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120 Sparrow Ln • DAVIE COUNTY HEALTH DEPARTMENT • " �� Environmental Health Section ��}1 P.O.Boz 848/210 Hospital Street �/ b Mocksville,NC 27028 j (336)751-8760 Account #: 989900216 Tax PIN/EH#: 5709-57-3990 Billed To: Paul Willard Subdivision Info: Reference Name: Location/Address: 482 Calahaln Road-27028 Proposed Facility Residence Property Size: see ma ATC Number: 3996 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 CONSTRUCT ON IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION fes-l��r `Z ru.�s C' **NOTE** The issuance of this Certificate of ompl ' shall indicate the system described on Improvement/Operation Permit has been installed in compliance with icle of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY aken a guarantee that the system will function satisfactorily for any given period of time. q b �D X3 Septic System Installed By: 14 r` Environmental Health Specialist's Signature: Date: ��O�, v DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT -- Environmental Health Section o P.O.Boa 848/210 Hospital Street _ �— Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900216 Tax PIN/EH#: 5709-57-3990 Billed To: Paul Willard Subdivision Info: Reference Name: Location/Address: 482 Calahaln Road-27028 Proposed Facility Residence Property Size: see map ATC Iirpber: 3996 **NOTE** is 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 ,l/ #People #Bedrooms #Baths o 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: NewM`^Repair❑ System Specifications: Tank SizeebeQ2 GAL. Pump Tank GAL. Trench WidthJ Rock Depth,,& Linear F�-J Other: /L�IOGrJ �eP �g�� G2Qcda Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMI LA UT APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Conta r esen tive 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. to 0 p. .on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) U ATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department FEB 16 2005 Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 6WRONMENTALHEA H (336)751-8760 DAViE COUNTY ***IMPORTANT*** THIS.APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 1. Name to be Billed !20 u� lel, ( Cid Contact Person lrnj a n r Pn L Mailing Address �� lL� I O h t CL /- N U Home Phone 13 l) 5 City/State/ZIP `��[)�.!�5�71 `�e nC�9b010 Business Phone t331pb 1 15 nr3itJ7734p 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ®'Both 4. System to Service: mouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified innovative 6. If Residence: # People C / # Bedrooms # Bathrooms a Dishwasher ❑Garbage Disposal Mashing Machine ❑Basement/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) 8. Type of water supply: Lam' County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 13-flro— If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # C 764573 110 ln4 Veil " -Ip (i Vahan 2J. Q boLk+ Property Address: Road Name J46A Ca llnkan ��. �t�z � �rn�le 5 01') 1"'1 a 1, �� -1— City/Zip M60Y-S�tr`lle A0 a7AAK If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date home corners flagged: 2 1//&/qS 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 an: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 `tt.2 i�t1�.►�� to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE Jua& Wwa& 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). Site Revisit Charge r y Date(s): Client Notification Date: Zo`� �qC 1-S't/ EHS: h� 77 o Sign given Account No. i3 `�/ Revised HD(05/03 Invoice No. ZO 7 (o // t 1/2" EIR Fnd L-14 1 / " EIR Fnd in Line _ _ L-7 1 2 L-6IRS -_ ` -------- 1 L-5 _ - _ — — 10'+ — Grovel rw—————————__ _ _� �2 , PK-Nail Fnd Point A L-4 NMP 210.00' 'total � IRS � N 31403 1 E IRS !*/a Propose �`;-- 179.98' !n Gn ed Para!! d 20,Acc �`_ _ n L-3 ; �, IRS Placed in Line et to the ess -- O c f ase�ent R°deuthern Ed ent Ad PK-Nail Set M d at Re 561 Pi i t Lot 1 to = oft N �" L-2 to b t 0.826 Acre +/- to 1.0 Acres + - C 'n Tax Lot 7.02 tai NMP N ao, � Tax Map G-2 'b r co n/f Jeffrey Wayr4 C4 o to DB 208 ® PG 3S CV CP oFbdr G N NMP '° �� cti�°\ o ice 182.29 1 214.17' Total42a 41 L-16— T-Bar 8'�5"�y ��' 0°c c� NMP T-Bar w/cap Fnd w - 140 S:4 �P 97 2028 05,w ti 4 657.54' S 2" -15 LEGEND Tax Lot 4.01 R/W —Right—of—Way FC — Face of Curb EIP — Existing Iron Pipe BoC Back of Curb Tax Map H-2 EIR— Existing Iron Rebar PP — Power Pole n/f Calahaln Friendship ' P — Post LP — tight Pole CM -Concrete Monument MH - Man Hole Baptist Church IRS — Iron Rebar Set CH — Chord Distance DB 112 ® PG 637 PA— Property line P/O - Part of DB 209 ® PG 981 C/A— Controlled Access DB — Deed Book CP — Concrete Pipe PB — Plat Book DB 212 ® PG 339 _ CMP — Corrugated Metal Pipe R9 — Record Book 1 (we) hereby certify t-at CPP—Corrugated Plastic Pipe PG Page —F— 1DO Year Flood Boundary CS — Catch Bosin described hereon, —a— Overhead Utilities —S— Sewer Line —X— Fence WM — Water Meter Davie County and that er, Fnd — Found WV— Water Valve consent, established n/f — Now or Fonnerty SM — Bench Mark streets, alleys, walks, -I'S TBM-TemporaryBench Mark private use as noted I Ii i, 2pp _ -- -. _ _ - ------_-----_- _ ---- -- - -__ -- - - - - _ 5 - - - '�Nf?RO �I I, II �I I II tl I .. III DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiySite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900216 Tax PIN/EH#: 5709-57-3990 Billed'Toa, Paul Willard Subdivision Info: Reference Name: Location/Address: 482 Calahaln 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 Landscape position 1_ Sloe% HORIZON I DEPTH iq Texture rou S CLConsistence VF /_ Structure Mineralogy / At HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH 4 4 L' 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: 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 TexturC 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 r ct re '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 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 05199(Revised) J 6° �n CW