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120 Mollie Road Lot 3-� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 a ijo /V►a/Ire Poco Account #: 990003796 Tax PIN/EH #: 5801-10-5600.03 MD Billed To: Mark Davis Subdivision Info: Sheffield Downs Lot # 03 Reference Name: Location/Address: Sheffield Rd. -27028 -roposea racuny rcesiaence ATC Number: 4260 ,5rze: utsa acres As stated in 15A NCAC 18A.1969(5) . accepted Systems may also be useas AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION 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 . 9 0 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE TION VAL OR A PERIOD OF FIVE YEARS. ital Health Specialist's Signature / Date: 1t D� CERTIFICATE OF COMPLETION TOTE** 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. -T!-\aYDnTS It -2i 12 QOIui_ U �-At Septic System Installed By: Health Specialist's Signature i DCHD 05/99 (Revised) Account #: 990003796 Billed To: Mark Davis Reference Name: 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 1,21— ( ?" 2A , V 1- (?"2A,o T Tax PIN/EH #: 5801-10-5600.03 MD Subdivision Info: Sheffield Downs Lot # 03 Location/Address: Sheffield Rd:27028 Property Size: .985 acres ATC Number: 4260 **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: icBuilding Type HW�Se #People #Bedrooms 7�S #Baths 2;,S Dishwasher: Garbage Disposal: C3'� Washing Machine: 121� Basement w/Plumbing: 121'� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size DP195 4CN.c Type Water Supply Q00r 13Ty Design Wastewater Flow (GPD) —151,00 Industrial Waste: ❑ Site: New Er Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width Rock Depth I Linear Ft )�' Other: 3 �t5mr3JT1D-'s accepted SystemsNmav 18A.1969(5lssssd ,I_ Required Site Modifications/Conditions: �r i�TN�I �^9 i OcXL/ i-��'P 16r dDFF O 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.**** F-1 Health Specialis't's DCHD 05/99 (Revised) At to, AR_ -.a. Date: E E APPLICATION FOR SITE f_VALUATION/IhIPROVENIENT PERMIT g fl v v Davie County Health Department B7vironmentalHealth Section NOV .16 2005 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENNHONMENTIII. HEM ***IMPORTANT*** INFOM-MTION IS TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL PROVIDED. to trhe.INFOMIATION BULLETIN for THE REQUIRED - instructions. 1. Nana to be Dilled /Ref/e/r�/ �!�-; Lirr 0, ✓1n/✓ Contact Person s, iY1 Mailing Address �� W/7oJ,5-1Z,9A/ 'I W4 Nome Phone LF /a /� (� t n& zs,9 0 - City/Stato/ZIP //�"(� i�,5— 0)-1-•. Business Phone t ? / �• 2. Name on Permit/ATC if Different than Above - - Mailing Address City/State/Zip J. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 9. System .to Services LI" House Cl 128bilo Homo ❑ Business ❑ Industry .❑ Other 5. Type system requested: 13/Canve'ntional ❑ conventional modified ❑ innovative t3aCCepted 6. IffRosidence:� IQ 0 People ,fl Bedrooms a Bathroom, s •�� CIDinhwashor L10arbago Disposal 13Washing Machine Dasement/Plumbing ❑Daooment/No Plumbing 7. If Duainess/Industry /other: verify type - 9 Peopla 11 Sinks ' 0 Commodon 11 Showers 0 Urinals 11 t•1a L•or Coolers IF FOODSERVICE: tI ,, Seats Estimated Water Usage (gallons par day) 8. Typo of water supply: L'1 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No Ifycs, (Shat type? ***IAIPORV,,INT*** CLI ENTS A/UST COAIPLL'TB TIIE REQUIRED PROPERTY MORMATION REQUESTED 13EL01V. Elther n PLAT or SITE PLAN AfU.ST DESVJMfITTL•D by the client with THIS APPLICATION. Properly Dimensions; / <gS WRITE DIRECTION m b'I cluville) to PROPERTY:' 'fax Office PIN: t1 1 d G'd 1 Property Address: RoadNantc d City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: 3 Date home corners Ragged: I0=03 This Is to certify that the information provided is correct to the best of my knowledge. I understand (lilt any perm(((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 ma responsible for all charges f icmard from this applicatfon. 