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133 Princeton Ct Lot 4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital-Street Mocksville,NC 27028 (336)751-8760 4 Account #: 990001307 Tax PIN/EH#: 5860-81-3295.4 Billed To: William Joyner Subdivision Info: Princeton Court Lot#4 Reference Name: Location/Address: Princeton Court-27006 Proposed Facility: Residence Property Size: 118'x 255' ATC Number: 2508 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 pennit(s)(in compliance with Article l 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION I VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: 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 .S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems;"but shall in NO WAY en a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: //'1/�� 0 Date: DCHD 05199 (Revised) .PLICATION-EO�;� TE EVALUATIONAMPROVEMENT PERMIT&ATC l i, avie County Health Department Environmental Health Section JL 2 P.O.Box 848 7 O - Mocksville,,NC 27028 El1YIR0111.1EMAI 11EAl111 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �- I %S Contact Person Mailing Address /Q 7m u4i ,-/2 U c s i?d4 Home Phone City/State/Zip 4 0i&g Alc�T, <� . Z 7UU G Business Phone 2. Name on Permit/ATC if Different than Above S.9 rtL Mailing Address !74"" L- � City/State/Zip 3. Application For: [,s4.Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: PJ House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal [ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply: [ ]County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,what type? E I IIl1.IC .1 1'L A l OR S I 1 L PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT***,A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �� 6 6 /,"2�;WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # S 66 O - lb Z - 3 Lf 5' , S /!Q0, LA S? o Property Address: Road Flame 44 4 L -7-MVa c g- /?,o A L L1z?9os('::z 1?0d:a City/Zip A,QyA,/[C7 n/. �'• 1 700 Ce4ee 414?Zcft-.. If in Subdivision provide information,as follows- � _ /a2 'Qc;4 n/ G.1 f'_ S 7- 5/AD 41— Name: 10L 4 Section: Lot#• i 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 am 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 to conduct all testing procedures as necessary to determine the site suitability. DATE 7- / Z -�2�l__ SIGNATURE Revised DCHD(06-96) / TilIS AREA AIA11 13E IISEb FOR bRAIVIN(i 11ollIZ SITE PLAN: r v 'Ole I asphalt BALTIMORE S.R. I' t ' I�I,,; -- - —• -. rte::• 5 02648'15"E 555' 247' 251' 255' "15" OCR 259' y xPz n 262' �F2' • I o� rn m N n 266' 266' 1 a' 2 70' 2 7,T c+ . • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900111 Tax PIN/EH M 5860-81-3295.04 Billed To: Gray Potts Subdivision Info: Princeton Lot#4 Reference Name: Gray or Betty Potts Location/Address: Baltimore Road-2700 Proposed Facility: Residence Property Size: 150 x 258 Date Evaluated: 2,5 Water Supply: On-Site Well Community_ Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscapeposition Y L Slope% HORIZON I DEPTH -14 13 Texture group G1.1 Consistence Er 5Y AJaL Structure Mineralogy - 1 ; HORIZON II DEPTH I — Texture group Consistence Structure Mineralogy HORIZON III DEPTH -2 Texture group G-t + Consistence Structure l< Mineralogy HORIZON IV DEPTH Texture group Consistence -r Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCERATE C SITE CLASSIFICATION: J EVALUATION BY:_ w. LONG-TERM ACCEPTANCE RATE: 0• 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 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 ois 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 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) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 3 /fir i Neela,cl Account #: 990001307 Tax PIN/EH#: 5860-81-3295.4 Billed To: William Joyner Subdivision Info: Princeton Court Lot#4 Reference Name: Location/Address: Princeton Court-27006 Proposed Facility: Residence Property Size: 118'x 255' ATC Number: 2508 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 CONSTRUCTIVALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa ON I D Date: 2 CERTIFICATt 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 I I of S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY en a guarantee that the system will function satisfactorily for any given period of time. T Septic System Installed By: Environmental Health Specialist's Signature: ,A/lo Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section �� /6 ' P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001307 Tax PIN/EH M 5860-81-3295.4 Billed To: William Joyner Subdivision Info: Princeton Court Lot#4 Reference Name: Location/Address: Princeton Court-27006 Proposed Facility: Residence Property Size: 118'x 255' **NOTf* i08 Is lmpro 5ement/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 3 #Baths 2. Dishwasher: d Garbage Disposal: d Washing Machine:Er"- Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size g X755 Type Water Suppl&-/��) Design Wastewater Flow(GPD) f7 Site: New 0 Repair❑ System Specifications: Tank Size[COO GAL. Pump Tank GAL. Trench Widtl;� Rock Depth 17'r Linear Ft.3L`)0r Other: I (3c7TKjt3 a" Required Site Modifications/Conditions: 1►Ja 4u. o.) Cr0,3 ToJe- %'P 1 S' epp I40JsS Itua 10 Orc 1-J 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 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 1 y t' I %00'-ASU X412, < �- IOop V 1 ops" L5� too, lot I Environmental.Health Specialist's Signature- Date: Z� DCHD 05/99(Revised) ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT'PERMIY&ATC Davie County Health Department JUL 2 7 2000 Envirvnmenfal Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTAL IT1f�LTH (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS /P,R?OVIDED.�Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Hillod(�/r%/��thij ✓o �/ /'f, /JC_ Contact Parson Hailing Address '." Home Phone City/stats/LIP 4P. /,(/-, Rusin.. Phons-?W- 2. / /-2. Bass on Permit/ATC it Different than Above Hailing Address City/state/Lip 3. Application For: 0 Site Evaluation -a�Mprovement Permit/ATC O Both 4. system to service: 0,Aouse 0 Mobile Home O Business 0 Industry ❑ Other s. If Residence: # People # Bedrooms 3 Bathrooms -- �S^ 47-Dishwasher �rbage Disposal � emsn shing Machine U aast/Plumbft ing li ea a t/Ho Plumbing 6. If Business/Industry/Other: specify type # People # Sinks # Commodes # Showers # Urinals # water Coolers IF FOODSERVICE: I) Seats Estimated ("Tater Usage (gallons per day) 7. Type of water supply: 0 County/City ❑ Well ❑ Community S. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes G-No— If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: / T5 / WRITE DIRECTIONS(from M'ocksville)to PROPERTY: Tax Oftice PIN: # `� U to Property Address: Road Name rn�Gr' L ou,-t� T� %°'►��t'+��► City/ZIp &6/0,1 c e- o�,ODp If in a Subdivision provide information,as follows: Name: ( �`L 7a n cO fit W , Section: Block: Lot: Date Property 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 1,also,understand shat I am 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 to conduct all testing procedures as necessary to determine the site suitability. DATE Z- ,Z= `-O ir 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). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No.`19 Revised DCHD(07/99) Invoice No. l0 Q i V crw PRINCETON COURT PRINCETON CT. N SITE m S 85044'151,E 118.61' 60R AATZER RU. - LOCATION MAP , I � I� 1 ^o ig I � 1 � 1 i 1 1 , 41.-30•-- _____ W E - 38.00• g PROPOSED HOUSE CA;c? o � 36.00' 0?_ ��'t QO i.