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128 North High Field Road Lot 40DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P. O. Bos 848/210 Hospital Street Mocksville, NC 27028 �Y (336)751-8760 / IMPROVEMENT/OPERATION PERMIT Account #: 990000955 Tax PIN/EH #: 5870-69-0403.40S Billed To: Samnaz, Inc. Subdivision Info: Windemere Fams Sect 2 Lot # 40 Reference Name: Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map **NOTES Nffibfinprov8ement/Operation Permit DOES NOT authorize the construction of aseptic 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. r Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: Garbage Disposal: CR"- Washing Machine: 0�— 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 ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth Z;L Linear Ft 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 1:0 p. the day of installation. Telephone # is (336)751-8760.**** 0 d Environmental Health Specialist's Signature: Date: ' O DCHD 05/99 (Revised) Account #: 990000955 Billed To: Samnaz, Inc. Reference Name: DAME COUNTY HEALTH DEPARTMENT, Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5870-69-0403.40S Subdivision Info: Windemere Fams Sect 2 Lot # 40 Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2879 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: Aie 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 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. It' V S je rti <1 / J y Septic System Installed By: - — -/t /, - Ile Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) 1. 2. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Heaft AmWan P.O. Box 848/210 Hospital Street 3 awl Mockaville, NC 27028 (336) 751-8760 ***II :N=TANT*** THIS APPLICATION CANNOT BZ PROG'aSSBD UNLESS ALL THE REQUIRED" INFORMATION IS PROVIDED. Refer to the 2NIUMTION BULLETIN for instructions. Name to be Milled rA" Q Z Contact Person V \ U e - Mailing Address "S O h C',STi�1. f b Roma Phone City/state/s2P ( A�Business Phone Mass, Mason Permit/ATC if Different than Above � � r./t, )failing Address City/State/sip 3. Application For: ❑ Site Evaluation 9 --improvement Permit/ATC ❑ Both 4. system to service: B' House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: # People i Bedrooms # Bathrooms 0 Dishwasher Garbage Disposal R4&shing Machine O Maaesant/Plumbing B"Basesant/Mo Plumbing 6. Zf Business/Industry/Others specify type i Commodes # showers I People • Sinks _ + Urinals # Nater Coolers Ilr IWDSERVICE: g Seats Estimated Water Usage (gallons per,day( 7. Type of Nater supply: 8-tounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is Intended to serve? ❑ Yes 9440 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 APPLICATION. Property Dimensions: 5*, -e o 2" Tai 08ice PIN: # 5-01 -71) - / 9 - a Property Address: Road Name City/Zip Ala. L 7� WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: C) ) /2" Name: lye% -e n-, t� i% 1 4" �� -!'' Section: v2- Block: Lot: 14!) Date Property Flagged: el t K� 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 suitability. DATE SIGNATURE t THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (In4e6 owing: ting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): I Client Notification Date: EHS• e-7 Revised DCHD (07/99) / ' �y 004C) Account No. ' Invoice No. APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Ent4tvnmenbal Health Se+ctlon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 AUG 2 5 1999 ***nWCRTANT*** THIS APPLICATION CANNOT BM PW=SMW UNLESS ALL TAS RSQUIRSD IMMrMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Maas to be Billed LIES IC,.1 Contact person ori) Goopacy Nailing address 2L31 ReVNGVnA'RQ. acme phone 336.16.1008 City/state/sip W 1,4I A-S.KLCV% ,NG 111010 Business phone 336-1.11- 401$ Z. tease on permit/ATC i! Different than above Nailing address 3. Application for: VOLte =valuation -/ jwoWsb0i a. systems to service: B HouseS O Mobile Home City/stag/alp O Improvement Permit/ATC O Both 0 Business O industry O Other S. If Residence: f People t Bedrooms • Bathrooms D Dishwasher 0 Garbage Disposal a Washing machine O Basement/plumbing 0 Basement/l10 plumbing 6. If Business/Industry/other: apeaify type f people # sinks f Commodes # showers f Urinals f water coolers Wit' 1O0DSSRVICS: # Seats Estimated Nater Usage twdions per day) 7. Type of water supply: O County/City D well O Community s. Do you anticipate additions or expansions of the facility this system b intended to serve? O Yes 5 -No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REOUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tex Office PIN: # �d �U in 41D' 1, 5// Property Address: Road Name L4112-14.11�� If City/Zip A c/d-ice /I/c-.2-%C If In a Subdivision provide information, as follows: Name: 1A)l )VrXAQV f albMS AjaP M410, ?-5-41 Section: ?� Block: Lot: yD Date Property Flagged: WRITE DIRECTIONS (from MockrAlle) to PROPERTY: /10ck5 CNVRUI To 12Aaff dpi REAVWMPA,/ PKPAMTV oAl [EV'f. 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 ani 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 suitability. leMply/Idw THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the f611ow1'ng: Existing and proposed property lines and dimensions, stractarm setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Revised DCHD (07/99) Account No. Invoice No. ���� LAWRENCE L. MOCK BY WILL REF:D.B. 49 P9. 8 IN PUCE 63 T FENCE C%NER • 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 #: 5870-69-0403.40 Subdivision Info: Windemere Farms Sec.2 Lot # 40 Location/Address: Beauchamp Road -27006 See Map Date Evaluated: 0 1a q Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % 3 HORIZON I DEPTH ©� S Texture group C"_ Consistence Structure ?� G Mineralogy HORIZON II DEPTH 2 r 13 Texture groupe- Consistence Structure Mineralogy HORIZON III DEPTH Texture group+ Se. Consistence Structure A6k- Mineralogy; HORIZON IV DEPTH Texture group Consistence SP Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE O.3 ' 3 SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: C)'35 REMARKS: EVALUATION BY: t --+e 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)