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121 Welcome Springs Way Lot 2a - DAME COUNTY HEALTH DEPARTMENT Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002703 Tax PIN/EH #: 5813-99-4502.02BS Billed To: Brian & Regina Sheppard Subdivision Info: Waters Edge Lot # 2 Reference Name: Location/Address: Bowman Road -27028 Proposed Facility: Residence Property Size: 2.11 acres ATC Number: 3441 **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 "U0 KIA #People S #Bedrooms L1 #Baths �2- Dishwasher: e Garbage Disposal: ❑ Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type 11 #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 2.1 nG�Cs Type Water Supply W ELL_- Design Wastewater Flow (GPD) Site: New 13�' Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width -13V Rock Depth Linear Ft. S� Other: -5 11) STe16JTiOt�) BoAen- U Oys l,C).0 . �••� •J . Required Site Modifications/Conditions: l4 -14L- C>A C-�V.J 7��c=� �� �Lm'o IMPROVEM NT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED G ADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system betwe 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� 1 � � a `Z T 1J` JA ARDN to;� 01 . G��Health Specialis s Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002703 Billed To: Brian & Regina Sheppard Reference Name: Proposed Facility: Residence ATC Number: 3441 Tax PIN/EH #: 5813-99-4502.02BS Subdivision Info: Waters Edge Lot # 2 Location/Address: Bowman Road -27028 Property Size: 2.11 acres 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 WASTEW TR ALID FOR A PERIOD O,F'IFIVE wYEARS. Environmental Health Specialist's Signa �Da)t 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' le 11 X G.S. ap r 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be en a gu ant that the system will function satisfactorily for any given period of time. "atit Ct r C6LL- aa::o 'Tali V-- --341 -0s Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) TSP &)Xz's Date:ZZi D-3 - - -- - -P CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC I i Davie County Health Department EnvironmentalHealth Section P.O. Box 848/210 Hospital Street L Mocksville, NC 27028 ENVIROMTNTAL HEALTH (336) 751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the IIN�NFORMATION BULLETIN for instructions. 1. Name to be Billed Erc G^ " `t' RQGG f 11-' 4 12Cc(A Contact Person scx-ry`P Mailing Address ' o� A c� s ^1��7 rr __ Home Phone 3 q �� ¢ p 7 City/State/ZIPyQ LQ /�/ `�! I��D Business Phone .�J(., A�� J --7q L' 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 11 Site Evaluation @'Improvement Permit/ATC ❑ Both 4. system to service: ❑ House L9/Mobile Home ❑ Business ❑ Industry ❑ Other 5. _Iff Residence: # People _ # Bedrooms _ # Bathrooms _ N7 Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing fl Basement/No Plumbing 6. 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 wWell ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes IV o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. el Property Dimensions: • lr����'� 1.1 he WRITE DIRECTIONS (from Mocksville) to PROPERTY: 1(3 d I 'J -'oTax Office PIN: # •OC Property Address: Road Name 8 t.J /*/ a .�► n�^. S City/Zip 0— If in a Subdivision provide information, as follows: ��`�-- vaa1e• (-- Name: Name: i % o �� ��' �--[ •"� L Section: Block: Lot: Date Property Flagged: �Z13 �0 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._ n (� THIS AREA MAY BE USED FORD PLAN (Include all of the following: Existing and proposed property lines and d777= ptic locations). Site Revisit Charge Date(s): A Client Notification Date: Z� EHS• Account No. Revised'DCHD (07l99)_ _ � _ 1 Invoice No. rL ' 'it APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A v Davie County Health Department Environmental Health SgWon MAY 2 3 l P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***ZltPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed k -"P ^� f1� /gs�% /� Contact Persony Mailing Address ( /'+/✓!