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188 Forest View Drive Lot 30DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900164 Billed To: Gray Laymon Reference Name: Carl & Melissa Robertson Proposed Facility: Residence ATC Number. 2523 Tax PIN/EH #: 5749-43-5798.30 Subdivision Info: Meadowridge Lot # 30 Location/Address: Sain Road -27028 Property Size: 2.72 Acres 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 WASTEWA C NST UCTION IS VALID FOR A PERIOD OF F/IVE YEARS. Environmental Health Specialist's Signature: Date: CS 290 krm i 4 Fort 3 Bda om 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: Ps uperry renes and dimensions, structures. sethaclrm. And aanlin i�n..�,snumue 211 of the foiiowings Existing and proposed •, '�, . ,� S :1.Jpp t If�i� i fi AEF ` KENNETH L. FOSTER 08 211 PG 857 19.614 Acres (dmd) DAVE CO a D!RE�.OR• The 10 Year Floodplain. �.vRT Fl -,,T; Or APPROVA OF Don,sZti 10 rear FModoloin ( Anoroximgfe location SEE SHEET 2 OF 3 MOCKSYtL ,+N-- IT:) S A F iSPOSAL M5 •, HEREBY CEI I HEREErr CERTIFY -THAT THE DAME COLWY HFALTH DEPARTMENT HAS HMON HAS 6F r if � EVALUATED TNF. SU301 MXN FNTFTLED • MEADOW RIDGE - WTH SU8VA$ION•RE( RESPECT TO CRITERIA AND CONDRIONS ESTABLISHED BY STATE LAW OR • V y .IF A PROMULGATED TNEREUNDEF{ AND THE SAME 1S FMD TO COMPLY WITH SUCH P .� CRRER+A AND CONOnTONS-EXCENT AS FOUND IN SUCH EVALUATION. FOR - REC=24 IN T .� DETAILS OF THIS' EV►L'alkT" ANTj FOR UY9A70Nl-- SE;- TWE WR!Tr—R DEPORT CW Nstcfiiif' NSUjQ - FRE AT THE SATO OEPARTTI W. . INCLUDE APPRV 30 !)LpQPtkLTT.unTlr T},te CERTIRU7E M57S DOES IT WCLUDI N ._? . /C ' U 3.2/7 Acres (dmd) CUM= A P£$MR OR APP t CF tMOMWN LOTS tN SAID S.l OrYI&ON -TJR INST IAT! tl S£1Y��F6idIiTIFS- OF BUILE NM C DATE wz;c a,nrF• 1A10 guild%ngs A.re Permitted 1.^, D!RE�.OR• The 10 Year Floodplain. q 10 rear FModoloin ( Anoroximgfe location SEE SHEET 2 OF 3 S 25 3 T 3T w i/ Azle 1 ------------�_ 20' CON1F 122.80' a ;�• /o r if � �� ,�-�,�i\`\�• �'/ 60.00' v o/l Ly 30 /�� f/ / �-- 2.7i9 Acres �cmd� N ._? . /C ' U 3.2/7 Acres (dmd) T • 41' A l �,,, l �v 29 l 2.9J8 Acres (dmd) l 16' pavement N G,6 } t i 27 2,2 Acres DAVIE COUNTY HEALTH DEPARTMENT -. Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 989900164 Billed To: Gray Laymon Reference Name: Carl & Melissa Robertson Proposed Facility: Residence Tax PIN/EH #: 5749-43-5798.30 Subdivision Info: Meadowridge Lot # 30 Location/Address: Sain Road -27028 Property Size: 2.72 Acres **NOTEC * Tfii blmprovement/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 14 #People #Bedrooms #Baths -S Dishwasher: C21"' Garbage Disposal: ❑ Washing Machine: 121`000' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply_ Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size iFOO GAL. Pump Tank GAL. Trench Width 310 Rock Depth �-- Linear Ft 00 Other: Required Site Modifications/Conditions: 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.**** ELJ Environmental Health Specialist's Signature: Date: d IAS od (&4Z DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900164 Billed To: Gray Laymon Reference Name: Carl & Melissa Robertson Proposed Facility: Residence ATC Number: 2523 Tax PIN/EH #: 5749-43-5798.30 Subdivision Info: Meadowridge Lot # 30 Location/Address: Sain Road -27028 Property Size: 2.72 Acres 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 WASTEWAT L2UCTION IS VALID FOR A 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. Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) Date: T r nn R APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT U u M R • Davie County Health Department Enviimmental Health Section A98 " 8 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEALTH DAVIE COIINTY ***IMPORTANT*** THIS APPLICATION CMWOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed L7eAV fl: keriy/rlU/V Contact Pe =son Mailing Address %,. L44 %t1"�J id_/ Homo Phone �7 City/State/ZIP / ' 1 . /(/G� Business Phone (/ 2 . Name on Permit/ATC if Different than Above l 45W Sd Ai Mailing Address City/Stato/Zip 3. Application For: O Site Evaluation wimy//provement Permit/ATC ❑ Both 4. system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: # People # Bedrooms _ # Bathrooms,2 VDishwasher ❑ Garbage Disposal ®'stashing Machine O Basement/Plumbing ❑ Basement/No Plumbs. -g 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: 131"County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes fd'INO If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Z. 7 Z 1116"C. WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # ,S'7 �q - 7 15-e - 7/41 -r..4.oW /2./ Property Address: Road Name -5 R/ R/ �/Yr•i S. w.r-1 City/Zip %j 644--, � IZC.. 27cZoe- If in a Subdivision provide rm tion, as follows: Name: Section: Block: Lot: : o Date Property Flagged: —46 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 ant 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 to conduct all testing procedures as necessary to determine the site suitapoy. DATE X— 7— /000 SIGNATURE (/ L,09U THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include 511 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: I EHS• q8-9000 I c� Account No. Invoice No. g A ,S1 � VVSS 3 v KENNETH FOSTER 171 a ` � D B 211 PG 857 2 ( 34.4 ACRES AGRICULTURAL) \ 1 AXLE FOLM \ \ QY SARAH HOLLAND - I _ WILL SK 4 PAGE 4 SO \ / OCTr! U 2.52 � / 2.72 acrqoI 1 I ''x µ spa N f 29 2 41 r, f acro -27 t 3.61 acres 4p, \ 1 V1 I b I ' 2.58 acres 383.1T -- 857'S 1 g 10.0,c W - R£BAR SL7 - 1100.90 S fl 1 00'0 W 3/4 IMCH PIPE FOUND 'SPE FOUND `— 1 O BASE OF 47 OAK 4 \\ SAMUEL S..SHORi, JR DB 63 PG 1,64. \ DB 66 PG 5 �� •� KENNETH L FOSTER �* FRANCIS McCLAt�AROCK ` _ - - - _ THIS MAP WAS DRAWN UNDER CERTIP DB 86—PG 504 ��.�++++�� VEY MADE � Al FIELD DSUPERVISION PERVISION FROM � �(N CARP E 30 19.x• I ;, • O .•.•.•.••.. F) NG TO SCUD ELD ER CERTIFY Tf PROPERTY LY SHOWN SEAL Cl.SION I:10, 0� " = ;C 62552 P -77J7 I('watL� A 7nM_T� 77ri(7�,AL 77--nfQ \iucvAA wr,cr a e o a:o o � • �� - ••. v- .,. , APPU(AIION FOIL SITE EYAWAIION/IMPROVEMENT PERMIT & AIC Davie County Health Department ' Enviranmental Health SLacdon B.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �01 W Ito 1A ***ZMPORTANT*** THIS APPLICATION CANNOT BE PROC'ESSE'D UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed KE hl n1 C- T N L... t o S R Contact Person � -N aE T H L • FmT-e p- !tailing Address _ I S (n YYl A PLL TRF LANG Boma Phone 704-54<o--7-70"8 C1ty/8tate/LID N�OCK5,[iL-LC ,4:27U�2 Business Phone 33Co-�I Z3-f38So Z. Nacos on Pe=it/ATC if Different than Above Mailing Address City/state/Lip a. Application Tior: It Site Evaluation 0 Improvement Permit/ATC 0 Both s. system to service: td House 0 Mobile Home 0 Business 0 Industry 0 Other e. It Residence: # People # Bedrooms 3- # Bathrooms L B'Dishxasher 0 Garbage Disposal R hashing Machina 0 Basaoent/Plumbing (] Basement/No Plumbing 5. if Business/industry/other: Specify type # Commodes # Shovers # People # sines # Urinals # hater Coolers ITT FOODSERVICE: 11 Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: O'County/City ❑ Nell O Cc=umnity e. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 0 No If yes, what type! """IMPORTANTP" CLIENTS MUST CIUMPLEiE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESU1U11TTED by the client elth THIS APPLICATION. Property Dimensions: 135 X 4 o.39 419 x 188 Tax Office PIN: # 574-9 - 4.3- S`I 9 8 WRITE DIRECTIONS (from MockrAlle) to PROPERTY: 1. AST O N V S NA w T_1 C; R Property Address: Road Name 15 A r -J Po A o T o S,N & t.3 RaP. o ( S R 1 (o 43) TV R tJ City/ZipTcc-KS0tI1s 91OZ6 R%G1%T 00 SA,a _ APPa-u O.e), MILC- If in a Subdivision provide information, as follows: Name: iYIEAoov�R� UGE �Prc�PoSEn� Section: Block: Lot: 36 -TCS S (Te n t-1 K\ C.-. %A T Date Property Flagged: 6 • AS - 94 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) Issued hereafter arc 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 axe responsiblefor all charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmerae to enter upon above described property located in Davie County and owned by tT'f/ , 7W - L' FQftT E R, to conduct all testing procedures as necessary to determine the site suitability. DATE -(.-?-8 -191)-% 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 (07/98) Account No. Invoice No. �'Z� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section _r SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account ##: 989900654 Tax PIN/EH #: 5749-43-5798.30 Billed To: Kenneth Foster Subdivision Info: Meadowridge Lot # 30 Reference Name: Kenneth Foster Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: 2.72 Acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope % $ HORIZON I DEPTH to - "L Texture group C G t Consistence Structure 6k Mineralogy HORIZON II DEPTH Texture group G Consistence P Structure MineralogyI : I HORIZON III DEPTH Texture group SA0 C,+<—, Consistence SS Fr Structure qg S Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE Q. (� SITE CLASSIFICATION: 0S LONG-TERM ACCEPTANCE RATE: d REMARKS: LEGEND Landscaae 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 os 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 OR - 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 I)CM (Revised 05/99) (,okra Davie County Health Department Environmental Health Section .8V316`& -n-' RECEIVED P O Box 848 Cz Phone: (336) - 7.53 - 6780 �13 210 Hospital Street, Courier #: 09-40-06 Mocksville, NC 27028 RECEIVED AUG 1 6 2013 DC HEA 1014.h�-tc L co . `Dao; c . nc.. uS ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement emodelin Reconnection Fia: (336) - 753-1680 Name: �� 1 MQ�v� SGS r72�S Phone Number ?J 3 t4 - 7S 1 " YJ 2 (Home) Mailing Address: Fo(e �r - \Jit'.A Q( (Work) Detailed Directions To Site: r) JG ` /J C— %1 S 1' Property Address: ( f:::SC`9� 4- J" (�'3 Nur _ k j Lj 1-(0 1—OJT-.- ai o .-.? Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: 0 Type Of Facility:'.3pQ C-Q— r 2do 3 Date System Installed (Month/Date/Year): % Number Of Bedrooms:- Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? / �• 73 �% Any Known Problems? Yes No If Yes, Explain:�'6 Please Fill In The FollTige ng Information About The NEW Facility: 11T 5ro Type Of Facility: Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: equested By: Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: %0 0 at /V&9 ev anm Environmental Health Specialist �,�,(d d,((��,(,(l lJ�( - Date: /Q—el7 *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:$lU U Date: X 1 1 q13 Paid By: 1013 Received By: Account #: W9 Invoice #: %6( , L5/7 1,&tfs1 Vt,CL.) -PA. N N