686 Riverview Rd , -
, .' � ' , DAVIE COUNTY HEALTH DEPART'MENT
• Environmental Health Section
P.O.Boa 848/210 Hospital Street �.._.._._ -
Mocksville,NC 27028
(33G)751-8760
Account #: 990003424 Tax PIN/EH#: 5776-33-6794
Billed To: Millenium III Holding,LLC Subdivision Infa '
. . � •. �--j.
Reference Name: Location/Address: Riverview Road-27006
ATC Number: 4179
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 CONS U T ON IS VALID FOR A PERIOD OF FIVE YE .
Environmental Health SpecialisYs Signature: Date: ��
� � � - � 5 - d �,�, - 1 do e� �,�
CERTIFICATE OF COMPL ION Q ` ' /
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**NOTE** The issuance ofthis 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 a�
given period of time. � �r� ��,/( -fr0
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Septic System�Installed By:
Environmental Health Specialist's Signature: Date:
� � 7 �
DCHD OS/99(Revised) ` \
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. —`�7 �G Fs.o I S
- DAVIE COUNTY HEALTH DEPARTMENT
. ' Environmental Health Section ,��
' ' ' � P.O.Boa 848/210 Hospital Street //".�— �� 6 S
• • /
Maksville,NC 27028 �
(336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003424 Tax PIN/EH#: 5776-33-6794
Billed To: Millenium III Holding,LLC Subdivision Info:
Reference Name: Location/Address: Riverview Road-27006
Proposed Facility Residence Property Size: 84 acres
ATC Number: 4179
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHORIZATION 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 T��INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
�
Residential Specification: Building Type #People #Bedrooms � #Baths ��
Dishwasher:� Garbage Disposal� Washing Machine:� Basement wlPlumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑
Lot Size Type Water Supply 1� Design Wastewater Flow(GPD)S�� Site: NewJ�l Repair❑
�i l�
System Specifications: Tank Siz%ODGAL. Pump Tank GAL. Trench Widtl��� Rock Depth� Linear Ftr���
Other:
Required Site Modifications/Conditions:
INIPROVEII'IENT/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 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(336)751-8760.****
�
�
Environmental Health SpecialisYs Signature: Date:
DCHD OS/99(Revised)
. ` • APPLICATlON FOR SITE EVALUATION/lhti'ItOVEhiENf PC(ih11T Sc A �
_ , , Davie County Health Department � (� � n � �
• Environmenta/Healt/�Section «
P.O. Box 848/210 Hospital Streo� •
, :
� Mocksville, NC 27028 � A�;�
��� ��tn��; � �k�r�,� �LL� (336)751-8760 1 ':5 2��J�
�
***IDJPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TH� RE��UNHE�
INFORtd1�TI0N IS PROVID�D. R fer to the INFORMATION BIILLETIN for i
l. 2.�amo Lo be Dilled (�. Contact Peraon ��j��/
. biailing 1lddrosa'�� �� G�✓f/��is �i!%v'� Iiomcs Phone ��/n d
City/Stata/ZIP 4�
�Q%�Ir��C�l/ �� 2���''J Businasa Phone r� � 3� �
2. Namo on Persnit/ATC if Difforent than Abovo �Z�Q �`�`"� � ° ��"—
Mailing Addroaa City/State/zip
3. ApplicaCion For: �ite Evaluation ❑ Improvement Permit/ATC f7 I3oth
4. syatam to servico: Houae ❑ tdobile Homo ❑ Dusines3 ❑ Induatry• ❑ O�her
5. Type ayatem reque�ted: �onventional ❑ conventional modified ❑ ianovativo p ac Cep ted
6. If itesidenca: A People ,�_ # IIedrooms � 11 �a�hrooma �
iahwasher (1dGarbage Dinposal L��Washing Machino �semant/P1tunUing �jaaement/27o Plumbing
7. If Duninesa/Industzy /Othor: varify typo # Feople A Sinka
A Commodoa it Showers # Urinals # Wal•or Coolers
IF FOODSERVICE: �� Seatts Estimated Water Usage (gallon� per day)
II. Typo oL• wator aupply: ❑ ,County/City dd'Well ❑ Comr.iunity
9. no You anticipate addition� or expansions of tl�e faciiity tl�is systeni is intei�decl to serve? G Ycs �
If}�cs,titi•liat t�•pc?
