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389 Cornwallis Drive Lot 17 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003453 Tax PIN/EH#: 5841-15-2201.17 GS Billed To: Gary Swan Subdivision Info: Pudding Ridge Lot# 17 Reference Name: Location/Address: Pudd. Ridge-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 3969 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 CONSTRU/C�TION IIS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 7T/ / Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system descr' j ent/Operation Permit has been installed in compliance with Article 11 of G.S.Ch esti, on.1900"Sewage Tre ent and Disposal Systems,"but shall in NO WAY be taken as a tee that the n satisfacto ' for any II given period of time. to 120 2� E-L r-J V24 T4� t Septic System Installed By: ��l��-K S�1� Environmental Health Specialist's Signature: Date: 196, DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003453 Tax PIN/EH#: 5841-15-2201.17 GS Billed To: Gary Swan Subdivision Info: Pudding Ridge Lot# 17 Reference Name: Location/Address: Pudd. Ridge-27028 Proposed Facility: Residence Property Size: 1 acre 96 **NOT *This Is 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 C—Fli Dishwasher: / Garbage Disposal:, Washing Machine:2 IO, Basement w/Plumbing:,P--"Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) 7 Site: New❑ Repair❑ System Specifications: Tank Size/A©%) GAL. Pump Tank GAL. Trench Width 3?' Rock Depth 1 Linear Ft>5��-'� Other: As stated in 15A NCAC 18A.1969(5) Required Site Modifications/Conditions: accepted Systems may also be used IMPROVEMENT/OPERATION PERMIT LAYOUT- AP RIO 'ED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of a Davie 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. o 1 atio . Telephone#is(336)751-8760.**** LPbjol Environmental Health Specialist's Signature: r Date: Revis(d DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section A P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003453 Tax PIN/EH#: 5841-15-2201.17 GS Billed To: Gary Swan Subdivision Info: Pudding Ridge Lot# 17 Reference Name: Location/Address: Pudd. Ridge-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 3969 **NOTE**This Improvement/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 /7' #People #Bedrooms A// — #Baths,-7,5 Dishwasher: e Garbage Disposal: ❑ Washing Machine:. Basement w/Plumbing: e Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply�SL Design Wastewater Flow(GPD) -Yed Site: New Repair❑ y System Specifications: Tank Si 00 "GAL. Pump Tank GAL. Trench WidthrK ' Rock Depth/V Linear Ft_5� 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: DCHD 05/99(Revised) AP ON FOR SITE EVALUATION/IAIPROVEh1ENT PERMIT&ATC Davie County Health Department 1 EnvirontnentaiHealth Section .0. Box 848/210 Hospital Street D1VIRQAN,p N� Mock(336)751-7028 8760 0 * *IM *** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I-1hF6RMATION IS PROVIDED. Refer ,,ton/the INFORMATION BULLETIN for instructions. 1. Name to be Billed [1b ,r1y ^ w71��v Contact Person d (' Mailing Address ("U 9 dD 1-7 Home Phone � ( � 7 50 City/State/ZIP L -Ldrn:±? /L6 a-mo G Business Phone 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: 19f House El Mobile Home 13 Business ❑ Industry E3 Other _ SNfirdV jvr , 5. , Type system requested: 'q Conventional conventional modified ❑ innovative 6. If Residence: # People # Bedrooms _ # Bathrooms 3 MDishwashor []Garbage Disposal MWashing Machine Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day) 8. Type of water supply: M County/City ❑ Well ❑ Community 9. Do you anticipate additions or CxpaIIS10IIS of the facility this system is intended to serve? ❑Yes ❑NO If yes,what type? ***IMPORTANT***CLIENTS AMST COMPLETE THE REQUIRED PROPERTY INI-ORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST 6E•SUBMITTED by the client with THIS APPLICATION. Properly Dimensions: I �'� �� WRITE DIRECTIONS(from Alocksville)to PROPERTY: Tax Office PIN: it Property Address: Road Name- Putt)11y t City/Zip NIOC(G a lk a 70 Z b' If in a Subdivision provide information,as follows: Name: p U QQ (t"� Section: Block: Lot: Date home corners flagged: 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 ain responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ^ ' ,U� SIGNATURE �✓-- TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: Sign given ND- Account No. Revised DCIID(05/03 Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME Z��CP DATE EVALUATED ADDRESS PROPERTY SIZE �2C' PROPOSED FACIILTY LOCATION OF SITEy k d t.1 sr �cQ s c Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit -/' Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group Consistence Structure Mineralogy7 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 n / SITE CLASSIFICATION: EVALUATED BY: LANG-TERM ACCEPTANCE RAT OTHER(S) PRESENT: REMARKS: e ' 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 .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 watef 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 �, ^r. is :.••.�;y: •; a a ;fes �• , :i• :a •'c .y •F • A • • • . Js _ • •. w 'Tt +f iim- '•x .x. •e• r,• L� • :t. y• •• •��•:•;is::•�'�•! ,•l ''L'� '?;-;a:;y,�,;i�`•'• .e `..ice... r. K 's