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417 Cedar Grove Church Rd. . � . _ DAVIE COUNTY HEALTH DEPARTMENT 1 , ;�; � " � l� �-,� -' `",' . , . . Environmental Health Section ,�� = =� �'` • P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 � � (L- �� "` � f� (336)751-87G0 � � �� /�� IMPROVEMENT/OPERATION PERMIT � Account #: 99p0022�6Q1 � Tax PIN/EH #: 5767-94-6289 Billed To: Allen W.Builders,LLC. Subdivision Info: Reference Name: Proposed Facility: Residence Location/Address: Cedar Grove Church Road-27028 Property Size: see map ** ��*�V�bgr: 3137 N is mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 ] 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. 'L � Residential Specification: Building Type �'T #People �_ #Bedrooms �_ #Baths � Z Dishwasher;� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: ❑ BasemenflNo Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �' Design Wastewater Flow (GPD) � Site: Ne�y.� Repair ❑ System Specifications: Tank Size�� GAL. Pump Tank Other: Required Site Modifications/Conditions: ,, i GAL. Trench Width� �� Rock Depth �_ Linear Ft:300 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depariment for final inspection ofthis 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 (33C)751-87G0.**** /�� Environmental Health Specialist's Signature: G��'�! �� Date: �"� �� 2- DCHD OS/99 (Revised) . - Y' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990002260 Billed To: Allen W.Builders,LLC. Reference Name: ATC Number: 3137 P. O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5767-946289 Subdivision Info: �� Location/Address: Cedar Grove Church Road-27028 Nropenv s�ze: see AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER O STRUCTION IS VALID OR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: � ', Date: '�-�'�fr `'�� CERTIFICATE OTr�.COMPLETION **NOTE** The issuance ofthis Certificate ofComplef n hal ' te system described has been installed in compliance with ' le 1 of . apter 130A, Section .1 Disposal Systems," but shall in NO W be e s guarantee that the system given period of time. Septic System Installed By: r �, Permit i or any y - � Environmental Health Specialist's Signature : !-�� Date: �- DCI-ID OS/99 (Revised) . � ; ,. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERhtIT & ATC R nn Davie County Health Department � L5 �� l'/ � Environmenta/Hea/th Section P.O. Box 848/210 Hospital 5treet qpR 2 g L-� Mocksville, NC 27028 ' � (336)751-8760 Ers�� v�.:�'�.�;�-;;�:=��'�� ,t;;� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOi2I�TION IS PROVIDED. Refer to the INFORI�TION BULLETIN for instructions. i. x�e to be silled _�//1.✓ W�inP �u; (�.Qr.S CL�. con��t Person �'P�,' f��u�,r,Q„ Mailinq Address �� (OvYr�Q �.� �,� , S�,t• �'�t� i 8 Home Phone % 3 �'�! D S City/State/zIP fJi nf' f-p� Sfl IP.