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360 Howardtown CirclePermittee's '`� DAVIE COUNTY HEALTH DEPARTMENT i Name:Environmental Health Section PROPERTY INFORMATION P.O. Box 848 Directions to property: #� r1U Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 i�1��,.'�t�:1��� 5�.%N� l _..�►.► Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION N AUTHORIZATION NO: A Road Name:L85 ip:`'' **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying dor Building Permits. (In compliance th Artic I of 13.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ) *NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR APERIOD OF FIVE YEARS. ENVIRON E ALN SPECIALIST.. UATE ISS ED RESIDENTIAL SPECIFICATION: BUILDING TYPE U# BEllROOMS # BATHS?' #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL /S�P/E�CGIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT• �f # SEATS INDUSTRIAL WASTE: Yes `or No LOT SIZE 1I& __4E WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE6—Y SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK' GAL. TRENCH WIDTH / ROCK DEPTH I LINEAR FT. OTHER 'l �,,,_.f) [ t REQUIRED SITE MODIFICATIONS/CONDITIONS: ' � -�- � �' , V_l:-V� �r �1 Jii' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM' BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. 22 OPERATION PERMIT BY: DATE: f' **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT T M DESCRIBED AOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 t 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. DCHD 02/02 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT • .. Environmental Health Section • P. O. Boa 848/210 Hospital Street �� 7� `�✓ Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001851 Tax PIN/EH #: 5861-12-3311,13m Billed To: Brian McDaniel Subdivision Info: Reference Name: Location/Address: Howardtown Circle -27028 Proposed Facility: Residence Property Size: 16 acres ATC Nupber: 2924 **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 an #People #Bedrooms #Baths Dishwasher: ,d Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �� Design Wastewater Flow (GPD) G 2 Site: New 00'Repair ❑ System Specifications: Tank Size &P GAL. Pump Tank Other: Required Site Modifications/Conditions: // e GAL. Trench Width < g Rock Depth � Linear FtOl IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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: Date: �� DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street MockrAlle, NC 27028 (336)751-8760 Account #: 990001851 Tax PIN/EH #: 5861-12-3311 B^' Billed To: Brian McDaniel Subdivision Info: Reference Name: Location/Address: Howardtown Cirde-27028 Proposed Facility: Residence Property Size: 16 acres ATC Number: 2924 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION T A **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 NSTRUC ION IS VALID O A PERIOD OF FIVE /YEARS. 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. �s ( 00)/1 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: "1- �i EJWE • ;i ,', APPLICAAN R SITE EvALUATION/IMPROvmm PERMIT & ATC Davie County Health Department ^ >> Environmental Health Section P.C. Box 848/210 Hospital Street ENVIRONMENTAL HEALTH Mocksville, NC 27028 DAVIE COUNTY (336) 751-8760 ***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 Bria%/����2%%��7i/7//(1?�e1 Contact Person �2��"/an /y c/ /� � f ) Mailing Address rid &x 5 / " J ALL �1M �1 Home Phone /, X�C/�"j QVQ'�4? ` 1 City/State/ZIP 0-0 k Wle- ALL o `022 Business Phone l�tY Q — oC 2. Name on Permit/ATC if Different than Above __/i Mailing Address 1, 18- 3. 8 3. Application For: ❑ Site Evaluation City/State/Zip Improvement Permit/ATC 4. System to Service: ❑ House, Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms XDishwasher ❑ Garbage Disposal 7` Washing Machine If Business/Industry/Other: Specify type L # Commodes ❑ Both ❑ Basement/Plumbing U Basement/No Plumbing # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: X County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Y�No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: (!0 &era Tax Office PIN: # J? 0 ^ In Property Address: Road Name am rd f D w rl U rel e City/zip If in a Subdivision provide information, as follows: Name: 0 ( Y-�' Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 15-q -k cQralf of C!°rde , fZ L05 &warAwri Cide Pioper�q_h�=& ocrgs &11 OW 1-a tt -e ax Date Property Flagged: YOu � I 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 1 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 YI Q h '-rdm S mu to conduct all testing procedures as necessary to determine the site suitability. w DATE VkIbI SIGNATURE C/ 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. n l �'��S �2u� �' JqoCx,51c, ?NdA �, I �� I '�'Ulcoq �'g t k D't1 m ,jf ac 2 Zcr, i 0 - wt lim, 1 f APPUCATION FON SITE EVALUATION/INIPROVEMENT PERMIT & ATC Davie County Health Department -� Environments/ Healfh Sec tion P.O. Box 848/210 Hospital Street MOcksville, NC 27028 (336) 751-8760 P,57-// T y- /ty 14y-- 0 r3.),, 5--7 fi/UdcSoille� til&X,0V ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to ©II 1 a��/���/ J� G �i�e� Contact Persona fp r 7 _ _ � , Mailing Address A City/State/ZIP 2. INamepp on Permit/AT�f Different than Above_( ) � Ur ing Addy 'YO, /✓�%/� � � 3. Application For:,, IR Site Evaluation 4. System to Service:House ❑ Mobile Home Home Phone Business Phone! City/State/Zip ❑ Improvement Permit/ATC ❑ Business ❑ Industry N ❑ Other ❑ Both 5. If Residence: XGarbage XWashing # People li # Bedrooms - 2 # Bathrooms �`j� DishIwasher Disposal Machine �I 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. Type of water supply: County/City ❑ Well _ ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes J�No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name-I'Da����'�JN City/Zip lU,e Jae,. Ila dc If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksvillc) to PROPERTY: Name: v b 1 Section: Block: Lot: Date Property Flagged: /l 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 De artmeut to enter upon above described property located in Davie County and owned by to conduct all testing oce ures as necessary to determine the site suitability. .01 DATE 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). D LAPR 1 6 2001 t N11lR0NNIF�ITAI HEA1711 Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. 7(W Invoice No. /kf rl ccc�,s 11 OIW 3 -Z-4 - ol DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT, Soil/Site Evaluation APPLICANT'S NAME 'X> k l/ / PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community, Evaluation By: Auger Boring (�_ Pit DATE EVALUATED PROPERTY SIZE ROAD NAME7lllJ� 6ClJ� (moi /G�i Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position SIC - Silty clay C - Clay -Slope % CONSISTENCE HORIZON I DEPTH Texture group FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Consistence Structure SS - Slightly sticky S - Sticky VS - Very Sticky Mineralogy SP - Slightly plastic P - Plastic VP - Very plastic HORIZON II DEPTH Texture group G Consistence Structure Mineralogy 1 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: EVALUATIONBY: LONG-TERM ACCEPTANCE RATE: i 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 maw 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 (01-90) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SEEM eENE M■■■■■■ MEMO ■■■NONE ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■E■■■■■■E■■■E■■■■■■■i�■■■■■MME■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■ME■■■e■■■■■eME■■E■ri�■■■._==�■■■■■Mee■■■MEEM■■■■■■■■■■■■■ ■■■■■■■■■■■EMM■■■M■■■■E■■■■■Y"��■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ UMMEMEMMENNENMEMNON MENNEN MMEMEMEMMEMEMENNENMENNEN ■■■■■e■■■■MME■■■■■E■EEE■c�c■■e■■■■■■■e■E■e■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■H■■■■M■■■�EMMn■■■■e■■■■■■Mee■■■■■E■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■ire■e��rJ■E■EM■■■■■■■■e■EE■■■ts■■sM■ ■■eE■EE■■■M■■M■■■■■■■■■■■■■■sr�eie��■e■■■■■■■■■■Mee■■■■■■■■■Mee■■■■■ ■■■■■■■■■■■e■■■■■■■■■■■■■■s:a►ate■■■■■■■■■■■■■■■■■■■■■■■■■■■EN■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E■■E■■Mee■■■■■■■■■■■■■■■■■■■■■■MMM■■ ■■■■■■■■■■■■■■■■■■■■■s■■MM■E■■■■a■■■■■■■Mee■■■■E■■■■■■■■■■■■■■■M■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■MEE■■■■■■■■■■■■■■■■EE■E■■Mee■■■■■Mee■■■■■■■■Mee■■ ■■■E■■■N■■■■■ ■■■■■■■■E■■■■ ■■■■■■■E■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ D I OUIJTY 1IEALTii DEPARTMENT ' ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40.06 Mocksvilie, NC 27028 Phone #c (336)751-8760 April 24 2001 Pennington & Company P.O. Box 577 Mocksville, NC 27028 Re: Site Evaluation/ 2 sites on Howardtown Circle Tax Office Pin : # 5861-12-3311.01 and 03 Dear Client(s): As requested, a representative from this office visited the aforementioned site on April 20, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Ave. j�4aAe Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Davie County Health Department 4;) P' 'r vironmental Health Section EIV P.O. Box 848 C' R 0 4 LU1 I 210 Hospital Street O U Courier # : 09-40-06 1911 Mocksville, NC 0028 Phone: (336) - 753 - 6790 ON-SITE WASTEWATER ICATION Far: (336) - 753-1680 (Check One) Replacementmodelin Reconnection Name: MRAI / 10AIN1 d Phone Number (Home) Mailing Address4-00 &q%t"_ aw LIZ (Work) Email Address: Detailed Directions To Site: Property Address: '2120 / UM1 AU) 9) 020 Please Fill In The Following Inforrmation Ab out The EXISTING Facility: Name System Installed Under.kam Type, Of Facility: _&# Date System Installed (Month/Date/Year): q -Z3-O Number Of Bedrooms: S Number Of People: Is The Facility Currently Vacant? Yes l =0 If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: r Please Fill In The Following Information About The NEW Facility: Type Of Facilityy:i— _96 Number Of Bedrooms: Number of People Pool Size: ! X 310 Garage Size: Other: Requested By: (S ignature) (Date Requested: For Environmental Health Office Use Only .Approved D sapproved Comments: Environmental Health *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check j�Money Order # Amount:$ . OU Date: t / Paid By: '►' 4 �- + (L Received By ll`` `;;�� • �/ (( Account #: �� Invoice #: 7&'70