229 Meadow Glen Ln (2) : � + DAVIE COUNTY HEALTIi DEPARTMENT
� �/
� ' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002035 Tax PIN/EH#: 5812-04-4109.JA
• Billed To: Joe Alvarez Subdivision Info:
Reference Name: Location/Address: ::�'� Meadow Glen Lane-27028
Proposed Faciliry: Residence Property Size: see map
ATC Number: 3058 �
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 WASTEWAT S N IS ALID FOR A PERIOD OF FIVE YEARS.
Environmental Health SpecialisYs Signature: Date: 2 2
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovementlOperation 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. ./��y
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Environtnental Health SpecialisYs Signature: Date: 4� �� �
DCHD OS/99(Revised)
I
. � , DAVIE COUNTY HEALTH DEPARTMENT /����.?�"�s-� '`
' �� Environmental Health Section (/
. , P.O.Boa 848/210 Hospital Street
'`.,� .��� Mocksville,NC 27028
.
(336)7S 1-87C►0
� IMPROVEMENT/OPERATION PERMIT
Account #: 990002035 Tax PIN/EH#: 5812-04-4109.JA
Billed To: Joe Alvarez Subdivision Info:
Reference Name: Location/Address: ':"��lleadow Glen Lan�-27028
Proposed Facility: Residence Property Size: see map
ATC Number. 3058
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHOWZATION 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type_�' �5�=- #People �2 #Bedrooms '3 #Baths 2
Dishwasher: � Garbage Disposal: � Washing Machine: u Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size n•� Q��S Type Water Suppl��^�� Design Wastewater Flow(GPD) � Site: New� Repair�
,� ��
System Specifications: Tank Size ��GAL. Pump Tank GAL: Trench Width�(o Rock Depth I2 Lineaz Ft. �C?7`
Other: � �1�Q��rt U/� ����. rNS7"61 LL C.1�/�-� �'�D.C. !�.l�1•
Required Site Modifications/Conditions: ��S�Q� (h� Go..1 TO�, �t�,� ��,oF� !-�v�Sz, �� ���'�F �(�
U J.7
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Departrnent 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)751-87G0.****
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Environmen al H alth Specialist's Signature: Date: � ��-
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DCHD OS/99(Revised) ��``��
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, � #. "� L„��,� APPLICATION FOR SITE EVALUA710N/IMPROVEMFM PEEiMIT&AT �
..�� • ' iI
�1 ' e1�'�' Davie County Health Department u
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� Environmenta/Hea/th Section �� _ 2 2���
� P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 ENVIRONMENTAL HF�iLTH
(336)751-8760 ' DAVIE COUNTY
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
�
INFORI�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions.
1. Name to be Billed � )�� ��� Z Contact Person ��///L��' �✓CJ�/�'/��'
Mailing Address V � G� Home Phon�3� vVy c/Ci��J
City/State/ZZP O/ � (i Business Phone 36 �3 -c���
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation (�"'Improvement Permit/ATC ❑ Both
" a. system to service: f�' House ❑ Mobile Home ❑ Business ❑ Industry D Other
s. If Residence: # People �_ R Bedrooms � # Bathrooms �
� Dish�rasher C7 Garbage Disposal L�Washing Machine D�Basement/Plumbing ❑ Base�ent/No Plumbing
6. If Business/Iadustsy/Other: Specify type N People � Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay)
7. Type of water supply: � County/City ❑ Well ❑ Community
a, Do you anticipate additions or expansions of the facility this system is intended to serve? �Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the clieat with THIS APPLICATION.