�•..9 w4136; g12. (�i --41.3 •--- S = •� SEAL �� o 09if i 04 _�• L-2890 Q O Z I I 1 N SITE PLAN ONLY ' THIS WAS MAPPED FROM A DEED OR IN RECORD PLAT AND NOT FROM A SURVEY 110 ,n ,� '� B'Y ME. 1 1 I 1 I ' I I 40 0 40 80 120 I 1 1 1 I 1 GRAPHIC SCALE — FEET I I I N 87°32'18, 18.67' _ _ _o FOR GLORY BUILDERS INC. SCALE TOWNSHIPCOUNTY STATE DATE.s 1" = 40' SHADY GROVE DAME N. C. 7-25-00 LOT 4 PRINCETON COURT HOWARD SURVEYING JOB NO. JOHN RICHARD HOWARD PLS 0067 P.O. BOX 276 ADVANCE. N.C. (336) 998-5396 PPLICATIO��N-FO _5f TE EVALUATIONAMPROVEMENT PERMIT&ATC ! `Davie County Health Department Q Environmental Health Section Lj -' P.O.Box 848 2 Mocksville NC 27028 Fl1V(Q(itlLtcaiTAL tik;+LTlI (704)634-8760 (lA'v"ic C('�i�ilY ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. J ?a 1. Name to be Billed_ �-ii7 A L� �� 7%S Contact Person S�r�L� Mailing Address /Q 717 UA./42e-2U c s i?o� Home Phone �5,4 m�� �3��%�- City/State/Zip A 0%14"r c N, C . Z 7 U U G Business Phone _ :5A �>L 2. Name on Permit/ATC if Different than Above :� .41wL a Mailing Address SArrJ L- City/State/Zip 3. Application For: [Site Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: N House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal [ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply: [ ]County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,what type? 1.11111.10 •1 1141 (V 6111. PIAN PROPERTY INFORMATION REQUIRED:***IMPORTANT***,A FLAT OF THE PROPERTY MUST BE // LLI SUBMITTED WITH THIS APPLICATION. Property Dimensions: C f- �� 4�T} � ,WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # 5 86 .5-7 o Property Address: Road Mame &A L ' IlVclz e,— j?a city/Zip 4aVA A16r Al. �. ; _lou ' /1/014-A d /-7 Ce��}7z�.� If in Subdivision provide information,as follows: / ,�I a,4 v /1-/ 411/ -e- S 7 S/. D 4.;— Name: Name: — ; Section: Lot#• '� 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 am 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 to conduct all testing procedures as necessary to determine the site suitability. DATE 7- SIGNATURE Revised DCHD(06-96) / 11115 ,11%'EA ,11,111 LtL 11SEL) f01% DGAIVINci !101110 SITE PLAN: v Ae DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900111 Tax PIN/EH#: 5860-81-3295.04 Billed To: Gray Potts Subdivision Info: Princeton Lot#4 Reference Name: Gray or Betty Potts Location/Address: Baltimore Road-2700 Proposed Facility: Residence Property Size: . 150 x 258 Date Evaluated: 2iJ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position -r L Slope% HORIZON I DEPTH Texture groupG[. Consistence w Structure k Mineralogy ' 1 ; HORIZON II DEPTH I — Texture group Consistence , Structure V_ _ lC Mineralogy HORIZON III DEPTH -2 Texture group C+ +Goa Consistence Structure k Mineralogy HORIZON IV DEPTH Texture group Consistence 4---r 10 15 Structure 541E Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: P S EVALUATION BY: J - w. LONG-TERM ACCEPTANCE RATE: Q• 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 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 oist 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 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) Ln 1 1 w Ld Ln CD oc iV N3 o 31 i 49 Sq. Ft. ;; 1 149 Sq. Ft. 31 49 Sq. rt. 1 18.04' i y.81 ' 1 1 .67' S 85°44' i YE 10 48.69' ----- 1 0��.41 -� 01 out S85c'44' 1 5'►E 1 u50.00' --- ----�. 1 16.94 r� 3 Acres 7347 Sa . Ft. 30347 Sq. Ft. 6.41 ' u a i� J,"'. '1"'rin.:',�-ay+- .'�ii +utr`-" Ft .➢,t� ,.,,�'.... ,.. r�. F s .: tr���7.::' -"o,��' '.a t, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section,- P01 Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) - REPLACEMENT p REMODELING ❑ . RECONNECTION ❑ Name: �Q ri C-- B/ /• Phone Number: $f ( / 9� (Home) ,p Mailing Address:—1 3 V �'�n�e. n G � '.S,7!= (Work) Detailed Directions To Site: R i.f t li+ o47- -Cron �a�7�ir�o/� �,G'. YA 17&t r,�_ o ij Property Address: /U Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: (/V/��/�I Y77 11Q(/n�/� Type Of Dwelling: 611 S- Date System Installed(Month/Day/Year): Number Of Bedrooms: �Number Of People: Is The Dwelling Currently Vacant? Yes❑ No 9--"If Yes,For How Long? Any Known Problems?Yes❑ No'❑esIf Yes,Explain: Please Fill In The Following Information About The New Dwelling- Type Of Dwelling: f O I — - ro Number Of People: Requested By: /.� �. Date Requested: /�0 (Signature) For Environmental Health Office Use Only Approved G3' Disapproved ❑ Comments: m�ri�rnum Environmental Health Specialist L� Date � 0 --_/� '"The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash'rI heck❑ Money Order❑ # Am t Date: ZZ-2-09 Paid By: �• 73�je/� Received By: Account #: 3 Z 3 Invoice #: U/