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197 Longwood Drvie Lot 51� � r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002162 Billed To: Bob Cope & Son Construction Reference Name: Proposed Facility: Residence ATC Number: 3191 M 1,01190co oocr v, Tax PIN/EH #: 5861-59-5239.51 Subdivision Info: Redland Lot # 51 Location/Address: Highway 158-27006 Property Size: see map 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ,OdU Date: oom-� 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 1 I 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. q-1 12.0`�3loxt2'� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) V (4;-/ U r 6-s -f i Ir -j 0(4 CQ, Date: /Z Z DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002162 Billed To: Bob Cope & Son Construction Reference Name: P17" I ci Tax PIN/EH #: 5861-59-5239.51 Subdivision Info: Redland Lot # 51 Location/Address: Highway 158-27006 Proposed Facility: Residence Property Size: 14see map ATC Number: 3191 7 tole **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 I 1 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 -? #Baths o2, 5 Dishwasher: 01, 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 Design Wastewater Flow (GPD) Site: New 2100" Repair ❑ System Specifications: Tank Size/ i OGAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth Linear Ft. -s IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) 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 thgoU of installation. Telephone # is (336)751-8760.**** J Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) ,)l -.20)-1)z • DAVIE COUNTY HEALTH DEPARTMENT ' r Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002162 Tax PIN/EH #: 5861-59-5239.51 Billed To: Bob Cope & Son Construction < Subdivision Info: Redland Lot # 51 Reference Name: Location/Address: Highway 158-27006 Proposed Facility: Residence Property Size: see map ATC Number: 3191 **NOTE** This Improvement/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 T #People #Bedrooms t -T #Baths d S Dishwasher 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 Design Wastewater Flow (GPD) Site: New Repair ❑ � J System Specifications: Tank Size GAL. Pump Tank GAL. Trench Widtll� Rock Depth�v� Linear Ft. Ill% Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APP FINISHED GRADE. ****NOTICE: Contact a representativi system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m "UVE ENT FILTER. RISER(S) IF 6 " BELOW )9Ke- Davie Cc6nty Health Department for final inspection of this n the day of installation. Telephone # is (336)751-8760.**** r h v Environmental Health Specialist's Signature: - Date: Dz -2 DCHD 05/99 (Revised) Account #: 990002162 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Billed To: Bob Cope & Son Construction Reference Name: ce ATC Number: 3191 Tax PIN/EH #: 5861-59-5239.51 Subdivision Info: Redland Lot # 51 Location/Address: Highway 158-27006 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 Syste-S ction .1900 Sewage Treatment and Disposal Systems). TIES AUTHORIZATION FOR WASTEWATE ONSTRUCTION IS VALID F R 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 I 1 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: �el 14 Wsi 4 d6 - O '16 f sl .97 • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERM ANDavie County Health DepartmentEnvironmenta/Health Section P.O. Box 848/210 Hospital StreetMocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. ,/ /Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed //D� C f�J�) '7o n Contact Person � d r_,_y Mailing Address / D //� ��(O� Home Phone 3Q a-kY yJ� City/State/ZIP Business Phone FZ9 2. Name on Permit/ATC if Different than Above _/�-0 Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. System to Service: E�House ❑ Mobile Home Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms ISI Dishwasher I!1'Garbage Disposal Iq**Washing Machine 14e'asement/Plumbing I.I Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: #% Seats Estimated Water Usage (gallons per day) 7. Typo of water supply: M"'C'ounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [A�PPo Ifycs, what type? ***1A1P0RT4NT*** CLIENTS AfUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either n PLAT or SITE PLAN MUSTBESUBAIITTED by the client with THIS APPLICATION. f / Properly Dimensions: / '39 X d- 7 5 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # Properly Address: Road Name City/Zip If in a Subdivision /p/rovide information, as follows: Name: / t ldlo/zal� WV Section: Block: Lot: Dale Properly Flagged: This is to certify that the information provided is correct to the best of my knowledge. 