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476-482 Calahan RdDAVIE COUNTY HEALTH DEPARTMENT �� ': Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87C0 Account #: 990003300 Tax PIN/EH #: 5709-58-6650.01 LB Billed To: Lifestyle Builders of Davie Subdivision Info: Reference Name: racintv Kesiaence ATC Number: 3937 Location/Address: Calahaln Road-27028 rropercv �ize: .u�i acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 2. Z�►-°� **NOTE** This Authorization for Wastewater System Construction MiJST 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 CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS. ' S�� Envu�nmental Health Srecialist s Signature: � )ate: � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall ' d tias been installed in compliance with Article 11 of .S. Disposal Systems," but shall in NO WAY be taken as a; Septic System Installed By: � the system described on Improvement/Operation Permit pter 130A, Section .1900 "Sewage Treatment and inte1e that the system will function satisfactorily for any �S� � f��s %��W!'�(� C�i�' yo �.���� ��t �G�-/�c�n �, /��� , , , � Environmental Health Specialist's Signature :��. // Date: � L DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , �, P. O. Boz 848/210 Hospital Street ' ' ' Mocksville, NC 27028 . (33G)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 990003300 Billed To: Lifestyle Builders of Davie Reference Name: Proposed Facility Residence a�� y.o� � Tax PIN/EH #: 5709-58-6650.01 LB Subdivision Info: Location/Address: Calahaln Road-27028 Property Size: .827 acres ATC f�mber: 3937 **NOTE** �s Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AUTHOWZATION 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 /T #People #Bedrooms � #Baths •1. Dishwasher: � Garbage Disposal: ❑ Washing Machine: �Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size Type Water Supply� ' a Design Wastewater Flow (GPD) �lo�� System Specifications: Tank Size ��%�`!�',AL. Pump Tank Other: Required Site Modifications/Conditions: Industrial Waste: � Site: New � Repair ❑ s, /� GAL. Trench Width �S � Rock Depth � Linear Ft� IMPROVEI�1ENT/OPERATION PER1111T LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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 (33G)751-87G0.**** Environmental Health SpecialisYs Signature: Date: l% DCHD OS/99 (Revised) ' APPLICATION FOR SITE EVALUATION/IMPROVEM1tENT PERMIT & Davie County Health Department Environmenta/Hea/th Sec[�ion P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 � ✓� �FC — � 2044 ***IMPORTAIVT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE ��:EQ__`� INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Silled L.� �� • 5`��r'c, �' (,,✓��, Mailing Addreas �,�� � �� �� � �5�.,�(, City/State/ZIP /�,i�ti�,�_,a , �V�� . y�lJD� 2. Nama on Pezmit/ATC 1E Diiferent than Above Contact Peraon Home Phone Busineas Phona /"� g��� 7� Z 7 Mailing Addresa City/State/zip 3. Application For: ❑ Site Evaluation L--l�Improvement Permi.t/ATC � Both 4. system to service: I�Fiouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. 2�pe ayatem requeated: Lr Convantional ❑ conventional modified ❑ innovative 6. 2f Residence: # People # Bedrooms � # Bathrooms � LdDishwasher ❑Garbaga Disposal WaL� shing Machine ❑Basement/Plumbing OBasement/No Plumbing . 7. If Busineas/Industry /Othar: varify type �k People # Sinks # Commodas # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gailona per day) 8. Type of water supply: L�'County/City ❑ Well ❑ Community 9. no You anticipate additiona or espansions of tl�e facility tl�is system is intcndcd to scrve? ❑ I'cs C-1'No � If ycs, ivl�at typc? ***IMPORTAN7"'** CLIENTS h1UST COMPLETE TIIE RL•QUIRED PROPCRTY INFORMATION RGQUGSTGD BELO�V. Eithcr a PLAT or SITE PLAN MUST BE SUB�YIITTED by thc clicnt witti T1iIS APPLiCATION. I, Property Dimensions: _ e_ b Z' 1�. WIZiTE DiRGCTIONS (Crom 119ocksvillc) to PROPGRTY: TaX orr,�� rrrr: �f i��,(� i- S-�'- �� ,, 0 v l.