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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 �WN'�.�JK��A-T� S 2'� 1'� �`� 3�Z 3 �� � +— �) `� � � `�� �� n�� �� J v� �O �l , � � °O -S � 'o � - �9 � M � � (4J �� ;�,, N N fN f�� . aJ/�1 �/� ��.�RD� �S Septic System Installed By: t'�� �4J'� ��C— �Q� 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.**** ? - � ��Vl�� ql ?f03 _- �� / � � d, ��� ��t�J� �}C`�J�%`� c� � a� � C���, P��6 � �vr a� �PF�s�� . � � . ,�, � �� 3s' � Environmen al H alth Specialist's Signature: Date: � ��- ��C� - � DCHD OS/99(Revised) ��``�� �J�^ \� 1 �� ��, �1..y�-C��,l �z_ � ,�•�_ , �./� � -� . �o-�� �,� � � � c o c,� <<. ��;�� , � #. "� L„��,� APPLICATION FOR SITE EVALUA710N/IMPROVEMFM PEEiMIT&AT � ..�� • ' iI �1 ' e1�'�' Davie County Health Department u r� � 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 � . �'' �t O .�y�Y`�� Client Notification Date: `1 �� � � �'s'f � EHS• Gt9 . f . � �� �.. 'l�S Z 7 � �`�— Accoe�nt Na o2.� ��S , � Revised DCHD(07/99) Invoice No. � . . ^ ��� � ►�',T / , .�.... - 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 � �� �,� ��(s)= L���-\ .� � � �r �Q � � ' �, Citent NotiBaiHon Date: 1� �n,c�t � �Y��.,� � ., �,��.-� C� � EHS: � � � �j� Accou�►t Na -��/ � �� ��.�(ltX-{Sx.l,v�ti� l��,�t,l.� �'� v i'i �t'�. �'�Ir i . . DCHD(07/99) � Invo[ce Na /-ZG.2.. . �u� . 1.v2, �'�0-V G S`�-�,C�.�-e- D� � W�eYe. VJ� W a,h� �-� 1�Uu5�. �- t,�.���.r e, `��- S�C �Ot.41IC� \� e�.P S, (�.,,y� �U Q�U �'�- �}��. QrCO� �U�` �'1�.2. �.J�. t�• � , ���� �,:_���C�J f'� ���(� l �',/ � . fdepnen 5. NICF � ,.�%�I�C"/— ' ' - � o.e. ns - ��s . � 5 s m ry v�\ . � ��i � �y �r. o � \ °l �sf • 15 .002 ACRES °�o. ssBs�. � �I N �� �V-� \% $ S J� \ Og. W S JJ. ?5•• ��96sJ E, �7 v{ � 6ZJ'94. E f� �_ m�. , + .,�i '_ tno,:on.) ' . . " . .. .. . — . — __ _� , , . __ .—/$' �"�'• c..'7���6^ A `/ ' / n' � O � � � 6 �� � �o� e 0 ^ y hh so � � as s � vr>,�s�� 2°�6�^A . 62 ACRES � 5��� "e.'° � �'� °' � �� ��� I � W �) , � ry N 1 V m �� n $ rv � 6� ^ � I 1� he � „ I m . W � : / /,� 6� � � 2 0 � 5ti•y�` 3 � � � m �� a o a , a / 12.617 ACRES � 11 .032 ACRES o V ~ ' X � 1078.80' 2A5.aG' 316J3' qR N 8�'13'YO"W 136�.26' �� E�P N B6•30'10' � I L��� C-Q-c��,� ol� , L � � �C� �eb. ;��- �_� _ I � ��p� P,�,��, -to �i.�,��,z � . � ... . • „� . � 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) ■������������������������������������������������������������!■ i ■������■�■�■�■��■��■�����■���■■�■��■������■�■■■������■�■■■����l�■■ ■�����■■�����■���■��■�����■■���■�■■■�����■■������■�■���■�■■����■■ ■�■��■�■■■�■��■■�■�■■��■�����■■■ ■��■�■■���■�■���■■�■■�■■��■ ■�■� ■����■■■�����■�■�■s�a�■���■���■��■■■�■��■■■��■��■��■�■��e����■�■�ti 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■����■■■�����■��■�■�■��■���■■■�■■��■�■��■■�����■����■■��■■�■�■���■ ■■■■����■■��■�■�■��■�����■�■�■■�■��■�■����■��■■�■�■■■�■�■■■■�■�■�■ ■��■�■���■■■����■■■����■���■■■�■��■■��■■■���■■■■��■■���■■■■■��■�■■ ■■■����■��������■��■��■■■���■�■■�■■■�■�■�■�����■■■��■■�■��■��■��■■ ■��■�����■������■■■���■■���■�������■■■�■������������■�■������■■�■ ■����■������������������■������■ ■�■��������■�����■�������������■ ■����■��■�■■■���■�����■■���■■�■���■■���■�■��■■■■���■�■��■■■■��■■■■ J_ . . a . • •� � • ' � ' � � 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)