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158 Bowman Road Lot 7v DAVIE COUNTY HEALTH DEPARTMENT <:ou Environmental Health Section P. O. Boz 848/210 Hospital Street S7, --2� Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002481 Tax PIN/EH #: 5813-99-4502.07RK Billed To: Randall & Violet King Subdivision Info: Waters Edge Lot # 7 Reference Name: Location/Address: Bowman Road -27028 Proposed Facility: Residence Property Size: 0.92 acres ATC NuMber: 3307 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 -DW yn 14 #People 2 #Bedrooms #Baths -- Dishwasher: 12" Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats _ Lot Size 0; I� 4�` Type Water Supply Design Wastewater Flow (GPD)3LA3-- _ Industrial Waste: ❑ Site: New G� Repair ❑ System Specifications: Tank Size 100( JAL. Pump Tank GAL. Trench Width,31F Rock Depth Z Linear Ft. q 4 Other: q i 1s10Lel �fi IOd �C-s, I/'ySjALI, L4A" Required Site Modifications/Conditions: PSl"gt..t o� "4toyk, ~L.& 10 Dcr, 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.**** L••I,,�,,J2)5n v� -4"0y-. ICO .j i Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990002481 Billed To: Randall & Violet King Reference Name: ATC Number: 3307 P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5813-99-4502.07RK Subdivision Info: Waters Edge Lot # 7 Location/Address: Bowman Road -27028 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 WASTEWAT-ER-CDNST-Ri6T� IO IS VAJAD QR A PERIOD OF,FIVE YEARS. Environmental Health Specialist's CERTIFICATE OF COMPLETION Date: **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 intaken as wee that the system will function satisfactorily for any given period of time. 10 FIE Q Septic System Installed By: Environmental Health Specialist's Signature: IA�a/l Date: DCHD 05/99 (Revised) • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERtOCT Davie CountyHealth DepartmentEnvironmenta/Heaith Section P.O. Box 848/210 Hospital Street7OMocksville, NC 27028(336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TH INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructio 1. Name to be Billed -AyQ// •1 L/ k% K1 Contact Person -2 rr �p Mailing Address.,&(Mocks, Wr- P1cn n! C y Home Phone6f 207_ J 1 Q 4Q ` City/State/ZIP / / ticks �/�I Ao O? / 0A 8 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation �C4,Improvement Permit/ATC ❑ Both 4. System to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People �# Bedrooms � # Bathrooms 2 EP Di.bmasher 11Garbage Disposal / Washing Machine ❑ Basement/Plumbing ❑ 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. Type of water supply: 1 ❑ County/City Le Well El Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: #�� — 1 — 50-1' 0 7 �e Property Address: Road NameD� J fti— /L City/Zip If in a Subdivision provide information, as follows: Name: \4" T --c� _ Section: Block: Lot:' Date Property Flagged: /V Z�— 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 to conduct all testing procedures as necessary to determine the site suitability. )10 DATE SIG THIS AREA MAY BE USED FOR DRAWING YOE property lines and dimensions, structures, setbacks, U Revised DCHD (07/99) M all of the following: Existing and proposed Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Invoice No. �� `� • M WE APPLICATION FOn SITE EVALUATION/iMRROvEMENT PERMIT & u Davie County Health Department Environmental Health section MAY 2 3 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***XMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed _.�.�(��ii/1�1�YTfi✓V �y(_ // Contact Person &— Mailing Address 116 '57 Some Phon G��yp— c2 47Q City/State/ZIP ae /y3,71a,,Vr/,4 p%C�ainesa Phone ,z 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: ❑ House bile Home' 0 Business ❑ Industry ❑ Other s. If Residence: # People y # Bedrooms .-37 # Bathrooms --:21 Dishwasher W-15arbage Disposal Washing Machine H Basement/Plumbing fl Basement/No Plumbing 6. If Business/Industry/Other: specify type # People # Commodes # Showers # Urinals # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City "ell ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: 0- ,�;2, Tax Office PIN: # Property Address: Road Name e0cev .,72 04 //acl, City/zip /j oc`� U;/lC- 2 7c, - R If in a Subdivision provide information, as follows: Name: Z Z E/, Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 6 Z) / Al -,6 ��n��eLe�,J ;40& 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 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 suitability. DATE -7 11�71 SIGNATURE lc 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 Revised DCHD (07/99) Date(s): I Client Notification Date: 1 EHS• Account No. ` Invoice No. l! �r• APPLICANT INFORMATION Account #: 990001199 Billed To: Ruth Spillman Reference Name: Ruth Spillman Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5813-99-4502.08 Subdivision Info: Waters' Edge Lot q07 Location/Address: Bowman Road -27028 Property Size: 0.92 Acre Date Evaluated: On -Site Well Community / Auger Boring Pity Public Cut FACTORS 1 2 3 1 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence Structure /I 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 i SITE CLASSIFICATION: 4 LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: /' z 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 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 DCHD 05/99 (Revised) ■ ■ ■ ■■ ■ ■ ■E■■MM■M■■MMEM■■■E■■ ■■MEMS■■■E■■ME■MUN■ ■EN■■■■■M■■MEM■■ ■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■E■MEM■■ME■■ME■■ ■ ■EM■EMEMME■MEE■■ ■ ■E■■ME■■E■■E■■■■■■■ ■■Nee■■■■■E■e■E■E■■Eeo■e■■■■ ■E■■■■■m■■E■■■E■e■■■■■■Nee■■ ■■■m■■■EM■■■■■■■■■■■■■ecce■■ ■■Nee■■■■■■eee■■■■E■■■■e■■N■ ■■■■eee■■■■■■■■■■■■■■■■■■■m■ Nee■■■■■■E■■■■■ENE■■■■■■Nee■ ■NEEM■■■■M■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■N■ ■S■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■E■■■■■■■■■■■ ■■■■■■■■■■■■■S■■■ ■■■■■■■O■■■■■■■■■ ■■Nee■■■■■N■■■N■■ ■■■■■■■■■■■■■■■■■ ME ■■ ■■ ■ ■■■■■ NONE n■■E■ w.■■■ SOMME ■■■■■ ■E■EMEM■ME■ ■■■E■ENMEM■ ■■■■■■■NEEM ■■■ME■■■ME■ ■E■M■M■■ME■ ■MME■■■■EM■ ■■M■■M■■E■■ ■■E■■E■EM■■ ■■M■■■■EM■■ ■■■M■■MM■■■ ■■M■■■■E■■■ ■■m■■m■■■■■ ■■M■■M■MEN■ ■■MEM■■■EM■ ■■M■■■■■M■■ ■■E■E■■E■O■ ■■EMM■■■M■■ ■EMME■■■ME■ ■■M■MEM■MM■ ■EN■■M■■MM■ ■■E■E■■N■E■ ■EN■EN■ ■E■M■M■■ME■ ■EMME■EMEM■ ■OMM■■EMME■ ■■■■■M■■■■■ ■■■■■■■MME■ ■■M■■■■■NE■ ■■N■■■■■■■■ ■■O■■■N■■■■ ■■■■EM■■■M■ ■■E■■■■M■■■ ■■■■E■■E■■■ ■MMM■■■■M■■ ■■■■E■■■■■■ ■■■■M■■■■■■ ■■■■■■"■■■■■■■N■ ■■■■■■■■■■■■■■■■■ No ■ ■ ■■■■EEM■ ■■■omm■■ ■■■EM■■■ ■■o■■om■ ■E■■M■ ■EN■EN ■■ENE■■■ ■M■■E■■■ ■■■■M■■M ■■■■E■■■ ■■■■■■■■ ■■■E■■■■ ■■E■■■■■ ■E■■■■E■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■■■■O■■■ ■■■memo■ MEMS■■■■ MEMO■■■■ ■■■■■■N■ i ■