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172 Hidden Meadows TrailDAVIE COUNTY ENVIRONMENTAL HEALTH -" - - ► P.O. Box 848/210 Hospital Street Mocksville, NC 27028 N (336)753-6780/ Fax # (336)753-1680 OPERATION PERMIT l Account #: 990005913 Tek. P.,INIEH #: F20000004302 } Billed To: Daniel Kooistra Reference blame: Hidden Meadows.Trail-27028 � :: Proposed Facility: Residential Pro periy Sixe: 2 Acres ; rs N8TThe AT * The�i suance of this Operation Permit shall indicate the system described on the ATG 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 �Gp �.. Tank Date 7//7 Tank Size iOvO Pump Tank Size Bedrooms: System Installed By:5 r Installer#7-7 Date:_ll /I z GPS Coordinate: Environmental Health Specialist DCHD 11/06 (Revised) t DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005913 Tax RIN,EH #: F20000004302 Billed To: Daniel Kooistra Sufdivisiori Info: Reference Name:. € ', :tocaiion/Address: Hidden Meadows Trail -27028 Proposed Facility: Residential Property Size: 2 Acres Site Type: ANew ❑Repair ❑Expansion ATC Number: 5958 f . **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 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Typej # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City OWell ❑Community Well System Specifications: Design Wastewater Flow (GPD) ICO Tank Size GAL. Pump Tank GAL. Trench Width�P Max: Trench Depth Rock DepthJi_rt Linear Ft �2b� 0@1lU�LBra( Site Modifications/Conditions/Other: ('41� %S% Contact the Davie County Environmental Health Section for final inspection of this system between Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005913 Tax PIN/EH #: F20000004302 Billed To: Daniel Kooistra Subdivision Info: Address: 202 Hidden Meadows Trail Location/Address: Hidden Meadows Trail -27028 City: Mocksville Property Size: 2 Acres Reference Name: Proposed Facilit�: Residential **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; XNew ❑Repair ❑Expansion, Permit Valid for: d.5 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement Basement plumbing Non -Residential Specifications: Facility Type BeZrA # People # Seats Square Footage(or Dimensions of Facility) Design FlowOD): Type of Water Supply: t]County/City 18Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initiala Ax e & ;15 . Re air or 25% Q&CIb1 Site Plan Environmental Health Specialist i.p. 11-06 r �1 4 �r 1 Date /i� P V APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/=To 680 Application For: ❑ Site Evaluation/Improvement Permit Construct (ATC) 0 Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPT.TCANT INFORMATION Name m;d 's • S Contact Person Address Z Q S7Fa1 Home Phone . City/State/ZIP 0dJ6nkSJi lle- Ne_ 27079 Business Phone ? Email 7 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged glPh 117, NOTE: A survey plat or site plan must accompany this pplication. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months 'th site plan iinZAP, irafon with omplete plaj.)F'�.ego Owner's Name ,� ;A Nl ASe ti Rhone Number Owner's Address biqA1261 K00 $ ✓ City/ tate/Zip Property Address City. Lot Size Z A 6, Tax PIN# 0 53"D1, Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "Yes",supporting doc a tion must be attached: Are there any existing wastewater systems on the site? _Yes Does the site contain jurisdictional wetlands? _Yes _ o Are there any easements or right-of-ways on the site? es No ON /q1 t9 Is the site subject to approval by another public agency? _Yes It Will wastewater other than domestic sewage be generated? Yes TF RESIDENCE FIT J, nT JT THF, BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: DYes ONo Basement Plumbing: ❑Yes ❑No TF Nf1N_RFCTiIFNf'F PTT T f)TTT TT -TP RfIV RFT nUU ... 11-1 ­. ... .- . . a.i a. • r . - /. T . Type of FacilityBusiness Total Square Footage of Buildin X # People # Sinks % # Commodes I # Showers . # Urinals Estimated Water Usage (gallons per day) _(Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: L9 nventional ❑Accepted OInnovative ❑Alternative 00ther Water Supply Type: ❑ County/City. Water KNew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 6'No 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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or sla�ii g the h se/fi ity oc tion, ploposed well location and the location of any other amenities. Q�/ '�� '�` Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 77 2,3 & / Z Client Notification Date: Date 1 1EHS: Sign given ❑Yes ❑No Account # qql3 Revised 11/06 Invoice # x.21 o `ro eft1 pti Ra1a�Q� .Pd ��i�� ots GZ�oun� 0 a APPLICANT INFORMATION Account #: 990005913 Billed To: Daniel Kooistra Reference Name: Proposed Facility: Residential Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Property Size: PROPERTY INFORMATION Tax PIN/EH #: F20000004302 Subdivision Info:' Location/Address: Hidden Meadows Trail -27028 2 Acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy - HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 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 CONSISTENCE Moist 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 Mineralonv 1:1, 2:1, Mixed lYatcs 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) C�Wit TE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Uealth Department SEp 2 0 2006 Environmental Health Section P.O. Box 848/210 Hospital Street / DMRONME At HEALTH Mocksville, NC 27028 op1� OUNTY (336)751-8760/ Fax (336)751-8786 Application For:. VSite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTAN1*** 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 Billing Address .0 t'A t r ' Home Phone _ City/State/ZIP J� �. Business Phone Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid forfig6mon s wi si a plan, no ex ara�io' with compl to plat. Street Address 0,, Tax PIN# 5g�v"� Subdivision Name ,ction/Lot# t Size Dire ions To Site: . 1Q 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 INO Does the site contain jurisdictional wetlands? ❑Yes /No Are there any easements or right-of-ways on the site? ❑Yes/vo Is the site subject to approval by another public agency? ❑Yes Ilo Will wastewater othet than domestic sewage be generated? ❑Yes fdNo IF RESIDENCE FILL OUT THE BOX BELOW # People__ # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes o Basement:JYes ❑No Basement Plumbing: ❑Yes /No - 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: /Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water /New Well" []Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of myknowledge. 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 inspection determine co 11 nce with applicable laws and rules on the above described property located in Davie County and owned bya�r Site Revisit Charge Prope y o er's or owne'representative signature Date(s): Client Notification Date: Date EHS: Sign givenes ❑No Account #��/ Revised 2/06 Invoice # t Y- ' , V �itY y} A �I 1 , i 58 f� t t t v 4 7p a v I t F _ I d�. I a � � � o-� � of a A • L x 7 A TF 4 s. 4 bC .. f { � . n a 3 .a rw` .rW i TR 0 Los 5909 W99'5L) NIL 9LSS (vswn) LM ( wat) s� o, oy %gavi Wee w9S'ZL OL89 � (VLE'9E) �o t VE9 OL y` a / 10i OBi tL'LLOt 8901 _ A � o APPLICANT INFORMATION Account' #: 990004115 Billed To: Susan Robinson Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH M 5810-56-3552 Subdivision Info: Location/Address: Hidden Meadows Trail -27028 Property Size: 2 Acres Date Evaluated: f'•/ lD�la p � On -Site Well V Community Auger Boring Pit V---- LO (ID • • ----------- Landscape position— HORIZON I DEPTH Texture roup— - • FIMM e�ra 2 9 Wi��r� EN - , groupMineralogy Texture Consistencerim®rte-arMY-MrMFMrRrOM1WOMM eralogy 'TOM -M . •HORIZON Consistence • : ®�e�C!���F IV DEPTH Texture group Consistence Mineralogy SOIL WETNESS I El AN N • 177,1154's �a����s©■� SAPROLITE CLASSIFICATION SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT. -.Z Q' REMARKS �� i� ��'}tc ctA 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 MQlSL - CONSTSTENCF 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 1YQtes 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(unsu table) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) o .r �. W ..f 13y j r pyx w�, ' ' k ;% r' . 7 A; � y`r .� a� r. c Ott' P r " 0 1 MGMn :. # R� �� ♦ h 'h[ 1 .rtiarn r x a f� �'S n 4 J r �.' 1V Y e' \;.i ,Off 0rj�� � pl�x r{*�,p gip' + z, s^ w..g"Y !' $ ap #' ,Ss�a '#'"fi'tl� d^;+cW' s 'rs ta}, ,P, d.+ h4 f ` fr MEADQVI/S Tl �I.' sq x � � t -11h": wit j �_" �� �, � ;� "` d� `+ •� '� �& � � r f'yroyr, `' ,.�,€� '2Y yar yl*F7 ^� 74, mx l n r - r 5 K {} 4 j 7 f: el My �2'r. ter: .�.,a � � ..� "A i� � �� �• M s -°s• a I 1 g t •rig z u� ... .... ... .. . :N S`.. Improvement Permit Susan Robinson 209 Hidden Meadows Trail Mocksville, NC 27028 . Re: 2 Acre Tract / Hidden Meadows Trail Tax PIN: 5810563552 Dear Client(s): 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 or the intended use change. System To Serve: r\ n -P =N)0Z Wastewater Design Flow(GPD): 3r'.,;,OValid: Years ❑No Expiration System Type: l6onventional ❑Accepted ❑Innovattyive ❑Alternative ❑Other Site Modifications/Permit Conditions: �� �`SS��M 1o` V.0K 1r ELL -Z 9-4- Site Plan&— 0 i.p.letter 7/06 A&0 Da 3 Z U V9 �g f DOArJLD D..B• �� �. G 0BPL�, , PC. 199 1, hereby cartify thct the Davie County Health Department has evc!outad the subdivision entitled : D.WiEL R. KCOITbt with respact to criteria and conditions eetabiished