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138 Mollie Road Lot 5Account #: 990002706 Billed To: Jeff Hayes Reference Name: Kesiaence ATC Number: 4257 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848!210 Hospital Street MocksAle, NC 27028 (336)751-8760 Tax PIN/EH #: 5801-10-5600.05 JH Subdivision Info: Sheffield Downs Lot # 05 Location/Address: Sheffield Rd:27028 t.7r�as�anxtat�� 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 WASTBWATEis;CQA;�iKUCX'IObjfS VALID FORA PERIOD OF FIVE.YEARS. Environmental Health Specialist's CERTIFICATE OF COMPLETION Date: 11 12-S.105 **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. F4ZWT NQy=C- I INQw, 00toy- .4 Sfb NAVea Z- '�"/�� Environmental Health SpdriaTist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT n 100 �O Environmental Health Section P. O. Bos 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002706 Tax PIN/EH M 5801-10-5600.05 JH Billed To: Jeff Hayes Subdivision Info: Sheffield Downs Lot # 05 Reference Name: Location/Address: Sheffield Rd. -27028 Proposed Facility Residence Property Size: 2.0 acres ATC Number: 4257 **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 "OSE #People #Bedrooms #Baths Z• 5 Dishwasher: Ca"� Garbage Disposal: Er Washing Machine: 0"' Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type n #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Za i93 Type Water Supply 00 N Design Wastewater Flow (GPD) 3W Site: New 171'� Repair ❑ �,�� System Specifications: Tank Size =GAL. Pump Tank GAL. Trench Width �n Rock Depth ;La Linear Ft.-7co' other:teed r L��aPRzet u� 25( "k Ioj 3 P/SwlM'-J's Required Site Modifications/Conditions: lt')bm t- rx� rA.1 Q Kca iMPROVEM 55, PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 `° BELOW OTICE: Contact a representative of the Davie County Health Department for final inspection of this 0 .m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is.(1336T)75(1-8,760r..*'*** > nvironmental Health Specialist's Signature: 1 .—n- _ n 1#CHD 05/99 (Revised)��M�) Date: I 7, 1 APPLICATION FOR SITE EVALUATION/141PROWAIENT PERMIT & A I' Q Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street NOV'.1.6 2005 Mocksvillo, NC 27026 (336) 751-6760 L ENNRONMENTAL HEALTH ***IPIPORTANT*** TIiI- APPLICATION CANNOT BE PROC&SED UNLESS ALL . INFORI-IATION IS PROVIDED. Reffer�et/�othe INrORZIATION BULLETIN for instructions , l� _. 1. Name to be Dillcd' y�01•-.q✓- Contact Parson Nailing Addrosa ! 6 ! / d .S Items Phone City/State/ZIP / ' �l I v`� / j//W� Dusinaza Phone '37 2. Name on Permit/NPC it Different than Above Mailing Address - - C%ty/State/Zip - a. Application For: ❑ Site Evaluation rImprovement Permit•/ATC ❑ Doth 4. System to Service: House ❑ mobile Home ❑ Business ' ❑ Industry ❑ Other 5. Type system requostod: ;w Conventional ❑ conventional modified'? ❑ innovative CTaCC.epted 6. If .1tenidenco: II People H Bedrooms 3 it Bathrooms Z•S .10inhwasher Aarbago Disposal ❑Hashing Machine Abasement/Plumbing ❑Danement/No Plumbing 7. - If Dusinean/Industry /Other: verify type 9 People It Sinks 0 Commodon It Showers it Urinals It Hater Coolers IF FOODSERVICE: If Seato Estimated Water Usage (gallons per day) S. Type of water supply-County/City . ❑ Well - ❑ Community 9. Do you anticipate additions or clp:msions of (lie facility this system is intended to serve? ❑ yes 60 If ycs, what type? ***1j11P0RTANT*** CLI ENTS AIUST COMPLET ETRE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either n PLAT or SITE PLAN MUST RESUBMITTTI) by the client tbitli THIS APPLICATION. Properly Dimensions: 1VR1TE DIRECTIONS,frooin 510claville) to PROPERTY: Il' Tax Office PIN: ���"%� Properly Address: RoadNamc City1711) If in a Subdivisi/opnprovide Nlf rt Cation' as follows: Namc: S 71// Section: _ _ _ _ _ Block Date Inonte corners flagged:r— This is to certify that the fhfornnaLis n 1)rovC�is correct to file best of my knowledge. I ulid ers(and that any perntil(s) issued hereafter are subject to suspension or 2 -evocation, if the site plans of intended Use change, or if file information submitted in (Itis application is falsified or changed. I, also, u nderstand than run resp onsihle far all changes lacurred from this application. 