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139 Peace Court Lot 11DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003401 Billed To: Ken Durham Construction Reference Name: Proposed Facility Residence ATC Number: 4058 Tax PIN/EH #: 5777-22-9823. 11 Subdivision Info: Still Waters Lot # 11 Location/Address: Highway 801-27006 Property Size: .8 acre 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�NNSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ,�J/ Date: C� CATE OF COMPLETION **NOTE** The issuance of this Certificate of mpl ionshall indicate the system described on Improvement/Operation Permit has been installed in compliance with i 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in O ,,- en aha guarantee that the system will function satisfactorily for any given period of time.U Septic System Installed By: , /W-, - � �, - " - �f, -e- Environmental Health Specialist's Signature: i'� �� Date: l� DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street c{ 1 7 — Jr Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003401 Billed To: Ken Durham Construction Reference Name: Proposed Facility Residence Tax PIN/EH #: 5777-22-9823. 11 Subdivision Info: Still Waters Lot # 11 Location/Address: Highway 801-27006 Property Size: .8 acre ATC Number: 4058 **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 Specifica ion: Building Type #People #Bedrooms #Baths ` Dishwasher. Garbage Disposal Washing Machin Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seaattis Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD�D v Site: New,121"O'Repair ❑ a GAL. Pump Tank GAL. Trench Width �� Rock Depth Linear Ft System Specifications: Tank Sizs��� 1-03 i l 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.**** Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: Ab - APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERAII AF 0 U Davie County Health Department v Environmental Heath Section P.O. Box 848/210 Hospital Street APR 55 2005 Mocksville, NC 27028 (336) 751-8760 rem„„__ ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE—RL INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Lf ftii+ eta Ct7i� S1/( -,r {/yyl Contact Person Mailing Address/ L7 % �% X Nome Phone ` City/State/ZIP OD 1 F44?J/LJ (2 (� 1\! C �V N Business Phone 3�3 6 5'2zz -7-2 6 � 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/State/Zip ❑ Improvement Permit/ATC Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: WConventional ❑ conventional modified ❑ innovative 6. If Residence:���� # People # Bedrooms # Bathrooms _2— Dishwasher il(aarbage Disposal 8 -w -aching Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0'No If yes, what type? ***IMPORTAN ** CLIEN S MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either LAT or SI E PLAN MUST BESUBAHTTED by the client with THIS APPLICATION. imensious: ► .4 f'eC Tax OfGcc PIN: # �%%"2 Zj/ D 2 3 Property Address: Road Name _ _ City/Zip If in a Subdivision provide information, as follows: Name: 71 —Ln 0 Al C- .9 S Section: Block: Lot: Q/ I WRITE DIRECTIONS (from Mocksville) to PROPERTY: I �4 4--i95f -Y� '50/ L flt.,do o/ % to nT����:.� L, 7 <;�n L e r' 1 D tc 1' come corners it gcd: !y/2 0 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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, understain! that 1 ani responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the D�vj'� County I1caltlj Department to enter upon above described property located in Davie County, nd owned by ^--�- to conduct all testing procedures as necessary to determine the site suitability. L, Li DATE / Z / / SIGNATURE —r TIIIS 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). Sign given Revised DCIID (05/03 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. / Invoice No. V-77 `� 0 a3 PAP LVOT 13 APPLICATION 1`011 SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section N EAP2 6 2001 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIROPt; DAUi, . LTH E_-- _._.._ ***I,MPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. /� 1,, I v 1. Name to be Billed t-IY\A4Pb(� 1S (pAlk pr1'Ot'4f�,Lv Contact Person RotVint-A . L7.T'Y7"1/ti()�j��� Mailing Address 900( ,JAI)OA; V 1IlAre- (+I Home Phone 33C -7.� - J llc2- City/State/ZIP 011JS%U/J-�'itehl_ ! C Z-712� Buzinass Phone 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: ,� Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. System to Service: I�( House,' ❑ Mobile Home ❑ Business ❑ Industry X Other Stt . iV;5ic/J 5. If Residence: # People # Bedrooms 3-q # Bathrooms/L Dishwasher �( Garbage Disposal Washing Machine ❑ 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 O(No If yes, what type? ***IAIPORTANT*** CLIENTS MUST COMPLETE THE REQ►JIRBJ PROPERTY INFOM''%IATiON I.EQUES7'Eu BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: #_,�j 5-177 3 Property Address: Road Name City/Zip �1JCq7(U06 If in a Subdivision provide information, as follows: Name: _ )` I kk o t't-fer s Section: Se Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: -J by SAS+ qO I iur,'l 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 (Ck the 11'5 194V r r;d;' b� 51�1 to conduct all testing procedures as necessary to determine the site suitab lity. DATE �/ j�/lel 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 #: 5777-33-1382.11 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 11 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Ito Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L_ Slope % 5 p HORIZON I DEPTH Texture groupL Consistence �r S Structure Mineralogy HORIZON II DEPTH $ Texture group�-t Consistence Structure Mineralogy1 HORIZON III DEPTH Texture group Consistence -rs Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE Ell CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: f S LONG-TERM ACCEPTANCE RATE: • L� REMARKS: EVALUATION BY: R-u6A hL 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)