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384 Ralph Ratledge Rd . � . '' . ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � ' ' P.O.Boa 848/210 Hospital Street - Mocksville,NC 27028 � ' (336)751-87G0 Account #: 990003737 Tax PIN/EH#: 5810-39-6845 Billed To: Dave Nelson Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 ATC Number: 4320 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be usetl AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST 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 WASTEWA ONS IS OR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Date: 2! � CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with icle 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and ' Disposal Systems,"but shall in�W be taken as a guarantee that the system will function satisfactorily for any given period of time. ��p, ��, ,�,�� � � �o�= � . ��cx�.�� �r��►�a�a� c�F �ST 2 tri�S �''ti'14'�4i'rN� IS �aCr��s Q�r 2o-u' �� �►.�c sr ��d 'f;S �� U 4 �5 �3 . � Ql���� u � �4r�.�.,r� ` _ � DIQ''` ('lL S `r�a�� ��. �-LS � ►��� Septic System Installed By: �'�- �1 1M �L � � Environmental Health SpecialisYs Signature: Date: `7 1� t9L DCHD OS/99(Revised) � I DAVIE COUNTY HEALTH DEPARTMENT . ;,. ' ._,."' Environmental Health Section n • P.O.Boa 848/Z10 Hospital Street �,�11� Mocksville,NC 27028 «�-1�p(� ' �� (336)7S1-87(0 n1 `� d� IMPROVEMENT/OPERATION PERMIT Account #: 990003737 Tax PIN/EH#: 5810-39-6845 Billed To: Dave Nelson Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 Proposed Facility: Residence Property Size: 35 acres **NOTE�*Th�islmproveme�ndOperation Permit DOES NOT authorize the construction ofa 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 Disposai Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type {"��E #People 2- #Bedrooms � #Baths 3 Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste:❑ Lot Size js•(�14CP� Type Water Supply V�"LL Design Wastewater Flow(GPD) 3� Site: New� 'Repair❑ ' System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width 31�" Rock Depth �Z� Linear Ft. "fCD � '1 As stated ln 15A NCAC 18A.1969(5) ��Z� Other: �f aST��Pt7rlE� �x� accepted Systems may also be used Required Site Modifications/Conditions: I►ssra,.�oa �-�� 1� 1� �M wlqL, �-� 15�c�� p,�C��-r INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FiNISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection ofthis ��5� 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)751-87G0.**** � � �K�' �o" Fa��� � �E%f�lT _ �� �I�A�c.TR�►s�•�t T�+�t-1 Z��` I3�FZ ���� u,�� �►� � Hcx35E ` cx s a W I �-�- � Lr��l�-t'i t�' -t�31+SC� ELEJ�.z'�onl� � Ir tJ' �ZL. C�LTvZ`�o i� � z �j`4�17 IS N��E1� F m `�o tF E�c�or�1 ����� ��l��y I � L�� 1����`�1 ( IoO Environmental Health SpecialisYs Si a ure: ►O� a : Ol0 �� DCHD OS/99(Revised) �A ' � �G1���� t� I � ; _�A �'��.� •,'�• . , � ` , � � ' �: 4 �..��`? e S7�L7� � � � ?_?R��„"b'--�„--........,,,, � ;' :, ' , �;: ,.< Cr,:�ek: " r , ' .. I\ .� ;; r r�; � T/2�� er,7 �rn �'nd in Lfne Pr�pa�ed Garaga � o j ���'3 ri0lGC�9 .�!Qi18� - � . ! � � . . �r. � . . ,•-.'�.:,:;..r;'. �C��,' �..Ca� ��.�� Propti��d House ; � y �l.Jl1 4V1�rv� ��� . � . l��`'F^�1 �'��Ji.la^J 17�.�'"J'(!':Y� � _ � {„� . . '�'---•._ . � . � �.1_� , . r - 35.G52 ?�rE>� -�-1– ---.__ •'�`_ -._. 