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106 North High Field Road Lot 42Applicant: Matthew Gniewek ---AddressT106 N High Field Rd City: Advance State2ip: NC 27006 Phone #: (336) 940-6081 Property Owner: Matthew Gniewek Address:-___.---- 106 N High Field Rd City: Advance State/Zip: NC 27006 Phone #: (336) 940-6081 1-1 Property Location & Site Information Address 106 N High Field Rd Subdivision: Windemere Farms Phase: 2 Lot: 42 Road # AdvaneA NC 27006 — Township: Directions Hwy 158 East to Hwy 801 turn right then right on Mocks Ch Rd. to stop sign. Right on Beauchamp Rd. Windemere on left 'Structure: SINGLE FAMILY # of Bedrooms: 3 water Supply: PUBLIC Basement: F-1 Yes R No "Proposed Improvement: Shed # of People: Type of Business: Total sq. Footage: No. Of Employees: Structure must be placed as shown in the site plan and site layout. The structure is shown being placed at the far left corner of the property facing the front of the house from High Field Road. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONo Applicant/Legal Reps. Signature *Date: *Issued By: 2140 -Nations, Robert *Date of Issue:. 0 8 2 7 2 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** 4 16 Drawir HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street —P.O.- Box 848 -- - ----- -- --- — -- --- Mocksville NC 27028 CDP File Number: 157428 - 1 F8-020-130042 _-_.---_.County File Number:-----.----- Date: umber:---__---Date: 08/.17 .2014 Q Inch Scale: QBlock = ,ft. �a Tvae: Health Department Release QN/A O'l000't, .� (d d Page 2 of 2 to T ro Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Section P.O. Box 848 PAID 210 Hospitid Street tlbt�t '54 Courier # : 09-40-06 ocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fxr: (336) - 753-1680 Name: 0A As',nk<-,Q Phone Number '33(,-11 tqo- GOT k (Home) Mailing Address: `-Q (p �3. Nk-r-L t -E t—'C> . 3-a- -75-7 -Q3c[ 1 (Work) A"PV ��T i t..— 'oZ?0.5Z, Detailed Directions To Site: tAta t Cc Ok 5,QCX'CXA '010 1k t.G Sr' —VIX . 'M -r -G( -E T QFD S(•� �-�' ' D Y`►o ^ l4S ' - '*k"k56 elpe- a Cot Ir - i 'Cid '&' ltelk 4 Ytiv, CI v Property Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: 664 �'r-a Type Of Facility: e' %-�coGL 's ( U q-: Date System Installed (Month/Date/Year): '11 \l �'V;L XXZ-> Number Of Bedrooms:_3 Number Of People: 3 Is The Facility Currently Vacant? Yes No If Yes, For How Long?y4z, V ei( o,4j Z Any Known Problems? Yes 0 If Yes, Please Fill In The Following Information About The NEW Facility: Type Of Facility: Kj!'irV Number Of Bedrooms:Number of People o61-91- Pool Size: t -P l VXGarage Size: �� � Other: 5Kr� Requested By: 1'4111e- Date Requested: 81 1 H 1 Signaa u e) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist 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 Order # Paid By: Received By:_ Account #: Invoice #: L- -vp<)Vprocor--, loc -;�noo(v DO m (D N e--,- ok-?5 I q, 0 C�� L 9 v a DO m (D N e--,- ok-?5 I q, 0 C�� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900573 Billed To: Glenn Johnson Builders Reference Name: lupuavu L-CIL.1Ilty. r%=wUGIII.G ATC Number: 2766 Tax PIN/EH #: 5870-69-0403.42 Subdivision Info: Windemere Fams 2 Lot # 42 Location/Address: Beauchamp Road -27006 r I UPUI Ly JILC. SGC 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 buildmi permit(s) (in compliance with Article I 1 of G.S. Chapter 130A, WastewTe: ems, Section .1 0 Sewage Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WASTE CO IS V L OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: T 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 in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Vis' .. Septic System Installed By: Environmental Health Specialist's Signature:Date: ✓ DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900573 Tax PIN/EH #: 5870-69-0403.42 Billed To: Glenn Johnson Builders Subdivision Info: Windemere Fams 2 Lot # 42 Reference Name: Location/Address: Beauchamp Road -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2766 **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 1 I 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 000 #People #Bedrooms rl #Baths 2 Dishwasher: Q"' Garbage Disposal: Ll' Washing Machine: 0"- Basement w/Plumbing: [?"�' Basement/No Plumbing: ❑ Commercial Specification: Facility Type//�� #People #People/Shift #Seats Industrial Waste: ❑ Lot Size . &��1' ype Water SupplycEw Design Wastewater Flow (GPDj 00 Site: New Repair ❑ System Specifications: Tank Size 1000GAL. Pump Tank GAL. Trench Width Rock Depth �Z � Linear Ft.� r Other: � "�STCA &)I 1©�J i=Jv�L�`—�SC�t� 1.1 n��5 1 O. C-. la.-• �i . Required Site Modifications/Conditions: ''��Tbl�— p,J LV„J`Toof— Vzao S1 0l iil7t�St, KELP 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.**** TI 'Isor Ro^'-f �09— q1b, S�f vironm—enta Health Specla ist s 1gnature: DCHD 05/99 (Revised) 1:�: pFF y �T QLL)w& �C, ' APPUCATION FOR SITE EVALUATION/IRIPROVEM1fENT PERMIT & AT p EC EE WE Davie County Health Department Environmental Health Section VAR P.O. Box 848/210 Hospital Street 2 6 2001 Mocksville, NC 27028 (336) 751-8760 E! OROVIEKAL HEALTH ***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 C2 &,L6l Z///yS22 k: •/dG�I�S % �� Mailing Address, City/State/ZIP ( 6 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person /�61! eeyn, rO Home Phone /,t57-j�jZ-- Business Phone 7 7tom '56.5/7 City/State/Zip 3. Application For: ❑Site Evaluation � Improvement Permit/ATC ❑ Both 4. System to Service: 9 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms_ Dishwasher YYGarbage Disposal VWa;hing Machine asement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: P-'Connty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U-Nv-- If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: f --v ---� S 6 Tax Office PIN: # �� L/-�-y ' o � Property Address: Road Name 4 City/Zip A If in a Subdivision provide information, as follows: WRITE DIRECTIONS (froom Mocksville) toPRI OPS Name: W�/4e /J'jn'e'�f Section: Block: Lot: / a Date Property Flagged: �,a 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 Countyhealth Depart} ent to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suita ' 'ty. DATE 3-a �~ dt SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (0 /99) the following: Existing and proposed Site Revisit Charge Client Notification Date: EHS: 9 nq , o Account No. -6-7-3 Invoice No. & -5- ✓ '- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Brant Godfrey Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5870-69-0403.42 Subdivision Info: Windemere Farms Sec.2 Lot # 42 Location/Address: Beauchamp Road -27006 See Map Date Evaluated: 11 lqq )/C1777111 Community, Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L_ L- Slo % 7,, HORIZON I DEPTH - Texture group CL_ CL, Consistence r=r Se Structure G2 MineralogyI: 1 HORIZON II DEPTH - 20 '7- 7 - Texture rou Texture C G Consistence Structure IL Mineralogy1 HORIZON III DEPTH 2Z-3 Texture group C_ + S Consistence rSP r 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 RA' REMARKS: Ps 0.5 LEGEND EVALUATION BY: ,2Z1Q9AA1, OTHER(S) PRESENT: 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) T LAWRENCE L. MOCK BY WILL REF:D.B. 49 Pg. 8 ON P ACE gq63 37 T FENCE Ca6NER i