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412 Woodlee Dr . . ' ' DAVIE COUNTY HEALTH DEPARTMENT � . Environmental Heaith Section � � ' P.O.Boz 848/210 I3ospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990001764 Tax PIN/EH#: 5863-61-6290.B Billed To: Ausbon Ellis Subdivision Info: Reference Name: Location/Address: Woodlee Drive-27006 Proposed Facility Residence Property Size: 1 +acre ATC Number: 3880 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 CONSTRUCTION IS VALID FOR A PERIOD OF IVE ARS. Environmental Health Specialist's Signature: ����/ Date: .,.G� �' CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemenUOperation 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. ' � ���- �s� r� `_�;, �,.� k s��� �o�� - " � � �.� C,������� ,- . , Septic System Installed By: � � Environmental Health Specialist's Signature: Date:����(;�,SJ`� DCHD OS/99(Revised) ,� DAVIE COUNTY HEALTH DEPARTMENT - '. • ' Environmental Health Section n� a y P.O.Boa 848/Z10 Hospital Street D` � �¢ � , ' Mocksville,NC 27028 � �� (33G)7S]-87Cr0 IMPROVEMENT/OPERATION PERMIT Account #: 990001764 Tax PIN/EH#: 5863-61-6290.B Billed To: Ausbon Ellis Subdivision Info: Reference Name: Location/Address: Woodlee Drive-27006 Proposed Facility Residence Property Size: 1 +acre ATC Number: 3880 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALJTHORIZATION 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 T7 #People� #Bedrooms � #Baths_,�_ Dishwasher: ❑ Garbage Disposal: � Washing Machine: 0 Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � Type Water Supply 1�eL( Design Wastewater Flow(GPD) �� Site: NewJ� Repair❑ System Specifications: Tank Size/UG�d GAL. Pump Tank GAL. Trench Width��I Rock Depth�'Linear Ft�� Other: Required Site Modifications/Conditions: Ih1PROVEh1ENT/OPERATION PERn11T 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(33C)751-87G0.**** �,W� ll ` Environmental Health Specialist's Signature: Date: � DCHD OS/99(Revised) � ' �' • � , �-_ � � � pd [� � � D . PLICATION FOR SITE EVALUATION/IMPROVEM1tENT PERMIT&ATC A�� 2 7 20� Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street ElJYIRONMEN1AtHFA�TM Mocksville, NC 27028 DAVIECOUNIY (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES5 ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. , � . .� l. Namo to bo Billed �-� �J/�. � �--�-�-5 Contact Peraon Mailing Addresa �-( �- Na2-A�/°t �.S /�� HomQ Phona ��lJ � ( �� City/State/ZIP /�-� l� Q /1 � �--- Buainess Phono 2. Nama on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �Site Evaluation � Improvement Permit/ATC O Both / 4. Syatem to servico: �House ❑ Mobile Homa ❑ Businesa O Industry ❑ Other 5. Type sy3tem requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residenca: # People � 1t Bedrooms � # Dathrooms �" vCJDiahwasher ❑Garbage Disposal 4�Washing biachine ❑Hasement/Plumbing ❑Basement/No Plumbing 7. If Businese/Industry /Othar: verify type # People # Sinks # Commodes # Shawers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gaiiona per day) s. Type of water aupply: ❑ County/City � Well ❑ Community 9. no You anticipate additions or expansions of tlie facility tliis system is ii�tended to serve? 0 Yes J6]No If ycs,wl�at typc? . -. ***I1lIPORTANT'k**CLICNTS MUST COMPLETE TII� REQUIRED PROI'ERTY INrORMATION RCQUEST�D � B�[,O�'V. Eitl�cr 1 PLAT or SITC PLAN MUST BE SUB�1fITT�D Uy the dicnt witl�TIIIS APPLTCATION. � 7pvO�a � � J Property Dimensions: / 1VRITL DIRGCT(ONS(froi� oc{:svillc)to PROPCRTI': Tax OfGce PIN: #�Sr 6 3 - �l—�, Z1� `"Z � � 2G�C a/'�� ' � ( �/' � Property Adclress: Road Namc �� ��f��e ��. � O / �� � 5�'~ � City/Zip ' � cJ-� �f� �—`' �P��' � � � If in a Subdivision providc information,as follotivs: Namc: Scction: BlocIc: Loh Dntc l�omc corners ilaggcd: � � � This is to ccrtify tl�at tl�e ii�formation providcd is corrcct to tl�c Ucst of my luio�vlcd�;a I undcrstand tliat any permit(s) issued l�crcaftcr are subject to suspension or revocation,if tlie sitc plans or intendcd usc cl�angc,or if tlic inforli�ation subtnittcd in tliis application is falsilied or d�anged. I,also, turdersta�rd 1Jrnt I ui�t responsiGle for all cltarges i�rcttrrcrl fi•au 111is npplicalio�r. I,l�crcby,give conse�it to tlie Autliorizcd Representltive of tt�e Davie County Hc�ltli Departmc�it to enter upon above described property located in Davie County and o�vned Uy to conduct all testing proccdures as ncccssary to dctcrmiiic tl�c sitc suit. ility. DAT� � � SIGNATURE � TIiIS AR�A MAY B�USED rOR DRAWING YOUR SIT�PLAN(Include all of tl�c follotiving: �xisting and proposcd property lines and dimensions, structures, setbacics, and septic locations). Sitc Rcvisit Chargc � Datc(s): "' /`'�. ��'l�- Clicnt Notification Datc: �HS: Sign 'ven ` Account No. . ....