160 Cornwallis Drive Lot 37 • • I / f
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003255 Tax PIN/EH#: 5831-95-5170.37 KA
Billed To: Kapp &Associates Subdivision Info: Pudding Ridge Lot#37
Reference Name: Location/Address: Cornwallis Drive-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3794
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 Syst s,-Seetie •190 a Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTE ATER CO TIS3 IS V ID FQ&A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: Id d4/
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 akin as a guarantee that the system will function satisfactorily for any
given period of time. i
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Septic System Installed By: L" '
Environmental Health Specialist's Signature: e:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT %r
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 7
IMPROVEMENT/OPERATION PERMIT
Account #: 990003255 Tax PIN/EH#: 5831-95-5170.37 KA
Billed To: Kapp &Associates Subdivision Info: Pudding Ridge Lot#37
Reference Name: Location/Address: Cornwallis Drive-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3794
**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 qDO' a #People E #Bedrooms 3 #Baths
Dishwasher: e Garbage Disposal: 2( Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
(�
2
Lot Size : CC`.C>4 Type Water Supply 0t3T? Design Wastewater Flow(GPD) 3t00 Site: New Repair❑
•t t
System Specifications: Tank Size I ECOGAL. Pump Tank GAL. Trench Width 3(e Rock Depth A Linear Ft.
Other: 3 �1STel�yrto.� �x�S
Required Site Modifications/Conditions: kS�f"-SIL- 00 C-C-3Ta')12
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.****
• S1�-f�M T11�T 1NLi�-TS
VSigna :
D1iZM- )0 _TX0-Environmental Healt Sate: (.9 10 d
V 4
DCHD 05/99(Revised)
CJS l� ��4-LaS �'RlV 15
05/31/2004 22:38 3367664442 CDQMPWA PAGE 01
e ArPU:ATION FOR SITE EVAL.VAIlOV/11011ROVEMEVT rEAMIT 4,ATC
Davie County Health Department {'
r 1 Ehr/ronmanwNuirmSection
P.O. Bok 048/210 Hospital itseet
Mockoville, NC' 27020
1336)751-9760
r01PORTANF••r .Alli A:TPLICATION c"mor aB PAOC$SBCD VUL3351 ALL TME RECIUMED
SNFORNATZON IS PAOV EVII. Iters to the S1rrORmA7Z0N BULLETIN for instructions.
to be rtli 7 fos,. coneaet P...s. e_,�)
star..t iris A•araa. 31 V O/. e /,L � tt«n. Pooa,e //�.3, 3�L,_ !. '.�•�
(:trrrat.t./sir V/ 'Ql_s 2 7D� 1..tn...Prion._[/'� '�/.
�. rreaa.a a.e.ile/ATC it*flees ee tAaq Af.a.e / /CP�/s{�,Hr/
tt.siinj basses* 3673CZ/1r/
✓f Application sor:X9ite Evaluation d Imprnvaarnt Varsait/ATC ❑ Belch
-A- syattw to aervtce:,XNoust: O Isoe1le Rome 0 business O ZnduAtrY ❑ Other
..I ryp. .y.tas r.auaatad:A co,v.nt tonal 0 convention*' waLtieJ 0 tnnovati�a
rpt. :e Rooldene.. a People —:2 s D.dr..— a Bathre,0a:a
a.� Utah....1ar �la•rbesa Dtao•.sat *aattia*"..kin. Qseesaront/rlurotn• ❑baatunant/ho rlwl.ino
ZZ C-ai.aRar/tnaYetry/Other r.rl PY try.___ • People T P aink..•.,�,
I Cvm dssa a .tnowra • urinals • traces Coolers
IF TOODSRRVICrt a Beata Caeimated water Usage t•alloas Der acyl _, ,
�. ryp.of t+star supply,x county/C1ty ❑ Wall G cosesunity
or you enueipate .Bahl— or espsnsiolu of the fatllity Ibis system It inleuded to ser t1?13 Yes (NI
If)ti.what gype?
•'°btlt•ORr�prp"CCtR!RT;' LLTBTt,RPQV1/(LDPROPLRTYorORMACION RLQt1CSl'ISU _
OCLOw, thrr*►LA7•r SIT�ft �/ 7G4 Sl/DNl7Tpp6D�br she ctlrar t.lth T1uS AYPGf,AT10N.
it--l-roperly i)intenslats &,7 p'^ /� 7 � 'PIVAITE UtRECT10NS(h-hn Dlochsr ue)ro 1'tl0t'lili'11"
was Ofller 1'1N: U yr
t✓s'roperh•AtlJras: Road Nume�!//OrN�"eV
Citymp�r/CS�/ a
a�DaB
tele•SubJirlslon yrOviJc informntlon,Aa fotiotrs: ___ •'
Minim L
QJII lrSt-el� [flock: Lot: �/ U�toMo careers(IAsgeJ.'_O/10 dl
'0116 1!to et-fir.11111t file Rtfornfatlua p,r.sided 1s correct to me bear/army knowicifge. j wtderslnhd(fiat oily perulR(.,)
issued btrtaffer are sttbjccl to suspensio i or revocaIlea,11 lite alts pkABs or tafeRded use•charge,or if tate into rtnauon
labtnitled in 1142 appllentton is flletlied e r chanted /,alav,und.retand that f roe rrrpanifOlefur ap rhagsis btrarred frvnr
this plgdicativn. 1,11e1'eby.Uwe eoarOJ)I t-.thCA UVIOrtaild Raprerentallve.if Use Dst7e tltyyctIt p-lrkrtte
w time upon atitivc doserltled property lnceleJ to Devic County aad owned by, -
1n rundncl
III
.J procedures as nece!sary to delerwiAe the site sul�ytJr111t). -
'— A'fU12L /�/� `,tw ! -- .
