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112 Mollie Road Lot 2: -- DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street MockrAlle, NC 27028 (336)751-8760 I�ti Account #: 990003806 Tax PIN/EH #: 5801-10-j5600.02 Billed To: Gray Potts Subdivision Info: Sheffield Acres Lot # 02 Reference Name: Location/Address: Mollie Road -27028 Proposed Facility Residence Property Size: 1.042 acres As stated In 15A NCAC 18A.1969(51, ATC Number: 4269 accepted Systems may also be usedd 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 WAST O ON VALID FOR A PERIOD OF FIVE YEARS. i Environmental Health Specialist's Signa 7!Date: (G Gv CERTIFICATE OF **NOTE** The issuance of this Certificate of Completion has been installed in compliance with Article 1 Disposal Systems," buts�all in NO WAY be to given period of time, r F idicate the system described on Improvement/Operation Permit S. Chapter 130A, Section 1900 "Sewage Treatment and a guarantee that the system will function satisfactorily for any I g-jrIAttIx Septic System Installed By: ram 8S Environmental Health Specialist's Signature Date:���� DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003806 Tax PIN/EH #: 5801-10-5600.02 Billed To: Gray Potts . Subdivision Info: Sheffield Acres Lot # 02 Reference Name: WILLIAM CREWS Location/Address: Mollie Road -27028 Proposed Facility Residence Property Size: 1.042 acres ATC Number: 4269 **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 �]o�s_ #People #Bedrooms 3 #Baths �- Dishwasher: 2r Garbage Disposal: E'1 Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Er� Commercial Specification: Facility Type #People #People/Shift 2#Seats Industrial Waste: ❑ Lot Size I' CA Type Water Supply �T�Design Wastewater Flow (GPD) Site: New C' Repair ❑ System Specifications: Tank Size �ePGAL. Pump Tank GAL. Trench Width Rock Depth 12- Linear Ft. 3� ' As stated In 15A NCAC 18A.1969(5) Other: 3 IS IF�,�J ���(� accepted Systems may also be used 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 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Tel ho - 7G .**** i � _ ARE& -y T�5 15 �,—Mlnl tt7' Health Specialist's Signature: DCHD 05/99 (Revised) ?6 TKOX-If ' lbg-1to 4mv- 041s7) .NM Fw o2 t3n>Ja) Date: ATC Number: 4269 **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 HaLeW#People #Bedrooms 3 #Baths Dishwasher: 93'� Garbage Disposal: 1710� Washing Machine: C?� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #P`e9ople #People/Shift #Seats Industrial Waste: ❑ Lot Size �. t`S Type Water SupplyT Design Wastewater Flow (GPD) Site: New L� Repair 0 u r+ System Specifications: Tank Size keDGAL. Pump Tank GAL. Trench Width& Rock Depth Linear Ft._� Other: 3 �9�M1P m0Y 3 bCr:� ac stated in tem15A N may also be accepted Systems may also be usetld Required Site Modifications/Conditions: 1 r�ATAl_t. R-�,Z CAi TD,` Q . VJO-A 6' cDr-P t kDS. - . KIN - 16 B 1MPROVEMENVOPERATION 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.**** t sir ;& r • � l I sr 5 r Environmental Health Specialist's DCHD 05/99 (Revised) �nA.ex`r�1Gj 1��1'aa 2yt' I -cam uoes to D- . w DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 . IMPROVEMENT/OPERATION PERMIT Account #: 990003806 Tax PIN/EH #: 5801-10-5600.02 Billed To: Gray Potts Subdivision Info: Sheffield Acres Lot # 02 Reference Name: WILLIAM CREWS Location/Address: Mollie Road -27028 Proposed Facility Residence Property Size: 1.042 acres ATC Number: 4269 **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 HaLeW#People #Bedrooms 3 #Baths Dishwasher: 93'� Garbage Disposal: 1710� Washing Machine: C?� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #P`e9ople #People/Shift #Seats Industrial Waste: ❑ Lot Size �. t`S Type Water SupplyT Design Wastewater Flow (GPD) Site: New L� Repair 0 u r+ System Specifications: Tank Size keDGAL. Pump Tank GAL. Trench Width& Rock Depth Linear Ft._� Other: 3 �9�M1P m0Y 3 bCr:� ac stated in tem15A N may also be accepted Systems may also be usetld Required Site Modifications/Conditions: 1 r�ATAl_t. R-�,Z CAi TD,` Q . VJO-A 6' cDr-P t kDS. - . KIN - 16 B 1MPROVEMENVOPERATION 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.**** t sir ;& r • � l I sr 5 r Environmental Health Specialist's DCHD 05/99 (Revised) �nA.ex`r�1Gj 1��1'aa 2yt' I -cam uoes to D- . w APPLICATION FOR SITE EVALUATION/141PROVEMENT PERM Q D Davie County Health Department Environmental Health Section DEC - 5 2005 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (33 6) 751-87 60 tNNRONMENIAL HEAtIN ***SPIPORTANT*** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INF0112•IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed t„a lit er LI/ /nom �.IG - ��j)��AA,,,,''��,, !� � �f,lv l I,I Contact Person Mailing Addres4LA/,t -5 /'ell Items Phone City/Stato/ZIP Business Phone 7 ` d 1 I_)2 2. Name on Permit/ATC if"Different; than Above Mailing Address City; Stato/Zip "3. Application For: �❑ 5cm Site Evaluation M-provement Permit/ATC ❑ Both 4. System to Service, 21"House ❑ Mobile Home ❑ Business ❑ Industry 13 Other S. Type system requested, 12 Conventional ❑ conventional modified ❑ innovative 't accepted 6. ,I_�f'RRosidence: If People PBedrooms It Bathrooms 1� ishwashor CSG rbago Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/Ino Plumbing" 7. If nuainess/Industry /Other: verify typo IIPeople 11 Sinks ff Commodes 11 Showers - It Urinals 11 Water Coolers. IF FOODSERVICE: 41 Seats Estimated Water Usage (gallons,per day) S. Type of water supply: 97 ea�County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes "a if yes, what type? . ***IAIP0Rt4N7*** CLIENTS AIUST COAIPLETC THE REQUIRED PROPERTY INFORNIAT'ION REQUESTED III;LO1V.EithernPLAT orSITE PLAN pAfUSTBESURAfJTTCDfly the clientivithTHISAPPLICATION. Properly Dimensions:Uf. I • �y 2 A,uS WRITE DIRECTIONS (fron A-locksvilie) to PROPLRTIT Tax Office PIN: 11_ O kwl0-5 sc( Properiy Address: Road N:unc cityizip '�n If in a Subdivision provide hirerumtion, as follows: Namc:� p141 kneS Section: Block: Lot: 2 Dale home corners flagged: tit• I to Ifl'� This is to certify that the information provided is correct to the best of my knowledge. I understand that any perutit(s) Issued hercaflcr are subject to suspension or revocation, if the site plans or intended tise change, or if ilia inforinalion ssbiuitted in this application is falsified or changed. 1, also, widersiand thatl ant responsihleforall charges incurred front this application. I, hereby, give consent to the Authorized Representative or the Day is C,olitty I alth Department Ito enter upon above described property located in Davie Comely and ownedby ` � ��.,�i taS to conduct all testing procedures as necessary to determine the site uitab' ity. DATE SIGNATU THIS AREA MAY BE USED PGI2 DRAWING YOUR S f PLAN (Includ all of the following: Existing anti proposed properly lines and dimensions, structures, setbacks, a s ti�ocations). Site Revisit Charge Sign given Revisal DC1ID (05/03 El F Datc(s): Client Notification Date: EIIS: Account No. v !. b r Invoice No. j 4 2001'1 oN 1.011 SITU CVALUATlON/lhlPliOVCAIENr l'L•uhuT Sc NI'C OCT Davie County Health Department - Eaviro,7inenta/Hen/f/150CGon fNNRONMENTAIHFATM - .0. Dox 848/210 Hospital Street UN1Y Mockaville, NC 27020 (336)751-8760 APPLICATION CANNOT DL -PROCESSED -PROCESSEDVNLLSS ALL TRE REQUIRED \ .INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for inst.ructiono. 1. Name to be Billed ri.�.l'/1//0.�0//p/_!Ln�[/iC _ Contact I -arson Mailing Address �`77t7 -/Br� Lp/111 �j,rlPr f�/' Noma phone-J��uiii� .City/+tate/ZIPL,(O,wz,.,�pfVT. IV.L. •2,762/ Duaincaa Phone G9—� X35 - 2. Namo on Permit/ATC it Different than Above .S/u-j✓�i Mailing Addroaa - City/Stata/Zip ..1. Application For: B�Site Evaluation - -❑ Improvement Permit/ATC ❑.DoL•h 4. Spa tont to Service. 9_90UDe ❑ MOI ile Home ❑ Dusincts ❑ Industry ❑ Other - S. Type system requested. LJ conventional ❑ conventional modified - - - ❑ innova Liva - 6. If Residence.. 11 People- p Bedrooms •3 II Bathroohlu z _ - ❑Dishwasher130arbagn Dinpoaal Meshing Machine ❑BasmaanL/Plumbing ❑11acontontf:70 Plumbing 7. If Dusiaoas/Industry /Other: verify typo - - a People #'Binl-s i Commodda 6 Showers- T 4 Urinals p linear Cool eru IF'FOODSERVICE: -0 Seats Estimated Water Usage (gallons par day) '8. Typa of water supply: la County/City - ❑ Well ❑ Colmnuui ty 9. bo you anticipate additions or ClpansioD3 or the facility this S)'S(C1ll is intended to serve? ❑ Yes ❑ No - !ryes, lvllat type? ' ***1AIPORTi1JyP**CLILNTSAIUSTCOAII'LCTCTIdL1tCQUIREDPROPERTY INFOR51XVIONItEQU SII:U' —I BELOW. L•'ilheraPLATorSITGPLAN AfUSTCCSUIIhfrfTCDbythe CURL )YR11 HISAI111G1'1'ION 1'roperlyDimaisious: �lo./o��J //tj % -� ��Q )VR1TEDIRICTIONS(rromA-luelm,illc)IulROVE'R'll': Tax 0-ffice 1'IN:11 S 82)� /� ,�(� �l7 i x//JJ p nn om/ Properly Address: RoadNamc / d [7 oL/ k�.r/ /19 Cltyizip A d5�,`�- Irin a Subdivision provide inrurnialion, as rollolvs: Name Scc(ion: Bloch: Lot: 0 2 Date honleCori lei's nagged: This is to cert* that the inrottilatioh provided is correct to the best ormy Imoliledge. I underslaud that tiny perulil(s) issued hereafter arc subject to suspension or revocation, if the site plans or inlenided use change, a• it llm information submitted in this •rpplicalioil is L•tisilled or changed. I, also, understand U1a11 run respoasibla jar all chalb'es incurred freer 1111s applicatlun. I, hereby, give consent to the Authorized Represcutativc or Lila Davie Co im (), Ilc:d(11 DcJ)a NOn cal to enter upon above described properly located in Davie County and onned bj, Mc to conduct all testing procedures as necessary to detcruliue UIC silo su(tabilily. DATE X27- O cSIGNATURE t�, TIi1SAREAMAYBE USED FOR DRAWING YOUR SITE PLAN(Incluf thefollolvng: Existing and proposed properly lines and dimensions, structures, setbacl(s, and septic locations): Client Notification Date. EIIS: Account No. . a 4 2001'1 oN 1.011 SITU CVALUATlON/lhlPliOVCAIENr l'L•uhuT Sc NI'C OCT Davie County Health Department - Eaviro,7inenta/Hen/f/150CGon fNNRONMENTAIHFATM - .0. Dox 848/210 Hospital Street UN1Y Mockaville, NC 27020 (336)751-8760 APPLICATION CANNOT DL -PROCESSED -PROCESSEDVNLLSS ALL TRE REQUIRED \ .INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for inst.ructiono. 1. Name to be Billed ri.�.l'/1//0.�0//p/_!Ln�[/iC _ Contact I -arson Mailing Address �`77t7 -/Br� Lp/111 �j,rlPr f�/' Noma phone-J��uiii� .City/+tate/ZIPL,(O,wz,.,�pfVT. IV.L. •2,762/ Duaincaa Phone G9—� X35 - 2. Namo on Permit/ATC it Different than Above .S/u-j✓�i Mailing Addroaa - City/Stata/Zip ..1. Application For: B�Site Evaluation - -❑ Improvement Permit/ATC ❑.DoL•h 4. Spa tont to Service. 