1, hereby,'give consent to the Authorized Representative of the Davfc Comity Health Del3artmcut to cnfer upon above described property located in Davie Comity and owned by to conduct all testing procedures is necessary to determine flu site suitability.. DATE /CJl'' d SIGNATURE _ THIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (L du e all of the following: Eliding m)d proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05103 Site Revisit Charge Date(s): Client Notification Date: EIIS: o Account No. �-7 Invoice No. 'C�2 r { LOT 5 ON L AREA;0 / I �3 i1V. rrj CO�' 0 CID ' 1 10' UTILITY DRAINAGE EASEMEt ' EXISTING `OLLIE zo A . PAVEMENT Ci ,, 10� UTILITY &' DRAIRAGE EASEMENT 1co.I LOT 1 ; NCO t&or LOT Z) 2004AIII O 4 N foil SIM EvfuUATtoN1INIFItovEhtr:W I'MMIT a ATC OCT Davie County Health Department Eni/irowenta/Hea/t/i Section ENVIRONMENTAIHI'll, .0. Box 848/210 Hospital Street . pp\gF.COUNN Mocksville, NC 27028 (336)751-0760 ***IbIPORTANT*** THIS APPLICATION CANNOT DL PROCUSSZD UNLESS ALL TIIE REQUIItED • INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for ina L•ruc L•iona 1. Noma to be Dilled.p LA/J//9.. �0 //p�'/�j/��-,(/,(.� - Contact Person^ Mailing Address 'WZ2 —/O'� - Cp[1J� �j�A�2 - f%/' Home phone city/state/zip _[„,{p,1r k,in/VS. 112 2%67/2 Business Phone 2. Nemo on Permit/ATC if Different than Above 51t2� Mailing Address City/Sta La/zip -- __'..•• 3. Application For: 911ite Evaluation ,. ❑ Improvement- Permit/ATC ❑ Both 4.. Systam to service. P-1rouse ❑ 1403zile Home ❑ BUSineba ❑ Industry ❑ Other S. Typo ayatem requenteci: E Convantional ❑ conventional modified - ❑ innovative 6. If Residence: a People 0 Bedrooms .3 11 Bathrooutu Z ❑Dishwaaher ❑Garbage Disposal ❑Washing Machin❑Basement/Pluud:ing ❑Dasanen L•/Ho plumbing 7. If Dusiasas/Induatry /Other: verity type It People U'ainks 4 Commodes - U Showara Q Urinals It Hater Coolaru --__ IF FOODSERVICE: # Seats - Estimated Water Usage (gallons par day) e. Typa-of-water supply: 2-County/City ❑ Well ❑ Conununity 3, bo you aatieipata additiona or expansioLls or tic facility this syslenn is in(euticd to serve? ❑ Yes ❑ Nu Ifpcs, I'vltat type? ***IMPORMYT*** CLIENTS MUST COdI!'LETETHE BEQU11Uw PR01'ER•1.1' INFORAIA•t'lON REQ ol S! I;1) _I BELOW. Elther a PLAT or SITE PLAN bfUSTItESUI1drFrMD by the client with T111S APPLICATION. ICATION PropertyDintchsions: /�.��3 / /`1-r"� �� �F IYRI fE ll1REC'1'IUNS (from Aiudtsvillc) Iu 11RO 'lilt'I. .. Tax sues PIN: 11 5- —/0 Properly Address: Road Nanle 5,/Ie c �a _ t7 dG/ i (� b .Q ter, city/zip c sG /1 .970g r Ifin a Subdivision provide information, as follows: Name: SccGot: Block: Lot: Date home corners Nagged: This Is to eertify,that the inforinatiou provided is correct to the best of lily knowledgo. I HIndC1'SL.Ind that Ally po•mil(s) Issued licreaftcr arc subject to suspension or revocation, if the site plans or intended use change, or if lho inlo•maliou submitted in this applicaliot is falsified ur cbattged. I, also, rrnrlerstand that I (till responsiblejor «1! chrnb'es iucurrc d fi nrir tris application. I, hereby, give consent to theAudloriicd Representalivc of Ell's Davie Cutill ty Real (h I)c)taNIII ell I to enter upon above described pruperty loca(cd in Davie County and owned bj, _,Jena to conduct all testing ln•occdnt•Cs as necessary to determine the si.