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882 Wagner Rd H EALTH DEPARTMEN T RELEASE �'ar o�ce use on�v . `*CDP Fil�e Number 198333-1 ` Davie County Heaith Department �,d r�6� F3o-oo0-oo2-2as: � 21U Hospital Street Caunty ID Number: � . � P.O. Box 848 Evaluated For. HDR/WWC "`���"` Mocksville NC 27U28 . Phone: 336-753-6780 F�x: 338-753-1fi80 PERMiTVAu� 1 � 1 0 3 l a 0 a 0 UNTIL: Applicant: Clayton Homes for Franklin Drye Proper#y (�wner: Franklin Dryer Address: 882 Wagner Rd Address: 882 Wagner Rd C��Y: Mocksville �M�Y: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: E7Q4) 6?7-8903 ?Phane#: (7Q4)677-$903 Propertv Location 8 Stte Informatfon Acidresssg�Wagner Road Subdivision: Phase: LoL Road# Macksville NC .27Q28 SINGLE FAMILY Township: 'SVutture: Directions #bf Bedraoms: � #af Peopie. Hwy 601 North�eft on Blackwelder Road,right on Wagner Rnad, Property an Right "Water Supply: �A Basement� �Yes a No ZYPe of Bu�iness: Total�q. Foatage: No.df Employees: 'Proposed imqrovement: Repiace home � 'Releasf Condhtons r This release in na way expresses or implies that the existing subsurface sewage treatment and dispasal system serving the site will continue to function for any period of time. ApplicantlLegat Reps.Signatu�e Required? QYes C�No Applicant/t.Q�al Reps.Signature• 'Date; � � #lssued By: 21+�0-Nations,Robert *Date of tssue: � . a 1 0 ? � � � 1 5 Auth�rized S#ate Agen • �`*Site PIan/Drawing atta�ched.** �Hand Drawing �Import Drawing HEAI.TH DEPAR7MENT RE4.EASE 1g8333 - 1 ,�csWF,, Davie County Health Department CDP File:Number: �d ��� �, , c. 210 Hospital Street F30-D00-002-208 � p.o.sox sas County FiI� Number: � Mocksvi8e NG 27Q28 Date: �a / 0 7 / � 0 1 5 '`�`�„'`"°•�°` Q lnch Sca1e: QBlack — ,ft. Draw�ng Type: Health G►epartment Release QN/A � � � � . 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Box 848 � � ��� ' 210 Hospital Street C' ;.'S'r `Z�f� ��._�___'� , p.� ��. ��u; � ✓ Courier# : 09-40-06 �g�� Mocksville,NC 27028 � Phone:(336)-753-6780 Tax:(336)-753-1680 � ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: C��y r�� �O�.v�CS �/ �f/}n��j;n �i��G Phone Number 7��I � C-��Z ' ��3 (Home) Mailing Address: �2 �t►-a,��.�- � (Work) ►'�e���5 J���c /�% Z?J'� Email Address: Detailed Directions To Site: ((�� /"��� �e��' p� �j�f}G� t,�c 1�G�' /��• Ri G� �- l�(J.� � � �r' r �E? ; , � � � Properly Address: ��Z A�q Ne r /��c.�i5�,'�l� rC.�: Z7 a"Z-$ , r���O�� � ���r�V �Please Fill In The Following Information About The EXISTING Facility: � _--------�_ Name System Installed Under: �'tA�y�C�i� � �<<�� �!'��c. Type Of Facility: 5�nq�� �„�.'�e Date System Installed(Month/Date/I'ear): Number Of Bedrooms: .3 Number Of People: � Is The Facility Currently Vacant? Yes �c If Yes,For How Long? Any Known Problems? Yes � If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: N�l✓ ��t��l�-r � Number Of Bedrooms: 3 Number of People_� Pool Size: /� �- Garage Size: ,c> .q- Other: Requested By: Date Requested: 1�-t U- zo+S (Signature) � , For Environmental Health Office Use Only � /� ( Approved isapproved �/1 / ��`� ..--�-- — � ,/ Comments: �.n fI.�i� '� S'�/ .)G�� � d��`/.� ,� �• G ,Sl ` ��vt �1 s � l �.� /'���w l` Environmental Health Specialist Date: / � — 7 —/ � *The signing of this fortn by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payme . Cash heck Money Order # Amount:$ •� Date: ,� -� ' Paid By: Received By: Account#: I(�9�(�7,� Invoice#: —� " �� DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section f�� y//-GO • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001053 Tax PIN/EH#: 5811-80-2353 Billed To: Ellie Brown Subdivision Info: Reference Name: Ellie Brown Location/Address: Wagner Road-27028 Proposed Facility: Residence Property Size: 1.005 Acres **NOTE'��ii b�inprovement/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 M•�-�UMV #People 2 #Bedrooms 3 #Baths � Dishwasher: � Garbage Disposal: 0 Washing Machine: �Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��4G2� Type Water Supply� Design Wastewater Flow(GPD) ? � Site: New�Repair� i System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth� Lineaz Ft. �—�b� Other: I �J1�'�il�l7 TIO��e3�., I�S'T�w l.l►J�S ��C�.C.. Iw 1�J. Required Site Modifications/Conditions: �� �P�r�, ��t, �� l0� t9� QP�P�,k.�,� i�C� ��� 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.**** �4-�1��M i►-�� I � � 1 � J TV 6' 12: t+�=��� U� � (n Z � � �, rC1 c t��...�- �, �. � �= ? 1� � � N N 1� � LpCA,T►�`J � �� _ � � I � �1 0 5T _ _ . . _ _ _. . � F� /�.PP2�u, �oo� �s �.�0��•►�►�, � N� � � Z re Environmental Health Specialist's Signatur . Date: DCHD OS/99(Revised) � .., • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990001053 Tax PIN/EH#: 5811-80-2353 Billed To: Eilie Brown Subdivision Info: Reference Name: Ellie Brown Location/Address: Wagner Road-27028 Proposed Facility: Residence Property Size: 1.005 Acres ATC Number: 2375 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 petmit(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 Trea ent and Disposal Systems). THIS AUTHORIZATION FOR WAST IS AL OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu • 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. � �qv ��� . 10 �O �� � �� � � 4? a° �?���� � � � ��J?� �� z ° -� �, +� �p� .� . .�o ' -�- �\`�p � �. Septic System Installed By: _�� `_� T��"J �' / Environmental Health Specialist's Signature: Date: !� Ekj DCHD OS/99(Revised) j: ,� ! . , � D C� (� [� � L�I C� APPLICATION FOR S1TE EVALUATION/IMPROVEMENT PERMIT&AT Davie County Health Department �n� z O �000 Envinvnmenta/Hea/Ifi Se�ction �u�ut P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRO�JA7ENTA1 HEALTH (336)751-8760 DAVIE COUNTY _ ***II�ORTANT*** THIS APPLICATION CANNOT SE PROCESSED UNLESS ALL THE REQUIRED INE'ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. � 1. Name to be Hilled �,���(� /��(,(J Contact Peraon �//�� � i��LJn Mailing Addresa , Home Phone ���Cp - yroC ' �GY(p� City/3tate/ZIP . U� Q Business Phone ,�(� - /J� '7'/ T� 2. Name on Permit/ATC if Mfferent than Above���j�P �[��l,Jj� / � ��� `./ ,F'U�'�1 bf�- Mailinq Addreas City/State/Zip s. .Appiication For: � Site Evaluation ❑ Improvement Permit/ATC krttoth a. syat� to seZ,►i�e: ❑ House f�'Mobile Home ❑ Business � Industry ❑ Other 5. If Residence: � People � � Bedrooms _,�_ � Bathrooms j� 47/iahwasher ❑ Garbage Disposal IyWashing Machine ❑ Ssaement/Plumbing ❑ Basement/No Plumbing 6. If Suaineas/Industzy/Other: Specify type N People # Sinka � Co�odea � Shopers # Vrinals # Water Coolera IE FOODSERVICE: # Seats Estimated Water Usage (gsllone per a$y) 7. Type of water supply: ❑ County/City �Well ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? ❑Yes �'No If yes,what type? ***IM1''ORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PI.AT or SITE PLAN MUST BE SUSMI77'ED by the client with THIS APPLICATION. Property Dimensions: �,��,,_� WRITE DIRECTIONS(from Mocksville)to PROPERTY: Taa Of�ice PIN: #�8/f"' Q� — ,��� .!`.�1 .i(� � ,��� �u C�t�a.�c �- Property Address: Road Name /e��j G✓CtAnL(' ��� �� — City/Zip .��SU���P �'D�8 ��. 'r��P 6Y? �i�� If in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Flagged: �"c�� "� This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued 6ereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible jor all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by ,f_�fi,� �nl..�l� to conduct all testing procedures as necessaty to determine the site suitability. DATE �'� -o� `" � SIGNATURE �� ,� /—"'� THIS AREA MAY BE USED FOR DRA OUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, �t$acks, and septic locations). tiv �2 Site Revisit Charge . � Date(s): �— Client Notification Date: �►� ��� �� �- EHS: � �� Account No. ./� �3 Revised DCHD(07/99) Invoice No. �� / G��: Hou��F,� � .� . , ,� �p w� BILL R. RATLEDGE, ET AL D.B. >91, Pf�. 747 _, � � �� P.B. 6 Pg. 175 ; � � �� TRACT 9 � v� `� S 86'11'S6' E —� � _ _ _ _ _ _ 30.02 H_a S 86'11'S6' E '— :.�N 119.26 S 85•46'33' E —� 196.03 I W � PA ULA ANNETTE CRANFILL �� R _ .0 5 AC. .� D.�. �9O, PG. B�9 �" INC U ES 5. . 1310 R/W � z ~ , . � 321.30 N 65�46'33' 4 �"'— N 85•46'33' V �e-- I PA UL H. CRANHILI & DELAINE K. CR� D.B. 179, PG. 889 � � l� 1� •� � DAVIE COUNTY HEALTH DEPARTMENT ' � � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001053 Tax PIN/EH#: 5811-80-2353 Billed To: Ellie Brown Subdivision Info: Reference Name: Ellie Brown Location/Address: Wagner Road-2702� Proposed Facility: Residence Property Size: 1.005 Acres Date Evaluated: ! � Water Supply:. On-Site Well � Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition v 2 Slo e% 3`7� 3 HORIZON I DEPTH B — �— � ` �— Texture rou ,_ G�— Gc_ Consistence �.55� SSSP �� Structure 5 G�L Mineralo <'1 l : HORIZON II DEPTH - ZZ • 1 lp Texture rou S:C S� � :•Consistence �-'� 'S '' Structure L �Mineralo ` � HORIZON III DEPTH �- Z Z— Texture rou } C� C_Y Consistence F� Structure 1 Mineralo � ' � HORIZON IV DEPTH � -� Texture rou Consistence Structure - Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ,) � LONG-TERM ACCEPTANCE RATE p � �. J SITE CLASSIFICATION: � EVALUATION BY: G1�1�-�P �' LONG-TERM ACCEPTANCE RATE: d 3� OTHER(S)PRESENT: REMARKS: ��) C .�.� , C�Ed� '� � I �'7�-� �L��� ��-e.)c�t9R� -�" Si ��-y�T�-KN�S L 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-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic MineraloEv 1:1,2:1,Mixed ' , Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface 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