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165 Meadowlark Lane Lot 16DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002222 Tax PIN/EH #: 5822-97-3654.16 RA Billed To: Tycor, Inc. Subdivision Info: Whip O Will Lot # 16 Reference Name: Location/Address: Proposed Facility: Residence Property Size: 5 + acres ATC Number: 3110 **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 #People_ #Bedrooms _ #Baths o� Dishwasher: 2'*" Garbage Disposal; Washing Machine: Basement w/Plumbing:Rr Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seatats Industrial Waste: ❑ Lot Size Type Water Supply _ Design Wastewater Flow (GPD) �6 Site: NewRRepair ❑ System Specifications: Tank Size AOao GAL. Pump Tank/PP 0 GAL. Trench Width sW Rock Depth �E Linear Ft.� 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). 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. /y�/�,. 1 ' Environmental Health Specialist's Signature: Date: 4/-.2 `? 2- DCHD 05/99 (Revised) Account #: 990002222 Billed To: Tycor, Inc. Reference Name: ATC Number: 3110 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5822-97-3654.16 RA Subdivision Info: Whip O Will Lot # 16 Location/Address: Size: o + 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 WASTEWATE O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �• AK Date: -;V 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 Inst Environmental Health Specialist's Si DCHD 05/99 (Revised) 2 V L..^.� ENVIRMWNTAI HEALTH IN FOR SITE EVALUATION/IMPRGVEMENT PERMIT & ATC Davie County Health Department EnvifonmentaiHeaith 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 ", Q, k Nc. Contact Person Mailing Address ,.`,��2 Home Phone City/State/ZIP ,Q,..J�c7�S 1w� 7710 'L Business Phone 2. Name on Permiat/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation M Improvement Permit/ATC ❑ Both 4. System to Service: ZHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _L_ # Bathrooms ZYZ I/Dishwasher Garbage Disposal F,(Washing Machine Id Basement/Plumbing LI Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U -No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: _ s- NLR% Tax OfficPIN: # ��ZZ�1 �„S�1 I � PA Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: V��►�-�t`�- \'u\ Section: Block: Lot: \U WRITE DIRECTIONS (from Mocksville) to PROPERTY: `ub\ 7 L fid. -� 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 ani 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 to conduct all testing procedures as necessary to determine the sitesnitabilit DATE SIGNATURE NT 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,k- a" O Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. ZS / APPLICA750N FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department �✓ Environmental Health Section P.O. Box 848/210 Hospital Street ' 7 2000 Mocksville, NC 27028 (336)751-8760 ***1WORTANT*** THIS APPLICATION CANROT BE PROCESSED UNLESS ^aIY INFORMATION IS PROVID]E�D. Refer to the INFORMATION BULLETIN for instructions. �) 1. Name to be Billed `I It, `, ✓inr� �o �^Sdi✓ 1- � . Contact Person �kk,,,,, V� Mailing Address -el 7727 0 7^ Home Phonal -1 o ` 2 (9 LI City/state/ZIP �sL� / W Rosiness Phone 2. Name on Permit/ATC if Different than Above_ Mailing Address / City/state/Zip 3. Application For: E3 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: O/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 61 , 5. If Residence: # People # Bedroommss � # Bathrooms _/� U/Dishwasher ❑ Garbage Disposal t3 hashing Machine t0 Basement/Plumbing O Basement/No Plumbing I-AaSJ_ ""'tel► 6. If Business/Industry/Other: specify type # People # sinks # Commodes # Showers # Urinals # hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: w/ounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # Property Address: Road Name City/Zip M c J,25 L- 27 Q:9 If in a Subdivision provide information, as follows: Name: W) ,!.- - (9 — �t� raW/ ✓v—S Section: Block: Let:.1� WRITE DIRECTIONS (from Mocksville) to PROPERTY: :{ nw,, 'x%117 7,-,12' J Date Property Flagged: 7r Z ^- o - 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 1, also, understand that 1 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 to conduct �all ltesting procedures as necessary to determine the site sVitFbility. DATE 1 / l '7 /�i�7 SIGNATURE / _Z THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN'Unclude all o1Jh ffojeMng: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS• Revised DCHD (07/99) Account No. 3-6 Invoice No. 7- 00 ,r G- �3 2-t' LAKE \� 5.afll'7 iG" c� CY � : V S LL A.