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125 South Madera Drive Lot 29• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street MockvAlle, NC 27028 (336)751-8760 Account #: 989900225 Tax PIN/EH #: 5749-63-6844.29 Billed To: Jeff Ferguson Subdivision Info: McAllister Park of # 29 Reference Name: Jeff Ferguson Location/Address: Sain Road -27028 Proposed Facility- Residence Property SizP7 qq platted ATC Number: 4313 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.A9 wage Tjqatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW S TI N I ALA PERIOD OF F VE YEARS. 7. Environmental Health Specialist's Signature: Date: re rLm. / f "It o&P1400fns CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certific of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sha 'n NO be taken as a guarantee that the system will function satisfactorily for any given period of time. tiv, 104 lip i 3� I� u= , H "-OX)S& (;iZO W T Septic System Installed By: Environmental Health Specialist's Signatur Date: i DCHD 05/99 (Revised) '-{ SbkgAF-1 000 SV?5 -'I bb -G�- APPLICANT INFORMATION DAVIE COUNTY HEALTH DEI'ARTMENT Environmental Health Section Soil/Site Evaluation JI PROPERTY INFORMATION Water Supply: On -Site Well Community Public / Evaluation By: Auger Boring Pit < Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND Lnndscnpe 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 Text tr 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 ois 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 Structurc SC - Single grain M - Massive CR - Crumb GR - Granular AB - 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 DC1ID 05/99 (Revised) HORIZON I DEPTH Consistence HORIZON 11 DEPTH Consistence HORIZON III DEPTH Texture group Consistence HORIZON IV DEPTH Consistence SOIL WETNESS ��s��s��s�� M. • •HORIZON �■��v■��.�� led W.WhIj 19 WEN I Eel 9 Nam�'��e�� SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND Lnndscnpe 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 Text tr 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 ois 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 Structurc SC - Single grain M - Massive CR - Crumb GR - Granular AB - 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 DC1ID 05/99 (Revised) APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: .Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.29 Subdivision Info: McAllister Park Lot # 29 Location/Address: Sain Road -2702t, Property Size: as platted Date Evaluated: Community Public Evaluation By: Auger Boring Pit Cut �S n� SITE CLASSIFICATION: EVALUATION BY: elifi P UaAPI�)_ LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: ~iO7 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 ois 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 r ct rc 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 DCIID 0.5/99 (Revised) LandscapeFACTORS �rr.�rt:��o��■��s�� HORIZON I DEPTH Texture groupConsistence REARM, FUR Consistence r�� r®��■r Mineralogy Texture Consistencer,r�E�u��■��o rte- aNw_im MOM a�o�� Consistence -_�-_-- -®-_-_- MineralogyStructure SOIL WETNESS SAPROLITE SITE CLASSIFICATION: EVALUATION BY: elifi P UaAPI�)_ LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: ~iO7 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 ois 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 r ct rc 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 DCIID 0.5/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section 'n P. O. Boz 848/210 Hospital Street b� Mocksville, NC 27028 (336)751-8760 �\ IMPROVEMENT/OPERATION PERMIT Account M 989900225 Tax PIN/EH #: 5749-63-6844.29 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 29 Reference Name: Jeff Ferguson Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: as platted **NOtT9*is7mprovem � lheent/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 Z"5— Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: d Basement/No Plumbing: ❑ Commercial Specification: Facility Type �,#,People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply CSI i n Design Wastewater Flow (GPD) "T18tD Site: New Repair ❑ System Specifications: Tank Size ICWGAL. Pump Tank GAL. Trench WidthZC' Rock Depth 1, A Linear FtACC-)} Other: J ► )=l t-' UTI C>i zJot i &qq,;rg) 25,7 �Ma--Tj gq —gsr 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 7 1 +'EED L11�tES IN ��tY►�4�lRA�a��rr-I �3� Environmental Health Specialist's Signatur( DCHD 05/99 (Revised) Date: APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit !/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 Z3 -,f if i(,)Z-VI , i Contact Person Mailing Address U �x Home Phone City/State/ZIP ;,% U % Business Phone Cell V3 -7g25" Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip 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 city "I Tax PIN# Subdivision Name 919/,'5211. orf Section/Lot# Q01 Lot Size Directions -To Site J / 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 CNo Does the site contain jurisdictional wetlands? i ❑Yes DNo Are there any easements or right-of-ways on the site? PYes ❑No Is the site subject to approval by another public agency? ❑Yes DNo Will wastewater other than domestic sewage be generated? []Yes DNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms �# Bathrooms j S-1 Basement: '" es 0No Basement Plumbing: Ryes DNo y, IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Kes idENee 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: W"County/City Water ❑ Newl Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No 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 1 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 z1 4 Pr owner'r er's legal representative signature Date Sign given ❑Yes 0 N Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # q" q 9 G 0725 - Invoice # - _V_57 If S�so{-•{`Y 3SX �' 2f, fY n_ .-... Ys—� . 4'y, _ __- ,,... ,..w_ __.. ...-.. ,— ._.l � zi i' c tv "�... �. f� � " 331 1 . +� f � ��i N ..... _ _ � iT✓y +A��. "y �n ,r 9j +..� .� � .ay �p .... .�. .__ _ - ---- Jy a,•� -gam 1 ; {; �� w ft "'.•8 �, r 4 ++ '�,� i .d a'�`"d � `�-ea..+�: ..,�...,. �,,.......a. .......,... ! +,m; r 'fir,. f t " x -32".6 m W 06 7. u..c •.cr� �M � �',71 l Sr .•.°'sem. 28'rh Ny[^'�' ''ppSS ij % ,7tyi 1 YYY .9=�n++'r•�4•', S i r' cole' K pj of yJ f G c+ F @ �...+..... .w..... ..,M� 300 a J } +S ...r,....,.. .... .... �}�ryt ,.� iii iRome ipj=hk k NoLdry Public 823.04' S 39' 45" W Fled for Registration atdock i .M. on. <-�<a. �:, ,L � 2006 and recorded ms in Plot Book Y,; Page .J M. Brent Shoof — Dovie County Register of Deeds H5 LOT 55 HAZEL SAIN BOGER DP 86 PG 427 486.05' X4.00° 15" W 108 00,2 J 6.00. 88,00' �J0 �, C 74.00' 65.00°� ' 9 t 09.99' ON A EA {1 TO 1 q Loa- 00. 92 p0. 43_200 108 76 `jd� 0 1 Op' 00• N1 I S 1$•48,29• NJ 48.0p. 1 TOB. I ,104.00' TOTAL 2 II 0 i iN o S A 2 41 4" W N 4' F 168-00' ' CS . .mac 1 810 1 i r ` 1 X6.74_ T AL 327.22 2 R/►y 75 00 L 22 60.53' - - 20 104.00' T07 pgyEO PUBLIC RD /T 17-50. -CF L• 41 =� 94.09' 1 S1• - ' Ao 07 0" E N w m �I �I M I� 00 04 N O I N j rn0, ', IO O1Y 11 �It O — 4 E _ I 00' 6 B. -� ---_ - �� r ! I I i _ I I i i \ J N 102.00' 102,00' 112.00' 1 50.00 i 00 � I � � j f Co i - t 0_' - 6 N cO I o I 213.94' 1 f I 0 .cl TOTAL 1009.79' N 0-39-32 E V F- rn N �D a 3 ALL DISTANCES SHOWN 'Co FLAT KEYNOTES: OTHERWISE NOTED. O10'x 70' SIGHT TRIANGLE EASEMENT Q m o Co 2 TYP. 5'W UTILITY k DRAINAGE EASEMENT Z 4. ON LOT SIDE OF ROAD R/W LINE. N 3 8'W SIDEWALK EASEMENT CENTERED TOTAL AREA BY COORI ON SIDEWALK d TOTAL NUMBER OF LO' 7. MINIMUM LOT SIZE IS; 4O 20'W DRAINAGE EASEMENT CENTERED 0 o ALL LOTS ARE BE SEB ON CULVERTS AND DITCHES `- 10. WATER IS PROVIDED 8' VAp A GS VIC sc� GENERAL NGTI 1. NORTH IS BASED ON P APPROXIMATE DAME CI FROM GPS POINT 'WOU U.S. 158 AND S.R. 164 2. ALL DISTANCES SHOWN HORIZONTAL GROUND I OTHERWISE NOTED. 3. ZONING IS OPEN SPAa WITH MINIMUM BUILD1Nf OF 40' FRONT, 30' REI 4. IRON REBAR WITH CAP! CONCRETE CONTROL 0 5. TOTAL AREA BY COORI AND OPEN SPACE ARE 6. TOTAL NUMBER OF LO' 7. MINIMUM LOT SIZE IS; 8. PROPERTY IS NOT IN I 9. ALL LOTS ARE BE SEB SEWAGE FACILITIES. 10. WATER IS PROVIDED 8' 11. AL! STORM SEWER, WI TV CABLE. LINES SHAII IN STREET RIGHT—CF-I 12. DUKE POWER HAS AB SUBDIVISION. 13. THE ROADS AND THE' NC DOT'S. 14. OPEN SPACES ARE DE OWNERS ASSOCIATION AS RECORDED IN OB1 15. CUL—DE—SAC RIGHT-( CENTER RADIUS OF 4' 1Jt, J M P C a T 29 4 APPLICATION FOR SITE EVALUATION/I&IPROVEAIENT PERtnll— Davie County Health Department0 VT Environmentailieaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 270283 ?405 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE —REQ11119up INFORMATION IS PRROOVVIDED. Refer/to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ��- i-ha•%Z� ��ri t �-� Contact Person /q— L Mailing Address l( �� / -! 1 E'_ �/' IS 4— Home Phone ZL<,' - 4.2- 7/S City/State/ZIP L�+nl�l'f�'+`� �� L-1 ` -0-7143 Business Phone 'f6 -7' 6 C/ -1-'7` 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: IE'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 2 --conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? #Bedrooms ,_) - #Bathrooms UDishwaaher []Garbage Disposal IBWashing Machine 7. If Business/Industry /Other: verify type, # Commodes # Showers IF FOODSERVICE: It Seats ❑Basement/Plumbing ❑Basement/No Plumbing # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) 8. Typo of water supply: 2"16ounty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of (lie facility this system is intended to serve? ❑ Yes ❑-N]j- byes, what type? ***IA1-P0RTAN7*** CLIENTS MUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESURAf17-FED by the client with THIS APPLICATION. Property Dimensions: n la4e,• Tax Office PIN:,/ Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: M ° lilt t i51e<- I ,+r � Section: Block: Lot: IYRITE DIRECTIONS (from Mocksville) to I'ROPEI ri,: �-- Lin cc'j,, l 'e P/aC c. 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 liercafter are subject to suspension or revocation, if the site plans or intended use cliange, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all changes incurred frown this application. I, liereby, give consent to the Authorized Representative of the Davie Comity Iieaitli 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 4� ' 3 - �J SIGNATURE / ` `- -��, � �• 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: EHS: Sign givcn__I&)D Account No. 7 Revised DCHD (05/03 Invoice No. APPLICANT INFORMATION Account #: 989900035 Billed To:' Richard Short Reference Name:. Proposed Facility.: Residence DAVIE COUNTY I-IEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.30 Subdivision Info: McAllister Park Lot # 30 Location/Address: Sain Road -27028 Properly Size: as platted Date Evaluated: 2 -- Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS i■■�®oo®��a Landscape position HORIZON I DEPTH Consistence rrsY�r �� a��■�� HORIZON 11 I)Elyl'H Texture group rr��■��s�� Consistence— Structure ��ra��■�� HORIZON- i� � sig �■■�� ®r■i■■� �� HORIZON IV DEffH Consistence Mincralogy SOILWETNESS CLASSIFICATION SITE CLASSIFICATION: f --S EVALUATION BY- l OC't� LONG-TERM ACCEPTANCE RATE-: • � REMARKSt/( OTHER(S) PRESENT: 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 Toist VFR - Very friable FR - Friable FI -',Firm VFI - Very firm EPI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky r 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 1 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(suitablc), PS(provisionally suitable), U(unsuitablc) LTAR - Long-term acceptance rate - gal/day/ft2 1)(11 In 05/99 (Revisal)