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1332 Baltimore Rd . : - . . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 990003707 Tax PIN/EH#: 5860-82-2987 Biiled To: CKJ Builders& Developers Subdivision Info: Reference Name: Melissa Johnson Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: 2.974 Acres ATC Number: 4453 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 Tre ment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW �(. C N IS V LID FOR PERIOD OF IVE ARS. Environmental Health SpecialisYs Signature: Date: CERTIITCATE OF COMPLETION **NOTE** T'he 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. ��� �i�.�'' zu `�� � _ �,Q � �,,�_� 1 � F F�v�•� � L G� , /� �' �� i ! �/� ��. � - , �, Q���'1�� �T� Gi�qw.��9> �1-� IpC�1 +�,1K C�-�) Septic System Installed By: 1tL � � �=� �� I.�o Environmental Health Specialist's Signature: '�� Da • " DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section ' • � ' � P.O.Bog 848/210 Hospital Street �� Mocksville,NC 27028 � �, (33f>)751-8760 'tiI� � � L . , IMPROVEMENT/OPERATION PERMIT Account #: 990003707 Tax PIN/EH#: 5860-82-2987 Billed To: CKJ Builders& Developers Subdivision Info: Reference Name: Melissa Johnson Location/Address: Baltimore Road-27006 Proposed Facility: Residence Property Size: 2.974 Acres ATC Number: 4453 **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 IN'I'ENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type � � - #People � #Bedrooms� #Baths�_ Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size �J�G' 'S Type Water Supply 1�����Design Wastewater Flow(GPD)_��.�L Site: New��Repair 0 �,�yr� 3 „ -/ �s System Specifications: Tank Size �/GAL. Pump Tank GAL. Trench Width � Rock DepthN A Linear Ft. Other: i� � 1� � � ��� �� �� � s �.�v! ��n� G� ,�� � ( � Required Site Modifications/Conditions: �� � ��(`��T��lr}� � � t-NI�C� �� �� � Il�'IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 .m�to 1:30 p.m. on the day of installation. Tele�phone#is(33G)751-87G0.**** oT"�Q.q,1 �"�[� � /(aD' '(�_ � ��10 `r- �R1V�C ���C.-�� s�HoP � -c� � s' , � o� ���L1��S ��J � � �' - - _ . ,,� ��. T�z��� � �,+�X.-���� � � � �, 8 CA �.� `� A�t+� ��� I �' � � Environmental Health pecialist's i a e: ate: �� DCHD OS/99(Revised) � �'�'"�"'��� ?�I ' 0 ' �l�L�'C�'��T � SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department JUL 1 B 2006 Enviro�zmental Healtlz Section . P.O. Box 848/210 �-Iospital Street ENVIRON��ENTAL HEALTN` Mocksville,NC 27028 oavi�cou�n (336)751-8760/Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Pernut Authorization To Construct(ATC) ❑ Both ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED , INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � Name to be Billed �� •<< �Y � - � c� fl L�� Contact Person /'�(�����SC��¢_ �5�,�i� ��. Billing Address �3 '�`� ` CF , . , Home Phone �!�CO�-a , City/State/ZIP � d Business Phone �-(/Y— �( -rj'D � Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Pemut is valid for 60 months with site plan,no expiration with complete plat.) Street Address /33�� (f;�,�,r��,�� City j�n(c'�'"� c� Tax PIN# Subdivision Name Section/Lot# Lot Size �, �� Directions To Site: � .c -- G� � L�� � � — � ��.. � � Date House/Facility Corners�Flagged If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes �Io Does the site contain jurisdictional wetlands? ❑Yes �2Qo Are there any easements or right-of-ways on the site? ❑Yes f1�Io Is