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357 Cornwallis Drive Lot 20 • DAME COUNTY HEALTH DEPARTMENT PL Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003122 Tax PIN/EH#: 5841-15-0716 Billed To: John Snyder Subdivision Info: Pudding Ridge Lot#20 Reference Name: Location/Address: 357 Cornwallis Drive-27028 ATC Number: 3736 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 COSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Aa d 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 take as t the system will function satisfactorily for any given period of time. r f Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section p� P.O.Boz 848/210 Hospital Street y— 9_ a Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003122 Tax PIN/EH#: 5841-15-0716 Billed To: John Snyder Subdivision Info: Pudding Ridge Lot#20 Reference Name: Location/Address: 357 Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 1 acre **NOTE *This improve7me6nt/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 —,-? #Baths \—? Dishwasher: e Garbage Disposal: ❑ Washing Machine:; Basement w/Plumbing Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: New Vl/"Repair❑ System Specifications: Tank Size,1jWAQ GAL. Pump Tank GAL. Trench Width �IRock Depth /.F' Linear FtS�� Other: Required Site Modifications/Conditions: 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 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.**** Environmental Health Specialist's Signature: Date: 4/ -- DCHD 05/99(Revised) t AI'i'LICATION FOR SITE EVALUATION/IAIPIiOVBIENT 111:1IM1T&A1•C '� 7 Davie County Health Department ' Envi�ona�enta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IDIPORTr1NT*** TRIS APPLICATION CANNOT DL PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROVIDED. `/Refer to the INFORMATION BULLETIN for ins truc tions. �� 1. Name to be Dilled �/0A4 A e,4 Contact Person Nailing Address 1"14q 'pox "4 �/c./�� Banc Phone -99g 6,q 3 V City/tate/ZIP tk, 2�o2C3 ., L Plluile (410) q�1� zol -J/ Name on Permit/ATC if Different than Above/ Mailing Address 49nr4l C ity/State/Zip �. Application For: ❑ Site Evaluation I/d'Improvement Permit/ATC LI Doth _-,-4. System to service: ltd House ❑ Mobile Home ❑ Businets ❑ Industry ❑ Otl:cl• 5. Type system requested: LI Conventional ❑ conventional modified ❑ innovative ✓G. ,I,,fm Residence:�� tl People ✓.. tI Bedrooms it Bathroou ai 3 �- ishwasher 19��Garbage Disposal UiWashing Machine l�'DasemenL•/Plumbing ❑DaLowent/lo plumbing 7. If Business/Industry /Other: verify type a People It Sinks _ # Commodes 1F Showers tl Urinals 1} Water Coolero IF FOODSERVICE: Il•,�Seeat-s Estimated Water Usage (gallons per day) Type of water supply. y! County/City ❑ Well ❑ Colrumunity S. Do you anticipate additions or expailsiolls of the facility this systull is illtelllled to serve': ❑ Yes vl/ '0 If yes,what type? **IAII' 1 1'LETETIIE IU QUIRED PRO1'lilt'i'Y INFORMATION REQltliS'1 ED - *BEL V. Either a PLAT orSITE PLANrl BE-SUBMITTED by the client nith'1'IIIS r11'1'L1G1'1'ION. I LIsr•operly Dimcllsiolls: ( � ttl'f�DIMC1'IONS(f-ojii n-locksville) to 1'1tUl'lat'1'1': �1a office PIN: 11 Sf3t �110 �w�Dtnllr J2r�Ls — -- pertyAddress; Road Nalne 3-5-1 coatJWALLIs o4y City)zip N044(wl ae i t-&-, 2 y�z If iii a Subdivision provide inlorniation;as follows: Natllc: Fu'ooltv& Section: Bloch: L t: Bate Ilonlc corners flagged: tAJ This is to certify that the inforl alio provided is correct to the best of my knowledge. I understand that:illy pernlit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use cliange,or if the iuforruatiuu submitted in this application is falsified or changed. I,also,understwul that I nut responsible for all charges incurred i-om this application. I,hereby,give conscut to the Authorized Rcpreserltativ )avie Cululty Health Dep:u-1111 ut to cuter upou above described property located iii Davie County all 11'11c to conduct all testing procedures a5 11=55ary to dcteruliuc the sit'suit• ility. ✓HATE SIGNATURE. TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PL l of the fullolvillg. Eaisling and prupused property lines and dimensions, structures, setbacks� and septic 10 ons - 11, _ --�� Site Revisit Charge Client Notification Dater EIIS: Sign given tN a — re.—`-' t e Ce Account No. Revised DCIID(05103 _ Invoice No. `s j z� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section eD Soil/Site Evaluation .� �ky/� NAME OC DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RA OTHER(S) PRESENT: REMARKS: t" , , 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