�'� he'ea q / It �(iJf, Boas Phon -/ 9 c2 City/State/ZIP iYy!'10/✓J ll�try/ �f / Cr%�a Rv/Business Phone .J 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: - Site Evaluation City/State/Zip ❑ Improvement Permit/ATC ❑ Both 4. system to service: ❑ House Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: �t People # Bedrooms t Bathrooms WReDish.asher Disposal e-w..hing Machine CJ Basement/Plumbing U Baaement/No Plumbing 6. If Business/Industry/Other: Specify type #i Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City ell ❑ Community a. 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: A-1. -1. �5 Tax Office PIN: # Property Address: Road Name &L -U'--72 GSI /P-cf City/Zipacye /lam ��u2S' If in a Subdivision provide information, as follows: Name: C,t� ��S E/, G&— Section: Block: Lot:! WRITE DIRECTIONS (from Mocksville) to PROPERTY: 6l)'/ Al -,6 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. 1, also, understand that 1 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. �f DATE _t22kwy?.:I , SIGNATURE v 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): I Client Notification Date: I EHS• Revised DCHD (07/99) Account No. Invoice No. �_ .•S Y � ( �ii`�� 1>E*L �� ��'' a 1�•1 'N�tiF.q .ter i or k; ? � � t . �)"�. � � %3°'� f � i 11`. .1 �"_ y •� r l �. fir a tl � ' k.. L '1,�y, Xi` '+¢ d" � e;Y t , .. �^�y+,a c 'S, �•� .'J+`'b i+_,. ?.`y3ry`,1. k1 �S a,4�:-. A� i Y�. j.�I Rpt 1k �j�l ,a a' _r! :.� ; ...'a f"° r r;• '• �'Ir t, b}yt S�4"r�.•°6J,..'{.$,�,rJ<"��S'�'•a.°.'J ,''+1 :%1 A.;r'S'.�+^ t. t • 308 / 47- '� r%/ / / 413• l f 1 i i It I I� r I I1t3 r I 1� o. 25. l�I I l rl l 0.22 ►r.RlscoU{i � 1 1,� r I_ I '12' 3.28 AGRm"co AMs(ow) 22a T\EIVPORARY ',1 FUTURE ,SECT/ON --- — -�--- -- 2927-7 t / / R 289.9' � � ^ � \ , tl � 477• T .57.08• L 112.71' 50' Pit -Oka Access k PutAk VtAty Eoe.~t c R 300.00' T43.83' APPLICANT INFORMATION Account #: 990001199 Billed To: Ruth Spillman Reference Name: Ruth Spillman Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5813-99-4502.02 Subdivision Info: Waters' Edge Lot # 2 Location/Address: Bowman Road-2Maa" Property Size: 2.11 Acres Date Evaluated: On -Site Well Ll Community Auger Boring 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 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: (✓� / LONG-TERM ACCEPTANCE RATE: REMARKS: 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) ■ i ■■■■■■■■■■■■■■■■■■■■■ ■■■■■..ease■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ..................... ..................... ..................... ....■................ moon MENNENiiMOMMENZ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ MEMO ■■■■ NONE ■ ■■ ■■■■■■■■ ■M■■MMM■ ■■■■■■■■ ■■■■NEEM ■NEM■■■■ ■■■■■MOM ■MMM■■■■ ■■■■■■■■ ■■■■■■■■ ■N■■■■■■ ■NNN■N■■ NOMMEN■■ ■MMM■■■■ ■■■■NEN■ ■M■■M■■■ ■■MNEME■ ■■MNEME■ ■■■■■O■■ ■■■■■M■■ ■N■■■M■■ ■■■■MMM■ ■■■■OO■■ ■■■■MM■■ ■■■O■■■■ ■■M■MMM■ ■■■■■■o■ ■■E■■■■■ ■■E■■EM■ ■M■N■EM■ ■MMMMEN■ ■O■■MEN■ ■■M■O■.M ■■■■■■■■ ■■■■o■■■ ■■M■■■■■ ■MMM■O■■ ■■■■O■■■ ■■omm"M ■MEMS■E■■■ ■EM■MNEME■ ■E■M■■■ME■ ■E■■■■■■■■ ■■■■■■ ■■■S■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■■■■■ ■■o■■■ MONS■■ ■■■■■■ ■■■■M■ ■O■O■■ ■■■■■■ MONS■■ ■■■■■■ ■OMNI. ■O■■ ■ O■■■■■ NOMMEN OM■■■■ ■■NOON M■■M■■ ■NONE■ ■■■N■■ ■■N■■■ ■MM■■■ ■■■■■■ ■■N■■■ ■■■mu ■■N■ ■■NEN■ ■■NN■■ ■■N■■N ■■■N■■ ■■■■■■ ■■■■N■ ■■■■■■ ■■MM■■ ■■M■■■ ■■■■M■ ■■N■■■ ■■NN■■ ■■■■M■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002703 Billed To: Brian & Regina Sheppard Reference Name: Proposed Facility: Residence Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5813-99-4502.02BS Subdivision Info: Waters Edge Lot # 2 Location/Address: Bowman Road -27028 2.11 acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit 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: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscaae Position EVALUATION BY: OTHER(S) PRESENT: 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)