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204 Longwood Drive Lot 28. 4 Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT f4 a"17r07�, Tax PIN/EH #: 5861-59-5239.28S Subdivision Info: Redland Lot # 28 Location/Address: Highway 158-27006 Property Size: see map ATC Number: 3257 **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 #People #Bedrooms '�" #Baths L Dishwasher:x Garbage Disposal. -X Washing Machine: Basement w/Plumbing,21-*11 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 [aQGAL. Pump Tank GAL. Trench Width 376_' Rock Depth Linear Ft. , Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED FINISIIED GRADE. ****NOTICE: Conta e o system between 8:30 a.m. to 9:30 a.m. or 1:00 p m- on the d, C� 11/ ��a ) &,o 9' F NT FILTER. RISER(S) IF 6 " BELOW ty Health Department for final inspection of this lation. Telephone # is (336)751-8760.**** Environmental Health Specialists Signature: Date: DCHD 05/99 (Revised) P�Qq-►?-oz DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000955 Tax PIN/EH #: 5861-59-5239.28S Billed To: Samnaz, Inc. Subdivision Info: Redland Lot # 28 Reference Name: Location/Address: Highway 158-27006 'roposed Facility: Residence ATC Number: 3257 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 WASTEWAT CONSTRUCTION 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 sys has been installed in compliance with Article 1 1, of G.S. Chapter 130A, Disposal Systems," but shall in NO WAYa ,asuarantee that t given period of time. t�D Y t1 Septic System Installed By: /C on Improvement/Operation Permit 900 "Sewage Treatment and will function satisfactorily for any 0— Environmental Health Specialist's Signature:. Date: DCHD 05/99 (Revised) FROM SAMNAZ, INC. Flu; 20. 0f, 09: 52a FAX NO. : 336 774 8701 drvie county onvhealth Aug. 20 2002 02:53PM P2 33G 751 V66 P.2 SPPUMION FOR SII[ CVAIUA1I0N/IA PnI)V0IC•!Yr rr.ItAIII 4 ATI Davie County Health Department Envirnru»ental Health Seatian F-()- Eox 040/20 Hospital street 14ockaville, ITC 27028 (336) 751. 0700 a eX *JglDf=r�jy+rAi A TitIS AP2LZC11'PION .^.ANNOT 1WPROCESSED (!N=ESS iiTAli THE iiEQUZftt:D I.NFOi MT10N I$ PROVIDED. ROEQ-c to the IN£ONATION DiTLLETIN for inotructions . ' 1. 11tWp Lo !s billed ---=CilV\Y\Ck �t contact Dozson /► \t\t;,.� Hailing AQdtYia ��:7y L 1 G�V�/ home pnonA City/Etwte/MVP _ ���,.1~ 101 JQ y rusiness Phone 2. M.,me on Pec:AL6/kTC at Dirfato:tt than Abovo �- Iililing Addma■ _ �� City/Stara/Zip a. Application Mr: ita ktralUati.on L Toprovament PertaitMTC t 1 8ot1, 4. Systoa to service: Glliolso !71 Mcbi.la Home L1 auainers L1 inductr-v L: otl'ter S. If Residence! f people '�tt Beetroons _ � # Bathroona 3 L.<.h.+ashar ilrt esl.1agc Disposal g Mbc3ainowMnI:/Pjppb'_ng 11 tiasew.nt/Mu I'lumbirg 6. Sf Buscnast/S.�dusecy/other: Spec—ICY rypa It pvcplo a sinks _ I # Coaeodea I shovers - .2 - a Urinals 1 ware_ Coolers IF FOODSERVICE: 11 3aat4; _.._ Estimated Water t'zago tga).lons go= day! 7. Type or aat6r Supply: County/C.i;y a well atmnunit�y a. Do you anticipate additions or cspans)ov—r of the facility Ibis system k in.ended to serve? .7 VCs ZIN !ryes' what type' •+•nlfraRraN70•*CUr"MMUS7COMr M- -THE RFQUIRW- Pt;OMWIYINFOR wriONIMQUEti'rt:l) } IIli1.U1�'. FitittraPLAT arSiTE.PLANMUS7n6S:ASMtr.[Db!,tLct6cnt Willi TRlSAPPLICATION. �{ 1'eulserty 1)itnonSiOn6: �.� _f�'3> 1��X n�' WRITE DII ELMONS (from Moclavilte) to 1'11011131,1'1': 7'aa Omrc PIN: Properly Address: Ruad Name Lk �L L;t� �• _.. _.. City/Zip 1(' k c &( If in a Subdivision provide] infurmotit:n, as follows: Name: CIL._ Block. Lot_ � Date Property rlagZed:liis W--n— I h, in certify ilial the Information providei! is correct to the best of my knowledge. I understand iiliaai any permit(s) issued hereafter 7rc subject to ttlspcnsion or reva:atirn, if the site putts or intended use change, or if the itiforawlirot subiniited it this appIienlion is falsirted or chap !ell 1. also, nnderslowl ikur I rin resnnuclG(ejernel c%rtt,(�rr t�irttrrcrl fiunr chis applicariuu_ 1, bcreby. give conscal to the Authurkwd Representative ortltc Gavic Cvunty IIca; Ill Dep:lrInw!?t torn itr upon aJove described proporty toeuled in Devic County mild ciivar4 by t4 conduct all testing praeedares as neccss:try in deterntittc the site saitabttily. 1)nTl: StCVA'rl:Rc ux' y THIS ARCA MAX BE USED FOR DRAWING: YOUR SITE PLAN (Incc all art g: Kitisting and llroposcd property lino and dimensions, stnteturc; setbacks, and septic locations). Site Revisit Ch:trge ! APPLICATION FOR SITE EVALUATION/INIPROVEAIENh PERMIT. l5 C LS Ur' , Davie County Health Department Environmenta/Heaith Section P.O. Box 848/210 Hospital Street AUG 1 6 2002 Mocksville, NC 27028 (33 6) 751-876.0 ENVIRONMENTAL HTALTH DAVIE WONTY **.