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140 Still Waters Drive Lot 3DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT(OPERATION PERMIT . Account #: 990001720 Tax PIN/EH #: 5777- _23-9260 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 3 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility Residence Property Size: see map ATC Number: 3764 **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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CO'N'TRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type No JS : #People #Bedrooms 3 #Baths � • S Dishwasher: d Garbage Disposal: e Washing Machine: Basement w/Plumbing: 0 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Q 1 A �`= ) Type Water Supply Nowy Design Wastewater Flow (GPD) ��tp Site: New CK Repair ❑ System Specifications: Tank Size I CLOD GAL. Pump Tank GAL. Trench Width' -S(-2' Rock Depth 12 Linear Ft.'3(2O Other: i Required Site Modifications/Conditions: 1 OSfAur OJ Veir-p is off- tt-F 0-0e.. L.i,o, 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.**** Pte' ujS7 Environmental Health Specialist's DCHD 05/99 (Revised) MuJ.lO Account #: Billed To: Reference Name: Proposed Facility DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section I P. O. sox 848/210 hospital Street Mocksville, NC 27028 (336)751-8760 990001720 Tax PIN/EH #: 5777-?2-'3A92Z 1'_ Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 3 Location/Address: Hwy 801-27006 Residence Property Size: see map ATC Number: 3764 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 CONS N IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: C1 v`'7 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 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. �1C I loG N X a4s tc �, Septic System Installed By: y��t Environmental Health Specialist's Signature: &::�ate:'(` I t,0,4 DCHD 05/99 (Revised) 04/19;2004 10:57 GUILFORD COUNTY EMERGENCY SRVCS d 913367518786 N0.146 001 •C APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davin County Health Department Fd7Wr0W7mentj1 h1wiM Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 714 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCtSSED UNLESS ALL THR REQUIRED INFORMATION IS PROVIDED. Refer to the INSORMATION BULLI;TIN for instructions. 1. Namo to be Dilled JAI V�� di.G . Contact Faroen IL (J1 0 palling Address home Phone Clty/SLatQ/ZIP [ auoineea Phone;36� L41-6564 2. Name on Fermit/ATC 1f Different than Above ' Hailing Addreea City/state/Zip 1. Application For: IT Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. Syatam to Service[ Is` XOuoo D tdobile Hate O Businesa ❑ induatry I] Other S. Typo eyatem requested: L7 Conventional conventional modified ❑ innovative e. ,LKCaI.,f Residence- / s People �� # Bedr0000m& Z s / e Bathroom t9D lahraohcr rbasa Dtaposal or.hing Machine L�Basemo t/Rlu}ahIng 4) Ehlasament/No Pluodiing (/:FM. V" 7. If Dualneas/Induaty /other, verity type 9 PeoPla tet•- # Sinks i• 0 Commodes 0 Showers r 4 Urinals 0 water toolorD IF FOODSERVICE: 0 Seats Estimated Water Usage (gallons par day) 0. Type of water aupp}y: FS County/City ❑ Well ❑ Community 9. Do you anticipate! tui clona or expansions of the [acitity this systcut is futcndcJ to serve? O YCs al -No If yes, what type? I i *•*1MP0RTAN7'f** CLIENTS AWST CO)UPLETFTHE REQUIRED PROPERTY INFOItMA'riON RGQUISTI'D 0201V. atlocr a PLAT or SITE PLAN MVS7'BESf1BAf177EZ1 by the client witliTHISAPPLICATIO) Proper(y Dimensions: a Y 60 Y, My 131 WRITE DIRECTIONS (front Mocksvilte) to PRO)')?11TY. Tas Office PIN: #i 4-7 7 ?n(ox -!4, b`f aw to 1 i" Ppt%064001 ropertyrtss. Road Name Siim('�tm Tsry' d %,mk ti�b�s St6dtntit� `♦ City/Zip _ 7 ti nal frdLK, — %' 3 IS � If in a Subdivision provide information, as follows: V'W tJ Nene: d Section: Block: Lot: Date hone corners flagged: 7 1q1° ,' d This is to certify that the inforutation provided is correct to the best of my knowledge. I understand that any peru:it(s) Issued hereafter are subject to suspension or revocation, if the site plans or intend&j use change, or if Ilse Infornr:rl!oil submitted in this application is falsified or changed. I, also, understand tlall om rarpansible for all charger incurred fr,arn this applicadan. I, hereby, -Ivo consent to the Authorized Representative of tiltavic County Heal (It Delia rinrcnt to enter upon above descriWd property located in Davie County and owned by fes lj�t Wr�(i(v Anter Ami L� ,�__ to conduct 211%testing procedures as necessary to deternine the site sultab' ' y. DATE / / Q/O+� - SIGNATURE r_ —T THIS 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). 2o4.1Y Sk+toi * (jtsW ftimAt +Wl�-'Eb Site Revisit Charge F� 1,c (e�.e Wfrw�FyAra'sis1 Date ile(y): LJ�, ` l3il,ys a"ar Ivlt,,��.sst i� { Mi 4tty{(wys t:9 Client Notification Ditc. ERS. ♦ J Sign given—L� (nom t/ c Account No, r) Z Revised DCHD (05/03 // ���f Invoice No. y APPLICATION FOR SITE EVALUATION/RIPROVEhIENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 DFAPR 2 6 200 1 ENVIROP1;ii DAV i E ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED PROVIDED. Refer to the INFORMATION BULLETIN for instructions. � //�� 1( ffI 19C.I1 S Pa ' /f r � r'f i\, 1. Name to be Billed A11,0 1 e 1 ,.1N� Contact Person 12DlJii�U Mailing Address .1 V(] V 1 ���}t,'e1 1.+. .]/}�O``t home Phone 33 — 795 QVC - 37t City/State/ZIP I --:// 01J&)S�"o!J-. 6(e..A1_ / C 2712 7 / Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: K Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: X House' ❑ Mobile Home ❑ Business ❑ Industry I( Other Stu i'v;sird s. If Residence: #People #Bedrooms 3 A #Bathrooms ,,� -- �A- '14 ADishwasher Garbage Disposal Washing Machine ❑ Basement/Plumbing q( 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 o. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIP. -D PROPERTY INFORMATION REQ'VESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: #, 17.7 3 3 - I M -v 5 Property Address: Road Name H i, l Zo City/Zip Ar�tlAtic� . dCR7()06 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from LMockslville) t(o� PROPERTY: riG �f 4AA a teed Ib- OA 1 �e o fJ Name: 15 Section: r}Se Block: Lot: Date Property Flagged: This is to certify that the information provided is cor ect 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 I,)avie County health Department to enter upon above described property located in Davie County and owned by (AAJk, [('IQqdiv !' :TNc to conduct all testing procedures as necessary to determine the site suitQlity. j .CDATE 3/%jo/ �1 SIGNATURE THIS 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). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. 1 y° Invoice No. 2`� DAVIE COUNTY HEALTH DEPARTMENT or Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001720 Tax PIN/EH #: 5777-33-1382.05 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: t 01 Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public I--, / Cut FACTORS1 3 4 5 6 7 Landscapeposition L j24 Slope % HORIZON I DEPTH Texture rou Consistence S Structure Mineralogy1 HORIZON II DEPTH - Texture groupC Consistence .� Structure Mineralogy- 1 - HORIZON III DEPTH 4S Texture group Consistence .� Structure S 51v -- Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE •, SITE CLASSIFICATION: lug LONG-TERM ACCEPTANCE RATE: REMARKS:,4- D"S L -t ^^-1 C.0 1`iJ�- Sit STl LEGEND Landscape Position EVALUATION BY: _kms �✓rmo"Auf OTHER(S) PRESENT: Wl-P 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) J 1ov,r+ 3 OL _ o 'm ! ! �S o�z'q� St•SL'*1•t0 ' .i �: `� '�' � ZO.�O•v85 � • 6 t t 5,6g h a M. ppS L 1 ZN1a1.tS vbl)3'tY.Lr Q3^ OV 06'0 jS 6 �� •6C ti CIO'S9Etv.t5 68 Z l 9Z 6 t t (� e IOOS M 64.9*•8/ afN QO'S94 zi Cry £L tti 0ot�tt� ,a y OL O Ln -4s LC c S r Lo .6C d 59 19 � P. 6t�5`' 96O'Q£ t .. :rotnr .�Lry 3 10J.-OCil") 10. oy OL'0£ 10 0 ze OL .gs's,£ to 1 �, .. jSLCAI M �,`,9y��5 �,�•04.1 � � � 4tf ., f 1.00 oa'Zo� 17 : , Y3 lYt5�a3 ILA $ a N $6 �Z ('1diOif:�1�� OLx Ot of otc� / 31' �aLld •�5 - o , aZ: - - y r 3did 011sy d CI31VJi1212l03 r -, ;dn3 3dl&lYljfl:lOU C li2103 `dJ23 3did ')NO3 033M03N138 APPLICATION FOR SITE EVALUATION/INIPROVEME1vl' PERMIT & ATC ` Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 Q�--- APR 2 6 2001 ENVIRMi'i;i, .0H DIME .::...._ ;__._._.... ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I PROVIDED. Refer to the INFORMATION BULLETIN for instructions. CAWIXII'S PaPeI6 IN- RDt,; d C6-iQ06C(( 1. Name to be Billed l!IuAIIIV es, c- Contact Person IJ, Mailing Address 9000,4i}AQrit V 11��41� C 1 . Home Phone 33G — 79 5- :� R City/State/ZIP 01i'1 I. - St}rLbi . rUC- Z7l 2 ^I I Buainass Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ,� Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: House,, ❑ Mobile Home ❑ Business ❑ Industry Other SK rV�SiCA% S. If Residence: #People #Bedrooms iz #Bathrooms ..,� -- ,Z � ADishwasher Garbage Disposal Washing Machine ❑ Basement/Plumbing Q( Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats t, 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 V No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFOR,'%I TION rEQL'ES'i'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # . 5 % 7 7 2 3 ` 1 , ,� d 3 Property Address: Road Name City/Zip �(yui,4fvc �. /�CrU06 If in a Subdivision provide information, as follows: Name: _>'-{-I k Drs Section: flAk Block: Lot: —� WRITE DIRECTIONS (from Mocksville) to PROPERTY: L -J 6 y e A S i n r,� A -A A on) reeA 1Y4 M. + (e c tJ 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 avie County Health Department to enter upon above described property located in Davie County and owned by 1�ua(� rU r it ay,.___. to conduct all testing procedures as necessary to determine the site suifAb lity. DATE �I j�ly( SIGNATURE THIS 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). 0 Revised DCRD (07/99) , 3 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. La Invoice No. Z`f —4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001720 Tax PIN/EH #: 5777-33-1382.03 Billed To: Campbell's Quality Propenes, Inc. Subdivision Info: Still Waters Phase 1 Lot # 3 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: � 1_ok) Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit Public ! Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 3 HORIZON I DEPTH - O Texture group��- Consistence 'S • r S Structure cnk 62 Mineralogy 1_1 ; HORIZON II DEPTH - 2 Texture group Consistence Structure S Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE Q• 3� SITE CLASSIFICATION: t J LONG-TERM ACCEPTANCE RATE: 0 REMARKS: LEGEND Landscaue Position EVALUATIONBY: S,C-- .Y"VGNAMP 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 DCHD 05/99 (Revised)