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5211 Hwy 601N Lot 3 DAVIE COUNTY HEALTH DEPARTMENT / � Account M 990000747 Tax PIN/EH#: 5813-88-8704.03 Billed To: Michael Duffield Subdivision Info: Oak Grove Lot#3 Reference Name: Location/Address: Children's Home Road-27028 Proposed Facility: Residence Property Size: 280x110 ATC Number: 2555 **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 �fl #People #Bedrooms 3 #Baths Dishwasher: 01"— Garbage Disposal: ❑ Washing Machine: ar Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification:'Facility Type '•'�l,1 #People #People/Shift #Seats Industrial 171Waste: Lot Size j1'0)c Type Water SupplywW� Design Wastewater Flow(GPD)?�� Site: New 21 Repair❑ System Specifications: Tank SizeAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.'Tw Other: S X-W V Required Site Modifications/Conditions: ^3S`�7_�t,l. n,J ��J Tyt �d DFC PQP1,t >--/ILL O 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.**** 10©*x?c 11,C1 1es loot v I°04 ci 71 30' P. u•!�e Environmental Health Specialist's Signature: Date: 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 #: 990000747 Tax PIN/EH#: 5813-88-8704.03 Billed To: Michael Duffield Subdivision Info: Oak Grove Lot#3 Reference Name: Location/Address: Children's Home Road 27028 Proposed Facility: Residence Property Size: 280x110 ATC Number: 2555 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 WASTE N IS ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa e: Date: alilao 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. 030T L-Dc,&1 ,-0 'rT bt,) Ih,1-4 �r 8 J O O Septic System Installed By: '� �T'e- Environmental Health Specialist's Signature: -� Date: /,R/"jD 0 DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC D Davie County Health Department AUG 3 0 2000 En14tvnment�/Health Secrion P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Re er to the INFORMATION BULLETIN for instructions. 1. Name to be Billed (�-/ Contact Person z (/ Mailing Address fit U �o✓ }` Home Phone -3 3 C" 26/,/- City/state/ZIP -,J J Business Phone _ �� 'O 2. Name on Permit/ATC if Different than Above 5-1011-- Meiling Address r City/state/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to service: ❑ House JR,Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms4 Dishwasher ❑ Garbage Disposal a Nashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. if Business/Industry/Other: specify type # People # sinks # Commodea # showers # urinals # Nater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Nater supply: ❑ County/City `&.Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑Yes -�"o If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions: �-O - X �l U WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 01 ' 0 —Property Address:Address: Road Name City/Zip L-T- If in a Subdivision provide information,as follows: Name: 0� Section: Block: Lot: Date Property Flagged: / a 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 1,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 to conduct all testing procedures as necessary to determine the site suitability. DATE O a U SIGNATURE 4 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: xisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS• r-t Account No. Revised DCHD(07/99) 1�so Invoice No. 1 IJS F C 3L/ 0'y /l�t-cJ of 0 O ,2ov� L vA # 3 N\ n n C M ` o G � v i 237.00' 4 � 130.00' 143.38' I N 28.00'00' W _ o o SECTION ONE I - i�IN \ 60.00 ,SECTION 7 PG 19 _ "I \'; 264 Z5�' a• � � }i, 3 b gid of $ 0'$I `\ \ \ 0 6 0 5 NI >I ��I =1 yi (Dof lois \\ \ o I I 30 k; 70� DRIVEWAY I EASEMENTS tTYP.