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162 Mollie Road Lot 8a3lOb DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section a P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003876 Tax PIN/EH #: 5801-10-0484 Billed To: CKJ Building & Design,LLC Subdivision Info: Sheffield Acres Lot # 8 Reference Name: Melissa Johnson Location/Address: Mollie Road -27028 ATC Number: 4318 As stated In 15A NCAC 18A.1969(5) accepted Systems may also be used 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 Fonn/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 .190 a Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWg1ER4 I VCTI ISAALI$FQR A PERIOD OF FI,VE YEARS. Environmental Health Specialist's Date: zo . CERTIFICATE OF COMPLETION **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 30A, 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. �a �Slit J1D lv � t g 7 H" h j �K lx�it; co . lL4 Fe rt t�acsc���e�1MA,� Septic System Installed B Environmental Health Specialist's DCHD 05/99 (Revised) Date: 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 990003876 Tax PIN/EH #: 5801-10-0484 Billed To: CKJ Building & Design,LLC Subdivision Info: Sheffield Acres Lot # 8 Reference Name: Melissa Johnson Location/Address: Mollie Road -27028 Proposed NF�aciliity: Residence Property Size: 0.799 acres **NO "t �* Tli slmprovement/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 PERMrr 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 I"1C #People #Bedrooms #Baths 2-5— Dishwasher: -Jc—Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type / .� ' #People #People/Shift #Seats Industrial Waste: 13Lot Size 0. � w Type Water SupplyC.W�YDesign Wastewater Flow (GPD) Site: New Gff"' Repair ❑ System Specifications: Tank'Size I Ow GAL. Pump Tank GAL. Trench Width �So' Rock Depth I Z{ Linear Ft.� Other:,6 b15T21(�) rOn1S . As stated In 15A NC 18� '6 (5d areepted Systems may als Required Site Modifications/Conditions: 11`,fa;;rNL L— 27x•1 C.E;oTc— t g. vra;�v J, pFp �6�, KEEP 10, IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED E�F P 'ALTER. )RISER($) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of Da ounty Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 in. to 1:30 p. a day of installation. Telephone # is (336)751-8760.**** 't 1 '� lFI uses 1-3 c I N T � 5x nvironmental Hed1th Specialist's Signature: DCHD 05/99 (Revised) �P- x �� env*r� Iti _ Date: O!i r 'Feb 03 06 IOs OSa davle county envhealth 336 751 6706 p.2 r t , APPLICATION FOR SITS EVALUATION/IM MOVEMENT PERMIT & ATC C W►"" Davie County HUM Department ExWmxmeNd Health SedIoa P.O. Boz 848810 Hospital Street Mor]avBte.NC 27028 (336)751-8760/ Fax (336);51-81M DE IlS ApplicationF0 U or. fte :rovers tpr�dt '<tbaimtiodToCua>hirct(ATC) 13 Both . ITIFOR�bUTIIONNISJMMP'PROVp® RRe_fft to the IN��ATR�nON UINftNLYM THE MM heauohom FEB - 8 2006 APPLICANT INFORMATION ENNR'NMENTALHEALTH NathetobeBiOed C cT Idi�na�w yah /f CouraaPusom i�rr5 ��inS/,'7� DAVIECADNTT Nemo on Permit/ATC if Diff ai ttan Above NOTE: Awarcyplato (Paint is valid Street Address Directions To Site: Date House/Facility Comas FlaggaI.O Ifthe amwerto any of the following questions is "yea . auppatmg doannm'E tion be attachal. Are thaaany existing wastewumrysteav on the aft? Dym BNo Does the site weamew. - Dyes am Are tbae anys of rigtr-of-ways on the site? Oyes 0ltlo lsihedtcmbjealoapprovalk;awdwpobUcagen.7? OYa Wo Will wasbruaerWherthmdomesticsowesebe generated? OYes OFto vrcupm a:camootos .13 9Mthrooms_4'L Crardea Tub/Whirlpool QYes ONo Basanmt•. OYes VWo Basement Plumbin¢ DYea 0340 IF NON -RESIDENCE FILL OVI THE BOX BELOW Type of Factli"miness Total Square Footatx of Bondi&_ # People # Shrlm #Commodes # Showers--# Urinals Estimated Water Usage (gallons per lay) (Attach docuentation of