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104 Mollie Road Lot 1DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 /oy A10ffI610 Account #: 990003057 Tax PIN/EH #: 5801-10-5600.01 Billed To: R.B.Hope Contracting Subdivision Info: Sheffield Downs Lot # 01 Reference Name: Location/Address: Sheffield Rd. -27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4267 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System ConsItruction 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 permits) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON RUCJTI N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature:/Date: f W %),D,. A5 / 4 n Dr CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall ind cat the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. h ter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a tee that the system will function satisfactorily for any given period of ti e. i,�Pv �t s7104 G Septic System Installed By: Health Specialist's Signature DCHD 05/99 (Revised) IS /11 /�pZ�� Date: ���� Account M 990003057 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Billed To: R.B.Hope Contracting Reference Name: Proposed Facility Residence ATC Number: 4267 Pd, p/ailo,6 - 60 79,uw Tax PIN/EH M 5801-10-5600.01 Subdivision Info: Sheffield Downs Lot # 01 Location/Address: Sheffield Rd:27028 Property Size:. 1 acre N **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. I Residential Specification: Building Type 1 #People #Bedrooms #Baths �Z— Dishwashers Garbage Disposal: ❑ Washing Machine- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Dishwasher:/ Commercial Specification: Facility Type #Peoplei #People/Shift - #Seats Industrial Waste: ❑ Lot Size Type Water Supply d Design Wastewater Flow (GPDD Site: New 0 -Repair ❑ System Specifications: Tank Size/L b GAL. Pump Tank GAL. Trench Widtiv,� ' Rock Depth Linear KI Other: AS stated accepted Systems may also be use Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT OVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a rep,pde9k9tivSpPthe 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. 010 p.X. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: DCHD 05/99 (Revised) r Date: APPLICATION FOR SITE EVALUATION/141PROVEh1ENT PEI Davie County Health Department Envlronmenta/ NeaXz Section P.O. Box 848/210 Hospital Street Mocksville, NC 27025 (336)751-8760. E C E � w E NOV 2 9 2005 D Ii' � - DAVIECOUNTY ***XlfPORTANT*** THIS" APPLICATION CANNOT BE PROCE SED UNLESS ALL TETE REQUIRED INF0RISATION IS PROVIDED. Refer to..1the INFORMATION BULLETIN for inutructions. 1. -Name to be Billed' gore e,, l��'^�'t, n G Contact Person Move- dope Mailing Addrass 3' �;,r. I/ /'/� Home Phone City/State/ZIP 4 d'V6n/!S(_� /ISG '700b Business Phone - 2. "Name on Poimit/ATC if Different than Above Mailing Address C1ty/State/Zip ]. Application For: L Site Evaluation VImprovement Permit/ATC ❑ Doth 4. System to Service: Ho__unne El Mobile Home 11Buninean ❑ Industry ❑ Other 13 S. Type system requested: 'Conventional ❑ conventional modified ❑ innovative r3aCCepted 6. If Residence: 0 People M Bedrooms 0 BaLhroolnn Z Gzirahwashar ❑Oarbago Disposal Eftashing Machine ❑Basement/Plumbing ❑Banament/no Plumbing 7. If Businens/Industry /Other: verify type 9 People it Sinks 11 Commodas 11 Showers It Urinals It Water coolers IFSFOODSERVICE: ff Seats - Estimated Water Usage (gallonsspor day) 0.. Type of water supply: LX County/City ❑ Well ❑ Community - 9. Do you anticipate additions - or CxpanSl0115 of the facility this system is intended to serve? ❑ Yes 2/N0 If yes, Mat type? ***LIfPOli:T'TINT***CLirNT'SMUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUES'rLD HIiLOR'. Either n PLAT or SITE PLAN MUST HESU11.411TTED by (lie client with THIS APPLICATION. Properly Diutcnsions: WRITE DIRECTIONS (from p•lsdaville) to PROPERTY: TaxOfficel'IN: II I'roperiyAddress: RoadNanie �1462ALJQ Cily/Zip If in a Subdivision provide informmjatio�n,, as follows: Nnmc: S�� iF i' e �� rf �iGui✓� Seddon: Block: Lot: _L Date home corners flagged: 'I'las is to certify flat 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 lie information subnnillcd in chis application is falsified or changed. I, also, understand that l ain responsiblejnr all charges hncarred from this aplVicafion. I, lcreby, give consent to the Authorized Representative of the Davie Counly Health Department to enter upon above described property located in Davie Comely and owned by to conduct all testing procedures as necessary to determine the site suitability. DATL I /I-�O/-6S SIGNAT'UR52 THIS AREA MAY BE USED TOR DRAWING YOUR SITE PLAN (Include all of (he following: existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Client Notification Date: EIiS: Account No. 3d S7- Invoice s/Invoice No. 12 S T ' i ?ALLETONE OF NORTH CAROLINA A CL C. ur. BRYANT i�CCLAMROCH � L.E. 392 PG. 810 a D.B. 986 PG. 484 ` ` ZONED- 1-2-S T ZONE r R -A _ N E CSAg.�SV o, /�49 SNC S Fop (J,y� 1/2" SOLD LOT 5 IRON FOUND W CONTROL AREA CORNER �u in N � r} o 2.193 AC. M �� LOT 6 AREA= 0 �� . �41) \ 2.097 AC. v °' C v, ?' Q a 11 All \ c Q), 0 J. BR_ 4NT' B�CCLAVROCH �'Se-e GL/� y \/ 0 3 ` °�.�� 5 B.B. 186 PG. 484 �� ZONED R -A 9 0�-'� \ 7 DRA10' UTILITY k ',s s Ste,• _ _ _ _ _ _ INAGE DASEMENT ((� i LS j� Ce � _ ', �J z'c 5� �y,� / i G N \ \ \ I J 2CP.4' tIMEN'T ��: iv;OLlIE 511 i3 4, Cs D-!1 h'DAD °a 00 LOT 7 �- _ . — . Cts U CYC /4"00 E AREA= 0.841 AC. u-1aT�.\ G z / SOR 2r c\ y Z 9 LU pRAlF1AG- EASEMENT ?az.!2 T� / a 2c'6? 10 � LOT 12 a � Eu S 84_*51'38- E AREA= 0.995 AC. certify that f'.e Davie County Health Department25' RADIUS (TYP,) itsd the =uGJlvision o SHEFFIELD ACRES LOT 8 o to criteria and conditions established z �q a1J N 81 `4j .40, V ow or promulgated thereunder and the o AREA= 0.799 AC. 30.95 12. ound to comply with aueh criteria and o FIRE FIRE EXCEPT as set ;orth_n such evaluation. �m j ,HYDP.ANi HYDP,PMT/ , ritten report onunle at said department.-°SEMENT �� - �\\ '{ /O LV I I I fav ^-1 1G'X70' 3(GHT�jf f NOTICE THIS CERTIFICATE DOES NOT AREA= 0.841 AC . q' % �"'EN`3 E A PERMIT OR APPROVAL OF INDIVIDUAL 2'71• \p o 0ti / 4•y �2 �.:', AID SUBDMSION FOR INSTALLATION OF 24 E `n �' - 4CILMES p9" '� 5 , h41Li LOT 9 Lsc°g o fk+NE COUNTY HWM- OFFICER AREA= 0.965 AC. N LOT 10 / \/ o L. Tutterow, certify that this plot was drawnz AREA= 0.812 AC. M� `() r supervision from an actual surrey made ' !75.00 I supervision (deed description recorded in�orl, o�_ I =J.p. 116 25 off% f ,Lo�tio/ F jV'L.� Pace etc.) (other);ihat the R"Ep I F...P./ mf n�� �i C ts not -m;atonfound in ed are Book indicated drawn I �_N 8P'4T`4, t7i5.50879 50,35 0 r/ / / � Fd rY p -ICV ratio of precision is calculated as 1: +20.000 I I TOTAL)0! / plot was prepared in accordance with G.S. / 55.00 / S amended. Witness my original signature, In number and seal thisI / ' r Oo NAIL ;-�P' �& CA- �� day of I Q ROAD _1 A.D., X05 I l J. °r`_ I�EA7'ON '{1 s'04 ._.yor D.B. 190 � PG. 12 f. 2 E� 1`011 SITE L•VALUATION/IhIPI(OVOIENT ITIMIT NI -C Davie County Health Department Enviro17menta/Hea/t/i Section O. Dox 848/210 Hospital Street Mocksville, NC 27028 (336)751-0760 THIS APPLICATION CANNOT DTs PROCESSL•'D UNLESS ALL TIIE REQUIltlill INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Dilled! ,w