121 Tulip Magnolia Dr Lot 20 �. �• _ DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.sox 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900093 Tax PIN/EH#: 5880-51-3209.20 SC
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#20
Reference Name: Location/Address: Tulip Magnolia Drive-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3963
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 FIIVE YEARS.
Environmental Health Specialist's Signature: �d�I Date: 1 '�S'
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Compl ' n s all indicate tem described on Improvement/Operation Permit
has been installed in compliance with Acle 11 hapten 13 ,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NOW be t as a guar ntee th the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date: ZZ. 75-f C
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section , Z7_o S
P.O.Boa 848/210 Hospital Street l
Mocksville,NC 27028 l�
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900093 Tax PIN/EH M 5880-51-3209.20 SC
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#20
Reference Name: Location/Address: Tulip Magnolia Drive-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3963
**NOTE**This Improvement/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 /7/- #People #Bedrooms #Baths
Dishwasher:p 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) lS Site: New��Repair❑
System Specifications: Tank Size AL. Pump Tank GAL. Trench Width,6T Rock Depth Linear
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- A ED EFFLUENT FILTER RISER(S)IF 6 11 BELOW
FINISHED GRADE. ****NOTICE: Contact a rprmntative vie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 to 13 m. ay of installation. Telephone#is(336)751-8760.****
r .t
Environmental Health Specialist'sSignature: Date:
DCHD 05/99(Revised)
APPLICATION FOR SITE EVALUATION/IAIPROVEMENn
Davie County Health Department1 2005
Environmental Health SectionP.O. Box 848/210 Hospital StrMocksville, NC 27028ry �
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer
to th�eC INFORMATION BULLETIN for instructions.
1. Name to be Dillod Contact Person
Mailing Address /2 S1 Gyf4/ari� Gni Home Phone 7S/' Stn Z
City/Stato/ZIP �nl� tili��/� .IY•L� 2702 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Addrasa City/S tato/Zip
3. Application For: Site Evaluation Cklimprovemont Permit/ATC ❑ Both
4. System to Service: 14 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type system requested: ;Q Conventional ❑ conventional modified ❑ innovative
6. If Residence: People # Bedrooms _ # Bathrooms U %2-
,QDishwashor ❑Garbago Disposal ®Washing Machine I313aaament/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /other: verify type # People #Sinks
# commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: 11 Seats Estimated Water Usage (gallons par day)
8. Typo of water supply: IQ County/City ❑ Well ❑ Community
9. Do you anticipato additions or expanSions of the facility this system IS intended to serve? ❑Yes 1UNO
If yes,what type?
***LifPOIZTANT***CLIENTS MUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BEL01V. Either2 PLAT or SITE PLAN MUST BESURAI17TE-D by the client tivith THIS APPLICATION.
Properly Dimensions: /L7 X -'3-3 X/Z4 X 2 3 WRITE DIRECTIONS(from Alocksvlllc)to PROPERTY:
Tax Office PIN: 11 Ss?Y.0 A— 2 6 9
Property Address: Road Name
Citymp Adil''oi"I! A42,
If in a Subdivision provide information,as follows:
Name: 1*"7A&-i1/yL11)- Ay-
section:
mSection: Block: Lot: . LO Date ]Ionic corners Ragged:
This Is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in tills application is falsified or changed. I,also,understand thatram responsible for all charges incurred from
this application. I,hereby,give consent to file Authorized Representative of file Davie County IIealth 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. p/
DATE f//—U S� SIGNATURE,
TIIIS AREA MAY BE USED I OR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
t
Datc(s):
Zd rX L,V Client Notification Date:
EHS:
Sign given Account No. '19- 7 9 Z0a 73
'`"`wised DCIiD(05/03Invoice No. 7
.,lee
DEPARTMENT OF TRANSPORTATION The Davie County Planning Boo-d hereby opproved STATE of NORTH CAROLINA Flied •o. ,oabvallee at 3, 15
net DIVISION OF HIGHWAYS the final plat for the _µ@CNO'I• e�a•.�.;_ COUNTY of DAME e
,h I° PROPOSED SUBONL9DW ROAD SubdMation. I,John Gallimors, Review Officer of Dark County, certify that the
'110,001 CONSIRI.Xtri STMDARDS CERnnGTiON map of plat to which thio certlflcatlon in affixed meet*oil �A( --•
4 2—g oY statutory requirements for recording.
/ kt�/�/ In Plat Bank Pool
/ Date
,34 APPROVEDee-. K Bloat Shoal. RYobi�p of Oil.a
TDIRTFarw Saob vo-0139 /;44t
'
DAI _ /E 4//1l�y 2�200�_ Chairrnon, County Planning Board
DEPUTY-90Rit=W
-0164.
art hn
'� asj�jan�, MAGNOLIA ACRES
Phase II 4 3/4" EIP I-nd
1 Q 1&1/4" EIP Fnd
3162 Reference: Tax Lot 65, Tax Map G-8 Tax Loi 6.01 x
RB 385 O PG 534 Tax Mop G-9
Control Comer Reference: Tax Lot 6, Tax Map G-9 n/f Mellleo Knox Hein
.3/,V' EIP RB 321 O PG 44 DB 25 O PG 32 Tax Lot 8
Fnd RB 322 OPG 624a Tax Mop G-9
RB 521 O PG 839 c e o n/f Jay Mintz
30' Dralnoge E.omment Ia f e DB 143 O PG 426
16.96' 15' Each Side of Property Line ° r e e n = :} DB 148 O PG 674
F .F1P3 0�•
1 30' Drab ,ge Easement o ^ i= �N DB 195 O PG 87
H 15' Each S 'e of Property Dna rn a to no
SB6.7 ' Total I
130.72' -
_�Y8.00'
?� 128.00' O 129.00_ 1 S 88"29'SY'I -.319
CA Tolol S8Q Hca R Hca
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- / 188.58• 3/4" EIP Fnd
€ 23 m
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err,
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0 387.32' Total e--N g6• r 127.90' @ L' c9-
6 Eosameet n
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l 565.35 Teta(•= 129. 0' 707.00' 72.75' 1.47.3 AC +/- L°
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8 177.68' IRSCC �f;'tYB
G 2 III - - 5 86°48'06"E 708.87'Totci $ 11 gY33.53"E-w V
G 259 "`•rp SE to.7D sF 749.00• ,
P 748.00' 148_ per• IR$CC '� 368.20' �o
8 3D•�T it P•VD,q y 264.87
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n a]o ry / O.P.9G Ac +/- E+ ,
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3 w •j•�, { �- —N 86• 4 y m e S 25.06'
D6 nv "'= - 13 3/4" EIP Fnd
242.25' } J Control Comer
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION__LOTS
Soil/Site Evaluation 4*1
APPLICANT'S NAME DATE�z�� DATE EVALUATED �d�J
PROPOSED FACILITY PROPERTY SIZE ,914P
SUBDIVISION ROAD f ROAD NAME
Water Supply: On-Site Well Community Public Z�
Evaluation By: Auger Boring Pit I,-," Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH /I
Texture groupSGG
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure /G
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: 4K EVALUATION BY: -
LONG-TERM ACCEPTANCE RATE: r OTHER(S)PRESENT:
REMARKS:
GEND
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 Sl-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)
LIAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)