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349 Serenity Hills Trail Lot 2t DAVIE COUNTY HEALTH DEPARTMENT PdEnvironmental a tion I Health c H S I P. O. Boz 84M10 Hospital Street C � Z13 Mocksville, NC 27028 (336)751-8760 Account #: 990003008 Tax PIN/EH #: 5864-42-5595 Billed To: Donald Lamonds Subdivision Info: Riverbend Hills Lot # 2 Reference Name: Location/Address: Serenity Hills Trail -27006 Proposed Facility Residence Property Size: 11 acres ATC Number: 3962 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 CONST UCTION 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 Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAYh�taken as a guarantee that the system will function satisfactorily for any given period o 7.7 Joe ,&/ ') V/1 II Septic System Installed By: L, i / v G Environmental Health Specialist's Signature: ��-1'/i� Date: DCHD 05/99 (Revised) t DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003008 Billed To: Donald Lamonds Reference Name: Proposed Facility Residence i o Tax PIN/EH #: 5864-42-5595 Subdivision Info: Riverbend Hills Lot # 2 Location/Address: Serenity Hills Trail -27006 Property Size: 11 acres ATC Number: 3962 **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 k1 #People _ #Bedrooms V #Baths Yl Dishwasher: Pill"' Garbage Disposal: Washing Machine-J2r Basement w/Plumbing: Er" Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #S��Ue�at�csIndustrial Waste: 13 Lot Size Type Water Supply Design Wastewater Flow (GPD) '71s Site: New Repair El System Specifications: Tank Size/ k GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width =C�ock Depth -jt-)L/'Linear Ft._iVD 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 day of installation. Telephone # is (336)751-8760.**** y✓cs ej Environmental Health Specialist's Signature: Date: aS / DCHD 05/99 (Revised) _ 12/10/2008 WED 12:37 FAX 386 741 4489 RJRT INFORMATION RES. Dec l u U�J uy: 5Ua O^v 1 o county envhom^ 1 th 336 7S I 9796 A APPLICATMN Fp0 SITE EVALUATION/IMPROVENIENT 1'ElIMIT & ATC Davio County Health Department Envilonmenta/Health Section P.O. box 848/210 HOSpitnl $tract mockaville, NC 27029 (336)751-8760 -**ZMPORTANT*** , VX$ APPLICATION CAMN02- 9S PROCESSED UNLESS ALL THF. REQUIIXED INFORMATION IS PROVIDED. Rofor to the INFORMATZON BULLETIN for instruCLionu. f a� NAma to be Billed r1 Mailing Atd4coag r r ---J— Nam" on ParmLt/ATC it Ditt.cant than Contact Portion Homo Phono __..l�U �Z♦Z�1%� ._._.____..... uWainonn Phone Hailing AJdroaa C..iCty/Scaca/tip Com). Application Fore Site M%-aluatiop Ed Improvement Pcr]ait/ATC ItO Bot1t 7 ��. Syat.a. to '7-46ee V Houno ❑ Mobiles Home E3 Suai.noas 0 Industry. E3 Otllar,. a-->. Type oyotrm requooc:.a: l Canventiooal L7 eonvontLonai mod:liad Q innovative z,.f//Hoaidcnce:0 People 1fL� 8 Bedrooms 'L 11 Bathroom= —-mDiahvashrr doO rbege Dlnpo5cl [YN(...hing lsachine 4aaaa..v.*n6/P}wSing ❑8aaemunt/No rei—w,ing 7. Ir 8uair..A0/Indu9try /Other: :ority type -- 0 A'ooplc 0 SanKo --.