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300 Meadowlark Lane Lot 23Pd 4 • i,. d, •.� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001694 Tax PIN/EH #: 5822-95-0706 Billed To: Rick Stover Subdivision Info: Whip -O -Will Lot # 23 Reference Name: Location/Address: Meadolark Lane -27028 Proposed Facility: House Property Size: 5.079 Acres ATC Number: 2808 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 CONSnUCTION IS VALID FOR A PERIOD OAF/FIVE YEARS. Environmental Health Specialist's Signature: 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 I 1 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. r -- Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section SECTION L LOT 2 Soil/Site Evaluation DATE EVALUATED APPLICANT'S NAME � _ PROPOSED FACILITY - PROPERTY SIZE SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring L/ Pit ROAD NAME Public I --- Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG' Consistence i Structure lG 2 Mineralogyr ' 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: EVALUATION. BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND 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 (01.90) VMnC,, Vff, V► rL-.- I b. mow J t "a or sump I Ragsbaoon Nu bw' 2527 1 Saar or Sump W comm.ss'on •■moss f a • .11.c WHIP -0 -WILL LAND 6 CATTLE COMPANY SGSWW ASSISTANI aooa 3 MV010M Of LOTS ! 24 AAWTJAMAL Q fOW AC, TRACT " wMP-O-WLL & CATTLE COMPA --1 KAT som a Mat To APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI i ? Davie County Health Department tiEnvironmental Health Section r ; 4 Zd P. O. Box 848. APR _ 3 99 first(� �p, Mocksville, NC 27028 d 5 (704)634-8760El �i y ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE1&4UJN ALL THE REQUIRED INFORMATION IS PROVIDED. ('.0 '� Contact Person Ohm&l e, 1. Name to be Billed / Mailing Address 3 6�y �S 15 Home Phone ?W-30�'t2 City/State/Zip / II 0 tKS( l(C 11 e- a `� 0 a9 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation X Improvement Permit & ATC ❑ Both 4. System to Serve:] House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: #People # Bedrooms # Bathrooms t Dishwasher / * Garbage Disposal " Washing Machine )(Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type / # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: l County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No /*" If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE S 0 7 4 4tiw SUBMITTED WITH THIS APPLICATION. Property Dimensions:, 563 A 2L 79A 9RX-2Y9)( 42 2,08 X yao 1 WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY: Tax Office PIN: # _ �.— a � - � - Q 70 � 1 Property Address: Road Name ij oyL k City/Zip 1" o ct s t/; . r" l C P 70 ?-'� � A Olt � 1 If in Subdivision provide information, as follows: 1 Name: W L2 1.0 ► 11 1 . 1 Section: Lot #: oZ3 1 1 1 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 i ' C'' to conduct all testing procedures as necessary to determine the site suitability. DATE 7 7 SIGNATURE Revised DCHD (06-96) IILL LAND a CATTLE COWAxY a rg ACRES 101 pp WHiP-0-WILL LAND a CA4LE COWAKY N-1 LIO Davie County Health Department and.Come Health Agency Environmenta[Health Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKsv1uE, N.C. 27028 PHONE: (704) 634-8760 George & Cammie Webb 3614 U.S. Hwy. 158 Mocksville, NC 27028 May 5, 1997 Re: 'Site Evaluation Whip-O-Will/Lot 23 Meadowlhrk Lane Tax PIN: #5822-95-0706 Dear Mr. & Mrs. Webb: As requested, a representative from this office visited the aforementioned site on May 5, 1997. 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 Enclosure(s) DAVIE COUNTY HEALTH DEPARTMENT PCP Environmental Health Section P. O. Boz 848/210 Hospital Street • Mocksvffle, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001694 Tax PIN/EH #: 5822-95-0706 Billed To: Rick Stover Subdivision Info: Whip -O -Will Lot # 23 Reference Name: Location/Address: Meadolark Lane -27028 Proposed Facility: House Property Size: 5.079 Acres ATC Number: 2808 **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 71-1 #People :�-2 #Bedrooms _ #Baths yY Dishwasher: � Garbage Disposal:: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �r� Design Wastewater Flow (GPD) 4'W Site: New e Repair ❑ System Specifications: Tank SizeAL GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width -Z ,, Rock Depth %g�� 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 a.m. or 1:00 p.m. to 1:30 p.m. on the da o . tallation. Telephone # is (336)751-8760.**** '0 fl r Environmental Health Specialist's Signature: 6�Date: DCHD 05/99 (Revised), ....,.� rnrrnu�U11t1d1 MIMII & AIG Davie County Health Department Environmental Nea/tb 5bcdon .O, Box 868/210 Hospital Street . Mockaville, NC 27028 �JJ 43361751-8760 t*221Ppg,,.; #firmTe 'nPbtc rrm I CANPb! BE PJWMSMW UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Wass to be Billed T CK Contact person Mailing Address GG 6LG1 {� - HowePhone city/state/Zip NC- C� �� Business Phone $ ) Zg q— CX5 a9 S. War on Pendt/ATC if Different than Above "ailing Address -- 3. Application For:10te Evaluation 4. system to servios: li House 0 Mobile Home city/sta rovemsnt Permit/ATC 0 Both 0 Business 0 Industry 0 Other a. It Residence: /j6 People Z _� # Bedrooms �_ Bathroom t�'Dishxashes t7 datyage Disposal Bflashing Machine 0 Basenant/Plmibing 0 Basement/No Plumbing S. If Business/Industry/other: specify type # people # sinks # Coam wWX # showers # Urinals # Nater Coolers IP TtOODSEMCZ: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply:County/City 0 well 0 Cosssanity s. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes 0 No U yes, what type? ***IMPORTANT•** CLIENTS MUST COMPLEfETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITI'ED by the client with THIS APPLICATION. Property Dimensions: �b 3 X 2-7 7 -,,((o0 2-Q x i2-4 X Tax Office PIN: # j 6 7 kZ4 u'� l a d ;q; 1- -tr '5az7--915-1 '700 Properly Address: Road Name L )- City/zip 124mt0mic If in a Subdivision n provide Information f as follows: UV Name: L Section: Block: Lot: WRITE DIRECTIONS (from MockrAlle) to PROPERTY: w(1� - - �Jj ate} �- Date Property #a(, -(e I -r -(,A" This is to certify that the information provided is correct to the best of my knowledge. I A rstand that an aY' Issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or t e information submitted In this application Is falsified or changed. I, also, andastand Kiat I am responslblefor all charges Incurredfrom this application. 1, 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. DATE D/ SIGNATURE �iTu�C 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). Please complete the highlighted area(s) and return. Revised DCHD (07/'98) l� Account No. Invoice No. Zz, 3 7