( -r r Z 37 P ��1 t M Cl- f� N •e NO •> n1 N o co `• 0 LA • Q � G o � ��� L 54kpI 5- US �D AREA FROM FENCE_ TO / EDGE OF ROAD IS COMMON AREA -70 tee- Iv Q O r 55 W 5NEET e V0 1..'Application/Permit Requested Mailing Address Home Phone i0li- aa -S -(401 `1 I 5� Sas 1-�-! 63 Business Phone"'t )0- � 2. Name on Permit if Different tpan Above 3. Application for: ❑ General Evaluation peptic Tank Installation Permit 4. System to Serve: U, 140 -u -Se ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision l-°� O O- O- W ` 11 Section Lot # 4�! No.,of People No. of Bedrooms `T No. of Bathrooms J '/-z- Dwelling Dwelling Dimensions � 100 5 44-:: 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers asement/Plumbing ❑ Basement/No Plumbing C7'GVashing Machine C -Dishwasher arbage Disposal No. of Showers Water Usage Figures 7. Type of water supply: LWI°ublic ❑ Private ❑ Community i. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2'No If yes, what type? 'NOTE: mprovements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. ; 1 Directions to Property: �o � s 6 r Ca r\ C. 12-A 4 W . �- `a r e; Oo 4 ( o� V b r\ c L42+ b ee Lo r -Y S�-v�co 0"e k0QSC--- This is to certify that the information provided is correct to the incurred from this application. Q - ) �,-�S DATE PROPERTY INFORMATION REQUIRED: Tax Office PIN # TfQ OCA TL P/0 3 Road Name 'a Tim G-L� Box # (if available) City apLL, �► mlo) �lo�gaa-� of my knowledge, and I understand I am responsible for all charges SIGNA' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY 1 ull� MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 todeter ine said site's suitability for a ground absorption sewage treatment and disposal system. — ) -) , V�- - / S- C.,� DATE SIGNATOR DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 42c .✓ > ADDRESS PROPOSED FACIILTY 4V.S`Y DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public_ Evaluation By: Auger Boring_ Pit Cut FACTORS 1 2 3 4 Landscape position ,I— Slope Slo e % 1 0 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 E_�'_ 1-2 1 SITE CLASSIFICATION: /l_� LONG-TERM ACCEPTANCE yATE: REMARKS: DCHD(01-901 EVALUATED BY: PTHER(,$) PRESENT: Z.iffiAiAN 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V ---.-y 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 3C -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 Davie Caunfv Nealtvi Department and dome Xealtlr Ayency 210 HOSPITAL STREET / P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-5096- 7160 January 26, 1996 Tony & Judi Tonti c/o Shannon Conrad 3411 Healy Dr. Winston-Salem, NC 27103 Re: Site Evaluation Whip-O-Will/Lot 16 Dear Mr. & Mrs. Tonti : As requested, a representative from this office visited the aforementioned site on January 25, 1996. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R. S. Environmental Health Section RH/wd i Enclosure DAVIE COUNTY HEALTH DEPARTMENT %�� 02 C-) Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001309 Tax PIN/EH #: 5822-97-3654.16 Billed To: San Filippo Companies Subdivision Info: Whip -o will Lot # 16 Reference Name: Anthony San Filippo Location/Address: Proposed Facility: Residence Property Size: see map ATC Number: 2511 **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. i Residential Specification: Building Type # #People #Bedrooms #Baths !Z S Dishwasher: RT"' Garbage Disposal: ❑ Washing Machine: ET Basement w/Plumbing:;2" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size IV— Type Water Supply Design Wastewater Flow (GPD) —11fd Site: New Repair//❑ System Specifications: Tank Size Z25'� GAL. Pump Tank'? -5Q GAL. Trench Width C � Rock Depth / ? Linear Ft. 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 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: zzooa Date: Y/-? ),61 DCHD 05/99 (Revised) DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001309 Billed To: San Filippo Companies Reference Name: Anthony San Filippo r1upubvu rdullny. rCeSluefll:e ATC Number: 2511 Tax PIN/EH #: 5822-97-3654.16 Subdivision Info: Whip -o will Lot # 16 Location/Address: rrupeny We 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: 0"� ' Q� 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: