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Academy Place Lot 1 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001588 Tax PIN/EH#: 5717-07-4137.01 Billed To: Allen&Catherine Westcomb Subdivision Info: Academy Place Lot#1 Reference Name: Location/Address: Davie Academy Road- Proposed Facility: Residence Property Size: see map ATC Number: 2702 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: Date:,l_,r CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate ofCompletio1 in 'tate the system described on Improvement/Operation Permit has been installed in compliance wit le 1 o S. hapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO AY t en a a gu antee that the system will function satisfactorily for any given period of time. r Septic System Installed By: Environmental Health Specialist's Signature: y Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001588 Tax PIN/EH#: 5717-07-4137.01 Billed To: Allen&Catherine Westcomb Subdivision Info: Academy Place Lot#1 Reference Name: Location/Address: Davie Academy Road- Proposed Facility: Residence Property Size: see map **NOTES*Tlii bfmproV7em 02 /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 .19. #Bedrooms #Baths Dishwasher:Z Garbage Disposal: ❑ Washing Machine:00" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑- — Lot Size J fa Type Water Supply ZVP/l Design Wastewater Flow(GPD) Site: New0 Repair❑ System Specifications: Tank Size/P4O GAL. Pump Tank GAL. Trench Width �lRock Depth_Z!E 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 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: C 9 DCHD 05/99(Revised) ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Environments/Health Section 6 ZUU! P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENVIRDAVIEECOUNTY HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 1 Contact Person SA nrnk 75-F 7 p Mailing Address (90 �a n lQ1H'� ^1 �7 �y Home Phone �/ � �17� — �I]5 O� City/State/ZIP - M OAS 11 -�1e ,W C o1 ! 0�O Business Phone 33 �7' ! 51 Ll 0 Y 0 2. Name on Permit/ATC if Different than Above S(A Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation j Improvement Permit/ATC ❑ Both 4. system to service: )? House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms _ TADishwasher ❑ Garbage Disposal X Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # sinks # Commodes # Showers # Urinala # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City 'Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 1XYes ❑No If yes,what type? wl h ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # �1 1�. Property Address: Road Name brn U 1 City/zip 1' ISS' s 0'AP- N c a-)oa + L If in a Subdivision provide information,as follows: _Q 01 W r 6� © Gl U 12 C1C�1►� Name: 1111"Yile3 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 am responsible for all charges incurre rom this application. I,hereby,give consent to the Authorized Representative of the Davie County Hea�-rx=rl'Ko- wej+eoyl-1 htment to enter upon above described property located in Davie County and owned byJA to conduct all testing procedures as necessary to determine the site s ' bility. DATE a- o 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: EHS: Account No. _�� Revised DCHD(07/99) Invoice No. .200302 u f W Fu4ur e. I I Imo. ,- - -- - I G 4- 70 - (b Z fiat i I a - r, - ar-- °°_ co ore�. m a w 3 4.� v v o _ i/ scw�e =30 � r p4 e P &/V Rd, " DAVIE COUNTY HEALTH DEPARTMENT ." Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900113 Tax PIN/EH#: 5717-07-4137.01 Billed To: Floyd Green Subdivision Info: Academy Place Lot#1 Reference Name: Mackie McDaniel Location/Address: Davie Academy Road-27028 Proposed Facility: Residence Property Size: 3.96 Acres Date Evaluated: 5 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ' Texture group Consistence Structure S <71 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 I t Yi SITE CLASSIFICATION: �� EVALUATION BY: &6Z LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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) ■■■■e■■■■■■■■■■■■■ee■■■■■■■■c■■■■■■■e■■■■■■■■■■■■■■■■■■■eee■■■c■■■ ■■e■■■■c■■■■■■■■■■■c■■ceee■■■■e■■■■■■■■■■■■■■■■■■■■■■eeeee■■■■■sc■ ■■■■■■■■■■■ceee■■■■■■e■eee■■eee■�■e■■c■■ec■e■■eeeeee■c■■ee■ec■■c■ ■■c■■c■■■■■■■■■■e■c■■■ee■■c■■eec■■c■■■■c■■sse■■■eeeeee■■■■sees■■■■ ■sc■eece■■c■eeeee■ecce■■■■■e■e■c■cc■■e■■■■cc■c■■c■cc■■e■■■e��e■■c■ ■sss■■■■■eeeee■■ase■■■e■■■e■■■■■s■■■■es■■■■■■se■■s■■■e■■es■ss■■s■■ ■■■■■■■■ee■ee■■e■e■■eee■c■■■■c■c■■■e■■■■■■■■eeeeeeee■■eeeeee■eiee■ ■■■■■eae■ee■e■■■cec■■■ec■■e■■■e■�■eee■ec■■cec■sccs■■c■■eeeee■■■s■ ■■■ceeeec■■■eec■ccce■■■c■ec■■ec■ ■eee■■ecce■■c■■c■ec■■■■c■cc■■cc■ 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County Health Department Environmental Health Section P.O.Box 848 toff — 3 2000 Mocksville,NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Alo-s e-e--,J Contact Person Mailing Address Com' eee-t-., AAA- a,N. Home Phone 9 9. V-3;L0 City/State/Zip � ��-S"'� '_ `ty `' Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address Z / City/State/ ip 3. Application For: 5 'Site ❑ Improvement Permit&ATC ❑ Both 4. System to Serve: -E House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms 9_ ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/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 a-vve--Il ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: k `�(7 �S CJ I WRITE DIRECTIONS(from 1 Mocksville)TO PROPERTY: Tax Office PIN: # 5-7 1 7 1 ,a( 1 Property Address: Road Name City/Zip &S�"u \\ Uv 1 1 If in Subdivision provide information,as follows: Name: C-A-S'JO-1v`°n Section: Lot #: - 1 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 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 �=fo conduct al sting procedures as necessary to determine the site suitability. ; DATE SIGNATURE Revised DCHD(06-96) Nsp 110 1 ,3 29. i . S.R. 1153 210 .377 43 - ti 50. 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Fc l iX23 :,wA' �' : 4.$IX125m > ,; ' ,'.• �25M2..uzc1875 t{ �.�, 'i� � '� ' X14, M "'t�.� � 4. \t���,1�Aa1 t�+�IS ,,,�"r' �1 i .� 15$'� ��a1 ,,�( ''p � •i �,K. .►A �i1.�1Y `+ray �,�Yri ��*�. �.Y r� 4�• �'� �1 f e h�•t1+'-� . i .S. Ak t•�:�/b I.�;y t'°.• •A��ayh+ilv---. ph • 'r..1'1,_ +' - FFzr 4 z�(}"ai' ij1 •+V' y i Y� 1 r. "'� . 11 by`'ar! wyT�w• � .. � f. f '.��,f .. e: g „�;�,;;i.Y�if�.. . s PCCZ Q 1836 :i2►w 1 �P `'�• (1.16A) 3304 82 This map is for PERC TEST and BUILDING PERMIT purposes N only. The Davie County e Tax Administrator's Office assumes no liability for any information contained on this map s6, (385) COUNTY-ID:K200000060 6879 February 02,2000 4:28 PMRnC Parcel Identification Number 5717-40-0795 �I )RS 3367513931 02/12/01 16:55 :02 No:5rn 6AVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALT11 SECTION P.0. Box 848/210 Na`pital Street Courler #00-417»06 Modu►vllle, NC 27028 Phone #; (338)761.8780 .000 J Green :n Hill Road Me, NC 27428 :e Evaluations—4 Sites rvic Academy Road/Aeadetny Place ix Office PIN: #5717-07.4137 Client(s): :quested, a represenialive from this offwe visited the aforementioned sites on 19, 2000.• Basad upon the infbmlation provided on the Applicwtlon(s)for Site luatlan(s) and after evaluations were completed, sites 1, 2, 3 and 4 were found to be visionally suitable for the installation of an on-site sewage system, Fore an Improvement PermitJAuthorizaiion to Construct can be issued the appropriate plication must be filled out and the house/mobile home location staked on each site. mu have any questions,please feel free to contact this office. tcerely, 4040 bort B. Hall, Jr., R.S. vironmental Health Specialist Vmp :Iosure(s)