158 Peace Court Lot 6DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003915
Billed To: Long Builders, Inc.
Reference Name: John Long
ATC Number: 4406
Tax PIN/EH #: 5777-33-1382.06
Subdivision Info: Still Waters Lot # 6
Location/Address: NC HWY 801 S.-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 1 I of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE NS IS ALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: O
CERTIFICATE OF COMPLETION
i
**NOTE** The issuanc of this 6erfificate of Completion shall indicate the system described on Improvement/Operation Permit
has been insstalled,i/ #mpliance with Article I I of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal�ystem ", ,but shall,in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given peiiod o jtimq.,
Ae a [ "o CCirA �
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
' P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003915
Billed To: Long Builders, Inc.
Reference Name: John Long
Proposed Facility: Residence
ATC Number: 4406
Tax PIN/EH #:
5777-33-1382.06
Subdivision Info:
Still Waters Lot # 6
Location/Address:
NC HWY 801 S.-27006
Property Size:
0.70 acres
Site Type:Xew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
-� Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms 'S # Bathrooms Z # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size O.?1�L=c=S Type of Water Supply:.01County/City El Well ❑Community Well
w�
System Specifications: Design Wastewater Flow (GPD) �-''� Tank Size L7LGAL. Pump Tank GAL.
n /
Trench WidthS� Max. Trencchh Depth Rock Depth MIA Linear Ft. Zco
Site Modifications/Conditions/Other: �.CC1� 2� ot��lo.3
C c • !roil , l4. �'_�FF , - -
Contact the Davie County nAronmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Civ �a%0
l Wr
ICU
MOO PAW154>
t�.
r_7t]<-
y5
1= f�v�1T
Environmental Health Specialist Date: 2 27
DCHD 11/06 (Revised)
I U
W_ /_I IN I .IF F. 1F-4 ",all
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 I ^ I
Uc `
IMPROVEMENT/OPERATION PERMIT
Account #:
990003915
Tax PIN/EH #:
5777-33-1382.06
Billed To:
Long Builders, Inc.
Subdivision Info:
Still Waters Lot # 6
Reference Name:
John Long
Location/Address:
NC HWY 801 S.-27006
Proposed Facility:
Residence
Property Size:
0.70 acres
**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 CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type t6o&- #People #Bedrooms 3 #Baths ;?--
Dishwasher:
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 lAV Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size 1C*0 GAL. Pump Tank
Other: hCcu-pvia) 2ff��
Required Site Modifications/Conditions: lr�,)
GAL. Trench Width S (; ' Rock Depth `A Linear Ft. 221S I
IMPROVEMENVOPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Dartment for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1 g ttl. otyth iy of installation. Telphone # is (336)751-8760.****
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Environmental Health Specialist's Signature: Date:
cow
DCHD 05/99 (Revised)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
DAyie-Co ealth Department � ��P-�lP�y
(� �v�o t Health Section
Q .O. Box O Hospital Street it W�tv peod /t
c , NC 27028
�i AY
j36 i-87160/ ax (336)751-8786
Application For: ❑ Site E aluati!!W]11)1M01ECP-01U1
tP,�i"t Authorization To Construct(ATC) ❑ Both
I11y
***IMPORTANT*** TH ATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Zoj! 4,4
Contact Person
0;J'w 46tiy
Billing Address /,7,02 Z
st✓irvi �.r
/, .Q-�•
Home Phon077-746-
.5-6 2 f
City/State/ZIP
'7d 7-3
Business Phone ,
774 - AYV- 5'917
0Yes44310
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
Ci
NOTE: A survey'plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Street Address K ]-Iyyq City MV4tioe, Tax PIN#
Subdivision Name �$'t.//W�- Section/Lot# 6 Lot Size , , 70 AG
Directions To Site: 9 X S. s7` o TiC & Ag"
7Z 04/ .�6,ocE G f_ /�-� .,r o,�..a-:�6� z� «, d ceele,4sic.
Date House/Facility Corners ,Flagged s//d/06
If the answer to any of the following questions is "yes", supporting documentations ust be attached.
Are there any existing wastewater systems on the site?
❑Yes; o
Does the site contain jurisdictional wetlands?
❑ Yes ; No
Are there any easements or right-of-ways on the site?
❑Yesj2No
Is the site subject to approval by another public agency?
❑Yes •0�4o
Will wastewater other than domestic sewage be generated?
0Yes44310
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms y -F # Bathrooms L Garden Tub/Whirlpool ❑Yes two
Basement: ❑Yes PJNo Basement Plumbing: ❑Yes
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: conventional ❑Accepted ❑Innovative ❑Alternative ❑Other.
Water Supply Type:ZCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
W.
