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176 Eastaboga LnHEALTH DEPARTMENT RELEASE "" NO Davie County Health Department Environmental Health Section 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1680 Applicant: Millennium III Holding, LLC Address: 686 Riverview Road City: Advance State/Zip: NC / 27006 Phone #: (336) 998-8800 Addre s: 176 Eastabo a Lane Road#: A vance NC 27006 *Structure: OTHER # of Bedrooms: # of People *Water Supply: N/A Basement: ❑ Yes ED No *Proposed Improvement: Outside Restrooms Permit Valid Until: 05/09/2019 Property Owner: Millennium III Holding, LLC Address: 686 Riverview Road City: Advance State/Zip: NC / 27006 Phone #: (336) 998-8800 Phase: Lot: Township: Directions:Hwy 64 East right on Hwy 801, go to Riverview turn left, follow to Left on Lester Foster Rd. then right Eastaboga Type of business: Events Total sq. Footage: No. Of Employees: *Release Conditions: Tie into existing 2 bedroom system. Existing system is no longer used for residential purposes and is now a wedding venue. **Site Plan/Drawing attached.** Total Time: (HH:14M) O Hand Drawing 01mport Drawing Hours Minutes Activity Code: HEALTH DEPARTMENT RELEASE MonDavie County Health Department Environmental Health Section Fes`` 4 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1680 Permit Valid Until: 05/09/2019 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? FiYes M No Applicant/Legal Reps. Signature: *Issued By: Nations, Robert Authorized State Agent: *Date: *Date of Issue: 05/09/2014 **Site Plan/Drawing attached.** Total Time: (HH:MM) OHand Drawing OImport Drawing Hours Minutes Activity Code: Phone: (336) - 753 - 6780 Davie County Health Department vironmental Health Section �►`' " P.O. Box 848 210 Hospital Street r' ��✓ Courier #: 09-40-06 Mocksville, NC 27028 �0i> Xvovvs Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name �` / �A ` 4cone Nu e� (Home ) Mailing Address: C4 O Work) Email Address: �5"..'rS}' � rAtia.asersr� Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Y,41,G"— ��� Type Of Facility: Date System Installed (Monfl /Date/Year): Number Of Bedrooms: '"ter Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes ) If Yes, Explain: Please Fill In The Following Information A hout The NEW Facility: Type Of Facility: ber Of Bedrooms: Number of People Pool Size: "'�'' arage Size: _ Other: !� 46 6O ' Requested By: Date Requested: e7) oor - For Environmental Health Office Use Only Approved ) Disapproved Environmental Health SpecialistDate: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash C Check,) Money Order #. Paid By: Received By: Account #: 1,3-7117- Invoice #: CJD ' DAVIE COUNTY ENVIRONMENTAL HEALTH • '• P.O. Box 848/210 Hospital Street r Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990004381 Billed To: Pat Hauser Reference Name: Proposed Facility: Barn/Living Area ATC Number: 4718 OPERATION PERMIT Tax PIN/EH #: 57 33 Subdivision Info: 17 Location/Address: Eastaboga Lane -27006 Property Size: 83.44 acres **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T. Manufacturer r Tank Date Tank Size X00 Pump Tank Size jj G System Installed By: .0 G5 E.H. Specialist: '4"oDate:'tK� '5� SIC f k k t o ( f%m 30 h6r5Y X05 1 4s w%?/ l&1441 DCHD 11/06 (Revised) waw Qrc I k:e, I D � 6o A -op" +0 Po i Y DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990004381 Tax PIN/EH #: 5776-41-0933 Billed To: Pat Hauser Subdivision Info: Reference Name: Location/Address::,. Eastaboga Lane -27006 Proposed Facility: Barn/Living Area Property Size: 83.44 acres ATC Number: 4718 Site Type-., Tew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms # Bathrooms # People 2 Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dinfensions of Facility) Lot Size Type of Water Supply: ❑County/City Kell ❑Community Well System Specifications: Design Wastewater Flow (GPD) 240 Tank Size 1000 GAL. Pump Tank GAL. Trench Width _ Max. Trench Depth yRock Depth � Z � Linear Ft. 7 � Modifications/Conditions/Other: Ao—L-, r.-l-OpIL 1rJ5fAQ the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m. on the day of installation. Telephone # (336)751-8760. rn cN . 5' L As stated in 15A NCAC 18A.1989(5) accepted Systems may also be use r.S�QTI�I .mental Health Speciali Date d 11/06 (Revised) / L� �o tr S• c'J tj O , r ` • -4. .wigs • ` .... APPLICAT TE EVALUATION/IMPROVEMENT PERMIT & ATC." 0 avie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 36)751-8760/ Fax (336)751-8786 Applica ' % : Q Site -ipr ent Permit ❑ Authorization To Construct(ATC) troth Type of plica iPv� ❑R.epair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPO TAN HIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMA ON IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION '0-0' 1 berWe y 1,,,. Name to be Billed Contact Person / 716 1� Billing Address rr Home Phone City/State/ZIP � -1 Business Phone{ Z Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged / 0 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is