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 (es(ing procedures as necessary to determine the site suitability DATE SIGNATURE I TRIS AREA MAY BE USED FOR DRANYING YOUR SITE PLAN (Include all of the following: Exis(ing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05/03 Site Revisit Charge Dalc(s): Client Notification Date: EIIS: ,,Account No. % G Lnvoice No. d / S � LANDSCAPE BUFFER ASPEP. DAME COUNTY STANDARDS f (SEE NOTF- 12 FOR DETAILS) I i LJ ! C� I 00 ON t� :n Nc) - 0 GE - - Gci7- Ncl_ 6 DR 21 C16 1� 11 u OCT 14 2004A1'( ON 1:011 sire EV,uuartON/MPIiOV0Ir: rr Plalnilr & arC u Davie County Health Department EnYironinenta/Hen/t/i Section FNVIRONMENTAEH�ETM .0. Box 848/210 Hospital Street pnVIEC011NTY Mocksville,NC 27028 (338)751-876'0 ***IdIPORTANT*** TRIS APPLICATION CANNOT Dns PROCD•SSED UNLLSS ALL TRE REQUIRED •I '\ INFORMATION IS PROVIDED. -Refer to the INFORMATION BULLETIN for instructions i. Name to be_ Dillod Z2 44 M6 _(0 /20 /l/7 ,(,1.{7 - . Contact Parson- B 3`i%(7 /Bra Leh �/iA&e A- !tomo Phone Mailing Address city/state/ZIPL ,{On_ T_gp�y7. 1VL .mac`%2/� nusinesa Phone 2. Nemo on'Parmit/ATC it DiCLoront than Above .Sim/vc.P� Mailing Addrsas City/State/Zip 3.' Application For: ��mite Evaluation 4 _ ❑ Improvement Pelzaiti/ATC IJ Doth 4. Sintam to service:- iLYHoS�use ❑ 1401yile Home ❑ Business ❑ Industry ❑ Other S. Typo system requested. ffConvantional 13 conventional moditiod - ❑ iunovativa G. If Residonce: It People U Bedrooms 3 - 11 Dathr000m; Z ❑Diahwaaher ❑Garbage Disposal ', ❑Washing Machine ❑aasomont/Plwnbing 1313aiamont/110 Plumbing` 7. It: Business/Industry /Other: verity type - - O People a'sinks a Commoddo 11 showers- 1 4 Urinals it Na L•cr Coolers IF FOODSERVICE: -tP Sedle Estimated Water Usage (gallona per day) a. TYPO OZ water supply. 2r County/City ❑ Well ❑ Colwnunity - 9. bo you 'anticipate additiona or eSpallsious or the facility 1111S SyS(C1111S lntelded to Serve: ❑ Yes ❑ No If ycS, what type? ***IMPORTdtYn"CL1LNTSAlUSTCOnircEMTI1EREQUIRED PROPERTYINFORMA•rloNIL1:Quts1(iu --I 13EL01Y. Either a PLAT• orSITE PLAN Al USTBESU11iI1=ED by the client 11it11 THIS API 1 KATION Property l)inicasiolls: /l.�/3 TM-/-/ `'/�0 wlirrEiiulEcrloNS(rrnnlnldchsldnc)(oiilt)1(;itrr: T:1I.011lcc PIN: lE_S 811/ /0 ��n Lf(J Properly Address: Road Nalnc cityrciP Iris a Subdivision provide inrornialton, as follolvs: Nautc: Section: Block: Lot: (9 3 Date honk corners flagged: This is to certify that the hlrormatiou provided is correct to the best of niy Iinowrledgo. i understand lbal any pernliI(s) . Issued hereafter are subject to suspension or revocation, if aic site plans or intelided use ch:ulgc, 01' Irma information submitted in this application is falsified or changed. 1, also, understand That I mn resp ollsible jor all c/unges iucurrrd franc Ib/sapplitatiaa. I, llercb3, give Conscst to the Authorized Representative of the Da" ic County Ilea](11 Dc lar(mcu( to cuter upon absvc described pi`uperty located ill Davie Cowlly and owned liy , j<rn,i /%L°v//, �,� j to collduct all tcstillg procedures as necessary to act rnli11C 111C Slll` SVIt1b1)II)'. DATE_ D SIGNATURE TRIS AREA MAYBE US);D TOR DRAWING YOUR SITE PLAN (Inelad all of the following: lxisting Wld propdsi:d properly lines and dimensions, structures, setbacks, and septic locations). Sign given AccowitNo, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002086 Billed To: The Cana Group,LLC Reference Name: Proposed Facility: Residence Property Size: Tax PIN/EH M 5801-10-5600.03 Subdivision Info: McCullough Property Lot # 03 Location/Address: Sheffield Rd '_27028 see map Date Evaluated: Water Supply: On -Site Well Community Public r Evaluation By: Auger Boring ITi Pit ! Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % *3)o .5 HORIZON I DEPTH 0 - Texture group Consistence SS r Structure C 2 Mineralogy 'K HORIZON H DEPTH Q - 2.41 2 2S Texture group 0- Consistence ti Structure Mineralogy` u HORIZON III DEPTH -S Texture group 0 b-a+'QA0 Consistence F: SS i sssv Structure Mineralogy HORIZON IV DEPTH -S Texture group n L L , Consistence Fr 55 N r Structure Aa Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P$ LONG-TERM ACCEPTANCE RATE 0.3-035 S SITE CLASSIFICATION: i S EVALUATION BY: Afk &_*X - A Y, I LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 5rs/ r% 6J I11brNelsIF,, 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 SLS - 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 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)