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124 Maple Knoll Dr Lot 2 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street i Mocksville,NC 27028 (336)751-8760 1 IMPROVEMENT/OPERATION PERMIT Account M 990000981 Tax PIN/EH#: 5749-74-3766.02 Billed To: San Filippo Companies Subdivision Info: Maple Knoll Lot#02 Reference Name: Location/Address: Sain Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 3791 **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 ff #People #Bedrooms (,P — #Baths _ Dishwasher: Garbage Disposal: 0 Washing Machine: Basement w/PlumbingA Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply _ Design Wastewater Flow(GPD) Site: New Repair❑ . System Specifications: Tank Size,C 'AL. Pump Tank GAL. Trench Width c;�KRock Depth� Linear F � Other: Required Site Modifications/Conditions: 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: Date: 15 DCHD 05/99(Revised) J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990000981 Tax PIN/EH#: 5749-74-3766.02 Billed To: San Filippo Companies Subdivision Info: Maple Knoll Lot#02 Reference Name: Location/Address: Sain Road-27028 Pro osed FacilitV Residence Pro ert Size: see ma ATC Number: 3791 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 WASTEWATER CONS UCTIOON IS VALID FOR A PERIOD/OF F VE 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& Davie County Health Department EnvironmentaiHeaith Section P.O. Box 848/210 Hospital Street C Mocksville, NC 27028 0 9I (336)751-8760 ON ! ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructio I — n n [fin 1. Name to be Billed �W 1—� L�11 P P G J�J1.� ZtJC ti O� 1 I1C_Contact Person,tA NTN DN SAI,) )"I L t PPO Mailing Address �� Y�'�/1�I IJ V-q LL�' `� �� Home Phone City/State/ZIP A6-JAW CA , ��(� Z;-700V Business Phone '33( 'No ` 2—/Z3 q 2. Name on Permit/ATC if Different than Above S 44,l A S A3 U,/, Mailing Address City/St�/dig �1.^ 3. Application For: V"Site Evaluation ❑ Improvement Pe t/ATC ❑ Both 4. System to Service: J House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms 11 Dishwasher l,!'Garbage Disposal 14 Washing Machine hA'Basement/Plumbing II 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 s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No Ifycs,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Proper( Dimensions: c�L^C PLA—t WRITE DIRECTIONS(from Mocksville)to PROPERTN,: T� �d 11 -5 n Tax Office PIN: # �J'� �-� ~3� .0"Z � 5 J j 5A i tJ T Property Address: Road Name SA 1 IZ City/Zip moC%614t 1L& Aw 0 < CS q?J O PG'►J Q . S'7 If in a Subdivision provid ir�formation,as follows: 07026 �eL 014- ✓j CKJ (5\/fJ+cUj SM h t \118 nOq Name: IxIA10LC— 1GN0 L, 41 L1\= Section: Block: Lot: Date Property flagged: t Z ` / U Z— 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 ant 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 Z:511J /-i t.s 10 00 �o rr1 Si!V C t� v_^� n i►y L to conduct�a7ll t stin procedures as necessary to determine the site suit bili DATE v O� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Inc ude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. " Revised DCHD(07/99) Invoice No. ---OY • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000981 Tax PIN/EH#: 5749-74-3766.02 Billed To: San Filippo Companies Subdivision Info: Maple Knoll Lot#02 Reference Name: Location/Address: Sain Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: /= 0 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ti/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Z Slope% 4' HORIZON I DEPTH ate Texture group Consistence Structure Mineralogy HORIZON II DEPTH •f ef Texture groupL Consistence Structure 59/1 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: L/ OTHER(S)PRESENT: REMARKS: P17 ,/c, /+� D G, ryG(Y l a {�oa I 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) ■■■■■■■■■■■■■se■■■■■■■■■■■e■■s■e■■■■■ee■e■■e■e■■■■e■■ee■■eee■■eee■ ■■■■■■■■■■■■■■■pie■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■ ■■■e■e■ee■e■■se�iee■■■■■■eee■■■■■■aeee■e■eee■ee■ee■■■■■■■■■■■ecce■■ ■■■■■■■■■■ee■c/ee■■■■■a■■■ec■e■e■■■■■■e■■■ee■■■seee■►��e■e■■et■■■■■ ■■■■■■■lur,�■■■■■i■■■■■■■■■■■■■eu■ire■■■■■■■■■■■■■■■■■■■■■■s■■■■■■■■■■ MENNENMOMEME ■ee■■ee■■ee■■■i�e■■■■■ecce■■■■e■■■■■■eee■e■e■ee■■■■ee■eee■ee■■ee■■■ ■■■■■■■■■■■■■■'/■■■■■■■IBJ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ee■■■eee■■■■i�■■■■s■■■e■■■■■■■■■■■■eeae■■eee■■■e■■eee■cee■■■ee■■■ ■■■■■■■■■■■■■■ire■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■e■■■■■■■ ■■■■■■■■■■■■■■ins■■■■■■■■■■■■■■■■�■■■■■■e■■■■■■■■■■■■■■■■■■■■■■e■■