- 0 _,_" Coamiodo■ 8 showara 2 urinaxs It Water Cool..aa XY FOODSERVICE: 1I Scats L'atitaated Water U0agc tgallonn par day) Typo of wot-X Lepplym ❑ Count.y/City Community c— .r vo you ancicip.te aduitlonu of expansiplis of tite facility this systcilt is itelc,[dcd t0 ier•ve? ❑ VCS Nu If yes, what '�"rIMPO.RTANT""" CLI GNTS '►iUST COAfPLCTE_ !'Ither a PLAT or SITE: PL ED I ROVERTY IN170MVIATION ItlmQues-mo the chrut with 'i't11S APPLICATION, I a-at.A- a--'Propet•ty Dienensiuns: 1'C' t-aMt(T I C DIRECTIONS (!rims Mucltwllic) to PIMV :ILTV: -ri'aa office rnv: N. L5595 i Zl z' �a��- �aDI nnlvt cI, l_e ` 4 L— Property Address: Ruud Nr?�tn /tom v -rJeA4 P -L- Ik ei V u VA l l ey City/zip- llilt�i �� %D�%Gj 1j1�11 ('llttt�v► n,104 r:---trin a Subdivision provide Information, as follu►vs: (Zt7 . � �a'* oU. m7e° or -e-, Ja ii �&'--d �- Kama: F+l V ✓:4 owl ' -I (-Ae-Aa dk lje�"Ti Section: Block: _ Lot. etc homer rsory Ilabecd: X7`•3 �t r This is to certify that the tnrnrrrmation provided is correct to the st of my Knowledgu. I understand [lint atmy perrsit(s) -- - I5sued hurcaftcr are subject to stispeusiva or revocation, if the site plans or intended use change, ur if the infornrntios�•- subntitted in this application is falsified or changed. 1, also, understand tkarl run I'VYPDAAsiblCjar al[ cGarSas:ncu,rc,/,%rum d,rp• applicad000. 1, hereby, give consent to the Authos-ired lxcprescntative or the I):rvic County Health Departsmeut �,c.r••j•,• ;� �:'-�:. c'"` to ester upon above described property located in Davie County :mod on•ucd by to conduct all testing procedures as ueccssary to determine1 : the site 214%bili(y, c"'�A �% �I SIGNATURE (� - TMS AREA MAY nE T.TSrf) FOAL DZLIWING YOUR SITZ PLAN (Include all ur the rnllnwing: LA ie tint and prupnxm:d property lines and dimensions, structur•is, setbacks, and septic location;)_ Site Revisit Chargc Clicut Notification pace: EIIS: Sign Riven Accuuut No. d Revised DCT -XD (OS/03 Invoice No. Alk APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE III th4l ` Davie County Health Department Environmental Health Section P. 0. Box 848 DEC 4 191.13� Mocksville, NC 27028 - i ; (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROC SE ALL THE REQUIRED INFORMATION IS PROVIDED. I. Name to be Billed )Q.tI 1>7 i1►.. �'1G +, s Com,+, -��� j�T�•�. Contact Person �4� �e �'�-�'e S Mailing Address 3 d 1 Home Phone 1910 ie, ZS -L 4 3 City/State/Zip A`l Jl< "GC i N L:. "z '? 0,0 6 Business Phone If -0 -7 e 8' S' 7 s 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 9^ Site Evaluation ❑ Improvement Permit & ATC ❑ 'Both 4. System to Serve: @--House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: ❑ Dishwasher 6. If Business/Other: 7 8 # People ❑ Garbage Disposal Specify type # Bedrooms ❑ Washing Machine ❑ Basement/Plumbing # People # Bathrooms ❑ Basement/No Plumbing # Sinks # ;,Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) Type of water supply: ❑ County/City 'a -Well Do you anticipate additions or expansions of the facility this system is intended to serve? Tf ves_ what tune? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE ISUBMITTED WITH TRIS APPLICATION. Property Dimensions: / / • 23!!? 1116.411 WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY - Tax, . Office ROPERTY:Tax;Office PIN: # SFS G 3 _ S -';� g 38' 1 ��/ h �. ,�% Property Address: Road Namee ,/ Ia ,,/ y City/Zip _�`f ✓Q h L' %Y ,Pe16: I 1 .