114 Glory Court Lot 17/7A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001720 Tax PIN/EH #: 5777-33-2505
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Lot # 17
Reference Name: Location/Address: Glory Court -27006
Proposed Facility: Residence Property Size: 3/4 acre
ATC Number: 3594
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 WASTEWATER CO T UCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: ` DO
%Q
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 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken uarantee t e system will function satisfactorily for any
given period of time.
�13
.hod
i3o
Septic System Installed By:
t v
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
j P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001720 Tax PIN/EH #: 5777-33-2505
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Lot # 17
Reference Name:
Proposed Facility: Residence
Location/Address: Glory Court -27006
Property Size: 3/4 acre
ATC Number: 3594
**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 #People S #Bedrooms ---/1 #Baths Z
Dishwasher: Xf*' Garbage Disposal: ❑ Washing Machine:' ET"" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type
#People #People/Shift #Seats
Industrial Waste: ❑
Lot Size Type Water Supply
Design Wastewater Flow (GPD)
Site: New Repair ❑
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width "Rock Depth 18 Linear Ft,20
1MPROVENIENT/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.****
Y
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
)N FOR SITE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
Environmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
OCT , �
?2003 /
Mocksville, NC 27028 tN�7' 0"
Nh GOONI� ZH (336) 751-8760M�VT
ppV1E OgFj fCO N��tAI
**PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
Name to be Billed -hi1V1 / ( O Tr)
/ \J t Contact Person _AAV Fel
-- -
/�,�,�—T
Mailing Address V`�.oD NIal(AL-
Home Phone �3% 76-377,z
.�
City/State/ZIP ��1)6.6y— S4Lt J 1.-- -2--ni Business Phone SOA&{.
2.
Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3.
Application For: Site Evaluation
L Improvement Permit/ATC ❑ Both
`Business
4.
System to Service:House ❑ Mobile Home
❑ ❑ Industry ❑ Other
5.
Type system requested: K Conventional ❑ conventional modified ❑ innovative
6.
'
If Residence: # People
Bedrooms �r Bathrooms 3
.5— #
#
Dishwasher ❑Garbage Disposal Washing Machine
❑Basement/Plumbing ❑Basement/No Plumbing
7.
If Business/Industry /Other: verify type
# People # Sinks
V
# Commodes # Showers
# Urinals 11 Water Coolers
F
IF FOODSERVICE:. #1 Seats Estimated Water Usage (gallons per day)
8.
Type of water supply: )# County/City
❑ Well ❑ Community
9.
Do you anticipate JIditions or expansions of the facility
this system is intended to serve? ElYes No
If yes, what type? {
S'
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPER'L'Y INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 3h Act,�2.
Tax Office PIN: #�-7 ! 7- - , 05
Lt u ►Vib"�
Property Address: Road Nam lir
City/Zip SIVt}n�,� ,lJ C 270c
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Al)v Gq G�+ -6 -�Lv Z61
iS = � !& Mi
If in a Subdivision provide information, as follows:Le
.
Namc: C
Section: Block: IAC APbUt: Date home corners flagged: 5J4
This is to certify that the info nation provided is correct to the best of my knowledge. I understand that any perniil(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 aur responsible for all charges incurred fi•oni
this application. I, liereby, give consent to the Autliorized Representative of the D/7 v�ic Coulity calth I) )arinieut
to enter upon above described property located in Davie County and ovine by WW1 S ruDet�2C4, C ,
to conduct all testing procedures as necessary to determine the site suits li
DATE 16Z16'3 SIGNATURE c
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
�i
Sign given_
Revised DCHD (05/03
Client Notification Date: /D ,
EHS:
�o
Account No. ,p►�/
Invoice No._�1 a Y
. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Ul' 15
Davie County Health Department �� 2 S 2��
En vironmenta/ Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 ENVIRIN,�-i .1LT11
(336) 751-8760 DAVM.:_..:.__.M
***I2tPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �rl/L(�(%( �(S ' ( Pry e' ! 1 C Contact Person 0 ';4 � (J� T7�u
Mailing Address t9OO () f SA-no"ti', V 1 14ce, 7l +. Home Phone 33 C, - 795 - 37(,'4
City/State/ZIP W JXA 1-0,J - ,]4f X14 _ %� C, G�127 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/state/zip
3. Application For: ,1Q Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: House' ❑ Mobile Home ❑ Business ❑ Industry Other Sit .;vi5jcn!
