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147 Peace Court Lot 10DAVIE COUNTY HEALTH DEPARTMENT n . Environmental Health Section J P. O. Boa 848/210 Hospital Street / Mocksville, NC 27028 (336)751-8760 Account #: 990001881 Tax PIN/EH #: 5777-33-1382.10AH Billed To: America's Homeplace Subdivision Info: Still Waters Lot # 10 Reference Name: Location/Address: Peace Court -27006 Proposed Facility: Residence Property Size: see map ATC Number: 3340 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� Date: Z— 1, —O9 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. IDD'k 45L?� >- I�r'k DATE t2-(� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT 4 Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT I!:70 Account #: 990001881 Tax PIN/EH #: 5777-33-1382.10AH Billed To: America's Homeplace Subdivision Info: Still Waters Lot # 10 Reference Name: Location/Address: Peace Court -27006 Proposed Facility: Residence Property Size: see map ATC Nurpber: 3340 **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 q #People #Bedrooms #Baths 1 Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: El Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New,2alRepair ❑ System Specifications: Tank Size& 6 GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width3�(I Rock Depth�I Linear F&&*940 { 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 1.12_2.m onlhe da_ y of installation. Telephone # is (336)751-8760.**** D F Environmental Health Specialist's Signature: Date: / �/o (/ DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION IhIPROVERIENT PERRUT & ATC ' �✓ Davie County p Health Department "y�l Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �C/�-(/) S I10AI � ly-LL, Contact Person & E� hvnC (k g �l�T ✓ Q ✓ 1 / C1 ( . (� C ;"�nIc/A/�(�/ Flome Phone _Td? SGT Mailing Address / / City/State/ZIP GI%itlSZ)/1/-C/� i^'),1(�C ��%7'/Q3 Business Phone (� 6r,-51-5.5 2. Name on Permit/ATC if Diffe/r�e//nt than Above Cl/Ie %Zn p�le-T 7 ,,/ ( �/ Mailing Address 57%3 _6Yz!g r ,fid City/State/Zip _fj -T 76 U 'Sa(C-m,,vC a7/o7 3. Application For: ❑ Site Evaluation Improvement Permit/ATC IrT Both 4. system to Service: &/House ❑ Mobile Home ❑ Business ❑ Industry I I Other 5. If Residence: # People'�t # Bedrooms 3 # Bathrooms IJ Dishwasher ❑ Garbage Disposal 11 Washing Machine LI Basement/Plumbing II 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 I Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? t7 Yes ❑ 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 APPLICA'T'ION. Properly Dimensions: 50/rt ,7� /7 J/ /il 3) /�I ITE DIRECTIONS (from Mocks -dile) to I'lu)1'E'RTY: -11 Tax Office PIN: # S? 1' 3 3 3 Y z �,k t�C—_ /�� ZA (-Ll---D / ✓lc -P Property Address: Road Name I✓r- Act 4-1;u eT City/Zip /�('�I�/r�illC�:27606 .00 If in a Subdivision provide information, as follows: Name: za Ch/ Section: Block: Lot: Dale Property Flagged: ed: oZ P Y bg This is to certify that the information provided is cor ct to the best of my knowledge. 1 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 iuc•urr•ed front this application. I, hereby, give consent to tltc Authorized Representative of the Davie County Iicalth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suytabilily. / DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PI/AN (Include all of the fol%wing: Existing and proposed property lines and dimensions, structures, setbacks, and septi locations). Revised DCHD (07/99) r� �63 F- ,__d Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. �c Invoice No. n6 I9q-1 m 0 3S � rorn g 13 � f to � P ecL c C Cour-k iR/ LTpOaT,611�CIS r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001881 Billed To: America's Homeplace Reference Name: Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5777-33-1382.17AH Subdivision Info: Still Waters Lot# 10 Location/Address: Peace Court -27006 Property Size: see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % 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 RATE: 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) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC U Davie County Health Department Entrironmenfal Health Section EARP2 6 2 M I P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIR01 `4TH (336) 751-8760 DAUI ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed CAI\ r/u/rI%(�,((S 1 01,1( 4 Pry F�UL Contact Person ,Ryt,;IIC�l7Q Mailing Address A00 ,)4 opL 01 1(164e- �+. Home Phone 33 (,' / Q5 - 374,L City/State/ZIP 11K ko/J- -kWeAk . / Business 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: IJ( HOuse,' ❑ Mobile Home ❑ Business ❑ Industry fX Other S(A . 1'V;51on/ 5. If Residence: #People #Bedrooms 3-4 # Bathrooms ,-2, --,A '14 ADishwasher X Garbage Disposal � Washing Machine 0 Basement/Plumbing q( 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 Y No If yes, what type? ***IMPORTANT*** CLIENTS M UST COMPLETE TH E RBQUII?.I:D PROPERTY INFORI MATiON RE, QUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: M,-2 10 Property Address: Road Name HW City/Zip IJCR70o6 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 4-I e y u s+ +0 Y'I an CEPA 114 eAi(c? oti �e- Name: DrjulrS Section: AOL Block: Lot: a 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 1 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the )avieCounty Health Department to enter upon above described property located in Davie County and owned by CW & it, �al� PT rtT4�'r�i� %Nc' to conduct all testing procedures as necessary to determine the site suitab lily. ,�Q DATE 3/ j0I SIGNATUREsv • \ 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. 1-7 z° Revised DCHD (07/99) Invoice No. r _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001720 ` Billed To: Campbell's Quality Proper#ios, Inc. Reference Name: Proposed Facility: Residence Property Size Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5777-33-1382.10 Subdivision Info: Still Waters Phase 1 Lot # 10 Location/Address: Hwy 801-27006 see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % 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 RATE: REMARKS: l LEGEND EVALUATION BY: OTHER(S) PRESENT: Landscape Position 'v 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)