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246 Walt Wilson Road Lot 1Account #: • 990001642 Billed To: Jay Stroupe Reference Name: I vvJGu 1 at.o ny. L\G.71umit'v ATC Number: 2757 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5747-30-6394 Subdivision Info: Walt Wilson Estates Lot # 1 Location/Address: Walt Wilson Road -27028 r-IUPUILY JILL. SCC 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 WASTE WATE CONSTRUCTION IS V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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 apter 130A, Se ion .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be t dts a guar e-t}t}ttsystem will function satisfactorily for any given period of time. �� 3� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) L_ Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 �-�, ��� (336)751-8760 0( IMPROVEMENT/OPERATION PERMIT Account #: 990001642 Tax PIN/EH #: 5747-30-6394 Billed To: Jay Stroupe Subdivision Info: Walt Wilson Estates Lot # 1 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2757 **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 Type A #People:— #Bedrooms 41 #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine:0 Basement w/Plumbing:ee Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size /. AL' Type Water Supply �� Design Wastewater Flow (GPD) Site: NeW4!T'o Repair ❑ System Specifications: Tank Size 100 GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width '` Rock Depth ,/.Z Linear Ft.-!�P& IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 f° 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.**** e. Environmental Health Specialist's Signature: l Date: DCHD 05/99 (Revised) / h • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT D Davie County Health Department EnvironmenhiLffealth SeWon 6 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMENTAL HEAtTN ***nJP0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer � to the,�INFORMATION BULLETIN for instructions. �1. Name to be Billed 2/ P l.� �!i Contact Person Hailing Address f -d in/ -,7 -.:5' Home Phone �1 ? t% city/state/zIP Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation 4. system to service: Y House ❑ Mobile Rome City/state/Eip Y---Iwpxovement Permit/ATC 0 Business 0 Industry ❑ Other 0 Both 5. If Residence: # People .2 � # Bedrooms �J _ # Bathrooms yam, (f Dishwasher n Garbage Disposal ww"aahing Machine 6-Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/Other: specify type # People # sinks # Co—odea # showers IF FOODSERVICE: # Seats # urinals # water Coolers Estimated Water Usage (gallons per day) 7. Type of water supply: 0" County/City s. Do you anticipate additions or expansions of the facility this system Is intended to serve? If yes, what type? ❑ Community ❑ Yes & o ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: 16L 4111 Tax Office PIN: is Property Address: Road Name �� %% 4�" City/Zip �?-5 If In a Subdivision provide information, as follows: Name: WRITE DIRECTIONS (from Mocksville) toP PERTY: J Section: Block: Lot: �_ Date Property Flagged: q/> �% O 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. 1, 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 to conduct all testing procedures as necessary to determine the site s bility. DATE —/ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (I ude all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): I Client Notification Date: `EHS• Account No. Invoice No.. ITY ........ ...... y::� � Al P. ��' �Ae isvation Number DIRECTOR OF PLANNING ( Seal a Stamp ) ���/ f ��� f/lf�ll0� 3 I \ \\ GGA ��� a — — —•` \ _ _ _ J., 4• p3.26 R/R QOM O \ 6 � \ SEE P.8.•5 PQ, 133! LOT 1 \ R/R\ crrooc + ......... 1.686 AC.) \ •X . . ............................................ _,,•062 \ \ � �, ) _._. v APPLICATION FOR SITE EVALUATIONAMPROVEMENT Davie County Health Department Environmental 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 W L LL. (A N, . & t l4 Q 'i-3 Mailing Address ,AO [I --_B() E L..L. SZ7 City/State/Zip �1=s i C 2, iml 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [A Site Evaluation ,S b .aa Contact Person SIV i LLI A L. L . Rd L-A 0 P Home Phone g In - &S -1-'l 17 ct Business Phone City/State/Zip [ ] Improvement Permit & ATC 4. System to Serve: N House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other [ ] Both 5. If Residence: # People_ # Bedrooms _ # Bathrooms 'Z V4 Dishwasher [>g Garbage Disposal PQ Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: N County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [XJ No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** COF THE PROPERTY MUST BE SUBMITTED WITH T,�i)ftS APPLICATION. Property Dimensions: Lz7 Lrr A c.tt�- WRITE DIRECTIONS (from ocksville) TO PROPERTY: Tax Office PIN: #.S -T 47 - 65 C14 Fmocu Property Address: Road Name Wht-T . Ch1 tt.5 ow Ri7 • T)1~ A S2 M D to A tJ p XN A LT (,U I LsOw 2D. City/Zip KAoCK- 11Li T-2-70 242> ; GD SCJk-'rt-( &F3ot1T V7- IVi (LC If in Subdivision provide information, as follows: R910PGp W t5T st©t=' Name: W A L -r W t L5o 1.1 Section: Lot #: ��CA A i4k(--L- W L L FL -Ar, Lor Fo (Z. ' C2 ; -1 O - 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 Cc ! LIE- it N C-U_t tl As W DELL- to conduct all testing procedures as necessary to determine the site suitability. DATE 4 - I l- R-7 SIGNATURE S a.. c.� 6� Revised DCHD ((K-96) /� N �'-� -I--�3 (� V �VTL�02 L ZC P 1 (� t%`1 O (ZK • I SCI 2" P H d OJ C THIS AREA RAY $E USED FOR DRAWING YOUR SITE PLAN: N 7U'� -'`}�{� - 74 77 ,71 ' ® Ao i �o 4 -+� f U 1= W pxur 1 0 ACOI /t Do LJ i I XF1 WAI, W(t-SoLJ '5lL 170"T-) ea . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT t Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION \)j c \".) Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit 5-S DATE EVALUATED 9-7 PROPERTY SIZE ROAD NAME Public LI -11 Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % —So HORIZON I DEPTH to it Texture group L Q L_ Consistence 'T Structure G C Mineralogy HORIZON II DEPTH 2 2 Texture group C Consistence Structure Q Mineralogy1 ; HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S ;$� RESTRICTIVE HORIZON —' SAPROLITE CLASSIFICATION z 5 LONG-TERM ACCEPTANCE RATE e SITE CLASSIFICATION: V ` ✓ LONG-TERM ACCEPTANCE RATE: 14 REMARKS:` \� � 6' \ v DCHD (01-90) LEGEND Landscape Position EVALUATION BY: V� OTHER(S) PRESENT: � a'c-� 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 - 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 ■■ ■E■■ ■M■■ ■OE■ ■E■■ ■ MEN ■M■MM■■MM■M■ ■■■■■■■■M■M■ ■■MMUM■MME■ ■■M■ ■M■■M■ ■■■■■MMM■■■■ ■■■■OMMM■■M■ ■M■■MM■M■■M■ ■■■MM■■MMME■ ■■MMMMMM■■M■ ■MM■MMM■MO■■ ■MMMUM■■MM■ ■■■■ ■M■■M■ ■M■MM■■MMMM■ ■MMMMMMMMMM■ ■■■■EM■■M■M■ ■■MM■■MMMMM■ ■■■MMMM■■■M■ ■M■MMM■■■MM■ ■E■MU■■MEM■ ■■■■ ■■M■O■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■E■ MESON ■ME■■ ■MEM■ ■■■■■ ■E■E■ ■EMM■ ■■ME■ ■ME■■ ■E■■■ mama■■■■ wommSO■■ ■/mim\■■ WANENVEM FIEDI\UNIMM■ MEMS■■■■■■■ ■■■M■■■E■E■ ■EEE■M■■EM■ ■■■O■■■■M■■ ■EEMMEME■M■ ■■■■■E■■S■■ ■EMM■■E■ME■ ■■■MEM■■EM■ ■E■M■■■EME■ ■EMMEMEMEM■ ■ME■■■MME■■ ■E■■MME■■■■ ■EM■■M■■EM■ ■E■EME■■ME■ ■EMME■■EME■ ■■EME■E■E■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ONE ■/■■■■■■■■//■■■■■■■■/■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■umme ■■MEMSUNK MEMEMEMER ■E■■M■■M■ ■E■■EMM■■ ■■E■EME■■ u■■■■■■■ ■■MEMS■ ■MMM■ME■■ MEMEMEMEM MEEMMEMEM ■O■■E■ME■ ■E■E■E■ ■M■■ME■ ■E■■M■■ ■E■■EM■ ■EMEME■ ■■M■O■■ ■■M■MM■ ■E■ME■■ ■M■MME■ Davie County Heafth Department and Home Heafth Agency EnvironmentafHeafth Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 May 14, 1997 William L.. Poland 680 E. Buell Rd. Rochester, MI 48306 -. Re: 5 Site Evaluations Walt Wilson Estates/Lots 1, 2, 3, 4, 5 Tax Office PIH: #5747-30-6394 & #5746-39-8778 f Dear Mr. Poland: As requested, a representative from this office visited the aforementioned sites on April 18, and May 5, 1997. Based upon the information provided on the application(s) for site evaluation(s) and after the evaluations were compl0 ed, the sites were found to be provisionally suitable for the installation-Sf on-site sewage disposal system on each site. Before any permit(s) can be issued the appropriate application(s) must be filled out and the house/mobile home location(s) staked off. If you have any questions, please feel free to contact this office. I f Sincerely, Charles E. Little, R.S. Environmental Health Section RH/wd Enclosure(s) cc: Zoning Office