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148 Meadow Ridge Drive Lot 21HEALTH DEPARTMENT RELEASE po Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: David Mallard Address: 120 Brittington Drive City: Lewisville State2ip: NC 27023 Phone #: (336) 399-7239 For Office Use Only 'CDP File Number 197346-1 County ID Number: Evaluated For. HDRMWC PERMIT VAUD 1 0 0 1/ a 0 2 0 IINTII Property Owner: Keith and Janice Dawson Address: 148 Meadow Ride City: Mocksville State2ip: NC 27028 Phone #: 'r Property Location & Site Information Address 148 Meadow Ridge Dr Subdivision: Meadow Ridge Road # Mocksville NC 27028 *Structure: SINGLE FAMILY # of Bedrooms: 'water Supply: N/A Basement: [] YesF] No 'Proposed Improvement: Garage # of People: Maintain a 5 foot setback to any portion of the septic system Phase: Township: Directions Hwy 158 right on Sain Rd. then right in Meadow Ridge Type of Business: Total sq. Footage: No. Of Employees: Lot: 21 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature, *Issued By: 2140 -Nations, Robert Authorized State Agent: 'Date: *Date of Issue: 1 0/ 0 1/ 2 0 1 5 i r **Site Plan/Drawing attached.** Q Hand Drawing OlmportDrawing HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Type: Health Department Release age CDP File dumber: 197346 - 1 County File Number: Date: 1 0/ 0 1/ 2 0 1 5 Olnch Scale: OBlock O N/A X Davie County Health Department �.18 Environmental Health Section dip P.O. Box 848 210 Hospital Street Courier # : 09-40-06 . - Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Named /� U ;���%�(� Phone Number�3co —3,99-7Z--39 (Home) Mailing Address; /�U _,`' _ �-r-/'� I (Work) Email Address:-&Trd/ 7�LJ/17i,1:L,Cc�(�l Detailed Directions To Site: /nC;g i D % /mdse Af Z_ Property Address:/469(f Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: �aa�Eli 0 0 Co - Type Of Facility: �Se Date System Installed (Month/Date/Year): ZZ- Q 7i Number Of Bedrooms: T Number Of People: Is The Facility Currently Vacant? Yes (ID If Yes, For How Long? Any Known Problems? Yes e�P If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: (�'I�'� I'�1 {G Number Of Bedrooms: Number of People Pool Size: Garage ize: Other: Requested By: � �� Date Requested: —�--f For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash (Check) Money Order #. Paid By: Received By:_ Account #: "� �� Invoice #: 2221 CD rl c� � F 0956 tti SOSIT- /T 287 i f t+l.. ofe �� All data Is provided as Is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied�� ^r, iW `f warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of it t3 ` Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out Printed: Sep 21, 2015 of the use or inability to use the GIS data provided by this website. DAVIE 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 Tax PIN/EH #: 5749-448961.SF Subdivision Info: Meadow Ridge Lot # 21 Location/Address: Meadowridge Drive -27028 Proposed Facility: Residence Property Size: see ma ATC Number: 3120 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 WASTEWAT TR VALI OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ate: %46— CERTIFICATE 46 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate o`f'C rrf s a 1 indicate the system eriNed on Improvement/Operation Permit has been installed in compliance Article 11 of G.S. Chapter , Section .1900 "Sewage Treatment and Disposal Systems," but sha ' NO A ntee that the em will function satisfactorily for any given period of time. / %O Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) LZ 0 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001309 Billed To: San Filippo Companies Reference Name: Anthony San Filippo Proposed Facility: Residence 2:CV /�O,-,�,t -7-22-d Z. Tax PIN/EH #: 5749-44-8961.SF Subdivision Info: Meadow Ridge Lot # 21 Location/Address: Meadowridge Drive -27028 Property Size: see map **NOTE** This-rmprovement/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 Ej 00EZ #People #Bedrooms `i #Baths 3 Dishwasher: Garbage Disposal: d Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size I '21 � � Type Water Supply Design Wastewater Flow (GPD) 490 Site: New G2r' Repair ❑ , o �/�,, System Specifications: Tank Size I 000GAL. Pump Tank GAL. Trench Width 3(o Rock Depth �� Linear Ft. ' &' Other: �1STQ 13JT►o•7SG�S �,,kS'�ALI. U��S tp.C�.. Ml�. Required Site Modifications/Conditions: jtJ�Tl u, 0"I Gtj1-w a , KEc(' IC; or -P Noe. u�w, �-P S �,� I -)WS -f IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) 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 j336 M-8760.**** ►o U Or oP �, •n ` � ST Of © _ - b� EhviFenmepial Health Specialist's Signature: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A -JC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 r - ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI v%vey`y�Ty'° INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �^w.�l , p �Q� fi�-4; G a.. Contact Person Mailing Address _ �`. 2.2 Z(7 Home Phone City/State/ZIP A Q L Z—?DO 6 Business Phone / 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 0 Site Evaluation City/State/Zip Improvement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 3 Dishwasher /Garbage Disposal Washing Machine ❑ Basement/Plumbing CI 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 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes e&o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: S�Zf kNZ .D WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # -Cr?y q� X t Property Address: Road Name M 'rrLW t\ td: o V`� City/Zip ��v�� �—� Q v� 1 ���%✓ e l If in a Subdivision provide information, as follows: ( 2-1 Name:Hc-e-10,0 a� Section: Block: Lot: l Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. 1 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 fir all charges incurred from 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 suit ili DATE /� \ /� �� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN In de 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. _� .y APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A -JC Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 r - ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI v%vey`y�Ty'° INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �^w.�l , p �Q� fi�-4; G a.. Contact Person Mailing Address _ �`. 2.2 Z(7 Home Phone City/State/ZIP A Q L Z—?DO 6 Business Phone / 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 0 Site Evaluation City/State/Zip Improvement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 3 Dishwasher /Garbage Disposal Washing Machine ❑ Basement/Plumbing CI 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 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes e&o If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: S�Zf kNZ .D WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # -Cr?y q� X t Property Address: Road Name M 'rrLW t\ td: o V`� City/Zip ��v�� �—� Q v� 1 ���%✓ e l If in a Subdivision provide information, as follows: ( 2-1 Name:Hc-e-10,0 a� Section: Block: Lot: l Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. 1 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 fir all charges incurred from 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 suit ili DATE /� \ /� �� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN In de 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. _� 271.20' -�h a DB 211. PG 857. 1.392 Acres (dmd) 1.274 Acres (dmd) r,45 THE N r 2�' ! 3 1.665 Acres' (dmd) S ;� 35.9 Acres (dm,) r d 3p a W L f� o w z •� 'Fetor '� G 746 FOvno' 1.590 Acres (dmd) I 71J Acres (dmd)0,1 ; ZS; SignLond scope 70 Edsemen f 1 M _� P.IDGEHAVEN PLACE �__. ,s• NawAt�. rc•c:s� ... , � .. � . •, .,_24 28" ,� � PNU Pt1eLN! tmmm MEIAE►at S ��. S— 0 212.91 145.353, '1 ` 4 •3'UEiW � ' A ��i/ � � •` _ '�-----off . 