'/
5. If Residence: #People #Bedrooms 3 �_ # Bathrooms ,� •- � Z
N Dishwasher X Garbage Disposal K Washing Machine ❑ Basement/Plumbing K Basement/No Plumbing
6. I£ Business/Industry/Other: Specify type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: �( County/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O(No
If yes, what type?
k"IMPORTANT*** CLIENTS MUST COMPLETE THE REC)UIREl1 PROPERT`= INFORIIATiON iiLQ::ESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: n,
Property Address: Road Name ii fl w �l Sy/D
City/Zip Nt)c �. �lC7y06
If in a Subdivision provide information, as follows:
Name: >'-�-1,� 01 t tZ r S
Section: Se Block: Lot:—a
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
k+ AAA DrvCees `/L A i I e otJ
Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(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 am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the I,javie County Health Department
to enter upon above described property located in Davie County and owned by AIQA� (1`S
to conduct all testing procedures as necessary to determine the site suit:ib lity. ,�Q
DATE 3 $o/bl SIGNATURE Wct v - \
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS•
Account No. I `1 1%
Revised DCHD (07/99) Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-1382.21
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 21
Reference Name: Location/Address: Hwy 801-27006
Proposed Facility: Residence Property Size: see map Date Evaluated: r_
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit 1/1
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
•L
Sloe %
HORIZON I DEPTH
6 ell,
Texture group'
Consistence
Structure
Mineralogy
HORIZON II DEPTH
+•• E'�'
Texture groupCom'
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
M
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
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
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)
• 4390
4418
PART OF
313
0
0
v
(468 IA4,
3276
355
(10.20A)
9176
817
4395
(43.20A)
0678
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-2505
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Lot # 17
Reference Name: Location/Address: Glory Court -27006
Proposed Facility: Residence Property Size: 3/4 acre Date Evaluated:
Water Supply:
Evaluation By
On -Site Well Community Public
Auger Boring Pit Cut_
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RA
REMARKS:
LEGEND
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
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)
APP'IICATIQfd FQII SITE EVAiUATiQM/RiPftQVE61ElYT PERMIT & ATC
Davie County Health Department
Envitwnmenta/ Hea/tfi Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
n M �
EAPR2 6 2001
ENV{RM 1r,: iCTH
DAVI;.Y.:.:._:
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
REQUIRED
INFORMATION IS
PROVIDED. Refer to the
INFORMATION BULLETIN for instructions.
L
1. Name to be Billed
CAMPc9C,JJ s - ,��((}[1�1 Pry e 1 '
Li( -Contact Person R01,40-
b. C*1yt)6e(
Mailing Address
900()1 _)TtIOPui JI«�;1� C+.
Home Phone 3G
95- R -7t 2-
city/state/ZIP
WINS1'o/J-,q1P1V1 NC 1-7121
Buainass Phone
2. Name on Permit/ATC
if Different than Above
Mailing Address
City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: �( House' ❑ Mobile Home ❑ Business ❑ Industry 0( Other Sti(. rV�Src �1
5. If Residence: # People # Bedrooms 3-4 # Bathrooms
ADishwasher X Garbage Disposal K Washing Machine ❑ Basement/Plumbing K Basement/No Plumbing
6. If Business/Industry/Other: Specify .type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply:( County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: # , 777 3 3 -1 3 a
Property Address: Road Name
City/Zip LIA",Cz- llMoO6
If in a Subdivision provide information, as follows:
WRITE DIRECTIONS (from Mocksville) to PROPER'L ,:
PAs+ +0 Lk) y Aa 1, 'ES121/
onceeA '�Z Mike 0 I
41
Name: S' -}-I k D (Ae, r 5
Section: 4Se Block: Lot: Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(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. 1, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the 12avie County Health Department
to enter upon above described property located in Davie County and owned by (rAMALJI'S
to conduct all testing procedures as necessary to determine the site suitab lity.
% / \
DATE �I �I SIGNATURE �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Revised DCHD (07/99) Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
{ Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-1382.17
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 17
Reference Name: Location/Address: Hwy 801-27006
Proposed Facility: Residence Property Size: see map Date Evaluated: 0
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
L
Slope %
5
HORIZON I DEPTH
- l�
Texture groupL
Consistence
r
Structure
CJL
Mineralogy
1
HORIZON II DEPTH
Texture groupi%
Consistence
S
Structure
Mineralogy
HORIZON III DEPTH
I c& - T7
—
Texture group
Consistence
Structure
k
,
Mineralogy
1 l `
1-1
HORIZON IV DEPTH
Texture group
Consistence
-T
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
. 3
SITE CLASSIFICATION: V
LONG-TERM ACCEPTANCE RATE:-��
REMARKS:
EVALUATION BY: v t - y_ L Z:AdaA t
OTHER(S) PRESENT:
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)