117 Glory Court Lot 23DAVIE COUNTY HEALTH DEPARTMENT
° Environmental Health Section
• P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028 12 y
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990004119 Tax PIN/EH M 577-33-1382.23
Billed To: M & M Construction Subdivision Info: Still Waters Phase I Lot # 23
Reference Name: Mark McKnight
Proposed Facility: Residence
Location/Address: NC Highway 801-27006
:Property Size:
ATC Number: 4519
**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 THIISPERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People "'I t #Bedrooms #Baths -13
&'(,4r 1ro'(U-P, —/
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: fid" Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industri173al Waste:
Lot Size 1).(A AC-✓ S C£�
Type Water Supply WDesign Wastewater Flow (GPD) �t{Gfl Site: New ® JRepair ❑
System Specifications: Tank Size 1000GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width 13L, Rock Depth 1U iA.Linear Ft.20S
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. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
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1al Health Specialist's
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DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990004119 Tax PIN/EH #: 577-33-1382.23
Billed To: M & M Construction
Reference Name: Mark McKnight
Proposed Facility: Residence
ATC Number: 4519
Subdivision Info: Still Waters Phase I Lot # 23
Location/Address: NC Highway 801-27006
Property Size:
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 CONST VA FO PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
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 as a guarantee that the system will function satisfactorily for any
given period of time.
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c14 sS (r 1
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Septic System Installed By: - tj _ M'e'
Environmental Health Specialist's Signature: e: z O
DCHD 05/99 (Revised)
,APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
` Davie County Health Department
Enw onmental Hea/Ifi Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
N1,10 r4 0 1..0'r l�
M 0 T IS
APR 2 6 2001
ENVIR01: ;; ikLTH
DAV11
***IMPORTANT*** THIS APPLICATION C =0T BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
/� A I o
1. Name to be Billed I-Ii\li��r�t W .` '( YC /t' IQS� �LNI. Contact Person DIJ�}kJ%Qbi t7-T-17�LtntJLit
Mailing Address ,9000 .SA- po,l, V 1, 11 Are- _ (+. �7 !tome Phone 33G — / Q 5 - J / � � _
City/State/ZIP 04)00/J- _( e. A - & 1712 1 Buoinass Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: 1X House' ❑ Mobile Home ❑ Business ❑ Industry 0( Other St4)4,'v;s1rAI
5. if Residence: # People # Bedrooms 3-y # Bathrooms ,
Dishwasher Garbage Disposal j)1�Washing Machine O Basement/Plumbing Q( 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 W No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIPr�'D PROPERT`; INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: #. _777 3 3 — I a •
Property Address: Road Name ��i�ll n0
City/zip i,Iati,z AIC27006
If in a Subdivision provide information, as follows:
Name: S+, u
Section: iiSe ( Block: Lot:,J
WRITE DIRECTIONS (from Mocksville) to PROPER'L'Y:
EJ b y e. A S+ q0 I
i" I ry ceeA 1I- M' (e 0 IJ
�"C1r
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 Ravie County Health Department
to enter upon above described property located in Davie County and owned by. LAA11'S
to conduct all testing procedures as necessary to determine the site suit b lily.
1. DATE �jOJ f)I SIGNATURE Cc_,121a
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. zo
Revised DCHD (07/99) Invoice No.
Y
Y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001720 Tax PIN/EH #: 5777-33-1382.23
Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 23
Reference Name: Location/Address: Hwy 801-27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit Z�
Public
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe % /
HORIZON I DEPTH !( y
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence If
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: �ia� /)% dy �r
Landscape Position
EVALUATION BY: 4 1
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)
10/08/2006 22:13 33699887BO M&M CONSTRUCTION PAGE 05
AGG 01,2005 07:27 :0040000000 pags4
PRZLIMINAR, I MAP
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10/08/2006 22:13 3369988780 M&M CONSTRUCTION PAGE 04
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