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185 South Madera Drive Lot 22DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital street ' Mocksville, NC 27028 (336)751-8760 Account #: 990003524 Tax PIN/EH #: 5749-63-6844.22 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 22 Reference Name: Location/Address: S. Madera Drive -27028 ATC Number: 4403 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 WASTEWAON= IS ALID FOR A PERIOD OF IVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMYLETIJON **NOTE** The issuance of this Certificate of Completion shall in�ci .ate the system described on Improvement/Operation Permit has been installed in compliance with ice o ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a antee that the system will function satisfactorily for any given period of time. �� / �D h-4 ' A40 F Septic System Installed By: ;;� j /V ")- � V-� Environmental Health Specialist's Signature: // Date: Q DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section oy P. O. Boa 848/210 Hospital Street 1 Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003524 Tax PIN/EH #: 5749-63-6844.22 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 22 Reference Name: Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 3/4 acre **NOTE* This Improvement/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 TypeH1= #People z #Bedrooms #Bathsz� Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specificat(iion�1 13: Facility Type #People #People/Shift / ' #Seats Industrial Waste: Lot Size � t -t- Type Water Supply Design Wastewater Flow (GPD) `t120 Site: New 2r" Repair ❑ System Specifications: Tank SizeJUDOGAL. Pump Tank GAL. Trench Width 3VRock Depth Linear Ft.10 Other: c'7 7,)ISTga�u Required Site Modifications/Conditions:,. *L a wI h 0ZV� ' N514t-L 0&) u %� IMPROVEMENT/OPERATION PERMIT LAYOUT APPROVED EFFLUENT FILTER RISERS) 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. tw, o 9:30 a.m. oar 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Zoll 0 1 ZOP i. 1 d 1�,= , r M . Environmental Health Specialist's DCHD 05/99 (Revised) r4 1,3. t O' ,— Date: � ; ,�� 1 ► .� " � ! I 1 i ( L I I t I� 'I � A j I ( (i � �' i t I /, j I�o. II II o 1 o u,, o, o •---776--__ I � i '! � I , lP Il it ; � ' �l ',1 t I / 319 IS r' I � 24 O'l I - 1 _ Pw it J --- ---� I 10 768--- --- \ Ii 9 i r—r ----- ——--�--- \ ---- — _ `\\ ' \ t 1 �, ` \ \ ,• )+Perc Pit ; \ \ \ a 1\ CP � \ / I I -- ----J , io ------ �\ \\\ J � --- I , , 343.78 \ \ \ v -�/ +Perc Pit — — — — — 17 4 ,, �-� �� ►r� I 22 � I I �J � � `� Vt Pit I 1 , ' I S O ► I I I j P P , it _-- , ---It-- ----------- ..--• - �- ' 1 _, - --- 349.49' r------�------f----------- -- -�- 752 APPLICATIO SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section D 200 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 EAS lication R� mprovement Permit Z-Aizthorization To Construct(ATC) ❑ Both **wMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. ADDT T('AATT TATV DT4ATTnkT Name to be Billed (�/-��(f �S �' Contact Person Cq Billing Address /o? Home Phone _ City/State/ZIPl' /�,� �-tyn s ✓ i iii Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address t �'fAOe/-4,ye- City /ti%l�C�ls•�[�' Tax PIN# Subdivision Name- Section/Lot# a Lot Size E '/'•�JiC. �/y G Cit Directions To Site: - 5 S<- �- .1-71 Z0_ AL2 E IYL�/s%- 44 4/,_ -727/ /D,,- L -Z Date House/Facility Corners Flagged & S//- 06 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 Dldo Does the site contain jurisdictional wetlands? ❑Yes u�x�o Are there any easements or right-of-ways on the site? ❑Yes LKO Is the site subject to approval by another public agency? ❑Yes No Will wastewater other than domestic sewage be generated? ❑Yes UNo IF RESIDENCE FILL OUT THE BOX BELOW # People 2-- # Bedrooms T # Bathrooms - Garden Tub/Whirlpool G�fe's ❑No Basement: ❑Yes. C�1� Basement Plumbing: ❑Yes C11�6 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: ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the cili this system is intended to serve? W� es' ❑ No If yes, what type? =/� rj�1 �o 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 Au Arized Representative of the Davie County Health Department to conduct necessary inspections to determine complia a41W laws and rules on the above described property located in Davie Count° and owned by �' P Sperty o er's or oM is legal representative sivature Date Sign given 'Yes ❑No Revised 2/06 8 Site Revisit Charge Date(s): l,t) Client Notification Date: EHS: Account # 35a� Invoice # APPLICATION FOR SITE EVALUATION/INIPIiOVEAIENT PEI Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 J)Eti) m AP GOT 2z �6\ APR 7 3 2005 I ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEME IMP —1 J INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. J 1. llama to be Billed � CL- %'tC ��' L �� Contact Person Mailing Address �'�� /III i 1 t'P_ I- �S'/' Home Phone,7/S City/state/ZIP L��w"�'��' ��`� -zt7163 Business Phone '/D-7' 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: E3 Som�ite Evaluation 13 improvement Permit/ATC ❑ Both 9. system to Service: [-house ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 0- Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms �� ,.�� #Bathrooms 13Dis2iwasher ❑ ,Garbage Disposal L@Wanhing Machine ❑Basement/Plumbing ❑basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals ti Water Coolers IF FOODSERVICE: It �Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: ILi'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-N, Ifyes, what type? ***In1P0RTAN7'*** CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BESUR.M17-TED by the client with TIIIS APPLICATION. Property Dimensions: �_� ,n IV 4f e Tax Office PIN: if S 7Y,1-63 " 6 eV4.23 Property Address: Road Name. C5 /4 r I) 21 J City/Zip If in a Subdivision provide information, as follows: Namc: Section: / Block: Lot: WRITE DIRECTIONS (from Moc(sville) to PROPERTY: ��-Lines'b"",- cF to/4cf-- Date home corners flagged: 'a- This is to certify that the information provided is correct to the best of my Imowledge. 