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207 South Madera Drive Lot 19DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900225 ; Tax PIN/EH #: 5749-63-6844.19 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 19 Reference Name: Jeff Ferguson Location/Address: As stated in 15A NCAC 18A.1969(5) ATC Number: 4333 accepted Systems may also be used 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 �ewageTreatment and Disposal Systems). THIS AUTHORIZATION FOR WAS ATER STfWCAS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on I provement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section . 190OVSewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that system function satisfactorily for any given period of time. 6� 1,Z 3 � 2' 3 i 5 a' T 2► 4 too -Porch 3 �31z vrou S Septic System Installed By: D U W h Environmental Health Specialist's Signatu Date: In G/ DCH 05/99 (Revised) S F 'ecu-• y— T�-Q ��►- = 332 ►► DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section fl • P. O. Boz 848/210 Hospital Street Q(y Mocksville, NC 27028 1N (336)751-8760 1� IMPROVEMENT/OPERATION PERMIT Account M 989900225 Billed To: Jeff Ferguson Reference Name: Jeff Ferguson Proposed Facility: Residence Tax PIN/EH #: 5749-63-6844.19 Subdivision Info: McAllister Park Lot # 19 Location/Address: Property Size: 310x216x290x **NOTE * This improvement/Operation Permit DOES NOT authorize the construction of 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 OCOEE #People 2 #Bedrooms 3 #Baths 3 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 2 Type Water Supply ZyOA tY Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size IDQ? GAL. Pump Tank GAL. Trench Width Z&" Rock Depth 12" Linear Ft.q IL5 6 01ST2t+3t7r1W As stated in 15A NCAC 18A.1969(5) Other: �(irS , accepted Systems may also be used Required Site Modifications/Conditions:1t'�Te.LL 0-3 -rANL, VES aox-o- I4EQ 16 ow )p L_1 .'k► 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.**** l� ,o I Un11=S 1N C k 1�30XIZ1 ''F 3 MbJ 10 0% \ 3Z, _3G 2/, Environmental Health Specialist's Signature: Date: ASD DCHD 05/99 (Revised) 6PVL R SITE EVALUATION/IMPROVEMENT PERMIT & ATC D_ Davie County Health Department 1 FSB 2 2006 Environmental Health Section P.O. Box 848/210 Hospital Street ��1RONMFNjA� HEAL Mocksville, NC 27028 oA�`Ecoua�► (336)751-8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit 4uthorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed -- 3 e r IS __i H _ Contact Person , err Billing Address o x 7 Home Phone City/State/ZIP vZ,Business Phone- - Lai /3 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address City . - - Tax PIN# ,'7 V 9 - Subdivision Name IIS Section/Lot# Zj Lot Size Directions To Site: a"3 •16 Date House/Facility Corners Flagged - (I If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Dyes 9<0 Does the site contain jurisdictional wetlands? Dyes C4<o Are there any easements or right-of-ways on the site? Wres ❑No Is the site subject to approval by another public agency? Dyes GK'O ^ Will wastewater other than domestic sewage be generated? ❑Yes �0 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _a # Bathrooms _;� Garden Tub/Whirlpool ❑Yes W No Basement: ❑Yes o Basement Plumbing: ❑Yes Xo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: nounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ri 1 • This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine mplianceClwc,,: applicable laws and rules on the above described property located in Davie County and owned by ; �iCl /�� rtnCr t 4 Iq - Site Revisit Charge P owner's owner's legal representative signature Date(s): _�l�Gtr Client Notification Date: Date EHS: Sign given Dyes ONo Account # Wqq002Z5, Revised 2/06 Invoice # K `7 _ --7-7777 APPLICATION FOR SITE EVALUATION/IAIPROVE&IENT PERtmlh— (�� Davie County Health DepartmentD V Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Z�05 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE --R 4i "' INFORMATION IS PROVIDED. �1Refer ito the INFORMATION BULLETIN for instructions. 1. Name to be Billed �� 1 Inc•=c1 ��1't p r� Contact Person Mailing Address O i�� ! Home Phone City/State/ZIP G:.J�n:,�F'�'`� c� -4-7,16 3 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: E Site Evaluation El improvement Permit/ATC ❑ Both 4. System to Service: CYH,_ousse E3 Mobile Homo ❑ Business ❑ Industry ❑ Other 5. Type system requested: ltd' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms , �� - � # Bathrooms ODishwasher []Garbage Disposal UsIa"shing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: it Seats Estimated Water Usage (gallons per day) 8. Type of water supply: lH'County/City ❑ Well ❑ Community / 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ m -o If yes, what type? ***1AIP0RT11NT*** CLIENTS AIUST COdiPLETET'HE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUBAI1TTED by the client witlj TIIIS APPLICATION. Property Dimensions: -5 on f cA6, Tax Office PIN: # �7 y2- 6,3 - 6 Property Address: Road Name 5t4;j,) 211 City/Zip WRITE DIRECTIONS (from Mocksville) to PROPERTY: �-- Imo, i n cc 'D ," '�c -q,-, C'e P/.