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137 Glory Court Lot 22DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001720 Billed To: Campbell's Quality Properties, Inc. Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5777-33-1382.22 fj q . 20 -6 T Subdivision Info: Still Waters Phase 1 Lot # 22 Location/Addresst3G�lory Court -27006 Property Size: see map **NOffQ- s%rdlAnt/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 #People #Bedrooms #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �D Design Wastewater Flow (GPD) Site: New+_/Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width,, Rock Depth Linear Ft.Sed Other: Required Site Modifications/Conditions: 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_&.pi-66-the day of installation. Telephone # is (336)751-8760.**** t/ Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001720 Billed To: Campbell's Quality Properties, Inc Reference Name: ATC Number: 3726 Tax PIN/EH #: 5777-33-1382.22 Subdivision Info: Still Waters Phase 1 Lot # 22 Location/Address:"81ory Court -27006 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 CONST CTION IS VALID FOR A PERIOD OFF FIVE ARS. Environmental Health Specialist's Signature: Date: �`�� y— 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 W Y be en 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) Date:� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001720 Tax PIN/EH #: 5777-33-1382.22 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 22 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: —!,�p -1f Water Supply: Evaluation By: On -Site Well Community., J Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON lI DEPTH Texture group Consistence Structure sr f2 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 RA' REMARKS: r� EVALUATION BY: 4& OTHER(S) PRESENT: 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) Al'PIJCATI051 FOR SITE EVALUATIOAI/Ihli'ROVEhICM-11ERMIY & ATC � O �' Davie County Health Department EnWonmental Hea/tfi Section [A:R2276 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRON , `;LTH DAVIE , ***IJ4PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed _ P1tJ,0bd1 S AUA& _Pry et fi fs, „�j 'c _ Contact Person ROt,;A0 b. C'q,uQ�j'�� Mailing Address '9000 .4P")OA` �� `��/r(//-1-7111 C+. Home Phone 33G — 795 - 37, City/State/ZIP �IRiS�U/J- Jli�PiLl. Al- 171 Z I Buoinass Phone 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: x House ❑ Mobile Home ❑ Business ❑ Industry ul Other Stl�c iV%SicA1 5. If Residence: #People # Bedrooms ^—q_ #Bathrooms ,2 --.A. '14 Dishwasher �f Garbage Disposal ,Washing Machine ❑ Basement/Plumbing 4( Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day) 7. Type of water supply: �( County/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VNo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIP—ED PROPERTY INFORINV�TION REQIJ'ESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 2 Tax Office PIN: m, Property Address: Road Name 11W 3 City/zip A UA,,czI, AILL6o6 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from ( LMocksville) to� PROPERTY: e'AS+ +0 (IJV aO't itr"I oa ceeA 1%Z 0e O t.1 l� Name: S`�'� i� D A-L:rs Section: r}SQ Block: Lot: 1--o(O 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. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the 12avie County Health Department to enter upon above described property located in Davie County and owned by (� W1'i to conduct all testing procedures as necessary to determine the site suijsib)lily. DATE 3 X0 /6 (f SIGNATURE 'T TRIS 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): Client Notification Date: EHS: Account No. l —o Revised DCHD (07/99) Invoice No. f A1,PLIC 10 FOR SITE EVALUATION/IMPROVEMENT PERMI & AT jf,QR Davie County Health Department EnvironlnentaiHeaith Section ALS Box 848/210 Hospital Street Mocksville, NC 27028 FN OV1F (336)751-8760 } *** RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer D tothe INFORMATION BULLETIN for instructions. 1. Name to be Billed `t if, fnf�PwrCfCX_ JG. Contact Person Rprlq�d b, (tf}rt1�W� Mailing Address 'zoo 1tWe, r~(` -+—t Home Phone W -79-3762 City/State/ZIP ON ri Sief&,. r IAC ?,7 Business Phone 336- 4 V -KU me 63086 �1 Mo=l�C 2. Name on Permit/ATC if Different than Above Mailing Address C ity/State/zip 3. Application For: ❑ Site Evaluation ltG Improvement Permit/ATC ❑ Both 4. System to Service: (House 13 Mobile Honie ❑ Business ❑ Industry ❑ Other 5. Type system requested: 2 Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People �# Bedrooms �_ It Bathrooms Z % WDishwasher ❑Garbage Disposal 93/Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type It People It Sinks 1. # Commodes It Showers # Urinals # Water Coolers IF FOODSERVICE:. # Seats Estimated Water Usage (gallons per day) 8. Type of water suppjy: IBJ County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes L7/1N 0 If yes, what type? Y ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BEE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:-e-�/Y`-�i� Tax Office PIN: # e5�-7 7 -7 3.3. /3 e---1 - 2'2 - Property Address: Road Name � j C0,1' _ City/Zip /ll'C�UQN� a70� If in a Subdivision provide information, as follows: Name: �i (( LA)g c, Section: Block: Lot: 7-2— WRITE DIRECTIONS (from Moclsville) to PROPE'RTN': We- W &v-4" iwvo(-krj&4kf t?nwA (L tit; (e , 5+,ti U�S SuUvi5W * �t-�• �-� �o-� o�J �ei-c iS l.o�P�. - Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any perntit(s) issued hereafter are subject to suspension or revocation, if tate site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I ani responsible for all charges iacw•red from this application. I, licreby, give consent to the Authorized Representative of the vie C unty Ilea ltVI)cpa menu to enter upon above described property located in Davie County and ow d by �. tS =1";`�`+'�- T C. , to conduct all t sting 'rocedures as necessary to determine the sit ui bi ity. DATE - 23 O SIGNATUREIla, THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensjpjisa_ structures, setbacks, and septic locations). '�40?j Sign given Revised DCI1D (05/03 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. -z'o /, Invoice No. 1-/079