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224 Longwood Drive Lot 30Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: 'r000sed Facilitv: Residence ATC Number: 3255 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 P& Cj,o ov Tax PIN/EH #: 5861-59-5239.30S Subdivision Info: Redland Lot # 30 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: -Y Aen i i 4 4�clon j s DA1112 CO. HMT i CERTIFICATE OF COMPLETION Date: **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, Sectio 1900 "Sewage Treatment and Disposal Systems," but shall in N ee a t e system function satisfactorily for any given period of time. /5-0 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r DAVIE COUNTY HEALTH DEPARTMENT s Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5861-59-5239.30S Subdivision Info: Redland Lot # 30 Location/Address: Highway 158-27006 Property Size: see map ATC Number: 3255 **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 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 Dishwasher Garbage Disposal Washing Machin Basement w/Plumbing: 173Basement/No Plumbing: El Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �� Design Wastewater Flow (GPD) IWZ� Site: NeviO Repair ❑ System Specifications: Tank Size GAL. Pump Tank � GAL. Trench Width 6V�Rock Depth Linear Ft� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT,,- APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a r es a 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.AQ-1. on the of installation. Telephone # is (336)751-8760.**** C4 // ,Wzao ,oe�o �e�,n,P Nolk Environmental Health Specialist's Signature: Date: 26232"-- .& k,1-3 /. z— DCHD 05/99 (Revised) ri7-rim .: SAMNAZ, INC. Flux 20 02 09:520 FAX NO. : 336 774 8701 davie county envhealth Aug. 20 2002 02:55PM P4 336 752 0700 P.2 W'PLIWIGN 1`011 Sllf•_ £vtLLUAltONJIitPi OMfENT nL)Ulltt' a Arc Davie County Health Department E7vinw07 ua/Nea/1`h Sectkao P.O. Box 849/210 Hospital 9treaet Mocisville, ITC 27028 (336) 751-•87G0 ***1)dP0=AK2-#* THTS "7LICATION CANNOT BE PROCESSED MMESS ALL T111: g>,QUIIO;D— 4 T INFORMATION IS PROVYDMI)..,, ,lR/e�for to the INFORbIXTION DU=TIN for instructions. 1. paWo Lo M B411wi ��`l`l �`W^i�Z �G CUACZGL VQXROn V� Mailing AAdrvua Cit)•/Ctako/SIP rusiness Phone 11 7, Nyco on Posit/A:C if niCfO[eat t:lta[c JibOVO Ha, -Ling td4mss �— city/Srzza/zip _ T 3. Application For: OSS to £valuation t.! Tasrrovcmerlt Peraaft/RTC r! Both a_ syntou to service: :louse '! Mbile ttome 0 Buainez3 R inductry {; Other `r 3 S. II flesidonoa: People _ r Bedrooms _ s Rat:hxootzla V i� ah.,astaCr lrGaebagc Diapass2 11 WA-b*ng 74A034iae lA—�iemenk/plutrl�Snq 1`1 D,e,ras,nt/H.i Plwrbug S. :f 3peciry r_ypaf�cr- s rcopl. s Sinks ^� A corrodes s SI)OVers J 1 uranals i oargt Cooloa Ir FOODSERVICE: 4 soah-a E3tiZatad Water Coale tgailonn per. day, z. Type or water supply: Z --d unty/Cs:y D Net 1`J Community a. Do you anticipate additions or expansions of the facility this system k iu:cnded to serve? ,-I Yes n No l r) ts. ,Visas type? `+`IMI'ORTXNTra t't'CLIFMAfUSrC0hfPLZrtTH£ REQUIRWPROPLIt•rvIINFOtt!IANTIO it .1 U �ti .1) —I II1;LOW. er s PLAT or SITE PLAN AWST IlESfitlttll'ril'A by the client rich TIUS APPLICATION. Ileo1wrly Inntensions: 1Zo�C X1(� X �� WRITCAtRLCno.Ns{rrom Atuckniit�.) to PROPEAUIV. 1'a( 0fficc PIN: i Property Address: Rend Namc cityrcip If in a Subd6i\Ion provide infurtuaticn, as [01101ys: Name: � �11q Soctitan: Block.: Lot: Unto Property Ttagged: This iv u1` certify that the information provided is correct to the best ormy knoavtedge. t andcrstand that any permit(s) issued h reatteram subject to suspension or revocation, if the site platts or intended use chs tgc. or if the inforaatatiota submitted in this application is ralsiGcd ur changed 1, olru, understand that I an: rr ipon iLlelvrall charger incurred /r,n,t !itisapplication. 1. hertby, give consent to the Authorizes! Reprercntsfive orthc than: Count; Ite ait Dquirinaeot its Cntcr upon above dc3cribed property locates in `Javie County and uwntd y to cunduet :,It testing prucedures as neccuary to dererntitte lite sit" suitabi y. nA*Fl;. � 2 S1GNATURG �7 THIS ARTA MAY BE USED FOR DRAWING YOUR SITE PLAN {Include a lwriltg t �nd osed property lines and Jimensions, structures, se(backs. and septic locations). �, Site ttevisit Chaty;e � I �,, • _. v APPLICATION FOR SITE LIIALUATION/Ih1PROVEhiENT PEEih1tT Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital StreetL!: 1 6 2002 Mocksville, NC 27028 (336)751-876.0 ENVIRONMENTAL NEALTH IE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. llama to be Billed Contact Person A, dH- ✓� Mailing Address oZ, C04n.P y CL -4 /� clJ� Home Phone City/State/ZIP "Af t IUs ra,J Business Phonet�� +}- 2. Name on Permit/ATC if Different than Above � - 4 -3 V a %a 0 Mailing Address Citt�y/State/Zip 3. Application For: ❑ Site Evaluation 12- Improvement Permit/ATC II Both 4. System to Service: House ❑ Mobile Home CI Business 0 Industry IJ Other ((M- 11 5. If Residence: # People S Ir # Bedrooms —/ # Bathrooms `� Z LI Dishwasher CI Garbage Disposal II Washing Machine LI Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 7. Type of water supply: `j County/City ❑ Well lJ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? f1 Yes &I-wo 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. Property Dimensions: Se -le- r�-p Tax Office PIN: # =-571 (c_1-59 - S'�3 %. 3 D-' Property Address: Road Name S City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: �--�� f— t�•� s t Sn) 0 e KJ' Date Property Flagged: R-J;Z. D �- 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. 1, 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: 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) C� I IV I✓e- Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Invoice No. D--7 APPL1CA11ON FOR SITE [VALUATION/IMPROVEb1ENT PERMIT & ATC Davie County Health Department ,�► En vIronmen tal Health S&Won V[d I '~ P.O. Box 848/210 Hospital Street Mockoville, NC 27028 (336)751-8760 t 4 2i��i1 ***IHPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL T RE ED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i structDa FN —1 / COUN1V 1. Name to be Billed G� ) k 1 f /'- - -- .. ;t / Contact person � t"/'g-�- t" }tailing Address J4 P some phone City/state/LIP Utl/, c-. AL Business phone 2. Name on permit/ATC if Different than Above Nailing Address City/state/zip 3. Application For% B"Site Evaluation ❑ Improvement Permit/ATC ❑ Both 6. system to servicat t'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other W.�.,.«• 5. If Residence: / People # Bedrooms i Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ washing Machine ❑ Basement/plumbing ❑ Basament/No Plumbing 6. If Business/Industry/Othert Specify type i People / sinks 1 Commodes i showers / Urinals 1 Water Coolers IF FOODSERVICE: # Seats Estimated water Usage (gallons per day) 7. Type of water supply: 0 County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the faculty this system Is Intended to serve? ❑ Yes 0 No 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 TIIIS APPLICATION. Property Dimensions: 6 5 1rto. rF'S 4 Tax Office PIN: # 5 i?'6 ) --5 — -7;9 Property Address: Road Name 11a.)LI 1591 City/zlp IIJ11.Ved ll -(f ,9/—at If in a Subdivision provide Information, as follows: Name: �R ;( /1,- n_ ..A- Section: Block: Lot: -� b WRITE DIRECTIONS (from M/ocksvllle) to PROPERTY: �r7O _ D-7-191 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 we 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 appllcatlon. 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 suits 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). 0 Revised DCHD (07/99) Site Revisit Charge Date(s): I Client Notification Date: I EBS: Account No. Invoice No. —=f ' DAVIE COUNTY HEALTH DEPARTMENT :�r~t Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5861-59-5239.30 Subdivision Info: Redlane Lot # 30 Location/Address: USHighway 158-27 28 see map Date Evaluated: 7 v -,7���� Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group C Consistence ' S ` Structure yc Mineralogy HORIZON II DEPTH 141- tTexture Texturegroup ell, toQ� Consistence SSS Structure G MineralogyI = HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 5 LONG-TERM ACCEPTANCE RATE .3 -DSS SITE CLASSIFICATION: PS�� LONG-TERM ACCEPTANCE RATE. d. ^ v' 3 REMARKS: EVALUATION BY:�--C� OTHER(S) PRESENT: 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)