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223 Rollingwood Drive Lot 1, Section 3DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900158 Billed To: Richard Hendricks Reference Name: Proposed Facility: Residence /1, DD Tax PIN/EH #: 5747-15-5721 Subdivision Info: Southwood Acres Lot # 1A Location/Address: Rolling Wood -27028 Property Size: see map ATC NuMber: 3518 **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 HGF #People #Bedrooms #Baths 2 Dishwasher: 13� Garbage Disposal: ❑ Washing Machine: Md Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 0 -SU ::* pe Water Supply &—W-IY Design Wastewater Flow (GPD) 5610 Site: New IR/ Repair ❑ System Specifications: Tank Size/000 GAL. Pump Tank 1CCOGAL. Trench Width '�R Rock Depth (Z` Linear Ft. 3�& Other: ')I iSy-1&�TtOnj &u-& 105-M LL L"Itj s � � � , (` , k"I tj. Required Site Modifications/Conditions: to SiAu - 0-3 C&j:[W12- �L`LP d �pJ Kit. �D�yFF ice. -_ LIQ 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 9-3-0-55-.M. or 1:0 o 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** 27' ten/ V+ \0Vr Environmental Health Specialist's Signature: 4' c------ Date: v-3 i j ,r_ ./ DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900158 Tax PIN/EH #: 5747-15-5721 Billed To: Richard Hendricks Subdivision Info: Southwood Acres Lot # 1A Reference Name: Location/Address: Rolling Wood -27028 ATC Number: 3518 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 WASTEWATU ON- VALI FOR A PERIOD OF FIVE 7 Environmental Health Specialist's Signature: ' 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: APPLICATION FOR SITE EVALUATION/IM PROVEh1ENT PERMfi Davie County Health Department EnvironmentaiHeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 4 3 ��n�fC�nT;i� y6V7u ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIR INFORMATION IS PRO741DED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Person Mailing Address Z3 U/t?,d/te4yz/1 Home Phone ?S/ - 91299 City/State/ZIP L/1C�U`Tv, �� & (f . ?0a d Business Phone 7-41F- ,,,lj 2. Name on Permit/ATC if Different than Above 3. 4. 5. Mailing Address Application For: LJ Site Evaluation System to Service: 02 House Type system requested: LK Conventional City/State/Zip ❑ Improvement Permit/ATC ❑ Both ❑ Mobile Home ❑ Business ❑ Industry 6. If Residence: It People ❑ Other ❑ conventional modified ❑ innovative # Bedrooms 3 It Bathrooms O� 1217ishwasher ❑Garbage Disposal I.JWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # Commodes It Showers IF FOODSERVICE: #�Se/atss 8. Type of water supply: CLT ounty/City It People It Sinks # Urinals It Water Coolers Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IAIPORTANT*** CLIENTS MUST COMPLETE, THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the clicut witl► THIS APPLICATION. Property Dimensions: � Y Tax Office PIN: #_ S2 V2 - /.S- -5- Property Property Address: Road Name sad If in a Subdivision provide information, as follows: Name: #4 Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: c,rh [�-�- /�' PSS; d.i. /•�! ��— ca-- c/, 47- 6,1 Leff Date llome corners flagged: 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 ant responsible for all charges incurred•j•on► this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Deparin►eu( to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suit- d tY. DATE 0 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). l c_ —J Sign givens o Revised DCHD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. �O ` Illvoicc No. Tax Blopk "A'� Tax Nap / n/f William C. and wife Margaret A My DB 202 O PG o R Fnd oo, � '�'� N G6`• C; 1 S 33,E N 00.00. 1 qs eg. ro f _ �°o/nt to/ �. �y 45.89, N 57023'5 c 1/21, FJR And kaMord cr� i ° � Lot 1 � Block H rn .. O N N uthwood Acres Addition 'Section 3 P PB 4-® PG 141 o 67 Acres � � pLu • 71.00 V Co Lot 1 A N - M Block H Southwood Acres Addition p ; 4 37.47- y Section 3 +i PB 4 O PG 141 j Proposed o° - House ; 11O \ -11 SV 33.67• _ MBL 50' Point Front Yord I n • cv toOrive 'II onnect to CG 'i R ing Drive � t7 Z 5/8" FJR F d I 119.22' !RS � 229.42' Total S10.20- „ 110.20- . X23 W i I I LEGEND _ _ center Line f I, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900158 Tax PIN/EH #: 5747-15-5721 Billed To: Richard Hendricks Subdivision Info: Southwood Acres Lot # 1A Reference Name: Location/Address: Rolling Wood -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Fj5Le?S Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Landscape position Texture group Consistence Texture group HORIZON II DEPTH Consistence HORIZON III.DEPTH Texture group Consistence Mineralogy Texture group Consistence Mineralogy SOIL WETNESS RESTRICTIVE HORIZON 1X0112163 1;1 -.40 W.19191a W Caere] SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Public Cut EVALUATION BY'�c��."� OTHER(S) PRESENT: 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 - laty 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)