the site subject to approval by another public agency? ❑Yes�No Will wastewater�otlier than domestic sewage be generated? ❑Yes�No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool _JYes ❑No __ Basement: ❑Yes o Basement Plumbing: ❑Yes fi�3�o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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 systemrequested: C11�onventional ❑Accepted �Innovative ❑Alternative ❑Other Water Supply Type: �unty/City Water O New Well �Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes � 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 pernut(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 in this application is falsified or changed. I understand that I am responsible for all charges incurred from tllis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to t rmiq ompl'anf�with ap ,1'cable laws and rules on the above described property located in Davie County and owned by ,���i,�"���`'"�C/(������c�fj/.i ` ,; ✓h—�—'�— Site Revisit Charge � Prop rty owner's or o er's legal representative signature r. Date(s): �� �' � Client Notification Date: ate EHS: Sign given ❑Yes ONo Account# U� Revised 2/06 Invoice# y�3�7.` . '^ � � II Io17 • �-� � � JN — N . �� �Z IrR Oylv_—'___—'_�____—_—__"____�___— _ _--___'_______- '_' _ 7�1,4�}__ NQ '.�- p...,m+� S 86°43'S3° E'�—"-- N � � �---___._ � � _� ._,_.______,_.__.__—_'_----------- c"� Q ��,� I'4 t1���'% �"i'\ � .rzo r� �..' � APR2 EOuE � � ^ - AREA = 2. 9 74 A CRES ��° >> ?j °� � --y � ' �� 2,�� fo W o � o •� �S �C�4pF�� _' t—�a� �V�/��a IE) found C".75" iror-3 232,71 four�d 50'x30' �00 SF CONCRETE p W N 87°11'27" W 353,97 � CONTRO! �" 195.65 �Ci NE�< N 8�'09'43' W C549,62 TOTAL) ,� � 'J.75" iron found 0.75" iron 29.F�' irem c/I r-d. f!l i I f'1 i"i v „�.. �° � iron piaced - �� "�'" � • �� � � " �� ' from c I rd. 29.8 f �� ��� ����.� �� �� . � _� �, � � �s . � �"� _ 3Q1 . 4� � � 8E��3'�3° � � . �Ew �' '� �: � � i R 01�1 `r�"'� '����=�. G� ��` ., � .� � � � � � � � � � � � o- � ,� . �" l � .� �.L�.� � ,� �b • '� �. . ' � �,�. �.�5` D U��' �''�'�#'�'}� ��' �'"' a : t>o `•'' 1'�' =v �� � � �. � 0.75" iron 3S3. 97 fo�nd � � 9S. �5 N $7• �9'4�° W C5�9, b2 Ti�TA�.) 5" iron fou�d _ : �=---r. �. �g.�� fC�(`l C j�i 'd• ` \ . ` l Rug 10 05 09:57a ��g u+ u� ui:aor uavae cpuniy envneaicn a�o rai oroo p.� P� 3 ,� , ', _ ' � � . � . • 1 .. � ,u�rc�cnrcav Fort sae Evatudnar/ta+rnuvnuavr rutvrr s nrc , �avie County Healtli Department • E�ivironmenWXealthSetion R_O. Hauc 04B/210 Hospital Stzwot / DforkeviL,Io, NC 2T028 ` v �� i {336)751-8760 � �o T N •4� •••.nsroa�xur•*• S}IIS APPLICATZO}7 G11�II4GT 8E PADCESSSD IINLESS ALL � R&QIIZ&ED 2. `J� ,�GQE$ urPOIUAxIati 7S pROVIDPo. Refer�to the �TFORtATZOY Bi7LLSTIIt for 3nstzvetione. I i. u.,.e co w n�ii.a r���a��[Di.a�c.��[/bM�[,�� ccacact ser.on �NPIS Jah�uS�N � 44 lLi2ivg lddisee Z3��ct...��c;rrE��D,�. R�o PAon� �^�7 8� ucy/sue./z:t D✓ N��_L�� 27���p aosinsa.enow� 4/4��'9�8 2. tia.a o.n iern1C/EiC!l 011tes'�:-C pw�t]1Dovu . � r.111ng Mds.�s C1Cy/St.le/ifp 1. AppliC,t30II l�i: PJ Site 1ivalnatioa � O Zmprovement leru�it/1►TC � Aoeh � �. 9yscen to S+s.ic�= ��une ❑Hobile xamo O Dueines� ❑ Eaduetzy� ❑ OLAar ...� i 6. zype ay,cro seQnencea. e7 c+�o�eacSonss� ❑ twn�atSoa�2 modi11o6 � ❑ inrorativo �acCepted 6. Zt Renidence: /Peop2e f eedrocas ,�_ �Hatbzooma 3i-� i BStann.nar QGar3ige DSapo�al @(i'.,nsay ti�ns=. �w.�c/�iuwtne L]na..