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397 Oak Grove Church Rd ` � ' , •� DAVIE COUNTY HEALTH DEPARTMENT �,. �f—� 7� S , ; ,, Environmental Health Section � P.O.Boz 848/210 I3ospital Street Mceksville,NC 27028 (336)751-8760 Account #: 990003300 Tax PIN/EH#: 5749-45-2908 Billed To: Lifestyle Builders of Davie Subdivision Info: Reference Name: Location/Address: Oak Grove Church Road-27028 Pro osed Facilit Residence Pro ert Size: see ma ATC Number: 3830 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** 'I'his Authorization for Wastewater System Construction MLJST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ,�f'�'�� Date:�/��/�Z� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. c�D � � I� 1 � Septic System Installed By: � � �i�/��/ Environmental Health SpecialisYs Signature: Date: /. _� DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • , r ,', • Environmental Health Section , - . ' P.O.Boz 848/210 Hospital Street n � �� Mceksville,NC 27028 I � (336)751-87C0 � .i � ,/�� b� IMPROVEMENT/OPERATION PERMIT Account #: 990003300 Tax PIN/EH#: 5749-45-2908 Billed To: Lifestyle Builders of Davie Subdivision Info: Reference Name: Location/Address: Oak Grove Church Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 3830 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AiJTHORIZATION 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 lT #People #Bedrooms �� #Baths_�� Dishwasher:� Garbage Disposal: � Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply�� Design Wastewater Flow(GPD)!� Site: New�Repair❑ �, l System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width� Rock Depth��Linear F� Other: Required Site Modifications/Conditions: Ih9PROVEI�IENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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(33(►)751-87(0.**** � Environmental Health SpecialisYs Signature: Date: DCHD OS/99(Revised) � .' � t ., � � � �} � � D � '' AP 1 ION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC . JUL 2 2 2004 � ie.,�ount Health De rtment " ,�ironme�'�-/,�''�`a/t,l�ection P.O. ox $�48 O. H.o,spi�al Street ENVIROt�14E�Tr,LHEAUH Mocksville, NC , 27028 DAVIECOUNTY (336)751-87�50 �,ti;;� ***IMPORTANI*** THIS APPLICATION CANNOT E PROCES �' ESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refe�,�`o _t ' �:-Z3�{F}O�TION BULLETIN for instructions. � ��,,,��ttt�� ) ' 1. Name to be Billed l� ��p�� ,,;'�c,,.-y��/�; �Contact Person �I/_� , /-- Mailing Address � 3U �(,,� �/ �C; � S,� � Home Phone � � City/State/ZIP �,/�v(,,.,.� �Z�.i /LJt� � 2 7UG� Husiness Phone "�f Q� — 3 �� 3 2. Name on Permit/ATC if Different than Above _ *' Mailing Addreas '' City/State/Zip 3. Application For: �!"Site Evaluation � ❑ Improvement Permit/ATC �Both 4. system to service: L�'House ❑ Mobile Aome ❑ Business ❑ Industry ❑ Other 5. Type system requested: LT Conventional ❑ conventional modified ❑ innovative �' 6. =f Residence: # People � #� Bedrooms �_ # Bathrooms _�` L�'6ishwasher ❑Garbage Disposal � a�ng Machine ❑Hasement/Plumbing ❑Basement/No Plumbing � 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers �# Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) s. Type of water supply: L�'�C:011nty/City ❑ Well ❑ Community 9. Do You anticipate additions or expansions of the facility this system is intended to serve? �Yes 0� If yes,wl�at type? ***IMPORTANT`'`**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUGSTED BELO�V. Either a PLAT or SITE PLAN�V1UST 6E SUBh11TTED by the client rvith THIS APPLICATION. Property Dimensions: �Z l�1 Z �L�/ ,� �}(Z�� WRITE DIRECTIONS(from Mocksvillc)to PROPERTI': Tax Office PIN: # �- S c7��4s 2 5 V� � S �� -v S c�-�►� j�� , �'o Property Address: Road Name (�G Ec �5��,•-� �-�'� �� cJ t� V�- �� -�. c�cyiz;p /l�o�s�;�(n Z 7�ZJ' c_ c� , ff�c . � �� >�- ;,,,Qti� If in a Subdivision provide information,as follows: //z,,,.-, p.� �-o�vv �.�...0. ��z�'1',� Name: / " - T ✓�-C�t� i�� (/ ' �,�;c v, (�1�-t La� _�. � � � � y Section: �� Block: � Lot: �`7. (S Date home corners flagged: This is to certify that tlie 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 cl�ange,or if tl�e information subnutted in this application is falsified or changed. I,also, uiiderstand tl:at I an: responsiGle for all cliarges i�ictu•red fi•on� t/:is application. I,hereby,give consent to the Authorized Representative of the Davie County Aealtli Department to enter upoa above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE �—�`�` v L� SIGNATURE -} G� 4 THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include al of tl�e fol(o�ving: Esisting and proposed property lines and di e sions, structures, setbacks, and septic locations). Site Revisit Cl�arge A � Datc(s): v,� �dv S �i ��"— Client Notification Date: �/� ,('� _ � EHS: �7, Sign given � Account No. �� Revised DCH (05/03 DAVIE �O. ENVIRONMENTAL HEALTN Invoice No. / 3 �i �i��a�li��a ��, � � , r ' ` 1 � r r r . � � �'�, � � �� „•� �ii��. .. �t '!�k} t f�� / � ° � � .�i � 4 l,f 'y{' *�«! � � - �1 1 � � t � �I S �: �`� ��. .. �A �'-�7 I(I) !.I�:.. '^+""-..,..., . . . . . .. . . �.. 7 . ..1 I . . _ . .._ '�:' ......,i ( � .. . . . .. . ... .�'a� i��i��)i��: e . . . .... . �+�� . . . . . . 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':�.,�� .� a.....�� -��.��q:..�: �,..�. ... �. , . . . -•, ' DAVIE COUNTY HEALTH DEPART'MENT J � � � � � Environmental Health Section � ' ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003300 Tax PIN/EH#: 5749-45-2908 Billed To: Lifestyle Builders of Davie Subdivision Info: Reference Name: Location/Address: Oak Grove Church 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 Landsca e osition Slo e% HORIZON I DEPTH L� �> Texture rou � ,(� �U+ Consistence , � Structure Mineralo HORIZON II DEPTH (o�' °"� Texture rou Consistence Structure ,��G �.,� � Mineralo � �' HORIZON III DEPTH �� -� y Texture rou G� � Consistence Structure i"� °" � Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo ' SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: ?1/� ��: 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 Mineralogv 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 OS/99(Revised)