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117 Mollie Road Lot 13Account #: 990003806 Billed To: Gray Potts Reference Name: Proposed Facility Residence ATC Number: 4270 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocicsville, NC 27028 (336)751-8760 III 011f& Tax PIN/EH #: 5801-10-5600.13 Subdivision Info: Sheffield Acres Lot # 13 Location/Address: Mollie Road -27028 Property Size: .0872 acres As stated in 15A NCAC 18A.1969(5) accepted Systems may also be usead 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 TI6N IS V TER CON B� OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signau�/ Date: % D�K [��[�Ti7;��i�iZOh�11111�1Y[�7►1 **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. 1 2"o uo� '"ir0K bArc 2 -ZS Septic System Installed By: Environmental Health Specialist's Signature DCHD 05/99 (Revised) Date: DAVIE COUNTY HEALTH DEPARTMENT p Environmental Health Section t P. O. Boz 848/210 Hospital Street MockrAlle, NC 27028 1 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003806 Tax PIN/EH M 5801-10-5600.13 Billed To: Gray Potts Subdivision Info: Sheffiaid Acres Lot # 13 Reference Name: WILLIAM CREWS Location/Address: Mollie Road -27028 Proposed Facility Residence Property Size: .0872 acres ATC Number: 4270 **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). TIM 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 0k� #People #Bedrooms #Baths 2 Dishwasher: Mr'� Garbage Disposal: 21"�' Washing Machine: O'�- Basement w/Plumbing: 2' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #P,E3eople #People/Shift #Seats Industrial Waste: Lot'8 Size 0-7/� 9 A ype Water Supply �-wy Design Wastewater Flow (GPD) /-5(00 Site: New la' Repair ❑ System Specifications: Tank Size I ®CO GAL. Pump Tank GAL. Trench Width 3(;' Rock Depth 17- Linear Ft. t LL As stated in 15A NCAC 18A.1969(5) 1 Other: �I'�1STV4e L2r1a-3 ' exdr- t accepted Systems may also be used Required Site Modifications/Conditions: f NISf41L 03 LDNh00*Z, via -4 5 eq:' 'Va--P l C �w W. c"j, 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.**** Health Specialist's Signature: DCHD 05/99 (Revised) Date: /Z O5- ' APPLICATION FOR SITE EVALUATION/141PROVEMENT PERMIT S: Davie County Health Department Enyironmenta/Health Section P.O. Dox 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 0 DEC — 5 2005 ***XHPORTANT*** TIiIS APPLICATION CANNOT BE PROCESSEDUNLESSALL THE REQUIRED INI'ORI-IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name Co be Billed YL" Contact Person C� t, , I Mailing Addresc� 0 0 `5 1 H 5 Home Phone City/Stato/ZIP %�C II�y /VL'S (;: ;7AL)U) Business Phone 5 41992 2. Name on Permit/ATC if Different than Above Mailing Address City/State%Zip 3. Application For:. ❑ Site Evaluation Id'Improvement Permit/ATC ❑ Doth R. System to Service: 21 Hrouusse El Mobile Home 11 Business El Industry 11 Other Ya 5. Typo system requested: Conventional ❑ convontianal modified ❑ innovative t2aCCepted 6. I__ff Itozidenco: 11 People t1 Bedrooms _ ErD-iehwashor Marbago Disposal ❑ 1ashing Machina ODas omen t/Plumbing 7. if Buoineas/Industry /other: verify type 9 People II Commodos 9 Showers IF FOODSERVICE: 0 Seats 11 Urinals 11 Bathrooms ❑basement/No Plumbing It Sinks 11 Nater Coolers Estimated Water Usage (gallons per day) S. Type of water supply: bounty/City ❑ Well ❑ Community 9. Do you anticipate additions or CSpanS!0Ds of the facility this system is II1tended to serve? ❑ Yes 91 -No Iryes, what typcl ***1AIP0RZ4NP**CLIENTS AIUS'TCOMPLETTTim REQUIRED PROPERTl'INPORAIATIONRIQUESTED 11MO1V. Either n PLAT or SITE PLAN AIU.ST BrSU11AfITTED by the client with THIS APPLICATION. Property Dimensions: Qom�• � �2 f ` �I 1VItITE DIRECTIONS (from T Alochsville) to PROPERV:' Tax Office PIN: II 5J 1 � C3 Property Address: Road Name City/Zip lyl fiLkslp/ If in a Subdivision provide information, as follows: Name: Section: I310CIC: Lot: Date home corners Ragged: 17-1 U I o T This is to certify that the information provided is correct to the best of any knowledge. I understwid that any po•mil(s) Issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information