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391 Elmore RdDAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900204 Billed To: J. D. Crews Homebuilder Reference Name: Proposed Facility Residence ATC Number: 4090 Tax PIN/EH #: 5812-70-9773 Subdivision Info: Location/Address: Elmore Road -27028 Property Size: 1.4 Acres 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 WASTE W CO ON I VA FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur ✓ Date: -C-4,24� 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 f 7 Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any 7 given period of time. Pbj!5- , Fi?ewr ro f�2 L)(C V 10 Septic System Installed By:1 Environmental Health Specialist's Signature: DCHD 05/99 (Revised) K DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section pd _ P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900204 Tax PIN/EH #: 5812-70-9773 Billed To: J. D. Crews Homebuilder Subdivision Info: Reference Name: Location/Address: Elmore Road -27028 Proposed Facility Residence Property Size: 1.4 Acres ATC Number: 4090 **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 floos� #People #Bedrooms 3 #Baths_ Dishwasher: C?' Garbage Disposal: 0- Washing Machine: © Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: H00" ❑ Lot Size =\C%S5 Type Water Supply Design Wastewater Flow (GPD) 3U0 Site: New ❑ System Specifications: Tank SizeI4CO GAL. Pump Tank GAL. Trench Width,-��' Rock Depth W' Linear Ft9tx:3 Other: -`� �DLST12.160TI C0 ?--BVjfS- Required Site Modifications/Conditions: IN STQLL- C>3 (� � Sy� I- qjJ orr- 000, t -#-JZ 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 fin1 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)51-8760.**** Health Specialist's Signature: DCHD 05/99 (Revised) Date: APPLICATION FOR SITE EVALUATION/IMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Str( Mocksville, NC 27028 (336) 751-8760 ECE�WE 5 & ATC MAY 1 6 2005 ENVIRONMENTAL HEALTH DAVIECOUNTY ***IMPORTANT'*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed !rAQ C�G�I,lis !>'CN�ERts%LOGS Contact Person W Mailing Address O 1 L LmORc Home Phone 95/0- 7qys City/State/ZIP 1hdCKS\/� L(cF- AJ6 72o7e Business Phone 119,7- 7&/P 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: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Iff Residence: # People # Bedrooms 3 # Bathrooms . / Af'Dishwasher M Garbage Disposal N"/ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. ^/ Lv Type of water supply: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBAfITTED by the client with THIS APPLICATION. Property Dimensions: jq3 'X 330 35S x -t 8 Y 1 Tax Office PIN: # S$1 Z 705 77 3 Property Address: Road Name E U M EQ E RA. WRITE DIRECTIONS (from Mocksville) to PROPERTY: AW" !oo i tV'o2T►•t I-EGl' on1 6-IM0945' City/Zip Mo&KSVfl l6. MG77oU S ► E- ij otj fR oPg�-z4 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date Property Flagged: -.5- I(,- os- This S 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by _ tt�w, Z -WV -.-E7 ckews to conduct all testing procedures as necessary to determine the site suit b' ' DATE .S-/6 -ps' SIGNATURE THIS 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). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. O / LO Fs o3 3A) 180 s" 6370 V 3742 3-14.10 222 (1.81A) 9218 A2 6 470 (a azn) 0]63 PFA (24.88A) 2708 (361A) Cloj 5354 17/9 (13/) 5084 (25.47A) 73A) 9939 010 szo, 115 N � 4 ko", 4 6276 v 0)_ X119 v � aaii I aao ]u (810A 83 1803 (57.75A) 9773 lO (105.7A) 4235 i Y � I i i / I / l 10 688A r ' 4966 7 5620��r0 I r DAVIL COUNTY IiEALTII DEPARTME, NT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900204 Tax PIN/EH #: 5812-70-9773 Billed To:. J. D. Crews Homebuilder Sybdivision Info: Reference Name: Location/Address; Elmore Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Z`3 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position l_ Slope % HORIZON 1 DEPTH &.- ! Texture groupCL CL^ Consistence S - SS Structure C lZ1-0 Mineralo t HORIZON II DEPTH 2_ .-2;?- - �C * Z Texture group r, C - C_ Consistence Structure xsv A Mineralogy HORIZON III DEPTH 2 -q- �' - 0 22 _q Texturerou CS `LFSc L i C Consistence ' r/ Structure F�1 Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 0.'2> SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:. OTHER(S) PRESENT: t`�`-ti LEGEND Landscape Position R - Ridge S - Shoulder L - Lincar 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 is 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 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 nCl ID 05/99 (Revised) ■■■■■OMM.■■....■N■N■n■nn.■■■■■..■■ /■NN■■■■■■/■■■■.■■.■// ■ /// /■ NNW././■■/won■./■■■■■■.■■■■■■■■■ ■ ■■■.■■■ ■■■/■■■■//■// ■■ ■ :::C:::::::::C:::C::::::minim :::N MENS■■""■■■■ ■ ■ : .........■.....■.■■/■■■.■■.......■■■■/■.....■■■::::::::::: �■ ;: ....■ ■.■■...■........■■.........■■■■■■E■■..nn■.NEn■...■■. .....:.■■■...■......■.■■....■...■MEMO■■■■■■■NNEEMENE. ■■ ■ ; mom .■.No no.....■..... .............................■.■■■■■.MEMENNEIM nC.■:nN ■ ONION.......■o.NNW....■......N..: EN...E:::::::::::::C:::::' ■..O...EEE....■.ON■E.E.■E■n...■.■■.../n....nnNE..■■.NM■■■MMC ■ :::::C:::C:0 NO N:C::::::::::::MOENINOUE NI::: ::::::C. 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