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119 Peace Court Lot 13DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boa 848/210 Hospital Street Mockcsville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001720 Billed To: Campbell's Quality Properties, Inc. Reference Name: Proposed Facility: Residence p,4,L/-../_ a 3 T b Tax PIN/EH #: 5777-33-1382.13 Subdivision Info: Still Waters Phase 1 Lot # 13 Location/Address: Hwy 801-27006 Property Size: see map **NChT&14�Mprd f ent/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 1 l 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 ly #People 3 #Bedrooms 3 #Baths 2 Dishwasher: tT" Garbage Disposal: ❑ Washing Machine:0 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/Goo GAL. Pump Tank GAL. Trench Width Rock Depth la Linear Ft..3 a o Other: Required Site Modifications/Conditions: 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.**** a Environmental Health Specialist's Signature: Aw//Date: ! —3-0 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001720 Billed To: Campbell's Quality Properties, Inc. Reference Name: Proposed Facility: Residence ATC Number: 3416 Tax PIN/EH #: 5777-33-1382.13 Subdivision Info: Still Waters Phase 1 Lot # 13 Location/Address: Hwy 801-27006 Property Size: see map 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 CONS RUC ION IS VALID FOR A PERIOD OF FIVE YEARS. &//, �Z— Environmental Health Specialist's Signature: Date: � 3, cDj CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indi to e s tem described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. C ap er 1 OA, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a gu tee t at the system will function satisfactorily for any given period of time. 45/� is a f Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: � --E A LJ �OU3 ENVIRONMENTAL HEALTH ***TMP ION IS PROVIDED. /I _ —I ") 1. Name to be Billed IN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 CATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED Refer to the INFORMATION BULLETIN for instructions. Contact Person Mailing Address�/4 - Home Phone3 c` 1�[7"�3 6 �-- (Ui11A4e_ City/State/ZIP W t ,t1 A) C, 21 �Z-7 Business Phone 336- CKs 6991 fqoi�le 2. Name on Permit/ATC if Different than Above 542L4 f - Mailing Address City/State/Zip 6,4y1h-2- 3. Application For: /-'� ite Evaluation `Improvement Permit/ATC ❑ Both 4. System to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 - # Bathrooms Dishwasher ❑ Garbage Disposal I Washing Machine EJBasement/Plumbing FJBasement/No Plumbing 6. If Business/Industry/Other: Specify type V # People ^—" # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats -- Estimated Water Usage (gallons per day) 7. Type of water supply: I County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? ***IMPORTANT*''`* CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Seo— rhq,1 2 Tax Office PIN: # 5,777 -33 -139.1 -AS Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: ✓T► ( Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: WV bq C �2%-hf. Gv S-,rA% of �� %z i � l e ��� 1�k (A)ds6 Ballo/ (DS h('(( -EU" 6'41E X" 10+ ON I�T1 Date Property Flagged: This is to certify that the information provided is correct to fbe 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 Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing rocedures as necessary to determine the site suite 'lity. DATE hL 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). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. I 7A10 Invoice No. APPUCATION FOR SITE EVALUATION/IMPROVENIENT PER&HY & ATC Davie County Health Department Environmental Heath Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 LOT 12 J EANP2 6 2001 ENVIROP!�';;: ALTH DAVIE ..::..:.m. _�... L***INPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. nn ^^rr IIII 1. Name to be Billed I-T!�(1:6 fill1 s I a e tf ,Lu Contact Person PCO/ n6� �C�ILin(!j21� Mailing Address ,-)600 Sano 111 Ll��z C{ , Home Phone 33 ��� /t: 2- City/State/ZIP City/State/ZIP �/IJIJ���"U/J- YtIP�11 / C- 1-71 11 Baniness 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: Ix House' ❑ Mobile Home ❑ Business ❑ Industry Other Sci& ,'v;sicr✓ / 5. If Residence: #People #Bedrooms -3 -q #Bathrooms -- A. '/- ADishwasher Garbage Disposal Washing Machine 0 Basement/Plumbing IX Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # 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 D(No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTi'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: —7 Tax Office PIN: #_,� % / 7 .3 3 -1 Ma' (3 Property Address: Road Name city/zip d0Aucz AUL00 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPER'T'Y: RJU 6q rl k+ A -A -A ory ceeA 1/4 M (.(e qtJ Name: S+1 kk D A4er S Section: I}Se (' Block: Lot: -- 3 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)avie County Health Department to enter upon above described property located in Davie County and owned by A-tdk' X1,5 qua_ ; _PrU� k i*5`_ to conduct all testing procedures as necessary to determine the site suipb lity. DATE �J $Q�yl SIGNATURE Wct�kA cc-m�( 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. APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Account #: 990001720 Tax PIN/EH #: 5777-33-1382.13 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 13 Reference Name: Location/Address: Hwy 801-27006 10 Proposed Facility: Residence Property Size: see map Date Evaluated: It 0 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH — 2 Texture group SCS Consistence S Structure n Mineralogy HORIZON II DEPTH Z - Texture group Consistence S Structure Mineralogy1 HORIZON III DEPTH Texture groupG Consistence �C� Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION PS F �In LONG-TERM ACCEPTANCE RATE L,).;4T: SITE CLASSIFICATION: EVALUATION BY: j rf J kkt4A 0& LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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)