� -P It If in Subdivision provide information, as follows: 1 r n r 1 Name: `?ii Yer$ef n cL l fs 1 Section: Lot #: 1 1 1 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 i the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by T c,. ✓ 10 M C. -IX e S Ca I A f-, 41-k , T)� C, to conduct all testing procedures as necessary to determinethe site suitability. / DATE L cj l � (_ SIGNATURE Revised DCHD (06-96) i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LOT Soil/Site Evaluation APPLICANT'S NAME ��F�it/� DATE EVALUATED 1 ��✓a4 PROPOSED FACILITY PROPERTY SIZE SUBDIVISION A �%` �i--�i rTROAD NAME Water Supply: Evaluation By: On -Site Well E/ Community. Auger Boring C/ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence - Structure / .t Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE I, SITE CLASSIFICATION: 4-1 LONG-TERM ACCEPTANCE RATE: REMARKS: &1?/U / �l L'.D ��)'l 7 �� DCHD (01-90) EVALUATION BY: /' ,"/ z OTHER(S) PRESENT: 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 ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■ 0 ■ ■ ■■ ■■ ii ii so No FROM FAX NO. Jan. 27 2005 11:53AM P2 APPLICATION FOR SITE EVALUATION, MMOVEMENT PERMIT & AT(: Davie County Neali i Department Enviranmenta/He:sr/!h Section 1?.O. Sox 976/210 x.>apital Street bpi ltocktovillo, NC:' 27028 (336) 751-11760 If ycs, tvltut type? c Ellitnyll/Xl 'tr l�S [{jL A K *IMPORTANT'** CLIENTS 11USTCOMPLETE REQUIRED PROPERTY INFORMATION IiLC2UL•'S rte 1 E/.O%N'_ Elther a PLAT or SIT t: 1�_L�UQM17':%3D by t1m client with Tt•I1S APPLICATION. EVlk�ttk�o... t- -'Property Dimensions: If ALrG swarf : D1RLe-r1ONS (froul Mochwille) to t•Rortarrv; —^l'.x office PUN. a�� int 25515 _V -UG ja.y� - jPl rJvt+i % - Ge+U PruperlyAddress: 1RuadN Ole ' y �,� j-,,.g1.ju!K f� ie ��. ~ �t5L4 City/zip j� Ila,ili� �Vi'_ _270,06Crii�rn �i , Lo��- a►. Sa1lrJot-� 4---n-sn a Subdivision provide inforntsltiOtl, AS follows: (2J kt OL. d, ✓ All Or. Notnc: V JG.r t3fuLd 111'S __Pry x6 X101111 42g 1'1-1(ArO.AQ L cls (As Section: Block. _ Lot: _ a__ -V -.1c honkcorattarlla4ked: Tltis is to certify that the Inibrmatlon provided Is correct to the br st of my kne,vtedgo_ I uuderstund that illy peveltlt(s) issued hereafter arc subject to suspension or revocation, if the sitz )clans or intended use change, or if the inforniatinu submitted in this application is falsified or changed, 1, also, anderrrand thar 1 ain respowtsibld for all charges bu.vnv edfirutrr rhi. oppllcallon. 1, yereby, gfve couscut co the Authorized Ttepresrntalive of the Davie Cuur.ly Fscalil> Dcparirnenl to enter upon above destribed property located in Davie County z ud o„•ncd by to conduct all t¢atinQ procedures as ucccsaary to dctcrminc the sit ) cul t►billtY_ �tlT$ Z�(,OCO,� _ �siGNATLlIiYL 1s�l� TIITS AREA MAX XI$ USRID FOR DnA"7NC YOUR SITE PL./.N (include xA or ti.c tirt)aaviag: 1`ai.[;nl; and prupu.cd property lines and dimensions, structut•!s. setbacks, and septic l,wallons). Site Revisit Cluu•>:c vatc(s): Client Notification Dnte: EtIS• SiCtt Civen, Accoutlt No. Revised DCIan (05/03 invoice No. ..