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148 East Knoll Brook Drive Lot 9DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000981 Tax PIN/EH #: 5749-43-5798.09 SF Billed To: San Filippo Companies Subdivision Info: Meadow Ridge Lot # 9 Reference Name: Location/Address: Sain Road -27028 Proposed Facility Residence Property Size: see map ATC Number: 4284 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]. 19 0 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW CO N IS ALID OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature. L Date: Z9 d J CERTIFICATE OF **NOTE** The issuance of this Certificate of C pl t n s a 1 ind has been installed in compliance wit i 11 S Disposal Systems," but shall in NO a given period of time. ✓� .'� �a 9 � r Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) TION the system described on Improvement/Operation Permit pter 130A, Section .1900 "Sewage Treatment and tutee that the system will function satisfactorily for any IN Date: 9 O G v DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,,QQ P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 I I (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000981 Tax PIN/EH #: 5749-43-5798.09 SF Billed To: San Filippo Companies Subdivision Info: Meadow Ridge Lot # 9 Reference Name: Location/Address: Sain Road -27028 Proposed Facility Residence Property Size: see map ATC Number: 4284 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 o� #People #Bedrooms #Baths Dishwasher: Zr Garbage Disposal: ❑ Washing Machine: 12" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type //11 #People #People/Shift #Seats Industrial Waste: ❑ Lot Size A� Type Water Supply �U�Design Wastewater Flow (GPD) _s Site: New Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width t� Rock Depth 4A Linear Ft. 300' Other: r abllTlQa r C CL� AWOFd 2570 kLLII.� cT S`(C nq� ,-- Required Site Modifications/Conditions: WSTALL. cj as 1Mg, l_C4^, ►.r.1'1" it; 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 sysXem bptyveen 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.**** Environmental Health Specialist's Signature: `Y _ / _ Date: _ t-aT V ►�W / DCHD 05/99 (Revised) 7 �v i PROVENI APPLICATION FOR Dav SITE e County HealthlM1Departrnent PLRhfI TC Environmental Healtly Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 0 E 2 B 2005 (336) 751-8760 ***I1•SPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS LL TH 12'QU � INFORIIATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instttlZtxons...-� 1. Name to be billed �+'✓` / /' D �Yay, Contact Person -5— -5—�d Mailing Address ��C .7s,", Home Phone / City/State/ZIP A 2 / © bbl Business Phone 76 / 0 2. Name on Permit/ATC if Different than Above Mailing Address /C3 ty/State/Zip 3. Application For: 11 Site Evaluation Improvement Permit/ATC 13Both 4. System to Servic©:�Qe ❑ Mobile Homo Business 11Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative Mact:epted 6. If Residence: # People # Bedrooms 13 # Bathrooms Z - ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type ` # People # Sinks # Commodos # Showers # Urinals # Water Coolers IF FOODSERVICE: t#,��Seats Estimated Water Usage (gallons per day) 8. Type of water supply: i12�CQunty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, }shat type? ***I,11l10Rt-1N7-*** CLIENTS hIUST CO.MPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN hfUST BE SUBJIfITTED by the client with TIIIS APPLICATION. Property Dimensions: Tax office PIN: # ,577 e- - 3 - 5 7 9S'. O Property Address: Road Name' City/Zip If in a Subdivision provide information, as follows: Name: M6�doJ � s Section: Block: Lot: WRITE DIRECTIONS (from Moduville) to PROPERTY:_' Date home corners flagged: 'Phis is to certify that the information provided is correct to the best of my knowledge. I understand that any perinil(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 nm responsible for all charges incurredfrom this