�r'C, � , Property Address: Road Name C.�. l��, �� v� f'��, S z�� �ir ! L°�-``�- � Cltj'�Zlp Y' �'� C.�S V . l � �`% � � Z �:%� � ��'7 ' • If in a Subdivision providc information, as follows: Namc: i Section: Block: Lot: Datc homc corncrs Ilagged: Tliis is to ccrtify tl�at tl�e information providcd is correct to tl�e bcst of n�y laiowledge. I undcrstnnd tliat any permit(s) issucd l�ercaftcr are subjcct to suspension or rcvocation, if tlic sitc plans or intendcd usc cliange, or if tlic information submitted in this application is falsified or cl�anged. I, also, iu�derstanrl llrat I am respousiGle for al! cJiarges i�rctured from r��;s ��rr«�r�o,r. I, Itcreby, givc consent to thc Autl�orized Representativc of tlie Davic County IIcalth Deplrtment to entcr upon above dcscribed property located in Davic Couuty and o�vncd by tu conduct all testing procedures as neccssary to determine the site suitaUility�. DATL � L� L d�-/ SIGNATUlt� -�it� / TIiIS AItEA MAY B� USED TOR DRAWING YOUR SITE PLAN (Include al! of tl�c follo�viiib: � xisting and proposcd property lines and dimensions, structures, setbacks, and septic locations). Sign given Sitc Revisit Cl�argc I Datc(s): Clicnt Notification Datc: �FIS: Account No. ��� � Reviscd DCIiD (OS/03 � � Invoicc�lo. � a� /2� 22�/— °� , _ - .. � . . ,. _ . _ . . . . - . - .. . _ ' � '4- a ._ . . _ _- - . . .. . . . ' ;'.- ` � . � " . .�i c. �+;�- � . � � , . �;;� - .. . • . . .. _ � . ; ... � r' , - . . . .. . . ' . ,�. -, ' �.. . , - . - . _ . '.w. . ' . .. . . . . . .. . . , • . _ flc y _ . . . . . . . - . . � �.� ..j - . , . . . ... ' ' . ��� ' . � . .. . ' . _ . � . . . • . .. . _ . ' �". i%' �. V ' _ I" / .. ... • • � . . .. . . , . _. . . . . / • / ' ,� / - ... _ . . � \ . . . / �., •. ' . . .. . � .� . ., / :. / .. � . . .. \ • . \ � / . � . . . � \ ' . c // / /� /f EXlSTING 2J' EASEMENT \ EXi„TING 30' EASEME�dT � � ti i SEE PL.BK. 8, P6. 134 SEE D.B. 561, PG. 9?2 `� .z \ � / ���4� / . � l i � �.°i / i . . \ F� , �� � �,�o . � � . . . " \ ��. � � - � LOT. 2- �. _ _ � � ' 9 �h'�' ,, � � �F �.�: ..JEFFREY�:�AYNE':� CA�L .,S'UBDIYISION • �2 � , �,_ � � - . :: PL. BK: 8, . PG: � � 134� � � i ' __ � . � �� . �� ��� . / rv . . : � ' � . . i c��� . / • S` �,6• . _ . � � � � ?U� • 1 `4� �� , q,h . � �/ / �O�v , :9�? 9� o�. � . - _ �:,LO�� �/ i tL'+ ' , - • a`L �'� - � � , P.o� � ._ LOT 1� : . . _ - s �� � �%,o�� .,�°'� AREA= 0.827 . AC. � . . , / � � .� . � � �NCLUDES S.R. 1313 R/W RFa ;. / / � / � � � a�, . _ ` / , o � \,a o �5,,_ . ° / '� w i . �, F / �`C:r„�� / � � �� Z�. , sCp�O�� , � . 5:�� �.� / � �� � 6.�j .` �°0 ��N • ��c . . /./ � / � � / �?o : � • ; _ � . �' _ �� � . 4.} � p � �'O, e� ' 33 ' ' � • / g . ' � � , _ � ' / � � ` . '� �L� � , � q . �. i � k � Zp. � . A' �� � 2 0 hrl,ti�`� ' / s 0 �� ``` "� R'tiWi� `` : . °e� � �2P� � � �9. -�C�� . / : ' � � � � . 4 ���a S9 3S 4 ` , , �G Ov, f6,� � ;P. / �� `J � , g�^ / � � G.. � _,�A �. � � � � � _ ,y � '(� . •�"�`� . ,ySl6ljy 0y ,.4,'4'� �/. ... r . � • ���.� ., �� - ��• .. , , � � . � � , �t �: ;.� ..� .