by state la.a or promulgated theraunder and the sarna is found to comply with such criteria and conditions EXCEPT as set fouth in such evaluation. For details of this evcluation and for limitations, see the writt-n report on file at said department. IMPORTANT NOTICE: THIS CERTIFICATE DOES NOT CONSTM fF A PERMIT OR APPROVAL OF INDPADUAL LOTS IN SSD SUBOMS:ON FOR INSTALLATION OF I ' '1 1 CONr�:iL �Nl,rnP VENT 30'EA F_Er AS OF DE0-4-2006 DAME COUNTY HEALTH OFFICER / 49 �60 G / G 3 / • ./O / t / NEW IRON / 1, Grady L Tutterow, certify that this plat was drawn under my supervision from an actual survey made �. under my supervision (deed description recorded in / y Book ; Page , etc.) (other);thot the boundaries Q 0J I hereby certify that I am the owner of the property shown not surveyed are clearly indicated as drawn from information found in PL Book , Page h / that the ratio of precision is calculated as 1: +20,000 Q that this plat was prepared in accordance with G.S. established minimum building setback lines and dedicate all streets, 47-30 as amended. Witness my original signature, registration number and seal this day of A.D., 2006 / �� W Surveyor sewer and watzar lines to the County of Davie (Seal or Stamp) Registration Number DATE THIS IS AN EXEMPT SUB-DMSiON 5umiV= Certir=tinr] faf CubdiV�alOn — DaYle C<1+i,nhr North r'nrnl'r-� I, Grady L. Tutterow, Registered Land Surveyor, Number L-2527 certify to one or more of the following as indicated by an X: _X a. That this is a plat of a survey that creates a subdivision of land within an area of a county or municipality that has on ordinance that regulates parcels of land; _—_b. That this plat is of a survey that is located in such a portico of a county or municipality that is unrNulctz�!d as to an ordinance that regulates parcels of land; _c. That this plot is of a survey of an existing parcel or parcels of land; _—d. That this plat is of a survey of another category, such as the recombination of existing parcels, a court-ordered survey, or other exception to the definition of a subdivision; e. That the information available to this surveyor is such that I am unable to make a determination to the beat of my professional ability as to provisions contained in a. through d. above. Signature Surveyor Registration Number U. (,"J' AT I T I' AN P FileJ for reg`5tr `.loo ct o'clock M. ___ --------- -___, 2006 cod recordaJ in Plat Book Page — --' Fling fee i paid. M. SPENT SHC:AF - DAVIE Co. Reg'str_r of Deeds by REVIEW OFFICER'S CERTIFICATE Review officer of Davie County, certify that the map or plat to which this certification is affixed meets all statutory requirements for recording. 4.11'13• F "'- NEW IRON 175.00 —` _---� -_.-- --- J- S 8359'24' u IRON CONCRETE -E -- uoN ONIR (+T) LLOYD D. BLACKyy;�LDE CON'ROL CORNER D.B. 351, pG• 7 1111 PLAT MAP: DANIEL R. KO OI S TRA OWNER ------------------ DEVELOPER DANIEL E. KOOISTRA 505 RALPH RATLEDGE RD. MOCKSVILLE, N.C. 27028 (336) 492-5041 CLARKSVILLE TOWNSHIP DAVIE COUNTY, NORTH CAROLINA DATE: DECEMBER -6-2006 TAX MAP REF.: F-2, P/0 53 SURVEYED BY: TUTTEROW SURVEYING COMPANY 107 NORTH SALISBURY STREET MOCKSV1LLE, NO 27028 (336) 751 -5616 1 " = 100' 100 50 0 100 200 300 SCALE IN FEET FILE NAME: COORD NAME: DRAWING NUMBER: K00 -RR DONGOBLI-73 30406-3 �. _REVIEW OFFICER DATE I hereby certify that I am the owner of the property shown and described hereon, which located in the County Davie that I hereby adopt this plan of subdivision with my free consent, established minimum building setback lines and dedicate all streets, alleys, walks, parks and other sites and easement to public or private use as noted. Furthermore, I hereby dedicate all sanitary sewer and watzar lines to the County of Davie DATE 4W a OWNER ' •. ^ OWNER ---^ 0 K00T D �•R• ' l9¢ly4 7� PC, SENAGE FACILITIES. DATE ' NOTES: I 1. TOTAL LOT= 1 2. TOTAL AC.= 1.999 AC. 3. NO NCGS GRID MONUMENT WITHIN 2000 FT. _ ! 4. PRIVATE WELL AND PIRIVATE SEPTIC SYSTEM TO B,E INSTALLED 5. THIS PROPERTY IS NOT LOCATED IN A FLOOD MAP 1 - AREA AS SHOWN ON PANEL # 370308 00025 C 4.11'13• F "'- NEW IRON 175.00 —` _---� -_.-- --- J- S 8359'24' u IRON CONCRETE -E -- uoN ONIR (+T) LLOYD D. BLACKyy;�LDE CON'ROL CORNER D.B. 351, pG• 7 1111 PLAT MAP: DANIEL R. KO OI S TRA OWNER ------------------ DEVELOPER DANIEL E. KOOISTRA 505 RALPH RATLEDGE RD. MOCKSVILLE, N.C. 27028 (336) 492-5041 CLARKSVILLE TOWNSHIP DAVIE COUNTY, NORTH CAROLINA DATE: DECEMBER -6-2006 TAX MAP REF.: F-2, P/0 53 SURVEYED BY: TUTTEROW SURVEYING COMPANY 107 NORTH SALISBURY STREET MOCKSV1LLE, NO 27028 (336) 751 -5616 1 " = 100' 100 50 0 100 200 300 SCALE IN FEET FILE NAME: COORD NAME: DRAWING NUMBER: K00 -RR DONGOBLI-73 30406-3