*IMPORTANT*** TATs APPLICATION CANNOT BE PROCESSED UNIX911 ALT, TXZ RILQUXUCD • IS PROVIDED. Refer to the INFO_tHATION BULLETW 4or inntrucL-i.cnu. (INFORMATION �r'i". names l.> b• O.�l loa _/^�� _�� .. Cun e.cc 1�urfon _.� _... ... _.. n��� ,�1t 1I� ''ll/- r_,�ltailinq Addraee �, �1 ✓�i lr f1lt� rf �%L f_Cl ty/State/ZXp _ (�(t-6GL.G / c.606 r_ Due Lnese Choho 13te 7111 -2707 ------- t1'r. Haoe on rertnit/ATC Jr Diriorent than Above _ _,_„__„•,,... Naillt» Addroas City/vvs.t./Ziv Cis. Application Pot: l” Site Evaluation xmpravomenC Dnrmit/A.TC itLl DOtIl '7 ,.f1. syntam to earvical d itOuao 0 Mobilo 3-10me L3 Bvsinena ❑ Industry ❑ Other �S. rrp. *yat.0 roquaacaaa M CO .ntlOeil ❑ convonc:.c•nal modariea ❑ tnnevacive )� f S 'l t xf RasLaonca_ T 0 people a I:odrooJams & Hathroomta C% -..age 012pootl 6ititaohinq Nachino (Va. m6nt/Plumbing T ❑eaeement/No P1v.Mling 7. X! au.lnese/Indueery /Other: ;arlry type 0 reople a 9lnica _,_•,.•.•___ ., e cq+ de* 0 3howats a urinal. N Water coolero _ Tr rO0D5SRVXC£: 0 Scotp catitnttad Water Ueage (gallon• per day) _ L__-*, Type of water supply[ O County/City dwell ❑ CommuriiCY LSA^" Do you .ntioAp.te additio•.. er expansions of the facility -.-his system is iotetulell to scl,ve? 13 Yes 06 No If ycs, tvltut type? c Ellitnyll/Xl 'tr l�S [{jL A K *IMPORTANT'** CLIENTS 11USTCOMPLETE REQUIRED PROPERTY INFORMATION IiLC2UL•'S rte 1 E/.O%N'_ Elther a PLAT or SIT t: 1�_L�UQM17':%3D by t1m client with Tt•I1S APPLICATION. EVlk�ttk�o... t- -'Property Dimensions: If ALrG swarf : D1RLe-r1ONS (froul Mochwille) to t•Rortarrv; —^l'.x office PUN. a�� int 25515 _V -UG ja.y� - jPl rJvt+i % - Ge+U PruperlyAddress: 1RuadN Ole ' y �,� j-,,.g1.ju!K f� ie ��. ~ �t5L4 City/zip j� Ila,ili� �Vi'_ _270,06Crii�rn �i , Lo��- a►. Sa1lrJot-� 4---n-sn a Subdivision provide inforntsltiOtl, AS follows: (2J kt OL. d, ✓ All Or. Notnc: V JG.r t3fuLd 111'S __Pry x6 X101111 42g 1'1-1(ArO.AQ L cls (As Section: Block. _ Lot: _ a__ -V -.1c honkcorattarlla4ked: Tltis is to certify that the Inibrmatlon provided Is correct to the br st of my kne,vtedgo_ I uuderstund that illy peveltlt(s) issued hereafter arc subject to suspension or revocation, if the sitz )clans or intended use change, or if the inforniatinu submitted in this application is falsified or changed, 1, also, anderrrand thar 1 ain respowtsibld for all charges bu.vnv edfirutrr rhi. oppllcallon. 1, yereby, gfve couscut co the Authorized Ttepresrntalive of the Davie Cuur.ly Fscalil> Dcparirnenl to enter upon above destribed property located in Davie County z ud o„•ncd by to conduct all t¢atinQ procedures as ucccsaary to dctcrminc the sit ) cul t►billtY_ �tlT$ Z�(,OCO,� _ �siGNATLlIiYL 1s�l� TIITS AREA MAX XI$ USRID FOR DnA"7NC YOUR SITE PL./.N (include xA or ti.c tirt)aaviag: 1`ai.[;nl; and prupu.cd property lines and dimensions, structut•!s. setbacks, and septic l,wallons). Site Revisit Cluu•>:c vatc(s): Client Notification Dnte: EtIS• SiCtt Civen, Accoutlt No. Revised DCIan (05/03 invoice No. FROM FAX NO. Jan. 27 20005 11:54AM P3 r -f )f4-E;ja () F l QLD 7RaG. �•p ads ' , p •t�nee3g0f�7�M1. 7 FROM . QLD ACT LINE— Lo -r Lor FAX NO. : oll Jan. 27 2005 oz AV rR •. `► S A4 ►► N � � rte• \ \�4.4~ \ . e 1 \ \ 10 sr 11:54AM P4