***lAIPORTi1NT'`**CLILNTS�fUST COAlPLETL TII� REQUIKBD PROPGRTY lNFORh1ATION REQUCST[sD
I�I:I,01V. �ithcr�PI.AT orSIT� PLAN�1lUST IlESU11hfI7TBD by tl�c clicnt �viU�'('lIIS APPLICATION.
Properly Diuicnsions: � ��'��'v� �VItITG DIRGCTIONS(fron lodtsvillcj to PliOl'LIiTY:`
Tas Officc PIN: i� D � 7 / ����
1�rop��Ad�sb R��Namc ��lJ -�'�s/_�%��l/l ,�/�. , �d�
cityiz�P�i�',�%� 27� �'-'' �� ' �
If in a Subdivision providc information,as follotivs: � �l/ ,
Namc:
l aS
Scction: Bloclt: Lot: llatc liomc corncrs flaggcd:
This is to ccrtify that tlic information providcd is ca•rcct to tl�c best of my l:no�vlcdga I undcrstand t1►at any permit(s)
issucd liercafter are subject to suspension or revocation,if tiie site plans or i��te»ded use cliange,or if tl�e information
submitted iu tliis applicltion is falsificd or cl�angcd. I, also, turderstaud tlrat I anr respolrsiGle for a!!clrnrges ir�crrrrerl Jrora
t/1is applicnfion. I,l�crcbp,givc consent to tlic Autl�orized Itcpresciitativc of tl�c Da��ic Cour�ty.I�Ica111�llcpartmciit
to cntcr upon abovc describcd property locatcd in Davic County an�oticncd by
to conducl all tcsli� procc �res as iicccssar�•to dctcrmiiic tl�c sitc suitability�
i ",�.� ,
ll�1T� U � � SIGNATURI;
TFIIS AIt�A A1r1Y B�US�D FOR DRAVVING YOUIZ SIT�PLAN(Includc all of tLc follo�viug: Lxisting and proposcd
property liiics and dimensions, structures, setbacics, and septic IoCations).
� Silc Revisit Ch�rgc
. Datc(s):
c[icnt Nol;rcaciou Datc:
� � �IIS:
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Sign givcn�� � '. Account No. —
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Reviscd DCIID(OS/03 �� Lrvoicc No. � 7
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, DAVIE COUNTY HEALTH DEPARTMENT
' : . � Environmental Health Section
. • • Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003424 Tax PIN/EH#: 5776-33-6794
Billed To: Millenium III Holding,LLC Subdivision Info:
Reference Name: Location/Address: Riverview Road-27006 /
Proposed Facility: Residence Property Size: 84 acres Date Evaluated: ������_
Water Supply:. On-Site Well � Community Public
Evaluation By: Auger Boring � Pit Cut
FAGTORS 1 2 3 4 5 6 7
Landsca e sition
Slo %
HORIZON I DEPTH !� '��
Texture rou
Consistence /
Structure r
Mineralo ��
HORIZON II DEPTH f'� %
Texture rou c—
Consistence
Structure L
Mineralo , `/
HORIZON III DEPTH
Tezture rou
Consistence
Structure
Mineralo -
HORIZON IV DEPT'H.
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFTCATION
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: EVALUATION BY: ' - � '
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS:
� LEGEND
i, n s ape Positi n
R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope - .
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
T�CLiILg .
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
.ON4IST�.N . •
MQI�.t . .
VFR-Very friable FR-Friable FI-Firm VFT-Very firm EFI-Extremely firm
�
� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic , VP-Very plastic
Sr� , �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
.
Mineralogv
1:1,2:1,Mixed
�S��S . � .
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 , DCHD OS/OS(Revised)
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