�clan rl,mblm � 7. ZZ Dmina�s/L�uniry/Other� rerif7 Ljya 1 9�Oplu p SSakO �[orcdn� 1 Shor�z� I �Vtloale /Nater Coolel'a � � IF FDODSEBVICE: 9 Soata � Iiatimatad Watcr IIeage (gallon�p.r dnp) a. iype oI+at.r•nvclr= B CountyJCity� 0-wall 0 r��,*++ty !. m you a�ctespa ce�t�tw�s nz�g�nsiods of thc fseility'Ikis syslcm 1s inlenJcd ta suvc?O Ycs � t (f jrs,�rGa!f�7�c? i ••`fAIPOICTil1YJ�"CI.lEM7':bILATTC00ltL6TES1[E RCQUlRF�PROTE1t771NFOlUtAT70N REQUFSrL'D uAL01Y. ELberaPl.ATarStTl3PLlNa1(�STBESIlRb!lTlCDhrGedlentnitLTiILSAl'PWCATIQ�L 1 � ProperlyDimeus3ous: �Z Q�e�/��( !77 {VJtYfE DIRELTiOf�S(4vm Motksrftle)fn PROPEIl7'1: r�:ornu rv�: a ._SRL:,8 2z 9 8"� �'�EACE S,�c� l�i4r� � PropcMyAd+►rr� Roul lvnau f��T��E �D I , City2iP AD✓!e�,.VcE Z7DC+(e ! lt in a Su6Jitiision psuvidc infotwatian,ss folla i: Nanu• ! 5oclion; Btxk: Lot-� Date 4oas corncrs(la�cd: s I ' Tuis is to certitr iIn!thc infonn�tion pr��vidcd is iorrect to Uie brst of mp knu.rkJEm I undcrstand tLat aay perW1(s) issued ACrca(Icr aft mbjeM to suspcnsica or reveeation,if fLc sifo plaax ar infencld use ehaugc,ar i[WQ LdOrfmllioa subaulted fu Ihis applieatiou[s[alsiltrd�r el�angcd,I,alro,onderstmrd rlmtl ar�rrspo�.siLlcJo.-otl diargcs iucarred j�aat rhtrg.pltcorio.c r,Lrrel�rrtrcrnasrntroWcAut�oriudRcprescntatireofeheDavicCoun#1[ealtAUcpsrtmcu[ to enfer opon aborc dacrlbul propvty Ioc�tM In�Darie Countl aud oKnctl lry, ��'Q/� �ot�+�t•�+ lo eonducl all talfng pracedures�s eecessary�lo delenidne tl�e stte suitn6ililp. �� D,ITE �/e�6� i S(GNATURL' � 7717SAR&A M.lYDL IJSLD FORDILk�YING YOUR Sl't£PLAN(Indnde alt af thc fotlorring:Eris2icC��ProP�� pro�Crty Itaa aad dtmcasiauy strueticrrs,utbnela,aad septie lodtioasj. � Si1c ItevLSit Cbarge i i . Da�e(�: I . . ; � CficAt Nn1iGt11iOD D��M. . ��$' - � � a � S�a�[va, � . necoaue Ko. � � Rcvised DC[ID(a5/03 � 2uvoicc�ln.� �� i � � � 1 Rug 10 05 09:57a P, 4 , `. , '� ` -� i , I I � br � BALTIMORE DOIIN BALTI�tORE DOA'NS SUBDIVISION Si/9DIYISlON PL. BK. 8, PG. 15 PL• BK. 8. PG. 150 LOT i f LOT fz � . . .. \ 3„ "- - W � �~ . �r o; CBRIS JOHNSON N N D.B. 60f. PC. f95 � DO1F'NS : >!ON PG. f50 ' D � . 620.57 S 83•p�•py. � � 'm� , :.a, w � � , . � o 0 N AREA = 3.036 ACRES :: � - � . � . lNCLUDSS DUYE P01IER R/� oW `° .ys �� . ... �'N. n N�' ¢n1 �_.'__ `� . Qo _.__._---�------•-- ---�_�_��701.4q N �z . S 86•t�3'S3' E ""_'- �._`�_ ! �� .. � m �� • . � AREA = 2.974 ACRES 9� . �' = INCLUDBS D(1KS POMBR R/!f !���' � o�D'' �� . f08.00 <TIE) . . 232.71 � � .. ,� -. � 87'_�]'27' 4 N 87•ll'27' 1/ 353.97 . � .. " 195.65 H 87'09'4J'� C544.62 TOTAI) D. P. FOL.YAR g � SUB B. FOLMAR D.B. 438, PG. 963 . I . 1 �' . X N o] v P --_�..-_ �� ��50_' �,� ' . � ; � � �7��� ��� � i 6/0 �� ` ;: ; -- % / � �.: � t , � � ' DAVIE COUNTY HEALTH DEPARTMENT .--. - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003707 Tax PIN/EH#: 5860-82-2987 Billed To: CKJ Builders & Developers Subdivision Info: Reference Name: Location/Address: Baltimore Road-27006 � Proposed Facility: Residence Property Size: see map Date Evaluated: lZ �� a.9����s Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 3 4 5 6 7 Landsca e sition L. Slope% � HORIZON I DEPTH �— 2 Texture grou •� Consistence r S Structure Mineralo � ,� HORIZON II DEPTH Texture rou ; Consistence - S . Swcture 3 Mineralo � `, HORIZON III DEPTH .,(,/ Texture rou � Consistence Structure Mineralo HORIZON IV DEPTH Texture rou . Consistence Structure Mineralo ' SOIL WETNESS RESTRICTIVE HORIZON ' SAPROLITE CLASSIFICATION • � � ; � � ';;��� LONG-TERM ACCEPTANCE RATE v. 1 � . ' SITE CLASSIFICATION: EVALUATION BY: i '�' LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT: {.. �' REMARKS: 'Z LEGEND � i.