similar facility water conaump6on) FOODSERVICE ONLY: #Seats TYpeayaoem-Wmtc'd:l!06�. i DAecapted Otmarvative OAlhrmdm 'a06c Wa4s SupplyType: we omsy/City Wsler O Nov WeO tl6aW,$ Well a Comm teltyyWca Do you smkipate&mumsoregascion;oftheficady"eyes= isintended waave?6•N Oyes o Hyes,whattype? Ibis is to =dfY that the isfcamadon prmided on this application is true and anted to the best ofury Imowkdge. I understand that my per®t(s) orATC(s) Issued hereafter aro subject eoamperaion mmvoeaticn if the site is elected, the intended use changes, or tf the Wmm dim a bnunW ro mi$ &Wbatioa i+feL•dmd or cheomed raadenFwd tlraf l am rrrpoar164faraR ehmgea tncarrad from rhitappiicadon. I hereby gram r*t of eahyto the Authorized Representative ofthe Davie County Hcd&Depmuum to conduct necessary iuspe.1km to dermdne rampUnaa wirb,pli able laws aidudes on the above described property located in Davie Countyy ad owned by Ckl-' tGD.�l�ile.SIGNt L.LG ( ✓"a•: ,` • 9s-,fD•••••�✓ Site Revisit Charge . Piopmy owner's or owmets kSafreprommourve, wgodm- Dam(a):— ti 7 Cheat Notification Datr. •. Dm EHS: Sigasivea Dyes DNo Acarm f Revised 2/06 Invoice ii F T U F-- a PALLETONE OF NORTH CAROLINA � o r, J. BR 'ANT MCCLAMROCH D.B. 392 PG. 810 . TALL '..� D.B. 186 PG. 484 -^N Foun,G ZONED 1-2-S T A ZONED R -A yah b og aaa 3k�'p0 F AN a4ij 12" SOJG r L T 5 IRON FOUND „ CONTROL CORNER, L CU AREA= N �f i a� 2.193 AC. N 6 � LOT 6 MCD 00 ,� AREA= �;� ` 10 4` J� p ®� \ \ 2.097 AC. Z \,o o'�% CIV Iz- S/, 4 J. BRYANT MCCLAMROCH �SeMe�TF �P D.B. 986 PG. 484 ss ��'r\ �' s�ga2x /yC., %�Q� s ZONED R -A 9 0�. r� \ 10' UTILITY i 6J 'bS oa) 00 ,2�/ 5 DRAINAGE EASEMENT/.F_ 1 r' o F \ L6 L5 CS w �� 7 ra o \\ I 20' EXISTING ftiOLli'FROAD cs` � O Cu PAVEMENT O R e co LOT 7 \ n _ LI1 �0 �°Ug�iOJ` , C4 a°�� , ��. E 3 AREA= 0.841 AC. 10 ' UTILm UI DRAINAGE EASEMENT OJ o } \ C76 ?A- ° 9. n 282. i 2 LOT 12 T ;� , �,2, 10 84.51'3e•E AREA= 0.995 AC. certify that *^e Davie County Health Deportment 25' RADIUS (r'P.) 0' RADIUS ( Utad the suWivision c �,� r., 4I;P.) �' \ \ \ v �a`V c�I10 11 SHEFFIELD ACRES LOT 8 " —� i og ct to criteria and conditions established J N 9i'4146- \(, �Z / i ow or promulgated thereunder and the z AREA= 0.799 AC. c 307,99 `tc� ,r7o} O� 12 ound to comply with such criteria and FIRE FIRE e E" CERT as. setforthin such 'evaluation. 6 RaNr n.. HYDRANT ` �n . .•• , c n <.�• Ca VP r1PAINACr 4w I /lT i ti / sitten4 report on file at said deportment.=�SEM6`1T-� i �\ LV I I I V l NOTICE: THIS CERTIFICATE DOES NCT �' 10'X70' HT E A PERMIT OR APPROVAL OF INDIVIDUAL i _ \ ' AREA= 0.841 AC. AID SUBDNISION FOR INSTALLATION OF 271. a,`�p / o ^Oi o -Q / =fLO I 9 DA\4r COUNTY HEA!(jbi' OFFICER o n C AREA= 0.965 A.C. " • I _ LOT 10 9` w Q), / L Tutterow, certify that this plat was drawn z AREA= 0.812 AC. I supervision from an actual survey made Pj P. 175.00 ��'j 1.... supervision (deed description recorded in CONTROL I P'I'P' lIb. ?O� �Sti� ��'"iffn Page etc.) (other);that the CORNER I 25 P -;. p_ / 3�, 'ti C s not surveyed are clearly indicated as drawn I i—N 82.47'24= �715.12�ITOTAL) P I p 156.35�o�° Irmation found in PL Book Page =; 50 ratio of precision is calculated as 1: +90.000 89. plat was prepared accordance with GS. / i 55.00 s amended. Witness m original incll signature, � :aRGE NAIL Nv �� CAP ROOT m � number and seal this 5 day of O ^; ROAD _iA'.D., 005)), (Yr ) l J. If KEAT��%tl 35.09 CTt 1 C . 11�v%purvey°r h i -- -- - -- --- - - �/ D. B. i9% 1 G. �2 � ' 82 47 2a �y cu ° Q� z E' i L6 EXISTING \ I P,4VE�IENT _JF e LOT 7 I !: AREA— 0.84 "i AC., co 282, t 2 I S 8�3�8 E -rrP 25' R-40VUS ( -) 4- -T' LOT 8 ARF,, --A= 0.799 AC, C5 / c ,n' EASEMEi`1 I LOT- 9 ,A -A = 0.965 AC. DRAI L( AR Win= DRADIUS (r R ) L fv' i FIRE p HYDRANT LUI ° AREA— LOT PE . LOT 10 }�2 AC D 1 2004Ar1 ON F011 SITE rMi DATION/lhlPllOVOiENT rlilburr 3 me OCT Davie County Health Department EnYironi11efl&1 Hen/i/i Section FNVIRONMENTAEN�ETM 0: Dox 848/210 IiospiLai Street pANECOUNTV Mocksville) NC 27028 (336)751-8760':' ***IMPORTANT*** THIS APPLICATION CANNOT DL•' PROCESSZD UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for ins L•ruc Lions. ..