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640 Cedar Grove Church Rd (2) DAVIE COUNTY HEALTH DEPARTMENT toV Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003883 Tax PIN/EH#: 5767-63-5720 Billed To: James Ellis Subdivision Info: Reference Name: James Ellis Location/Address: 640 Cedar Grove Church Road-27028 ATC Number: 4331 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 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONST,R,U/CTION IS VALID FOR A PERIOD OF FIVE YEARS./ Environmental Health Specialist's Signature: Date: �� W CERTIFICATE OF COMPLETION r' **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improyement/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 fungiion satisfactorily for any —given period of time. —� — — -4 5t Zz.� �' ° 's g a WS 1{ Q o Oki- Vr s1.o•� � tr � St°s'11rp Io.o� C'Z`�4t 111 G, Septic System Installed By: •Det�a 6 Environmental Health Specialist's Signature: Date: I D-Z 3-av DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Or Environmental Health Section P.O.Boz 848/210 Hospital Street Mockw lle,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003883 Tax PIN/EH#: 5767-63-5720 Billed To: James Ellis Subdivision Info: Reference Name: James Ellis Location/Address: 640 Cedar Grove Church Road-27028 Proposed Facility: Residence Property Size: see map **NO`I lql*%sgmprovement/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 CONTRACT/OR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ty" #People ? #Bedrooms I.-V #Baths A Dishwasher:Z Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Y Type Water Supply Design Wastewater Flow(GPD) QraO Site: New Repair❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width &K Rock Depth /2C/' Linear FtOVO Other: As Stated in 15A NCAC 18A.1969(5) accepted Systems may also De OEM Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofth 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 t of installation. Telephone#is(336)751-8760.**** �1> r �Y CY e Environmental Health Specialist's Signature: Date: `w DCHD 05/99(Revised) r • : ' ' APPLIC FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department (� Environmental Health Section 6 O P.O. Box 848/210 Hospital Street Mocksville,NC 27028 FE8 (336)751-8760/Fax(336)751-8786 /Both App ' at* Za uation/Improvement Permit ❑ Authorization To Construct(ATC) PORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed :5o meS a4-s--contact Person set vVte- Billing Address D 4 Home Phone City/State/ZIP Mnr,4Csji 1 . Vl[-/--To Business Phone cq-f I Name on Permit/ATC if Different than Above �(.�YY12� Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 mgqnths with site plan,no expiration with complete plat.) Street Address G O �e�lpl Gry✓�C ��rc� pity: I,(c„1i' Tax PIN# 576742,S79-0 Subdivision Name Se tion/Lot# Lot Size Directions To Site: WY - [ C-CpVe— 6k.PC61Xi1 Date HousOFacility Corners Flagged 8-7 If the answer to any of the following questions is"yes",supporting documentatio}must be attached. Are there any existing wastewater systems on the site? ❑Yes @No Does the site contain jurisdictional wetlands? ❑Yeso Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? ❑Yes o Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People _3 #Bedrooms 'I ��``#Bathrooms 2 Garden Tub/Whirlpool E4es ❑No Basement: 9*Yes ❑No Basement Plumbing: C/Yes ONo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY:: #Seats Type system requested: SIConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V<O If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to de rmine comp ' nce with applicable laws and rules on the above described property located in Davie County and owned by l9 rbAr a-au 165 Site Revisit Charge Property owner's or owner's legal representative signature Client Notification Date: Date 1L� EHS: Sign given Yl Yes ❑No Account# �0(3 Revised 2/06 Invoice# T.U3lA 'T y ' MWA 5767635721 if 211 4. ail WA } _ J t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003883 Tax PIN/EH#: 5767-63-5720 Billed To: James Ellis Subdivision Info: Reference Name: James Ellis Location/Address: 640 Cedar Grove Church ad-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well000lol Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope% 6 j;;�V HORIZON I DEPTH t i' Texture group Consistence Structure n Mineralogy HORIZON R DEPTH Texture group - Consistence Structure f' 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: EVALUATION BY: 0 of - v LONG-TERM ACCEPTAN TE: _UiER(S)P ENT: REMARKS: �/ e4� t-.,tdxI mo AU,_ LEGEND Landscape Position CSZD M. A, Ir 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 M41St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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 lYateS . 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 05105(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ec■■■■c■■eece■ee■■eee■■■■■■■■■■■■■■■■c■■■■■c■■■■■c■■■■■■c■■■s■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■s■■■■I■■rI■c■■■■■■■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■s■■■■erl■Ire■■■■■■■■ei�■■■■■e■■■■■■■■■■■■■■■■■c■■■■■■■■■e■■■■■■■■■ ■eee■■■■■11■■lee■■■■■■■■■■I■■eY■■■■�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■11■■I■■■■■■1■■Gid■I■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■e■■■■■Ile■I■e■t%It;1■vai.S'%9rINN e■■■■MEN■■■■■■■■■■■ONE■■■■■■NONE■■e■■■ ■■■■■■��i■■■■■■�■■■■■■�■C��I.u.Oji■■■■■■�■■■■■■�ie■■■■■�■■■■■■� ■■ce■■■cs■■■e■■■eee■■■■■■■■■c■■■■cc■■■■■■■ecs■■c■■■■■■■■■■■ecce■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■e■■e■■■e■■c■■■■■■e■■cc■■■■■e■■■■■ecce■■■cc■■■■■■c■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �JY IMPROVEMENT/OPERATION PERMIT0 2�3 � 6 Account #: 990003883 Tax PIN/EH#: 5767-63-5720 Billed To: James Ellis Subdivision Info: Reference Name: James Ellis Location/Address: 640 Cedar Grove Church Road-27028 Proposed Facility: Residence Property Size: see map **NOIIQE, s7mprovement/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 #People c-? #Bedrooms ? #Baths Dishwasher:)!� Garbage Disposal: ❑ Washing Machine: 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) &G D Site: New:Repair❑ System Specifications: Tank Size 109 GAL. Pump Tank GAL. Trench Width--3 `) Rock Depth Linear Ft&D Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT kLTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a represent tive of the Davie County Healt epartment for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 m.on the day o 'nstallation. Te hone#is(336)751-8760.**** i � t 1 Environmental Health Specialist's Signature: ( Date: / DCHD 05/99(Revised) Davie County Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville NC '27028 (336)751-8760/Fax(336)751=8786 February 23, 2006 Mr. James H. Ellis 3109 US HWY 64 East Mocksville,North Carolina 27028 Re: Cedar Grove Church Road Tax Pin#: 5767-63-5720 Dear Mr. Ellis, As requested, a representative from this office visited the above site February 22,2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal.system. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit j System To Serve: USE Wastewater Design Flow: "?6 0 System Type: 1S�onventional ❑Accepted ❑Innovative ❑Alternative ❑Other System Location: 640t; 6&t?-6;2ovu-e17, Valid: ears ❑No Expiration Site Modifications/Permit Conditions: '71Z Zh Environmental Health Specialist D to ps-i.p.letter 2/06