va ' rMm onths with site 1 o/� ,pation with complete plat.) Owner's Name ��I1 A l (�l I'L$ %—X r l�t,1• Phone Number Owner's Address City/State/Zip Property AddreS Lot Size C T x PIN# Subdivision Name(if a licable Sect' n/:, ?t# . Directions To Site: ) © L� i P(� "&A-: - If the answer to any of the followint questions is "yes", supporting documentation must be attached. Are there any,existing wastewater systems on the site? ❑Yes Digo Does the site contain jurisdictional wetlands? El Yes 2No Are there any easements or right-of-ways on the site? ❑Yes C�'No Is the site subject to approval by another public agency? ❑Yes IrNb Will wastewater other than domestic sewage be generated? ❑Yes ❑No t IF RESIDENCE FILL OUT THE BOX BELOW [# People# Bedrooms ` # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL UT THE BOX BELOW Ifi4a, Type of Fac' ityBusiness Total Square Footage of Building Wfbt # People # Sinks # Commodes # Showers % # Urinals W11:41 446�J Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: Seats Type system requested; gConventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ❑ County/City Water Pq ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,�dS 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 permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the info tion submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of th -5 of County He th Department to conduct necessary inspections to determine compliance with applicable laws and rules. g hat I a r sponsible for the proper identification and labeling of property lines and comers and locating and flagging hous fa ili locat'on,prop�ae ell location and the location of any other amenities. Site Revisit Charge e s or owner's legal representative signature Date(s): Client Notification Date: Datg"/'/ Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # Davie County Health ,Department C 4�`► �fEnvironmental Health Section +P.O. Box 848[� .�, 210 Hospital StreetO Courier #: 09-40-06 Mocksville, NC 27028 Phone: (336).751- 8760 Fax: (336) - 751- 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Che c One) Replacement Remodeling Reeccoonnec 'on Name:0(7 6�� z Phone Numbet`� ! (Home) Mailing Address:N(Work) Directions To Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long?, Any Known Problems? Yes No If Yes, Explain: Please Fill In The Type Of Facility:. Requested By:` Approved Disapproved Comments: About Number Of Bedrooms:_/Number of People_ Date Requested: For Environmental Health Office Use Only Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account #: Invoice #: MW 0 lMwi af+ww. Ibmu - 100.0' w / / / .rad Benb,. / srt� sw Ii i i �R "ISO `` m 4 �8�t s�t co (83,44A) (2.72A) 0933 4201 s f 176 (40.71A) PaD �9 N � � g 2042 {' ' sf 32 8--- C 24147A 447A __"'� 2 � -a(i t PcC2 264 0742 1� 78 r } 272 r t 280 g---- Tl.723A f 9477 J y� N ChA .- y DAVIE COUNTY HEALTH DEPARTMENT %. Environmental Health Section Soil/ Site Evaluation APPLICANT INF4 •` Tax PIN/EH #: 5776PQ1~RTY IN Billed To: Pat Hauser Subdivision Info: Reference Name: Location/Address: Eastaboga Lane -27006 Proposed Facility: Barn/Living Area Property Size: 83.44 acres `Date Evaluated: Water Supply: Evaluation By: On -Site ,Well Community Auger Boring Pit Public Cut SITE CLASSIFICATION: EVALUATION BY LONG-TERM ACCEPTANCE RATE: 0• OTHER(S) PRESENT: Q REMARKS: 36 ��� � � �y 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 u. VFR - Very friable : FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 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 05105 (Revised) Landscape position HORIZON I DEPTH Texture group ®��--- Consistence ����r-��s��� Mineralogy HORIZON 11 DEPTH Texture group MW Consistence— WIMwRaluo Mineralogys�;r0 1 a M 01 W=NRM HORIZON IV DEPTH group cam■cam]Consistence ®®®® 7 Mineralogy SOIL WETNESSv®�v®�■�®® CLASSIFICATION r-z��►�s��®e® SITE CLASSIFICATION: EVALUATION BY LONG-TERM ACCEPTANCE RATE: 0• OTHER(S) PRESENT: Q REMARKS: 36 ��� � � �y 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 u. VFR - Very friable : FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 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 . 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Box 848/210 Hospital Street Mocksville NC 27028 (336)751=8760/ Fax (336)751-8786, IMPROVEMENT PERMIT Account #: 990004381 Tax PIN/EH #: 5776-41-0933 Billed To: Pat Hauser Subdivision Info: Address: 3631 Links Drive Location/Address: Eastaboga Lane -27006 City: Conover Property Size: 83.44 acres Reference Name: Proposed Facility: Barn/Living Area **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: I'Kew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People—Z Basement[] Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility)_. Design Flow(GPD)s 2�10 Type of Water Supply: ❑County/City All ❑Community Well Site Modifications/Permit Conditions: scgoz' 'DaN1/.3S Svstm Type LTAR Initial / Repair ✓ Qty �.