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152 Redmeadow Drive Lot 23DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900573 Billed To: Glenn Johnson Builders Reference Name: Proposed Facility: Residence ATC Number: 3657 Tax PIN/EH #: 5861-38-2199.23 GJ Subdivision Info: Redland Place Lot # 23 Location/Address: Red Meadow -27006 /54 Property Size: 3/4 Acre /5Z Redw4o A21' ve" 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 CONSTR IO S V7 FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate: rJL CERTIFICATE OF COMPLETION © H t� **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 0, has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and N'� 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)<{ -V,131 1 i3' Septic System Installed By: I -- Environmental Health Specialist's Signature :, DCHD 05/99 (Revised) Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section . • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900573 Billed To: Glenn Johnson Builders Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5861-38-2199.23 GJ Subdivision Info: Redland Place Lot # 23 Location/Address: Red Meadow -27006 Property Size: 3/4 Acre ATC Number: 3657 **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 #People #Bedrooms 1 #Baths 2 Dishwasher: G! Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: 2� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size eDD�ype Water Supply `^' Design Wastewater Flow (GPD)oriry '7 O Site: New Repair ❑ System Specifications: Tank Size /1000 GAL. Pump Tank GAL. Trench Width 3110 Rock Depth 12- Linear Ft. 4(66 Other: �9 lei5M6VTrori -9PY , liJ- Ml _ Q4tS O•C. AA 14/1 Required Site Modifications/Conditions: Lti5 I LL CQ C.orl t-ott 5 f ; 99 c tc-- cD64-� P"• Z-1jt 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 th of installation. Telephone # is (336)751-8760.**** Gn �D EnvironnWtal Health Specialist's Signature: DCHD 05/99 (Revised) ��� U•�� S r.s c�RD� ate: / D (, }� API' FOII SITE L•Vf1LUAT10N/IhIPIiUVG11L"V'C PLlirlilT a JiTC Davie County Health Department 6 Environn7CnA71Hes/t/1 Section P.O. Box 848/210 Hospital Street- P`HEA�� Mocknville, NC 27028 (336) 751-8760 * * *IPOR * * * THIS APPLICATION CANNOT DL•' PROCRSSLD UNLESS ALL THEREQUIRED ` INFO TION IS PROVIDED. Refor to tho INFORMATION BULLETIN for illstructa.on.r. 1. Name to be Billed ('t�s,II:I L/GG�/.r5" ��/'- /`� ��� Z-"1eContact Person Mailing Address �j/I7 1.9116;r i!�e/,//' he/ Home Phone City/State/ZIP /Tr"/<v/t , Y 11L, 27ee'G yfz 'SE�r7 2. Name on Permit/ATC if Different than Above ____...._.__.._. Mailing Address Ciityty/StaLc/Zip 3. Application For: ❑ Site Evaluation l- Improvement Per)nit/ATC Ll ISuCh 4. System to Service:IL�3' Iouse ❑ ISobile FIome ❑ Businc!,-s ❑ Industry ❑ Otl,cr 5. Type system requested: L -Conventional ❑ 'conventional modified ❑ innovaL•ive 6. If Residence: It People 0 Bedroou►S it Bathioulm; []Dishwasher ❑Garbage Disposal ❑Washing Machine 0Bascmen�L•/11l�umbing ❑Uai einent/Ifo Plumbing 7. If Business/Industry /other: verify L•ype 11 Pcoplc It sinks ...... _ ff Commodes It Showers 11 Urinals It WaLcr Coolcr:, IF FOODSERVICE: # Seats. Ei3timated Water Usage (gallons per day) S. Type of water supply:,•1 —60-linty/City ❑ Well ❑ Coliununil'y 9. Do you anticipate additions or eXpalisions of (hc facility this s)'sicln is ililcii(icd (o sei'1 e? ❑ yes t_ u If }'cs, what (3'1)C? ***11I.00I1TiINT'°** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION !tls(?IlliH'i'I;ll BELOW. Either n PLAT orSITE PLAN MUSTBESUBUITTED by the client with'1'IIIS APPLICATION. Property Dimensions: ,e� n —{ _ 1YRITI; WRLCTIONS (from llluchsville) lu I'ItUI'l;it'I'1': 1'aa Office PIN: if ;5790 23 l i 44 e4%. Pro pert Address: Road Nanic �d� J�[y� ,� e- f/LJ / J , A.),,',-' 1 Y /'/ \ K-Gi.� � (� . / /'(� -T C� f;'I /��i'i:�. L�t�l City/Zip If in a Subdivision provide information, asfollows: Nance: �a _� d PA C_ �— Section: Bloch: Lot: Date Donne corners flagged: q V y This is to certify that (lie information provided is correct to the best ofiny knowledge. I understand that any pern)il(s) issued licreafter are subject to suspension or revocation, if the site plans or intended use change, lir if the information subn)itted in this application is falsified or changed. 