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135 Redland Road Lot 33•'f " l DAME COUNTY HEALTH DEPARTMENT - Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 /3d f�ed��doc� Account #: 989900317 Billed To: Glory Home Builders Reference Name: ATC Number: 3709 Tax PIN/EH #: 5861-38-2199.33 GB Subdivision Info: Redland Place Lot # 33 Location/Address: Redland Road -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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:,/ Date: CERTIFICATE **NOTE** The issuance of this Certificate o 11 inc has been installed in compliance w�+��W Disposal Systems," but shall in NO WAY be takensa a given period of time. Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) MPLETION described on Improvement/Operation Permit 13 A, Section .1900 "Sewage Treatment and t t the system will function satisfactorily for any t00 Date: DAVIE COUNTY HEALTH DEPARTMENT" I �,,,: ' • . Environmental Health Section P. O. Boz 848/210 Hospital Street Ce& 7 j Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900317 Tax PIN/EH #: 5861-38-2199.33 GB Billed To: Glory Home Builders Subdivision Info: Redland Place Lot # 33 Reference Name: Location/Address: Redland Road -27006 Proposed Facility: Residence Property Size: see map **NOTES* This'lmprovement/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 Z) #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_ Design Wastewater Flow (GPD) -11// ib Site: New ❑ Repair ❑ System Specifications: Tank Size �b GAL. Pump Tank/ GAL. Trench Width Rock Depth Linear Ft.���1 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_R.m. to 1:30 p.m. on the day of inst lation. Telephone # is (336)751-8760.**** r - Environmental Health Specialist's Signature: Date: l�rl�b1i DCHD 05/99 (Revised) • rh �'L� � M . 2004 'PLICATION 1:011 SIM EVALUATION/iMPROVI• IlIfff PE11i11117' lac A•1'C MAR ' 9 Davie County Health Department 7Yi1onme,7ta/Hea/t/1 Section P.O. Box 8'I8/210 Hospital Street DAME COUNIY ENS' DWMEOUNTYNTAL LTH bfocksville, NC 27028 (33G)751 -87G0 ***IMPORTANT*** TIiIS APPLICATION CANNOT BL PROCLSSE'D UNLLSS ALL "i 3 Q2723� INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN or instructions 1. Name to be Billedb1'3'^" r W - Contact arson �v/ vu�. ..___. Mailing Address -r TOJq- Q"•r.clkJ Nome 'hone City/State/ZIP C 7-70 r 7— Dusineas Phos 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation I Improvement- Permit/ATC ❑ UuLh 4. System to Service: 8'1[ouse ❑ !Mobile Home ❑ Business ❑ Industry ❑ OL•):er ti 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative G. If Residence: 11 People a Bedrooms ' 11 Bathroo►n,; Z • 5 i ❑Dishwasher (Garbage Disposal (Washing Machine ❑Basement/Plumbing Elba semen t/17o Pluiubing 7. If Business/Industry /Other: verify type 0 People 11 sinks # Commodes 11 Showers 11 Urinals 11 water Coolers IF FOODSERVICE: iI Seats Estimated Water Usage (gallons par day) 8. Typo of water supply: County/City ❑ Well ❑ Coirununity 9- Do you anticipate additions or espansious of the facility Ellis sys(cill is intended to serve': ❑ Yes ET -Nu If ycs, what type? _-- ***IAIPORTAjYT*** CLIENTS jVUST C0A11'LB'TL•'TI1L REQUIRED PROPERTY INFORNIATION RE'Q01,Sr1;u BEL01Y. EEtllcr a PLAT or SITE PLAN 41USTBCSU11AlI7`PED by the client with THIS APPLICATION. Properly Dlnicusions: 1':u Office PIN: fl Property Address: Road Name City/Zip If in a Subdivision provide inforniation, as follows: Nanic: 41 Laej PIS e - Section: Block: Lot: WRITE DIRECTIONS (frau► 11luclo%111c) lo PROPI;It'1.1•: C'j Date ]ionic corucrs flagged. This is to certify that the inforniatiou provided is correct to the best of wry I nowiedge. I understand that ally peril►it(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use cll:ulgc, or if the