268 Timber Trails Lane Lot 9BDAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990004162
Billed To: Sam Montebello
Reference Name:
Proposed Facility: Residence
ATC Number: 4545
Tax PIN/EH #: 5812-01-9445.913
Subdivision Info: Timber Trails Lot # 9B
Location/Address: Timber Lane -27028
Property Size: see plat
As stated in 1.5A NCAC 18AA969(5)
accepted SYstf:ms may also be use
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 eatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT CO N S R A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur - . Date: )7,11,ln(,
JI
31
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on I
has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .190p
---disposal stems," but shall in NO WAY betaken as a guarantee that the system
given peri of time. �i
7a' jA'2 Com` c
1 to fI
5 A0jN(--_ t oCae,1
C(c Y2- L-) Septic System Installed By:
Environmental Health Specialist's Signature: C)4 A& 7�1 L
DCHD 05/99 (Revised)
li
any
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DAVIE COUNTY HEALTH DEPARTMENT
? Environmental Health Section
1' P. O. Boz 848/210 Hospital Street f�h�
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990004162 Tax PIN/EH #: 5812-01-9445.913
Billed To: Sam Montebello Subdivision Info: Timber Trails Lot # 9B
Reference Name: Location/Address: Timber Lane -27028
Proposed Facility: Residence Property Size: see plat
ATC Number: 4545
**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 �o�- #People #Bedrooms #Baths•)
Dishwasher: 21'�' Garbage Disposal:. Washing Machine: ET'- Basement w/Plumbing: ❑ Basement/No Plumbing: Ja
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ,5-A6;&S Type Water Supply 6—w Design Wastewater Flow (GPD) Site: New Zr- Repair ❑
System Specifications: Tank Size 0000AL. Pump Tank GAL. Trench Width �� � Rock Depth I'L Linear Ft. SCO
As stated in 15A hCAC 18A.1969(5)
Other: -3 015re-lewl-loo 2 x0 5 accepted Systems may also be used
Site Modifications/Conditions:
M
g Z-� � fr"a+—
VEMENT/OPERATION PERMIT LAYOUT - APPROVE D' EFFLUENT FILTE RISER(S) IF 6 " BELOW
ED GRADE. ****NOTICE: Contact a representative of the Davie County Health Dejartment for nspection oftt
,etween 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Tele36 751-8760.**
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Environmental Health Specialist's Signature::::�� Date: )Z (o
DCHD 05/99 (Revised)
Nov 13 06 12.34p Nadine Montebello
PAL
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336-201-3257 p.2
FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC + / 01,
Davie County Health Department N It j •�`C 1j'
Environmental Health Section
.0. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***I THIS APPLICATION CANNOT BE FROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORb-%TION BULLETIN for instructions.
11'n,op
2. Name to be Billed S�t ir� &(I ft 114 Contact Person �1'✓I �O , �� 1/:� Mani »g Address 4- �a�i i:) l i Z/K� :`J �t ✓� Noma Phane 2J �`' ' �Q - a�Jr ,00'd�City/State/ZIP f�<(�Ji0s7• .�%�rte,-)IU/ Business Phone-7'SL_IGP_ /q.5 V3Q/�
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/zip
3.
Application For: KSite Evaluation
❑ Improvcment Permit/ATC ❑ Both
4.
System to Service: Am Sousse ❑ Manufactured aome ❑ Business ❑ Industry ❑ other
5.
Type system requested: JR Conventional ❑ Accepted
❑ Innovative ❑ Experimental
6.
if Residence: T People :_ #
Bedrooms S_ # Bathrooms Z., A'
.'CiDishwasher Garbage Disposal Washing Machine
Aasement/Plumbing ❑Basement/No Plumbing
7.
If Business/Industry /other: verify type
# People # sinks
# Commodes # showers
# Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
9.
Type of water supply: S+e County/City
❑ Well ❑ Conmunity
9. Do you anticipate additions or expansions of the facility this system is intended to sere? ❑ Yes W 0
If yes, what type?
***IMPORTAN7" CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 35r;Z JC Crii 3 X I S& W t{ LAI
Tax Office PIN: # _4,
Property Address: Road Name 1 tfrl�� viii f
Cityaip.NkKX>1"11
If in a Subdivision provide information, as follows:
Name:
Section: Block: lot: "t
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
"40 to ic-) eq' + i•'U
riA.hf or !tet- 1an�
Date home corners flagged: 11 1 '
This is to certify that the information provided is correct to the best of my knowledge. 1 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 thatI am responsible for all charges incurred from
this application 1, 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 suitabi
DATE 11-13-06 SIGNATURE jr/
Nov 13 06 12:34p Nadine Montebello
11/U0/GUUO 13:1L PAA 430 f14 4401
336-201-3257 p.3
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003679
Billed To: Michael& Rebecca Holt
Reference Name:
Proposed Facility Residence
R01,5 s-- d
Tax PIN/EH #: 5812-01-5250
ok 1, 40 oV,s
Subdivision Info: Timber Trails Lot # 91,6
Location/Address: Timber Trails Drive -27028
Property Size: 5 acres
ATC Number: 4150
**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 qo5q:7 #People 2- #Bedrooms 3 #Baths 2'
Dishwasher: 2" Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply ar. wDesign Wastewater Flow (GPD) Site: New GalRepair ❑
System Specifications: Tank Size /1MAL. Pump Tank GAL. Trench Width �I Rock Depth 'i Linear Ft.r
Other: �� TIOr� � As stated in 15A NCA( 18A.1969(5)sed
�"'� accel2tP�d�Syct��mc may also hp visP�
R6qu�red Si�eodifications/Conditions: �/J �%9LL f,Y4 Gil /�'t�
, dS
MPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 « BELOW
INISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
Mem 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.****
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Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
,c�c Y-
an-
1�
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Date:
Account #:
Billed To:
Reference Name:
Proposed Facility
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990003679 Tax PIN/EH #: 5812-01-5250
Michael& Rebecca Holt Subdivision Info: Timber Trails Lot # 90 $
Location/Address: Timber Trails Drive -27028
Residence Property Size: 5 acres
ATC Number: 4150
As stated in 15A NCAC IGA.1 C15)
accepted Systems may also bo =
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 . a e Trea ent and Disposal Systems). THIS
AUTHORIZATION FOR WASTE W S CTIO IS V A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatu e: Date: Lk
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 I 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
Jul 18 2005 2:58PM CARDIAC CATH LRD
Jul 11 05 09:13a davis county envhoalth
a �
703-558-3259
336 7511:6786
APPL1C4110N TOR SM 1YALVAT1OWMPMEM(M• P MUT &A
Davit County Health Depac melte
EhvownNUAW Naall/t SACOOM
P.C. Box e48/210 Heopital street
MockimMe, NC 2702e
(336)7S1-9760
e.eyxpORrjNr►oa MU EPPLICATZMF C MOr D3 P20CE352W MASS ALL I
rwrojotaTloM is pAtYmico. aaEnr to the nwos]tmow atJL X1,111 for i
Q.i ear to be aill.d M,LC.FL/its/1�w. JW069Gl4 �YL�14-/� 4Cbat.et -•recd j
selling Aadsss. ,+1�� 1 S. IgarjTVIP4 `'r APV s-,09 a -u . ytww.
v Clty/that./Zir AIL I1 S T�1u1 Y fi swiMao rAeae
blow, as reemtt/ATC it alltaeeat Wa Above
eallloat address Ci h'/-Lata/Lily
tea. application rort *cite :valuatjA= O Ivproveorat peratit/
'f. system to t.rrioat �(Hou•a V Mobile Homo D Business O Indust
S rypo drat.. r.queat dt ff canwatloaal D canvoncloaas si*wled 0 is
—,e- ZeeidenCot a people �' t l DedrIo{msss.,. _
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yp
7. It a.aiaesalladostsy /othorL verity te ! a •aepl•
a t:aaaaa.s a rko..ry a vrinala
It PODDSZRVIC6t / Seats i■timatad Nater Usage tltallao
Type at water sepplrt fCeeutty/City D Mall ❑
` s. m yes smttsip.t. addtciasa er ezpamiaasofflset:a'tityNt(ssyctomtslattudedt•iort.