7�g,��w � ncfusive o; �rea`�,r:,�tn S.n. 1312 R,�'�J) – _ —.__ ` _ _ j . _'_ `_t ! ...,� � ; t . . � . - �i� NG'f9G . . G1•� 40n` � �. � r .,� � t?ag Lot Fenos Crass�s Prop�rty Line � �3.ar�. Creek -,.e.=...a.......��--....�,..�; 24�2.�5" � . � - �" _ � p 2 Tataf �`CrAAk ,,, --�-•---�-.-,-�.,:_...._...m....,< 1/2" El� Fn� (n L3�e ^��'i F�rcnch � % ' t�AtP'k9'; � � � � 7;�x �.�t 5� # 7ar 4;��� �--?_ 1 ��/€ �c-ht� St�ivEn f��:�.:u� cr�d }fSf� D�n�s� T�i�•�t.� :��u�€: � C)� 1�� �,"_ �f. �5 . � � � i-�1� 7ia Lirts . � � � � ! Feb 09 06 11:28a davie county envhealth 336 751 8786 p.z APPLICATIO SITE EVALUATION/IMI'ROVEMENT PERMIT&ATC ' � � � Davie County Health Department � � 4 Environmental Health Section � P.O.Box 848/210 Hospit:�t Street Mocksville,NC 270 Z8 n � 9 2006 (336)751-8760!Fa:(33 �'.�l 8786 ppli�a�!n For: ❑Site Evalu ' 1mFrov ent Pernut 6'Autha 'rtza+:on To Construct(A7 C) ❑Both *"IMP APPLI' CANNOT BE PROCESSED U'dLESS ALL OF THIi REQUIRED j' . Refer to the INFORMATION BULLfi'I'IN for mswctions. i/ �,�15 AP IN}�ORMATION Name to be Billod 1/'d�E Pi ls°"� Conixct Person �✓�- '� S�h �� 0 � . Billing Address ( Hc me Phone __ '_/� 'N� City/StatelZIP Bus ness Phone � 7 �.- �� � Name on PermidATC ifD�erent thnn Above �� � Mailing Address _ _ City/StFde/Zip � ��5�/ PROPERTY INFORMATION � NOTE: A uuvey ptut or aite pIm nnut acco�any this applicadon. (Pemtit is valj r 60 mostk v�' s e plaa xpiration with conq lete plat) Street Address / _������City :� ' Tax PIN# ���3 Q�o S'I� Subdivision Name S tion/T.o Lot Directio�o Site: / � u��t. ��(�,��L_ ,� 0 /10%C -0 .A - �� ,d��_ /M� , Date House/Facility Comers FIaggec If fhe answer ro any of the following quaoaons is`�es",supporting documeuta:ion must be attached. Are then any existing wastewat:r systems on the site? OYes�No..-... Does the site conuia jucisdicdc�ml wedands? OYes.KfNo�-•- Are there any eascments ot ri�tn�of-ways on the site7 OYes q�lYo is the site subject W approval b�another public agrncy? ❑Yes'E]No Will wastewater other than dom�tic sewnge bc gcncrated? ❑Yes�10 IF RESIDE E FILL OUT THE:�30X BkI.OW #People #Bedrooms � #Bathrooms__ Gardrn'fub/Whirlpool�lYes pNo Rasement: Yes CNo $asersu:ntPlumbing: �I'Yes ONo IF NON-RESIDENCE FILL Oi;T THE BOX BELOW Type of Facility/Business Total Square Foota��of Building_ #People #Sinks #Commodes #Showcrs #Urinals Estimated Water Usage(gallons per day) (Attach docurr.zntation of similar facility water consumprion) FOODSERVICE ONLY: #Seats Type system requested:�fConventional OAccepted ❑Innovative OAlurnafive ❑Other Water Supply Type:G Counry/City W�u� �1Vew Well �Existing Well O Communiry Well L' Do you anticipate addiaons or txpansi�m;of the faciliry tlas system is mtmdul m servc?O Yes �IO No ]f yes.wbat type? � This is to certify tfiat the information pro�ided on this appliation is true and cc tinct to the best of my Imowledge. I understand that any pamit(s)or ATC(s)iuued hereaft�x are subject to suspcnsion or revocatio►if the site is altettd,the uitendod use changes,or if the infonnation subtni[ted in this applicatiqn is[alsified or cfianged. I andersta ad lhat I am responsible jor a(l charges incurred from this application. I hereby gcant riqh:of enhy to the Authorized Rtpresem ntive of tl�e Davie Coimty Health Departrnent to conduct neeusary inspectio to det ' e compli widi��Plicable laws and rules oa the above desedbed property located in Davie County and owcxd by����.