- < <. If in a Subdivision provide information, as follows: Namc: M 1 S le (" pl+r L Section: / Block: Lot: Date home corners flagged: /g This is to certify that the infornlation provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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 l ain 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 dctcrllline the site suitability. — DATE C� S. � ' � �" D � SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lilies and dimensions, structures, setbacks, and septic locations). Sign givcn_,A)D Revised DCIID (05103 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. 17rif go o Invoice No. APPLICANT INFORMATION Account #: 989900035 Billed To:. Richard Short Reference Name: Proposed Facility: Residence See Map DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.20 Supdivision Info: McAllister Park Lot #-20— /9 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: D:s Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS Landscape position Consistence HORIZON 11 DEPTH Texture group Consistence �t�r ., ���■���e��■■� Structure HORIZON III DEPTH F7_M:ALAM"K .'ta_O��o Texture • L]Consistence ��'1���0— • NOMNWTAHORIZON ����O IV DEPTH ConsistenceM, SOIL WETNESS RESTRICTIVE HORIZON u-tcolowim CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:C— OTHERS) PRESENT: -371,© Z75— Landscape Position 0'n, R - Ridge S - Shoulder L - Lincar 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 NSISTENCE 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 'tr c rc '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 DCI ID 05199 (Revisal) APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.08 Subdivision Info: Richard Short Lot #.98' Location/Address: Sain Road -27028 Property Size: 5 acres Date Evaluated: O7 Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: ' REMARKS: �51 l�4Ji��1� I--% Ca EVALUATION BY: OTHER(S) PRESENT: 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 it 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 MineraloQv 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 DCI -ID 05/99 (Revised) Landscape position Consistence • _ IMMUNE --- WASTINHORIZON 11 DEPTH Texture group Consistence Mineralogy —ArTIPWASE; "K, HORIZON III DEPTH Consistence Mineralogy HORIZON IV DEPTH Textu group__ Consistence Structure SOIL WETNESS RESTRICTIVE HORIZON CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: ' REMARKS: �51 l�4Ji��1� I--% Ca EVALUATION BY: OTHER(S) PRESENT: 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 it 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 MineraloQv 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 DCI -ID 05/99 (Revised) i s Nt;t� MAP 1,v7- APPLICATION TAPPLICATION FOR SITE EVALUATION/MPROVE&JENT PERMIT Davie County Health Department 0 Environlnental Health Section P.O. Box 848/210 Hospital Street APR Mocksville, NC 27028 3 z�05 (336) 751-8760 P,,„„_ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEME 7 lq / ll INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions---, 1. Name to be Billed �t < <-I� a•z�C,p ��/ t C�� Contact Person Mailing Address ��� / -! 1 E7 ,/' �S -,_ Home Phone City/State/ZIP - L:.� �'��'� `� 5 • le -`t A7/6_ } Business Phone ,e e) 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: CY Som�ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: se ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 2— Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms 3- ,..,� ,.,., � ,y� #Bathrooms MDishwasher ❑Garbage Disposal 1210ashing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: it �Seea�ats Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-No-,, If yes, what type? ***I/1IPORTAN7'*** CLIENTS dIUST COMPLETE THE REQUIRED PROPERTY INFOR119ATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN MUST BESUBAIMFED by the client witli THIS APPLICATION. Property Dimensions: 42 %VI E , Tax Office PIN: it 3- 68� `f l Property Address: Road Name c5't4 :, 1j City/Zip If in a Subdivision provide information, as follows: Name: M ` R11 i's-ke 1��r Section: Block: Lot: 0 - WRITE DIRECTIONS (from Mocksville) to PROPERTY: �'t- L”, d- < '�tr4�c'e i°1R< Date Dome corners flagged: Z/ - .Z.,I- o-.' 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 clianged. I, also, understand that I ani 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 properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 3 - D SIGNATURE TIIIS 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 IDatc(s): Client Notification Date: EHS: Sign givcil Account No. IrP Revised DCI -ID (05/03 Invoice No. DAVIE COUNTY I1EA1;rI1 DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH #: 5749-63-6844.19 Billed TO: Richard Short Subdivision Info: McAllister Park Lot # 19 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence property Size: as platted Date Evaluated: I_ ad— Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS -Landscape position Emu HORIZON I DEPTH Texturegroup Consistence Mrs"# HORIZON 11 DEP`rH Consistence III DEPTH ConsistenceHORIZON 1������������� Structure ��a����������■ HORIZON IV DEPTH Consistence SOIL WETNESS �iiis ME • ®�■�i kmakaelloy CLASSIFICATION SITE CLASSIFICATION: Y S EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �' OTHER(S) PRESENT: REMARKS: -L17- tom" �_J LILQ- bar,)-\ IQ ta A DOT IQZ�w t.A TG" 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 lois 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 Structurc SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogx 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(suitablc), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/dayM2 DCl ID 05/99 (Revised)