9_90UDe ❑ MOI ile Home ❑ Dusincts ❑ Industry ❑ Other - S. Type system requested. LJ conventional ❑ conventional modified - - - ❑ innova Liva - 6. If Residence.. 11 People- p Bedrooms •3 II Bathroohlu z _ - ❑Dishwasher130arbagn Dinpoaal Meshing Machine ❑BasmaanL/Plumbing ❑11acontontf:70 Plumbing 7. If Dusiaoas/Industry /Other: verify typo - - a People #'Binl-s i Commodda 6 Showers- T 4 Urinals p linear Cool eru IF'FOODSERVICE: -0 Seats Estimated Water Usage (gallons par day) '8. Typa of water supply: la County/City - ❑ Well ❑ Colmnuui ty 9. bo you anticipate additions or ClpansioD3 or the facility this S)'S(C1ll is intended to serve? ❑ Yes ❑ No - !ryes, lvllat type? ' ***1AIPORTi1JyP**CLILNTSAIUSTCOAII'LCTCTIdL1tCQUIREDPROPERTY INFOR51XVIONItEQU SII:U' —I BELOW. L•'ilheraPLATorSITGPLAN AfUSTCCSUIIhfrfTCDbythe CURL )YR11 HISAI111G1'1'ION 1'roperlyDimaisious: �lo./o��J //tj % -� ��Q )VR1TEDIRICTIONS(rromA-luelm,illc)IulROVE'R'll': Tax 0-ffice 1'IN:11 S 82)� /� ,�(� �l7 i x//JJ p nn om/ Properly Address: RoadNamc / d [7 oL/ k�.r/ /19 Cltyizip A d5�,`�- Irin a Subdivision provide inrurnialion, as rollolvs: Name Scc(ion: Bloch: Lot: 0 2 Date honleCori lei's nagged: This is to cert* that the inrottilatioh provided is correct to the best ormy Imoliledge. I underslaud that tiny perulil(s) issued hereafter arc subject to suspension or revocation, if the site plans or inlenided use change, a• it llm information submitted in this •rpplicalioil is L•tisilled or changed. I, also, understand U1a11 run respoasibla jar all chalb'es incurred freer 1111s applicatlun. I, hereby, give consent to the Authorized Represcutativc or Lila Davie Co im (), Ilc:d(11 DcJ)a NOn cal to enter upon above described properly located in Davie County and onned bj, Mc to conduct all testing procedures as necessary to detcruliue UIC silo su(tabilily. DATE X27- O cSIGNATURE t�, TIi1SAREAMAYBE USED FOR DRAWING YOUR SITE PLAN(Incluf thefollolvng: Existing and proposed properly lines and dimensions, structures, setbacl(s, and septic locations): Client Notification Date. EIIS: Account No. . a _• .. �C1laJElJr�®®®®® OREM • 1 .I Yrl ®®--S®- au.;o a ave. a a v u nva�ar.va� - - SAPROLITE CLASSIFICATION . LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: +'` EVALUATION BY: LONG-TERM ACCEPTANCE RATE- i OT/,HER(S) PRE'E T: REMARKS: r J .<✓� LEGENIV 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 EFT -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 chrome 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation j APPLICANT INFORMATION PROPERTY INFORMATION Account :#: , 990 002086 Tax PIN/EH #: '5801-10-5600.02 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property. Lot # 02 Reference Name: Location/Address: Sheffield Rd: 27028 Proposed Facility: 'Residence Property Size: ''see mapDate Evaluated. 1 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring l Pit -' V - - Cut FACTORS 1. 2... 3 4 5 6' 7 'Landscape position . Sloga % _• .. �C1laJElJr�®®®®® OREM • 1 .I Yrl ®®--S®- au.;o a ave. a a v u nva�ar.va� - - SAPROLITE CLASSIFICATION . LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: +'` EVALUATION BY: LONG-TERM ACCEPTANCE RATE- i OT/,HER(S) PRE'E T: REMARKS: r J .<✓� LEGENIV 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 EFT -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 chrome 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) uc N ON . WA`"t 4 T 1` �' fi . - - Lo 20 B5 l C 24 LOT 2 Ln i MINIMUM BUILDING SUBACK UNES TYP. � �'