*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�/►�I'Y� Contact Person �� 1� V w ✓� Mailing Address / l a I co.-'Vf-r!/ CL /r rs Home Phone ¢ City/State/ZIP -,At'MS rer> Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address C_ityy//State/Zip 3. Application For: 0Site Evaluation .,Improvement Permit/ATC II Both _/ 4. System to Service: "Ouse ❑ Mobile Home LI Business I_l Industry H Other 5. If Residence: # People # Bedrooms # Bathrooms II Dishwasher CI Garbage Disposal 11 Washing Machine 11 Basement/Plumbing II Basement -/No Plumbing 6. If Business/Industry/Other: Specify type # People ff Sinks # Commodes II Showers # Urinals It Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City 0 Well CI Community o. Do you anticipate additions or expansions of the facility this system is intended to serve? CI Yes G -K Ifyes, what type? ***Id1PORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Properly Dimensions: 5 42-'-- m�-fo WRITE DIRECTIONS (frau Nlocksville) to 1'R01'l;RTN': Tax Office PIN: # �� �o l -sal - ��3 %� Sy t' le Property Address: Road Name .S 1--�� f ��s t %-A) O 0Kf City/Zip If in a Subdivision provide information, as follows: Name: Section: Block Lot: C7 -r—_ Date Property Flagged: 8-h / (0 /D L This is to certify that the information provided is correct to the best of lily 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 incarred.lrutr, 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. DA'L'E 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). Revised DCHD (07/99)C7 I\j C, Site Revisit Charge Datc(s): Client Notification Dale: EFIS: Account No. Invoice No. y APPLICA1ION fUil 511L LVALUAIION/ IMPROVEMENT PERMIT & ATC .. Davie County Health Department -- Environmental Health Secdon P.O. Box 848/210 Hospital Street Mockoville, NC 21028 (336)751-8760 [JUN t 4 ***IIFORTANT*** THIS APPLICATION CANNOT BE PROCSSBZD UNLESS ALL T REW18ED J INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i structiD�,- ,icn -J rI utiV1t C011N1Y 1. Name to be Billed 4'411i -"(J ? Contact Person Cr14-: f �1 (� Mailing Address '-5 � fl l� F Hose Rhona 1Y^ �,)/ ` City/State/EIP U/1/, c. MCI. c Business Phone 2. Us" on Perteit/ATC if Different than Above Mailing Address city/State/Zip 3. Application For: @"Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to savviest 13"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other oJA...« 5. If Residence: # People f Bedrooms f Bathrooms ❑ Dishwasher ❑ oarbage Disposal O washing Machine ❑ Basetaent/Plumbing ❑ Basement/No plumbing S. If Business/Industry/Others Specify type # People t Sinks 1 Commodes 4 Showers / Urinals # Water Coolers IF rOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 9--County/City 0 Well 0 Community e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes 0 No If yes, what type? "61141PORTANT"* CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with TRIS APPLICATION. Property Dimensions: 6 5-4e. reS 4 Tax Oftice PIN: 4 1 --SI? — 5 -3 'meg Property Address: Road Name h1 LtJC S City/zlp c�lilyyee, AJZ . If In a Subdivision provide information, as follows: Name: P ,-,(' /11 "A - Section: Block: Lot: 2 g WRITE DIRECTIONS (from Mocksville) to PROPERTY: S 5`J P 4 t/ ; V 4- 7!1- D - 7-/,q l -4- i3,; of Date Property Flagged: 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 we 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 appl/catlon. 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 sultal)llity. DATE �, — �-,?)/ 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 Date(s): I Client Notification Date: I EIIS: Revised DCHD (07/99) Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900136 Tax PIN/EH #: 5861-59-523928 Billed To: Westview Development Co. Subdivision Info: Redland Lot # 28 Reference Name: Location/Address: USHighway 158-270?8 Proposed Facility: Residence Property Size: see map Date Evaluated: 7 3 1 Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit Public / Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % S� HORIZON I DEPTH • I Texture group ("L_ C Consistence Structure k Mineralogy1 T HORIZON II DEPTH - Texture group Consistence Structure Mineralogy HORIZON III DEPTH 3 — Texture groupG Consistence S Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O.3• • 3� SITE CLASSIFICATION: PS EVALUATION BY: ���41tltp LONG-TERM ACCEPTANCE RATE: O' �•�� OTHER(S) PRESENT: REMARKS: �1, 4IN I- KAJ X t 1 N fW 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)