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 to determine compliance with applicable laws and rules on the above described property located in
Davie County and owned by
q-
Property er's or ownea legal representative signature
S sy v�
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Sign given ❑Yes ❑No Account #
Revised 2/06 Re 4 Invoice #
�,JEv3 MAP LOT- CO
rg
APPLICATION FOR SITE EVALUATION/]NIPIIOVEAIENT PERMIT & ATC VEANPR
` Davie County Health Department
En wronmental Health Section 6 2001
P.O. Box 848/210 Hospital. Street
Mocksville, NC 27028i;
(336) 751-8760 ENVIROt. iLTH
***.IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed CA/i,�/,4rIi' i S hu'�
alk Prt t' / 1 'S, Lu'(. Contact Person 'RD/,;Ad
Mailing Address ,900r(An
0 _ 440 l V�1 ��e' 1 +. Home Phone 33 — 95 -
City/State/ZIP AJC 1-7121
Buoinass Phone
2. Name on Permit/ATC if Different than Above
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 111, Other Stt0 .;vi5icn1
5. If Residence: # People # Bedrooms 3-q # Bathrooms '� -
Dishwasher Garbage Disposal 1 Washing Machine p Basement/Plumbing Q( Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City 0 Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes !if No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE R)-7QUIRL'D PROPEItT`; INFOR,%IATi-ON I:EQL'ESTED
BELOW. Either a PLAT or SITE PLAN MUSTBESUBM17TED by the client with THIS APPLICATION.
Property Dimensions:
kg
Tax Office PIN: #.-5-:z-7,7 3 3 - / , )b �V
Property Address: Road Name
City/zip 0An,cz . /IC.q7()()6
If in a Subdivision provide information, as follows:
Name: O Ft- ul r 5
Section: q SQ Block: Lot: /A
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
�-� LJ b e A s+ h Sy 1.
ri kf PAA op reed 'jz M'i le 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 theavie County Health Department
to enter upon above described property located in Davie County and owned by �Au�!Ix� �I�iua1_L., pryjjrd()(!�, :iN(
to conduct all testing procedures as necessary to determine the site sui ib lity.
DATE/ jowl SIGNATURE �2tiw
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).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. ,-.'Z'
Revised DCHD (07/99) Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
�Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-1382.16
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 16
Reference Name: Location/Address: Hwy 801-27006
Proposed Facility: Residence Property Size: see map Date Evaluated: 5 D
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
L
Sloe %
Lf I&
HORIZON I DEPTH
C2 -11
Texture group�-
Consistence
SSS
Structure
Mineralogy1
1
HORIZON II DEPTH
1
Texture groupC
Consistence
Structure
Mineralogy)
)
HORIZON III DEPTH
1 `b'
Texture group�+
Consistence
%SS
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
'S
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
Q .
SITE CLASSIFICATION: PJ
LONG-TERM ACCEPTANCE RATE: O
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
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
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)
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APPUCATION FOR SITE EVALUATION/IMPROVEMEW PERMIT & ATC
Davie County Health Department
. Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
�M4tOT73
APR 2 6 2001
ENVIIiOFJ is , i0li
DAUI; , ..
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
REQUIRED
INFORMATION IS
PROVIDED. Refer to
the
INFORMATION BULLETIN for instructions.
F}ltiU�9L��Sh,0AtJV4 PoTpe
fiK,�14
RL'PAO
b. CAlLy6ei1
1. Name to be Billed
Contact Person
Mailing Address
9000 .`�AAOti: V � t� �
1 1 .
Home Phone '33� ' /
Q 5- �71
City/State/ZIP
I ,�I
(NilU/J-.�iIP.L1 /�/(^
1-7117
Business 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 OtherSt�� �V�Slr!✓
s. If Residence: # People # Bedrooms 3—q # Bathrooms
ftDishwasher X Garbage Disposal �, Washing Machine ❑ Basement/Plumbing I)( Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: �( County/City ❑ Well ❑ Community
a. 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 RECUIP.rD PROPERTY INFOlMmATION RE
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: #5---777- 3 3— I a, O
Property Address: Road Name 11W
City/Zip A 088 AI RZ006
If in a Subdivision provide information, as follows:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
r � � � Pf Dly CeeA 114 M.. (e 0 r.%
Name: S+I It
Section: &Se Block: Lot: 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 theI,javie County HealthnDepartment
to enter upon above described property located in Davie County and owned byW6� rrUitnzrti_�ri•�c , __
to conduct all testing procedures as necessary to determine the site VZ:69
%- C
DATE 3I $0 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
Da te(s):
Client Notification Date:
EHS:
Account No. / -7 �- a
Invoice No."--
. ,. DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-1382.06
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 6
Reference Name: Location/Address: Hwy 801-27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
O11
FACTORS
1
2
�3
4 V 5 6 7
Landscape position
1'✓
Slope %
le;
00
HORIZON I DEPTH
O - 20
69`'7
Texture group
C -)LL_
S Cly
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Y -f"
Or`
2D - 141
Texture group
G
;
Consistence
/-
Structure
S /
g
Mineralogy
,
HORIZON III DEPTH
-
Texture group
Sa117r,
i
Consistence
'
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
^
CLASSIFICATION
S
SOS
LONG-TERM ACCEPTANCE RATE
, C
Com,
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS: cre r x%%14 n r
Landscape Position
EVALUATION BY:
OTHER(S) PRE/SENT:
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)