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196 Forest View Drive Lot 28DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001461 Billed To: R.A. Hewitt Bldg. Reference Name: Proposed Facility: Residence fl- 3,---2 9-' V/ Tax PIN/EH #: 5749-43-5798.28 Subdivision Info: Meadow Ridge Lot # 28 Location/Address: Sain Road -27028 Property Size: see map ATC Nwbfr: 2752 **NOTE** 'Phis mprovement/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 X/ #People G #Bedrooms &— #Baths S Dishwasher: X Garbage Disposal: Washing Machine: a Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats IndustCIriaal Waste: Lot Size Type Water Supply Design Wastewater Flow (GPD) —a& -Site: New 0 Repair ❑ �01S System Specifications: Tank SizeZW GAL. Pump Tank GAL. Trench Width �Z Rock Depth / Linear Ft. Other: �Q 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.**** Environmental Health Specialist's Signature: 1�7Date: �-4-Z1Z DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001461 Tax PIN/EH #: 5749-43-5798.28 Billed To: R.A. Hewitt Bldg. Subdivision Info: Meadow Ridge Lot # 28 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2752 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 ONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �� /1(1 1J 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 A 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NOW betaken azantee that the system will function satisfactorily for any given period of time. P1 �xsXi2'e01?5 Septic System Installed By: y''Y Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) %--0 O APPUCATiON FOR SITE EVALUATION/1MP110VBIENF PERY11T & ATC`I- Davie County Health Department D Environmental Health Section off P.O. Box 848/210 Hospital Street Mocksville, NC 27028 LVIO (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed } _ C • Contact Person i Mailing Address _�/�/�� s Home Phone /�/✓'b'/�� / �y l) C Ci6 ty/State/ZIP �i(C /V ( 2200 Business Phoneoo 2. Name on Permit/ATC if Different than Above � 6 Mailing Address City/State/Zip 3 3 to 06 -�L3 M 3 -15— 0 3. Application For: Site Evaluation ❑ Improvement Pet/ATC ❑ Both 4. System to Service: 14/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 4 # Bedrooms 5 # Bathrooms 3 IV161shwasher VGarbage Disposal V"W'ashing Machine rJ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify typo # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: W---County/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. R 5;-82-7- (rr 6 Nt- 3 e Property Dimensions: Ql) -`L30-1{ Tax Office PIN: 0 Sz- T3 —'5%7F Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: z%/si�aft Section: Block: Lot: WRITE DIRECTIONS (from� %Mocksville) to PROPERTY: ��'q " 0 A 1/ 111p0 Date Property Flagged: ) �"/ 2, This is to certify that the information provided is correct to the best of my knowledge. I understand that any perinit(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. 1, 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 to conduct all testing procedures as necessary to determine the site suitabil' DATE - �t� �,�� L SIGNATURE -ev THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setback, and septic locations). Revised DCHD07/99 Co ( ) a Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. tP Invoice No. r c -a -C.o'C. i - ra, APPLICAl1UN FOR SIIE EVAIMIION/IMPROVEMENT PERMIT do 2 @ L2 15 A 1 ( a IE ,A i Davie County Health Department 5 lam* 5 Env/tonmentallfea/ffi SmWon D P.O. Box 818/210 Hospital Street JUL i M Mockaville, NC 27028 (336)751-8760 ***DWCRTANT*** THIS APPLICATION CANNOT BE PROCLSSf:D UNLESS ALL THE YREQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nam to be Billed KE N A T N L Contact Person FOSTE Q - Halling Address l s (o M A Fuc TgEi- Lq4c nom Phone 704 -54<o--7-7 ; 8 City/state/LIP 1!F1ocKsJ�� , N •c - .270 -?e Easiness Phone 33(o--IZ3-88S0 Z. Nam on Pewit/ATC if Different than Above Nailing Address City/State/Lip s. Application For: KSSite Evaluation U Improvement Permit/ATC 0 Both s. system to service: 0' House 0 Mobile Home 0 Business O Industry O other s. It Residence: i People_ i Bedrooms 3" i Bathrooms WDiR�shxasher O Oarbage Disposal G41shing Machine 0 Basement/Plumbing 0 Easement/No Plumbing 6. if Easiness/industry/Other: Specify type i Coemodea i People i sinks i Showers i urinals i Nater Coolers IF i'OODSERVICE: # Seats Estimated stater Osage (gallons per day) 7. Type of water supply: 0' County/City 0 Well 0 Coumunity a. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 0 No 11 yes, what type' *"IMPORTANT'" CLIENTS 11IUST CohIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN OUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3(01 X65'7' X 639 Tax 011ice PIN:, # 5.74-9 - 4-6- S`19 8 Property Address: Road Name 15 A 113 Ro a c� City/ZipT'Acc.Ks,J .11E 91 OZ€S It In a Subdivision provide information, as follows: Name: MEAnoWR.(-QGE (PlQPoSED) Section: Block: Lot: 2 8 WRITE DIRECTIONS (from Mocluville) to PROPERTY: L asT o ti►y S w.��i S R To �i0 Ratio isR I(o43) TuktJ RkGVkT oP SA,•.s _ Atpp"x 0.15' MIL!- -Tb S ATE n t-1 t, \ L 0 T Date Property Flagged: Lo -018 - 94 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 app/fc:adon. I, hereby, give consent to the Authorized Representative of the Davie County Health DepartmeAi to enter upon above described property located in Davie County and owned by ��!NErH - L• FQ�TE R. to conduct all testing procedures as necessary to determine the site suitability. DATE (o - Z 8 - 199-1 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. 6✓ " / Invoice No. /'2c DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900654 Tax PIN/EH #: 5749-43-5798.28 Billed To: Kenneth Foster Subdivision Info: Meadowridge Lot # 28 Reference Name: Kenneth Foster Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: 2.58 Acres Date Evaluated: Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit ./ Public e_�_ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % -71(71-7 Zf1c HORIZON I DEPTH 0 "/ — Texture group G Consistence rSS Structure 5 6, Mineralogy I HORIZON II DEPTH Zo Texture group G Consistence S , Structure Mineralogy HORIZON III DEPTH Texture group Consistence S Structure SIL Mineralog HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S F 7). LONG-TERM ACCEPTANCE RATE 0.�5S SITE CLASSIFICATION: Vs LONG-TERM ACCEPTANCE RATE: ©•ate REMARKS: LEGEND Landscape Position EVALUATION BY: —�'` ► Gr -i1 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 _0:1 JS VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic tructure 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/112 DCHP (Revised 05/99) FACTORS DAVIE COUNTY HEALTH DEPARTMENT Landscape position ,L Environmental Health Section 6 HORIZON I DEPTH Soil/Site Evaluation L APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001461 Tax PIN/EH M 5749-43-5798.28 Billed To: R.A. Hewitt Bldg. Subdivision Info: Meadow Ridge Lot # 28 Reference Name: Structure Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut HORIZON IV DEPTH Texture group FACTORS 1 2 3 4 5 6 7 Landscape position ,L Sloe % 6 HORIZON I DEPTH Texture groupS L Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r - Structure it Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure ' Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE S SITE CLASSIFICATION: T" LONG-TERM ACCEPTANCE RATE: - REMARKS: LEGEND Landscape Position EVALUATION BY: ley // 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 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) ■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■/■■■■■■■■e■■ ■■■■■/■■■■■■■■e■■ ■■■■■■■■■■■■■■e■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ii ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ i ■ ii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ IiiiiiiiiiiEN MENNEN MENNENZ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■ ■■■t■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ November 1, 2000 R. A. Hewitt Building Co., Inc. 119 Highway 801 S, Suite A-400 Advance, NC 27006 Re: Site Evaluation/Meadow Ridge Lot 28 Tax Office PIN: #5749-43-5798 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, October 31, 2000. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, &x*e %e' g�4eA. Robert B. Hall, Jr., R.S. Environmental Health Specialist Enclosure(s) Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NG 27028 !rA y Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name:. �✓� �" ✓��i Phone Number -Jy _(Home) Mailing Address: / %ZF 5/ �1 !V/G (,) (/1_71 _ % ?,'7a04 Email Address: Detailed Directions To Site Property Address: Please Fill In The Following Info/rm%a�tion About The EXISTING Facility: Name System Installed Under: �"✓ �0� Type Of Facility:�� Date System Installed (Month/Date/Year): (�� / Number Of Bedrooms: -Number Of People: ~ Is The -Facility Currently Vacant? -Yes � If Yes, -For How Long? - - Any Known Problems? Yes le If Yes, Explain: Please Fill In The Following Information About The AWW Facility: Type Of Facility: ; l��lV ?6x50 x I A14umber Of Bedrooms: Number of People Pool Size:_ Requ/sted By: Approved ) Disapproved Garage Size: Other: _Date Requested: For Environmental Health Office Use Only Environmental Health Specialist Date:" Date: *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 #: Invoice #: