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195 Redland Road Lot 1r , r' DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: Proposed Facility: Residence ATC Number: 3670 Tax PIN/EH #: 5861-38-2199.01S Subdivision Info: Redland Place Lot # 01 Location/Address: Redland Road -27006 Property Size: see map 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 WASTE WA S R N IS FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:Date: )c)q kit CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on 1pro tiro�it_ has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .19 0 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system 11 function satisfactorily for any �a given period of time. G O 0 is l U' 9DV'z:A-, Septic System Installed By:�- Environmental Health Specialist's Signature DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT l Environmental Health Section oC P. O. Boa 848/210 Hospital Street -2- /7 ' Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT �� �riK/� kol- Account #: 990000955 Tax PIN/EH #: 5861-38-2199.01S Billed To: Samnaz, Inc. Subdivision Info: Redland Place Lot # 01 Reference Name: Location/Address: Redland Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3670 **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 I 1 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 f WSE #People #Bedrooms H #Baths .2, 5 - Dishwasher: Dishwasher: 1?r Garbage Disposal: 12' Washing Machine: 1�r Basement w/Plumbing: ❑ Basement/No Plumbing: 12" Commercial Specification: ` Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size b. 15$ �- -&ype Water Supply tel" Design Wastewater Flow (GPD) © Site: New Repair ❑ System Specifications: Tank Size /OCQAL. Pump Tank GAL. Trench Width Rock Depth %Z h Linear Ft. yLe� Other: Required Site Modifications/Conditions:Z 6Ll t. , a,s 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.**** mewlsn, `-fi 1 C Tam 1- UOT -S Mvs-T - r 15 SLA 0 � N A U 3g' Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 1.1, 6tiOR1 5 WUA�- Icy- P V42D t^, r��►c��s to �- �-- Date: =jq )(::o DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000955 Tax PIN/EH #: 5861-38-2199.01S Billed To: Samnaz, Inc. Subdivision Info: Redland Place Lot # 01 Reference Name: Location/Address: Redland Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3670 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 WASTE WAT S R N IS A FOR A PERIOD OFIq FIVE YEARS. Environmental Health Specialist's Signature: Date: d CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .19 0 "Sewage Treatment and 1`J Disposal Systems," but shall in NO WAY be taken as a guarantee that the system 'll function satisfactorily for any o given period of time. t 150 f To 7)j 1� DAPI 3 7 Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) ' SAMNAZ,INC. 3367746700 01/27/04 OS:46pm P. 00Z It; ' Davie County Health Department F✓iYironmenta/Hca/thSectran �,�� �. P.O.. Dox 848/210 Hospital Street tlocksville, NC 27028 (336)751-076D **•D11P011TANT*** THIS A''PLICATION CANNOT BE PROCESSED UNLESS ALL TUE REQUIREA) INFORMATION IS PROVIDE:). Refcr to tho INFORMATION BULLETIN for inaL):uctions. I. Nave Lo be Billed — ��]N+Ly`�i�r L 5�1�+ CooLaCL YorJon 17, Nailing Address t� TZ\ l.uti"'�C,1,t/�rj �,.� lloa�c 1'bonc 1 ( U' City/ZtaLe/ZIPt/� ��- �� Duaineas phase Z. Namo on Permit/ATC if Diffcrcat than Above ) cky.`` —'—"'- Bailing Address _y`'�-`-- city/State/Zip 3. Application ror: ksite Evaluation 0 Improve mauL 1'ex'sit/ATC LI boUt <. Sistem to service: IkEouse ❑ Mobile Home D liuninauw ❑ Industry U Ott3cx 5. Type system requested; Conventional ❑ conventional modified G innovative 6. If Resid(nce: It Peoplc_ @ Bedroom _ 4 llatllroo:u:. .Z 1r2 Jkiahxashez IIarbage Dispoaal mashing Machina 08ascuient/Plumbiny asuemue/No 14.n,L; of 7. It DUD1De35/Indu3try /Othor; verify type c People Y Couurode3 A Showers &Urinals U water coolw" IF FOODSERVICE: JI Seata Eatiatated water linage tryallono per day) __ ... 8. Type of water supply; K-CotuLLY/City ❑ well ❑ Coinmunity{� 9. Do you anticipate additions or ezpallSiolts of 111c facility this S)•Slcnu is iulcndell lu serve? ❑ Yes Liu Uyes, 01st tI j10 •••IBIPORTiLV7' CLIENTS.i1USTCOd1PLL7CT11E K -C)IM C'D PROPERTY IN ORIVIATIOIY ifELO%V. hither n PLAT or SITE PLAN hlt/ST BE• SURA1177WO by the client s1•it11 T1115 APPLICATION. PropcAyDintcnsiolls: 2 21 X [ ��a Y O 1$It[1'1 UlJ1L'C77UNS {Arum hlucls�illc) nu Plcu1 l.rt n Tax Office PIN: fl e / "3� - a ( 9 Properly Address: Road Name VC. L -U -J ci(yrzip_ 1*�- 11, If in a Subdivision provide infurnlatiou, as follows: N2111C. 2i �C-c Section: Block: Lot: Date Itonte corners flagged: This is to certify that the iuformatiou pro,ided is correct to tim best of lily ILAOLCIL•dge. I understand that any permit(s) issued licreafter are subject to suspension or revocaliou, if the sire puns or inlcuded use change, or if the informal !on subtaii(ed in this application is falsified lir ehaltgcd. I, also, audersfand that I 11811 r esporesible for ail charges incnrl ed lranr this application. I, hereby, give consent to the Authorized Representative of Ifit: Vavic CUU)Jt)• lie. 1fla Della rttriellI to enicr upon abore described properly Jo,:ated in Davie Cumay and uuned by to cuaduct all testing procedures a�s�)neceessss:uy to deterusiue (tie site suitnbI-A DnrI: THIS AREA MAY BE USED FOR DRAWING YOURSI`i'E PLAN (Inclai Lxist' nrupused property lines and dimensions, structures, setbacks, and septic locations Silc Res•isit Cllarl;t Clicat Notificatital Date: EI3S: � C ! q 0000 S APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT O Davie County Health Department Ellvifwmenta/Health Section QFC P.O. Box 848/210 Hospital Street 3 xo2 Mocksville, NC 27028 (336) 751-8760 RONMfNT �AI%fCO�t NFA1J)y ***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 V) V Contact Person Mailing Address 6:j/ 1/1 )Ci�/y' LL Z<"4 vv�� / Home Phone City/State/ZIP b��✓ e l�, oe%Q l0 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: P'5ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ouse ❑ Mobile Home ❑ Business ❑ Ilndustry ❑ Other 5. If Residence: # People # Bedrooms .� !�^� # Bathrooms" o Dishwasher ❑ Garbage Disposal U Washing Machine Basement/Plumbing ❑ 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-1(�,ounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? fomes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # 9 7 • Property Address: Road Name L 0-/ City/Zip If in a Subdivision provide in rormation, as follows: Name: �— Section: Block: Lot:_ WRITE DIRECTIONS (from Mocksville) to PROPERTY: 1-529")6,44-1 �� 0-A, L AP -01 A '0 0&�' Date Property Flagged: lr�7 ^-3" 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 an 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 _cS4'_& 5 to conduct all testing procedures as necessary to determine the site :sVuitaility. DATE SIGNATU _ 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. 18'1 0 -0 3 Invoice No. -3-3 r . 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: PROPERTY INFORMATION Tax PIN/EH #: 5861-38-2199.01 Subdivision Info: Louise Smith Adams Lot # 01 Location/Address: Redland Road -27006 see map Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L C_ Sloe % 70 HORIZON I DEPTH � — it f� - fo Texture groupC Consistence S sr SSS Structure CT Mineralogy1= 1 (�^ HORIZON II DEPTH —2Co - o Texture groupG Consistence Structure 1c is Mineralogy HORIZON III DEPTH 2(0 Texture group Consistence r SS S S Structure S Mineralogy1` 1 HORIZON IV DEPTH `d Texture group Consistence Structure Sok Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: CSS LONG-TERM ACCEPTANCE RATE: ©• ` REMARKS: Landscape Position EVALUATION BY: OTHER(S) PRESENT: "- c, r'wTrL'„Z& F u 2 & qt.• 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) SAMNAZ,INC. FROM : PHILLIP R BALL CO TN/- TWAKWO IS NOT FOR RECORDARON n 3367746700 FAX NO. : 3369455268 NOT A CERT/RE0 COPY fON !LWSTRATIOU fURMSE 0lVL r 01/27/04 05:46pm P. 001 Jan. 26 2004 03:35PM PI f REDLAND ROAD SR 1442 CrN 40 � 40 1ju 120 GRAPHIC SCALE — FEET Phone: (336) - 753 - 6780 wavav0a ieCounty Health Department Environmental Healdi Section P.O. Box 848 R,ECENE 210 Hospital Street Courier #: 09-40-06 Date; Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 klm-a'-4j33� �0o7asz Name: ' �IQsS r 2 Phone Number (Home) Mailing Address: oc iee (Work) ' va �,we- l � 0 5j 3��Co2 Detailed Directions To Site: / Li i " 250 o 8756LLI, i i 7 L 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 j 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 U N� 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 S data provided by this website. Pr-Inted.Jul 27, 2016