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148 Peace Court Lot 5` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section /41 P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003738 Tax PIN/EH #: 5777-33-1382.05 GW Billed To: Gary Walker Subdivision Info: Still Waters Lot # 05 Reference Name: Location/Address: Highway 801-27006 ATC Number: 4201 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 UCTIO IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � �S 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 m N en as a guarantee thesystem will function satisfactorily for any given period of time. c Septic System Installed By: 1^ Environmental Health Specialist's Signature: v Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 v (336)751-8760 L IMPROVEMENT/OPERATION PERMIT Account #: 990003738 Tax PIN/EH #: 5777-33-1382.05 GW Billed To: Gary Walker Subdivision Info: Still Waters Lot # 05 Reference Name: Location/Address: Highway 801-27006 Proposed Facility Residence Property Size: see map **NO� � IsTmprovement/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 'y #People #Bedrooms -- #Baths Dishwasher: / Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seatss Industrial Waste: 171Lot Size Type Water Supply �)D Design Wastewater Flow (GPD) .fid Site: New 0'0" Repair ❑ System Specifications: Tank Size y/"26AL. Pump Tank GAL. Trench Width��'Rock Depth Ay Linear Ft.1010 Other: An st&ted in 15A NCAC 18A.1989(5) 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: / Date: DCHD 05/99 (Revised) SEP -1 L Ipw 'r tv" �w t / ,PRY WAKER INC 336 349 8436 TO:13367518786 P.1�1 ,i7a a+avte county envnealtn .ap 101 o.no Y•+ 1411,ulA110N TOD SM EVALUATION/IAIPI[C 1FAItNT MAW & ATL' Davla County HeaRh Dcpi Itmont EnyfrwMenralAwlfh S rclion P.O. Do= 541/21U eoapiru1 dtseet nookov111ar NC 21)211 (936)751-8760 SEP e•eiYDfJIRTdtA'eee Ts29 APPIACATTON CAAMTT 09 Pto=.." 8D 11218-19 ALL TEE RVUZ= IW108101T102f itl PAOVIDSD, meter co the xNromn►rro t t1 ML=XV for innrruc �MRa� 2�+taeo to be 10412"10412" ,�l{ lllf ,t,+ i li l l� .rI_ "hiewc #.easy. v L,)tani.4 Awress SffiZidt`,M.,ig� I Ci .bone .3314_(v ✓ L.s.��. City/ttato/9V. �3 t.alasea shone �A. "gaaa on rerale/AiC If Atfieraat thea AbDra Jtrsllna mare.. Appiloatioa ro:r 0 9See Rraluation �--� irm,ial. to sarrseat kV Louse 0 Mobil* Mme `j+' Tram, erec" raavaaoede X eonvantleAa - -.0. 3.9Assid.ua.0 a ►ooplo ��C11t.tY/St-te/aip X( %wi aveRanc Perstit/ATC 13 Doth D ousi lose 0 Iaduatry O Other 13 eoae.Atim,am,l a dis'sed D iwnwatt.a 83acceptad ,/ 0 aedrota M� a IIathzaoattl� �Lm,b.aaaar OoL&aoo pispcXl wl tuhlep lteealae On usaeast/rlwrinp Oo.e.srur/s. yi.waase 1. SI waine0a/industm7 /other# vorsfy type a People a stale 0 coew.e.taa a ets.ar■ a Vein: to a xator coolers tit 100IMM MCS( / Costa Satimaw Ne car IIsage (halloos per dart L1Y. zrpe of .star a:gplr. l7 County/City 13 we: 1 0 rlomswity L.&!' D. YOU m,aticla.c. ft"mem,a at expandens of the focatty Wit sytt. at Is bltauled to set re? D Yet 1Jo / � 11 eJ !PORTANT" am, CLItiNI`i CofifpLSTZTIIZ if6QU/Ri 7 r+rOr6RTY INYORMATION RSQUCSTKD n___0_.-Zkberjrt,A1*or.%rr LAN A114frOBSUDMIYIED by 11.e t/tNfnt with T1119 AP►LICATION. l /Properly Uhnent)npa: Ci aM, out W- 'IONS (fropt Mae twilit) to rRomILTY: prelierty AJdre u. Road Cltymp it to a Subdivision prrovWc Intormaitm, as tollowi. Name: �„ 1�],,Lylak Cf Section' Bloett Lot 4__v*tv1 orae comers natCat. 