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102 N Benson Lane Lot 22Account #: 990001212 Billed To: Dennis Grubb Reference Name: Dennis Grubb Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5746-48-2346.22 Subdivision Info: Twin Cedars Lot # 22 Location/Address: Benson Lane -27028 Property Size: 109x156x190x 2: ©d **NO 11r* i�iIss proveei ent/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.MC #People #Bedrooms #Baths vS Dishwasher: Garbage Disposal: ❑ Washing Machine: �Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ 1 Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New ®Repair ❑ System Specifications: Tank Size /pa GAL. Pump Tank GAL. Trench Widt�i Rock Depth /ol Linear Ft� Other: Required Site Modifications/Conditions: 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 in. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** 0 t /_n 1 V81 C� p ) Tifs �„ /cad (•✓i`%oma —Boxes. U +u Spin Av6, ,, labu- -% I Iy 0 Environmental Health Specialist's Signature: Date: (050-01 DCHD 05/99 (Revised) Account #: 990001212 Billed To: Dennis Grubb Reference Name: Dennis Grubb Proposed Facility: Residence ATC Number: 2443 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5746-48-2346.22 Twin Cedars Lot # 22 Benson Lane -27028 109x156x190x 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 C014STRUCTION IS VALID FOR A PERIOD OFF FIVE YEARS. Environmental Health Specialist's Signature: .�s ��``O``—Date: Lp `/—DD 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) q ST M / lK I IP M&l APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Health Section MAY 2 620oo P'.0. Boa 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 EINIROMENTAL HEALTH DAVIF rnumw ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Contact Contact Person Mailing Address 0 T' 41--n y Home Phone A City/State/ZIP Business Phone (��— ---' 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to service: 2 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People —4-1 # Bedrooms_ # Bathrooms Dishwasher ❑ Garbage Disposal WWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: al,6ounty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes aw-0 -11 If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: A.c4. p Tax Office PIN: # 57�ta • qe 23 7-) Property Address: Road Name City/Zip YAO c.c.s J• l4 ►%.C- Z ?,c+7f' If in a Subdivision provide information, as follows: r Name: `//e'� r��rz nr�,/`,< "I 110r,r�'�) Section: Block: Lot: N rZ WRITE DIRECTIONS (from Mock1,2 to PROPERTY: �4T l9}1 �P_CI111�'% 0/9,. Date Property Flagged: 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 Da� County Health Department to enter upon above described property located in Davie County and owned by p��✓'� �r :�I . to conduct all testing procedures as necessary to determine the site suitability. DATEi�/�,1)� SIGNATURE 0 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 Date(s): Client Notification Date: EHS: Revised DCHD (07/99) Account No. r�� Invoice No. 1 l4�' Q1, APPUCATION FOR SITE EVIIWATION/IMPROVEMENT PERMIT & ATC Davie County Health Department .4 Environmental Hea/gh Sec[i'on R P.O. Box 848/210 Hospital Street O R 9 W ff Mocksville, NC 27028 (336)751-8760 MN 17 WS ***ZWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS JAMLL T"F.-= TARED �J INFORMATION I3 PROVIDED. Refer to the INFORMATION BULLETIN fo init 04�FIEALTH ,/ /� 1. Name to be Billed /�Z? ` Contact person 1"U/ f�K xt% 5�J/,',✓L'�/�i,%L�' Nailing Address - Home phone City/state/Zip _ D Business phone 4q L- 56 /G 2. Name on permit/A1C It Different than Above Hailing Address City/State/Zip 3. Application For: .�p�Site Evaluation a. system to service: KHouse 0 Mobile Home S. If Residence: Q'161shwasber # People Z - 0 improvement Permit/ATC 0 Both 0 Business 0 Industry 0 Other # Bedrooms 3 # Bathrooms 11 Garbage Disposal $flashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # Commodes # showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Tppe of water supply: County/City 0 Well 8. Do you anticipate additions or expansions of the facility this system is intended to serve! If yea, what type. 0 Community 0 Yes 0 No ***IMPDRTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3 0.00 0 WRITE DIRECTIONS (from MocksAlle) to PROPERTY: Tax Office PIN: # 5 % ¢b �S 2-3 4 E 416) (oU/ 5 %b Aid"_ Property Address: Road Name l� f 4460,-' at,, i i'l/c 5'."✓ City/Zip A14660S-lla /V/C- ry C' C"�7 If in a Subdivision provide information, as follows: aq lr�" Name: /��% 64.117 tZ S �' -1/ � 0 wAf Section: Z Block: Lot: to oP�rty Flagged: MAP 12-WOS 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 respons0le for all charges incurred from this application. 1, 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 21 c to conduct al esting procedures as necessary to determine the site suitability-. DATEZZ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN cl all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. -3 / Revised DCHD (07/98) Invoice No. 3 ya SBA DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation 7-1-11 APPLICANT'S NAME 7C J PROPOSED FACILITY -6J7C� SUBDIVISION a1.A) I rJ C,�2s Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit DATE EVALUATED IZ/1 to� t' PROPERTY SIZE %S3 Y3) i 0 ROAD NAME V14t,T \,,jiu�yV Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 5 Sloe % 91 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence F42 S Structure i /L Mineralogy; HORIZON III DEPTH _ Texture group 0 SAP- af Wil' Consistence SS F— SS Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure $ 4' Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S S LONG-TERM ACCEPTANCE RATE . y SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND DCHD (01-90) Landscape Position EVALUATION BY: C.�:� �/ 4•""P OTHER(S) PRESENT: 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■■■■■■■EMM■■■■E■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■RIONME■■■■■E■ ■■■■RE■E■■■■■■■■ ■■■■■u■■■■■■■■■■ ■■■■M■NN■■■■■■■■ ■■■■■■■■s■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ SEES NOME NOME OMEN NONE ■E►■ ■■E► ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ NEMESES ■■■■■ ■■■E■ SOMEONE ■■■E■■■ ■■■E■■S SOMEONE SOMEONE NEMESES SOMEONE ■E■■■■■ SOMEONE ■■■E■■■ ■■■■■■■ ■■■E■■■ SOMEONE NEMESES ■■■■■ ■■■E■ SOMEONE ■■■E■■■ ■■■E■■S SOMEONE SOMEONE NEMESES SOMEONE ■E■■■■■ SOMEONE ■■■E■■■ ■■■■■■■ ■■■E■■■ SOMEONE