subnni(tcd in this application is falsified or changed. Jr, also, understand thatl ran responsiblefor all charges incurred front this applicafion. I, hereby, give consalt to the Authorized Representative of the DIXic Comity Illh Department to enter upon above described property located in Davie County mid ovncdby . �� / rC) /� S to conduct all testing procedures as necessary to determine the slicruitabrtity. j I Z'� �o'f • -�� C -o OW MAP Lor 13 u/ IIYNIL/I Y4.il.L/V(/ FNNRONMENTPLHFA�TM 0 Dox 848/210 Hospital Street 1NV Mockaville, NC 270211 (330751-II76(1 I x**ulrvitlatvT*** TRIS _ APPLICATION CANNOT DL PROCL•SSL•'D UNLESS ALL THE REQUIliLD - \ 11 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions 1. Name to be'Dilled/1//6.. �()/p !G/) �C(. -Contact person_ . Mailing Address�' y7Q - /O'a Cp/1J� ,�j,/Qee ' �/^ Inane Phone ? i; Vei jn // /p''' %L� nuuincea Phone / . -- City/State/ZIP 1�6 Ta/✓5.1�A� 7/ � I. Nemo on Pormit/ATC if Different than Above 5Sal � - Mailing 'Address : City/Stato/Zip .. 3. Application For: 2ISite Evaluation 11ImprovemenImprovementPerinit/ATC ❑DO1:1i 4, Sint= to service: P-:90use ❑ XOIl ile'Home - ❑ BUSineDD ❑ Indus L•ry ❑ OL-hci 5. Typo system requas taa: it conventional ❑ conventional modified ❑ innovative -_ 6. If Residence: At.People R.Ilodrooms - - -..II Bathrooms 2 _ ❑Dishwasher ❑Garbage Disposal ❑Washing Machin ❑Daacmont/Plmnbing ❑Daamnon L•/tlo Plumbing 7. It.•Dusinass/Industry /Other: verity type I) People 9 Oinles- Y Commodda It Showers- -.— -_— . "0 Urinals 0 Na L•ar Cooloru _ IF FOODSERVICE: tl Sesta Estimated Water USage (gallons per day) _-•____ s. Typo of water 'supply: 91"County/City ❑ Well ❑ Cotmaunity 9. Do you astitipato additions or. capansious or me facility tills syslciu is iulcuticd lu sm•ve? ❑ ]'cs ❑ No lfyes, wlnat type? ***IMPORTANT***CLIINTStI1USTCOh11'LGTE-TIIEItGQU//fGD1'ItOI'lRT]'1NIeO1thIA'I'fONRLQIUS I -,J) —I BELOW. Either aPLAT orSITE PLAN T)/USTI1CpSUlIb1/7TCODythedic:il nillr'1'IIISr1HP11CA1'ION I'ropcllyllinncnsiotis: WRITE DIRLCfIONS(rrumnmclcsville)(uI'RUI'hIt'I'1': Tas oificc FIN:!l s 81�/—/0 5`G (t7 Froperty.Address: RoadNannc le cityizjp o sG`� 1��7ootS� Irin a Subdivision provide inroi'nlation, as follows: Name• Section: Block: Lot: Date hone corners flagged: . This is to certiry that the information provided is correct to the best of lily knolvlcdgc. T mldcrsland plat any pern:il(s) issued hereafter are subject to suspension or revocation; if the site plans or intended use change, ur it (he inrurma (ieu subnnitted in (itis application is L•IlWiied or changed. 1,, also, «ndcrsuu1d illall (tut respollsiblefor all choiges iuemored.fi-om lhisapplicariaN. I, hereby, give consent to the Authorized Representative of the Devic Cminly Iic:dlh DcJnu Uiielil to enter upon above described pruperty located in Devic County and ulvacd by J erne./ lVe. / to euuduct all testing procedures as necessary to deteruninc (he site Sultabilit),. ' DATE SIGNATURE- TIM IGNATURETRIS AREA MAY BE USED I OR DRAWING YOUR SITE PLAN (Includ all of the fullolving: Existing ;litd prupustd property lines and dimensions, structures, setbacks, and septic locations): Sign givan AccountNo. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002086 Tax PIN/EH #: ,;580.1-10-5600.15 Billed To: 'The Cana Group,LLC Subdivision Info`. McCullough Property Lot # 15 Reference Name: Location/Address: Sheffield, Rd: 27028 Proposed. Facility: ResidenceProperty Size: see map Date Evaluated:: Water Supply: On -Site Well Community' Public i Evaluation By: , Auger Boring Pit 1Y Cut FACTORS 1 2� " 3 4 5 6 11 7 Landscape position Slone% - 1 1 0P6 1 11 1 1- HORIZON 1 DEPTH < /i � �/ ' ., . ' - Texture groupG., Consistence Structure Mineralogy HORIZON H DEPTH yJ', 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 c E SITE CLASSIFICATION: SITE BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS:A / 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 V FR - 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) C5' C4 '—x'-" N -G 6"_ SDR 21 3 N