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 ani responsible for all charges incurred front this application. I, hereby, give consent to the Autliorized Representative of the Davie County I-Iealtl► Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE Lf - t,3- D 5J SIGNATURE / "-�'-• ��I � 4 TIIIS 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). Site Revisit Charge Datc(s): Client Notification Date: EI -IS: Sign givcn Account No. '78-7�,O°° 3s Revised DCFID (05/03 Invoice No. • DAVIE COUNTY HEA.L'TH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT' INFORMATION Account M 989900035 Billed TO:. Richard Short Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH M 5749-63-6844.23 Sypdivision Info: McAllister Park Lot # 23 Location/Address: Sain Road -27028 _ Property Size: as platted Date Evaluated: S Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS Slope % ----- HORIZON I DEPTH • AwConsistence Mineralogy �UlmWNSM ORIZON 11 DEPTH HTexture group E� H MEN III DEPTH Texture group LAROVVEM RIM= ConsistenceHORIZON [d&l= SEWN �� HORIZON Consistence SOIL WETNESS CLASSIFICATION SITE CLASSIFICATION: 4-s LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY:yKE �&�A--P OTHER(S) PRESENT: Landscape Position R - Ridge S - Shoulder L - Lincar 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 of 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(unsuitablc) LTAR - Long-term acceptance rate - gal/day/ft2 DCI In 05199 (Revised) Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 Phone: MW - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 /\ Name: _FCwrA,-rN,_ 4��}i nr D n Phone Number (Home) Mailing Address: 1C,1 5 -S Mg derma Ir%r. (Work) M netsv i l l's MC a rl M'B Email Address: Detailed Directions To Site: Property Please Fill In The Following Information About The EXISTING Facility: i Name System Installed Under: imlsh Type Of Facility Date System Installed (Month/Date/Year): �� % Number Of Bedrooms.—_Number Of People: Is The Facility Currently Vacant? `'Yes No If Yes, For How Long? Any Known Problems? Yes 6 If Yes, Explain: Please Fill In The Type Of Facility:. Pool Size:_ /1�equested By. / 1 Approved Disapproved AA . Information About The NEW Facility: Number Of Bedrooms: Number of People Garage Size: Other: Requested: �-) - l 1-1 1 For Environmental Health Office Use Only Environmental Health Payment: Cash Check Money Order # Amount:$ Date: APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH M 5749-63-6844.22 Subdivision Info: McAllister Park Lot # 22 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: )P-fT- �Af— 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 of 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 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 rill - 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 DCI In 05/99 (Revised) Kv Texture group 7 Consistence �la�.�ar��■�� HORIZON Bit 1,90M ■�■■■�� HORIZON III DEPTH Texture group Consistence Mineralogy HORIZON IV DEPTH Consistence SOIL WETNESS . �o�s�■�� MAI U tie]i��■�� SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: )P-fT- �Af— 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 of 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 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 rill - 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 DCI In 05/99 (Revised) APPLICATION FOR SITE EVALUATION/Ih1PROVEhIENT PEI Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 N&W PI AP 1,,,"7- 21 :tinrzJ APR 73 2005 �D ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THERE ftp "'R INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed '�r<- : ulu••'c/1C�9 �t !� Contact Person �1; "V, C Mailing Address �i/ I I t f� y' S4Home Phone•2- ' City/State/ZIP ' Business Phone 7 �T 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 13 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 1 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 12 Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms - #Bathrooms -� Dishwasher ❑Garbage Disposal M1a`.hin4 Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals $ Water Coolers IF FOODSERVICE: It ��Seats Estimated Water Usage (gallons per day) S. Typo of water supply: ILl'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0-N15-' If yes, what type? ***1,11'P0RTA1Y2'*** CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BE SUBAfIT'rED by the elicit with THIS APPLICATION. Property Dimensions: Tax Office PIN: #,7 V 7— -3— Property Address: Road Namc (5l4 t.) z City/Zip If in a Subdivision provide information, as follows: Namc: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: i Date home corners Nagged: This is to certify that the information provided is correct to the best of my luiowledge. I understand that any permits) issued bercafter 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 ant responsible for all changes incurred front this application. I, liereby, give consent to the Autliorized Representative of the Davie County I ealtli Department to enter upon above described property located in Davic'County an(] owned by to conduct all testing procedures as necessary to determine the site suitability. DATE t,3— D 5 SIGNATURE THIS AREA MAY BE USED FOR DRANYING 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_2J(D Account No. Revised DCIID (05/03 Invoice No. <-