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197 Forest View Drive Lot 27' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000981 Tax PIN/EH #: 5749-43-5798.27SF Billed To: San Filippo Companies Subdivision Info: Meadow Ridge Lot # 27 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3619 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /' G.�i 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 ' WAY en as a guarantee that the system will function satisfactorily for any given period of time. 9/2�"Tl D 12 l0 12 Septic System Installed By: Environmental Health Specialist's Signature 00 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section - • P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 r (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000981 Tax PIN/EH #: 5749-43-5798.27SF Billed To: San Filippo Companies Subdivision Info: Meadow Ridge Lot # 27 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: see map * *NU IT�iiPfr ipro�gent/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 #Bedrooms #Baths —Q3 Dishwasher: Garbage Disposal: -0"" Washing Machine: 711- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seaatts Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) 4 p 6) Site: New Repair ❑ System Specifications: Tank Sizg�OG' GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width � Rock Depth Z "Linear Ft. l& 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: T ( �� Date: &/ % "rfa-�? DCHD 05/99 (Revised) UNg 1 2 2p03AP. NpV FjyV1R0�ME� 11N�t LtH OPV1E J FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnVftfiMenta/Hea/th Section .0. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 WW*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 r �l' f Contact Person Mailing Address 1 %v2,(�� // Home Phone / G City/State/ZIP d1./QM* re— /� l..- � 'y�� Business Phone � /���� � �� O y/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House ❑ Mobile Horne ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 1� 6. If Residence: # People # Bedrooms # Bathrooms 2 -L1Dishwasher ❑Garbage Disposal L[E1Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE:' # Seats Estimated Water Usage (gallons per day) S. Type of water suppvy: ❑ County/City ❑ Well ❑ Community g; C 9. Do you anticipate a!dditions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No i. 5 If yes, what type? I �' ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either aAAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:3 S�71 Tax Office PIN: 5,7%� Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from MocCksville to PROPERTY: Date home corners flagged: , i t O 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 ani responsible for all charges incurred front 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 suit ility. DATE J 3 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN a all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given, Revised DCHD (05/03 EHS: Account No. �` g Invoice No. �� APPLit'A110N FOR SITE EVAWAl1ON/IMPROVEMENT PERMIT do A Davie County Health Department ~' Environmental Healfh Section D P.O. Box 848/210 Hospital Street Moakaville, NC 27026 JUL I lag (336)751-8760N , ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED moms ALL! INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN for/ instructions. 1. Namis to be Billed KE N nl E T N L - t- O t i c R contact Parson Kt N ^1� T H �. • FOS T� 12 Mailing Address l 8�i G fnaPty TREE LaNc acme Phone 704 -54(o --7i "8 Cilty/State/LIP tOCKS,JI LLC , .2i0-2 Business Phone 33co -� Z3-88So 2. Nems on P*=It/ASC If Different than Above Nailing Address City/State/Lip a. ]Application For: KSite Evaluation 0 Improvement Permit/ATC 0 Both 4. system to Service: E House ❑ Mobile Home 0 Business 0 Industry ❑ Other a. If Residence: i1 People • Bedrooms .3 _ � f Bathrooms Z PID-11shwasher 0 garbage Disposal ANashing Machine 0 naseeimt/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type ti Caaomodes f showers • Urinals / People / Sinks 0 Nater Coolers IP FOODSERVICE: I Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: B'County/City 0 well ❑ community 6. 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 AIUST CVMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN hIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 385 X 4.19 X 3 (.3 ),/ 3 Tax Office PIN: # 5i4-9 — 43— S-7 9 s Property Address: Road Name ` Roan City/Z.ipTAG -.Ecs") Lila a70%8 if in a Subdivision provide information, as follows: Name: MEAooW Ri OGE \'t �P�SED� Section: Block: Lot: Z 7 WRITE DIRECTIONS (from Mock:ville) to PROPERTY: L A. -ST o P V S To o RtP, (sR 1(o43) TURV1 P1G1%T oP SA, -J _ APP" -,s. OSS MILts TU S tTF n,,1 \L%AT Date Property Flagged: (o • c18 99 This is to certify that the information provided is correct to the best of my knowledge. I underhand that any permit(:) 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, anderstannd that I am responsible for all charges incurred from this applica Born. I, hereby, give consent to the Authorized Representative of the Davie County Health Departmeml to enter upon above described property located in Davie County and owned by 1iEngtJETif - L. Pty'ST E R. to conduct all testing procedures as necessary to determine the site suitability. DATE G -?-8 - 199't 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. 6,017- Invoice No. �� DAVIE COUNTY HEALTH DEPARTMENT w ` Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900654 Tax PIN/EH #: 5749-43-5798.27 Billed To: Kenneth Foster Subdivision Info: Meadowridge Lot # 27 Reference Name: Kenneth Foster Location/Address: Sain Road 27028 Proposed Facility: Residence Property Size: 3.61 Acres Date Evaluated: Water Supply: On -Site Well Community Public /__ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position (4 - Slope % HORIZON I DEPTH Texture groupCr_ Consistence CrS SP Structure 5 Mineralogy HORIZON II DEPTH 3 • Z Texture groupC Consistence ; $ Structure l c Sg) Mineralogy I: I ; HORIZON III DEPTH - q2 - Texture group G Consistence G,- S P Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE p. SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: EVALUATION BY: OTHER(S) PRESENT: REMARKS: P4 2 OPe_-ck_ r,,-3 Cha D im i Ir i ta�Bo�i ;� LEGEND Landscaae Positio 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 ois 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(provisional Iy suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 bCHb (Revised 05/99)