110 Welcome Springs Way Lot 4DAVIE COUNTY ENVIRONMENTAL. HEALTH
P.O. Box 848/210 Hospital Street
+ Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT
Account M 990004245 Tax PIN/EH M 5813-99-4502.04
Billed To: Juan Bartolo Subdivision Info: Waters Edge Lot # 4
Reference Name: Location/Address: Bowman Road -27028
Proposed Facility: Residence Property Size: 1.838
ATC Number: 4596
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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 be taken as a guarantee that the system will function satisfactorily for any given period of
time. (/� i
System Type:..11lI S.T. Manufacturer a V/, Tank Date 10 [6 rank Size I�
Pump Tank Size
System Installed By: SAM— E.H. Speci
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DCHD 11/06 (Revised)
WZL11
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC. 27028
(336)751-8760 Fax #(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004245
Billed To: Juan Bartolo
Reference Name:
Proposed Facility: Residence
ATC Number: 4596
Tax PIN/EH #: 5813-99-4502.04
Subdivision Info: Waters Edge Lot # 4
Location/Address: Bowman Road -27028
Property Size: 1.838
/1: 30
Site Type:.,?<ew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # Bathrooms 3 # People3 Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply:. ❑County/City Z<e11 ❑CommunityWell
System Specifications: Design Wastewater Flow (GPD);Xld ank Size I COOGAL. Pump Tank GAL.
Trench Width �� Max. Trench Depth Rock Depth14 & Linear Ft.�
Site Modifications/Condition,A/Other: �1�1 El �>o ��dC•�% ��- % [, — , —
Jr- ` rill /? y
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on!the day of installation. Telephone # (336)751-8760.
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Environmen al Health Spec' ist
DCHD 11/0 (�
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davie county envhealth 336 751 8786
FOR SITE EVALUATION/IMRIOVEMENT PERMIT & ATC
,ANew System
Davie County Environmentar. Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
provement Permit . lAuthorizaticn To Construct(ATC) ❑ Both
:11t.epair to Existing System ❑Expansion/Modification of Existing System or Facility
"� **IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE .REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed d, Conta,-t Person
Billing Address _�n3 L 1,� Horne Phone
City/State/ZIP _N%ei�s v: I •. �1, L 0.2 Y Business Phone i �� -i(0 4'1
Name on Permit/ATC if Different than Above `Ti..A,it 1�c4tJe
Mailing Address City'State/Zip
rKUrr1K1 Y lBrUFUMAHUN *Date House/Frlcility Corners Flagged ) O 01
NOTE: A survey plat or site plan must accompany this application. Included: Iii' Site Plan ❑Plat(io scale)
(Permit is vali for G0 months witli site plan, no expiration with complete pat.)
Owner's Name N Phone Number
Owner's Address �ln'�� ..,� ,Som, C-}- t.", —SJ -1 City;State/Zig, So,�,...,. X'1(2.1
Property Address
Lot Size_ I '6 �tXcr Tax PIN#
Subdivision Name(if applieable)�,DMNI. =s T.1. Scctior./Lot# .`'r _
Directions To Site: k.,C)l tv fl�a,.2( � '?qhl Q A >h0- At o o 0
If the answer to any of the following questions is "yes", supporting documentation. must be attached.
Are there any existing wastewater Eystems on the site? ❑Yes 1'J' O
Does the site contain jurisdictional wetlands? 0Yes 17 0
Are there any easements or right-oi-ways on the site? Ryes 01\b
Is the site subject to approval by another public agency? Dyes ONO
Will wastewater other than dornesti:: sewage be generated? ❑YesAIN,o
IF RESIDENCE FILL OUT THE BOX BELOW
# People _ 3 # Bedrooms _ _ # Bathrooms Garden Tub/Whirlpool-0,Yes CNo
Basement: ❑Yes., -No Basement Plumbing: ❑Yes tNo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage o:'Building #f People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per days (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: &onventional V.ccepted ❑Innovative ❑Alternative ❑Other.
Water Supply Type: ❑ County/City Water XNew Well DExisting Well 0 Commtmity Well
Do you anticipate additions or expansions of the facility this system is intended to , erve? ❑ Yes KNo
If yes, what type?
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 ;-abject to suspension or revocation if the site is altered, the intended use changes, or if
the information subnritted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to co: educt necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the prober identification and labeling of prop.:rty Iines and corners and locating and flagging
or staking the house/facility location, propose.I well location and the location of an)- other amenities.
s /(I�t1 -) tS
Property owner's or owner's legal represcntat ve srgnaturk"z", :5>q` -"�
a l3-0 `%I
Date
Sign given Dyes ONo
Revised 11/06
Received Time Dec -29.
3:26PM
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
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Invoice it
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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 #: 990001512
Billed To: Special K Builders
Reference Name: Bill Kageorge
Proposed Facility: Residence
pd. 1. 2 °I- of
Tax PIN/EH #:
5813-99-4502.04
Subdivision Info:
Waters' Edge Lot#4
Location/Address:
Bowman Road -
Property Size:
see map
**NOTL�* its gmproveei ent/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 J(� �BM #People I #Bedrooms a_ #Baths 2 -
Dishwasher: Wr" Garbage Disposal: ❑ Washing Machine: Ef'— Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industria13�l Waste:
Lot Size A C � Type Water Supply OZ"� Design Wastewater Flow (GPD) V Site: New'_Repair ❑
System Specifications: Tank Size E+OGAL.
