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175 High Meadows Road Lot 23i G DAVIE COUNTY HEALTH DEPARTMENT ,pd lo - Environmental -Environmental Health Section r Ir3o P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900259 Tax PIN/EH #: 5870-69-1136 Billed To: David Mallard Subdivision Info: Windemere Fams Lot # 23 Reference Name: Location/Address: 17511*1A�►rer�,�s F -b Proposed Facility: Residence Property Size: see map **NOT>J*'�i�iis ?rripr2v8e lent/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. V� Residential Specification: Building Type � #Peo ple #Bedrooms #Baths Dishwasher: Garbage Disposal: M'�' Washing Machine: Basement w/Plumbing: 02'*' Basement/No Plumbing: ❑ Commercial Specification: ++Facility Type ##P 13 Lot #People/Shift #Seats Industrial Waste: Lot Size 0-7-71P g -t i��3l'ype Water Supply , ; l� Design Wastewater Flow (GPD)3(O0 Site: New 7"' Repair ❑ System Specifications: Tank Size 'DCD GAL. Pump Tank GAL. Trench Width --S6' Rock Depth \ 2 " Linear Ft.007a r 4 Other:j�1 S i (Ll 1 tC� i�`� �C F[��Ltl l -1 o . C. Required Site Modifications/Conditions: fir, iAu��1 C�roozt'�ro l-bc�sr✓ 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.**** o'x36: X4Z', Environmental Health Specialist's Signature: DCHD 05/99 (Revised) SE-\,ZC -.S Po,vt- 0 VOP E I I Date: 25 v • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900259 Billed To: David Mallard Reference Name: Proposed Facilitv: Residence ah Tax PIN/EH #: 5870-69-1136 Subdivision Info: WindemereFams Lot#23 Location/Address: Property Size: see map ATC Number: 2851 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 Trent and Disposal Systems). THIS AUTHORIZATION FOR WASTE C is, ID FOR A PERIOD OF FIVE 7ARS. Environmental Health Specialist's Signa e: Date: o 61 CERTIFICATE OF COMPLETION 7.. **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. TAIT -7-2Z off�p� ECC�t-� url► - 00 `i I I W .� 1.1 Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) Date: "1 12& I a l Z.N �N'ly " At'�' ION EOR SITE EVALUATION/IMPROVEM1IFM PER611T & ATC Davie County Health Department Environmenia/Hes/ihSe�ction AY 1 7 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 HEALTH (336) 751-8760 VIE COUNTY TANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to'be Billed �o¢t/.d 15: & 8g? Contact Person 5'r ,'A �,�O Mailing Address Z4 D %. jy. ,•icer �i� Q�j�. Home Phone S — / / p 77 QQ City/State/ZIP a •P.KJ -'5 y- l�'t' , K7 C. ? %024 Business Phone -7 Z.7 7 ^ n4 2. Name on Permit/ATC if Different than Above se!gmc Mailing Address S.�tp City/State/Zip S,dtynQ_ 3. Application For: ",,Site Evaluation Improvement Permit/ATC ❑ Both 4. System to Service: '[L House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms =.E # Bathrooms --P Of Dishwasher Garbage Disposal )d Washing Machine j9 Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes -,No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions:C� Tax Office PIN: # Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: WJ14 d"c.-,- �-,�i�r� Section: Block: Lot: Z-3 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date Property Flagged: f-=/ 7--01 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 Ilealth Department to enter upon above described property located in Davie County and owned by loVWrV, ew - De -1 -to conduct all testing procedures as necessary to determine the site suit_q,6i.(ity. DATE 6-1-1 ! ' 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). Site Revisit Charge Date(s): Client Notification Date: ERS: Revised DCHD (07/99) Account No. f� T Invoice No. -�L :3 %L LAWRENCE L NOCK BY 'RILL •e, t REF 0 B 49 R9, 9 CARL J 'ULLJCI< `E.. 08 '91 Ry 535 38 17 \ ' r49 25 u0o c _ t ,�`•' �L 1 461 / R' I 19 37 x 18 f^,Y. 15 50� J zs 20 .HIGH MEADOWS ROAD - 1 — - - r. - - ^'ytl1 .. - O - ..•. ,.. •ani - I - 42 /_' 43 44 uoiwtrr.