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178 Graywood Court Lot 13Account #: 990002162 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 /W �r�l ywod V , Tax PIN/EH #: 5861-38-2199.13 BC Billed To: Bob Cope & Son Construction Reference Name: ATC Number: 3710 Subdivision Info: Redland Place Lot # 13 Location/Address: Redland Road -27006 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 CONSTRU TION S VALID FOR A PERIOD OF FIVE YEARS. /' Environmental Health Specialist's Signature: � )ate: J Z/ 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: ��1 01 V Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002162 Billed To: Bob Cope & Son Construction Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5861-38-2199.13 BC Subdivision Info: Redland Place Lot # 13 Location/Address: Redland Road -27006 Property Size: 174'x 144' **NOff rs iImprovement/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 #People #Bedrooms #Baths- , S Dishwasher: e� Garbage Disposal: 7"' Washing Machine: X 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) 1��46 Site: New;?"Repair ❑ System Specifications: Tank Size /D0� GAL. Pump Tank GAL. Trench Width �� Rock Depth /.Z Linear Ft.1ir%v 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 D_m. ca the day in tallatio . Telephone # is (336)751-8760.**** i Environmental Health Specialist's Signature: Date: -�,MY4 Jpy DCHD 05/99 (Revised) t,API'LICATIO FOIi sm: L-VALUATION/MlPHOV1 IEtYT 11L'11MIT & A'1•C Davie County Health Department - I_JA`- %U ii En 1=111en47111W/t/l SectiOn i?• ` �, . ?!! Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 * * *I!•IPORTANT* * * TIiIS APPLICATION CANNOT DL' PROCESSED- UNLESS ALL THE REQUIIiLll 1 INFORMATION IS PROVIDED. Refor to the INFORMATION BULLETIN for instructions. 1. Name to be Dilled r//8J� lV�17 e-o'l , CO. /' Mailing Address O'Q �2� j/ Q City/State/ZIP &%eme,- NC, '9-?D/c/ 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: Orsite Evaluation Contact Per:;on_�� Nome Phone Dusinous Phuuc City/Sta• "ip Improvement- Pexmit-/ATC lJ ]loth 4. system to service. O House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other _ ti 5. Type system requested: a Conventional ❑ conventional modified ❑ innovative 6. If Residence: it People Il Bedrooms ��/ � Il Bathroom.; l9ishwasher CJGarbage Disposal fat aching Machine easement/Plumbing ❑Da:;ement/Ido Plumbing 7. If Business/Industry /Other: verify type Q People It Sinl:s # Commodes It Showers tt Urinals 11 Water Cooleru IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Type of water supply: YJ County/City ❑ Well ❑ Coirununity 9. Do you anticipate additions or CxpallSiolls Or tile facility this syslelll is inteNded to serve? ❑ Yes CI Nu If yes, what type? 'IMPORTANT' CLIEN'fSri1USTCOAIl'L.ETETIIE REQUIRED 1 ROPLltTY INFORMATION KLQ111"'S' E'D 11BL01V. Lilllera PLAT or SITE PLAN 41USTBESUBMITTED by the client ivilli THIS APPLICATION. Property Dimensions: / "7V X /yy Tax Office PIN: 11 Property Address: Road Nallle City/Zip If in a Subdivision provide information, as follows: Nanf✓ Clc: ej 1/m'4'i a' «C E' Section: Bloch: Lot: V whin DIREC11ONS (fl'urll Mudisville) to 1'R01'I;It'1.1': Date ]ionic corucrs flagged: This is to certify that Elle ]nfornlation provided is correct to the best of illy knowledge. I understand that any perNril(s) issued hereafter arc subject to suspension or revoca(]on, if the 51te plans or intended use cll:lig q 0 if t11c ill furuclliurl subulittcd in (leis application is falsified or changed. 1, also, understand drat I aur rcal�unsiLlc fur al! c/rur3 cs luau rrd %r uu; thus application. I, hereby, give consent to tllc Aulllorized Representative or lilt 1):n•ic Cuullty Ilealtll 1)cp:u•(uluwit to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to detel•Illine the site su]ta ity. DAT'LSIGNATUREZ�.f� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLANelude all of tlic following: Existing and prop used property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCI (05/03 Site Revisit Charge Client Notification Date: ERS: Account No. S o0+ 2'"��' Invoice No. 1-10-73 0l = „ 8/E 1: r ./i , bl ' E 4 1 r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department EnvifwmentaiHealth Section DEC P.O. Box 848/210 Hospital Street 3 2��2 Mocksville, NC 27028 (336) 751-8760 EIVVIRpNMEN �AVIfCp�1 yFA[Ty ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 2 Name to be Billed Mailing Address City/State/ZIP 4 12 -5 e Name on Permit/ATC