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272 Cornwallis Drive Lot 2 i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section J f" P.O.Boz 848/210 Hospital street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002509 Tax PIN/EH#: 5841-06-1580 Billed To: Chris Atkinson Subdivision Info: Pudding Ridge Lot#2 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 175 x 250 ATC Number: 3399 **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 #People '�' #Bedrooms ,? #Baths 11,71.5 Dishwasher:15", Garbage Disposal: Washing Machine:-C" Basement w/Plumbing:: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 1,46 Type Water Supply�� Design Wastewater Flow(GPD) Site: New 2Repair❑ System Specifications: Tank Siz&/POD GAL. Pump Tank GAL. Trench Width Rock Depth `O Linear Ft.-��b Other: Required Site Modifications/Conditions: 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.**** 5� Environmental Health Specialists Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT' Environmental Health Section ,7 P.O.Boz 848/210 Hospital Street Moclksville,NC 27028 (336)751-8760 Account #: 990002509 Tax PIN/EH#: 5841-06-1580 Billed To: Chris Atkinson Subdivision Info: Pudding Ridge Lot#2 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 175 x 250 ATC Number: 3399 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 CONSTRUCTJION IS VALID FOR A PERIOD OF FIVE//YEARS. Environmental Health Specialist's Signature: / 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 Art I I aW S Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO Y e taken as a guarantee that the system will function satisfactorily for any given period of time. Sa d' 1, P G✓ATl/' r N2 1xKrl �} r4 7 is -5� Y Septic System Installed By: Environmental Health Specialist's Signature: Date: /g/y DCHD 05/99(Revised) Nov 06 02 04: 23p davie county envhealth 336 751 87,86 P. 1' ' 07 'Y APPIJCATlaN FOR SITE EVALUATION/IMPROVEMENT PERMIT AT Davie County Health Department Environmenta/Health 5ectfon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 P6-1 ( ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED �+0 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 1. Name to be Billed ` TK�..JSo:J Contact Person 0—LOC-4,- Mailing —LOC-4,-Mailing Address .� ( �ZR0 ��1 Home Phone .94!e,— City/State/ZIP e-L-t_`Z►1�. o'vS /J�C— 270/, Business Pho4 2. Name on Permit/ATC if Different than Above �^ Mailing Address 3• -� 3. Application For: � Site Evaluation Q Improvement Permit/ATC �l� t:l Both 4. System to service: /House ❑ Mobile Home ❑ Business ❑ Industry 1tAY'Gther l ora l` 5. If Residence: t People t Bedrooms N Bathrooms �Jd Dishwasher 1rJ Gazbage Disposal As Ung Machine ,,SCI Basement/Plumbing 1.1 F3asemonL-/No Plumbing 6. If Business/Industry/Other: Specify type # People ft Sinks I Commodes i Showers I Urinals V Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: , runty/City ❑ Well la Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes P-1 0 If ycs,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with T1 11S APPLICATION. Property Dimensions: /S�jC � wRiTE DIRECTIONS(front Mod(sville)to PROPE'RTY: s. Tax Officc PIN: # �S' D(p,�gd y0 C To Property Address: Road Name LCr—Q -J'ALL1 S O�,) Jf4kr.o&cTc,:,3 7Z:� City/Zip -fhoc-& we If in a Subdivision provide information,as follows: ��1 . L� � ��w 2tN.�. Name: �U t'�G- r-t"r,.G-c' L6 P— CoZwLz Ac c_t Section: �_ Block: 14 Lot: Date Property Flagged: 1' C/1— 0a This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any pern3ii(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 that I am responsible for rill charges incarredfi-om this application. 1, hereby,give consent to the Authorized Representative of the Davie County Health Della t•ttuell( 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 11— 9-O Z' SIGNATURE THIS AREA MAYBE USED FOR DRAWING OUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setb eks, and septic locations). Site Revisit Charge Datc(s). 3 (IX aw Client Notification Date: 1:5r 9 ) EUS: Account No. Revised DCHD(07/99) Invoice No. 2S �� ' DAVIE COUNTY HEALTH DEPARTMENT �� Environmental Health Section Soil/Site Evaluation D NAME _ r'(ZC P DATE EVALUATEDi ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well (/ Community Public Evaluation By: Auger Boring Pit i/ Cut FACTORS 1 2 3 4 Landscape position L 1— Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH '`- Texture group Consistence Structure h Mineralogy HORIZON III DEPTH 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: )TEVALUATED BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: She r t 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 DCHD(01-901 Koo Spatia! Dula 1)10-r er 1( -' North Carolina Click on the Map to: Map Layers C* Zoomin r' ZoomOut r Recenter Map t' Identify:�arcels Draw Layers Zoom Factor: 5X_._. f^ Radius Search(feet) - Draw selected layers: - Boundary l�w�r 3' rvE I-Census Tracts ❑ City Boundaries County Zoning �0.684 Multi Symbol (-E911 Fire Districts ❑ 1-Flood Panels ❑ r Flood Zones ❑ Parcels q 1-School Districts Multi Symbol y 6841061580 r Solis ❑ Town Zoning ❑ r Townships G Multi Symbol Precincts (-Voting P i t ❑ Infrastructure S _.. Driveways r Rail Lines — 1-Street Centerllnes — ;. .! ', r US/NC Highways Multi Symbol SW 41 SE US Highway— NC Highway— Parcel Data Interstate— Find Adjoining Parcels Aerial Photography ❑ • Land Unit/Type:1 :/LT Physical r Creeks and Rivers • Deed Book/Page:00181/0719 • Deed Date:1995/07/17 (-E911 Addresses � • County ID:E5020A0002 (-Fire Departments =w • Account Number.,E5020A0002 • Sales Price:$0.00 • PIN:5841061580 • Property Address: 1-Schools .