wastewater Flow(GPD) Site: New 0'*"Repair❑ r/ r r `/ � System Specifications: Tank Size�CiAL. Pump Tank GAL. Trench Width Rock Depth 1.3 Linear Ft.`ICO Other: Z ThsTE1 gOTO Ca `'Tb-LL U►JC,,S 9 1©.C.• 1l'l,►►J. Required Site Modifications/Conditions: LL UP.) �E-; 16 Q • W^�v IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6-BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this ystem 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.**** 721 V E El-�PoSs►��c ARP2s�c. vowez c Q 0 aC9 Environmental Health p iali is Signature: e: DCHD 05/99(Revised) PC-. • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000673 Tax PIN/EH#: 5831-98-8052.32 Billed To: Jerry Kapp Subdivision Info: Pudding Ridge Lot#32 Reference Name: Jerry Kapp Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 1.010 Acres ATC Number: 2421 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 WASTE W CO N IS V/AKID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this 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"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. s T 1� 114' Septic System Installed By: i Environmental Health Specialist's Signature: Date: `7 1 DCHD 05/99(Revised) r • . . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT L5 0 W Davie County Health Department Environmental Health Secdon MAY 2 ��� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the,INFORMATION BULLETIN for instructions. 1. Name to be BilledJCIYry W. /QAp� Contact Person Mailing Address _ -7o7 A, �a' 1 r' Home Phone '�-'�`L' yy// City/State/ZIP C h,b4 w S /V. L_• 270/2- Business Phone 74G y737 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both 4. system to service: R""House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. IfResidence: /Residence: ! People Z ! Bedrooms ! Bathrooms 3 IK Dishwasher M Garbage Disposal V Washing Machine II Basement/Plumbing IYBasement/No Plumbing 6. If Busineas/Industry/Other: Specify type ! People ! Sinks ! Commodes ! Showers ! Urinals ! Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 6r County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes No If yes,what type? ***/IMPORTANT***CLIENTS MUST COMPLETE HE R-E2—LWX ED PROPERTY INFORMATiUN REQUESTED BELOW. Eftberp PLAT or SITE PLAN UST BESUBM/TTED by the client with THIS APPLICATION. 0,(t4 Prc- -•" dU JC L 20 +C LOU X 12p ....p�..y u�werssions: 1 WRITE DIRECTIONS(from Mocksvil3e/)to PROPERTY: Tax Office TIN: g 000 S L Property Address: Road Name tnu�,� c..�.��'S DR• A��%` City/Zip If in a Subdivision provide information,as follows: Name: / v�v�, y �►��X, Section: Block: Lot: Date Property Flagged: A44t G z u o This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation,if the site pians or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that!am responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned r;. -.7 e- I to conduct all testing procedures as necessary to determine the site suitab' )ty. DATE p�l 1 �u 0 SIGNATURE 'I'Iiig Ai?lri A MA"' USED FOR UKAWING YOUR SITE PLAN(Incl a all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge 1�• Date(s): Client Notification Date: I•a10 A EHS• iL• y G v s*T S.k Account No. -� 21 U / Revised DCHD(07/99) L-Ld U Invoice No. / l-` C. or•. 4.v�(� S /rive' 1� S�•f��' �a P� � b P pLL15 goo - O o► G 1w20. tT- 40-- zoo 00 G��S w of 1, too 00- ���� P an �- s 1 PPEP ' �•, O -1 : REQ_ V64, 1114, n 1.4 20000 1 ori �o 2 J t °° 0 •"� Pap* 1 of 3 IL 29 OE• �. EASEW.N1 DESCRIP1ION 4 N 09' 27 V1,41IO A. SS 1S B ti 11 � ''•1 9a' ;tz F! aa' R4 •1) F. • '...7n n ►i (16. 04 29 ►+, 2)i 3 FitAIMW nW POWflR.W OWMRS DEVFL `y G/'ARYpp//��WDE GRO 1d�Gl pRl1iE P S�uP 40 EMIL {ill F� LEMS R " HWa OKi4M GROCE Kf DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 4;�rDc'e DATE EVALUATED ADDRESS PROPERTY SIZE lC PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well L/ Community Public Evaluation By: Auger Boring Pit ✓_ Cut FACTORS 1 2 3 4 Landscape position Slope L HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH d13 J6 Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE k?/ SITE CLASSIFICATION: y s EVALUATED BY: W LONG-TERM ACCEPTANCE RAT OTHER(S) PRESENT: REMARKS: L' 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 :lay 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-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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 - gal/day/ft2 DCHD(01-90)