lil—a Contact Person j Mailing Address 3r{•7o—/pa el."VeY�iAee D/, Homo Phone City/State/ZIP Lif Ovn vn_� IVA o270/,2 Business Vliono 2. Noma on Permit/ATC it Difforont than Above Mailing Address City/Stata/Zip - 3. Application For: 21ite Evaluation 13 Improvement- P"-mit/ATC'❑ DoL-13 4. Spatam to Service: &-House ❑ Mobile Home ❑ Dusinebs ❑ Industry ❑ Other 5. Type system requested: E Convontional ❑ conventional modified ❑ innovutivo 6. If Residence: it People a Bedroomz v? II Bathroolllil 2' ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Ilasomant/llo Vlumbing 7.- If Duainaus/Induatsy /Other: verify type it Pcopla Y Commodda It showers U Urinals It l4aL•cr Coolers IF. FOODSERVICE: 11 Seats Estimated Water Usage (gallono per day) s. Typo of water supply: 21 County/City ❑ Well ❑ Community 9. bo you anticipate additiona or expansions or the racjlity this syS(C311 IS hl(CIIdW to serve: ❑ yes ❑ Nu iryes, what type? ***IAIPO1tTd)VT*** C1.lENTS hIUST COA4I'LGTG THR /tL•'QUIItGD PROPEIfry 1NFO1t14IATION RLQllliS'I'lil) BELOW. 6(411cra PLAT or.SITE PLAN rlIUSTBC SUBrIIl7TL•D gythe clialt 1Yth TRIS APPLIrXrIr)N- Properly Dimensions: Ala. 416. IVRITE DIRBC)'IONS (from 11•locicsville) to PROPEiltTY: Tax0fit cc11IN: Property Address: Road Name- 'ht<e '(L oat City/zp Irin a Subdivision provide information, as rollolvs: Name: i%Y tit' C�1 �%ti�ti O/ e /aen�y $CC(10I1: B10Cli: Lot: Date hole corners flagged: This is to certiry that the Information provided is correct to the best Orly knowledge. I understand lh:lt ally permit(s) issued hereafter arc subject to suspension or revocation, it the site plans or Intended use cliange, or it tie jnrornultion submitted in this application is Dllsjtlad or changed. 1,, also,1111derstand that 1 it,,, rcslurrlsible jor all cbrubes irrcurr rd,jr ill this applitatlorr. I, hereby, give consent to the Authorized Representative or the Davie Couuq' Health Dc mr(olsn I to enter upon above described Property located jn Davie County and owned by to conduct all testing procedures as necessary to determine (he site suitabj 113,. DATE %^ 02% d SIGNATURE TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Inclucd all or tlto rellolving: Existing ;old proposed property lines and dimensions, 'Structures; setbacks, and septic locations). Sign given *`-: Rt viscd DCHD (05103' Site Revisit Charge Da(c(s): Client Notiricalion Date: TITS: AccountNo. DAVIE COUNTY HEALTH DEPARTMENT A. •'' - - Environmental Health Section - Soil/Site.Evaluation APPLICANT INFORMATION PROPERTY INFORMATION • . Account #: 990002086 Tax PIN/EH #: 5801-10-5600.01 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property Lot # 01 'Reference Name: Location/Address:. Sheffield Rd. -27028 Proposed Facility: Residence Property S¢e: see map:. Date Evaluated: ��"✓7 I� 'Water Supply: On -Site Well t Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1. 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH E Texture group_ '� Consistence Structure Mineralogy HORIZON R DEPTH' it 3Yir` Texture group i Consistence / 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 r/_ 1 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: rr� %- LEGEND, Landscape Position R - Ridge - S - Shoulder, L - Linearslope ., FS - Foot slope N - Nose slope CC - Concave slope CV c Convex slope T -'Terrace FP - Flood plainH - 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 _. oisL VFR - Very friable FR - Friable F1' Firm VFI - Very firm : EFI - Extremely firm Wet NS Non stick 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 Mineraloev 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)