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185 Cornwallis Drive Lot 30 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000981 Tax PIN/EH#: 5831-97-8682.30 Billed To: San Filippo Companies Subdivision Info: Pudding Ridge Lot#30 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 1.005 acres **NOTE'S*This a rovement/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 #People #Bedrooms 4/ #Bathe Dishwasher: Garbage Disposal: Washing Machine: ©-`- Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial EIWaste: Lot Size ©o Type Water Supply Design Wastewater Flow(GPD) �� Site: New SlWRepair❑ / System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width Rock Depth L Linear Fj j; Other: f7 /. Required Site Modifications/Conditions: �/O,,, IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS)IF 6 u BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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. Tel hone#is(336)751-8760.**** 1„�i( � )'V Of; IY o0/ -e!5d 1 Environmental Health Specialist's Signature: Date: 0—/4/—o C7 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000981 Tax PIN/EH#: 5831-97-8682.30 Billed To: San Filippo Companies Subdivision Info: Pudding Ridge Lot#30 Reference Name: Location/Address: Comwallis Drive-27028 Proposed Facility: Residence Property Size: 1.005 acres ATC Number: 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NOW ak as guarantee that the system will function satisfactorily for any given period of time. z� 1 5 (-V Flnrsto�edBy: C)LtSeptic Syst I-%=�?�!J i` "t �� i Environmental Health Specialist's Signature: ate: l� DCHD 05/99(Revised) APPLICATION FOR SITE EVAIIATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Environmental Health SeWon AUG - 8 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONP,IENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. l Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �� CSO N Cfirt, 2.— Contact Person y`ifLAA�.r1��1,1/ Hailing Address�. '('. T 2Z Z Q Home Phone City/state/SIP v CA X)6- `� V�b Business Phone -/ y� � z- �� 7 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Sip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC 0 Both 4. system to service: House ❑ Mobile Home 0 Business 0 Industry ❑ Other L� 5. If Residence: # People ? # Bedrooms _ # Bathrooms —4 Zt.N/ Y W Dishwasher Garbage Disposal W/Washing Machine �Sasement/clPlumbing O Basement/No Plumbing(- 6. If Business/Industry/Other: Specify type # People # sinks # Commodes # Showers # Urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Nater supply: 0 County/City ❑ Well O Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes 0140 If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. 00 Property Dimensions: p WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: S 2-- /T2- Property —Property Address: Road Name Lv f) C'm Ll/,L.&< A. 20 A30 City/Zip A_�N�-�� If in a Subdivision provide information,as follows: , Name: T , t �— Section: Block: Lot: ` Date Property Flagged: SA d This is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation,If the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I 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 by \ to conduct all to(ti�ng procedures as necessary to determine the site suit bi ty. DATE TS SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN ude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Revised DCHD(07/99) Invoice No. J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAMEDATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well 4_� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 4 Landscape position Sloe Z HORIZON I DEPTH - Texture group Consistence Structure Mineralogy ` HORIZON II DEPTH Y Texture group Consistence Structure h 14.1 Mineralogy HORIZON III DEPTH - Texture group Consistence ' S Structure Mineralogy ' HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ' SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RAT OTHER(S) PRESENT: 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 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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 - gal/day/ft2 DCHD(01-901 ■�\/./■■■■■■.■■/■E■■E■EEE/EEEE■N■E■■.///■E■■EEEEE■■■■■■■■■■■////■■ ■■■/■■\�■■E■NEEEE■EEE■E■■N■E■E■EE■■■/■/■■■■■■■■■■■■■■■■■■■■■■■■■■. ■■■■EM■EE►�aer�E■■EMF■EEE■■EEE■■■■EEE.■.■■■el.■■■■■■EE■■■■■■■■■■■■E■ ■■■■■■■■■■■■■■■■.\It!�///■■■■ ■L`G■■tit■■E/.■■■■■■■■■■■■■■.■■■■■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■Nee/■■■■■►gee■■■■■■■■■.■■■■■■■■■■■■■■■■■■■■■■ ■/./■/./■//■■■./////■■■■E■MESE■��E■EE■EN■E■■■■■EEEE■E■■■■■■■■■■■■ ■■//■■/■//eEEMM/E■E■EEE/■EEE■MMMT■■//.■■/////■■■■■■■■■■■n■■■■■■E■ ■■■■■■■■■■■■■.■■■■■►�■►Er�■E■EE■■■EEC■.■■■■■■■■■■n■■■■■■■■■■■■■■■_■� ■/■■■EEM■■EEEEEE■E■E►\■■■//■/////■■■//■■■■■■■���■■■■■ i■■■■■i■■ ■■■ ■■■/■■■NEE■■■■■■■M■1/■■■EE■EEE■ /■■■■■■//�//////////////////�E■■ ■■■■■!■■■■■■■■■■■■■■■i\■/■■■■■■■■ a■■■■■■■■ ■■nom■.■■■■.■..■■■Nee/ ■■■■■lt■G1.■■■■■■■■■■■■EH■■Ea■■■■■■■■■■..■■■.■■■■■■■■■ E■■CME■■■■N ■■■■■■►�E■■.■■■■■■■■■■/■■■■/////�\■EE■///eee.■■■■■i■■■■■■■■.■■■E■■■ ■■■■■■■■■■a■►��E■■NE►■■■■■c■■■■■■.■■■■■.■�■■■►i■■.=■■■��i■■■■■■■■■■■■■ iiiiiiCiii► �� ■.■■■■ ■■■■■■ r■■■■■ ■■.■. �■■■■■■ N///■/ ■.■EEENEr�MM■M/ ■ NOME MEM■■■ ■■■■■EE■11■■E:EII�\!N�i ■■■\�\■E■■■■■■■■■■■/■■■■/■ MI ■EEE■■EM\EEE■■/E■\��JE1��1►■E���'E■■EMME■■■■■/i■■EE%■ ■■■■■■■E EEEEEEE■ ■■■■■E■■■► ■■ne■E r+t _`��■►M■►"�\E■■■■■..■n% ■■■=■EC u■■■■m EMMOMM■■ ■■■FEMME/►\■E■vEE■res�a �eE►�-\M■��\E�� EE■EE r■ mom ON ■ ■EMM■ ME■MEMEM ■■■■■■E■NE■nl���J■NN J\■►!■\EN\lt��il.■■■■� M/MEM IMEMEMMEE■MEMN■ //EEEENMMM■EEEs■E■■M■le■a�■Ir��EaaN`a�►eMMME■� mom 0 EMC MCMMI■=MMMMMM■I ■■■■EeEM■■HEEEE■■■■■EE.EOaEat/�►►e+�■■■N E■■a ■■ ■ on MEM■MM ■■EEa■■EEMEEMMMM/MMEMME®\�Q"i�7EEl ■■! 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