(c suitability.r- DATE SIGNATURL 7I11S AREA MAYBE USED TOR DRAWING YOUR SITE PLATY (Includ all of the fallowing: Existing aid proposed propertylilicsaudditucnsiolis, shuclures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: BUS: Account No. ON 1`011 SITEEVALUATION/INIP1i0VCAIENT 13L:11iMIT 3 A'1•C 4 2020001" OCT Davie County Health Department EnY1r0n1nenA71 Hes1t1i SeCGon E%V104MENTALHEALTH .0. Dox 848/210 Hospital Street DAVIEtpUNN' Nockiville,; NC, 27028 x*xJ.oJVVATRNT*** THIS APPLICATION CANNOT DTs PROCESSED UNLESS ALL T1IE l:EQUIRLll \ INFORMATION IS PROVIDED. Refer to the INFORMATION. BULLETIN for instructions. 0 1. Name, to be Dilled AI Contact Person Mailing _ Address W70—/OA Dr Memo Phone 90,e—�-qo City/state/ZIP t pi.,z,.,tpwS, NL �c%Q7/,� � Duuincua Phoite 1i P—I3_S 2. Nano on Pornit/ATC if Difforcnt than Above SiQ7vctli .Mailing Address City/State/zip ...... 7. Application For: 21ite Evaluation a El improvement Permit/ATC - ❑ Roth 4. 8yatem to�sorvicue L4 Ouse ❑ MolTile Home' ❑ Dusinebs ❑ Industry ❑ OL•her. 5. Typo system requested. E Conventional ❑ conventional modified - ❑ innovative 6: IL Residence:.. It People If ,Bedrooms 3 II Bathrooilu Z ❑Dishwasher ❑Garbage Disposal ❑Washing Machina ❑Daaement/Plunbing ❑Dacmnmt/ire Plwabing 7.- If Dusinans/Industry /Other: 4arify type - - 11 People 6 JinL•s' 4. Coauwdes�- ,1`f Showers '.. .-- 8 Urinala p Water Cooloru IF FOODSERVICE: 1`F Sedts Estimated Water Usage (gallons par day), 8. ;Type of water swPly: @ Cotmty/City ❑ Well _ ❑ Coitununi L•y —__— S. Do you aaticipato additional or Cxpallsions or the facility tills systclil is i11lellded to serve? [:)yes . ❑ ND . ifycs, what type? ***Ar41FGITA1YP**CLIMTSAIUSTCOAil'LL•'TL•THE•'/tL•'QU//tBUYli01'LR'1'Y1NIr0RIYLYI'IONREQiJ SIlU _I SEL01V. Glitters PLAT arSITG PLAN AfUSTBCOSU1141177BD by the client ni(It •PIIIS Al 111CATION 1'roperly llimcnstats: �(o./e�?i / jt�-r-i / o/� WRITE DIRLM•IONS (frmit Alucl:stille) lu PRUI f It'TY.-/. Tax Office PIN: Property Address: RoadNaine /Lg r c a Vana/ City/zip c 5; "de 1L g70,3r U 117111 a Subdivision provide infurmaiion, as rellulys: Nautc; Section:Dat]Ionic cornc Block: Lot: Date d S rsflagged• This is to certify that the inforillation provided is correct to the best of illy knolvledge. I understand (hat ally permi t(s) issued hcrcar(Cr arc subj'cct to suspension or revocatiml, it tllc site plans or intended use cll:ulge, or it lite inlornt:ltioll submitted in tills application is 1"WIlled or chmlged. I, also, anderstaud that 111/1, responsible for rill charges iucurrrrl Jrrinr this appfieation.. I, hereby, give coltsclit to (tic Authorized 11cpreson(ative or (Ile D:n•ie Cuuuly health Dc al-Oucul to cn(cr upon above described pruper(y locaOwnedted in Davie County and uted by J rn<,_ J /y/c C✓��nc r // to conduct all testing procedures as necessary to dclerutine (lie site suitability. ��— DA'rE 49— O SIGNATURE TRIS AREA MAYBE USED TOR DRAWING YOUR SITE PLAN (Inciud6 all of L11c fulloivmg: Existing and proposed properly lines and dilaensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(sj: Sign given Anide*d Tnvn theme' • ` DAVIE COUNTY HEALTH DEPARTMENT 4 ®6 Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M, 990002086 Tax PIN/EH #: 5801-10-5600.05 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property Lot # 05 Reference Name: Location/Address: Sheffield Rd: 27028. . Proposed Facility: Residence PropertySize: 'see map Date Evaluated: t� MAO �*0613UIME&q Water Supply: On -Site Well Community Public ' ' I Evaluation By: Auger Boring Pit - Cut �McIMMEM-Mm —® FACTORS®®� 4 ®6 HORIZONIDEPTH • ■rte®�.r�■s®®® MAO �*0613UIME&q �McIMMEM-Mm —® ... • ��O®®off®j SITE CLASSIFICATION: r EVALUATION BY: : LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT(: REMARKS: Mott , WU I� roti . 1 ' S. B FF �T FW� a•i V [ t Jt�t 3 kZ / } LEGEND - cpLP2'ion R - Ridge S - Shoulder L - Linear slope F- Foot slope NNose slop�e � . 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 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)