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131 West Chinaberry Court Lot 20., Account #: Billed To: Reference Name: DAVIE COUN'T'Y HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 990004057 Tax PIN/EH #: 5747-21-5610 Structural Designs LLC Subdivision Info: South Arbor Lot # 20 Andy Beauchamp Location/Address: W. Chinaberry Court -27028 ATC Number: 4466 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 CTION IS VALID FOR PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 of time. G ^ SHw•r CT• '7 \ b l it is lk Septic System Installed By: t ►i .1 \ n 0 Bo�1Gk n� Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT _ ..... Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004057 Billed To: Structural Designs LLC Reference Name: Andy Beauchamp Proposed Facility: Residence Tax PIN/EH #: 5747-21-5610 Subdivision Info: South Arbor Lot#20 Location/Address: W. Chinaberry Court -27028 Property Size: . **NOTE *This Improveme6nt/Operation Permit DOES NOT authorize thp 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 C- #Baths 2 Dishwasher: iff", 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 C6 Design Wastewater Flow (GPD)�� Site: New ffRepa r ❑ System Specifications: Tank Size A6 b GAL. Pump Tank GAL. Trench Width--g�"Rock Depthh� /l Linear FE7P Other: acce ted 3 , 15A NCAC 18A.1969( Required Site Modifications/Conditions: p Y tems may also h 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�>A,&Iktion. Telephone # is (336)751-8760.**** P Health Specialist's Signature: Date: DCHD 05/99 (Revised) SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street MocksvilIe, NC 27028 (336)751-8760/ Fax (3 6)751=8786 )rovement Permit uthorization To Construct(ATC) 0 Both ***IMPORTANP*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. - 1Nt'U&U 11VN Name to be Billed Contact Person Ano. Billing Address 7.n' Home Phone City/State/ZIP 2..7o?a Business Phone •S1-34-3c/_S=IWI i Name on Permit/ATC if Mailing Address '3 NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for„6g months with site.Rlan, no expiration v Street Addres Subdivision I� Directions To It .Date House/Facility Comers Flagged 7L Dlv If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Zfes DNo Does the site contain jurisdictional wetlands? Dyes {?No Are there any easements or right-of-ways on the site? Dyes PN -0 Is the site subject to approval by another public agency? Dyes Bifo Will wastewater other than domestic sewage be generated? P -Yes DNo lN' RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Z Garden Tub/Whirlpool Dyes X?No . Basement: OYes E11?6- Basement Plumbing: OYes IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building .# People # Sinks I # Commodes # Showers I. # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Offonventional DAccepted DInnovative DAltemative ❑Other_ Water Supply Type: 2 County/City Water D New Well DExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes If yes, what type? 7 ,� 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 Sign given Dyes DNo Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # - MI I t��aZ �rJ�N .,,, • _� - LLJ I' III LO Est O 1S 89009'15"E 191.32' Totall S 86°15' P i .74"� �-145.58' _EIP^ 1d0.1 22 j6'•�.. ,s.%. \ \F 4 q N g87°14'10* r 209.40' w I N N 20- I 0 r I o. N J.r W S 86 15' ' '00'E 208.71Totai EI EIP ° 3 I o104.35. 104.8'— I o I oa 1 o I _ _ M 7n. N EI I N M♦ I is a M I h rn W I I V J� Ql ° V1 I (a n I I 99.9 EJ IEIP `T� I I LS 86° 5'00"E 'n S 86°15'00"E I S 88' I o I I EI � 0'—EI 3 w EIP 0 i 1 II R EI oho 100.00' ��Itol � II I t ry �' 0 0 to it la a I -5 y -0z ZM �i4, 25 0 � 26 M N N M E ,ate'` 3 1 I �� Iw PS II ea 80.00 CN -1 I .' O O J I Yom`• -� 10' X ]0' SE AL1 � 25°W N 84°55'43"W N 84055'45"W 2 ' 127,° 8Osoe C7f 3iGL.ber `'„.''`°• 7' cTi--+av-U-CI 60' Pu 7'}}}C --yam C &84°55'45"E 405.00' Total 1,--- f 33. r— —134.00'— 10' U ent� I ,/y{� Q C el 1n . :I- I I ` II I I jaU/ J �J �I 3I _ apRPta V°P`P $ 19 NI 1gN 17 y x.16 0 11 II 15 1110 P90-0_uttlity Easement) I_V I I —'I / 10' Wily sament '— 129.70' — J t— '11/33.50' — 3.50'—^ 1 N 84°55'45"W 1127,48" Total Parcel 24 Carl T. Carter Deod;aQk 44 0 001 tar --,J R/A a .` PPLICATION FOR SITE EVALUATION/IMPROVEMENTS P I V 15 jr NC/ Environmental County Health Department V� 6 Environmental Health Section FEB 2 8 1996 P. . Box 665 0 7 Mocks ille, NC 27028 1:.-Application/Permit Requested By' T Kute Swicegood agent Ayoh MA./M/r.h. Kod Woodwand 300 South ftm StAeet Home Phone 704-634-1010 Mailing Address MOCKSVILLE N. C. 27028 Business Phone704-634-2222 2.. Name on Permit if Different than Above 3.; Application for: 0 General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown a D 2 k 5.* If house, mobile home: Subdivision -iiR$ Section Lot # ❑ Basement/Plumbing No, of People 3/4 ❑ Basement/No Plumbing No. of Bedrooms 3 91 Washing Machine 2 No. of Bathrooms Q Dishwasher Dwelling Dimensions 73UO 6q. Ueet +- ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served N No. of Commodes No. of Lavatories A No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ® Public ❑ Private 8. Property Dimensions See attached map Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If .,— urhe/ hme9 ❑>rNo ❑ Community 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFORMATION REQUIRED: Tax Office PIN: # .S71%?yZ294U� PROPERTY ADDRESS, as follows: Road Name: South ARbbh City: Mock3v.Lf'X_e, N. C. SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. Vebauaity 26, 7996 T.'Kyte Stoceegood, agent box DATE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. DX 2. 1 DO NOT OWN the property.. If you checked Box #2, the rest of this form MUST be completed by the owner totehr ��aeeperson authorized by the owner: I hereby give consent to the authorized represent ive of� % e CQodylUooWD aartment to enter upon above described property located in Davie County and owned by Jo conduct all testing procedures as necessary to determine said site's suitability fora ground absor tion sewage treatment and disposal system. T. SJcego d -ebRuaAy 26, 1996 DATE 6, r N4WATVRE DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY \� LOCATION OF SITE 1J1Nr�� Water Supply: On -Site Well _ Comm upity Public Evaluation By:Z� Auger Boring PitS ✓ Cut FACTORS 1 2 3 4 Landscape position 5 Slope Z 6 - HORIZON I DEPTH Texture groupC Consistence - T Z Structure L C L Mineralogy l HORIZON II DEPTH l' u Texture groupC Consistence Structure A Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS SS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 1 1-41 LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: T,S . EVALUATED BY- 1 LDNG-TERM ACCEE\P ANCE RATE: ` OTHER(S) PRESENT: REMARKS: die V4 — ,1� al tso.� 'a b 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 r.lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay Moist VFR-Vc-y 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/fta DCHD(01-901