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165 In & Out LnAccount #: 990004035 Billed To: Tim Freidt Reference Name: ATC Number: 4447 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5880-28-4239.02 Subdivision Info:- Location/Address: In & Out Lane -27006 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: '41A// Date: Z,11114? CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in com fiance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but s 11 inNO4Y bq aken as a guarantee that the system will function satisfactorily for any given period of time. �\ 500tF � T KC .- lle) 001a 4 -:5TD z-014� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: l0"/ll 1069 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section „ P. O. Boz 848/210 Hospital Street - Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004035 Tax PIN/EH #: 5880-28-4239.02 Billed To: Tim Freidt Subdivision Info: Reference Name: Location/Address: In & Out Lane -27006 Proposed Facility: Residence Property Size: 3.556 acres **NOff &*NqfI§tIAfproM47nt/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 1),4 #People !j� #Bedrooms & #Baths -I— Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size C1 7h e Type Water Supply �f� Design Wastewater Flow (GPD) Site: New 0" Repair ❑ System Specifications: Tank Size,/,a&! GAL. Pump Tank GAL. Trench Width Rock Depth/ Linear Ft Other: As stated in 15A NCAC 18A.1969(5) Required Site Modifications/Conditions: accepted Systems may also be usedd IMPROVEMENT/OPE ATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ** *NOTICE: Contact a r r tative of4he Davie County Health Department for final inspection of this system between 8:30 a.m, o 9:30 a.m. or 1:00 p.m. :3 p.m. on e y of in allatio Telephone # is (336)751-8760.**** 1 Tri -w,) de, o tom✓ Atw � R Environmental Health Specialist's Signature: _ 444kd Date: DCHD 05/99 (Revised) t A 1211 -IC A111� TTflljn4 = �T R �� E _. JUL 1 1 2006 5 - 1 FWRONMEWAL HEALTH i SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie `County HealthDepartment Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (3 751-8786 irovement Permit Kthorization To Construct(ATC) ***IMPORTANT*** 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 Billing Address ; � feia � Contact Person' Home Phone / i -&6!� . a, YJ07if 33h ^ 900 - 0)3<0 City/State/ZIP cJgNCe OC _ a ;?(>t7!�2 Business Phone 3 -�7 Name on Permit/ATC if Different than Above L Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) C� Street Address%, / City - Cv/0e,(n c e Tax PIN# Subdivision Name Section/Lot# 1 @**Z Lot Size�q_h-5T. AAres Date House/Facility Corners Flagged If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yeso Does the site contain jurisdictional wetlands? ❑Yes 90 Are there any easements or right-of-ways on the site? ❑Yes XVo Is the site subject to approval by another public agency? ❑Yes ,CNo Will wastewater other than domestic sewage be generated? ❑Yes XNo IF RESIDENCE FILL OUT THE BOX BELOW # People L4 . # Bedrooms 3 # Bathrooms Garden Tub/WhirlpoolIxl'es ❑No Basement: ❑Yes XNo Basement Plumbing: ❑Yes ❑No 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: Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:XCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? �(No 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 tete a cI pliance with applicable laws and rules on the above described property located in Davie County and owned by //K f s Site Revisit Charge Property or s owner's legal representative signature • Date(s): l/ 9& Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # 'Tt/ev") Revised 2/06 Invoice # l 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department.- no nvironmental Health Section rP.O.Box 848/210 Hospital Street' Mocksville, NC 27028 JUN - 9 2006 336)751-8760/ Fax (336)751-8786 ' Q i Appli ationitt_ :-9RXov(ent Permit ❑ Authorization To Construct(ATC) ❑ Both ENVIRONMENTAL HEALTH *** CAAWOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT. INFORMATION Name to be Billed r�CIN MaUl� Contact Person i2s d l 7 STeN►= Billing Address q 0 % � t cowl rK, yn4s f /to Home Phone --- City/State/ZIP A Q A In c o l 1�N C 2,7o o U Business Phone 3 3 6 �1 q$� q 7.3 3 Name on Permit/ATC if Different than Above. Address PROPERTY INFORMATION City/State/Zip NOTE: A survey'plat or site plan must accompany this application. -T-4 X (p-[ I ( Z t V-ylA 0 F'. g (Permit is valid for 60 months with siteplan, no expiration with complete plat.) Street Address r+i N' D V 1 L q 0 os City �NGt ,O C Tax PIN# 58 8 OZ 4 Z 3� Subdivision Name /21 c,>< Mir Q C, lM-01Q4 Section/Lot# I -t! z Lot Size 3, L ,a C t: A C 1-1 Directions To Sit/e: t� rel (e ST l� C 1-4 W 23 U 1 Q ILc" W C N utJ $a 1_v A vQ �A Cy Ll_ 'rt%✓L N 61 O'N to 0 -T -r-f 7t 0A T -41 l —LSA_*-) Fowl SOa1 , S�-i►T 1S tar A7�� n� LF Date House/Facility Corners Flagged - " d If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Dyes 91�0 Does the site contain jurisdictional wetlands? Dyes A0 Are there any easements or right-of-ways on the site? T"Yes ❑No Is the site subject to approval by another public agency? Ales ❑No Will wastewater other than domestic sewage be generated? Dyes CK10 IF RESIDENCE FILL OUT THE BOX BELOW # People Ll # Bedrooms 3 # Bathrooms � Garden Tub/Whirlpool El Yes Flo Basement: ❑Yes N.No Basement Plumbing: ❑Yes Colo 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: R60'riventional CiAccepted ❑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 1f yes, what tvpe? W 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 determine compliance with applicable laws and rules on the above described property located in Davie County and owned by 12i �;1t` MA6F!;;AAON 5 i G A,_ Site Revisit Charge ' e Property owner's or ownergal representative signature g D 1, - 8 -oG� Date me(s). Client Notification Date: EHS:_ Sign given Dyes ❑No Account # _//Oa Revised 2/06 Invoice # Tax Lot I" Tax• MOP E-8 n/f James Sanders 's and wife . Debra E. sanders �6> DB 197 ® PG 566 � w SQ ti R� - Give{ _ — IRs. �. ' • Existing 20' Easement. Reference PB 5 0 PG 17 p-� ane i :I Road (See Note #4) i, t' IRS placed in tine%Cor�tr IRS 20.08' Doty, Jr. 72.73 v 199 4nd � t . 77.27'-` ;stiRg 20' Eas • 1 '� t beryt xitness .ron iP F-13 iginc,,14 K. i��'hicker `j 7 PG 414 '`'T-7 ag 5.0 PG 17 Tax Lot 111.02 Tax Map n/f Larry Hicks US 158CpG716 AREA !N QIiESTiOiV: GAP L Lot 1 pat L of Tax Lot X112 Tax Vap 3.756 Acres 7 Total - 990. 1 4' otal-990.14' Lot art of Tax Lot 112 Tax -trap F--8 Acres - Tax Lot 113 T,, F 0c) r—g New Paw E Perty trine south Cr «lea nk T-• 4 —� 1 NhSP in Creek Bed tRS 1\ e \ 5 i ,S Control ntrol_ .�°� AREA iii Q UES f t i L-3 j-T-3/4" OP rtd FeRci {' i 3 ! ��,nproxir:;ot•� Center t_ir,s t� �i i� 96 ag 5.0 PG 17 Tax Lot 111.02 Tax Map n/f Larry Hicks US 158CpG716 AREA !N QIiESTiOiV: GAP L Lot 1 pat L of Tax Lot X112 Tax Vap 3.756 Acres 7 Total - 990. 1 4' otal-990.14' Lot art of Tax Lot 112 Tax -trap F--8 Acres - Tax Lot 113 T,, F 0c) r—g New Paw E Perty trine south Cr «lea nk T-• 4 —� 1 NhSP in Creek Bed tRS 1\ e \ 5 i ,S Control ntrol_ .�°� AREA iii Q UES f t i L-3 j-T-3/4" OP rtd FeRci {' i 3 ! ��,nproxir:;ot•� Center t_ir,s t� �i i� APPLICANT INFORMATION Account #: 990004006 Billed To: Rick MABE Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5880-28-4239.02 Subdivision Info: Location/Address: In & Out Lane -27006 Property Size: 3.5Acres/Lot#2 Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1-1 41 Slope % iib 6 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture groupC Consistence s r Structure Mineralogy,• / =1 HORIZON III DEPTH 2j Vill Texture group Consistence (' Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: EVALUATION BY-. � LONG-TERM ACC PTANCE RATE: OTHER(S) PRESENT: REMARKS. Gt 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 ONSIST .N .E Moist VFR - Very friable FR Friable F1- Firm VFI - Very firm EFI - Extremely firm 33gt 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 Min&alggy 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 05105 (Revised) July 6, 2006 Mr. Rick Mabe 407 Zimmerman Road Advance, NC 27006 Re: Site Evaluation/IP: Site #2 Tax Pin #: 5880-28-4239 Dear Mr. Mabe, As requested, a representative from this office visited the above site June 29, 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 T^ System To Serve: ` A5- Wastewater Design Flow: (5:�o System Type: ❑Conventional P-<ccepted ❑Innovative ❑Alternative ❑Other System Location: A/ � l�6wD" ��Y.v e Valid: ears ❑No Expiration Site Modifications/Permit Conditions: ps-i.p.letter 2/06 Date