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130 White Dove Way Lot 6DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001881 Tax PIN/EH #: 5820-54-9074 Billed To: America's Homeplace Reference Name: Robert & Judy Cobb Proposed Facility Residence ATC Number: 3803 Subdivision Info: White Dove Acres Lot # 6 Location/Address: White Dove Lane -27028 Property Size: 4.68 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 WASTEWATER CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 1` �%(/1 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 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) edl ),o n J, & Date: J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section F"i 7- P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 0 3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001881 Tax PIN/EH #: 5820-54-9074 Billed To: America's Homeplace Subdivision Info: White Dove Acres Lot # 6 Reference Name:?o b,,r +Shy C d Et B Location/Address: White Dove Lane -27028 Proposed Facility Residence Property Size: 4.68 acres ATC Nrpber: 3803 **NOTE** Tis 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 16we #People � #Bedrooms — S-?--- #Baths f' Dishwasher Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ L Lot Size �� Type Water Supply ( O Design Wastewater Flow (GPD) —,-?6 Site: New Repair ❑ System Specifications: Tank Size/ 100 V GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width�� Rock Depth ,42' "Linear Ftsl;� IMPROVEMENT/OPERATION PERM A OUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Co to a epresentative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1: 0 .m to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature:/..If// Date: 6&zo�?( DCHD 05/99 (Revised) Dec 03 02 09:25a davie county envhealth 336 751 8786 P•2 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Envir vnmenW Health Section P.O. Box 848/210 Hospital Street Mocksville, HC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �� Name to be Billed /fi t% S !JU!//�E P�S�-��/��G Contact Person Vl�f�>/r1'e's ty vMailing Address ,• i7S riG(tI� aL e��L11y Home Phone 47�y 7d/�(��7/ /•-City/State/ZIP W[A671-4- 941-44M; 1V C g2 ZM3 Business Phone [/2. Name on Permit/ATC if Different than Above tCoa� 7 C� J U e( l: ('Qt Mailing Address City/State/Zip f� Application For: 'Site Evaluation rovement Permit/ATC er Both ,,A-,--SystemS System to Service: "Ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other If Residence: # People # Bedrooms_ Bathrooms_ ,_,,Ft Dishwasher II Carbago Disposal twr Washing Machine Il Basement/Plumbing 11 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) Type of water supply: VCounty/City ❑ Well ❑ Community `�. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes P-90 If yes, what type? *'**IMPORTANT*** BELOW. Eith a PLEith a P� ETETHE REQUIRED PROPERTY INFORMATION REQUESTED BESUBM17TED by the client with THIS APPLICATION. l/ Property Dimensions: 441 (09A (key TDIRECTIONS (from Modwillc) to PROPERTY: Tax OtTce PIN_,��n�(P.�J' 7 9G!7� Property Address: Road Name W,1;nr 06 mr I.tjl City/Zip%i j�''f i�, LL ' A/C If in a Subdivision provide information, as follows: Name:DD\.)LS�� Section: Block: Lot: , tc Property Flagged: 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 front this application. I, hereby, give consent to the Authorized Representative of the Davie Count Health Department to enter upon above described property located in Davie County and owned,by, R d t� to conduct all testing procedures as necessary to determine the site suitability. /DATE�(�u7 SIGNATURE�Ie -- - i- J"/- —X�4 ✓. THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAf the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) 7� Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. 1 J"f Invoice No. Y2 474 7 v • �PONDpI' \ UNE BEARING DISTANCE WHITE DOVE ACRES L1 N 60.19'31" E 75.28 � L2 N 6d•16'4S" E 77.27 SAMUEL P. HALL PLAT BK: 6 Pg. 193 L3 N 72'29'35- E 94.19 D.B.. 191 Pg. 85 / L4 N- 79'39'00" E 82.40 L5 S 87.29'02' E 71.72 L5. j L4 S 35' 27' 32'. W ' 13 CESS EASEMENT ,79 59.S�TAL pqt,4 POSE OF 29.79 0o i �� OR QE55 6L �S 52' 21'58' E — — — v F 69.26 It Ile Cl z 00 1 i � \ s .fl o O(G x.09°\\. `• _ ., - . O SEE PLAT RECORDED IN �r PLAT BOOK 7 Pg. 8 FOR F LOTS. 2 & 3 REVISION 0 0 .. ra \ A� g% DO _ 2 i r WHITE. DOVE ACRES i F . �- _ 5$•,5,17; 'd �VNE g Pg� 664 B . 5 24 \- — � D•B. 72 P9 .s aftL _ qty tie � rl cfr< Erz �S� F5 C G A✓k. �D IRON STAKES MARK CORNERS ROBERT TV. COBB CAf; �` ".•''•'••''•./rj i �\sTEgr�...� I, SAM P. HALL, CERTIFY THAT UNDER MY DIRECTION AND SUP£RVISIIAI, THIS MAP' % Q` WAS DRAWN FROM AN ACTUAL FIELD.SURVEY SURVEYING - SEAL . r MADE BY TUTTEROW .COMPANY. L-2930 a: = ,,�''S��V1•P• `'`,�` REGISTERED LAND SURVEYOR L 2930 �rttittltlwo TUTTEROW SURVEYING. COMPANY - 127 LIBERTY CHURCH ROAD H❑CKSVILLE; , N, C. 27028 (704) 492-5616 _. IRON STAKES MARK CORNERS ROBERT TV. COBB DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME Z �, ADDRESS PROPOSED FACIILTY M DATE EVALUATED 7�2Z1441 PROPERTY SIZE ��AC LOCATION OF SITE &/A/1 Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut Texture group Consistence FACTORS 1 2 3 4 Landscape position L Sloe R _11— HORIZON I DEPTH -• �` Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i 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 1-r t SITE CLASSIFICATION: EVALUATED BY: 1AK l/ LONG-TERM ACCEPTANCE RATE: r OTHER(S) PRESENT: REMARKS: 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 :lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V+. -y 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 3C -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(01-901