1 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 am 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 suitability. DATE. a -o�--o 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). Site Revisit Charge Datc(s): Client Notification Date: d EI -IS: Revised DC14D (07/99) Account No. Z�/ G _-" Invoice No. 0 7 L� F APPLICATION FOII SITE EVALUAIION/ IMPROVEMENT PERMIT & ATC f Davie County Health Department En vlronm en tal Health SeWon • P.O. Box 848/210 Hospital Street Mockoville, NC 27028 (336)751-8760 * * * Ib1PORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL INFORMATION I8 PROVIDED. Refer to the INFORMATION BULLETIN for 1. Name to be Billed i I (? ' / Mailing Address 63?e t I VS City/state/zIp ,t 0/7/ 2. Name on permit/ATC if Different than Above, Mailing Address 3. Application For: EQ'Site Evaluation Contaot Person Hose phone Business phone IND Li) JUN t 4 20.01 I, RE UD truotflasi;eN�-- _77 7P7 ;7 1ourdlY City/state/zip ❑ Improvement Permit/ATC ❑ Both 4. System to servicet Er House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other �� •; 5. If Residence: 1 People 1 Bedrooms 1 Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basament/No Plumbing 6. If Business/Industry/Othert specify type f People / sinks 1 Commodes 1 showers 1 Urinals 1 Nater Coolers Ir rOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 0-County/City ❑ Well ❑ Community a. Do you anticipate Additions or expansions of the facility this system Is intended to serve? ❑ Yes ❑ No If yes, what type? "**IAlPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 6 5 g. r&5 4 Tax Office PIN: # 5-ijv l —5 — S1-23_ Property Address: Road Name AdL S City/Zip AbIll fed, )4Z , `�1 If in a Subdivision provide Information, as follows: Name: �P /-1 ti Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: • 5_ Y P t/ 1'0-3 -3 i > - 6P, . f2!�_ D -7-/,9I Date Property Flagged: 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 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 sulta Ility. DATE `f"L�/SIGNATURE - THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). u Site Revisit Charge Date(s): Client Notification Date: IEIIS: Account No. Revised DCHD (07/99) Invoice No. 1 • ,�`' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900136 Tax PIN/EH #: 5861-59-5239.51 Billed To: Westview Development Co. Subdivision Info: Redland Lot # 51 Reference Name: Location/Address: USHighway 158-277006,, 1 Proposed Facility: Residence Property Size: see map Date Evaluated: / Z7 Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH • Z 2S Texture group Consistence ; Structure lc L Mineralogy1 ` HORIZON II DEPTH 17 Texture group C+ 5A. Consistence Cr S . Structure SRak Mineralogy1 l I t HORIZON III DEPTH Texture group Consistence S Structure 5 k Mineralogy1 HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5 S LONG-TERM ACCEPTANCE RATE C)55 -D.; SITE CLASSIFICATION: n r s EVALUATION BY: - tiC,-14,AP LONG-TERM ACCEPTANCE RATE:©3� OTHER(S) PRESENT: n q REMARKS: 1 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 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) �. avi unty Health DepartrnenftMtyj I>,� 20tn mental Health Section,,y, r T, AUG 2 7 �r, 0�, 'T. P.O. Box 848 mss, rt TH 210 Hospital Street n C3 EVftOp;N,VMEfdfALhEAI C -40-06 Mocksville, NC 27028 s Plione: (336) - 753 - 6780 Fxr: (336) - 753-1680 ON-SITE WASTEWATER CERT FICATION FOR DWELLING (Check One) Replacement Remodeliln Reconnection Name: C047— 5 Lce C W r L, g Phone Number b�S��o �' `���� 9cp� (Home) Mailing Address: f 7 Lo v v 33Co- 2?(7-/47 7 (Work) Qd>l ce . ffC o2706& Detailed Directions To Site //u)W %U!.yjilGt_ (,�/lre — 1&11011311-1o J/'U � / on uJua / 0V 'OtapProperty Address: /97 G 2 W yJop d E -)r - lq d 0A ACG Please Fill In The Following Information About The EXISTING Facility: y� La pC Spy WO-019'�. Name System Installed Under: Type Of Facility: / Date System Installed (Month/Date/Year): l! `� "�%/ Number Of Bedrooms:_ O Number Of People: Is The Facility Currently Vacant? Yes If Yes, For How Long? Any Known Problems? Yes kVo If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: '5w r M r✓t j i`cx=' ( Number Of Bedrooms: Number of People Pool Size: /6 X 32 Garage Size: Other: Requested By: ��' .:-- --,- Date Requested: (Signature) Cl For Environmental Health Office Use Only Approved Disapproved Comments: 6 Environmental Health Sp Payment: Cash Account #: —Invoice