�. y3� .2 Reviscd D (OS/03 Invoicc No. ^ v;,,,..�,��. �c f� � ,���� . � �� ��Z�/ °Y . . . _ I .. �h� - �f�---- I � j , Z' .� 1 ��� I 4� �� �v�'4j� � . � . . � , �� � �,°��� �;'� . a . aot . . . t ,�, . � � � • .. � � .. ' . l.,�-- � `�,�`�I, . �`•r� � � ti��.' _. � � ���.�:, � I �G� .�.. �. �� t/' � �'i: �' O � � �+ Y'. �j 1."!"'l.�t � ��� , �I . �a ; ri �►� �I � Yr �� 6'� "i'e�'. . . - �..:�:: � �.j . ' � ,y�� �� . � •`. 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P � ���y �._ � � / -, , � .�, .� ., , i , s � �'��,��� ��7� '�� .Q � �t�� � ' � � ✓ • ' , � ° • � DAVIE COUNTY HEALTH DEPARTIVIENT • Environmental Health Section , Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001764 Tax PIN/EH#: 5863-61-6290.6 Billed To: Ausbon Ellis Subdivision Info: Reference Name: Location/Address: Woodlee Drive-2700 Proposed Facility: Residence Property Size: 1 +acre Date Evaluated: �_7�� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L Slo e% � HORIZON I DEPTH - 7 �LU � i G� � " Z Texture rou L i(..L �Li.., Consistence � Structure S Mineralo 1�1 HORIZON II DEPTH �- - Texture rou LS " � Consistence �' rN. •` T�►5 Structure k-, Mineralo n� t, HORIZON III DEPTH J�5- Texture rou Consistence T1 1J Structure Mineralo L'�C HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .� � ! . '�- SITE CLASSIFICATION: EVALUATION BY: � �z��!-`�""'s" LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: A� �/ 1 ���,7 I� �� 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 MineraloEv 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) ■���■���■������■���■■�■■��■����������■�\■�����■����■�����������■�■ ■���■����\�■■��■��������■■�����■��■�■■�\����������■���������■ ■�!� ■��������■�������■������\����■■■ ■■����■��■�■��■�■■�■■������■���■ ■�����■�������������■����■��■�■��■■■���■���■■�■��\���■����������■ ■��������■���■■■���■�■■����/�■��\■����������■�����������■�■ ■��■�■ ■��������■■��■�■���■������■��■�■�������������������■�������������■ ■���������\�����������■�\����������������������������������■ ■���■ ■������■���■���■����■��■■�����■���■��■����■■�������■■�����������■■ ■�����■��������■����■��■��■��■�����■������■���■��\■����������■���■ ■�����■�������■��■�■■�■�����■�■����■■����■����������������■\�■���■ ■�����■����■������■���■��������■ ■�������■■�■�■■�■��■���r�����■�■ 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■■■��■■■�■���I�■�■���■�����■■■■■■ ■��■����■�r■■�����■J��■��■����■�■ �������������I��/������������������������������������i�������/����■ ■��■�������■!I■����������■�����■����■����■����������■AIA���������■�■ '.....�..■�....�����������.��������.���■,I�� / � .' • • �'�:.���..,,�.�..w.....�..�.��"���'�,�i��l�l rg'�����'���"1��T��,:; .<�.�.....��`._k�..,�,..�,��.� � � � Environmental Heaith Section � � P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 `� �" (336)751 8760 � �`u� �� ;;: i �t k� �.� ...,.........�......w,...... _»_....�..__... ..r..�_...._..�_r....._.,..a.....,.........__..»....,.._....a..,,� � . �....._..... _.�.�...�,..,.m.W.._...� •� September 8, 2004 Ausbon Ellis 212 Norma Lane Advance, NC 27006 Re: Site Evaluation/Woodlee Drive (2 sites ) � Ta:c Office PIN: #5863-61-6290 Dear Client(s): • . As requested, a representative from this office visited the aforementioned sites on, September 3, 2004. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the sites, they were found to be provisionally suitable for the installation of on-site sewage systems. Before an Improvement Permit/Aa�thorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, �������• Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s) .�� ��,� ,. ��-� . � . �',Q�..�'� � -,s'���"��.Q. ���� C� 3� � ���:� �(�: `���. �'� �7��► � S'..�1�'i-�`L�f.�Z.� 7 �� - 1 • - O � SYSTEMS INC � Environmental Onslte Wastewafer Solut(ons'" North Carolina Five Year Limited Warranty Approved Effective Apri124,2002 Infiltrator Systems Inc.(hereinafter"the Company")hereby extends,for a period of FNE(5)YEARS,the following Limited Warranty to the system owner who acquires through an authorized Infiltrator Systems installer a new residential infiltrator nitrification trench system including each chamber,endplate, wedge,and other accessories manufactured by Infiltrator(herein afrer collectively the Units)located in the State of North Carolina. The Units are warranted to be free from defective materials and workmanship and to perform.in accordance with the state performance requirements(15A NCAC 18A Section.1900)in effect on the date of installation.This Limited Warranty is subject to the terms and conditions stated below. I. WARRANTY ELIGIBILITY The system owner is eligible for this Limited Warranty provided all of the terms and conditions of this Limited Warranty are sVicdy followed. The terms of this warranty shall transfer from the original system owner to subsequent system owners for the duration of this limited warranty. This Limited Watcanty covers only the performance of the Units as manufactured and installed in accordance with the manufacturer's design specifications and current state regulatory approvaL II. CONDITIONS OF LIMITED WARRANTY This Limited Wananty shall only apply if the Units are installed for use with domestic strength ef�luent and located in the State of North Carolina and all of the following terms and conditions are satisfied: (i) The design and installation of the Units is according to all applicable plumbing and building codes,ordinances,requirements and regulations. (ii) The design and installation of the Units is strictly according to the rules and regulations of the North Carolina state agency or state-authorized agency that is responsible for inspection and approval. (iii) The design and installation of the Units is strictly according to all applicable permitting procedures for the Units adopted by the North Carolina state agency or state authorized agency that is responsible for inspection and approval. (iv) The Units are subject to use permitted by the applicable North Carolina rules and regulations for on-site systems. (v) Only an authorized Infiltrator installer shall perform the installation of the Units. III. WHAT IS WARRANTED AND FOR HOW LONG The Units are warranted for FIVE(5)YEARS from the date of issuance of the Certificate of Occupancy,or date of issuance of the Operation Permit, which ever is later. If the Units fail within the five(5)year period of this Limited Warranty and all of the terms,conditions and requirements of this Limited Warranty have been met,the Company shall provide all materials and labor that may be necessary to provide a fully functional wastewater system at no cost to the Owner. This section shall not be construed to require that a manufacturer wanant an innovative wastewater system that is not properly sized to meet the design load required for a particular use,that is improperly installed,or that is improperly operated and maintained,in accordance with 15A NCAC 18A.1900 et.seq. Warranty repairs such as full replacement of the nitrification system,extension of the nitrification system or other repairs shall be completed pursuant to a repairAuthorization to Construct to be issued by the local health department in accordance with Rule.1961(1). A system failure is defined by North Carolina 15A NCAC 18A.1900 rules. IV. WHAT IS NOT COVERED BY THIS LIMITED WARRANTY 1. The septic tank and all septic tank filters,unless required to make the system fully functional. 2. Effluent distribution box(es)and headers,unless required to make the system fully functional. 3. Improper installation. 4. Failure due to excessive use or improper use as defined by state rules for on-site wastewater systems,including,but not limited to, excessive water usage,improper grease disposal,or failure to remove septic tank solids(digested sludge). 5. Landscaping costs other than those specified by rule. 6. Failure due to improper sizing as defined by state rules. 7. Repair work performed prior to a claim or which is done without the Company's authorization. 8. This Limited Warranty does not extend to incidental,consequential,special,indirect or punitive damages. 9. Drain fields repaired or modified by an unauthorized Infiltrator installer. V. THE COMPANY'S OBLIGATIONS: No representative of the company has the authority to change this warranty in any manner whatsoever,or to extend this warranty. No warranty applies to any party other than the original system owner or subsequent system owner. VI. OWNER'S OBLIGATION: I. Must have signed and dated Operation Permit from the duly authorized representative of the North Carolina state agency or state authorized agency that is responsible for inspection and approval of the Units. 2. Must have a Warranty Certificate from an authorized Infiltrator installer. 3. The system owner must notify the company in writing at its corporate headquarters with 90 days of being notified by an authorized agent of the state that the system has failed.Notice shall be sent to Infiltrator Systems Inc.,6 Business Park Road,P.O.Box 768,Old Saybrook,CT 06475. 4. The system owner must have the septic tank solids(digested sludge)properly removed in accordance with state rules for on-site systems. VII. DISCLAIMER AND LIMITATION ON IMPLIED WARRANTIES ALL WARRANTIES AND REMEDIES CONTAINED HEREIN ARE EXCLUSIVE AND 7HERE ARE NO OTHER WARRANTIES.ANY IMPLIED WARRANTIES OF MECHANTABILITYAND OF FITNESS FOR A PARTICULAR PURPOSE,IMPOSED ON THE SALE OF THE UNITS'f0 THE NORTH CAROLINA SYSTEM OWNER,ARE,BY LAW,LIMI'IED TO FIVE(5)YEAR DURATtON FOR 'THE UNITS AND TFIEIR CONSTITUENT PARTS,AND ARE SUBJECT TO THE TERMS AND CONDITIONS OF"fHiS LIMITED WARRANTY. THIS WARRANTY DOES NOT EXTEND TO INCIDENTAL,CONSEQUENTIAL,SPECIAL,DIRECT OR INDIREC'f DAMAGES,WHETHER ARISING IN CONTRACT OR TORT. THE COMPANY SHALL NOT BE LIABLE FOR LOSS OR DAMAGE TO PERSONAL PROPER"CY,PENALTIES OR LIQUIDATED DAMAGES,LOSS OF PRODUCTION AND PROFITS,OVEHEAD COSTS,OR OTHER LOSS OR EXPENSE. SPECIFICALLY EXCLUDED ARE DAMAGE DUE TO WATER DAMAGE,ORDINARY WEAR AND TEAR,ALTERATION,ACCIDENT,MISUSE,ABUSE,OR NEGLECT;THE UNITS BE SUBIECTED TO STRESSES OR VEHICULAR TRAFFIC GREATER THAN THOSE PRESCRIBED IN THE INSTALLACION INSTRUCTIONS OR OPERATION INSTRUCTIONS;FAILURE TO MAINTAIN THE MIMMUM GROUND COVERS SET FORTH IN THE OPERATION INSTRUCTIONS;THE;SYSTEM FAILURES DETERM[NED TO BE DUE TO NONCOMPLIANCE WITH THE ON-SITE WASTEWATER LAW OR RULES(130A-133,etseq.;15A NCAC 18A Section.I900)MCLUD[NG BUT NOT LIMITED TO IMPROPER S[TING,EXCESSIVE WATER USAGE,IMPROPER GREASE DISPOSAL,PLACEMENT OF IMPROPER MATERIALS INTO THE SYSTEM,IMPROPER OPERATION OR IMPROPER MAINTANENCE;OR ANY OTHER EVENT NOT CAUSED BY THE COMPANY. TH[S PERMIT SHALL BE VOID IF THE SYSTEM OWNER FAILS TO COMPLY WITH ALL OF THE TERMS SET FORTH[N SECTION II AND IV OF T}IIS WARRANTY. FURTHERMORE,IN NO EVENT SHALL THE COMPANY BE RESPONSIBLE FOR ANY LOSS OR DAMAGE TO THE ORIGINAL OR SUBSEQUENT SYSTEM ON'NER(S),THE UNITS,OR ANY THIRD PARTY RESULTING FROM SHIPMENT OF THE UNITS,OR FROM ANY PRODUCT LIAQILITY CLAIMS OF THE ORIGINAL OR SUBSEQUENT SYSTEM OWNER(S)OR ANY THIRD PARTY. THIS LIMITED WARRANTY GIVES YOU SPECIFIC LEGAL RIGHTS,NORTH CAROLINA LAW MAY GIVE YOU CERTAfN SPECIFIC OTHER RIGHTS WHICH ARE NOT MENTIONED HEREIN. VIII. TRANSFER OF WARRANTY This warranty extends to the original system owner and each subsequent owner of the system during the term of this limited warranty. IX. INSTALLER CERTIFICATION "I acknowledge to the company and the system owner that the wastewater system and the Infiltrator have been installed in accordance with the installation instructions of the company,state wastewater laws and rules,the innovative wastewater system approval,the improvement permit and authorization[o construct,and any conditions on the permit or authorization to construct,and other applicable law,�and rules." 1 �� 6� �i� U/�L � L= j,� 1� . ��� ,.��-e�� !c�c /.�r�'' Physical Address of System Installation or Lot Number Business Name of nstaller , (.����,�.Q �, ,� - `�-,'7��� � ��C,� .S I�n l�j � l� Z.. � S Name f Person S�gning(Print) �u.�.��-���� ���� :z — r� �c � Signature Date 6 Business Park Road • P.O.Box 768 • Old Saybrook,CT 06475 • 800-221-4436 • 860-57'7-7000 • Fax 860-577-7001 • www.infiltratorsystems.com White Copy: Department of Health Yellow Copy: System Owner Pink Copy: Infiltrator Systems J210403AG