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120 Glenwood Rd Lot 17 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section - P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002484 Tax PIN/EH#: 5726-57-8401.17SH Billed To: Schult Housing Advantage Subdivision Info: Meadowood 2 Lot# 17 Reference Name: Location/Address: Glenwood Road-27028 Proposed Facility Residence Property Size: .086 acres ATC Number: 3822 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 FI YEARS. Environmental Health Specialist's Signature: Date: / 6 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems,"but shall ' e that the system will function satisfactorily for any given period of time. A 1, Septic System Installed By: i Environmental Health Specialist's Signature: Date: / 'C. DCHD 05/99(Revised) ! DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002484 Tax PIN/EH#: 5726-57-8401.17SH Billed To: Schult Housing Advantage Subdivision Info: Meadowood 2 Lot# 17 Reference Name: Location/Address: Glenwood Road-27028 Proposed Facility Residence Property Size: .086 acres ATC Number: 3822 **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 #People #Bedrooms §- 0 #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 �d Design Wastewater Flow(GPD) Site: NewRTRepair❑ �c System Specifications: Tank Size ®Db GAL. Pump Tank GAL. Trench WidthFC Rock Depth Linear Ft,�W Other: �0� 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: t- installation. Telephone#is(336)75Y-870.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IhtPROVEAIENT PERA1IT Davie County Health Department Environmental Health Section l J v P.O. Box 848/210 Hospital Street (J rrtt Mocksville, NC 27028 Ju� 16 2004 (336)751-8760 ***IIdPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS •AL iN INFORMATION IS PROVIDED. JReefer to the[► INFORMATION BULLETIN for instruc 1� 1 ! 1. Name to be Billed J CA"A ( , O1�S-t1rA. !7 ed Va.�.1'Cp contact Person �L r r"41 '[p�Y Mailing Address 16 31 S.�il� Al., r711.cres_r f, Q Home Phone pl.+ - 9 a Z 1 O 3 6 City/State/ZIP �t.�.,, l 2.,rs V.I 11 Q_ A/ C 2 C a 7(� Business Phone 2. Name on Permit/ATC if Different than Above Sq w'.o_ Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both 4. System to Service: 'K House ❑ Mobile Home ❑ Business ❑ Industry H Other S. If Residence: # People # Bedrooms # Bathrooms ADishwasher u Garbage Disposal Washing Machine 1.1 Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/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 ❑ Well L-1 Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes )(No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUES"17ED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli THIS APPLICATION. t! Property Dimensions: OA16 cac-r*-s WRITE DIRECTIONS(from Mocksville) to l'R01'ER'TY: Tax Office PIN: #�/ � � � . 1'x'12 w c1 a u o o c� S wb of .trry ,tai. � 'i'� 17 Property Address: Road Name City/Zip H'to c./r t✓. l If in a Subdivision provide information,as follows: Name: L Section: Block: Lot: Date Property Flagged: 6/9 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 ant responsible fur all charges incurred front 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 to conduct all testing procedures as necessary to determine the site suitability. DATE /G . , c *� SIGNATURE IV 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 Datc(s): Client Notification Date: EHS: 0 J--/ Account No. �-� Revised DCHD(07/99) Invoice No. �� I DuS11NG 50• R/1V Y O .C"4 u. T T' 3 E � pT � � JBNfiiFER SOL33 LO . D.B. 364, PG. 330 ' BIUCKFN ! `P D.B. 44 PC. 980 ! Z014ED R—A ( MEADOI'OOD S DNISION 88' S 32'44' E 1 PL.BB. 7, PC. 136 .4C. �- 64.28 K1WG EXISTTSDTAL� 115�31� RM TUrAL- 220.00 ! ; ZONED R , Mom ( 20 ry EXIS M 9.1 NEW -^+ 194.81S S 88'26'17' E r. $ 8B It714 IRM `{a r 3flujTIHC 220.01 RON ` +/4• EXISyb%i'c In.49 IRON T; os AREAS 0.945 AC. 8 1 N w o AREA= 0.909 AC. H 10�6, ► w R .BERT 0 7 N% m c Z * / 0 S 85'23'15' tir g .B• '0, «� o a /�I►/ l� ,� 222.19 W �, - co � � 6r Y• NQS' 4- l tJ�,I CZT7 AREA= 0.862 AC' �c 7i lo'tmtm I_./5 31• EAS`71FNi 0� RA• •6 5Qr ,.-c7� r AREA 0.956 AC. �� x N 87.32'14' E 163.59 o Gilt -,A% .,�,�6 �•�►� It LES �� o o •� AREA= 0.699 AC. AREA= 0.809 AC. y �� "f-� ! ;�•�� 3�41 r 24'0 Z .hCi ,` of5 AREA= 1.006 X. ,EO isKEN 6116. C�• i Ib ro •- r TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Q ti0�� Environmental Health Section PV P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ISS (336)751-8760 ***IMP T*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED VNFOTION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed - ��`- /�/�t(`/Z� Contact Person /` Jj Mailing Address ��(U 0 O G A10�[-�V/�f� �.. Home Phone City/State/ZIP llnQcicl-$yi.t, A( _ IVC Z 70zbbusiness Phone ' 41 - 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House obile Home ❑ Business ❑ Industry ❑ Other 5. IfResidence: # People # Bedrooms s� # Bathrooms W-151shxasher LI Garbage Disposal f ashing Machine LI Basement/Plumbing I:I Basement/No Plumbing 6. I£ Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated 17ater Usage (gallons per day) 7. Type of water supply: ounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes u4gt` If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. 1 / l Property Dimensions: to� � QC.{Ri� WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: "• / t �� �l�±i) Property Address: Road Name �Ic�:.t ons /�%f ,'e City/Zip b _116C zoo z� If in a Subdivision provide information,as follows: Name: 0//�.4 I�OLtiI Q ' `J c-�J1v,,� _� _�% / cYOC✓dC — �)�9✓ �f �c ' Section: �T 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 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 to conduct all testi g proce ores as necessary to determine the site suitabili . DATE / 7�— SIGNATURE ` TI-IIS 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. �3� v DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001004 Tax PIN/EH#: 5726-57-8401.17 Billed To: Martin Lee Barber Subdivision Info: Meadowwood Two Lot# 17 Reference Name: Location/Address: Junction Road-27028 Proposed Facility: Residence Property Size: see map 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 Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON lI DEPTH Texture group Consistence Structure l/C 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: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: e LECOD 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)