163 Mollie Road Lot 11DAME COUNTY HEALTH DEPARTMENT
`% Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003876
Billed To: CKJ Building & Design,LLC
Reference Name: Melissa Johnson
ATC Number: 4319
Tax PIN/EH #: 5801-10-5367
Subdivision Info: Sheffield Acres Lot # 11
Location/Address: Mollie Road -27028
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 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 . 00 Sewage Tr atm d Disposal Systems). THIS
AUTHORIZATION FOR WA N I VALID FOR ERIOD OF FI YEARS.
Environmental Health Specialist's Signa Date:.2 lD t�J
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has b.9m installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO�AY be taken as a guarantee that the system will function satisfactorily for any
given period of time. L t
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Environmental
DCHD 05/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health.Section
- s j P. O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990003876 Tax PIN/EH #: 5801-10-5367
Billed To: CKJ Building & Design,LLC Subdivision Info: Sheffield Acres Lot # 11
Reference Name: Melissa Johnson Location/Address: Mollie Road -27028
Proposed Facility: Residence Property Size: 0.841 acres
**NOTE*"Th s 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 H DOGt #People #Bedrooms _-75 #Baths �.
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size C)-�tq I AC.t2CSType Water SupplyC--uNTY Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size IeCIOGAL. Pump Tank I OCOGAL. Trench Width 5t Rock Depth VZ Linear Ft."rW
Other. 4 AkSTRiNmorJ Zw<, ac stated In tem15A N may
also b969(5)
accepted Systems may also be usend
Required Site Modifications/Conditions: FILL ON - P 5 CV R t
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. 1:00j.,nto 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised) \ I
Fob 03 06 MOS& davlo counts anvhealth - 338 751 8786 p.2
APPLICATIONFOR SM EVALUATIOMMPROVO4MT PBRMU & ATC
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N®a m lftmitlATC ifDjpbenr ttan Above _ _
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SubdivisiouName � SU`l owmew size
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Type ofFecifityMosntas TOW SgtmeFoot4geOfBuiidm&-- #People
#Sinks #Commodes #Shovers #Urhols
Eat®ted WaWUsage(sdkws per Jay)-----___(AUwb doo mematim ofsomaw facility water consumption)
FOODSMVR:EONLY: #Seats
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aqr pmsY(s) arATC(Q bad hema6ar a sabjatb aopmsim a ravocstien if6e tits b abbd. 6e iatmded we ehatpts, a if
the ioktmHmsobio dib spplimtimis $16fisdorcieigd. I swdos�+dsiarla.nepasNbkl6raBo{mtes dursrwd
five arirappNaatba IksdryyrasatcdmoybthaAstLatiasdRepnaeahtive oftbeDaHeCmtyBWtltDeprtmmtb
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Date - EliS:
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E c E P w E
FEB - 8 2006 D
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I PALLETONE Off' NORTET CAROLINA. -
T C'
o a J. DRYANT MCCLAMROCE I --AI_L D.D. 392 , PC. 890 n
Z 00 D.B. iB6 PC. 484 'RrN .c3UND ZONED 1-2—S T
w ZONED R—Alis r
� �gAB 6 T {135 a
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1 /2" SOLID LOT 5 3 V { 1$
IRON FOUND La
CONTROL AREA= a,
N N
6ORNER 10 N
CU 0
2.193 AC. ^o� ti v S
LOT 6 Cq M o "' o o tto
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AREA=CO
\ \ 2.097 AC. w \ Qj
a CIV?i <v� �~ �r 4
All
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- J. tBRYANT MCCLAMROCII
D.D. 186 PC. 484 � s se��r\ � � j 'q° 2" O C
ZONED R —A i o�,_ 18 \ 1 D' UTIUT `t j/ oma: io~ o°' � S
DRAJNAGE EASEMENT '/' /v` ,��/ O •: P
L6 L541 7
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200
o \ ' EXISTING I ' '-'}-
\ I t\ PAVEMENT l� rcIVWE C�
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LOT 7 \ . J _ ul AD (PI
AREA= 0.841 AC.
