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116 South High Field Road Lot 33DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT /4 Account #: 989900259 Tax PIN/EH #: 5870-69-0403.33 Billed To: David Mallard Subdivision Info: Windemere Farms 2 Lot # 33 Reference Name: Location/Address: Beauchamp Road -27028 Proposed Facility: Residence Property Size: see map ** * jVbgr: 2623 N �s mprovement/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 Ov 5e_— #People _ #Bedrooms #Baths Dishwasher: C; --'-'—Garbage Disposal: Ca ----Washing Machine: �—Basement w/Plumbing: $--'�Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size t 1 Type Water Supply Design Wastewater Flow (GPD) 3�� Site: New E ' Repair ❑ System Specifications: Tank Siz%0 GAL. Pump Tank GAL. Trench Width " Rock Depth Linear Ft,�1 Other: Required Site Modifications/Conditions: 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: DCHD 05/99 (Revised) Date: A9-30 ^(56� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street MockvAlle, NC 27028 (336)751-8760 Account #: 989900259 Tax PIN/EH #: 5870-69-0403.33 Billed To: David Mallard Subdivision Info: Windemere Farms 2 Lot # 33 Reference Name: Location/Address: Beauchamp Road -27028 r1VPU0Vu raUuny. r%V0JU=11%,W ATC Number: 2623 rlupulty oicc. 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:Z2�e,._..Q A -� Date: /O 7:70 —0u 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. U x Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) too Date: � Cp —1� D L9 -- ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department OCT Z 5 Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 l (336) 751-8760 ***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 ._/Qy"41 Contact Person /�i�t'liry Mailing Address Ab Home Phone �yfS 30 City/State/ZIP �,P��t_J,s' -- 1 , ['• .2:Z0Z 3' Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: >1 Site Evaluation a. System to Service: IY House ❑ Mobile Home City/State/Zip Improvement Permit/ATC ❑ Business ❑ Industry ❑ Other ❑ Both 5. If Residence: # People # Bedrooms —:9Z # Bathrooms -'-`Z N,Dishwasher 1 Garbage Disposal t/ washing Machine K Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type 11111-9 # Commodes tZ # Shower- L- # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ,.NfCounty/City ❑ Well f.] Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Jy INo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE,THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. n Property Dimensions: co�� /-N—T Tax Office PIN: # 5-9 70 -0-0003 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Section: 7- Block: Lot: 3---5 WRITE DIRECTIONS (from ksville) to PROPERTY: �� 6n b-rti— Le f -� Date Property Flagged: 1-1-5-100 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. 1, 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 suita DATE io "�S ®� 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) Site Revisit Charge Date(s): Client Notification Date: EHS• Ir v� n Account No. Invoice No. (� `' APPLICATION FOR SITE EVAWATION/IMPROiIEMEW PERMIT & ATC Davie County Health Department Ent*vnmental Health Secdfon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 AUG 2 5 1999 i I' ***IMP01RTANT*** THIS APPLICATION CANNOT BR MWMSSW UNLESS ALL TSE REQUIRED INFORIMION IS PROVIDED. Refer to the nVOIMTION BULLETIN for instructions. 1. Name to be Billed wESrVINa J��JCWP,- CW COMPJW`/ Contact Person Mailing Address 2L3% kypirs nA f`O. some shone 336.116• 1009 city/state/3=P ,Nr, 2110( Business shone 336.11-1' 0019 Z. pore on Permit/LSC it Different than Above hailing Address 3. Application >ror: GYSite Zvaluation _/ SW0"100 1. system to services (3 HouseS ❑ Mobile Home s. If Residence: i People city/state/sip ❑ improvement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other f Bedrooms s Bathrooms 0 Dishwsher 0 Garbage Disposal O washing Machine a Basement/plumbing 0 Basement/no Plumbing 6. if suainese/2ndustry/Others speoity type # Commodes + People ! sinks i showers f urinals # Nater Coolere IT T0OD8ZRVICZ: # Seats intimated Nater Usage (galions per da]t) 7. Type of water supply: ❑ County/City ❑ Well ❑ community 9. Do you anticipate additions or expansion of the facility this system is intended to serve? ❑ Yes H No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPWCATION. Property Dimension: Tax OMce PIN: # �d �U in� 110 Property Address: Road Name �C uC ��A City/Zip H in a Subdivision provide information, as follows: WR17M DIRECTIONS (from Mocknille) to PROPERTY: )10ck5 WtM To 12-I0N1 GW 8r4V J1AMP„%,/,_ PKPPMTY o� L -f Fr. Name: IM ukam I A�"lS Nz;,J MAP Section: Block: Lot: _� 3�? 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 1, also, understand that I ant responsible for all charges incurred front this appQcadom t 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 aU testing procedures as necessary to determine the site suitability. 63FFpAVAVYFMAMTW THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the 2611owing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Revised DCHD (07/99) Date(s): I Client Notification Date: I EAS: Account No. Invoice No. / ��O 1D' hl LAWRENCE L. MOCK BY WILL REF:D.B. 49 Pg. 8 ON PUCE% 37 T FENCE CORNER - 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 #: 5870-69-0403.33 Subdivision Info: Windermere Farms Sec.2 Lot # 33 Location/Address: Beauchamp Road -27006 See Map Date Evaluated: ]O% q 9 Community Evaluation By: Auger Boring Pit ' Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position LL Slope % 1 HORIZON I DEPTH 0-2J4 Texture group G Consistence Structure Mineralogy HORIZON II DEPTH Texture group U +50 Consistence Structure le- GMineralo Mineralogy HORIZON III DEPTH Texture group + Consistence `� Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: - 2l LONG-TERM ACCEPTANCE RATE: • 3S REMARKS: EVALUATION BY:4,P 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)