(L�I/�N . ' Site Revisit C�arge Property o 's r o r's legal npn:sentative signature Date(s): Client Nod6cotiaa Date: Date EHS: Signgiven OVes ONu Account8 3?3� Revised 2/06 Invoice# �� Z� ;' � lP.�}SC C.A-GI ' . . a . • , •'�D Tj 1V�,f�R1`�+.� � � � APJ'LICATION 1'OR SITE EYACUA710N/l511'(iOYGft-Ni pEflSUi&ATQ � • �.*'� �eJ-�-�;,5 ' Davio CounryHealth Ocpattmont . • 33(,-�a Z. Environmenta/Hea/t/i Section �0 � '-'�-PC�[7l� P.O, Box Bd8/210 Noapita2 Straot • . M o o k s V i l l e, N C 2 7 0 2 8 � s`� I � (336)751-8960 • •rslllPORTANT+�*�.THSS ApPLIC11TI0N CANNOT BE PROCL•3SED pNyES9 ]1LL THE RL•'QUiRT..D . �` � �tl�` INFOItH7►TION 23 PROViDED. Rafer to tha 22iFOItPATION SULLSTYN for inetruetione. �� ,f�,� � � l. Nuao tu ba Dtll�d_(]A_��N��f o-.� Cone�ct Porobn�n 1� �/►,�1di.A'T-r,t I ��FG���H Ne11inQ Addrasa�_3� K. � , �.,�p�T TC)G:J �. flf } ry� _ �. uomo ahona _`�I'IZ.- ZE�B- O�/'i Clty/9tau/ZIP�4l �•�. Glt-. �#�1 ��15�oDu�lnoa•?hOn� 3. Hamo on Y�rm1t/AtC it Dlftor�at Ch�a xbov� ' tt�lllnQ AEdree� � City/9[�t�/Zlp � � 7. 1lpplieation Fori �$iCo Lvalu�tion � Improvement Pnziuit/ATC � Doth t �. 8yatcro to serviea��iouso Q L2obilc Homo ❑ Dua1a08e ❑ Induatly ❑ Othar _ S.' 7Yp• o)•atem raqu09tWs q�Convontional ❑ ConvenCloAal modlti�d ❑ 1nAoratiro paCCOpted � - -' / � s. 2f ftaaldoncos .A Peopla Z 1 De�ooms 3 o z�a�brooms �_ �lnhwaahar �Oarbag� Diapofal �wuhing Hachina Ons.emone/ri�a,inq ��ee�aont/fto vlun�lrinp � � �. i! Duatn��a/Sn4uatry/Oehur� verily tyD• / P�oplo � sinko�= i Commole�Z_ � +howors � . . � 0 tlrlaal��_ / Hator CoolarA IF FOODOERVICEt 0 Scata Eetimatad Water veagu (g�llona per day) � •. iyps ot vatOs �upplyt ❑ Cotulty/City �;S�fell� O CommuniCy s. co yo� .nctesa.co �d�lelons or cxpnnsions of tt�c��u'li(y this sys�cu�is(utcuJcJ to scrve?U�cs �o If pes,�rltat typ¢? "RklAIPORTd1V7"'�CLIENTShcUSTCOAIPLET6T11E REQU/REDPROhCRTY/1VPORM1UT10fVREQUCSTED BCI.01V, TltheraPLATorSITF.pLANhlUSTAESUIlA/!TT/;'DbyfAetllent�vi�1tT111SAPPI.1GTfON. !'roJurly Diu�ensiona: � � I�C J�S' 1VRITE DIRECf10N5(brout 111odcsriUc)tu PROI'ERTYr .Tax OfTcc 1'JN: 11�.�� � O -3 y- ��ysS t-�-r 1 r o r� t� '� p�D�+- I'roperty Address: Road 1Vamc Q��1�E1 i2r�7"[�t L� li��r�a�-r P c�a a 0 �'"�_ c►�y�z;n,ma, ��t(!�- N �a�1 If(n a Subdivlslon proviJc informalion,as follotivs: N�mc: Scclioa: Dlocic Lot: Aatc l�omc eorncrs DarreJ: 7'4is is to cn•flfy piat Il�c iulonn�tton proviAcJ is eorrcct to tLc bcst ot tny kno�r�edgc. I unJcrslaud fLat any pernril(s) issucd hcrcaf�cr are svbJccc to suspcnsion or rcroalion,tf thC sitc plans or Inlcndcd usc chaugc,or iC fbc inforu�alion , subndcfcd in Uiis applicnttun is(a(siRcd or cliangcd t,afso,undcrsran�lUiatl anr rcrpo,uiLlejura!ld,nrgcsinairrcrlJrurn t/ris oppiiertrlore. I,hcrcbp,givc tonscnt�o Uu Autl�orlud Itcprescutativc oC Wc DavlC Cou�tty IlcallL Dcparttncut � lo cnter upou aLovc�cscribcJ property lonlcd Lt Davic Couuty and on•ncd by , con Ct AII(cSling pracCduTC315 ncccssary(0 tlCl � � uitabilily. DATE SIGNA7'URI: TIIIS AItEA DIAY B�US�D FOR DitAWINC R S1T� AIV(Iucludc a11 of tlic Collo�vint: Ezisliu�anJ proposcd property IIriCS and dimCnsfOnl, structures, sctLacks, an scpHc locations). Sitc ltcrtsit Clurgc . Datc(o): Clicnt NoliGcaliou DqtC: �IIS: � � 3 � Sign glvcn____� ` . 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I � . �,�. .� _ ._, r �` ' �7 � / I i �:������ ' < < ..o i%' � '' ,� ' � � , , � � °� � � j , _ .�.,_ — � \ \ / i.t;,zsi � �`!. �� � �' �� ..�: s z � ` 7 . \ _ �. �''� � � �� � i , � ( ;� ` �.,` , �.�; r .s,,.� � , � ` � �'�._. � - ,' Y <_ ; . � � � � , i � ; :a � .. ✓ �� \ ;��.....:--��, „' ' '��. / `fi, i' S � . . �' � i . . . / +,e ..r' -z.:,'� '��' \ "+"�� . ._ ___ � ;`7 � �.�,,�. 1 _ . ,{ F�ii.q,� _`. � � ;;,. . -. • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' " Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003737 Tax PIN/EH#: 5810-39-6845 Biiled To: Dave Nelson Subdivision Info: Reference Name: Location/Address: Ralph Ratledge Road-27028 Proposed Facility: Residence Property Size: 35 acres Date Evaluated: � ��(p�O� Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition L '� Slo e% 1 O �Z�v � o' HORIZON I DEP'TH p- —'� p - i p r Texture rou L Consistence S sS Structure Gl� Mineralo HORIZON II DEPTH - 1 � -3 l'n -ZZ. Texture rou � - Consistence � Structure � S � Mineralo C7l HORIZON III DEPTH J,�-- � 2 Texture rou D Consistence P. Structure � k !� fc Mineralo $��, HORIZON IV DEPTH -1 ,1- � Texture rou Consistence Structure Mineralo ... . ; SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE , CLASSIFICATION - LONG-TERM ACCEPTANCE RATE .3 .3 SITE CLASSIFICATION: �� EVALUATION BY:S��":fT lx.l�l�-�' " , LONG-TERM ACCEPTANCE RATE: ��� OTHER(S)PRESENT: � ��n� ��s: � ��-t+ ��+--�"' �— A 93 LEGEND , i, n s ne P�sition R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope . CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope ��. 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 � ON4I4T ,N . . : II'IQiS� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm �'et • NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic $ r, ,r . , SC-Single grain M-Massive CR-Crumb GR-Granulaz. ABK-Angular blocky - SBK-Subangular blocky PL-Platy PR-Prismatic � Mineraloev ' _ 1:1,2:1,Mixed �� . Horizon depth-In inches _ Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface 3aprolite-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 . 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. . . . . . . , . , . . . . . . � � DAVIE C4UNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street ' Mocksville, NC 27028 Phone: (336)751-8760/ Fax: (33��751-8786 September 19, 2005 Dave Nelson ' 5139 S.W.Hammock Creek Dr. Palm City,FL 34990 Re: Site Evaluation- 35 Acre Tract/Ralph Ratledge Rd. Tax PIN#: 5810396845 Dear Client(s): As requested, a representative from this office visited the above site September 16,2005 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 to serve a three-bedroom residence. House location, size and other design criteria may necessitate the use of an alternative or innovative system. System design will be determined at the time an Improvement Permit/Authorization to Construct is applied for and issued. Before a representative of this office will revisit the site to issue an Improvement PermidAuthorization to Construct,the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. � If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G.Beauchamp, .S. Environmental Health Section Enc(s)