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150 Mollie Road Lot 6DAVIE COUNTY HEALTH DEPARTMENT 1 - Environmental Health Section ((�� P. O. Boa 848/210 Hospital Street Mocksville,NC 27028 I ,3 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002706 Tax PIN/EH #: 5801-10-5600.06 JH Billed To: Jeff Hayes Subdivision Info: Sheffield Downs Lot # 06 Reference Name: Location/Address: Sheffield Rd. -27028 Proposed Facility Residence Property Size: 2.097 acres ATC Number: 4258 **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 Hoose #People #Bedrooms #Baths 2 S: - Dishwasher: 1!1�- Garbage Disposal: la�- Washing Machine: Er Basement w/Plumbing: Car Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People_ '#People/Shift #Seats Industrial Waste: 13Lot Size 2 a Type Water Supply � i Design Wastewater Flow (GPD) c o2 Site: New 00� Repair ❑ System Specifications: Tank Size 1000GAL. Pump Tank a1eTft�'AY�iL1710 Required Site Modifications/Conditions: GAL. Trench Width SV Rock Depth I.) A. Linear Ft.? IMPROVEMENT/OPERATION PES OUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. **** ICE: Contact a representatives Davie County Health Department for final inspection of this system betwesa8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1: in. on the day of installation. Telephone # is (336)751-8760.**** Lcental Health Speciali s Signature: Date: Ij J DCHD 05/99 f�3 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mockr4lle, NC 27028 (336)751-8760 Account #: 990002706 Tax PIN/EH #: 5801-10-5600.06 JH Billed To: Jeff Hayes Subdivision Info: Sheffield Downs Lot # 06 Reference Name: Location/Address: Sheffield Rd. -27028 -roposea racn¢y Kesiaence vroper y maize: zmvt acres ATC Number: 4258 As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used 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 .1 00 Sew. Treatment and'Disposal Systems). THIS AUTHORIZATION FOR WASTEW RU TI N LID FOR A PERIOD OF FIVE YEARS. ital Health Specialist's Signator Date: I l CERTIFICATE OF COMPLETION The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 1 I 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. 2,7* (SZ IAN L4-iDCAA QN4;et IAaK i>A-W- ({-9 Septic System Installed By: Environmental Health Specialist's DCHD 05/99 (Revised) ��� 1'J �f APPLICATION FOR SITE [VALUATION/141PROVEMENT PERMIT Sc Davie County Health Department • Environmental Health Section P.O. Box 848/210, Hospital Street Mocksville, NC 27028 i (336)751-8760 NOV 16 2005 ***IIYPORTANT*** THIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRED INFORI•IATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions 1. Name to be 1311led Nailing Address City/stato/ZIP 2. Name on Permit/ATC if Different than Mailing Address 3. Application For: ❑,,,, Site Evaluation 4. System to Service: / ttttNp����,, House ❑ Mobile Home Contact Person name Phone bBusiness Phone 3 9 -/ — 6--nl City/State/zip rimprovement Permit/ATC ❑ Business ❑ Industry S. Type system requentodi Conventional ❑ conventional modified 6. If ;Itanidence: 11 People 9 Bedrooms -Apinhwasher 7. If DUnineun/Indust-ry /ether: verify type ❑ Doth ❑ Other ❑ innovative paccepted v Bathrooms %•S Aarbago Disposal ❑Washing Machinaasemont/Plumbing I Commodes 11 Showers 0 Urinals ❑Ilanement/No Plumbing 9 People It Sinks 0 Nater Coolers IF FOODSERVICE: 11 Seats Estimated Water Usage (gallons par day) a. Typo of wator nupply-�ACounty/City ❑ Well ❑ Community 1 9. Do you anticipate additions or expansions of the facility this system is intended to serve? El yes 60 ifyes, what type? ***lAIPOR7fiN2*** CLIENTSAIUSTCOAIPLE7ETIIE REQUIItED PROPERTI' INBORt12AI'ION REQUESTED BEL01V. Either a PLAT or SITE PLAN KU.STBESU6AfITTED by the client ivith TI IIS APPLICATION. Properly Dimensions: �y2— iV / / .IVRITE DIRECTIONS �frum p•Iudcs u 1']t�0}1�ERT�I'�:' ,., Tax Office PIN: 11 Property Address: Road Namc City/Zip ICin a Subdivisia�i,idc��ndiay as follows: Name: SS Section: Block: Date home corners (lagged: //,/I./ ` e�)= 'Phis is to certify that the information provic cs correct to the best of my knowledge. I underslaud that any permits) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if lice information subntit(cd in this application is falsified orchanged. I, also, understandthatlant responsihleforall charges hicm7•ed front this application. I, hereby, give consent to the Authorized Representative of the Davie Comity IlealUc Department to enter upon above described property located in Davic Comity and oened by to conduct all testing procedures is necessary to determine the site suitability. DATE �i—Q r SIGNATU TIIIS AREA MAY BE USED TOIZ DRAIVING YOUR SITE PLAN (h1u a all of the following�Exlstlng`llndprol3c�scd property litres and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Sign given Revised DCIID (05/03 D:dc(s): Client Notification Date: EIIS: Account No. �7 . Invoice No. 2 -off ��.-- �` 340.00 N 68046'4'9,k � 548.61 61 S � 09 � � �T <6 . 20' � Cb ��m aq�Xis�7nr G U , p 7C , � R�7y Q36 A F1 ON F-011 SITE EVALUATION/IhiNIOMILNT POMIT & ATC Davie County Health Department Enuironmenta/Hen/t/1 Section .0. Dox 840/210 Hospital Street blOcksville, NC 27028 (3315)751-0'/150 ***IbIPORTANT*** THIS APPLICATION -CANNOT DL PROCL•SSLM UNLLSS ALL TIM MQUIRLD \ -INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructiouo 1. Name to be Dilled.Q/I//t>-��rM-!!J7 �,1.� Contact Person ^ �Lo�s Mailing Address� Q-/04 Lev) ,���Q�C D/- home Phone . City/State/ZIPL6 Gn,�pw�.. /yL `1%7/� - Dusincus Phone I. Name on Permit/ATC it Different than Above 5104--Q, Hailing Address City/State/Zip 7. Application For: 2`Site Evaluation El Improvement Permit/ATC � ❑ notll 4. Size= to Servica: P-40use : ❑ Mobile Home - ❑ Business ❑ Industry ❑ Other 5.. Type system roquosted: 1r Convantional ❑ conventional modifiod❑ iuuoviltivit .. - 6. If Residonce: - I1 People - U Bedrooms 13 11 BaLllroomu Z ❑Dishwasher ❑Garbaal ge Disposal ❑Washing Machina ❑Dasament Plumbin . .. - / g ❑Dasmnont/No 11umUing .7. If Duoinons/Induaery /other: verify type U People I)'SinL-s $.Cosimodaa¢ Showers -¢ Urinals- - ^ 11 Nater Coolors ___-.•_.-, _ IF FOODSERVICE: tF SSeeots - Estimated, Water -Usage (gallons par day) 7- a. Typo of water supply; E County/City ❑ Well ❑ Comiliuni L•1, 9. bo you anticipate additions or Cxpallsion5 Grille facility this SyS(CIn is lutelldecl to serve! ❑ Yes ❑ No ifyes, }vital type? ***IAIPOR:CiLV' CLILNTSAMSTCOMPLEM r IE tie;QUIREDPltOPINVI'l--INFORMATION REQ1JESTED -- BELOW. Elthern PLAT or SITE PLAN UUSTBESUIG1rI7-TED by the Client Arndt THIS APPLICATION. Properly Dimensions: �, �3 TM-%-/ / -/'� 0 1WRITE DIRECTIONS (rroDl hlochsville) W I'RO )/ilCTY: Tax.oircc PIN: If 5-8�� /0 <S G 6b a �i r' / ILL;•a !� Property Address: Road Nannc /if / City/Zip if in a Subdivision provide information, as fullolrs: Name Section: Bloch: Lot: "4,7 Date Monne corners nagged: This is to eeraly, that the information provided is correct to the best of ury luloivledge. I understand that any pel•ntigs) issued hereafter are subject to Suspension or revocation, if the site plans or intended use change, or if the informs lieu subnn►t(cd in this •application is L•tl'siliied ur changed. I, also, understand that I aia responsible jor all chalb•es iucurrrd jrour this rgiplitativa. I, hereby, give consent to the Authorized Represcuta live or file Devic Cu till ty Ilyd(It 1)cpa N III cul to elder upon above described property, located !it Davie County and owned by Jcrnea Me to conduct all testing procedures as necessary to determine ilne site suitability. DATE_ SIGNATURE .. THIS AREA MAYBE USED TOR DRAWINC YOUR SITE PLAN (Includ all of lllc fulloving: LsiSling ted proposed propertylines and dimensions, structures, setbacks, and septic locations): Site Revisit Charge ' Datc(s): Client Notification Date: r, HS: AccountNo. 1,: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION - PROPERTY INFORMATION Account #i '990002086 Tax PIN/EH #: 5801-10-5600.08 Billed To: The Cana Group'LLC Subdivision Info: McCullough Property Lot # 08 Reference Name: Location/Address:. Sheffield Rd. -27028 Proposed Facility: Residence, Property Size: see map -Date Evaluated:, Water Supply: On -Site Well Community Public Evaluation By: Auger Boring t Pit i Cut DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION - PROPERTY INFORMATION Account #i '990002086 Tax PIN/EH #: 5801-10-5600.08 Billed To: The Cana Group'LLC Subdivision Info: McCullough Property Lot # 08 Reference Name: Location/Address:. Sheffield Rd. -27028 Proposed Facility: Residence, Property Size: see map -Date Evaluated:, Water Supply: On -Site Well Community Public Evaluation By: Auger Boring t Pit i Cut SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: p OTHER(S) PRESENT: REMARKS:4�LQoG� 1 ��X6, ..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' VFR - Very friable FR - Friable - FI - Firm VFI - Very firm EFI -Extremely firm i 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) HORIZON ID1717As • ��i�®®-® WUM01M11111111m�fiv�rJr�y®®-® ORTM 171111111111111111 0 W'M01MUM swim -Ra 53NIM �'t1«iL • . • -®rP1.i�i♦--®® SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: p OTHER(S) PRESENT: REMARKS:4�LQoG� 1 ��X6, ..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' VFR - Very friable FR - Friable - FI - Firm VFI - Very firm EFI -Extremely firm i 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) ✓i i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002086 Tax PIN/EH #: 5801-10-5600.06 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property Lot # 06 Reference Name: Location/Address: Sheffield Rd. 27028 Proposed Facility: 'Residence Property Size: • see map Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS: 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture groupGL Li' Consistence . Structure 'Loll • • r��7�®®®®® Consistence lite ULASSIMUA'11UN - - JC' J I1 : . LONG-TERM ACCEPTANCE RATE / SITE CLASSIFICATION: EVALUATION BY:, LONG-TERM ACCEPTANCE RATE:OTHERS) PRESENT: REMARKS: FXm= L Xzo;�iLEG ne-Y' END La pe o t 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 • MOW - ... VFR - Very friable, FR - Friable FI - Firm VFI - Very firm . EFI - Extremely firm Wet . NS - Non sticky SS - Slightly sticky S - Siicky VS -Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure r 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)