��,. , �� , i . - _ ��, ,�` :=/�` . _ . � �` �9;t, . ♦ 60' R/1M ': ' . / A'� ... . ' `� O _ . . ` � F _. . .. . ' ... . . . . - ,�` ., . � ��� � � . . - . . . ".. .. ' `` . . .. � . . - _ .. . � . � d �,, •,< �����[� . �` APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT � ' (� j� Davie County Health Department D�J � ��I1/ Environmenta/Hea/th Section Q�T � P.o. soX 848/210 Hospital st� t 3 2004 � Mocksville, NC 270 0 (336)751-8760 /� /� %�� � FjVVlRONMENTq�H Gf DqV,iEC i r �� ***IMPORTANT*** THIS APPLICATION CANNOT BE PRO S UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BVLLETIN for instructions. V 1. Name to be Billed ;.J L� 1` � C� /`t L� Contact Person Se �� ��L � Mailing Addresa / / � ��/�'� f'( y, Home Phone % �� � ��` ! � City/State/ZIP _��C� sU/ �/� /�/i l �p� %(�%��JBusiness Phone "/ �� ^ � L� ` � 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: � Site Evaluation , ❑ Improvement Permit/ATC ❑ Both 4. Syatem to Service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type aystem requested:� Conventional ❑ conventional modified ❑ innovative 5. If Residence: # People # Bedrooms �_ # Bathrooms �` lJDiahwasher L7Garbage Disposal L�+Tashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Businesa/Induatry /Other: verify type # Commodea # Showers # Urinals # People # Sinks # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) s. Type ot water supply: County/City ❑ Well ❑ Community 9. no You anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Cr�-fio If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with TiII5 APPLICATION. � Property Dimensions: �`��`'�-�� _ WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # �� � d � /� �'�•�4 sfj'f" u ``�� � S � Property Address: Road Name CFLL--�4 %w �*'� �t G-G`��i� �t �� ehsR� c� City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: � Date home corners t7lgged: �� � r��-% ��� 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 cl�ange, or if the information submitted in this application is falsified or changed. I, also, ttnderstafid tliat I ane respoi:sible for all c/iarges i�:cirrred fron: this applicatioi:. 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 SIGNATUR� �2�/' � G�'2' ' 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). �d �� � T �S � �s L� � 1 G.�� � � t b h►�- ��' a.�. Sign given '� � Revised DCHD (OS/03 Site Revisit Charge I Date(s) Client Notification Date: EHS: Account No. � Invoice No. � �'�Sg APPLICANT INFORMATION Account #: 990003385 Billed To: Jeff Call Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5709-58-.6653.01 JC Subdivision Info: Location/Address: Calahaln Road-27028 / Property Size: 0.826 acres Date Evaluated: l�l��L(3 � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit � Cut_ icx�uic �ivu}� Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 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: EVALUATION BY: 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- Tenace 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 day loam SC - Sandy clay SIC - Silty clay C- Clay CONSISTENCE Moist VFR - Very friable Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Piastic VP - Very plastic Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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 - gaUday/ft2 DCHD OSl99 (Revised) ■ � ■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■ ■ ■�■�■ ■��■■ ■���■ ■�■�■ ■ ■ ■ ■�■ ■�■ ■�■ ■�■ ■���■�■ ■�����■ ■/���■■ ■�■■\�■ ■��■■�■ ■■■��■■ ■��■��■ ■�����■ ■��■��■ ■�■�■�■ ■��■��■ ■■ ■■ ■�����■ ■�■��■■ ■�■��■■ ■��■��■ ■■���■■ ■■���■■ ■����■■ ■����■■ ■�����■ ■�����■ ■■���■■ ■�■��■■ ■���■�■ ■■����■ ■�����■ ■A���■■ �1����■■ 1�■�■■■ ■���■ ■�■�■ ■���■ ■��■■ ■��■■ ■��■■ ■�■■■ ■���■ ■���■ ■�■ ■■■ ■■■ ■ Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 October 22, 2004 Jeff Call 197 Cana Road Mocksville, NC 27028 Re: Site Evaluations/ Calahaln Road Tax Office PIN: #5709-58-6653 site 1 and 2 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, October 20, 2004 Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the sites, the sites were found to be provisionally suitable for the installation of on-site sewage systems. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, /'1��2K►K �• ��`�j• Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s)