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170 High Meadows Road Lot 25• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900259 Tax PIN/EH #: 5870-69-0856 Billed To: David Mallard Subdivision Info: Windemere Fams Lot # 25 Reference Name: Location/Address: Beauchamp Rd -27006 t-acwty: Kesiaence ATC Number: 2926 r1upul Iy JILL. Z)= IItop 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 .19 0 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAVAL FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature ;r ate: 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. G /v 9� Septic System Installed By: ®" Environmental Health Specialist's Signature Aimi 4 I ate: DCHD 05/99 (Revised) Account #: 989900259 Billed To: David Mallard Reference Name: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5870-69-0856 Subdivision Info: Windemere Fams Lot # 25 Location/Address: Beauchamp Rd -27006 176 141" *teo S Proposed Facility: Residence Property Size: see map �C nbr: 2926 * * N is 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 o1r-- #People #Bedrooms #Baths 3, S Dishwasher: lr Garbage Disposal: 121' Washing Machine: 171`� Basement w/Plumbing: 121""' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size I I97 A PZ Type Water Supply Design Wastewater Flow (GPD) 3400 Site: New G2f Repair ❑ r+ , , r System Specifications: Tank Size JCW GAL. Pump Tank GAL. Trench Width� ? Rock Depth IZ Linear Ft. X-'� ViSTQ� other: —ii o •� ��. Xis . � NS't'ALL. u '1z -;S - i C.C. ,rn, r3 . Required Site Modifications/Conditions: I�Si/�l� () -3 C OrS'1i t �r c!:�C-C Aar_ - �P Icy oFF PQfk Ll 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.**** ir x + 8 8 Fa -:Du, --'Gs 1t-� C1 MIA. �— Environmental Health Specialist's Signature: D e: D i DCHD 05/99 (Revised) IN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPS ZUM"*-'1'� APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED FORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed/ " ' -, 44g44!:k2 w Contact Person Mailing Address 1i�0 /�� .� r- t ,' ? n� Home Phon� City/State/ZIP L e,4/_ s L/; // r , C , 2:ZO2=S Business Phoney—5519 Int 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation i$sImprovement Permit/ATC ❑ Both 4. System to Service: �k House ❑ Mobile Home ❑ Business 1 ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms 3 XZ Dishwasher XGarbage Disposal KWashing Machine �VBasement/Plumbing 11 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: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 4No 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 THIS APPLICATION. Property Dimensions: Tax Office PIN: # t,�: 9%O - 6 / - 09-54 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name:,4e,olS WRITE DIRECTIONS (from Mocksville) to PROPERTY: Go/I Aro/ Lor aC,�S L Al -t-0 A/y �OYD� 622 rr c 3? �/ rA C ol-- o IV P Section: Block: Lot: ,� 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. I, also, understand that 1 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 suita�"ky. DATE 7- /1'9-0/ 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). i Revised DCHD (07/99) Site Revisit Charge Date(s) Client Notification Date: EHS: Account No. 6tA( % g o 0 c2 5'S Invoice No. 3 19-3 I CARL D. TULLOCK I D.B. 191 Pg. 635 S 83.23'571 E �_ 200 14 i S 83.23'37• E 340. 9S 49 , 25 h 1.401 AC. Z f 1.187 AC 5 207.4 �?8J ze 26 s �C. cP/ ;� 1.282 AC. o �) N R-- 1 9 r l84 8 CURVE DELTA RADIUS C1 C2 28'24'14' 3330'39" 200.00 260.00 - -- _ _ -- - - 340.70- - - S 86'22'36' V - - C4 CS 52'02'08' 5324'28' 50.00 50.00 116.4q !QTAIr 492 19 8 ROAD Cs C7 c2'18'21 97' 55'08' 50.00 50.00 ffG �,(�,i W S 1d1 J-��D o E - - -. _ - _ - - - - C8 4r50'00" 25.00 N 86'22'36' TOTAL. 482.19 - 120.00- - C9 CIO 4r50'DO' 94'19'28' 23.00 50.00 �---- - - 120.00 - - C11 87'55'38' 50.00 7-7166.c- - C12 8324'57' 50.00 i. 93 C13 42*50'00 25.00 83 C14 33.30'39' 200.00 Cts C18 C17 8"08' 14' 58'02'03' w48'31' 200-00 35.00 50.00 �� G ? C18 C19 81'13'54' 31'3701' 50.00 50.00 / �� N C20 50'37'30' 50.00 50.00 0.829 AC. 0.778 AC. N C21 C22 13'45'07' 8'59'28' 260.00 � N � cd CD O J V �1� AZA 1p0 S7 77'34 ,1• z PN � — — ` _Q��O .►� nM � _ 10 i Y CARL D. TULLOCK 1 D.B. 191 Pg. 635 14, r S 83.23'571.E 200 14 S 83•E3.57• E- 340.97 - q.� 49 -OI M 2.l In 25 ��'�•, e 1.401 AC. 1 1.187 AC. U It 0u A//► Z. ... nn-. O 67 ?7"J3, 207 1 .4 ��� � f !{° N 78'18.08• � � -_J �-_ i i5! E 2a n� V FIM PcO6 .-�--- 1 W 50 ....r P��: s= 26 g 1.124 AC. 1.282 AC. o �I `• �� !� J ,84 H rn j CURVE DELTA RADIUS ARC CHORD TI 777 C1 26'24.14' 200.00 92.17 91.35 C2 33'30'39' 260.00 152.07 149.91 7 C3 475000' 25.00 18.69 18.26 340.70 - - - c4 52.02'08• 50.00 45.41 43.67 - ---- -'116.49- - _ TDTAL� 482.19 S 96.22'39' V H C5 5524'26' 50.00 46.61 44.94 --- MEADOWS C7 5r15.21• 50.00 54.37 51.73 ,22 HIGH,' ROAD - - - - - - - - - C7 97'53"05• 50.00 65.69 75.42 H e6•zz•3e• E --T---- Cs 4750.00• 25.00 15.69 15.28 TOTAL- 462.19 C9 4750.00* 25.00 18.69 15.20 _ _ 120.00- - - -120.00- - C10 94.19.25• 50.00 $2.31 73.33 t66.24-- - C11 $r55'38• 50.00 76.73 89.42 _ 75.95 C12 $x24.57• 50.00 72.79 08.53 C13 42.50'00• 25.00 Meg 1$.26 ,83C14 3730'39' 200.00 116.97 115.31 t 21 C 1 5 (roe 14• 250.00 27.83 27.84 • ,� /,, Cte 5fr02'03* 35.00 35.45 33.95 ^ W C17 50'4$•31• 50.00 53.07 50.61 ciser13'54• 50.00 70.e9 65.10 22 C19 31'37'01' 50.00 27.59 27.24 r 24 'Z'3 �+ C20 50.37.30• 50.00 44.18 42.78 �, ¢ 0.778 AC. N ci1��ie50.00 12.00 i:i0.829 AC. t e'' zo0 3. 3o Ito Q/ lo0.3T •34, AT' V �c �• i C-171 4 faC♦^nf0• -le 0' s TT to 'rcl In.\ G'Ct •Cf CrepC• ,tl a r=s ES / 'w'S SUavE' Z•4 /Jp NDN CEq.. O u Or •.l./�_ - uj W i911. •,1-EcnA f. Lj i "" 5''�'S ^f'i SECTION TWO •.1'NIMI.4 �E.a;=Y ..INE, t•.:n• ..� 30' WINDEMERE T Geo• � ns STREET ADDRESS ; 5"eQ' _ OWNER ------------------ DE • APPUCATION FOR SITE EVAtVAT10N/I111PROVEMENT PERMR & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �! AUG 2 5 1999 ***IMPORTANT*** THIS APPLICATION CANNOT BZ PROCCNBSND mass ALL THE REQUIRED IWMrMATION IS PROVIDED. Refer to the INrORM=ION BULLETIN for instructions. 1. X ft to be siaied WEMICI,1 DCJCLOF 49W C"VA P/ Contact person &W Gooracy Mailinq Address 2L3% ' 4yv Jgkna TZO. some phone 336-10-1.008 city/state/a:p u1:Ntra,�-S�► «� ,tic 2'1106 saet.nese Whoas 336•11-1- 0018 Z. Rase on perait/&= it Different than Above 1lailinq Address City/stag/sip 3. Application ror: Vaite =valuation 0 Improvement Permit/ATC 0 Both _/ fw0wK�ow 6. systems to service: C� Houses 0 Mobile Home 0 Business O Industry 0 Other a. If Residence: 6 People I Bedrooms i Bathrooms 0 Dishwasher 0 garbage Disposal 0 Washing Haobine 0 sasenent/plumbing 0 sasesent/No piunbinq 6. tf susiness/ladustry/others spsoify type # Commodes t people f sinks # showers • Urinals f Rater Coolers It FOODSERVICR: # seats Estimated Water Usage (gallons per day) 7. Type of water supply: 0 County/City O Well 0 Community e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes tfNo If yes, what type? ***IMPORTANT'*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBIW77ED by the client with THIS APPLICATION. Property Dimensions: Tax 0111ce PIN: Property Address: Road Name /J�'C uc Lalnj��Z/�' City1Zlp WRITE DIRECTIONS (from MockrAlle) to PROPERTY: /ho&5 Cuwtm 1"0 R,1a# aW '�cAvdamp„fz'l PKP1k-k1 y ori i-EF1. If In a Subdivision provide ^^Information, as follows T: : I�M Name: WlWr-6 s— Section: Block: Lot: 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 I, also, understand that I ant 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. M11 / L / DATE of Q 7 _ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the glowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: I EAS: Account No. /3C Invoice No. ©cr Wo 30 tib 811 891 691 NV % T �-,Xtio �b0\ 22l 001 6 8S � 1 + Ls / ►s D n ,60,E L6 %68 / \ g� 0 ONO O-1 N081 310 5 16vo 192 '2'2 i,ee.s8 s 292 9 E Moov Sal 3� \° 921 612 of t + � 81 122 2 i r0-+ y tOi rjL\ Lt2 L6l 861 661 0 ZII SLI 2 bL 961 961 I f:► 2 1" �6 rr2 I o01 SL 9t2 2� steel f6[ ut GNU 6 1 pMl 8S1 LSl 1 + i8it E61 C 98I Z d� Le1 G�f 691 r2 L2 6S2 esz O U2 tl� est iSt •� U J,%, ►c 02 m i oz►2 + O 9Y r_ ^J J 82 5 A 201+ 02 ►2 � 6012 CbZ U61 2L2 SL- A� 05 OS2 p t 1 SSI "� �� ; ,O 902 � sir AA'� "0 99 r6� S2 ti ►SZ C 1 2S2 of f•I ILZ f �t c 62 92 6P, 8p, h 60919 3 .L9,E2.Cq + 91 92 S 0 ONO O-1 N081 310 5 16vo 192 '2'2 i,ee.s8 s 292 9 E Moov •0 ti APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnWronmenta/ Hea th Section P.O. Box 868/210 Hospital Street Mockaville, NC 27028 (336)751-8760 r AUG 2 5 1999 ***nffs0RTANT*** THIS APPLICRTION CANNOT BN PWMSSED UNLESS ALL THE REQUIRED INrORMRTION IS PROVIDED. Refer to the INr MWION BULLETIN for instructions. 1. Nus to be Billed WEsv1E•JJ 1DCJCW1-;A� C01"10wW1 Coatact person -WJ G09REY Nailing Address 2L3% 94V)'JMA RO• soma phone 336- alb• 1.o08 City/stat•/xxv 1A1%141Tj5M-SAtZr% ,NC 11106 Business paces 336.111- 00"1$ Z. flame an ?arait/ATC i! Different than Above Nailing Address a. Application ror: Fite evaluation / 1,,0oW%J0JJ s. Breton to services 13" Houses O Mobile Home City/state/sip 0 Improvement Permit/ATC 0 Both 0 Business 0 Industry 0 Other S. If Residence: # People # Bedrooms # Bathrooms 0 Dishwasher O Garbage Disposal O lashing Machine 0 Basement/plumbing 0 Basement/lto plumbing 6. If Business/Zndustry/Others specify type # Commodes # people # sinks # showers # Urinals # hater Coolers Ir rO0D8ERVIC3: # Seats Retimated hater Usage igalloas per day) 7. Type of Maur supply: O County/City 0 Well 0 communi itty a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes Ei' io If yes, what type? ***IMPORTANT'** CLIENTS MAST COMPLETETHE P.EQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: vSec /n Tax Office PIN: Property -Address: Road Name City/Zip f%Gyr✓a�tcc /I�c%� WRITE DIRECT[ONS (from Mockaville) to PROPERTY: 'rocks Cuwtm ro iWtt• aur 8E4uGqAMP„%'/' i A-MIV a.PJ i-EFr. If in a Subdivision provides Information, as follows: Name: All 0 6A T Atu-S Section: Block: Lot: I'nW Date Property Flagged: (W ,425- 4 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. 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 suitability. DATE 8I Kl/Q 9 SIGNATURE AO� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the i6ilowing: Existing and proposed property Imes and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: I EAS: Account No. /J 6 Revised DCHD (07/99) Invoice No. ace MVO vo V 30 BIT r�---Sr 02I 8 891 A 691 /4\0 1y(6�A`�b 221 Vol s 8S � + LS S / ►s 017 A ,60,E 1S L6 ` l� 68 �4 / Q'�l V,3 \° 921 612 O c - pd + A 08 P 9y' + X01 Lt2 81 122 L61 B6[ 66I 2 + r.y\ 211 0 ill 2 n I I;I 6L 961 961 1 E4 26 G6 ►►2 I o ZA Qrll ' SL 912I Sti ` QL1 '�' sl2ei ►61 w MBs1 LSI E61(O1 ►2 ? >71k { B1 981 -� 1,81 881 04,. 68l LZ 6SZ 8S2 D EL2 i ,a Est 1st r ►Lc 02 09 ►2 9t 82 /� 7 r A 201+ OZ Y2 ,� n> U61 6►2 Os2 ^ 20 � SL ,:1 1 SSI 0, S y9 ,C 902 6� 9S2 S2 � 1'r.22s2 1 OS f I tL2 + 62 + 92 O 6 f 6 p Q 1 60'919 3 •LS.EZ.EB S S2 + 91 0 r� ONIIOJ Noal NYE S<rL 22.2 192 3 .80.EE.68 S 292 8 't, I N001 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME O PROPOSED FACILITY SUBDIVISION ��fiJti>7tS Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit_ �S SECTION_ LOTCW DATE EVALUATED �V///99 PROPERTY SIZE 1-t -4 e ROADNAME —A Public c---**� Cut .FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH I Ll Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure Mineralogy�f 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: UT LONG-TERM ACCEPTANCE RATE: Az1lg__ REMARKS: DCHD (01-90) EVALUATION BY: ✓` 1a ll — 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 Datea• Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Section P.D. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Fax: (336) - 751- 8786 Name: j v— �i��L Sr�1,/n5©t✓ Phone Number -T56 D (Home) Mailing Address: MiO / ,�1/%�✓n�,c.5 s�d D— 3,11 Email Detailed Directions To Site: d `. Property Address; Please Fill In The Following Information. About The EXISTING Name System Installed Under: n�m ���1� f ' Type Of Facility: , �y Date System Installed (Month/)ate/Year): /b -G_-0 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Ye�'� If Yes, For How Long? Any.Known Problems? Yes 6) If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Apag2 Number Of Bedrooms:y Number of People Requested By: Date Requested:�9��fC (Si ature) For Environmental Health Office Use Only Appro ed Disapproved _ / Comments: G! r ✓l�Ll'. — C J d apt Dr J/ a lif Q "'.E nvironmental Health Specialist G ��G,��` —� Date: „Z — / _ J Y *The signing of this form by the Enviriniental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the onsite wastewater system will function properly for any given period of time. Payment: Cash QQhec Money Order # 1 3� Amount:$ `(y Date: Paid By: ka `(a ek Received By: Nj M"i ! C) P, 5 Account #: ^ , Invoice #: t �g?0^6 q— 09Y—Ce