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383 Pleasant Acres DrDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990004022 Billed To: North Ridge Building Co. Reference Name: Wayne Boger Proposed Facility: Residence ATC Number: 4444 Tax PIN/EH #: 5755-17-4861 Subdivision Info: Location/Address: 383 Pleasant Acres Drive -27028 Size: 5 acres 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 CO RUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Aee Date: in 15A NCAC 18A.1969(5) Systems may also be used CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate t e system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chap r 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guara ee that the system will function satisfactorily for any given period of time. C-�, � j UN N Septic System Installed By:v— Environmental Health Specialist's Signature : Date: 1 2 ' '7 " c '1- DCHD 05/99 (Revised) oI —I v d N n fi CA J � z 19 v -1 UN N Septic System Installed By:v— Environmental Health Specialist's Signature : Date: 1 2 ' '7 " c '1- DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' � o Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990004022 Tax PIN/EH #: 5755-17-4861 Billed To: North Ridge Building Co. Subdivision Info: Reference Name: Wayne Boger Location/Address: 383 Pleasant Acres Drive -27028 Proposed Facility: Residence Property Size: 5 acres **N041IG- {WMWpro4AAgnt/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 _ #People #Bedrooms #BathsjS-- Dishwasher: Prr -- 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 (46 Design Wastewater Flow (GPD) C,� Site: New 0 Repair ❑ System Specifications: Tank Size,/PAP GAL. Pump Tank GAL. Trench Width c-F4.'/Rock Depth -,�'.i ".1 Linear Ft. ret'�F Other: Required Site Modifications/Conditions: As stated in 15A NCAC 18A.1969(5) 9 acre Sysieisr -aTsa be osettff IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Day' 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 y of i station. Telephone # is (336)751-8760.**** rnur9 �� r Environmental Health Specialist's Signature: //A//. P � DCHD 05/99 (Revised) V> Date: `/0` 6k Jun 26 06 08:04a Martha Boger Jur, j2 O6 11:.S2a V# davie county envhealth (336) 996-4988 336 751 8788 P12 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Dupartment Environmental Health Section P.O. Box 84=10 hospital Street Mocitsvitty NC 27t2s (336)751-8760/ Fax (336)"51-8786 Application For: D Site Evaluationlhgrrovement Pemnt Q Autttoris sioaToConstsuct(ACC) kloth_ •••IMPORTANT'• TINS APPLiC: 110N CINNOTBE PROCE.SSEDUNLESS ALL OF THE REOVIRED INFORMATIONISPROVIDER R.:festotbeiNFORAfATIONSULLMNfor instructions. APPI ICANT INFORMATION Nano to be Billed r ! l d 1 rl er Contact Person Billing Address barZ 1) �'1 [„rj„ L'L il-me Phonc _ 1'31 Ciry/State/ZtP�1Q/ 1�D1SViili t�(r ?`�,� Bu:incssPhone r` Name on Pcnnit/ATC if Different than Above, Mailing Address s­City/Stile/zip NOTE: A sung plat or site plan mus: accompany this application. (Permit is valid [ 60 moths with site plan. no expiration withtxi plete plat) Street Address QerJpl- Citymc.Catjl.t Tax Subdivision Name Sectiorl/Lot# . 1 Lot Size Directions To Site: WISAA —I C41 On Flvdi0c& At Im VE, L& U i NIP t Date Housc/Faaility Comcm FhMi J If the ar"a to any of the following quritioos is •j es', supporting docua>cnttnon trent be attache( Are there any existing wastevvrter systems on tlu site? CxYe:. DNo Does thesirecoo kja sdicti1nat*Cdands? ,7Yc`CNo Are there any easements or right -of --ways on the site? -'Me" ONo Is the she subject to approval by another public agency? DYm SNo Willwamwttta olharth—x yes - begersetated? OYc `IR}o -- �8PeoplelPBedroom 'k- #Bathrooms_.');s Garden' I'vb/Whirlpoo13%Ycs UNo Basement Dyes No Bas ecru Plumbing: DYes '% 4e,! IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityfHusintxs Total Square Foote3e of Building # People # Sinkt # Commodes _ # Showers # Urinals Estimated Water Usage (gallons per day) _(Attach documentation of similar facility water consumption) FOODSERVICE ONLY: N Seats Type systemregnested:Conventional UAcoepted 13Innev2tive CAlterrative OOther Water SumlyType�Camry/Ciry Wats [T New Welt tlExiving Well t] Community Well Do you anticipate additions or expansiar.t of the facility this system is intende d to serve? D Yes "'�No Ifyes, what ype? This is to certify teat the information ptevWd on tiffs