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209 Hidden Meadows TrailY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003930 Billed To: John Robinson Reference Name: Tax PIN/EH #: Subdivision Info: Location/Address: 5810-57-4601 209 Hidden Meadows Trail -27028 ATC Number: 4370 As stated in 15A NCAC 18A.1969(5) 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 WASTEWA O HC`i'I N I FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: // %/X- ill� 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. 14'6' �S T F -y • Rae1<IZC4 Septic System In lled B Ll S 1 Environmental Health Specialist's DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT -,j Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (� I (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003930 Tax PIN/EH #: 5810-57-4601 Billed To: John Robinson Subdivision Info: Reference Name: Location/Address: 209 Hidden Meadows Trail -27028 Proposed Facility: Business Property Size: 20 acres "-NO'I��P*% 70 sl mprovement/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 #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type`#People #People/Shift #Seats Industrial Waste: ❑ Lot Size 20.0254CJ26Type Water Supply 1A/1ZLL. Design Wastewater Flow (GPD) 100 Site: New ❑ Repair ❑ System Specifications: Tank Size ICCO GAL. Pump Tank GAL. Trench Width to Rock Depth 17 " Linear FdccC ' k�5f As stated in 15A NCAC 18A.1969(5) Other: j2j&0 j0^J ( accepted Systems may also be used Required Site Modifications/Conditions: (hlSrpt-i- p,J G�rJTt� . ���={� ��' of:P Eb,J�, kap jr os� �'Q.,�. 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 p.mo e day of installation. Telephone # is (336)751-8760.1= **** N t C �E — ep41 Ao1Vr:�-RT S0'RRV->t v xref:� Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 111710Cv Davie County HealthDepartment Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 April 7, 2006 John Robinson 209 Hidden Meadows Trail Mocksville, NC 27028 Re: 20.63 Acre Tract/Hidden Meadows Trail Tax PIN# 5810574601 Dear Client(s): As requested, a representative from this office visited the above site April 6, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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. Improvement Permit System To Serve: 1p�-rg4'N �r Wastewater Design Flow:? System Type: P onventional ❑Accepted System Location: ❑Innovative ❑Alternative ❑Other 00R-ro StDq— ar t ct= Valid: D-6'Years ❑No Expiration Site Modifications/Permit Conditions: Irt-OD c:Re- T,,J'4- , IC"P W .Fg ps-i.p.letter 2/06 4 " ry `° {17 bre ar ,W k R � 5 fir ', � � � � � ��� � � � � °, � �r�#' � r p Ab„„, Y r '• x' 63A x w * � a v 4601 � u IN "as a �" •- ax� a a' a� � %q- '4 ti + ; ot m'FE Voi Po �" P � � , a 1 OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie CountyHealth Departmentartment 2006 Environmental Health Section MpR P.O. Box 848/210 Hospital Street Mocksville, NC 27028 �v,RONMEMAI uN (336)751-8760/ Fax (336)751-8786 DAVlECOUN � L �,� n or: / Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both l ***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 tt� Contact Person �,� �„_ Billing Address c(' _ Home Phone V? 2— -7 3,0 City/State/ZIP �' a E Business Phone 399.79/c� 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 for 60 month with site plan, n�pir tion with complete plat Street Address Zc �� ty ��O 'S �- `` �- �1 P Tax PIN# 116 0 % Subdivision Name Section/Lot# Lot Size Directions To Site: . 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 fft <o Does the site contain jurisdictional wetlands? ❑YeS.PNo Are there any easements or right-of-ways on the site? []Yes leo Is the site subject to approval by another public agency? ❑Yes -E no Will wastewater other than domestic sewage be generated? ❑Yes-Blllo ,l IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business �✓ �-Kct, cj, (4ioXotal Square Footage of Building G -5 _ # People # Sinks # Commodes _� # Showers 67� # Urina or s Estimated Water Usage (gallons per day) /Q (Attach documentation of simi ar 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 If yes, what type? /No 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 information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred front this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to dete 1' th applicable laws and rules on the above described property located in Davie County and owned by IF Property owner's or owner's legal representative signature -3- Date Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given ❑Yes ❑No Account # (37,?O Revised 2/06 Invoice # i S " v 1 C .. • t' e a F _ ion_Ya ,`� _ � gy Y r 9 r.. . k a Q , I n a Mk F l DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003930 Tax PIN/EH #: 5810-57-4601 Billed To: John Robinson Subdivision Info: Reference Name: Location/Address: 209 Hidden Meadoyv Trail -27028 Proposed Facility: Business Property Size: 20 acres Date Evaluated: �f G0lv Water Supply: On -Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: O �� 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 ONSIST +.N - . 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 xVery 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 Nstes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) EVALUATION BY: OTHER(S) PRESENT - 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 Mineralogy HORIZON II DEPTH Texture group Consistence LORR Mineralogy HORIZON III DEPTH Texture group 11rapr", 16"Alm. Consistence Mineralogy HORIZON®—®®— DEPTH,Texture —O—®®®— group Consistence --�---- Mineralogy SOIL WETNESSRESTRICTIVE HORIZON SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: O �� 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 ONSIST +.N - . 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 xVery 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 Nstes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) EVALUATION BY: OTHER(S) PRESENT - 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)