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104 North Madera Drive Lot 32 P/O 31• v' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 � b� �dQ Account #: 989900225 Tax PIN/EH #: 5749-63-6844.32 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 32 Reference Name: Location/Address: Madera Drive -27028 Proposed Facility: Residence Property Size: 250x104 ATC Number: 4531 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 .19QQ Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE W TIO IS V ID F A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur . Date: 4A &Vfoiw� 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. 1 a , , —. IS _ ( �1U L 5c---) 0A4,WA-:Q- Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r DAVIE COUNTY HEALTH DEPARTMENT • � ' Environmental Health Section P. O. Boz 848/210 Hospital Street �d • ' Mocksville, NC 27028 C (336)751-8760 b IMPROVEMENT/OPERATION PERMIT Account #: 989900225 Tax PIN/EH #: 5749-63-6844.32 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 32 Reference Name: Location/Address: Madera Drive -27028 Proposed Facility: Residence Property Size: 250x104 ATC Number: 4531 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 flw�e#People #Bedrooms 3 #Baths Z- 5' Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size , &5A A - Type Water SuppIy6—n>jtyDesign Wastewater Flow (GPD) Site: New0"00'Repair ❑ v r System Specifications: Tank Size E-000AL. Pump Tank _ GAL. Trench Widtlf� Rock Depth4 / fl~ 'Linear Ft. Other: -D-V61-S .._a:r_ �: _/I- _a:.: �. 1 _%in .,,.1 r �- .. V V.ti _P c' , c t_ , )Cs ✓. �� t�'��F ! P iXoyuuvu ouc iviuuutcattvit_ �i%,vuuiuvua it v �-v r — r+• L U JtS _-- 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.**** L SL= j t7►�ivt� N A, r sr epptx.6.0 Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLI 06CT 2 X20 5 App EVALUATION/IMPROVEMENT PERMIT & ATC County Health Department ironmental Health Section . Box 848/210 Hospital Street Mocksville, NC 27028 )751-8760/ Fax (336)751-8786 Permit E Authorization To Construct(ATC) ❑ Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed e r U ' Contact Person & iT Billing Address t A-3 Home Phone City/State/ZIP ,a G/ 1 Business Phone G%tG 9 27 `3 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION NOTE: A survey*plat or site plan must accompany this application. (Permit is vali or 6p months ite plan, no expiration wi complete Street Address ! ) r G kw f l� r ✓ � City of 6 v, li Subdivision Name, Directions To Site: Section/Lot# Tax PIN# Size 50 Date House/Facility Comers ,Flagged %Cl 2 S lid 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? Dyes 19Ko Does the site contain jurisdictional wetlands? ❑Yes Ml Are there any easements or right-of-ways on the site? Dyes 9,90 Is the site subject to approval by another public agency? ❑Yes @fNJo Will wastewater other than domestic sewage be generated? Dyes o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _,2 # Bathrooms Garden Tub/Whirlpool P Yes ❑No Basement: ❑Yes 0?1�o Basement Plumbing: ❑Yes AO 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, P1 . Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [�o 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 permit(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 det@rmine compliance with applicable laws and rules on the above described property located in Davie County and owned by— -�e Ftr Ir} t ,�,;., -111 L IJ Prop owner' or er's legal representative signature m Date Sign given ❑Yes io Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # `_� oZ� Invoice # PCr (f Jeff Ferguson Inc P.C. Bax 2153 Advance, NC 27006 12.9 6 aW2 5.6 8 C-%olol 240.95, 4 212 3 52 9 0' 17 5 APPLICATION FOR SITE EVALUATION/IAIPROVEMENT PERtrml— fl/� Davie County Health Department0 U Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028Z17�5 (336) 751-8760 ***XPIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEEtE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 21 A-1-- .�� l p ri— Contact Person H C Mailing Address % r / "/ I LE'_ /' �S'/' Home Phone City/State/ZIP L��� �'f�' �jy`� --;L7/e)3 Business Phone 7' 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: E Site Evaluation City/State/Zip ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ''House ❑ Mobile iiome ❑ Business ❑ Industry ❑ Other S. Type system requested: 0- Conventional ❑ conventional modified ❑ innovative 6. If Residence: it People # Bedrooms ,.'., �� , 3- � # Bathrooms Dishwasher ❑Garbage Disposal IB9lashing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /Other: verify type # People # Commodes # Showers IF FOODSERVICE: It Seats S. Type of water supply: lta ounty/City # Urinals # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes am If yes, what type? ***Ili1P011TANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BESUBAIIT'I'ED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: it ::i- % 3- Cod '3 3 Property Address: Road Name 5 4 : jj 21� City/Zip If in a Subdivision provide information, as follows: Name: M ef}JiIS 'c' / I+r Section: Block: Lot: 1VRITE DIREC'T'IONS (from Mocksville) to PROPERTY: �" � t ✓� (� � t" Ca GL. LQ /4 C L Date home corners flagged: 41- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter arc 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 cha:ges iacin•r•ed fi•oiu this application. I, licreby, give consent to the Authorized Representative of the Davie County IIealth 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 ' 13 - 0 S SIGNATURE 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). Sign given--Z\-JD Revised DCIID (05/03 Site Revisit Charge II . Date(s): Client Notification Date: EHS: i Account No. Invoice No. e AIC J rn4/' G©T 2/ V, ,lam APPLICATION FOR SITE EVALUATION/Ih1PROVEhICNT PL•Rh11T :PR Davie County Health Department EnvironmentaiHeaith SectionP.O. Box 848/210 Hospital Street 773Mocksville, NC 27028 Z005 (336)751-8760 I ***IbIPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE—IZLsLi ""' / I INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions:_ 1. Name to be Billed �� L�u••zC Sky rl Contact Person Mailing Address �I (e I- IS'(' Home Phone City/State/ZIP L�J�n%'�'f�'+`a CS; le -f-1— --0-7/6.3 Business Phone -Ve) -7 -2-<1 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 13 Site Evaluation City/State/Zip ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 2' -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 2"Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,.,�, � _3'LIt #Bathrooms I.SDishwashor []Garbage Disposal Washing Machine 7. If Business/Industry /other: verify type ❑Basement/Plumbing ❑Basemont/No Plumbing # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Type of water supply: I"County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-N0 If yes, what type? ***IIIiPORTANT*** CLIENTS df UST C0,1fPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: A-5 ,n ic.:'{��G Tax Office PIN: It 7� 9- 3'(o yY`i. 3 -2- Property Address: Road Naine c57l4 n Ill City/Zip If in a Subdivision provide information, as follows: Nanic: Section: / Biotic: Lot: WRITE DIRECTIONS (frons Mocksville) to PROPERTY: Date home corners flagged: `/- This is to certify that the inforniation provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if tilt information subniitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurredl-onn this application. I, hereby, give consent to the Authorized Representative of the Davie Comity Ileallh Departnient to enter upon above described property located in Davie County and owned by to conduct all t testing procedures as necessary to deterinine the site suitability. DATE ' t'3- D S SIGNATURE THIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn - -10D cd DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. _ Invoice No. Davie County Health Department v t8 jzEnvironmental Health Section SO P.O. Box 848 PAID 210 Hospital Street V , i" p Dom; -3--/ Courier # : 09-40-06 X10 4 Mocksville, NC 27028 R Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: bu�� � (/� P0 d s Phone Number 2 W'41%7 0 (Home) Mailing Address: �&2,71 (Work) /UL 0_7117 Email Address;.SOtYil)Waff, uP/ Detailed Directions To Site: -N akO r6t, . r2�it,Or aiyo 5'S s, Am -AL 32, �v Property Address: MO 5/ Please Fill In The Following Information About The EXISTING Facility: - Name System Installed Under: � j,! 4 " 1 `e A) Type Of Facility: Date System Installed (Month/DateNear): Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes//N0J If Yes, For How Long?. Any Known Problems? Yes (Df Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �o6 i Number Of Bedrooms: Number of People x'Requested By: Other: For Environmental Health Office Use Only Approved Disapproved �` Comments: I �P P.ln JO D I 16' "1 Dm c5 ,'19- , cS US+rj_ l Environmental Health Specialist Date: *The signing of this form by the Environmental Realth 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. Payment: Cash Check Money Order # /V!7 Amount:$ / (JU> V U Date: Paid By: Received By: Account #: 8 723Z Invoice #: —. IL �� 'O �nVsajti' !a. s Printed:Apr 03, 2014 All data is provided as is'without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. r DAVIL COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation A1111LICANT INFORMATION Account M. 989900035 Billed To: Richard Short Reference Name:.. Proposed Facility:. Residence 11 PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.32 Subdivision Info: McAllister Park Lot # 32 Location/Address: Sain Road -27028 i Pfoperty Size: as platted Date Evaluated:' _ Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit / Cut M SITE CLASSIFICATION: -0-S LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: )�-`,L�"^� OTHER(S) PRESENT: LEGEND' Landscape Position It - 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 CONSISTENCI; Qi VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Vcry Sticky NP - Non plastic SP - Slightly plastic P - Plastic VI' - 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 Saprolitc - S(suitablc), U(unsuitablc) _Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less '--sir - S(suitable), PS(provisionally suitable), U(unsuitablc) - Long-term acceptance rate - gal/day/fit HORIZON I DEPTH Fs i� roStructure Consistence rat��.�■���■■� MAN HORIZON III DEPTH Texture group r�arr��...■■�i■..■..� Consistence ca��■v��a��o� . �������os���■���Consistence SOILWETNESS gwi CLASSIFICATION �-��■u����n����� SITE CLASSIFICATION: -0-S LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: )�-`,L�"^� OTHER(S) PRESENT: LEGEND' Landscape Position It - 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 CONSISTENCI; Qi VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Vcry Sticky NP - Non plastic SP - Slightly plastic P - Plastic VI' - 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 Saprolitc - S(suitablc), U(unsuitablc) _Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less '--sir - S(suitable), PS(provisionally suitable), U(unsuitablc) - Long-term acceptance rate - gal/day/fit