126 Mollie Road Lot 4Account #:
Billed To:
Reference Name:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
990003057 Tax PIN/EH #: 5801-10-5600.04
R.B.Hope Contracting Subdivision Info: Sheffield Acres Lot # 04
Blake Location/Address: Mollie Road -27028
ATC Number: 4419
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
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 CO NIS LID FV PERIOD OF FIVE YEARS.
dal Health Specialist's Signa Date:
R CERTIFICATE OF COMPLETION
./7
"DOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
t has been installed in compliance with Article I 1 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� Cr
7'
� L.
I vll
T
j Ij m Septic System Instal ed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT too
Environmental Health Section
P. O: Boa 848/210 Hospital Street
Mocksville NC 27028 4 I
(336)751-8760 ll
IMPROVEMENT/OPERATION PERMIT
Account M 990003057 Tax PIN/EH M 5801-10-5600.04
Billed To: R.B.Hope Contracting Subdivision Info: Sheffield Acres Lot # 04
Reference Name: Blake Location/Address: Mollie Road -27028
Proposed Facility: Residence Property Size: 1 acre
OTE *Trvee**Niromnt/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 STYE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM
Residential Specification: Building Type 'r #People #Bedrooms _ #Baths 2
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: e Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size I. a AOR� Type Water Supply Design Wastewater Flow (GPD) 31x0 Site: New Repair ❑
System Specifications: Tank Size lox GAL. Pump Tank GAL. Trench Width 3V
Rock Depth, • Linear Ft.��
Other:�S'TQi J
6rlOW c izS
Required Site Modifications/Conditions: /,JSj71w O cil7oti2, /Lr4,n��� 6�r✓T, /��/a•oF�
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILT�RISER(S) IF 6 "
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Hea tl h Department for final in
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 E �-o the da of installation. Telephone # is (336)751•
%Fja;j:) LI>k--S 1,-1
.t
44 -
Environmental Health Specialist's
DCHD 05/99 (Revised)
�1
of this
�tAzr=p L -IA S 00ro_z)�4
ate:
ate:
`A.PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
D DEnvironmentdl Health Section
P.O. Box 848/210 Hospital Street
' 20� Mocksville, NC 11 27028
jUN -
(336)751-.8760/ Fax 6)751-8786
Ap icatio For: @�lon/Impro ement Permit Authorization To Construct(ATC) D Both
ANT * I HIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
UNP UKIVIA I WIN
Name to be Billed P1 8 #0,0-e_, Contact Person P l 1
,Billing Address 2 C iniv. r 121"i Home Phone
City/State/ZIP fijvc4c r% C 27 0® Business Phone 3 f P- 0,4-1 5
Name on Permit/ATC if Different than Above
Mailing Address I City/State/Zip
rMirrKl r IlNr VKN1H
NOTE: A survey'plat or site
(Permit is valid for 6
Street Address /)70
Subdivision Name .5
Directions To Site:
must accompany this application.
ttlhs with site plan, no expiration r
lat.)
'e-- Tax PIN#
_Lot Size
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms _ 9 Bathrooms `j - Garden Tub/Whirlpool B- es ONo
Basement: nes ONo Basement Plumbing: CofYes ONo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) .
FOODSERVICE ONLY: # Seats
Type system requested: Pr onventional DAccepted DInnovative DAltemative ❑Other
Water Supply Type: CO County/City Water D New Well CExisting Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes C <o
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 subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed I understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections tt,Q /determincod, mpliance with applicable laws and rules on the above described property located in
Davie County and owned by 13lf%er /}sip r`/
Property owner's,6r owner's legal representative signature
Date
Sign given OYes DNo
Revised 2/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account# 3657
Invoice #
i
Date House/Facility Corners Flagged -
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
❑Yes O1Qo
Does the site contain jurisdictional wetlands?
❑Yes [ Nb
Are there any easements or right-of-ways on the site?
❑Yes BtIo
Is the site subject to approval by another public agency?
OYes 9l4o
Will wastewater other than domestic sewage be generated?
DYes n?To
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms _ 9 Bathrooms `j - Garden Tub/Whirlpool B- es ONo
Basement: nes ONo Basement Plumbing: CofYes ONo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) .
FOODSERVICE ONLY: # Seats
Type system requested: Pr onventional DAccepted DInnovative DAltemative ❑Other
Water Supply Type: CO County/City Water D New Well CExisting Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes C <o
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 subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed I understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections tt,Q /determincod, mpliance with applicable laws and rules on the above described property located in
Davie County and owned by 13lf%er /}sip r`/
Property owner's,6r owner's legal representative signature
Date
Sign given OYes DNo
Revised 2/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account# 3657
Invoice #
i
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PLAT MAP nF: -
SHEFFIELD ACRES
O MER _____________ DEVELOPER
ME G IRMuP. LLC
247102 COON R E M.
O NI) sN.G 21013
CLARKSVILLE TOWNSHIP
- DAVIE COUNTY. NORTH CAROLINA
AUG -25-2005
TAX MAP REP.: Y-1, PARCEL 112.00
SNMYtD R1: -
TUTTEROI! SURVEYING COsffANY
101 HIM 100ISM! SRaE1
NCCNSVLLE. NC 2)028
(JSC) 151-5515 -
$G1E 1• • IW'
100 50 0 100 200 300
SCALE IN FEET -
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M➢NL IKKIt R0. A4 EIDWX
a EMI lDI AWL IYIE /N 010M1 SEPAL' I" lD
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TRRS xMnm a a• ox rA2lErL .
PLAT MAP nF: -
SHEFFIELD ACRES
O MER _____________ DEVELOPER
ME G IRMuP. LLC
247102 COON R E M.
O NI) sN.G 21013
CLARKSVILLE TOWNSHIP
- DAVIE COUNTY. NORTH CAROLINA
AUG -25-2005
TAX MAP REP.: Y-1, PARCEL 112.00
SNMYtD R1: -
TUTTEROI! SURVEYING COsffANY
101 HIM 100ISM! SRaE1
NCCNSVLLE. NC 2)028
(JSC) 151-5515 -
$G1E 1• • IW'
100 50 0 100 200 300
SCALE IN FEET -
DI£ WNL COORS WING
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ECCI 20ON roll SITE L•v/uuATIONIMPHOVOIENT I)EMIT & Ni -C
' Davie County Health Department
AEHFALIH
-0.. Box 848/210 Hospital Street
�1)0Mockoville,.NC 27020
(338)751-87G0
"x1MYORTANT*** TIiIS APPLICATION CANNOT BE PROCD•SSED MMESS ALL. TILE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. -I
1. Name to be Dilled 2/y/8.. �//rp «/��d�+/ 7 e Con LacL Paraon
..._......... ...
Mailing Address _3y/'7O -/Oa ego 7/� 4 e Home Phone
�-b'i/Ti 9. -
City/3 tate/2IP Z114
Rro;,.,tn��, Business 11110110
2.
Namo on ParMit/ATC 1E,Di9tarent than Above 55th -c --
-
Mailing Address' City/State/tip
_
--
3.
Application For:: 2 -Site Evaluation - 13Improvement Permit/ATC
❑ noL•h -
i
"❑
-
4.
System to Service:gplrouse ` ❑ Molyile Home BASincts ❑ Industry - ❑ Other
_ 5.
Type system requestad; E Conventional .- ❑ conventional nodi Eiod ❑
innovu Livu - -
s.
If Residonce: It People A Bedrooms `3
II BaL•hroount z
❑Dishwasher ❑Garbago Disposal ❑Washing Machine ❑Basement/Plumbing
13Ilaae111COt/tlo dumbing
-7.
II: Duainaos/Iadua Lry /0thar: verify type -SII Poopla -
II Sinks
8 Commoddo 0 Showers"�'--•
$ Urinals
A IlaBor Cooloru
-
IF FOODSERVICE: tl seats - - Estimated Water Usage tgailons par day) _' -•
.' .8.
Typo or water supply: �®-I'County/City - ❑ Well
__
❑
Comutunity
9.
bo you anticipato additions or expans(ous or We facility this SyS(CIII IS 1I1tCI1dUd to See
-ye? ❑ Yes - ❑ No
ir)'cs, what type?
"**tnIPORli JyP** CLIENTS MUST COMPLETETHE 1X2111RED PROI%RrY 1NIeOImwl-ION REQusri,5
13EL01V. Either It PLAT orSITE PLAN AtrITTEESU/l IM7.7 D by the client I itiI TIIIS APPI ICA ION
Property Dimensions: n�j �jt� /--/ `'� OG )YR1TL DIREMIONS (frulu Alucksvillu) Ilu�P1tUI'lilt't'1':
ax•officeFIN: 1l S 82)/—/O,.SG�b /. 1x�L
Property Address: Road Name
City/ZIP
If in a Subdivision provide information, as follolvs:
Nalile
Section: Block:r
Lot: Date 1101110 corners !lagged:
This is to certify that the inforinatiou provided is correct to the best of my knolrledge. I understand (Ilat any per,uit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or If the information
submitted in this applica(iotl is falsified or changed. 1,, also, «nderStruid [hat! mil respousiGla jur «I! c/usgcs lucurrrrl Jinni
th/s dppfitatrar: I, hereby, give couscut to the Authorized Representative of the ll:rvic County Il(111 c alwas hicur t
to enter upon above described property located in Davie County and olvued by
to conduct/all testing procedures as necessary to determine Lite site suitabili(y. -"
DATE -7 ^ Z7 0 SICNATURL
THIS AREA MAYBE USED TOR DRAWING YOUR SITE PLAN (Inciud all of the follotring: Existing turd proposed
property lines and dimensions, structures, setbacks, and septic locations).
j Site Revisit Charge
Cliant Notification Date:
Sign given
EES: '
Account No.
SITE CLASSIFICATION: EVALUATION BY: agf=1
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
..REMARKS:
Gin e �� Gv7s ,
,LEGEND
Landscape Position
R - Ridge ' S - Shoulder L - Linearslope 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 -Sand 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
oist
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
Mineraloev
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)
"
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation' .
APPLICANT INFORMATION
PROPERTY 1NF'ORMATION
Account #:
990002086
Tax PIN/EH #:
5801-10-5600.04
Billed To:
The Cana Group,LLC
Subdivision Info:
McCullough Property Lot # 04
Reference Name:
Location/Address:
Sheffield Rd: 27028
Proposed Facility:
p ty:
Residence
a
Property Size: see map Date Evaluated:
Water Supply:
Orlite Well
Community
Public
Evaluation By:
Auger Bonng!
� Pit #
! '
- Cut
SITE CLASSIFICATION: EVALUATION BY: agf=1
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
..REMARKS:
Gin e �� Gv7s ,
,LEGEND
Landscape Position
R - Ridge ' S - Shoulder L - Linearslope 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 -Sand 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
oist
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
Mineraloev
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)
10119MINA
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6 11M
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SITE CLASSIFICATION: EVALUATION BY: agf=1
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
..REMARKS:
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,LEGEND
Landscape Position
R - Ridge ' S - Shoulder L - Linearslope 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 -Sand 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
oist
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
Mineraloev
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)