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165 Redmeadow Drive Lot 30Account #: Billed To: Reference Name: V DAVIE COUNTY HEALTH DEPARTMENT d Environmental Health Section { P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990002811 Tax PIN/EH #: 5861-37-1875 Stafford & Reader Enterprises Subdivision Info: Redland Place Lot # 30 Location/Address: Redland Road -27006 ATC Number: 3702 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 WAS WAT O ON IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Sign e: Date: C�Aalaq 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 WAY be taken as a guarantee that the system will function satisfactorily for any given period ogtime. v T- '737 7s Septic System Installed By: Environmental Health Specialist's Signature: Date: �Z DCHD 05/99 (Revised) ' DAVIE COUNTY HEALTH DEPARTMENT ai Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002811 Tax PIN/EH #: 5861-37-1875 Billed To: Stafford & Reader Enterprises Subdivision Info: Redland Place Lot # 30 Reference Name: Location/Address: Redland Road -27006 ATC Number: 3702 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 WAS ON IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: e3ltu 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 WAY be taken as a guarantee that the system will function satisfactorily for any given period ogtime. I � 1 r V17 �-- 4 T q %St tR 7,S g' Septic System Installed By: Environmental Health Specialist's Signature: Date: 12 DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section •• • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002811 Tax PIN/EH #: 5861-37-1875 Billed To: Stafford & Reader Enterprises Subdivision Info: Redland Place Lot # 30 Reference Name: Location/Address: Redland Road -27006 Proposed Facility: Residence Property Size: see map **NO41gE l%,slmprovement/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: BuildingType H #People #Bedrooms #Baths2' J Dishwasher: 10" Garbage Disposal: d Washing Machine: Q Commercial Specification: Facility Type #People Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People/Shift #Seats Industrial Waste: ❑ Lot Size p:-748 A ESType Water Supply CV0413W Design Wastewater Flow (GPD)3%C7 Site: New C?� Repair ❑ 1�GAL. Pum Tank GAL. Trench Width " Rock Depth 1�� Linear Ft." System Specifications: Tank Size p ep Other: 3 �� l ort&3 loCsi& Required Site Modifications/Conditions: U •� 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.**** Dip. L_1-3 , I APF c . 7a' $ Id µi.S . — • 1 ,-%l� 0 ol �wv� 400&� 3 BR W Environmental Health Specialist's Signature: DCHD 05/99 (Revised) -)r � 1 ��-Q 1:011 SIM [VALUATIONIM111110VOICNC I'01MIT & M -C Davie County Health Department Envirofl111W a/flealf/1 Section 0. Dox 848/210 Hospital Street Nocksville, NC 2702£3 (336)751-8760 ***II•SPORTANT*** TRIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRED I INFORMATION IS PROVIDED. Refer fto the INFORMATION BULLETIN for in:, tr�ui c tions . 1. Name to be Dilled 6twAotl�l `�ge,71ly- ft, te Df,Je5 Contact Person 5-45t':t-//���_C��y Mailing Address PIA &Y -IN !tome Phone j j -, % 1-1 __..__.... [_..._ Al(:-siness Phone ✓�5 074 / City/State/ZIP ,Cl2K1/YtOi'r$ /1/.2%�%� 2. Name on Permit/ATC if Different than Above Mailing Address 7. Application For: ❑ Site Evaluation Cit State/'Lip �/' Improvement- Permit/ATC L1 1)otlt 4. System to Service: 51 House ❑ Mobile home ❑ nusinets ❑ Industry ❑ Other 64 5. Type system requested: LJ Conventional ❑ conventional modified ❑ innovative G. If Residence: 11 People � I1 Bedrooms -3 I! l3athroaut; 9Dishwasher 2/Garbage Disposal ru Washing Machine ❑Basamen t/Plumbing ❑Easement/lio Plumbing 7. If Busincaz/Industry /Other: verity type # Commodes # Showers IF FOODSERVICE: # S L's 8. Type of water supply: OG County/City # People 11 Sink:; # Urinals 11 WaL•cr Coolers _ Estimated Water Usage (gallons par day) ❑ Well D Comliluni t -y S. Do you anticipate additions or expansions of the facility this Systciil is hitcudc(i to serve': ❑ yes iryes, wliat type? L***1M1'0RTAjYY*** CLIENTSIVUSTCOAH'LtTLi THE R QUIRE'D PROPERTY iN1�ORNIATION W!"Q111i'1SED �I BELOW. Eitlicr a PLATorSITE PLAN r1IUSTBESUBKITTED by the client willi THIS APPLICATION. ilz �y4441- iitl'fE 1 roperty Dimensions:G Front- 5�d >!s 130 11 IU11ZI;Cl'IUNS (ui 11 fru•Iucksvillc) to I ItUI !;ti'l'l': Tax Office PIN: fl 5W 37 /�1> �a U reworC15 aetjlln0e/S Property Address: Road Nanie �e��a �1G1 �- e -r/ f' O"rl Iledh 7G-1 &l. . City1zip Adv, - 11c -C � - e �t i 1, �o If"441/c1 / �r; -e If in a Subdivision provide jnforniatiojt, as follows: Lot #-30 lotnv Lbw hW -r�- Cvkle--;�C- 121- Natuc: t'�l A tiLi I Ig C Sccliou: Block: Lot: JO Date !tonic corucrs flagged: _3 — y ~ 0 This is to certify that ilia jnforaiation provided is correct to the best of lily ktiowledge. I understand that any perniii(s) issued hereafter are subject to suspension or revocation, if the site plails or jntendea use cli:uige, or if iiia iuloraiation subutitted in this application is falsified or chauged. 