if Different than Above Mailing Address Contact Person r / Home Phone Business,Phone City/State/Zip 3. Application For: 911 ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: -use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ID, Dishwasher 0 Garbage Disposal ❑Washing Machine Basement/Plumbing 11 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: aunty/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? EHYcs ❑ No If yes, what type? t**IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED 3ELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name. 21—Z40J, City/Zip If in a Subdivision provide informatioq, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 2/7 241 1.� ,1�-vu- Nam`,, e: ,s .fir � Section: Block: Lot: -&-C_ r 13 Date Property Flagged: 1i;7 —3— e �— 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 Davie County Health Department to enter upon above described property located in Davie County and owned by ,(ffl�;p�f�✓�tltt15 to conduct all testing procedures as necessary to determine the site suitapility. 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. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT : Environmental Health Section Soil,/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5861-38-2199.15 Subdivision Info: Louise Smith Adams Lot # 15 Location/Address: Redland Road -27006 see map Date Evaluated: 12 �Z3 �D2--- Community, Auger Boring Pit Public .--," i Cut FACTORS 1 3 4 5 6 7 Landscape position Slope % LA HORIZON I DEPTH Texture group —G Consistence ; SV S . Structure lk g Mineralogy I' HORIZON II DEPTH 2to Texture group Consistence 5 5 Structure k Mineralogy1 1 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 1 O 3S• 0. ID SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RA' REMARKS: LEGEND EVALUATION BY: ")Cfr OTHER(S) PRESENT: 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) on on ME ■ ■■■■■■■■ee■■■■tet■■■■■■■■■■t■■■■■■■■■■■■■■■■■■■■t■ ■■■■■tee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■t■tet■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■t■■■■t■■■■■■■■■■■e■■■■trete■■■■et■■eee■■■■■e■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■tt■eet■■■et■■rte■e■■et■ete■te■eee■et■■etttee■ ■t■■■t■■■■tree■■�i■■■ee■■■e■■ee■■■■■t■■eeee■ee■e■■ ■t■te■tet■■tet■■■t■■■■■■■■■■■e■■■■t■■■■■■■■■■■■■■■ ■t■■e■tett■■■■t■■e■■■■■■■■■■■■■tteeet■tttee■■■■■t■ ■et■t■tet■■■■■■■■■■■■■■■■■t■■■■■■■■■■■■■■e■■e■■e■■ ■e■ee■■eee■eee■■■■■■■e■■e■■ee■ee■■eee■■■■■ee■t■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■te■■■■■t■■■e■te■eee■et■te■■e■e■■■ee■■■eeeee■t■■e■ ■■■■■tet■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■e■■■■■■■■ ■■■■■■■■■■■■ere■■■cert■■tt■e■■■■■■■■■■■eeet�e■■tt■ ■■■■■■■■■■et■t■■ ■■ett■■ee■■et■tt■ee■■■eee■■te■t■ ��.■■e■■eee■thee■:apt■■■■eee■e■e■eee■■e■eeeetee■ e■■ ■t tett■■■ ■tet■■■tet■ � \��It thee■ ■■et ■ ■■■■■■■ ■■■■ ■tet■■■e■■■■e■■t■■ettttttt��ttt■■tt■ett■■■et■=e■■t■ ■■■■t■ee■■t■■t■te■■tee■■c�■■tett■■■■■■tett■■ ■■■■■ ■■■■■t■e■■et■tete■t■e■■■■■■■■■■■■t■tet■■eee■■■■■■■ �ttttt■�■ttttt�■teett�iettett�ittee■■�ittteee� eetttt■■■■■■■t■tt■■tete■■ee■■t■■t■■■■■■■■■tttttttt tt t tt ■■■■ ■■tet tt■ttttttttttttttttttttt ■■ t ■ t t t tett t ■t■tett■■■t�■■■■■■■■■■■�,■■te■■t■■■■■■■■■■■■■■■■■■■■ ■■■■■■■e■■i�e■■■e�■■■■�i■■■tett■■tet■■■■■■■■t■■■■■■ ■■■■■■te■■ire■■■■■■■■■■i�■■■■t■■t■■■■■■■ee■eteeete■■ ■et■■■e■■■�:�■■■■::::o�t■■t■■tet■■■■■■■■e■■■■e■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■e■■e■■■■■tee■ee�■te■ee■■eee■e■■e■■■■■eeeeeeeett■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■tet■■■■t■■t■■■■t■■■ee■■■■t■ttt■■■ ■■■■■■tt■tt■■■■tt■tee■ee■■■■■tt■e■■■t■t■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■t■ere■■t■■t■eet■■■■■■■te■ee■■■■■■■ ■■■■■t■■■■■■■■■■ ■■■■■■■■■■■■■tet■■■■■■■■■■■■■■■■ ■■■t■■■■■■■■■■rte■eee■■■tt■■■tttte■e■■eetttt■■■■e■ ■■■■e■■■■■e■■tee■■■■■■■te■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■te■■t■■■■■etttteee■■e■■■eeeee■ ■rte■■t■■e■■■■■■■■■■■■■■■■t■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tet■■■■■■■■■■ ■■■■■tet■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■t■■■■■■t■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■t■■■■■■■■■■tt�i■■■■■■et■■■t■■■ee■■■■tet■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■e■■etre■■■■■■■e■■eee■e■e■■■eetttt■■■e■t■■e■■■■■ ■■■■■■etttte■■■■tet■ere■■e■tt■■e■tt■t■■et■tee■■■■■ ■■■■■■■■■■■■■■■■■■■■■■t■■t■tt■■■■tt■■■eee■■eee■■■■ ■■■■■■t■■■■■t■■e■■■■■■e■■e■tt■■■tet■■■■t■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■