Pump Tank
�1 • f
GAL. Trench Width Depth ) Z Linear Ft.�
Other: 3 DaL
�
r { ��AL.I. � c1 cam$
/Rock
"1 tU, C, r►'l.�.l.
Required Site Modifications/Conditions: �►�Tgll.,
(��Ol�
n
�C�' 5
(d1i�jC 1t1'�.�f41
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.****
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EnvironmpptaIA4ealth Specialist's Signa(u
05/99 (Revised)
�14P.C.
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Date:1 00
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990001512
Billed To: Special K Builders
Reference Name: Bill Kageorge
Proposed Facility: Residence
ATC Number: 2662
5813-99-4502.04
Subdivision Info: Waters' Edge Lot # 4
Location/Address: Bowman Road -
Property Size: see map
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 buildi permits) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .19 0 Trea ent and Disposal Systems). THIS
AUTHORIZATION FOR WAST ATER C ATS TIO S VALID RIOD OF FJVE YEARS.
Environmental Health Specialist's
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 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:
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
S - Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
DEC
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed -X'- eCIZI K '/��- -r Contact Person 73,ot �/1) ealrPc
Mailing Address 14 0, Uoy loll G Home Phone /� / y-29 y/ /r33
City/State/ZIP `��►^�IT�`� NC Z728;�' Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address f
3. Application For: Site Evaluation
4. system to Service: ❑ House Mobile Home
5. If Residence:
City/State/Zip
Improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
# People / # Bedrooms
l� # Bathrooms 2
LY/Dishwasher ❑ Garbage Disposal O washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Buainess/Industry/Other: Specify type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes iQ i o
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: oZ0 G X 3 0 6 Q 9 d X 3 o v
Tax Ofrice PIN: # S&1: 9 9 yS—gL ,� J
Property Address: Road Name 13 arm a, GU%
City/Zip
If in a Subdivision provide information, as follows:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
�Q()� Nai;r to 1 JJOuJw-2n R - a
4 -
Name:
Name: ,Wafers EdF4
Section: Block: Lot: Date Property Flagged:
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 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 suitability.
DATE ( SIGNATURE t�lhwa-o✓ K_ 1 K4 RD-'
THIS 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
Date(s):
Client Notification Date:
EHS:
Account No. ' I
Revised DCHD (07/99) Invoice No.
W
-OA- -7 -/X o
ee'- `r APPLICATION FOR SIIE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
Environmenb/Hea/tfiSeWon
P.O. Bos 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
MAY 23�- D
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to bs Gilled_ /'C�'� ^ Contact Person
Nailing Address :r 47 �� 4A1,e Agza /y 0� f Home Phon �Z A/
City/State/ZIP L''l �A- r?W' ;Ve' / 41-Z 07c usiness Phone
2. Name on Permit/ATC it Different than
Nailing Address City/State/Zip
3. Application For: Site Evaluation 0 Improvement Permit/ATC
O�7
❑ Both
4. system to service: ❑ House 0' mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People y # Bedrooms # Bathrooms
e'-5`i.W6//.ge Disposal all -aching Machine 0 Basement/Plumbing f_1 Basement/No Plumbing
S. If Business/Industry/Other: Specify type # People # Sinks
# Commodes
# Showers
# Urinals
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of Water supply: ❑ County/City 'Well 0 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: o. /r2 //-/s �
Tax Office PIN: #
Property Address: Road Name &w -W&17 �e
City/Zip 11&&11;MC ,2%02 �
If in a Subdivision provide information, as follows:
Name: [..t/ /4- 7�S E/,
Section: Block: Lot:
WRITE DIRECTIONS (from Moksville) to PROPERTY:
Al
Zez/
Z-.u� YL'
Date Property Flagged:
L/ -cmc
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 aft 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 determine the site suitability.
DATE 2 /_/ v? aZ G �� SIGNATURE �/
THIS 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 location .
0
Revised DCHD (07/99)
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No. -16&
I
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001199 Tax PIN/EH #: 5813-99-4502.04
Billed To: Ruth Spillman Subdivision Info: Waters' Edge Lot # 4
Reference Name: Ruth Spillman Location/Address: Bowman Road -27028
Proposed Facility: Residence Property Size: 0.92 Acre Date Evaluated:
Water Supply: On -Site Well Community Public Public
Evaluation By: Auger Boring ` Pit !/ Cut
FACTORS
1 2
3� 4 5 6 7
Landscape position
L L.
Sloe %
HORIZON I DEPTH
Texture group
Scu
Consistence
(nr SS
Structure
Mineralogy
HORIZON II DEPTH
Tie, " d
Texture group
Consistence
Structure
S'
Mineralogy
HORIZON III DEPTH
Texture groupt
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Y
Mineralogy�a
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION:
'As
LONG-TERM ACCEPTANCE RATE: r S
REMARKS:
EVALUATION BY: AV/
STT
OTHER(S) PRESENT:
d" - / 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)
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• DAVIE COUNTY HEALTH DEPAR'T'MENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990001199
Billed To: Ruth Spillman
Reference Name: Ruth Spillman
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5813-99-4502.05
Subdivision Info: Waters' Edge Lot #/
Location/Address: Bowman Road -27028
Property Size: 0.92 Acre Date Evaluated:
Water Supply:
On -Site Well
Community
Public
Evaluation By:
Auger Boring
Pit 1
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
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:
kT
LONG-TERM ACCEPTANCE RATE: 112
REMARKS: 6/% .9
EVALUATION BY:
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
DCHD 05/99 (Revised)