1$' 6 •� 14$•33. ` 20 urutt e/SEUErn _ ----_—_ w 4j -� w KE Ewe t w i A 1.562 Acres (dmd 1.179 Acres (dmd) �, K� okNe t $1 M N !access d8tvtient !-1 b .:W Re i f' Ad t]T S R7o. 'K W JI 1 t1 .: CONTROL. •COR14ER' 351.18' G 1 �R(1 CUE 25 s RV1EtiG[t 157.38 S '3(YU4'4 ' W 31.. 71 qp8'2 W'if 2 T: fiO. 3 - c 1c�0A0 s',. BEING 425 00 - 3: 73: C-4 3Da.7$•. 294.5+~` S"�'� . sw t C_�, 35319 �.� 44' :154:46° 1gt824. MOCKC-6 X403 88" . t.4fT43*4 ' £ L KENNETH C-7 A�OJa9 147:09`. 146:78 u5 C-7 44:47 - C_g 44.2u, :' 4 a� T�03"2.# £ - t� t�►Y NAY INTERSECTION. C—Q 75C� 9.82 239.67- xt1 : p ' £ 2200 —�l "575 00 243.95'- c—» s�o J7 a8�:gz s .°4 E 1NINSTON• r APPLI(A110N FOR 611E EVALUAIION/IMPROVEMENT PERMIT & AT Davie County Health Depardnent D , Envfivamenta/Hee/fftSeWon P.O. Box e4e/210 Hospital Street JUL 1 1999 Mochsville, NC 27028 (336)751-8760 Ll ***IIWORTANT*** THIS APPLICATION CAMOr BE PROCBSSBD UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Referrer to the INFORMATION BULLETIN for/ instructions. m 1. Nato be Billed KE N a C T NL - t- o E r F- R . contact parson _KE l� �1 E T►� L . Fos -(E t2 Mailing Address l $ (o 111 a PLc Tt2,-c. Ln -,i some phone 704 - 54(o--7'7 98 city/state/zip 14tOCKSv11LC , N .0 • .2702e imss phone 33Co--I23-8$So 2. Name on Pewit/A= if Different than Above Mailing Address City/state/zip a. Application For: I( Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: U House O Mobile Home 0 Business 0 Industry 0 Other s. It Residence: •People i Bedrooms 3— # Bathrooms Z B'Dishxasher O Garbage Disposal mashing Machine 0 Basement/Pluabing 0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks # Commodes # showers # Urinals # mater Coolers IF TOODSERVICS: # Seats Estimated Mater Usage (gallons per day) 7. Type of water supply: O'County/City 0 W013L 0 Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No If yes, what type? ***IMPORTANT*** CLIENTS IIIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUB.&HI TED by the client with THIS APPLICATION. Property Dimensions: 219 X 207 X 271 X 2 g 4- WRITE DIRECTIONS (from MocksAlle) to PROPERTY: Tax Office PIN: # 5-74-9 - 4.3- S-7 98 L AST o B Property Address: Road Name 5 A'a Romeo City1ZipTAr-CKSi3 ME 91 O -Lb If in a Subdivision provide information, as follows: Name: rAeAaou Pj-QGE" (Pia0--sen) To 0 ROND (sR 1(o43) TuRiJ 9,IGNT oN SA., -3 _ APPRp,t. 0.16 MILG-' -To S mr n► 1 P\ L %4 T Section: Block: Lot: 2I Date Property Flagged: ( • 018 - 94 This Is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 fi,om this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departmep-t to enter upon above described property located in Davie County and owned by L. FOI?iT Z R to conduct all testing procedures as necessary to determine the site suitability. 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 (07198) Account No. i!J "'-y Invoice No. /--- C APPLICANT INFORMATION DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Account #: 989900654 Billed To: Kenneth Foster Reference Name: Kenneth Foster Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5749-43-5798.21 Subdivision Info: Meadowridge Lot # 21 Location/Address: Sain Road -27028 Property Size: 1.31 Acres Date Evaluated: !!V Community Public Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 47,p 71k) HORIZON I DEPTH t9 - 10 Texture group Consistence j _ Structure Sg Mineralogy HORIZON II DEPTH 62- Z Texture groupG Consistence Structure Mineralogy; HORIZON III DEPTH - Texture group Consistence Structure MineralogyI: HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE r-> . SITE CLASSIFICATION:_ l LONG-TERM ACCEPTANCE RATE: tDi REMARKS: LEGEND Landscape Position EVALUATION BY: L;�VC 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)