{ MIS AREA MAY OF,USIO WR DRAIVINt;YOUR SITE PL.&M(include all of fir followlsig: E.elsting will propose)
properly lines and dinte)uioas, sfrueturm,setbacks, and septic locations).
She RcrlsU Chur6c
Datt(s):
Client NottOc.alch Date:__ f
' LHS:__
Situ eit'rn_,. Accotnss Na _
Revised VCM)(USipi llwotet No. "+..
2-it
EC E � v " CATION FOR SITE[VALUATION/1hIPRUVI AIL,11T I'L•Ihti11T S)1'TC
D
Davie County Health Department
JAN - 5 2004 EnYftnmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
� Oi rt ENT1�L fiFJtlTli (3 3 ti)7 51-8 7 6 0
DA'+E COUt,IiY
***IMPORTANT*** TIiIS APPLICATION CANNOT DL PROCESSED UNLESS ALL TRE REQUI1tLll
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed Cont-act Person
Mailing Address oAl4e44 Home Phone
City/State/'LIP Business Photic
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/'Lip
3. Application For: cite Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to service:LE;eHt7use ❑ Mobile Home ❑ Busine!,s ❑ Industry ❑ Other -
5. Type system requested: Conveeentional E3conventional modified '[ ❑ innovative
e,w
G. If Residence: It People a"kayjl G-t7-ZII Bedrooms -->0;— 11 LaLliroom:,
\-25i-shwasher []Garbage Disposal L-EW shing Machine ❑BasemenL-/Plumbing ❑BasemcnL•/No Pliuubing
7. If Business/Industry /Other: verify type It People 11 sinks
II Commodes It Showers It Urinals 11 Water Cooler:,
IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day)
8. Type of water supply: County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansi011s of the facility this system is intended to serve? ❑ Yes 0
If yes,what type?
***Ih11'0ItT11JYT'*** CLIENTS AIUSTCOAII'LETG'rIIE R.GQUIRBD PROPLItTY INFORMATION ItI:Ql1Is5'1'h;U l
BELOW. Either a PLAT or SITE PLAN iVUSTBE,SUBUITMD by time client n'itli'1'l1IS Af1'1,ICA'I'ION. J
Pi-upcm'ty Dhnctisiomis: 0 �Qc1Ps WRITE DIRECTIONS(froom 11•luchm-ille)/to I'1 OPE'ltTY:
Tax Office PIN: 393)g si- 7 0 E 31 tin
Property Address: Road Name C,t Vn LUa 11 j � 0r, t tOrz9 176-'
City/Zip t��Ui IIf ,2 20x8
If in a Subdivision provide information,as foilo�
n � �
Name: / — –o
14
01
Section: Bloch: Lot: > Date liome corners flagged: � CorA e x qL
.-mss Ea0 0 0 0 D 4 1-3 tj feC(
This is to certify that the information provided is correct to the best of luy knowledge. I understand that any pernmit(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, «nderslaud that I aur responsible for all chaiwes incurred front
this application. I,hereby,give consent to the Authorized Representative of the Davie Comity Health Delt:u•tuu'n(
to enter upon above described pruperty located in Davie County and owned by
to conduct all testis procedures as necessary to determine the site suitability.
DA'L'E .� fD 3 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing au • used
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit CI►:u•hc .
ACL Client Notification Date:
EIIS:
Sign given Account No. �
Revised DCHD (05/03 Invoice No. ✓
1 � LCIS.
• + . DAVIE COUNTY HEALTH DEPARTMENT
_ Environmental Health Section
r. Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001109 Tax PIN/EH#: 5831-95-5170.37
Billed To: Earl Groce Subdivision Info: Pudding Ridge Lot#37
Reference Name: Location/Address: Cornwallis Drive-27028
Proposed Facility: Residence Property Size: .7 acres Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS1 2
. 3 4 5 6 7
Landscape position G-3 L_ t/
Sloe%
HORIZON I DEPTH fJ ' Z
Texture group
Consistence •S 77737T)
Structure C- Ge,
Mineralogy
HORIZON II DEPTH
Texture group C_
Consistence r
Structure <qC__
Mineralogyl�
HORIZON III DEPTH
Texture group
Consistence • IS
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE \^,,
SITE CLASSIFICATION: �� EVALUATION BY: �4—
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: i� r ( �L
V�72t_. C-� ''
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
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
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
DC14D 05/99(Revised)
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DAVH; COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 / Fax: (336)751-8786
January 15, 2004
Earl Groce
154 Valley Oaks Drive
Advance,NC 27006
Re: 3 lots/Cornwallis Drive
Addition to Pudding Ridge Subdivision
Tax PIN#: 5831-95-5170
Dear Client:
As requested, a representative from this office visited the above site(s) January
13, 2004 to perform site evaluations. Based on information provided on the Application
for Site Evaluation and results of the evaluations, lots#35-37 are classified provisionally
suitable for the installation of on-site wastewater systems.
It should be noted that house size and location may be limited. Additionally, a
pump station may be required on any of the three lots due to topography and/or house
location. System design will be determined at the time an Improvement Permit is applied
for and issued.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct,the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
Enc(s) v