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290 White Dove Way Lot 10DAVIE COUNTY HEALTH DEPARTMENT 6 �� Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900130 Tax PIN/EH #: 5820-64-9480.010EP Billed To: Sam Hall Subdivision Info: White Dove Acres I Lot # 10 Reference Name: Doyle & Lynda Seymour Location/Address: White Dove Way -27028 Proposed Facility: Property Size: **N& * * Thi bfmprov� t/Operation Permit DOES NOT authorize the construction of aseptic 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 H005i5 #People 2- #Bedrooms `. #Baths . Dishwasher: e Garbage Disposal: d Washing Machine: d Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size to xal:�s Type Water Supply COONlY Design Wastewater Flow (GPD) "D Site: New M Repair ❑ System Specifications: Tank Size 111 �GAL. Pump Tank GAL. Trench Width Rock Depth 12 Linear Ft. Other: 2 I)QoQ t3Okds 1 T %STQa 60it;,,) I �S'TD.u, 1�1 �tiS 10. e— rA t r-3. Required Site Modifications/Conditions: W -s-i% u_.. 1o") C 1, -T-T tz , kr.1LP Is' Off ►{-Osv, K► -0 10, dFP W 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 j;gQ_p..m. W the day of installation. Telephone # is (336)751-8760.**** �jp�7-�-,5 P�Lr�►►T E / P S�QI �4G:- �. ISsJc> 121 Mous, 2� 7&,3007--:> PIR ►02 -camPL 1G� ► 5' c9t=F G+�3a,J �,n�..-�-r 3=� �, �i> tAcJt:1C /:v -- i mW. Environmental Health Specialist's Signatur .Z Date: DC14D 05/99 (Revised) WS, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900130 Billed To: Sam Hall Reference Name: Doyle & Lynda Seymour Proposed Facility: ATC Number: 1844 Tax PIN/EH #: 5820-64-9480.010EP Subdivision Info: White Dove Acres I Lot # 10 Location/Address: White Dove Way -27028 Property Size: 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 WASTEWATNS CTION IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: &1on 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. wed EfP YJ -'re Septic System Installed By: Z,24 "L,/ Environmental Health Specialist's Signature: Date: v �_ DCHD 05/99 (Revised) IZATIQN'No:, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittees• P.O. Box 848 Name: ` = �`�"� �-`>'h�t7�?n. Mocksville, NC 27028 Subdivision Name: Ofl' c Je i t )1 nJ 'T v G� IiI Phone # 336-751-8760 Directions to property: �' � Section: Lot: �U AUTHORIZATION FOR WASTEWATER Tax Office PIN:# �L (a� _ go SYSTEM CONSTRUCTION Road Name: 1A 1+1r- 6A tip: 2 707 19 **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for,, Building Permits. (In compliance)with Article 11 of C.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1 �Y IS VALID FOR A PERIOD OF FIVE YEARS. ENV[RO HE LTH SPECI IS DATE ISSUED , DAME OUNTY. HEALTH •DEPARTMENT ."IMPROI TMENT AND OPERATION PERMITS PROPERTY INFORMATION Perrrutee a SubdivisioriName: sif CK %/6, Directions>Eo property4 C�/. ,"7r R1�. 71�R Section: • Lot: t �4 Y L tJrrJ{b r <��I PERMIT Tax Office PIN:#`* C`'_• - J"7u Road Name:i I+J� / Cr/L f'Zip: Z•7y'�lk **NOTE** This Improvement Permit DOES NOT authorize the cons; or installation Of a septic tank system or any wastewater system An f ; AUTHORIZATION' FOR WASTEWATER. SYSTEM ;CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system of ft issuance of a building permits (In compliance with -Article 11 of Q.S. Chapter 130A Wastewater Systems, Section_.1900 Sewage Treknent and Disposal.Systems) ***NOTICE*** THIS PERMIT IS SUBJECT' TO REVOCATION IF SITE ! PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER: r ENVIR TH SP DA I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE } ? INSTALLING THE SYSTEM. . RESIDENTIAL. SPECIFICATION BUILDING TYPE AM�#BEDROOMS ✓ # BATHS # OCCUPANTS - GARBAGE DISPOS A *� or No COMMERCIAI; SPECIFICATION: FACILITY TYPE #PEOPLE ' # PEOPLE/SHIFr. # SEATS INDUSTRIAL WASTE: Yes or No LOT SITE D', TYPE WATER SUPPLE+ 7 DESIGN' WASTEWATER FLOW (GPD) —�" NEW SITE ✓ REPAIR SITE ' SYSTEM SPECIFICATIONS: ;TANK SIZE GAL PUMP TANK. GAL. TRENCH WIDTH, ..Ti ROCK DEPTH �� LINEAR FT. — . OTHER REQUIRED SITE MODIFICATIO QNDITIONS: ��' o�� G� -lob �. b IMPROV EMIT LAYO /Zo r 120 . r L l.. •.^ y. a 1.1. _ , . .�`.• , **CONTACT A REPRESENTATIVE OF•THE, DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM t BETWEEN 8:30 - 9:30 A.M. OR 1:06'= 1:30 P.M. ON.THE DAY OF INSTALLATION. TELEPHONE # IS (336)751=8760. ' I)CHD 05/96 (Revised) rr DAVIE C OUNTY HEALTH DEPARTMENT n permittee s.. Directions to property: IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Subdivision Name. Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# - - Road Name: '''1. `- "LIP: c **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ww*N0'11UE " '1'H1S Yr:KM11' IS SUIIJE I lU REVOUA11UN lk' Sl'1'L PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DAfiE� SUED SYSTEM CONTRACTOR MUST SEE TIM PERMIT BEFORE INSTALLING THE SYSTEM. l RESIDENTIAL SPECIFICATION: BUILDING TYPE 1&y5 —# BEDROOMS # BATHS�� # OCCUPANTS GARBAGE DISPOSAI! or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE D l�C� TYPE WATER SUPPLY(. d l y DESIGN WASTEWATER FLOW (GPD) - '� NEW SITE ✓REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE hVQ GAL. PUMP TANK GAL. TRENCH WIDTH s ROCK DEPTH 1-'3 LINEAR FT. 3 OTHER �—' 1 157%2/64"I't"J REQUIRED SITE MODIFICATION SONDMONS: I TALL 04 cavi--oo< 4 ert-,: P ��(! r/1� f �(� x E :( 0' 1 r�-'/G �^'Y leil� c 7- 0 del ;, /I./Lf Cs AP('2� . -2 v' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT i TEU'IALL$D AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUMCE OF THIS OPERATION PERMIT SHALL INDICATE THA THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTIGL-)~ 11 OF G.S. CHAPTER 130A, SECTION .19'00 `SEWAGE TRIATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FbR ANY GIVEN PERIOD,OF TIME. DCHD 05/96 (Revised) i +..0 A.rruniLAa ruirdla at ABC Davie County Health Deparbnent � —9M Environmental Heath SmWon �d U P.O. Box 848/210 Hospital Street A0"�e�1 Mockaville, NC 27028pj� DA,� h� (336)781-8760 ■ it . ■I AA to nn "m Iur■... ..�...... ***I?FORTRNT*** THIS APPLICATION CANNOT BE :PROCESSED UNLESS ALL Tfffl W uwrvn ie1FONW.C1O'1 IS PROVIDED. Refer .to the INIUMTION BULLETIN for instructions. Mans to 2ya Billed Contact Person Mailing Address Ha1oe Phone City/State/ZIP ffi-. ai r$usiness Phone neQt-4 t. M on Pernit/ATC if Different thaw Above _' /�[ D o Ct_ 4 , .n! eon „,f iw1 P Mailing Address Appliea:ion For: U Site Evaluation 0 Improvement Permit/ATC XBo:h System to Service: House 11 Mobile Home D Business 11 Industry a other If Residence: # People A_ # Bedrooms . S�— # Batbrooms a ,15 Dishwasher Garbage Disposal washing Machine Basement/Plumbing 0 Basement/Mo Plumbing If Business/Industry/other: Specify type # People # Sinks # Commodes # Showers # urinals # water Coolers IF FOODSERVICE: # Seats Estimated Watea Osage (gallons per day) 7. Type of water supply: County/City 11 wall a Commiuzity e. Do you antic-i9At; auditions or expansions of the facility this system Is Intended Zo serve? 