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130 Glenwood Rd Lot 16 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003616 Tax PIN/EH#: 5726-57-8401.16 RB Billed To: Robert Brake Subdivision Info: Meadowwood Lot# 16 Reference Name: Location/Address: Glennwood Drive-27006 Proposed Facility Residence Property Size: .669 acres ATC Number: 4067 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: i ! 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 in NO WA taken s a guarantee that the system will function satisfactorily for any given period of time. / A �h / 1� 10 Septic System Installed By: �8 Environmental Health Specialist's Signature: Date: 2/,2-ze8J DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boz 848/210 Hospital Street s Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003616 Tax PIN/EH#: 5726-57-8401.16 RB Billed To: Robert Brake Subdivision Info: Meadowwood Lot# 16 Reference Name: Location/Address: Glennwood Drive-27006 Proposed Facility Residence Property Size: .669 acres ATC Number: 4067 **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 #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) Site: New 0`4 Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width //Rock Depthhl. Ft.-TAC Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 L°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.**** r Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) U —CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC D Davie County Health Department MAY - 6 2005 Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 UMR.0��l1NH 1H (336)751-8760 ***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 ekon i2ra ko Contact Person �j Mailing Address 1 [ � 11 u r W ID 0 zX L4 - Home Phone 7 n 9 O —'5 7.3 e City/State/ZIP � n C.- A `� 4-7006, Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site EvaluationImprovement Permit/ATC ❑ Both 4. System to service: House ❑ Mobile Home 13 Business ❑ Industry ❑ Other 5. Type system requested: �4'Conventional ❑ conventional modified ❑ innovative s. IrDishwanher esidence: # People # Bedrooms # Bathrooms ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes *0 If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SIIBMIT7BD by the client ivitl:THIS APPLICATION. Property Dimensions: / / qt', � WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # � �o S yo/.1 Property Address: Road Name&fAAdoecc- J-P ` .1 u C f City/Zip If in a Subdivision provide information,as follows: Name: rC., w 4 0 Section: Block: Lot: /4/y Date home corners flagged: 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 ani responsible for all charges incurred frons tlds 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 w /�/(� SIGNATURE JJJ TIIIS 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: Sign given Account No. ':3 Revised DCHD(05/03 Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003440 Tax PIN/EH#: 5726-57-8401.16 Billed To: Southern Showcase \� Subdivision Info: Meadowood Two Lot# 16 Reference Name: Location/Address: Glennwood Drive-27028 ti Proposed Facility modular home Property Size: .699 acres ATC Number: 3945 **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 INST.ALLING SYSTEM. Residential Specification: Building Type #People #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) Site: New Repair❑ System Specifications: Tank SizeGAL. Pump Tank GAL. Trench Width 19�Rock Depth/ 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 ins Natio Telephone#is(336)751-8760.**** Environmental Health Specialist's Signature: Date: / DCHD 05/99(Revised) y . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section i P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003440 Tax PIN/EH#: 5726-57-8401.16 Billed To: Southern Showcase Subdivision Info: Meadowood Two Lot# 16 Reference Name: Location/Address: Glennwood Drive-27028 Proposed Facility modular home Property Size: .699 acres ATC Number: 3945 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 C STR TION IS VALID FOR A PERIOD OF FIVE YEARS. � Environmental Health Specialist's Signature: � Date: 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 I 1 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 function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) Dee 21 04 04:52p davie county envhealth 336 751 u - - DEC 2 2 2004 APPUCAMN FOR SITE EVALUATION/lAtP0011110T PULltll"ll Davie County Health Departlnont Enwimmeawfledffisectivrl ENVIRONMENTAL HEALTH V.0. Boz 848/210 Hospital Stroot DAVIECOUNTY Ptoas,rille, NC 27028 (336)752-8760 eweMPaJ:MFIr1e. =X3 API'LZCATXW CAMW7 BE PROCEBSRD II2II= ALL TR$ RYQUXMM THPOSMATtON ISARCNZ(DXD�.�� Refer to the INFOFUW10t7 MLBTIN tar ivata ttctSoae. — l 1. Rase is b•alSlad �T'�"+�- , Q�'�-��elect Peron •"�2../ry-, aniline ad4saee1q15;4- �' g/f. � stone rbons Yl 1/•'1 j�•�GI eitylst•t.lcsy r �S - .,.tie,.,mD. a. Aw ow rsesLt/A=3t Diff.reat than Abe.s mallI a addm.e City/siren/Z3P 3. 3tpplieation Por' O Sits SYalwt:ion PIQravement Permit/ATC Cl both t. tyt"to sereies: 13 aloune R tfob32e Barco O Buaineas 13 Sadustry t Othos ' •`��^w(/� S. Type Greer requa.t.d. P4a vntieaal 13 conventional modified Q innovative ^ S. IfReaideaot' a people _ a eedracma —Z— e -- a Dathrotm+ -2 Id53-0hwaaher CICarba4o Dispa.sel Qw-uinS nachtne Qaesame.t/r1uob1nq Qaasessat/Ro Plmbin9 7. it aasluesi/Indostry/other.verity type a People a Siau s Malmodsa a rnewera P Tlrinal■ a stater coolers 1T' 800 mvlc se Y 8ee`te tatimated Hater Usage, tyallmaa Per day) S. Sype of water ou,Ply. d/COurtY/City 17 well CI c——g ty !. Do you anticipate additions or eapauslons of the facility this system Is intended to serve,.❑Yes 044- Ifyes,nbat type! "*XW0RTAN7—e CLIENTS A1=COAUPL87SETHE REQUIRCD PROPERTY WFORXATiON REQUESTED DELOW. EftheraFIAT erSITEPLANM84TSES118AMMEDbythe dimi w1tbTHIS APPLICATION. Property Dimensions. ; il0 9 t WRITE DIRECTIONS(rram Sioeksac)to PROPERTY: Tax Office riN: s S7265-2 -No l./b Propertydress:AdIiaadNamcT( rYe�iw((�iti'•0G16 1, Ilia a Subttivisioa provide iorum,arriott fas fans l 0�6 Ntwta '"�P.LL 1©1.�)LLIyCX sortfon: Mock. _ W. Date Lame corners Sagged: This is to tertifl that the tafurluation provided is correct to the best ohms knowtedga I understand Ihat Anypennit(s) Issued Jtcmartcrare subject to suspasira or revocation.if the siteptarts or hucaded ase dmt:c,or If We Information suhntlaed In then application Is L-"Gcd or ehungcd.I.d",andersraatf dwf am responsfbk jet aft cfwrges IncarredJraat Win apj.ficafka I.hereby,give consent to the Authorized Repnscntative or the Davienter calth DclutrlataU I*enter upon above drstribcd properly.opted is Darie County and osraed try L iILJ to conduct a8 tcsttng Procedures as necs:aary to datcrudne the site cult pity. . DATE SIGNATURE IUIS AREA MAY BE USED FOR DRA.WING YOUR SITE PLAN!(Include allot the following:Esfstlog and proposal properiylines and diatattrioas,sttuctims,setbacks,and septic locations). Sltc P"isit Charge Datc(s): Client Ctot)llcation bate EUS: f� 'ltL Stgn given Account Nal`oo(�*3 7TO Revised DCHD(05103 Invoke No. J~ 2—d eac:ai b0 as o9a EXISTING 50' R/W EXISTING 20' PAVED _ 4 TARA CT. a � 30' RAO EXISTING 50 R/W 0 ExiStING + Y`� 1 1 'Jr,Y IRON LOT 4 4 LOT 3 L 01 2 ZONED R—A INS, 88'32'44' E 64.28 TOTAL4 115.31 TING S 88'40'30' E NEW TOTAL= 220.00 CIRON S 88 32'II' E S 88'31'50 E EXISTING 90.12 NEW 194.81220.01 3/4" EXISTING � 3/4" EXISTlNC E IRON �� y�i� IRON lF2ON 1 } ✓ * q NtS,�`� ! �r = 0.945 CIO, s AREA C 3cn6' Ln AREA= 0.909 AC. — " 714000 o N N� S 8� CU AREA= 0.862 ACI i c s �' -r�► R --� IV UTIUT1 �. 5o f AREA 0. EASEME i -C7, C NEW H 87'32'14' E IRON a o J, 1 cot. o i fo c9 (�4) p oN�oo a � '� o AREA= Q.809 AC. �o� °� r 7- 5 �R 0 � 0 .O� z ab b .� C/5) s AREA= 1 .006 AC, b A .�2 010 tRO� ' V '12'Lb 45 j.03•32 S 66' NEW � s 8 6 'd eae =ai bQ as oaa TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATG Davie County Health Department Oti0�ti EnvironmentaiHeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ' (336)751-8760 E ***IMP T*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �j� / ? 1. Name to he Billed // Z���(�� /�/�r(���/ Contact Person /ry'�//_6 6 6A/t,/{t Mailing Address /S&0 �.J�/t' tG /Jd�{/V1'G�( Home Phone -T.)(U " � City/State/ZIP </ �( L Z ,yam 8Business Phone 36 7�1 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 n Industry ❑ Other 5. If Residence: # People # Bedrooms 1- # Bathrooms Z_ 1-Y- ish.asher fl Garbage Disposal I ashing Machine II Basement/Plumbing 11 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Tfater Usage (gallons per day) 7. Typ© of water supply: ounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U-W If yes,what type? ***IMP0RT11NT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERi'Y INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION. 1 _ � Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: #c;j 6—� ��y /•✓ Property Address: Road Name City/Zip 2,7o e, If in a Subdivision provide information,as follows: I *_L Name: 1 //6,4_b0jj0 '`� ��1c±nf ���YOG✓d�C J4✓ _<<f rC Section: Block: Lot: _ l�o _ 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 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 testi g proce ures as necessary to determine the site suitabili DATE 3 / v SIGNATUREc� 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: la-2.2 EHS: /!440,,¢act 01 �� V Account No.g V �g000'3 Revised DCHD(07/99) Q_� Invoice No. ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPL r,Ac]�1hTitill FQ D1i1bT�t i Tax PIN/EH#: 5726 TV INFORMATION Billed To: Martin Lee Barber Subdivision Info: Meadowwood Two Lot# 16 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 I/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% y HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH G Texture group ' Consistence Structure 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: 12 lee i""L ��r 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 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) S(provisionall suitabl'�,U(unsuitable) LTAR-Long-term acceptance ra e-ga day/ft2 DCHD 05/99(Revised)