1,, also, undershirt [hal I aur reshuusible for rill Charges iucur•r ed.Jruui thisapplicaliou. I, licreby, give conscut to the Authorized Representative of the Davie Comity IIealth I)ep:u•(uicu( to enter upon above described property located iii Davic County and oiyiied by u4ite5 r to coatduct all tes(fng procedures as accessary to delerniine the site suitability. „ DATE 3 '6_0q SIGNATURE TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAKIticlude all of the f'ullowhig: Exfsling acid proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given_ RtAlid DCHD (05103 Site Revisit Charge Datc(s): Clicut Notification Date: EIIS: Accouut No. Invnirt Nn. ~� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department U EnvironmentaiHeaith Section DEC P.O. Box 848/210 Hospital Street 3 2 Mocksville, NC 27028 (336) 751-8760 ENV�RONM fN DAVIfCO�i HFAit ***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 Mailing Address City/State/ZIP 2. Name on Permit/ATC if Different than Above Contact Person Home Phone LlY'K- 7/D �? Business Phone P4?—/W35- Mailing Address City/State/Zip 3. Application For: P-tite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: Ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms .� # Bathrooms � Dishwasher ❑ Garbage Disposal ❑ Washing Machine Basement/Plumbing CI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: R—County/City ❑ Well ❑Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? EHfts ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # J9 ,'39- ;199 7.3— Property Address: Road Name zhl4Jt/i ,2/ City/zip WRITE DIRECTIONS (from Mocksville) to PROPERTY: /-5-g-j r� 4 -J- / �0 �� arc, ,21 L If in a Subdivision provide information, as follows: Name: v Section: Block: Lot: 3--f�'LOT'36ate Property Flagged: ^3--- t) 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 Davie County Health Department to enter upon above described property located in Davie County and owned by an,�T� L ftf 5 to conduct all testing procedures as necessary to determine the site suits ility. DATE� -----. _-_ _ SIGNATU , i 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: •5 Account No. Revised DCHD (07/99) Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900136 Tax PIN/EH #: 5861-38-2199.32 Billed To: Westview Development Co. Subdivision Info: Louise Smith Adams Lot # 32 Reference Name: Location/Address: Redland Road -2700 Proposed Facility: Residence Property Size: see map Date Evaluated: 2 ��-- Water Supply: Evaluation By: On -Site Well Auger Boring Community / Pit Public -� Cut FACTORS 7Dt 3 4 5 6 7 Landscape position L Sloe % L420 HORIZON I DEPTH © - to 0-A Texture group CL, CL., Consistence (CSS Frss Structure Mineralogy HORIZON II DEPTH I J - 3 l In '3tP Texture group Consistence Structure$ Mineralogy HORIZON III DEPTH 33-,- Texture group t -S Consistence r �$ Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 3S SITE CLASSIFICATION: (7s 4�'-F LONG-TERM ACCEPTANCE RATE: ©' REMARKS: K al LEGEND Landscape Position EVALUATION BY--< 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 F1- 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) oaf 30 fedlW PL Davie County Health Department 46jfi Environmental Health Section , P.D. Box 848 .. ED 210 Hospital Street J �� k O ,RF,CEjV,I'Courier # : 09-40-06 ZT 22 '�i Mocksville, NC 27028 Date. l� Phone: (336) - 753 - 6780 Fax: (336) - 751- 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: IQIS506U—L'�C)N�q�EE� Phone Number —S41 (Home) Mailing Address:: f 2F—o MEA kxzz7)0 VCf 4 I (Work) &MMU- UC— 61:70'Q)(4 Email %%1 YYl i -O ccaI(� 1(A�1GCy. 0-0 Y1'1 Detailed Directions To Site: 40 1 T- x'11 A--. 4 J n� C 1''`S�C �7 a- ' - Please Fill In The Following Information. About The EXISTING Facility: Name System Installed Under: -'1"rd Type Of Facility: u� Date System Installed (Month/Date/Year): Number Of Bedrooms: 3 Number Of Peop e. vZ Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any.Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: --a = Number Of Bedrooms: 0 Number of People d Requested By: ���- Date Requested: � -� (Si re) For Environmental Health Office Use Only Approved Disapproved ments: - -- Environmental Health Specialist�CDate: *The signing of this form by the Environmental Health Staff is 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 Check Money Order # Amount:$ Date: Paid By: Received By:_ Account #: 6AS2- Invoice #: L XL%, error r 1,tTarning,:c-%IItI,I{e'gaLMediaSize _ I 1 _ 1 - Il II II Il II -� IIII �,i1 I 1 1`f_II AA v ty Printed:Mar 18, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. I ' , I.