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146 Hidden Valley Ln- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003292 Tax PIN/EH #: 5729-28-6465 Billed To: Gerald Tomberlin Subdivision Info: Hidden Valley Reference Name: Location/Address: Hidden Valley Lane -27028 Proposed Facility Residence Property Size: 1.93 acres ATC Number: 3820 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE ARS. Environmental Health Specialist's Signature: 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. I \ _ Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section d P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �V IMPROVEMENT/OPERATION PERMIT Account #: 990003292 Tax PIN/EH #: 5729-28-6465 Billed To: Gerald Tomberlin Subdivision Info: Hidden Valley Reference Name: Location/Address: Hidden Valley Lane -27028 Proposed Facility Residence Property Size: 1.93 acres ATC Number: 3820 **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 A #People #Bedrooms #Baths Dishwasher-)2r"' Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size /'� fije Type Water Supply," /) Design Wastewater Flow (GPD) Cj / b Site: New Repair ❑ System Specifications: Tank Siz�� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width 1,7JVRock Depth 'Linear ,10/ 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.m. on the day of installation. Telephone # is (336)751-8760.**** , Environmental Health Specialist's Signature: a7 Date: DCHD 05/99 (Revised) v— APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmental Health Section P.O. Box 848/210Hospital' Street Mocksville, NC 27028 (336)751-8760 kAp ECEPWE JUL t 13 2004 ENVIRONMENTAL HEALTH DAVIE COUNTY ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED PROVIDED. Refer to the I/NFORMATION BULLETIN for instructions. 1. Name to be Billed fL Q of L`'ti ' / Contact Person GGA /G� �i22( (j FC Mailing Address II-IrAe^Home Phone City/State/ZIP �d C �^ I!/� 4 /(/` C-' -9 Business Phone / 306`0 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �❑ Site Evaluation El Improvement Permit/ATC OPIoth 4. System to Service: Id House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ER/conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms 1,3 # Bathrooms 8/Dishwasher[]Garbage Disposal L1Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: 1:1County/City. 92/Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 18- O If yes, what type? '**IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED 3ELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: / , ,��/�r WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # JT? oZ ! �� C�(J j ). -7c- Property Property Address: Road Name 6)4[L. 1,V 4116, AJ— 02 KoJ on iC y �d7` City/Zips cL�J?> I/� /Il G �JID �s �1 t rf'�en (/� I�: — s� ,Qr ✓ew . 5. If in a Subdivision provide information, as Name: pre- S w� /� /JP — r4 Otis Section: Block: Lot: Date home corners flagged: % ' 13' 04 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 ara responsible for all charges incurred front 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 to conduct all testing procedures as necessary to determine the site suitability. DATE f 3 " U `t 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). Sign given 'Revised DCHD (05/03 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. �9f� Invoice No. y a q —7 7 � 6 r DAVIE COUN'T'Y HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003292 Tax PIN/EH #: 5729-28-6465 Billed To: Gerald Tomberlin Subdivision Info: Hidden Valley Lot # Reference Name: Location/Address: Hidden Valley Lane -270 Proposed Facility: Residence Property Size: 1.93 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring a� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % COP HORIZON I DEPTH �, d Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH - Y Texture group Consistence Structure Mineralogyc ( 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: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: w OTHER(S) PRESENT: 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 Moist 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 DCHD 05/99 (Revised)