� 000272 000272 DR Draw Layers • Legal VLOT 2 PUDDING RIDGE • County Zoning:R-A • Owner Name:GROCE GARY W • Census Code: • Owner/Address 1:GROCE GARY W • City Code: MAP CUrreriCV • Owner/Address 2:GROCE RICHARD E • Fire District: • Owner/Address 3:154 VALLEY OAKS DRIVE This map is prepared for the • Flood Zone:ZONE X inventory of real property found • City,State Zip:ADVANCE,NC 27006-0000 • Flood Community. within this jurisdiction,and Is • Land Value:$40,000.00 compiled from recorded deeds, • Flood Panel.0025 C plats,and other public records • Building Value:$0.00 • Flood Map Date: hereand data.Users of this map are • Out Building/Extra Features Value:$0.00 • Soil. aforementioned public fied that oprimary • Assessed Value:$40,000.00 • Township: information sources should be p consulted for verification of the • Property Record Card • Town Zoning: information contained on this • VotingPrecinct:FARMINGTON map.The Davie County, mapping,and software • School District:PINEBROOK companies assume no legal responsibility for the information contained on this map or in this ' •' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002509 Tax PIN/EH#: 5841-06-1580 Billed To: Chris Atkinson Subdivision Info: Pudding Ridge Lot#2 Reference Name: Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 175 x 250 Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring V Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position l L. Slope% HORIZON I DEPTH (o" ' Texturegroup �% Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure AA Mineralogy HORIZON III DEPTH �• ' Texture group Consistence 1' Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION J LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: *. g M J, EVALUATION BY: / <c-d 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 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 DCHD 05/99(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■tt■■■t■■t■■t■■■■■■■■■■t■■■■t�■■■■■■t■■tt■■■■■■■■tett■t■■■■■tt ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■tttettset■■■■t■■■■■■■■■■■■■■■■s■■■■t■■■■■■■■■■■■t■■■t■t■tte■t■t■ ■tt■■t■tet■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■t■tt■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■tttttt■■■■tt■■■■■■t■■■■t■■■■■■tttt■■■■■t■■tt■t■ttttt■■tt■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■t■■tent■■■ttt■■t■■■■■■■■■■■■■■t■■■■tt■tt■tt■t■■■■■■■■■■■■te■■■■■ ■■■■■ttt■■■■t■■■■■■■t■�■■■■t■s■■■■■■■■■■■■t■■ttt■■■t■■■■■t■tt■tt■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■std■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ iMENNENMEMNONiiiiiiMONSONMEMNON ■■t■■t■tttttt■■■■■■■■■■■t■■■■■■t■■■■■■tttt■■■t■■■■tt■ttt■t■■■t■■t■ ■■■■■■■■■■�■■■■■■■■■■■■■■■■iii■■ii■■■■■■■■■■■■■■■■■■■■■■s■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ r� 33 -dit 27 n 7 811 0 26 - n :0 7 0684 - s � - GnB2 1580 - o s - - s nC2 Mae 3318 00 3 317 O 2291 ,c --J 24 C� 0 2026 5 � : DAME COUP HEALTH,DEPARTM ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751.8760 November 25, 2002 Chuck Atkinson 3405 Tramore Court Clemmons,Ne 27012 Re: Site Evaluation/Cornwallis Drive Tax Office Pin : # 5841-06-1580 Dear Client(s): As requested, a representative from this office visited the aforementioned site on November 20, 2002. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site,the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization 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 RH/df L)L) C6f cb Davie County Health Department Environmental Health Section Payment Due Now. PO Box 848 (210 Hospital Street) Please Return a Copy of the Bill with Payment. Mocksville, NC 27028 Your Check is Your Receipt. (336)751-8760 Chris Atkinson Account No: 990002509 3405 Tramore Court Invoice No: 3463 Clemmons, NC 27012 Billing Date: 3/26/03 Sry Date Service Code ID/ATC# Description Sry Cost Quan. Extended Cost 3/26/03 SEPTIC-NEW-R 3399 Pudding Ridge-Lot 2-27028 $75.00 1 $75.00 3/26/03 PAID-CK - ($75.00) 1 ($75.00) Balance Due Now: $0.00 66-7788/2531h DAVIE CO. ENVIRONMENTAL HEALTH -Date'' t PAY to the s S = ORDE�` - A �..�CJCL?Q.� t-QJ-� DOLLARS u :� e gam' P.M Bo 14%Rlmto"g m,NC 27103.1456 - MEMO' =-- ---- — — nm is 2 5 3 1 7 788 7i: 128000,93116 iis