-�� /�. �• .2 -1 � �� Business Phone .39�f' - lm ,'S l 7 � 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application Eor: ❑ Site Evaluation ❑ Improvement Permit/ATC � Both a. system to service: I�( House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 3 # Bedrooms 3 � Dishxasher ❑ Gazbage Disposal D(I Washing Machine ❑ Hasement/Plumbinq 6. If Business/Industzy/Other: Specify type # Peo le P _ # Commodes # Showers # urinals # sathrooms z'Jz � Basement/No Plumbing # Sinks # Water Coolers ZF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type o£ watar supply: Q�County/City O Well ❑ Community �� e. Do you anticipate additions or expansions of the facility this system is intended to scrvc? ❑ Ycs � No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUGSTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by thc clicnt with THIS APPLICATION. [�, �� lft r� • Property Dimensions: 7�� Frf. X�BD, `7�% k S�Q7. SB WRITE DIRGC'I'IONS (from Mocicsville) to I'ROI'GRTY: Tax Office P1N: #�% (2% � �% �a, � Cj PropertyAddress: RoadName C'�UQr' �rp.� �fiu7h��. �! Y �/� /��-� City/Zip � lf in a Subdivision provide information, as follows: Name: Scction: Block: Lot: Date Property Flagged: r� c7 "�— 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, uirderstand tliat I am responsib[e for nll c/tnrges i�tcarred Jronr this application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine t6e site suitability. DATE �— � � —a '� SIGNATURE Q-----__ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (In ude all of t ollowing: Existing and proposed property lines and dimeasions, structures, setbacks, and septic locations). , � `��". � Revised DCHD (07/99) Sitc Revisit Chargc Datc(s): Client Notification Datc: EHS: Account No. � Z-� 6 Invoice No. !� S � ..-.. �.,..._ ,..� v�.ou r,1.� PB 2 RR Spike(existing) PG 1 � �, � • f i I T'ax Lot 4i.�� Tax Map K—� � I Roqer Oafa Cope a/w doy S. Cope � D� 187 6 PG 42i 1 I 1 3J4"�1? Tia 4r,a ' S 6'29'S0"W - 449.53' "A" Existing 7-8or with cap ! 7ax !ot 49.01 � Tox Map K-7 R�by Lae L.u��nan 0 G�� jfi O �. �L'�i�i�ii � ee t s� 3 � �s � . , . . Tox Lot 49.02 Tax Map K-7 Vemon Oexter Brodshaw. Jr. e/w �enee Luffman Bradai�aw Do i o�r v t�u a75 �S �� A9s� `�� . `�+` �°'� � , I � ! �` °�, . �w �+ h �, � G .� "�< .� RR Spi e(existJng) � � IS -- 't �i f�003 04/25/02 THli 09:36 F:1Y NOTe n,r, gL ;•,e}Kt m ony Ecaam.na. ,tq,.„. ; w wvM.-o�-war a+ roaan+ , P� 4! dab d ehh viat. ■rJd, rrw� n � N� d Uf� Ikn� d rtq �F� � � � Ta� LQt 111 � Tax Map J-7 � Cfiarlie W. Cope � �LO i o/w Virginia B. Cope � � DB 7o e PG 3S8 �. \ Q'^ i L'S 75 E.' PG 210 i� J �,� � Q � ��` �� 1� � ��' , � �s �o h .�; ;�/ a7J1' � ; �. ��` ��1� Tatal I P�'O.f- v ' / i r � ti Thie rtwp or Orarving and a�y occompanytng documerc� ata fumfahsd !a !!� puscr.(a) ncmad thataon and no albrotlo�t or us� by athen la permtttad unlass authalzed by $tons Lnnd Survsyirc� Ca ' ?Aap not for reccrtlation. _ ar�t,iw, t:�o.000� Tax Lot 11 � .Q2 Tox �1ap J-7 J. st�rvon N�-t�`� a/� K�*.hryn F. North DB 180 O PG 880 i s ��f,� ,°� lO Su;�ey for.� � � • Q ' ti �. '� �' / G''�iar�ie � Part f Tax Lot 47 ' � � - �, O°o�~ �� 6'p. � s Tox �iap K—? �, � � � 5 Acres +%- �b � X,., •'' pw s" ,,� ys 79Q.1 • T�t�f "�' ta ��C� S 80°29'.iii"tii 7o0.i�' � LEGEND R/W - Rf9htrof-W% � Cant� UrN E? - Esu-L'r�g {rc� Prya C�. - Cent�r ma�ii F1R - EzTating Iro Robor �_� s°� R -� �-'oi�it - �t CII - Cooerata N� umant �p ht Po IRS - iron Rsbar �si �`,rj �� H� pI�- - ��y Une R - RaC(�w � C A- Controllad �' Cri - Chortt Ge P.:b - P.trl;.�cl�, �^t�a Pi;� PLO - Por! of ,a C1lP - Cwrugctad I�istcl PTps �-�t Eaa� C� - CorruQote�i FYa�ua FSya �_�� BOK -F- 100 yser Adod Bovndary � -0- Ovefiaod UtlllUea � - £'-�,.r.� P=t -X- Fence i -5- SSewer Wie .�ZN� Rp� � ..• ,, �T'n ;��sT�,;�, . •, ��s. � - �.� .. . _, . _.. A / afllt ?�1J�8 !� `��c� �?"9'2722CZ .d: .= f� � . . Part of Tax L� Tax Mop K- Deed 600K i�2 � Deed Book 167 � Cedar Grove Chu 2.705 Acr:.s 1; — h� 1� � �� ;� �w� �s� . � r • L • i � DAVIE CUUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002260 Billed To: Allen W.Builders,LLC. Reference Name: Proposed Facility: Residence Property Size Water Supply: Evaluation By FACTORS Slope % HORIZON I DEPTH Texture group Consistence HORIZON II Texture grou� Consistence Structure HORIZON III DEPTH Texture group Consistence HORIZON IV Texture group Consistence Structure PROPERTY INFORMATION Tax PIN/EH #: 5767-94-6289 Subdivision Info: Location/Address: Cedar Grove Church Road-27028 see map Date Evaluated: �-/ -_3 0- o'L � On-Site Well ?' Community Auger Boring Pit SOIL WETNESS RESTRICTIVE HORIZON CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: Public L�_ Cut ��0000� ��----� �� L�� i��1,�� -----� �-----� �-----_ r� �� rL�� r�r�r�� EVALUATION BY: OTHER(S) PRESENT: 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 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 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 OS/99 (Revised) ■ ■ ■ ■ ■■�■■ ■��■■ ■��■ ■��■■ ■ ■ ■■�■�■■ ■■��■■ ■■■�■�■ ■��ea�■ ■�■��■ ■�■��■■ ■��■ ■■��■�■ ■��■ ■��■■ ■��■ ■��■ ■■■�■�■ ■��■■ ■��■ ■��■ ■�■�■�■ ■�■��■■ ■��■■ ■■■�■�■ ■ ■ ■�■■■�■ ■��■ ■��■ ■�■��■■ ■�■�■■■ ■��■ ■��■ ■��■ ■��■�■ ■■��■�■��■�■■�■■�■■■■�■■��....,■��■ ■��■��■6��=:i��■■ ■��■ ■��■��0�■��■��■�■��■■��■■�■■i��■�■ �� ■■��■��■��■��■■��■��■■■■■ ■��■��■■�■�■■��■��■��■��■�i��■ ■��■��■�■�■��■��■■�■��■��■��/I��■ ■■��■�■��■��■��■��■��H■�■�■ ■■��■�■■��■�■■��,��i��■■�■��■��■ ■��■ ■��■�■�■■�■��■��■■ ■f��li1�■�■■��■ ■■��■�■��■■��■■ ■/�/■■��■��■■■ ■■��■��o�■■�■■��■■��■■r�■��■ ■■�■■��■��■��■�/��■��■��■�■ ■��E/��■ ■■��■�■�■��■��■��■■��■■��■■■��■��■ ■��■��■■��■��■■��■■�■■��■�■��■��■■ ■■�■�■■�■��■■�■■■��■■��■■�■��■■�■■ ■��■ ■��■ ■��■�■��■�■��■��■��■ ■■��■■��■ ■��■�■�■■��■��■��■��■��■��■�■ ■■��■��■��■■■��■��■�■�■■��■■■ ■■��■��■��■�■��■��■��■■ ■��■�■ ■��■��■��■��■��■��■■■��■■��■ ■��■�■�■��■��■��■��■��■■��■■ ■■�■�■��■��■��■��■ ■��■■■ ■��■��■�■■��■■��■■��■�■■�■��■��■��■■ ■��/��■��■ ■■��■�■��■��■■��■■��■�■�■�■��■ ■��■■��■��■��■��■��■�■��■■■��■■ ■��■��■��■�■��■��■■��■��■��■�■ ■��/��■ ■��■■■��■��■��■�■��\■■■��■�■�■ ■■��■�■��■■��■��■�■�i�■�■��■■ ■■�■��■��■�■��■■ ■��■��■�■�■�■ ■��■�■��■■�■��■��■■\■�■ ■ � � i i ■��■ ■■�■ ■ ■