> I I� l'u I I I I 4D' MBL ------- ------- - - ------ ------------ ------------2�_� \ 130.00' ' I _143.38_ _ 120.00' J I i _110A0' — 171.27' = 299.64' _ �OX70 SE CCESS EASEMENT — _ Oj•I*S 1586.05' NEG. ACCESS.EASEMENT NEG ACCESS EASEMENT NIP -- S 28'00'00' E _ 2051.47' 601 — — SECTION 2 OAK GROVE SUB—DIVISION SURVEYED OCTOBER,1996 BY KENNETH L. FOSTER OWNER—DEVELOPER P.L.S. 2552 MICHAEL K. & DELANA J. DUFFIELD TOTAL AREA = 4.727 ACRES ( DMD ) 4770 COUNTRY BOY LANE TOTAL LOTS = 3 CLEMMONS, N. C. 27012 AVERAGE LOT SIZE = 1 .576 ACRES Ms TELEPHONE: 336-766-7071 ,UNDERGmLM iHT OF WAY INTERSECTION. 0'CONTROL PLAN IS NOT REQUIRED BEING TAX LOTS 31 .10 & 31 .03 MAP B-3 KENNETH L. FOSTER & ASSOCIATES , DEED BK 191 PG 911 & BK 191 PG 916 CLARKSVILLE TWSP., DAVIE COUNTY, N. C. PLANNERS—SURVEYORS 9 _ 2200 SILAS CREEK PKWY. FM KV= CLARKSVILLE TOWNSHIP SUITE 1 B DAVIE COUNTY, N.C. WINSTON—SALEM, N.C. 27103 PROJ nTHERWISE NOTED. --' —PHONE: 336-723-8850 r )I APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT& Davie County Health Department SEP 2 7 199 Environmental Health Section P.O.Box 848 Mocksville,NC 27028 flIVIRONMENTAL HEALTH (704)634-8760 DAVIE COUNTY ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed rA IN, 'R t e C2 Contact Person -e,a • Mailing Address �� U h:e�. Cress . Home Phone g l0—3 66_y366 City/State/Zip Business Phone 910- 3 u— 'QRnr) 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Gi '*"Site Evaluation ❑ Improvement Permit&ATC ❑ Both 4. System to Serve: House ❑ Mobile Home D Business ❑ Industry ❑ Other 5. If Residence: # People _ # Bedrooms _3 # Bathrooms 2 QdDishwasher ❑ Garbage Disposal Washing Machine ' ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: 0 County/City WWell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes M'-*�No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: S 2¢- O\ �d��—�0 d �4 1 WRITE DIRECTIONS(from Mocksville)TO PROPERTY: J Tax Office PIN: # o.. ` ` Property Address: Road Name `r ��`S- c+%.pt Ll7 , Zs' :`0rens 1 1 City/Zip 1 1 If in Subdivision provide information,as follows: 1 J /�/+1 1 Name: n �` CT co v e 1 1 Section: Lot # 1 r 1 1 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 Department to enter upon above described property located in Davie County and owned by Ly b,, &-C_LQ� to conduct all testing procedures as necessary to determine the site suitability. DATE Z SIGNATURE , Revised DCHD(06-96) • DAVIE COUNTY HEALTH DEPARTMENT 14 Environmental Health Section SECTION LOTS Soil/Site Evaluation Lynn M. Reece APPLICANT'S NAME DATE EVALUATED ouse PROPOSED FACILITY PROPERTY SIZE SUBDIVISION Oak Grove ROAD NAME Highway 60110. Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit t/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON I1 DEPTH V0 ' Texture group Consistence l Structure 46 le WhI2 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 I , SITE CLASSIFICATION: A2� EVALUATION BY:. �� LONG-TERM ACCEPTANCE RATE: Z 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(O1-90) ■■■■■■■tt■■■■t■■■t■■■■t■■■■■■■■■■t■■■■■tt■■■■■■t■■■■■■■■tree■■■■■■ ■■■■■■■■■■■■■■■■t■■■■■■■■■■t■■■■■t■■■tttttt■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■t■■■■t■■■t■■e■■■t■■■■■�i■■■■■■ttttettt■■■■■■■t■■■■■t■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■■■■■■tttt■■t■■cert■■■■■■■■■este■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ere■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■t■■■■■■■■■t■■■■■tt■■tt■■t�■■■■■■■ttttttt■■■■t■■■■■■■■■■■t■ ■■■t■t■■■■■■■■tt■■■t■■t■■■t■tt■t■�■■■■■■■■■■■■■■■t■■■■t■■ettt■■■■■ ■■■■■■■■■■t■■■■t■■■■■■■■■■■■■■■■sit■■■■■■■■■■■■■■■e■■■■■■■rte■■■■■ ■■■■■■■■■■■■■■■■■t■■■■■■t■■■tt■■ ■■t■tee■e■■■tt■■tt■t■■■t■■■■t■t■ ■■■■■■■■t■■tt■■■■■■■■■■■e■■■■■■■■■■■■■■■■tttttt■■■■■■tt■t■■■■■t■■■ ■■tt■■■rte■■■■■■■t■■■■■■■■■tt■■■■■t■■■■■atttetee■■■■tt■■■■■■tttt■■ ■■tttttt■■■■■■■■tent■■■■■■t■■■■�i■■■■■■■tttet■t■■■■ttt■■■■■tttt■■ ■■■■■■■■■■t■■■■■■■■■■■t■■t■■■■■■ett■■tee■■■tt■ette■■■■tt■■t■■■■t■■ ■■t■■■t■■■tet■■■■■■■ttt■■■■■■■■■■■■■■e■tt■■■■■■■te■t■■■t■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■t■■t■■■■ett■■�i■■e■t■■■ttt■eet■ttt■■■■tts■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tt■■t■■■■■■■tt■t■■■■■■rte■■■■■■■ ■■■■■■■■■■■■■■■■■t■■■■■■■■■■t■■■■■■ttt■■■tet■■ttttt■■■■tet■■t■■tt■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■t■■■ ■■■■t■ ■■■■■■ ■■■■et■tt■■tet■■t■■■t■■t■■t■■■■■■■■■t■■■tt■t■■ttttt■■■e■■■ttte■■■■ ■■■■■■■■■■■t■■■■■■■t■■■■■tt■■t■■te■■ttt■■■■tt■■■■■tt■■■■tet■■■tt■■ ■■■t■■■■■■■■tt■■■■t■■t■■■■■t■t■■ttt■■■■te■■■ttt■■■rte■■■■■e■t■■t■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■tttttt■■ttt■■t■t■■■ttet■■t■■■■t■ ■■■■et■■■tt■■■tt■tt■tt■■tt■tt■t■ ■rte■■■tt■tet■■■t■t■■t■■■■■■■■■■ ■■■■■■■■■■■■■■■■s■■■■■■■■■■■■■■■• ■■■■■■■t■■■t■■rte■■t■t■■t■■tt■t■ ■■■■tt■■■t■■■tt■■t■■■■■■t■■ttt■■►.�it■ttt■■ttt■■ttt■tttt■ttt■■■tttt■ ■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■t■■■■■■■■■■tt■■tet■tttttt■■■rte■■■■ ■■■■■■■■t■■■■t■■■■■■■■■t■■■t■■■t■■■t■■■■tt■■■■t■■■t■■■■■tett■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■■■■t■■rte■■■t■■■■■t■■■■■■■t■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tt■■■t■■rte■tt■■■■■■t■■tt■■■ ■■■■■■t■■■ttt■■■■■■■■■■■■ttt■■■■■rte■■tt■■ttttte■■■■■■■■■■■■te■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■t■■tett■■■■■t■ Davie County Health Department 1836 Environmental Health,Section - P.O. !Box,848 s„ 6 210 Hospital Street Ctuier .09-40-06 1911 U Mocksvill' STC. 27028 Phone:(336)-753-6780 ONY-SITE WASTEWATER`CERTIFICATION Fax:(336)-753.1680 (Check One) Replacement Memodeling Reconnection Name: ` Q(,iJ Phone Number7L-2 (Home) Mailing Address: w (Work) Email Address: 1 j Detailed Directions To Site: 61 Al &y � '(` :_ L� l� / }�(/� fY) ' Property Address: 62-4# �l/�1/ Q� �V '.• Please Fill In The Following Ififorwation About The E)qSTIJyG Facility: i Name System Installed Under: .G✓ 1 Type Of Facility:7L—AW T� ti� Date System Installed(Month/Date/Year): f - -� Number Of Bedrooms:_-�_Number Of People: Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes ('No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: � -I A"l f`q1' V x�� Number Of Bedrooms: Number of People Pool Size: Garage Size:_6040 Other: `requested By: �1- / 'r(t _Date Requested: / (Signature) For Environmental Health Office Use Only Approved Disapproved / Comments lCA11` I d L i i '(SCI L �G rib JIL Environmental Health Specialist Date: ! 4/ Zn-// *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. Payme Cash Check jneyOrde'r\# Amount:$ /00,00 Date: Paid By: /rl �� � ��U Received By: Account#: V LP J Invoice#: -16:22 :22