�ndscape 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 T�Ct�urg 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 �'IQ1S� VFR-Very friable FR-Friable FI-Firm VFI-Very�rm EFI-Extremely firm �.�t' - . ' ', • � NS-Non sticky SS-Slightly sticky � S-Sticky VS-Very Sticky NP-Non plastic SP-Slightiy 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 Mineralo�v 1:1,2:1,Mixed LIQts� Horizon depth-In inches � . Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) il wetness-Inches from lan�l'surface to free water or inches from land surface to soil colors with chroma 2 or less ` sification-S(suitable);�AS(pipvisionally suitable),U(unsuitable) -Long-term acceptatice rate-gaUday/ft2 DCHD OS/OS(Revise ■����■�■0���������■���■�■����������■■�■■■�■■■■■������������■ ■�������■�r��■■■����■■�■■�����■�����■■�■���■����■��■■�■����■ ■���■��■��■���■������■■��■ ■�■e�■■�������■■��������■���■��■ ■�■������■■1��������■���■�■��������■�■■■�■�■��■�■��■■■e■■■�■ ■����■■■��■I��������■�■��■■■��■����■■■■�■��■���■��■�■■■��■��■ ■���■����■��I■■������■■������■■■�����■■�������■�■■■■�■e��■�■�■ ■��■��■■■�■��i�■�■��■��■�������■��■■■■�■■■■��■■■■■■s■��■��■�■�■ ■�■■■�■���■■��■i■■�■■�■■■■■��■■��■■������■���■�■■�t■�■��■■■�■���■ ■�■■���������■�■�i�����■�■�����■�■■���■■■■��■��■��■��■�■■�■■��■���■ ■������■�■■��■�■■i�������■■�■�■■■■����■�■■■�■�■■��■�■■�■■�����■■■■■ 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■�����������■■■■■����■��■■��■�ea��■_�.������������■i�■�■■�����■■�����■ ■������■��������■i���■■�■�■■�■��s������■�■■■■■■��i■�������■���■■���� ■■■■����■■��■���■�������o■�■■��■��■■■■�■�■■■■■■■�i�����■■�■■■■������ ■�■■■�■■�■■■■■��■�������������■��■■����■��■������i���■�■�■■�■■■����■ ■��■■�■■■■�■�■■��n�■■■■��■�■�■���■��■��■■■�■■���i�■■■o■���oo�-.�t��■ ■�■���■�■������■����■■■��������■■��■������■���■�■�■��■������.■■��■■■ ■■�■����■������■������■�■■������■ ■����■��■�■�■�i■■���■������■��■■■ ■������■�■��■■■�■������■��■s��■�■�■����■��■�■�■�i�■�����■��■�■■■■�■ ■■�■�■�������■��■�����■■����■�������■����■���������■�.��■■����■e■��■ ■■�■■�����■�����■������■��.�■■�■��■��■■�■■�■■���■a�-.�����■�■��■���■■ ■■��■�■�■����■■�����■��e■�■■�■����■��t�����■t���.���■��■������■����■ ■■��������■■�■■■���■���������■��■�■■��■��■�■����■;�■■�■���a■��■���■■ ■���■�■����■�■■�■���■■■■��■��■����■������■r.��■����■��■��■��■�■■��■■ ■■�■■����■�����■�����■■■■��■s■��■■■�■�■■■■i►�■■�����■���■■��■■■■��■■ ■■�■■■�■■■■■■��■■���■■■■��������■ ■��■■�■e��■�■�����■■■�■■■■�����■■ ■���■■■■■���■�■■��������■���■■■�■��■��■��r�r��■■��■■��■■■�■����■■�■ ■■■��■��■����■�■�������■■■■�■■■■��■■�■��■■���■■■����■��■■��■���■��■ . � ' 1 � ► . � ., DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 � Phone: (336)751-8760 / Fax: (336)751-8786 August 17, 2005 � CKJ Building&Design, LLC Attn: Chris Johnson � 233 Falling Creek Dr. Advance,NC 27006 Re: Site Evaluation- 2.974 Acre TractBaltimore Road Tax PIN#: 5860822987 Dear Client(s): As requested, a representative from this office visited the above site August 12, 2005 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at 751-8760. Sincerely, I � . � Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s) i / �r / 1� ___ 7s � ,% .� � !. �fhl �, ------ J � / �� � , �� - � , � i ._�_ / . ,: ��� ; �, ; . i ���