application is true and r orreet to the best of my knowledge. I undctstand that any pemut(s) or ATC(s) issued haaafict are subject to suspension or revoeati m if the site is alu rdl, the intended use changes, or if the information sabmittcd in this applica Lion is falsified or changed f uudern and that] am retpoatible for all charges incurred from rhu apphcv6on. 1 hereby grant rig u of easy to the Autbaritcd Representative of the Davie County Health Department to conduct neem ry inspections to decamine compliance with applicable laws and rubs on the above described propetty located in Davit ouoty and owned by y ;J/ / _ Site Revisit Charge roperry otvrni s or o4bers lefal repees.mtative signature Date(s) / � Meet NotifKation Dox: Dau Elfs� Sign given Dyes ON* Account 0 % Revised 2/06 Invoice p �1 p n I p.2 JUN 2 6 2006 ENVIRONMENTAL HEALTH DAVIE.004TY t `T' ROBERT M. TENERY do WIFE I WILLODEANE F. TENERY `1' ► DB 107 PG 511 j 678.73' N 89.19'46" E ' m I l � LOT 1 0 54" w l� I MAGNOLIA FARM LANE A PORTION OF M6 000005 1 1 GRAVEL ROADWAY SEE D3132 PG 380 5.000 AC. RE3�RPJ�fD� FOR ROAD MAlN1ENANCE AGREEME�i 211,815.4D .F� n \\ 20' EASEMENT OF INGRESS, REGRESS AND EGRESS, jj�' H 21 5150 w �/ SEE DB 119 PG 274.0 *� Z EXISTING t7�r \ 6'00' � � v � r►+ .1' 2666' S 89'04'24" W 628.03' OTAI1 ImP9 ROBERT M TENERY 1 ROBERT M. TENERY do WIFE WILLO'DEANE F. TENERY 1 WILLO'DFANE F. TENERY J \ DB 78 PG 1;3 4 DB 107 PG 511 PB 4 PG 49 L PB 4 PG 49 \ 1 \ 1 \ 11/2' IRON PIPE SME 1" = 100.' BAR GRAPH OWNER 4 SURVEY BY: s to to 3 o► z ct 7 01 w O ov �D 's DENNIS 73301 LEWISV m cD c� m .a ca m m PLAT FOR : ROBERT M� TENERY & a JERUSALEM TOWNSHIP m 0 m - 0 m SURVEY BY: s to to 3 o► z ct 7 01 w O ov �D 's DENNIS 73301 LEWISV m cD c� m .a ca m m PLAT FOR : ROBERT M� TENERY & a JERUSALEM TOWNSHIP Fled for Registration of o'clock ____M . 2005 and recorded in P[AT BOOK PAGE M. BRENT SKOAF - ME COUNTY Register of Deeds LOCATION MAP ( NTS ) rti�r .�' SITE •,u,aV7�piE,�F WE HEREBY CERTIFY THAT WE ARE THE DINNERS OF THE PROPERTY SHOWN AND DESCRIBED HEREON AND THAT WE ADOPT THIS PIAT OF SUBDIVISION WITH OUR FREE CONSENT , ESTABLISHED MINIMUM BUILDING SETBACK LINES AND DEDICATE ALL STREETS (ROADS) , ALLEYS WALKS , PARKS AND OTHER SITES AND EASEMENTS 1O PUBLIC OR PRIVATE USE AS NOTED . D!600000445 OWNER _ R _ DATE ROBERT M. TENERY k WIFE W(LLO'DEarIE F. TENERY OfiNER DATE DB 107 PG 511 a c� '�: � �< �r* s �a� �s=^�r'.� s �*vR u�'r� � �,„� „�i - ��:�`�_ ,��`� ' .��-- �'` ��� t `� �, � �r� �._ �. � {� •.�. � '$'� _�' �� � � g ; ,.,�-+ �,r � <:� , - � � -� .- �` � =� �, ����- .��.=�� ��� ` a s =,�� .::�.. • s�;,,.A ��* � � �::� r:�� .� �s�-� ��� � �� �. 4; _� `4,�. r. z _ ; ��' �., � � ,� � ��� � �` � � rY� � . 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Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5755-17-4861 Suodivision Info: Location/Address: 383 Pleasant Acr �sjDf ive-27028 5 acres Date Evaluated: �' On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 1 HORIZON I DEPTH �< 6�' Texture groupC G Consistence Structurer` MiAeralo <' HORIZON II DEPTH �' Texture groupG' Consistence Structure All/ Mineralogy A"P41 HORIZON III DEPTH ✓—Lr 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: ///tom (/`Z&Y__Y7C P LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: �r� t 4 1A LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 of VFR - Very friable FR - Friable FI - Firm VF1= 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 VI' - 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) i � .........................�_.........�..... ............ ... .�.................. ............... .............. 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Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760/ Fax (336) 751-8786 July 10, 2006 North Ridge Building Company 609 Nickel Court . Kernersville, NC 27284 Re: Site Evaluation: Pleasant Acre Drive Tax Pin #: 5735-17-4861 Dear Mr. Boger As requested, a representative from this office visited the above site July 10, 2006 to perform a site evaluation. 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. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Serve: Wastewater Design Flow: 'Z�� Zf System Type: ❑Conventional eAccepted ❑Innovative ❑Alternative ❑Other System Location: �b� Valid:Years ❑No Expiration Site Modifications/Permit Conditions: ps-i.p.letter 2/06 Date