application. I, liereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and o vned by to conduct all testing procedures a necessary to determine the site sun bility. DATE 12 Z �c % Q 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). Sign given Revised DCIiD (05/03 Site Revisit Charge Datc(s): Client Notification Date: EES: Account No. v ` Invoice No. �A., 2— APPLICATION FOR SITE EVAUMTKIN/IMPROVEMENT PERMIT & ATC Davie County Health Depa)lment Envimmental Health Smffon P.O. Box 848/210 Hospital Street Mockaville, NC 27028 (336)751-8760 D I�I L� JUL 11999 U ***IIPORTANr*** THIS APPLICATION CANNOT BE PR=SSBD UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed KE N nl E T N L. �o S i E R . Contact person KE l� a E T N L . FOSTI= fZ Mailing Address M A PL,- Tj ;:r; LA.Jx nome phone ?04 - 54co--7 -7 9 8 City/State/zip --)702e Business Phone 33Co--IZ3-bSSo Z. Name on Permit/ATC if Different than above Mailing Address City/state/Lip J. Application ror: KSSite Evaluation O Improvement Permit/ATC 0 Both 4. system to service: Er House 0 Mobile Home 11 Business 0 Industry 0 Other a. IfRResidence: # People # Bedrooms (3" y / Bathroom H'Dishwasher 0 Garbage Disposal jYMa/shinq Machine 0 Basement/Plumbing U Basement/No plumbing 5. If Business/Industry/Other: Specify type # Commodes # showers # Urinals # people # sinks # Nater Coolers IF TOODSERVICE: 11 SeatsEstimated Hater Usage (gallons per day) 7. Type of water supply: a/� County/City 0 well 0 Comaunity a. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes 0 No If yes, what type? ""IMPORTANT" CLIENTS 11IUST ComPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 15 o 1 4-15 X 15 o K 4--75 Tai Office PIN: # 5i 49 - 4-5- S-7 9 8 Property Address: Road Name 15 A 1-1 Po A o CRy/zip'Mac.Ks,j k11e 9-707,0 If in a Subdivision provide information, as follows: Name: McAnnW2.l-DG6 (-21-21maD) Section: Block: Lot: 9' WRITE DIRECTIONS (from Mocksville) to PROPERTY: C -4.->T p N U 5 S R To o Roc�,O (sR 1(o43) Tu P, 9,IGNT oP Sn.,a _ A.PP0.ny. 0.e3M1Lt✓ Tu S (TE n ti.1 R \ L kA T Date Property Flagged: 6, • a F - 94 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 cbanged. I, also, andewand that I am reiponsible for all charges Incurred f -om this appficaadom 1, hereby, give consent to the Authorized Representative or the Davie County Health Departmerar to enter upon above described property located in Davie County and owned by J`rEniN�TEf - L. Pr E R to conduct all testing procedures as necessary to determine the site suitability. DATE G • Z 8 -199-, SIGNATUR*9&� 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). Account No. Revised DCHD (07/98) Invoice No. ��� • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPiIACANT INFORMATION PROPERTY INFORMATION Account #: 989900654 Tax PIN/EH #: 5749-43-5798.09 Billed To: Kenneth Foster Subdivision Info: Meadowridge Lot # 9 Reference Name: Kenneth Foster Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: 1.63 Acres Date Evaluated: 9 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit �Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slo % HORIZON I DEPTH Texture group t' c, Consistence .r ..- Structure k Mineralogy HORIZON II DEPTH - 70 Texture group Consistence Structure Mineralogy " HORIZON III DEPTH e7o - Texture group C-4- C4 Consistence ; Structure Mineralogy1 HORIZON IV DEPTH 4 Texture group Consistence Fr Structure Mineralogyr SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PJ EVALUATION BY: fK LONG-TERM ACCEPTANCE RA_T1E:p Cin_ OTHER(S) PRESENT: REMARKS: 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 pis 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 Mineraloev 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 !"C-qb :Revis'ad 05/99) This map drawm From survey maps prepared by Kenneth L. Foster and John Richard Howard The Art Works Building Design Service 7712 Amber Forest Lane, Lewisville, NC 27023 (336) 945-2416 F O R E S.T VIEW DRIVE (private) {S ITE PLAN- t* Scale 1" = 50' - 0"