� .. .. •.. «.:.•............. • (�-•,_�f'�' � •�- f'" � ' / / - - - / 21 U — �L•�Y•yt_} ti� ;.. rrw 7 l`7 / w.r le, as - fo.mo w r• �' • -•wue /3 w rwr bb 7l 44 r .r . 0 +a• t �I 34 27 / �I �� AiV b r ��i.� 1. ]wY Gwlr �•� • 1 �7 99 1/ V _ - - - " �..t �'�:.»�w y ichor n°•r..... I �~ . 8. " tin• � -,.. c.•w...,,, / . , . •r •,.......a . •j,r 33 rQQ—Q A-.. s. v r .w".w may" ii28 -r LY•M w TMr M/ ]• 1-Ir�.N FOR SITE EVAt.UATION/IMPROVEMENT PERMIT & ATC Davie County Health Department JlprdO�N Envirotb nmental Hea Section .O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 AUG 25 1999 ***nVC)tTANT*** THIS "nicnioN CANNOT BE PROC6881i,'D UNLESS wl THE REQUIRED IMMR1WION IS PROVIDED. Refer to the nVOMWI011 BULLETIN for instructions. 1. Blame to be filled W f S i Vlfkl DC JE W?JP STT C0"11PAW1 contact ftrson -�W—J Gtya CY mailing address _ 2431 9-4y)J6tnA %. some phone 33b•10-loo8 city/state/sip "NC, 2'llob fnsinese phone 336.11-1- 60'1$ Z. hams oa permit/&= if Different than above mailing address !. Application rot: a/site !valuation syQp�°:r s. system to service: D�Houses ❑ Mobile Home City/stag/sip ❑ Improvement Permit/ATC ❑ Both 0 Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms 0 Dishwasher O Garbage Disposal 0 lashing Machine O fassmont/plumbing 0 fassmant/No plumbing 6. If fusiness/ladustry/Other: specify two # commodes # showers # people # sinks # Urinals # water Coolers I! 3`OODSERVICE: # Seats Estimated !later Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well ❑ Communitty s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ®No If yes, what type? ***IMPORTANT*** CLIENTS MAST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tai Office PIN: # �d �C� ' in� �dJ r 23 Property Address: Road Name lee V CityrLip AC1Vd1ce,-Z1C-;2%Uv(" If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from MockrAlle) to PROPERTY: A0&5 CuurtW To QIONf �W A��fA}1D %Z� .r. �AEn�►, a� i.EFf . 1 Name: W1 Yr*AW ' .dam! - -- Section: Block: Lot: -2_3 Date Property Flagged: -2 r �� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation, If the site plans or Intended use change, or if the information submitted in this applications falsified or changed. 1, also, understand that I ant responsible for all charges incurredirom 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 8' M / /q 9 SIGNATURE /�/ AO THIS AREA MAY BE USED FOR DRAWING YOUR STM PLAN (Include all of the V&Iuwi'ng: Existing and proposed property (lues and dimensions, structures, setbacks, and septic locations). Revised DCHD (07199) Site Revisit Charge Date(s): Client Notification Date: I EHS: Account No. Invoice No. t 262 32 S 8533'08' E R I M i E IRCIN FOUND 5 2.22 + 0 S 83'23'57' E 616.09 + ;a 26 48 49 + t 21 271 50- 56� 252 25 L,4 55 l5 47 lob 56 57 (` 272 `7 249 2a 21) l02 51+ 2b r � t 46 2a 2u4 l8E 74 �. 258 259 27 169 163 167 ISB 1�. -- 273 24 1 iR81 + 157 45 2a l93 44 19" 11215 + 244 21 b 195 ] 96 9 c, ��L J� � I .._._ `q- In 43 ' �Gy 197 I 21 199 198 103 +, + 2 221 18 J l 2 28 80 12 + r 30 219 125 /$ a6 12 / jD f 77 8l 70 (� 101 } 2 9 + 220 + 123/ + / 9 / 12 89/ l Ip< / O 120 ; O / C - 9 51 54 / 5 57 RGE ('Ah - 46.97 + N 8 •03' 09' V / 58 + W 0 7 OL • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME C �' PROPOSED FACILITY SUBDIVISION Water Supply: Evaluation By: On -Site Well Auger Boring Community SECTION_ LOT DATE EVALUATED PROPERTY SIZE ROAD NAME Q/,/% 6lG��r�v 7 Public Pit I Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH e Texture group> > Consistence Structure 1G 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: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) LEGEND Landscape Position EVALUATION BY: AI41 e uClflt1 o OTHER(S) PRESENT: 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 tructure 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