11 Yes kNo If yes, what type' ***IMPORTANT'** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: —1n, LqC. WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tax Office PIN: # PS(7'-)n16 Property Address: Road Name city1zip Baa g Y in a Subdivki.•,ci provide information, as follows: Name: ,LA4 C/7 4-0 Section: r I Block: lot: _ aDateOProo y Flagged: ' MEN -Me, This 6 to certify That the Information provided is correct to the best of my knowledge. I understand that any permit(s) rued 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 ro ponsible for all charges Incurred front this application. I, hereby, give consent to the Authorized Representative of the Dave Countyealtreng-rhnent to enter upon above described property located in Davie County and owned by n-� 12 V to conduct all testing procedures as necessary to determine the site suitability DATE L);b I SZ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PIAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07198) Account No. 150 Invoice No. 3g 6 — l —� � C4✓4 lokD - 27`: 9.58 .21,, 69.2E s , (1-- 5 q� 6 7111 4 Sam G� e 50' EASEMENT I s • S 0 / 50' EASEMENT 8 9 7 I .q o S 10 6. o 1� MAP SHOWING DMSION OF: WHITE DOVE ACH MAY 12, 1997 REMSED: JULY 21, 1997 1 300 150 0 300 600 k'N^MQ- COMPANY — 1.14 J>i2 H ROD — �..� C, 27028 SCALE IN FEET {92--5616 �. , _a ti . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME �)AAt nALV PROPOSED FACILITY SUBDIVISION N O17Sar' SUBDIVISION W% 1 hT� '� AC4& Water Supply: On -Site Well SECTION LOT `o DATE EVALUATED 1,2-W b PROPERTY SIZE rr 11 11 j E> A C 2P 5 ROAD NAME�I %r, bA wm( Community Public 11�� Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 5 HORIZON I DEPTH p - Texture groupG (� Consistence S Structure ICA k - Mineralogy: 1 ' HORIZON II DEPTH 14L .- Texture groupG G Consistence ` Structure 5 f> 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: PS LONG-TERM ACCEPTANCE RATE: 0 3S REMARKS: QV�2TZ r� y� Ilv 1 j Tc3 2Z, l LEGEND DCHD (O1-90) Landscape Position EVALUATION BY: IAv, 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 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■N■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.■..��===��:::�■■■■■■■■iii■■■ ■■NOON■/I■■■■■■■■■■■■■■■■■■■■■■■■Gil■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■rIN■■■■■■■■■EE■NOES■EMNE■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E!1►I■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E■E■■■■■■■■■■■■■■■■■■■■Ori■■■ ■■■■s,■■■■■■■■■■■EMM■■■■E■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■►�■■■ ■■■■��ii■■EE■E■■EE■EEN■EEE■E■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■s■■■■ ■■■r�■■■■■■■■■■EEE■■ENNE■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■��o■■■■■■ MENNENiiiiiiiiiiiir iiiiiiEMMEMEONE"-'M M iiiiii ■■ ��■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■E■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■�■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■ ■■■■■f.■■■■■■■■■■■■■■■■■■■PaN■■■(•■■til■■ ■■■■!■■■■■■■■■■■■■■■■■■■■■■■A■ill■■■ ■■■/■■■■■■■■■■■■■■■■■■■■■■■�!�7ti�_ ■M■■■ ■■►►IO■■■■■■■■■■■■■■■■■■■■■■■■ti�7�►!■'NOON ■■I■■■■■■■■■■■■■■■■■■■■■■■■!!CJI■■■■■■■■ I■■■■■■■■■■■■■■■■■■■■■■■■■■liil�l■ ■■■■■ ■■■■■■■■■■■ ■■ ■■ ■■■■■■■■■ ■■�Nf■�■ NOON ■■■■■■■■■■■■■■■ ■■■■■■■■■ ■■fir■■■■■;■■■■ NOME ■■M■ ■■E■ ■O■■ ■■E■ MEMO ■M■N OMEN noun ii ii ■ ■ ■ ■ ■ ■ ■ ■■NEM ■ENE■ ■ENE■ ■ENE■ ■EN■■ ■■MM■ ■ENE■