1D' UTILITY &! ` SgR \ o.
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DRAINAGE EASEMENT \ , 21 O+7 \ A C
��
282.12 ! ! LOT 12 \ \ . \ ��T / `=G rg��>� 10
y s a4�s,'36. E AREA= 0.995 AC.
certify that *'ie Davie County Health Department 25' RADIUS (T-(P.) r�
cu 4
ivision aD' RaDlu=_ (I;R.)
ited the suWLOT 8 ^
SHEFFIELD ACRES
pct to criteria and conditions established z a N SI'aj •� \ rZ /
ow or promulgated thereunder and the AREA= 0.799 AC. 307.990 , } ` .2
ound to comply with such criteria and 0 � FIRE � RRE Q /'
EXCEPT as sat forth in such evaluation. �� �6�/ J ' /HYDRANT HYD Rwr '?
.. .�•_ _.._iu&jzor, u-' for n u tn' !1RCINdl:F ✓¢P" Ly I !1T -1 -I ti A-
` /
ritten�report on rile at V said department. EASEMEAIT� i - �\\C•C /o LV I I I /hv ^� �• 10'X70' AGHTk// ' V
NOTICE THIS CERTIFICATE DOES NOT ' y p� AREA— 0.841 AC. �' ,,,,,,//// { V
E A PERMIT OR APPROVAL OF INDIVIDUAL i b01 �i�.
:AID SUBDIVISION FOP. INSTALLATION OF �2'71.24�D' E / o ^ O �� �� i7- / ti�y2/
4CIl.rIIES. p•69 m +, .# T 1~^�
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LOT 9 0!� rya,$�o6 o �`"`����r�`/s
DAME COUN71' HEALjW-OFFiCER oo cQ-(p�y y5/
Go AREA= 0.965 AC. LOT 10 9.� �€ o
�o /
L. Tutterow, certify that this plat was drawn z AREA= 0.812 AC.
supervision from an actual surrey made a%-P 175.00 / h•h° B '
supervision (deed description ,recorded in CONTROL I PA. 116 j4s"
Page etc.) (other);that the CORNER122 99
not
. mat on founddin are
PL i6o k indicated ges drown I I—N 8237`4 k (715.50 TOTAL)
P.LP. 156, 35 �o
ratio of precision is calculated as 1-- +20.000 ; I L) / /
plot was prepared in accordance with G.S. I I / 8�' 01 55.00
s amended. Witness my original signature,
/ LARGE NAIL\ql �.k
)n number and seal this 25 day of r-)CA.°
I IN ROOT c ROaO
O
A.D., 05 I 01� I / J. €Y. KEATON 3
5. 0D.B. 190 , PC. 12 � ° 82'4 j 14'
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ON 1:011 SITE L•VALUATION/Ih1PROVEMENf PERMIT 3 ATC
Davie County Health Department .
Eniironn�enta/Hen/i/i Section
.0. Box 848/210 Hospital Street
Nocksville, NC,;"27028
(330751-87G0'`
***Sd1PORTANT*** THIS APPLICATION CANNOT DE PROCL•SSEo UNLESS ALL TIIE REQUIRED \
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for 'inztructionn
1. Name to be'yy� � /7 Contact Parson
- �Dilled _!__1_L�LA/1//B-�(, tp_sGJ/7��(,(-[!
' - Nailing, AddroS.. )1 ttomc Phone
;City/State/ZIP �,j p��,at n✓/S. '��L �rC �/' 'Duuinoo 3'Phuna r^� �.• S_ .,
2. Namo on Permit/ATC if Different than Above - Siay9 g�
Hailing address - City/stats/Zip. - -
1. Application For: L9��ISi to Evaluation ❑ Improvetne L• Pel.lnit/ATC - ❑ 1'10L11
4. System to servica: L4 --House ❑ Molzile Home ❑ DuaineDD ❑ Industry ❑ Other
5. Type System requested: EY—Conventional ❑ conventional modified Cl innovative
6. If Residence: 11 people p Bedrooms eJ p Bathrooms L
❑Dishwasher ❑Garbage Disposal ❑Washing Machina ❑Dasoment/Pllumbing ❑Daaomont/No Plumbing
7. If Dusinoas/Industry /Other: verify type p'3inls
p Commodes p Showers - - p Urinals--__�
II Walar Cooloru
IF FOODSERVICE: .IF S�e3L•atimated Water U nage (gallons per day)'_
8. Typo of water supply: l7 County/City ❑ Well ❑ Conununity ---
9.. bo you anticipate additions or ClpatlSIO1IS of (lie facility this sys(clll is Intended to Surve? ❑ Yus ❑ Nu
Iryes,lvhattype?
***1d1P01tTdNT•k** CLIENTSntt/STWAIPLL•'TL• THE REQUIRED 1'1{O1'L'It'1'Y 1Nir01{a7A'1'lON HEQ0 S 1'XD
BELOW. EltleriPLATorS1TL• PLANdfUSTACSUIIdll7TEDbytile client llllll'rIRSA111ICA'I'ION _I
Property /� /o/moi �j�-/ -/ �� 0Y mliirrE DIRECTIONS (rrom Mucl:sville))IIII
�l''It01'lil(TY,
Tax Ofrice 11IN: it S 81)/—/0 S G 6b d ) / l r�}i a
Property Address: RoadNaine
Citylzip A§
If in a SubdivisiDli provide ilifornlatioil, as follows:
N2mc:
Section: Bloch: Lot: Date honk col•ucI`s flagged: "
This is to certify that tiro information provided is correct to the best of my k "Olt Iedge� I uaderSland (IIII( :Illy
Issued hcrcaf(cr are subject to suspension or revocation, if the site plans or Inlcilded use ch:mgq or if the infurma f imI
submitted in this application IS L•tlsilied or changed. I, also, ruu(ersYand that 111111 resirri ISIOle jor rill Chru6VeS iuciu rrr!•jrunr
Orisapplieatiou. I, hereby, give consclit to the Authorized Rcpmenta(ive orilte Davic CutulO' IladIIID C m]'Imi111
to cater upon above described pruperty located in Davie County and oivlled by r e ee
to conduct all testing procedures as necessary to determine the site suitability. '
DATE SIGNATU
TRIS AREA MAYBE USED FOR DRAWRIG YOUR SITE PLAN (Includ all of Ulc follolving: Existing and Proposed
propertyRncsand dimensions, structures, sctbacka, and septic locations).
j Si(cltcvtsil Ch:u•gc ,
CH utNotificaliuullatc:
ERR:'
Sign given.!Account No.
t' ,ply
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002086 Tax PIN/EH: 5801-10-5600.13
Billed To: 'The Cana Group,LLC Subdivision Info: McCullough Property Lot # 13
Reference Name: Location/Address: Sheffield Rd. -27028
Proposed Facility: Residence ' Property Size: see map Date Evaluated
Water Supply: On -Site Well P Community Public
' Evaluation By: Auger Boring Pit �� 1 Cut
i
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: ( - _ �. OTHER(S) PRESENT:
REMARKS:
EGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slopeN =Nose slope
CC - Concave slope CV -Convex slope T -:TerraceFP lood plain H - Head slope
Texture
S -Sand LS - Loamy sand SL -Sandy loam L -Loam 51 -Silt
SICL - Silty clay loam SIL'- Silty loam CL - Clay loam' SC 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 pastic
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 1
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
surface to soil colors with chroma 2 or less
. • .. •..
®res®®®®
12-4 We -
HORIZON IV DEPTH
®o®®®®a
91 • t •
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: ( - _ �. OTHER(S) PRESENT:
REMARKS:
EGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slopeN =Nose slope
CC - Concave slope CV -Convex slope T -:TerraceFP lood plain H - Head slope
Texture
S -Sand LS - Loamy sand SL -Sandy loam L -Loam 51 -Silt
SICL - Silty clay loam SIL'- Silty loam CL - Clay loam' SC 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 pastic
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 1
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
surface to soil colors with chroma 2 or less