•I'. 1: Name to be,Dillod 7-1"a�Y�lnrn��� Con tract• Person ^ Nailing AddressCp�7{1 ,���QeC Hama Phone City/state/ZIP �p,.,_ _ ,,k,t� 1\14) (267/, Duainess phone -.._.. ..... 2. Hama on Permit/ATC if Different than Above S-ldm-Qi - Nailing Address - ' City/StaLa/Zip 1. Application For. C9 Somite Evaluation Cl oven lent; Permit/ATC ❑ ))o L•h 4. Spatam to Service: 9-1ouse ❑ Mollile Home, ❑ Business ❑ Industry ❑ OL•lrer y _ _ 5. Type spatem requoutod: E aoavontional ❑ conventional modified ❑ innova L•iva� _ • 6. If Residence: g _People p Bedrooms -.3 It Bathrooluu Z _ ❑Diahwashe.r ❑Garbage Disposal ❑Washing HachinO ❑Dasemant/Plumbing ❑1)aaammlt/1)o llumbing 7. If Duoinana/Industry /Other: verify type - - ¢ People I1'L'inks - I Commodua-.1" Showers - - 11 Urinals�_-- U Water Cooloru IF FOODSERVICE: 0 Seats- - Estimated Water Usage (gallana par day) ., s. Type of water supply: 211 County/City ❑ Well ❑ ColmnuniL•y - 3- bo you anticipato addition or eximnsious of the facility IIIIS SySLCut IS filICIHIC(I to Seryc! ❑ Yes ❑ No if yes, what. type? ***It1IP0-RTA1yT*** CLIENTS tIIUST COAR'LL••TL• THE REQUIRED PROPER'1•Y 1NFORNIA'1•ION REQUI S I El) YI BELOW. Elthera PLAT arSITE PLAN bfU.TrBf SUllhrFrTCD by the client lyMI HIS AI'l 1 ICATION Prol)crty Dinl nsiolIS7 /Ln.�e/3 T/N-% -/ N: 0ly WRITE DIREC)IONS (rrom A•luel;sviue)) ill Jl JlarrY: Taz.OificerlN 0 S-910 /0 <SG6b Properly Address: Road )`tonne City/Z7p . g sG) �HC ll If in a Subdivision provide infornmtion, as follows: Name Section: Bloch: Lot: `i -e Date holuc col•ucrs 17aggcd: This is to certify that the information provided is correct to the best of my knowIcage. i understand (hat :uly perm t(s) Issued hereafter arc subject to Suspension or revocation, if the site plans or hHeaded use change, or if the inrarmation submitted in tllis applica(iol is fal'sirled ur cllangcd. 1,, also, andersttn d that I t ut reslioasrblcjor all claages litcarrrd Jrtnn f1drapplleatiun. I, hereby, give coliscuf to file Authorized Representative of the Davie Cu only Ifealtll De mrtgmHI (o enter upoin above described liroperty located in Davie County and wyncd by ,i, rn , 111e&111 to eunduc( all testing procedures as necessary to dc(Lriuine the site suitability. DA'rL_ SiGNATURL TRIS AREA MAYBE USED TOR DRAWING YOUR SITE PLAN (Ltclud all of the following: Existing and prop..... properlylines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Dalc(s): Client Notilicatiol Date; EIIS: Account No. DAVIE COUNTY HEALTH DEPARTMENT LONG-TERM ACCEPTANCE RATE: J OTHER(S) PRESENT: REMARKSr 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 � 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 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) Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002086 Tax PIN/EH #: 5801-10-5600.10 Billed To: The Cana Group,LLC Subdivision Info: McCullough Property Lot # 10 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 LONG-TERM ACCEPTANCE RATE: J OTHER(S) PRESENT: REMARKSr 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 � 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 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) 001RL# MGM ®®®®® HORIZON 11 DEPTH MATM TF OWN • �'5�7�1�T7®®®®® LONG-TERM ACCEPTANCE RATE: J OTHER(S) PRESENT: REMARKSr 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 � 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 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)