�
Property Dimeusions: ���•.��G WRITE DIRECTIONS(from Mocksvillc)to PROPGRTY:
Tax Oftice PIN: #_� /�D�/�/U9 .��'' CnDI lV �-0 ���c�i�"ly �h�/�� 1Q� . ,
Property Address: Road Nam��i����� C��"c �ir� � ,o„ %%%���e-u a=�'�, ��Y
City/Zip � .�i�vi II�,' �L _
a70a�'
If in a Subdivision ovide information,as follows:
Name: �1 �1 D Z
Section: ' Block: Lot: _��" Date Property Flaggedc���
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. 1,also,understanr!t/rat 1 am respunsib[e jor all c/:arges incurred frum
this application. I,hereby,give consent to the Authorized Representative of the Davie o n He Ith e en
to enter upon above described property located in Davie County and owned 6y r' �-*L��� .
to conduct all testing rocedures as necessary to determine the site suitabili
DATE I � G� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN clude�11 of thc following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locatio s,).���
,2� Site Revisit Charge '
.� �� Date(s): � ``�i a
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�t O .�y�Y`�� Client Notification Date: `1 �� �
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Revised DCHD(07/99) Invoice No. �
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- APPUCATION FOR SRE EVALUATION/IMPROVEMENT PENMR&ATC D I-K � i5 O V lS
'�� � ' � Oavie County Health Depafinent s�
. • . '.• � Envi►ronnreenta/Kas/tfi se+c�on JAN I 8 2000
. � : .�� • p.0. 8ox 8�8/210 Hospits]. Str�e�
, . Mocicavill�, NC 27028 � •
, ' � (336)7b1-8760 � ENYIRONMENTAL HEALTN
. . _DAVIE-COUMY
***I�ORTANT�'** '1'8I8 I�IIPLICATIOTT C71M�10T B� PROCC�BS�D VI�SS 71LI+ THL' R$QVIRaD .
ZNF0I�+AT=ON i8 PRCV=DED. Raler to th� II�'OR'�IATIG�t BULL�TII� �or iastruatioas. '
i. �,�. to n. siii.a �.���° 'N�` �� ►'� � ti � �C�/1 �
��� �... D C��'c��� �r �a. �. C33(�� �lSl—1`7��
cihr�saa�:x� 1'Yiti�SV� 1�-2 �-- 2 /�28` sn.�.,. re�.
�. llaa� aat P�raith►zC i! DS!!�t !h�► 11boa� \
Ifailiuq 7lddsr�� Cily/9tat�/=ip .
9. !►pplicatioa ror: 0'Sit.� ivalustioa 0 Improv�at 8�rmit/71TC 0 Hoth
a. sp.t.a. to s.=.so.� �' Hons• 0 Mobilo Hom� 0 Bnsia�ss 0 2adnstsy 0 Oth�r
s. I! it�sid�a�: � p�opl� � E Bedrooms 3 # Bsthrooms !-
�Di�Lxasl�r 9 �aq� Dirpo�al g 1�aahiaQ NaoAi� 0 tas�n!/pltabinQ O Sas�s►!/No plv�biaQ
6. tr swsn.../zaan.ts�r/otl�r: sp.osrr Lyp. � D.apl• � aiak,
t Com�ooel�� � 8hoxsz� � Vrinals � Nabr Cool�r�
=r a�ooDsaav=ca: � s.sta �i =�timatad Nstar Usaq. c��• � �r�
,. �rp. o� ,�ti.= .��Y: a countY/ca� o'x•ii o �o�it�
e. Do yoa anticipate�ddiHo�u or espanelone oi the facWty t6is eyrtem is intended to urveT 0 Yee B�l i�o
uy�,wbat ty�ei
***dll�lPORTANT�'**CLIENT3 MUST GIDMPLETETHE REQUIRED PROPERTY INFORMATION REQU�3'fED
BELOW. EiWer a PI.AT or SITE PI.AN MI/ST BE SUBbIITTED b t6e elient w�t4 THIS APPIICATION.
