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118 Edwards RdAccount #: 990004127 Billed To: Lynn Hendrix Reference Name: Proposed Facility: Residence ATC Number: 4524 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5800-07-5147 Subdivision Info: Location/Address: Edwards Road -28634 Property Size: 6.542 acres accepted Systems may also be used 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 WASTEO UCTI N I ALID R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa 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 taken as a guarantee that the system will function satisfactorily for any given period of time. C\I is T Roost,? \, 2 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Ivo Environmental Health Section P. O. Boz 848/210 Hospital Streettv Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT I Account #: 990004127 Tax PIN/EH M 5800-07-5147 Billed To: Lynn Hendrix Subdivision Info: Reference Name: Location/Address: Edwards Road -28634 Proposed Facility: Residence Property Size: 6.542 acres ATC Number: 4524 **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 f+oo`e #People 2- #Bedrooms '� #Baths 2 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size (.0' Type Water Supply (?&)o Design Wastewater Flow (GPD) Site: New Repair ❑ t System Specifications: Tank Size J rAL. Pump Tank GAL. Trench Width;a;' Rock Depth " Linear Ft. 411b As stented in 15A NCAC 18A.1969(5) Other: �1�fiQl gUTIDr� accented Systems may also be used 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 mm. on the day of installation. Telephone # is (336)751-8760.**** Environmental DCHD 05/99 (Revised) i Specialist's Signature: Date: 11 ` APPLICATI,ON-F-0 - 1• ' SEP 2 7 2006 ENV1011MENTALHEALTH TE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Cement Permit ❑ Authorization To Construct(ATC) Zo ***IMPORTANT'*** 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 ' �( Contact Person e4 ` Billing Address 3 e Home Phone 0 pilo - City/State/ZIP & Business Phone Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months wtt� site plan, no expiration with complete plat.) Street Address FQi 6-45 W6CitY a- r OA y Tax PIN#' 5 U 0 %�j�/L�°J Subdivision Name Section/Lot# Lot Size 6,SVQ Directions To Site: llwq, W On Ro!�:r�4-,Qprox, r rn; Ie s a t7 _ .... - -.. 1 ' - _ D , ,. A 1„ ) _ r L _ n_ --J.- I + - _ �,.., �'1 /. Ad d' - o s Date House/Facility orners P lagged_ 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 XV0 Does the site contain jurisdictional wetlands? ❑Yes bio Are there any easements or right-of-ways on the site? Yes []No Is the site subject to approval by another public agency? ❑YesXlo . Will wastewater othet than domestic sewage be generated? ❑Yes)(No IF RESIDENCE FILL OUT THE BOX BELOW # People_ # Bedrooms # Bathrooms a. Garden Tub/Whirlpool Wes ❑No Basement: ❑Yes )(No Basement Plumbing: ❑Yes X40 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 system requested: Wonventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type:XCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo 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 permits) 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 this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determinelia/nce with applicable laws and rules on the above described property located in Davie County and owned by J- y Aid Bco p 1 e.n ar,)( �bJiL Site Revisit Charge Prope4 owner's or owner's legal representative signature Date(s): VX7 ln � Client Notification Date: Date ��— EHS: Sign given ❑Yes ❑No Account # /a7 Revised 2/06 Invoice # S7� (2.10A) 1s1.eo N (9.62 A) (ioo) r (330) ' 4845 ^ro N�'N o ��o/ ^�1 ?08 dp9' jg2 N 362: M 1 INDEXED ON 5800 1.383A I 0541 °O ry 1494 00� ry F100000048 112 7299 N 300 (37.45A) 495 (120) �� 5147 Ci o� 4.234A 7949 0 495 (450) "580 Q 075147 417 (760) � M O a (2.66A) C 5590 Q 50 " 285 1.88A (14.369A) 337 5279 N 818 30 — Zo3 o � 303 co i° (530) X301 r � — R' 382 (ARDS FOD ROAD 481 (3.17A) 6560 7949 15312 rn (ARDS FOD ROAD 481 (3.17A) 6560 7949 15312 291 1.00OA 5811 8802 12 41524 1523 30 5638 230 658 1 1 658 CIO (40) (190) "6,37 5556 (2., f503 -4- 6p 5442 280 1490 14917) 1. 9 7A 5265 J038 (41 148 6 (00 8 V r d:. y a 0.zJ o.. a• _ a j y 1'i I �po INV- APPLICANT INFORMATION Account #: 990004127 Billed To: Lynn Hendrix Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5800-07-5147 Subdivision Info: Location/Address: Edwards Road -28634 Property Size: 6.542 acres Date Evaluated: 10 i3 0�0 On -Site Well / Community Auger Boring `� Pit Public ✓ Cut SITE CLASSIFICATION: ' EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS 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 a'11>!1St' CONSISTENCE 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 rlQtes 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) scape position HORIZON I DEPTH roup Consistence ■teS•� rd�jil!��5��®� Ram HORIZON II DEPTH • Texture _..Consistence "M Mineralogy HORIZON III DEPTH Texture group . _wq S&IMU' W142-W43101Mha-®� . • . • �Q��■ia-se Texture group • m Q►m'swl�l �-�® Consistence rr�i®�■��es■ • • • • • �. - .y�v■��■� CLASSIFICATION SITE CLASSIFICATION: ' EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS 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 a'11>!1St' CONSISTENCE 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 rlQtes 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) ■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■Eli■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■e■■e■■■Eli■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■e■■■■■■■■■■■■■Eli■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ss■e■■■■■■■N■■■■■■■■N■■■■■■■■■■■■■■■iii■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■iii■■■■■■■■■■■e■■■■■ MEN ■■■■■■■■■■■■■■■■■RVA'10'■■VRZAMMEN !?NNE ON ■■■■■■■■■■■■E■■■■■■■ESC!■►`y■■■E■i/11�■■■Ali/ilEi■■■■■■■■■11■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■Ill�i'L•�a ■■■■■■■■■■■Eli■■■■■■■■■■■■■■■■■ ■■■■■■■■■■s■■Ee■■■■■_■■■■■■■■Elia■■■■■■■ee�:i■■■ii■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■m':■■■■■■■■Flo _.JnMMEEME 99mPTWINNEME■■■■■■■■■■■■ MEMEMEOMMEME MEMiiii MMEM"McdiiiiMEMNONMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■E■■■■■■■■■■��===�''■■■■Nil■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■`�►�■�.■uii■■■Nil■■■■■■e■■N■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■l�i■■■■■■■■■■■■■Nil■■■■■■■■■E■■■■■■■ ■■■■■■eE■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■■■■■■■Nil■■s■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■s■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Eli■■■■■■■■■■■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■