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110 Maple Knoll Dr Lot 1 i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 \ ^�' Account M 990000981 Tax PIN/EH M 574reKnoll 765.01 -- - Billed To: San Filippo Companies Subdivision Info: Ma Lot#01 Reference Name: Anthony San Filippo Location/Address: Sain Road-27028 j ATC Number: 4327 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 Sewa a Treatm t and Disposal Systems). THIS AUTHORIZATION FOR WASTEW R ON V D F A PERIOD OF FIVE YE//ARS. Environmental Health Specialist's Signature. ate: jot0 As stated in 15A NCAC 18A.1969(5) accented Svstems may also be usetltl CERTIFICATE OF COMPLETION *�*DNO✓TlE*** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 1 I 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. L V1 �V-Al- :5L-D� Septic System Installed By: L Environmental Health Specialist's Signature: ate: o DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • �;_�, Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Y IMPROVEMENT OPERATION PERMIT Account M 990000981 Tax PIN/EH#: 5749-74-3766.01 Billed To: San Filippo Companies Subdivision Info: Maple Knoll Lot#01 Reference Name: Anthony San Filippo Location/Address: Sain Road-27028 Proposed Facility: Residence Property Size: see map **NO" IQ.Thislmprovement/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 :�)c #People #Bedrooms 3 #Baths 2. Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: 2"' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 32901 V-t"- Type Water Supply Design Wastewater Flow(GPD) ?J� Site: New Repair❑ System Specifications: Tank Size 1=GAL. Pump Tank GAL. Trench Width 3t: Rock Depth"JA Linear Ft.Zyo Other: 3 _/%S 7_9/gW r/aJ AeCr;, 'rL-,D 2S?o Zeb JcTr ici..1 S' 7�/►1 i As stated in 15A NCAC 18A 1969( ' ,.� RequVn,dj8iTd14odtfic=ionWaftbt'IIoBsUs(� STA. _ O� L.p.,)��92, �� J r - JT', � l�o� P pcc �f G u I IPROVE NT/OPERATION PERMIT LAYOUT- AP ROVED EFFLUENT FILTER RISER(S)IF 6`°BELOW FINISHED G DE. ****NOTICE: Contact a representativ of the Davie County Health Department for final inspection of this system betty 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.ml on the day of installation. Telephone#is(336)751-8760.**** � A ua 1,316Z�EP, o GA _cam -��ec��o� +�w�Q99- En ronmental Health Specialist's Signature: te: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751=8760/Fax(336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit "uthorization To Construct(ATC) ❑ Both ***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 i i Yt b0vContact Person ,, 7<// Billing Address` !F.Q . Home Phone City/State/ZIP L, cc& Business Phon��U' ! i-{ (75 cls o Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) _ Street Address City : ' Tax PIN# Subdivision Name /`,oVx oll I o r 1 Section/Lot#__j Lot Size J Directions To Site: Date House/Facility Corners Flagged 2 OZ 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 E(No Does the site contain jurisdictional wetlands? ❑Yeso Are there any easements or right-of-ways on the site? ❑Yes to Is the site subject to approval by another public agency? ❑Yes 13m Will wastewater other than domestic sewage be generated? ❑Yes 970 IF RESIDENCE FILL OUT THE BOX BELOW #People _/ #Bedrooms _3 athrooms 2i Garden Tub/Whirlpool es ❑No Basement: YQ es ❑No Basement Plumbing: eBs ❑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 e1410 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 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 from this application. 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 on the above described property located in Dave County and owned by Site Revisit Charge Pr i)r, er's owner's le representative signatureDate(s): p Client Notification Date: Da EHS: n (/ Sign given ❑Yes ❑No Account# y�a Revised 2/06 Invoice# 5Z.�S • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department Envit»nmenta/Health Section P.O. Box 848/210 Hospital Street C Z Mocksville, NC 27028 O ZQ0Z (336)751-8760Rati Oq Meq ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructio 1. Name to be Billed -5Al-4 ht t-1 PP O /�Jt�l$F'Z1lCZt QIP 1 I1CContact Person,/ANTND)Q $f�N art 1 t Mailing Address /t3� y��l�l/J VA 1�1' 0-0 Home Phone City/State/zip AONJAWCAE , i'lL Z^700ko Business Phone '33( '!�40 2-/Z3q 2. Name on Permit/ATC if Different than Above S"\1F AS A3y J j Mailing Address City/State/Zip // 3. Application For: U Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: Ell House ❑ Mobile Home ❑ Busines ❑ Industry ❑ Other S. If Residence: # People # Bedrooms •L L j # Bathrooms 21 fJ Dishwasher /Garbage Disposal J Washing Machine tnasement/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) et 7. Type of water supply: ' County/City ❑ Well CI 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 COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: ��( �C.A( WRITE DIRECTIONS(from Mocksville)to PROPERTY: TL Tax Office PIN: # rte-14 9.-1 q 3-7(o(o . O \J5 ISS? j SAIr-� 2� ; T Property Address: Road Name SA 11, IZ ��L�'�� en i i✓ti I City/zip mo LA-X'1 L Phio P,,=A< <-S A%3 O l, s ' 11�� If in a Subdivision provi tnJformation,as follows: 07702-8 � L 0 k7 v� 6\1 1 t \1 I'S 10 t-� Name: rel A10 -: 1Lt"0 L-L Section: Block: Lot: f Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. 1 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,untlerstand that I am responsible for all charges incurretl from this application. 1,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 Z51-)N J=t t,i io 00 Cc,r4,s-vyC t1 G N 1 ,►V L to conduct all t stin procedures as necessary to determine the sit#((Incude DATE OZ— SIGNATUREr THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAof the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: qglAccount No. Revised DCHD(07/99) Invoice No. Z- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000981 Tax PIN/EH#: 5749-74-3766.01 Billed To: San Filippo Companies Subdivision Info: Maple Knoll Lot#01 Reference Name: Location/Address: Sain Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 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 I DEPTH � Texture group .SGL Consistence Structure Mineralogy HORIZON II DEPTH y" Texture group Consistence Structure ,L Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 71 LONG-TERM ACCEPTANCE RATE ,c SITE CLASSIFICATION: EVALUATION BY: r !/ 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 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ell■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMNONiiiiiiI�il■iiiMEMNON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■��■II■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■��===�I�CJI■I?�i��i■■■■■■■■■■■■■■■■■■■■■■■�i��■■■■rte■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ` 7 :$� yha k 1S ry 172 Test Pit Site O \� 0 00 0 v: Patch of Trees ` Cp- 32,901 sq.ft.+/— well � gp �► o N o6e5p'1g 34,387 q.f .+/—. fest 1�o Ar�-p y� ' 3�° � ��• of Tr es �p1 p1 1�' „� g �o tcro ,t6' � 1 % 1693 Test Pit Site PP '00 E 0 a �1�2p 1733 Test Pit Site o P' 1 P,Bg ok�,1�„w o22y� o � x t Pit Site N Op N pS��gOg,�� E a�• 'o p 1g12a 18, N00 �� F 1"25�12'W WOCO N 0128 22 0 16