I r yet, what lyre?
MUSMOAiIIBTT TUs RMUIRED PROPERTY
p.2
V
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D other
.ati— paccepted
8athroov Y-•5"
lassm"at/tto slMolaa
a Sinks
Mater Choler.
per QaYT
Cmxtnity
! Q Yes r—
REQUMED
t.,41'r-oputy Dimat(ons: 5,4g& c�Y g& L 0iT D1REE710MNS (!roan Iktvpfe) to PROPGt M
--ftaxori tc PIN.- s r LC VA>
L.
'i�12►7t j
L,Prspert7Addrtss: headNarruN2' Tirnhtr2Ta-471L
If in aSubdiThlonprovide inrorntatioa.asfollows. I IwLbraL Iff
Nacre: EjM 11r;4- -rEA=LS
Section: — DledL r Loft bmw cdsaersifatted:
This as to eerAly that the Information provided Is correct to the but oftey haetvledte. I undo"
lssvcd hereafter are sob ject to stspendao er revotallon, If the We plans or intended urA eltanta
submitted to GIB application Is raisin d or changed. 1, &Am xadertIm4thatlaa mpomil6for
Mr dppitcMi s. 1. hereby.'gNa cement to The Authorized Itepsetestaths of the Davie Gusty r
to eaherupon above described property located in Davie Couallaad owned by
to conduct all testing procedures as accessary to deicmiac the site snits ty.
VDATL �a�af" SICXATUAE Q �
THIS AREA MAY DE USED FOR DRAWING YOUR SECS PLAN (Include a0 of We Tailor hn
property dace aid ditatas:ons, stmdrra, setbacks, dad septfe leeafiotss).
t
Revised DOM (OSM
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7 zr ,Pr
ad that any renait(s)
rif the inkrM11011
7 disrltr laarrred f vew
tlth Departeteal
5a
Existtac pad proposed
a lleviril Char&
tion Date:
Aster No. 6 %
1- I
p.2
Jul 18 2005 2:58PM CRRDIRC CRTH LRB 703-558-3259
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! - PRE hIfINARY SITE )PLAN
unxr a. Bous
TOTAL ' AREA; . 9f:865AC. '
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Account #: 990003679
Billed To: Michael& Rebecca Holt
Reference Name:
Proposed Facility: Residence Property Size:
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
PROPERTY INFORMATION
Tax PIN/EH #: 5812-01-5250
Subdivision Info: Timber Trails Lot # 9 A
Location/Address: Timber Trails Drive 02
5 acres Date Evaluated: 214
Community
Pit
Public
Curt
FACTORS
1
2'
3
4:
6 7
Landscape position
LL
L-
L
Slope %
5 '
S
3 -v
HORIZON I DEPTH
p .
r7 - 1
Texture group
$ GL,
S LL_
L,
GL.
Consistence
j
Structure
LP,
Ca
AF-k—
Mineralo
N
6
HORIZON H DEPTH
i
Y-7-0
Texture group
L_
'S C_
S c
S C_
' a_
Ci
Consistence
l
Structure
Mineralogy
Av ,.a�>
I Y.+ -
HORIZON III DEPTH
Tq -
- Lt_
3
Z6 -
c 3
Texture group
C -*
C- 1'
5Z L,
' 4 ct
Consistence
Structure
ASIC
Mineralogy
1
M I XV
AAj
HORIZON IV DEPTH
Texture group
Sf
-r
Consistence
5
Structure
Mineralogy
SOIL WETNESS
(�
RESTRICTIVE HORIZON
t
SAPROLITE
r
CLASSIFICATION
6
U
LONG-TERM ACCEPTANCE RATE
O •
S
0 - -
U.'L�
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
EVALUATION BY: 4Jo"�"
OTHER(S) PRESENT:
;REMARKS: 4 1 7 -LY ' 3(;,
LEGEND
Lans pe 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
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Ka
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
1:1, 2:1, Mixed
1Y0
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)
a
11 LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ,
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