hifornlalion submitted in Ellis application is falsified or cl►augcd. I, also, understand that I aur re3pousible fur all cha►3es inC►u•red.fi-uu: this application. I, hereby, give consent to the Authorized Representative of Ula Davie County IIcalll! llep:u Uncal to enter upou above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE 3-5.1101 SIGNATURL: l THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all 91 tllc follwvia, . ]dill j; and I Iused property lines and dimensions, structures, setbacks, and septic locations). "` Sign given Revised DCHD (05/03 Site Revisit Charge Datc(s): Client Notification Date: ERS: Account No. ,) O Invoice NO. v � 1 • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT IF 0 • Davie County Health Department Environmental Health Section SEC P.O. Box 848/210 Hospital Street 3 Z�Q2 Mocksville, NC 27028 (336) 751-8760 PON A Oq� E��4( PITH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ! e V Contact Person % l/ Mailing Address �j� 3 � I Home Phone City/State/ZIP —,r))-5. e6 , 2 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: P1151te Evaluation 4. System to Service: ouse ❑ Mobile Home 5. If Residence: # People Dishwasher EJ Garbage Disposal 6. If Business/Industry/Other: # Commodes City/State/Zip ❑ Improvement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other # Bedrooms .i # Bathrooms IDLI Washing Machine Basement/Plumbing F1Basement/No Plumbing Specify type # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 9-16o­unty/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? EFYcs ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Cf A-cl- S TaxOfrice PIN: #� "' ,•3�'' �� 9 %'3y Property Address: Road Name / ZZ410«LCA/ City/Zip If in a Subdivision provide informatioQ, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Name: b-��r�h� /M�G�i �— /1u%W MAF Section: Block: Lot: 3�Lar 33 Date Property Flagged: lr;2 — — 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 incurredfrom this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health De�ep//artment to enter upon above described property located in Davie County and owned by ,(/IL,�;OrfEC /�rt��15 to conduct all testing procedures as necessary to determine the site suitapility. 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). Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Revised DCHD (07/99) Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5861-38-2199.35 Subdivision Info: Louise Smith Adams Lot # 35 Location/Address: Redland Road -27006 see map Date Evaluated: Z Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % a HORIZON I DEPTH — Z— y Texture group GL Consistence Structure Mineralogy HORIZON II DEPTH 2 Texture group Consistence E, V; Structure 1 S Mineralogy HORIZON III DEPTH -.601 kto' Texturerou T'AL I n1 Consistence IV IT- (' Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RAT •5S' SITE CLASSIFICATION: r, n LONG-TERM ACCEPTANCE RATE: REMARKS: `umfO -/y LEGEND Landscape Position EVALUATION BY-��5� 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) No ■■ so ■■ No No No ■E■ ■■■ ■N■ ONE ■ ■■MME■■ ■EMEM■■ ■EM■ME■ ■M■ME■■ ■EMEME■ ■■MME■■ ■■■MENS ■■■EME■ ■ENE■■■ ■■■ME■■ ■■■MEN■ ■■mm■■■ ■EMM■■■ ■oommo■ ■■MEM■■ ■■■EME■ ■■■■EE■ ■M■■ME■ ■■■■■■■ ■■■mums ■■m■■mp m■mmads som■s■ ■■NN■■ ■■M■■■ ■■MME■ ■■MEM■ ■ENNE■ ■ENNE■ ■ENNE■ ■■M■■■ ■■EME■ ■E■■■■ ■■M■E■ ■EMME■ ■■NN■■ ■■■o■■ ■E■E■■ ■omm■■ ■E■NE■ ■EMN■■ ■■■■■■ ME==== ■M■MM■ MEMEME ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■MEMENN■M■■■■■ ■ENN■■ ■■■ ■ ■ ■ ■M■■E■■EM■ ■■M■■E■ME■ ■■M■N■MME■ m■EEE■■■■■ ■EMM■■MEM■ ■■MME■■M■■ mmmommosom ■E■M■M■■M■ MEMEMENNEM ■■■■■■mono MEMEMMENME MENEEMEMME EMMEMMEMEM ■EEE■EEE■■ NOMMEMMEEMMEMEMEMMEN NEMEMEMEME ■■■■EMEM■N■E■M■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ No