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Natures Place Way Lot 3 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 rd (336)751-8760 �/j ff 10 IMPROVEMENT/OPERATION PERMIT Account M 990004051 Tax PIN/EH#: 5739-99-9491 Billed To: David Taylor Subdivision Info: Nature Place Lot#3 Reference Name: Location/Address: Main Church Road-27028 Proposed Facility: Residence Property Size: 460x499x400x ATC N Mber: 4461 **NOTE** I nis Improvement/Operation Permit DOES NOT authorize the construction of aseptic 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-- #Bedroomsy #Baths Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing Commercial Specification: Facility Type /f #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Lr6 Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Size 1APGAL. Pump Tank //G��AL//.��Trench Widttt--� i Rock Depth Linear 1`4* Other: Gt A !�- As stated in 15A NCAC 18A.1969(5 Required Site Modifications/Conditions: accepted Systems may also be use 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.**** r Environmental Health � Specialist's Signature: / 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 Account #: 990004051 Tax PIN/EH#: 5739-99-9491 Billed To: David Taylor Subdivision Info: Nature Place Lot#3 Reference Name: Location/Address: Main Church Road-27028 Pro osed Facility: Residence PropeU Size: ATC Number: 4461 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: /9 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 11 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) APPLIC; TO R SITE EVALUATION/IMPROVEMENT PERMIT & ATC t _V,V. --" Davie County Health Department Environmental Health Section r JAL 2 2� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 e�c��tarTP� (336)751-8760/Fax (336)751-8786 ECA \I DNJ.'% A lcauoniSite Evaluation/Improvement Permit Q'Authorization To Construct(ATC) ❑ Both ***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed '-'J>AVfD d.-7R-11-at.. Contact Person �Dpya Billing Address a3 o LW1sy1zZZ 6 .[ A& -,22> Home Phone 33L- 7!.L-5339 City/State/ZIP 0-ZZ/0We//5 4Je- 17oi l Business Phone-.334.- 996,- 360_U Name on Permit/ATC if Different than Above 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.) Street Address—/279//J eNu&_4 -PD. City Jrloc t ,,a Tax PIN# 373199 9 07 Subdivision Name JJg7r",s pMer- Section/Lot# ,3 Lot Size YeQ xg99 x Srcb x,44 Directions To Site: 15g-ERsT In,914/UZDP� 0 Z47Y 1 n�/cG o,J LtFT Date House/Facility Corners Flagged 7-a�G•o!r 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? ❑Yes C�'1G Does the site contain jurisdictional wetlands? ❑Yes Uo Are there any easements or right-of-ways on the site? 5&s 0-No Is the site subject to approval by another public agency? ❑Yes C�"iV Will wastewater other than domestic sewage be generated? ❑Yes QNo IF RESIDENCE FILL OUT THE BOX BELOW #People 3 #Bedrooms 3 #Bathrooms $ Garden Tub/Whirlpool ❑Yes o Basement: (q o Basement Plumbing: ❑Yes 2<0 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: EVCounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ei If yes,what type? 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 pemmit(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 jP-o,tlR/2 ZMttp /• o/Ct Site Revisit Charge Property owner's oro r s legal representative si ature Date(s): X17 All, Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 2/06 Invoice# � Lavic %,vcui(y, ivviui%,aLviuia opauai Lata i:Ajjivici rage i ui�. Ol 7l,6. ® atial Data[=:jlorer ®� Nortel Carolina Click on the Map to: Map U Zoomin (' ZoomOut !: Recenter Map f Identify: PBrCeIS Draw L Zoom Factor: ZX W f Radius Search(feet)FO Draw select Boundary NW AVE r Census Tra City Bound county Zor I Multi Syi E911 Fire p Flood Pane Flood Zone (� Parcels School Dis+ �. �. Multi Syl (—Soils 57 9999 7 Town Zonir j r Townships r Voting Pre( ' ^� t Infrastructu i (— Driveways Rail Lines } r Street Cent rv— US/NC Higi `k Multi Sy SW SE L K Parcel Data Find Adjoiningj arcels r Aerial Phot Physical • Land Unit/Type: :/AC r Creeks and • Deed Book/Page:00557 10699 E911 Addri • Deed Date:2004/06/21 r Fire Depart. • County/D:6500000159 • Safes Price:$0.00 • Account Number.