7 COUNry% 'Ills Is to certify &bat the ioforMatles provided it correct In 1La best of 1117 knowledge. I ooderltand that spy psrmills) (stand bct'raher are subject to suspetulon or revocation, tr the site pbna o • Intended oto ehaurc, or If the tafar=11011 subluiticd W ibis application is falsiGcd ey chnged T, alto, nodos/and Ik x/ da+ nespaa ;bfe%nrdl clrsrrrs IRurrsJJrv#e rkiT afrilesilsp, 1, hereby, Civs consent to the Autlearized Itepresentative 4tba Davin County 11031111 D"I"Wi tmt to enter upon above described proper _- located in Dario County and esrn:d LY to ronduc(a17 Icsthip yrocoJurds as nerarsury to determluo the site suit* ity. TnIS ARBA MAY DE USr.A FOR Ult,MNC YOUR SM PIAN (lad de all of the folio Ing. uslin=aud proposed property lines and dimetulant, structures. satba" and cellos IOC1160111 . Site L(Crlslt CAarte Dalc(s): Client Mollification Lab: VIS: �. Armrnt tea. Sirs givfu Peapod DCND (I)SM3 1avoite No. —;5;7 3 S ow.'W APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATI; ro Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 EAPR2 6 2001 ENV(ROI ` •� :iLTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions - 1. 1. Name to be Billed AMPbejlIs � ' f I PMP,?t7fl' , INCContact Person RC)t,;�}�79 ��� Mailing Address ��(](� .SAti) no�/ 1 ��t e- C+. . nome Phone 33C — 7 95 - R -!7t 2— City/state/ZIP ��ltis "U/J- JftIPM _ Ak 17121 Buzinass 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: (l( House* ❑ Mobile Home ❑ Business ❑ Industry 11( Other 6,k �v 51'ct✓ 3 ` # Bathrooms '/ s. If Residence: #People #Bedrooms �_ ,� •�:� Z 'Dishwasher Garbage Disposal Washing Machine O Basement/Plumbing Ix Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # People # Sinks # Urinals # 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 W No If yes, what type? ***IMPORTANT***.CLIENTS 111 UST COMPLETE THE RBQUIP D PROPEILT`; INFOP.%!ATiaN REQ'V'ESTEIJ BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: � Tax Office PIN: # . 5 --777 3 3 - I , 2 () � Property Address: Road Name City/Zip A o'4"CZ1. dCM06 If in a Subdivision provide information, as follows: Name: Yti ll I Section: aostj. WRITE DIRECTIONS (from Mocksville) to PROPERTY: 6q e11w, Rv I , i On) ceeA V - M'I (e c t.% v 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. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the 19 avie County Health Department to enter upon above described property located in Davie County and owned by C.AAMIR,W5 lualiL,, Pry :TNr to conduct all testing procedures as necessary to determine the site suijab lity. Ct DATE �I j0{ �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). l V Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. \.q Invoice No. POW OAPPLICANT INFORMATION Account #: 990001720 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation Billed To: Campbell's Quality Properties, Inc. Reference Name: Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5777-33-1382.14 Subdivision Info: Still Waters Phase 1 Lot # 1'U Location/Address: Hwy 801-27006 1 Property Size: see map Date Evaluated: t a/ Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L� Slope % HORIZON I DEPTH - Z Texture group Consistence c S Structure Mineralogy I HORIZON II DEPTH Texture groupCiT Consistence Structure Mineralogy HORIZON III DEPTH - Texture group C Consistence Pr SS Structure Mineralogy< HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION r5 F-5 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: V,5 LONG-TERM ACCEPTANCE RATE: O - `� "J 0' REMARKS: LEGEND Landscaue Position EVALUATION BY: E4U_-"4 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)