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159 Peace Court Lot 9DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003401 Billed To: Ken Durham Construction Reference Name: Proposed Facility Residence ATC Number: 3917 Tax PIN/EH #: 5777-33-1382.09.KDC Subdivision Info: Still Waters Lot # 09 Location/Address: Peace Court -27006 Property Size: .7 acres 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 1 / CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ,e Z Date: `/ 0 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: a &. ;Xe -, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section a S P. O. Boa 848/210 Hospital Street <� Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003401 Tax PIN/EH #: 5777-33-1382.09.KDC Billed To: Ken Durham Construction Subdivision Info: Still Waters Lot # 09 Reference Name: Proposed Facility Residence Location/Address: Peace Court -27006 Property Size: .7 acres ATC Number: 3917 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 / #People #Bedrooms '--2 #Baths Z Dishwasher: Z/ Garbage Disposal: ❑ Washing Machine: 7r, 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: NewXr Repair ❑ System Specifications: Tank Size, -,4y GAL. Pump Tank Required Site Modifications/Conditions: CI GAL. Trench Width Rock Depth Linear Ft. '� �� 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 am. 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) DE C E " EATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department NOV 2 2004 Environmental Health section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Et4mmv, ENTAIHEAUH (336) 751-8760 7. If Business/Industry /Other: verify type # Commodes # Showers IF FOODSERVICE: # Seats 8. Type of water supply: I13/County/City # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? lb'No ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli THIS APPLICATION. Property Dimensions: , :Z fl C e e S WRITE DIRECTIONS (from Mocksville) to PROPERTY: c _ ii Tax Office PIN: # 57-7�, — 3 3 - (3 9a K s(9 En- S f T,4 v ''► ek" Property Address: Road Name &FAL-e l.1c", /01'. a uAna- .•700 - m i e -Pi City/Zip ( r v � If in a Subdivision provide information, as follows: Name: 7 T l f; t'. � *'SMPORTA1VTw w w INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL PROVIDED. Refer the INFORMATION BULLETIN for THE REQUIRED instructions.] Section: Block: I q Date home corners flagged: %/ %t / o z/ Ito 1. Name to be Billed Ile 111 I_J Ajt�: cj4 `EN�j•If,-:Cf�u�Contact Person Q/rl �M ✓� �C A— Mailing Address 3L, x �J G.. Home Phone 3'3 2�j� y — p� 69 City/State/ZIP (!� �n Fe e yy► e f / l ti o�7U Business Phone 6, / y O '� 6 a G L 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both `Business 4. System to Service: 0house ❑ Mobile Home ❑ ❑ Industry ❑ Other S. Type system requested: P Conventional ❑ conventional modified ❑ innovative -?# 6. If Residence: # People Bedrooms #Bathrooms dishwasher ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers IF FOODSERVICE: # Seats 8. Type of water supply: I13/County/City # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? lb'No ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client witli THIS APPLICATION. Property Dimensions: , :Z fl C e e S WRITE DIRECTIONS (from Mocksville) to PROPERTY: c _ ii Tax Office PIN: # 57-7�, — 3 3 - (3 9a K s(9 En- S f T,4 v ''► ek" Property Address: Road Name &FAL-e l.1c", /01'. a uAna- .•700 - m i e -Pi City/Zip ( r v � If in a Subdivision provide information, as follows: Name: 7 T l f; t'. ►�✓ 7 r� Cz S Section: Block: Lot: q Date home corners flagged: %/ %t / o z/ 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 inncurred fronn 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 procedures as necessary to determine the site suitability. / �I DATE ,' SIGNATURE >` �'"Vl (-�Zk✓�—�� 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). CatL U Sign given Ay O Revised DCHD (05/03 CAXT (:"-k a"--- a l�- Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. APPLICATION F011 SITE EVALUATION/IRIPROVEMENT PERMIT & ATC -� Davie County Health Department Enwronmental Heaft Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 [APR 2 6 2001 ENVIROI:;' iLTH DAVIT ***IIdPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed /�,►`/Olk II 5 Au A , r '116 f Pa Mttfi f S+ 1 'C Mailing Address �ou� SfiAOti: V l�i{l C 1 . city/state/ZIP ai&Ato") .Al Z71 2I 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person oatlic� b�-T7✓un62tt Home Phone 33 G— 795-- J �� Buainoss Phone City/State/Zip 3. Application For: X Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: X House, ❑ Mobile Home ❑ Business ❑ Industry Ix Other Sit ,V;SicrV 5. If Residence: # People # Bedrooms 3-q # Bathrooms ,;Z -- A. //- ADishwasher �1'Garbage Disposal {'Washing Machine ❑ Basement/Plumbing K Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers IF FOODSERVICE: # Seats # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) 7. Type of water supply: J County/City ❑ Well e. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes O(No ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIPMD PROPERTY INFORMATiON REQUIMi i -ED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: #_ l •%� 7— — M,2 L� v Property Address: Road Name b D r City/Zip ��i,�A+vr e nlC7v06 If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPElrl'l': 0 b y P A 2f -1-0 JAW qO L i u "/ rl ' ' kf P+"'A on) reeA 111- "tie of-' e4, Name: _>+I « 1� 4 Section: flffk Block: Lot: 1— 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 frons 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 11, �ua�� Pru` zrfi to conduct all testing procedures as necessary to determine the site sui)ab lily,.�% DATE 3 j0 6I SIGNATURE cc�( 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—a Revised DCHD (07/99) Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001720 Billed To: Campbell's Quality Properties, Inc. Reference Name: Water Su 1 AT�Rumber: Evaluation By: On-Site Well PROPERTY INFORMATION Tax PIN/EH #: 5777-33-1382.19 Subdivision Info: Still Waters Lot # 19 Location/Address: Hwy 801-27006 ��`DI D� Ornnorhi Ci -7c• i-7• emn Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH - fl Texture group -7 Consistence Structure Mineralogy ; 1 HORIZON II DEPTH © _W Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group r_+03314 Consistence ' Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �S .r— LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscaae Position EVALUATION BY: vjt IL� M-,)C44A-) t" 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) CH- '26.5a' �. . L � R= loo 41"E 0194.51 1 S' Q �VEa _�. 4 51' TO"T AL) Nsg'57 41 E X19 119.8 0-7 0 �• o ��� 30, v 0. __...- �89.3�'pf BEEN NA 4�' WITH 2 - • 7HE APPR DEED RECO tTi'7ninr►r. ..n .......--- ._ 1 -7t'A�ua APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Q �� Davie County Health Departments 2 6 2�� Environmental Health SectionI [A P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIROfd' is ' 1C (336) 751-8760 DAVIE ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PR/nO�VInnD((ED. to the INFORMATION BULLETIN for instructions. 1. Name to be Billed /Refer �rll1�{'6�LLis [11(L l PYCiPe4ififF , �jJ C. Contact Person 'ROliAU(J� Mailing Address l 9000 )A OA;``; 01 1 ke- �-'7I Home Phone 33 (0 -7g5 City/State/ZIP i/ tov -.]Fi Ai NC Z (IZ� 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: �( Housed' ❑ Mobile Home ❑ Business ❑ Industry Other Si{ . ,v 5ird !% s. If Residence: #People #Bedrooms 3 -q # Bathrooms_ ,,� •- :� Z ADishwasher X Garbage Disposal K Washing Machine 6. If Business/Industry/Other: Specify type ❑ Basement/Plumbing K Basement/No Plumbing # 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 s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O(No If yes, what type? ***1A1P0RTANT*** CLIENTS 111USTCOMPLETETHE R-rQU!Pr-n PROPERTY 1NFO101ATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: #, 5--7-7-7- 3 3 — I Ma - o I Property Address: Road Name q w � City/Zip A 0An1cZ /)(27006 If in a Subdivision provide information, as follows: Name: S+t « U) A -kr S Section: 041SC.1 Block: Lot: WRITE DIRECTIONS (from Mochsville) to PROPERTY: &A pa ceeA i1L M i (e) 01i 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 theavie County Health Department to enter upon above described property located in Davie County and owned by �wt!1P(�iuA�U��z, ie:iN< to conduct all testing procedures as necessary to determine the site suitab lity. ,(Q DATE �/ �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). Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. I I2° 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 #: 5777-33-1382.09 Billed To: Campbell's Quality Properties, Inc. Subdivision Info: Still Waters Phase 1 Lot # 9 Reference Name: Location/Address: Hwy 801-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: 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 ©• © r Texture group G Consistence C Structure Mineralogyh I HORIZON II DEPTH Texture group Consistence Structure MineralogyI 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: f s, EVALUATIONBY: T�"L)"Ao l LONG-TERM ACCEPTANCE RATE: tom` OTHER(S) PRESENT: REMARKS: JP& r.�o iU7A-- LEGEND Landscaue 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)