•000082516230 (�Schools • Property Address: • P/N:5739999491 WY ':Draw'L • Legal1:LOT 2 NATURES PLACE • County Zoning:R-A • Owner Name:STROUPE RONALD J • Census Code: MAP Cl • OwneNAddress 1:STROUPE RONALD J • City Code: • OwnerlAddress 2:STROUPE PENNY R • Fire District.,MOCKSVILLE FIRE This map is preps • Owner/Address 3:PO BOX 338 • Flood Zone:ZONE X inventory of real 1 within this jurisdic • City,State Zip:MOCKSVILLE,NC 27028-0000 • Flood Community.370308 compiled from ret • Land Value:$28,700.00 • Flood Panel:0075 C plats,and other F and data.Users c • Building Value:$0.00 • Flood Map Date:12-17-1993 hereby notified th http://sdx.roktech.net/servlet/com.esri.esrimap.Esrimap?name=Davie&Cmd=sParcel2&PIN... 7/9/2006 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT : Davie County Health Department 0 Environmental Health Section P.O. Box 848/210 Hospital Street #4? J Mocksville, NC 27028 3 �Q (336)751-8760 fiyi,/�ON� 12412 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TH INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruc on . 1. Name to be Billed �A,f Contact Person ) f O Mailing Address / Home Phone ;4� (J Z/'�.z City/State/ZIP Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address _ City/State/Zip 3. Application For: Ellsite Evaluation ElImprovement Permit/ATC ElBoth E 4. System to Service: house ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 2---conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms _ # Bathrooms t( �� LV1Dishwasher �bage Disposal 1dWashing 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) 8. Type of water supply: ❑ County/City I/cC Well ❑ Community �/!V 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes lJ O If yes,what type? ZtA&AJ044'� � a<. A & —1 ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMA'rION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: ,�. t/ WRITE DIRECTIONS(from Nlocl:sville)to PROPERTY: 7'ax Office PIN: 11 "-M UZU Property Address: Road Name .11641'A 41'A j�r�t �cs • d'�L. Ad >.4( 21WJ4'i. City/Zip (1 If in a Subdivision provide information,as follows: Name: Section: BIock: Lot: Date home corners flagged: 'Phis 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 lain responsible for all charges incurred fi•oin 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 b to conduct all test'ig procedures as necessary to determine the site suitability DATE SIGNATURE TIES AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the fol wing: 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 tr 7- Revised DC1ID(05103 Invoice No. �- OA : t 38 X808 36a fm. 1 � f5 { flts x l } [ Ytv 3'"u �y?,.� yam+ "L.r-1 q- t: x1 e, ,.k �}?`Yr YTiy-'� ,{?Y `F S t 4-2) YS -< r . Fr�jtr'a f}n-�: aS-,')r�� 4•f-r'+.z�:,'� °�.a�!a •i t s-� Y. � 1 c i # -,kit a ++"!,.yd-.n 1• ? deYg .y: t fb 'URS'.. J' y cry +a<' ,r �. yt';•'4 .,i-� 3t �_.�. J.`t�n,:.. r ru } ka, N' ayx ,t,' 'v*+'f""t4"' 7� , t Pttypt��(p Ary A�0F9 a. °yy ' z K4�3 "fiat �1\eHUR i_..fit Fylk j }� '400) ,(253) 4RQ'e L5i1 1M/"{.:y f 4+. { 1 (�/�• +� 2 s - i ''y..✓ : z: 5A1 -t "H z. {S t /'i" 1 (6.40A) 7912 31 1 -1 —172/ 603 G500,0100, ;803 Z r n i E f t:_ 1, f � 7 J a ; sl X556 tj A � �, a �r •-.x �} i`i' �;� ✓_1�? 3 (1112A) 5234 S 50 74097 x r 8243 i r (6.43A) 2162 4 x :-Y -- - 5�0 •. �{ 4 f h r f 8,43626 t. 1 �. 630 200 2I53 _A1➢. r 27655 4u )I^1 -7 h1'} kyr 1 .��' a� G5000001 5 (d 81VA 5.07A 1401 . r + 299 215, +, 251 $r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990001389 Tax PIN/EH#: 5739-99-8243.03 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupes Lot#03 Reference Name: Location/Address: Main Church Road_-'2702/8 Proposed Facility: Residence Property Size: see map Date Evaluated: 6 ~L Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit L/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position 41 Sloe% `° / " HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 ACCE ANCE 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)