1,, also, understand that I ani responsible joi- all chal3'es uuvu•rrd %rum this application. I, hereby, give consent to the Authorized Representative of (lie Davie Cuuuty Iical(1( I)CI);n•luicnt (u enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine (lie site suitabilivy. / DA'I'S AA- C� SIGNATURE TIIIS 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). Sign giver) Iteviscd DCI D (05103 Site Revisit Cluu•ge Client Notification Date: EI -IS: Account No. "' 00 3 Invoice No. � • r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT 0 �� • Davie County Health Department Environmental Health Section DFS P.O. Box 848/210 Hospital Street 3 2oo2 Mocksville, NC 27028 (336) 751-8760 EN4tDON SAV/E ENT yEA1Ty ***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 i e �/ Contact Person % Mailing Address '2( f �,� � /�� Home Phone .�ge r�-- City/State/ZIP �G� ���71,0 Business Phone 22 2— &S5- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/zip 3. Application For: Lsite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 171L, Dishwasher El Garbage Disposal H Washing Machine Basement/Plumbing O 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: R-Iounty/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? B -yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # "� ; •3�'' a2 9 % Property Address: Road Name L. r / City/Zip If in a Subdivision provide informatioQ, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: /.��EA-5-/ /'0- C�� arc, Name: Lyyr 2 S `J MIA /4+-ta M AV - Section: Block: Lot:at�jl' Dr ate Property Flagged: Z2 ^3 e9 This is to certify that the information provided is correct to the best of my knowledge. 1 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. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitaoility. 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 Datc(s): Client Notification Date: EHS: Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT E' t I H Ith S f "Y 1%J"111en a ea ec ion • SoiVSite 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 #: 5861-38-2199.25 Subdivision Info: Louise Smith Adams Lot # 25 Location/Address: Redland Road -27006 see map Date Evaluated: 2 Community Pit Public Cut FACTORS 1 24 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH - - Texture group Consistence of S Structure Mineralogy1 HORIZON II DEPTH 1 - Texture group Consistence ; 5 Structure S. C un Mineralogy HORIZON III DEPTH - p Texture group Consistence V 1nl FIT, Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE 5; ()_1 CLASSIFICATION S LONG-TERM ACCEPTANCE RATE D "n • 3 SITE CLASSIFICATION: P 5 LONG-TERM ACCEPTANCE RATE: ' 3� REMARKS: EVALUATION BY: B EA Or -4.4 w� 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) Davie County Health Department ' 9 his __1 Environmental Health Section , P.O. Box 848 C� ,S„ 210 Hospital Street O U TA Courier #: 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: Phone Number %�s��� (Home) Mailing Address:,/ cif ^^ /n� T'l.L `� ��y©r �3� (Work) ADL) Email Address: Detailed Directions To Site: 9'7pl- '40023 c d, 5 Property Address: � S�- 12-e-10 �'l6Odu/ lbw t'ig1ZF9'i-lxjgG oI) —3 Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: &' howty JA /1,5C4 Type Of Facility: GCJ Date System Installed (Month/Date/Year): 1512b Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes If Yes, For How Long? Any Known Problems? Yes If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Sc j n �2a?^- /o��k Number Of Bedrooms: Number of People Pool Size: G ize: Other: Requested By: a e Date Requested: A) " (Signature) For Environmental Health Office Use Only =ApprovedDisapproved Comments: Environmental Health Specialist Date: /(� D Leq- *The signing of this form by the Environmental Health Staf s in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash t6ecY Money Order # Amount:$ 100 , U o Date: 1511&7t--z- Paid U / Cz- Paid By: A• n r5o Received By: Account #: 6270 Invoice #: �� d OW ��� ' '�;.... .'1.! J 'j ,� i 1. �v�:, �f� � � ,� � _ ti l Ii r' � �jl ���