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343 Serenity Hills Trail Lot 1Account #: 990002860 Billed To: Larry Frazier Reference Name: Proposed Facility: Residence ATC Number: 3523 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 #-3q3 Tax PIN/EH #: 5864-43-6171 Subdivision Info: Riverbend Hills Lot # Location/Address: Serenity Hills Trail -27006 Property Size: 17 acres 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 WASTEWATER CONSST/RUCTTIION IS VALID FOR A PERIOD OF F VE YEARS. Environmental Health Specialist's Signature: `/ V�G / Date: i CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion ze-s35tem'described on Improvement/Operation Permit has been installed in compliance with ticle 11 of G.S. Chapter ion .1900 "Sewage Treatment and Disposal Systems," but shall in NO t en as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: -: C /I- ATC ` • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Q� l0- ~ P. O. Boz 848/210 Hospital Street „ ` Mocksville, NC 27028 (336)751-8760 Cis IMPROVEMENT/OPERATION PERMIT Account #: 990002860 Billed To: Larry Frazier Reference Name: Tax PIN/EH #: 5864-43-6171 '7 !rcA Subdivision Info: Riverbend Hills Lot # x Location/Address: Serenity Hills Trail -27006 Proposed Facility: Residence Property Size: 17 acres ATC Number: 3523 –4f-343 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of aseptic 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 ? 5 Dishwasher: 9 Garbage Disposal: K Washing Machine: a Basement w/Plumbing:. Basement/No Plumbing: 13 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: El Lot SizeType Water Supply 6122e Design Wastewater Flow (GPD) `�dC� Site: New Repair 173 System Specifications: Tank Size Z0 GAL. Pump Tank Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PI FINISHED GRADE. ****NOTICE system between 8:30 a.m. to 9:30 a. Avde�<��,�� GAL. Trench Width JC Rock Depth l` Linear Ft.4<� 0 RA IT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW Nct a representative of the Davie County Health Department for final inspection of this p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** f-- Environmental Health Specialist's Signature: Date: illl eL L/ DCHD 05/99 (Revised) O lu APPLICATION 1'011 SITE EVALUATION/1hIPROVDIENT PE•I MIT & A -1C t Davie County Health Department Eaviroamenta/Hea/t/i Section B i Box 848/210 Hospital Street r t e Mocksville, NC 27028 (336)751-8760 ***IMPORTJTNT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRLD INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruct-ion.r. 1. Name to be Billed L.yif—a)L '�jtA?uz"j— Contact Person Icy, - Mailing Address 12-25 Orr- home Phone — 7yo -s9(/ a City/State/ZIP &UJVWC, - /V( Business Phone 3j6 —29,- 2. Name on Permit/ATC if Different than Above Mailing Address City/State/'Lip 3. Application For: tier Site Evaluation Pl Improvement Pennit/ATC L Doth 4. System to Service: LN House ❑ Mobile Home ❑ Busine§s ❑ Indust-ry ❑ Other - 5. Type system requested: fir Conventional ❑ ' conventional modified ❑ innovative 6. If Residence: it People 3 i1 Bedrooms 3 11 BaLhrooitw 3.5 UDishwasher L7Garbage Disposal 0/washing Machine 0:15asement/Plwnbing ❑Basement -/No Plu,ibing 7. If Business/Industry /Other: verify type 9 Commodes It Showers IF FOODSERVICE: It Seats 8. Type of water supply: ❑ County/City ii Urinals 0 People 11 :;illi::; 11 Water Cooler: Estimated Water Usage (gallons per day) OK14e11 ❑ Couununi Ly 9. Do you anticipate additions or expansions of tllc facility this systelll is intell(ica to sl`rve? ❑ Yes If yes, what type? Ll No ***1A1P0RTANT*** CLIENTS jVUST M11PLETE THE REQUIRED PROPLRTY INFORAIATION RI,QUISS'I'I:D BELOW.. Eithcr a PLAT or SITE PLAN MUST BESUBi1ffTTED by the elicit with TIIIS APPLICATION. Property D11llcllsions: a 5 Tax Office PIN:����'� Property Address: Road Nanle6Tuay,z�1 1Ae,-6 7kAi- City/Zip Aom-,,,a-, N,,,, WRITE DIRECTIONS (f -om Aluc((sville) to PItUI'P:I:TY: arm g0,4z r- ty lrt- h 0/uo 14, L C S v If ill a Subdivision provideinnformation, as follows. Name: :�F� ' fo Section: Bloch: Lot: + Date Monte corners llabged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernlit(s) issued hereafter arc subject to suspension or revocation, if tile site plans or intended use change, or if (lie infornlatioii submitted in this application is falsified or changed. I, also, understand that 1 run responsible fur all chruges inctn•red front this application. I, hereby, give consent to the Authorized Representative of the Davie Comity Ilcaltll Dep:u-tulcill to cuter upon above described property located in Davie County and owned by to conduct all testing procedures as ilecessary to determine tilt site suitabili(3., T DATE SIGNATUI THIS AREA MAY BE USED FOR DRANVING YOUR ITE PL(Inude all llm clc foulg: Existing :old proposed property lines and dimensions, structures, setbacks, az d septic oc tions). y Site Revisit Change Sign given Revised DCHD (05/03 Client Notification Date: EHS: Account No. �� d Invoice No. 4 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PETr7[ Davie County Health DepartmentEnvironmental Health Section P. O. Box 848 Mocksville, NC 27028 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed !�—)r, 0 to �"tG h e s Cr ,• �•k. «,� i �S� �. Contact Person Q" ib Mailing Address -Sol �A c c S i ; I Home Phone 'tto ` i IS 'Z 7/-13 City/State/Zip At 1)Un nG6 IN ► L. Z 2 as 6 Business Phone 4 f° el k 1'7 cSr 7 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: ❑ Dishwasher 0" Site Evaluation House ❑ Mobile Home # People City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry ❑ Other # Bedrooms # Bathrooms ❑ Both ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: # Showers # Seats # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: ❑ County/City 'M Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE f BrITTED WITH THIS APPLICATION. Property Dimensions: / 7. /32 a �•- J (J /�• 37 '/K, `ARITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # SFS to 3 - S - 5-2 39 / Property Address: Road Name e Ise IK GrI�F'Q4(J 1 `� 1 City/zip A4 V a-h�' �� ��D� If in Subdivision provide information, as follows: .Sere niCAI Name: ► Yer'8e n Section: Lot #: 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter 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 for 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 c. ✓ %'D M . c.., c S C, fir '�JNwC to conduct all testing procedures as necessary to determinethe site suitability. L / DATE ( ' I/ l - SIGNATURE Revised DCHD (06-96) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_/— LOT-/ Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY / SUBDIVISION _�'Ve, hGn�JY;��s Water Supply: On -Site Well L-"" Community DATE EVALUATED / PROPERTY SIZE 17,, ', ROAD NAME Public Evaluation By: Auger Boring [ef�' Pit r/, Cut FACTORS 1 2 3 4 5 6 7 Landscape position Al Slope % HORIZON I DEPTH // -• Texture group S` Z 1e ,c SC Consistence Structure Mineralogy HORIZON II DEPTH Texture group /P Consistence - P r l Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) 16Y,2 e�lfg 6Z J - EVALUATION BY: PRESENT: I ' LEGEND Landscape Position /" ) R - Ridge S - Shoulder L - Linear slope FS - F of slope N - Nose slope W ' / 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 �G/f 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 - 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 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■NOON■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■r:NOON■■■■■s■■■■■■■■■■■��■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■■■►I■■■■■■■■■■I�■■■■■■■■■■ NOON■■I■■■■■■■■■■■►I■■■■■■■■■■ NOON■■I■■■■■■■■■■■�■■■■■■■■■■ ■■■■epi■■■■■■■■■e■r�e■■■■■■■■■� ■■■Rn►�■■■R■■R■RRer�■■■■■■■■■Ori ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ RENAME MENiEN MEMEME ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■EE■e■■■■ENEe■ME■■■Nee■ ■■■■■Nee■■■■R■■■■■■■■■■■ ■.ENE■■■■■■■EE■■E■■■■■N■ ■E■e■■:--e�■e■■Nee■■■■E■ ■ ■ ■ NONE MEMO ■■■■ ■E■■ NONE SEEN MEMO ■■■MENM■ ■■EMEM■■ ■■■Emma■ ■■■■■a■■ ■E■EMEM■ ■EMEMEM■ ■■■SEMEN ROES■■■■ ■E■M■■E■ ■■E■■"■ ■■ MONOMER ■EMMEM■ SOMEONE ■E■■EM■ ■E■ ■ ■ ■ No ME ■■■■■■■■ ■■■■M■■■ ■■■M■■■■