Property Dtmensiona: �2 � ��? �C�� R+RITE DIREG'fION3(from Mcekavtlle)to PItOPERTY:
Ta=Ogice P1N: # 5�I p��-1 `[ I� (._0�`Yv `�"'C� �.���C'�.1 C�'l. I��• -'
Property Addrea�: Road Name����v����-�,ov�����,� L� U ti1 � I�.���r� �.I'�•�C�. )
1 1 f f�b�ur���'�`
� Clry/zip 1 � �T�O Y�1�Uac� (�,-�i°n+� havt� c'�✓11F�
If in a Sabdtviaion provide intormsdon,as follmvs:
Name:
.,.Secdons Btock: Loh Date Propetly Fl��als �—/`�O O
T6ia la to cerNty t6at t6e intormsNon pravided ia correct to t6e beet ot my kno7vledga I aaderstsad that�ay permit(s)
isaaed 6ereaRer�re eabject to easpeneion or t�evocadon,U t6e slte p1Ans or intended ase chsnQe,or it t6e InformeHon
aabmitted in t6ia appBcaHon is fsisitied or chan�ed. I,also,xnderstQnd that I ant nspo�stbl�jor ul!cliargts lncurr�d frone
tbu appUcado�r. I,6enby,giv�eoaaent to t6e Aat6ortied Represenbtive of the Davie Coanty Hait6 Department
to enter npon aLove deacHbed pcoperty lacated in Davie Coanty and mrned by
to conduct sll tesNng procednra aa neceaa�ry to determine the site soibbWty.
DATE D �S $IGNATURE C1 %�.1��_�Cl/�'��:��C.Cc�//�
THIS AREA MAY BE USED FOR DRAWII�IG YOUR STTE PI.AN(In¢lade�U of the foll gs Faiating and prnpoeal
property linee and dimenatona, etractares, aetbacka, xnd eeptic IocaHons� \Y Q..�
15 3��� ,.- , sfc��t cw��e
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L���-\ .� � � �r �Q
� � ' �, Citent NotiBaiHon Date:
1� �n,c�t � �Y��.,�
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. DCHD(07/99) � Invo[ce Na /-ZG.2..
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1078.80' 2A5.aG' 316J3' qR
N 8�'13'YO"W 136�.26' �� E�P N B6•30'10'
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� DAVIE COUNTY HEALTH DEPARTMENT
' � • ,' � Environmental Health Section
' � ' ' � y Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000951 Tax PIN/EH#: 5812-04-4109
Billed To: Matthew or Kristie Killlian Subdivision Info:
Reference Name: Matthew or Kristie Killian Location/Address: Meadow Glen Lane- 7028
Proposed Facility: Residence Property Size: 12.617 Acres Date Evaluated: G io
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 3 4 5 6 7
Landsca e osition
Slo e% Z
HORIZON I DEPTH F� " 'C� - o — CP
Texture rou •Gv ` G� �C,.�
Consistence �SS — SS� Gr P
Structure c� L Gf�
Mineralo �" (
HORIZON II DEPTH . 2v - 30 —32
Texture rou C L-
Consistence " S �: S �
Structure 1° � c �L<
Mineralo /% i: 1'� 1
HORIZON III DEPTH �i� �ZFS 30— ,�h
Texture rou � G k �-
Consistence 5 — : S P �
Structure 6k 5 � 5�31�
Mineralo t� l •"l: I
HORIZON IV DEPTH Zsr't L12} +
Texture rou a S<<
Consistence
Structure PL-
Mineralo
SOIL WETNESS 2
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION s S PS �
LONG-TERM ACCEPTANCE RATE p .' � � .�
SITE CLASSIFICATION: �S EVALUATION BY: �--� �����J
LONG-TERM ACCEPTANCE RATE: � •3 •� OTHER(S)PRESENT:
REMARKS: �=� �-�`� �n� SOI�. tJ�STh/f�S � �G�/�1� �%�UGTv� ��J ��1 -;
LEGEND
Landscape Position �
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
Mineraloev
1:1,2:1,Mixed
No es
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-gaUday/ft2
DC�ID OS/99(Revised)
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� � Z�avie Gounty,�fealrh Z7e�arrment
Erivlronmental,�fealth Secttorr
, no s�84s/zio��c�s�t
Mocksville,NC 27028
Phone: (336)751-8760
February 10, 2000
Mr. IVlatthew Killian
150 Circle Drive
Mocksville,NC 27028
Re: Site Evaluation-12.b17 Acre Tract
Meadow Glen Lane/Tract#3
Tax PIN#: 5812-04-4109
Dear Mr. Killian:
As requested, a representative from this office visited the above site on February
10, 2000. 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
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct the appropriate application must be completed in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
Ifyou have any questions, feel free to contact this office at (336)751-8760.
Sincerely,
JeffG. auchamp,RS.
� Environmental Health Section
enc(s)