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198 Meadow Ridge Drive Lot 18Account #: Billed To: Reference Name: Proposed Facility DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 M(/ b / 5749-44-7233.18 SF Meadow Ridge Lot # 18 Meadowridge Drive -27028 990000981 San Filippo Companies Residence ATC Number: 3957 Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: see map 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 CON S V ID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: 1 fl 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. fV v A � `-rT-X.J1L Septic System Installed By: Environmental Health Specialist's Signature : Date: qek.3 1 DCHD 05/99 (Revised) ,, f DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Boz 848/210 Hospital Street $�g� Mocksville, NC 27028 pp g (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000981 Tax PIN/EH #: 5749-44-7233.18 SF Billed To: San Filippo Companies Subdivision Info: Meadow Ridge Lot # 18 Reference Name: Location/Address: Meadowridge Drive -27028 Proposed Facility Residence Property Size: see map ATC Number: 3957 **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 aOJS>✓ #People #Bedrooms Li #Baths 3 Dishwasher: 121 Garbage Disposal: ❑ Washing Machine: 9!( Basement w/Plumbing: 2 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size I.0( 4 - Type Water Supply �T� Design Wastewater Flow (GPD) Ll 20 Industrial Waste: ❑ Site: New Id Repair ❑ System Specifications: Tank Sizela70GAL. Pump Tank GAL. Trench Width'su, Rock Depth IZ!' Linear Ft. 1-W Other: L4 *015TE.lgt)T"10--3 aooXz'S Required Site Modifications/Conditions: 1r3S'f-6-Lt, 0.3 orp -sae— 1o,Ew- Palo 4-1.y. 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 Environmental Health Specialist's Signature: DCHD 05/99 (Revised) ' /�\M (� 10, 60 D ��Qa APPLICATION FOR SITE EVALUATION/IAIPROVEAiENT PERMIT Davie County Health Department ,AN — 6 2005 Environmental Health SeCdOn P.O. Box 848/210 Hospital Street ENYIRON69ENTgtH Mocksville, NC 27028 DAVM TAT �Tn (336) 751-8760 ***IMPORTANT**_* TRIS APPLICATION CANNOT DE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �C.� �t �O L tiop 04"1'S`�*L-. l^ Contact Person n�.,av-) Mailing Address t- w City/State/ZIP 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Shite Evaluation L Home Phone n Q' / Business Phone ! U CCi4yy/State/Zip ID/Improvement Permit/ATC ❑ Both A. System to service: House El Mobile Home EJ Business E3 Indus try ❑ Other 5. Type system requested: L1, Conventional ❑ conventional modified ❑ innovative $ 6. If Residence: # People # Bedrooms # Bathrooms Mishwasher ❑Garbage Disposal OWashing Machine 6dBasement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers IF FOODSERVICE: # Seats S. Type of water supply: County/City # People # Sinks # Urinals # Water Coolers Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions or the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***1A1P0RTANP** CLIENTSAfUST COAIPLETETHE REQUIRED PROPERTY INhORMATION REQUESTED BELOW.. Either n PLAT or SITE PLAN AfUST BESUBAIITTED by the client with THIS APPLICATION. Property Dimensions: Tax Officc PIN: #/ �� 1 -ii'{ `? '.—� Property Address: Road NamH6&kV111t-- cl City/Zip 'ODZt If in a Subdivision provid inforination, as follows: Name: �Ae-e— �kJ� Section: Block: Lot: / t5 WRITE DIRECTIONS (from Nlocksvfllc) to PROPERTY. Date home corners flagged: N 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, untlerstaud that I am responsible for all charges fucurred frour this application. I, hereby, give consent to the Autliorizcd Representative of the Davie County IIcalth Department to enter upon above described property located in Davie County and Ivnicd by to conduct all testh proce res as necessary to determine the site;Tl� DATE SIGNATURE TRIS AREA MAYBE USED FOR DRAVS'ING YOUR SITE PLAN (In udc all of is itig: fisting and proposed property lines and dimensions, structures, setbacks, and septic loca ons). Sign given Revised DCIID (05/03 Site Revisit Charge IDate(s): Client Notification Date: EHS: Account No.0 Invoice No. APPUCAIION FOR SIZE EVALUAIRONf1MPROVEMENi PERMIT a A -H R3 0 n/7 H Davie County Health Department D l"J ` x Entr/tvnmental Health Serctlon t. P.O. Box e4e/210 Hospital Street JUL 11999 Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT' BZ PROCESSED UNLESS ALL`THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. i. Mane to be Billed KE N 1l E T N L. t o E; -, F- 2 Contact Person Kt N �1 E T H L• FOS-rE 12 flailing Address 1 8 G r n a PL -c Tt,--� Ln -ix epee Phone -704-54<o--7-7S8 City/State/LIP t410CK-;q i L -LC- , N .0 - .2702,' Business Phone 33Co --1 Z3-8850 2. Mane on Psait/ATC if Different than Above Dialling Address City/State/Lip a. Application for: It Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: 0 House O Mobile Home 0 Business 0 Industry 0 other S. If Residence: # People # Bedroom3 _ # Bathrooms Z Jk1filshwasher 0 Garbage Disposal iifrashing Hachine 0 Basement/Plumbing 0 Basement/No Plumbing S. If Business/Industry/other: specify type I Ccamodea # Showers # People # sinks # Urinals # Hater Coolers IP FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 1st/County/City 0 Well 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 AIUSTCVAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESU01ITTED by the client with THIS APPLICATION. Property Dimensions: 205 X 40 4 X 159 X 40-7 Tax Office PIN: # 5-749 — 43— S`I 9 F WRITE DIRECTIONS (from Mocksville) to PROPERTY: Property Address: Road Name 15 A 1-4 Q a o TO S a Rn a p i s R 1(o 43) ru P J City/ZipTicC-K5,J.11E 91 OZ IB If in a Subdivision provide information, as follows: Name: iYlEAooWP.(pG6- �ProPosen� 1G4�T 00 SA -i-3 _ APPQ- x 0.5 W1tLt' -ru S t'TE n ►, P \Ltd T Section: Block: Lot: 18 Date Property Flagged: & - a 9 - 94 This Is to certify that the information provided is correct to the best or 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 ibis application is falsified or cbanged. I, also, understand that l am rrsponsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departmerl to enter upon above described property located in Davie County and owned by XEANe-7W - L. F:V%-r to conduct all testing procedures as necessary to determine the site suitability. DATE G - Z 8 — 199-► SIGNATUREqg�� "ZI r�--L 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 (07/98) q -2233 Account No. �S Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900654 Billed To: Kenneth Foster Reference Name: Kenneth Foster Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5749-43-5798.18 Subdivision Info: Meadomidge Lot # 18 Location/Address: Bain Road -27028 Property Size: 1.69 Acres Date Evaluated: 1 hl Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: REMARKS: OTHER(S) PRESENT: *TTL ,fMaim.rium 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 05/99 (Revised) Lan scape position HORIZON I DEPTH -Consistence II DEPTH ConsistenceHORIZON HORIZON III DEPTH Texture group Consistence mmMineralogy MineralogyTexture - Mineralogy •RESTRICTIVE HORIZON CLASSIFICATION SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: REMARKS: OTHER(S) PRESENT: *TTL ,fMaim.rium 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 05/99 (Revised) 4J& N OVO3'Og' E 3M.a' 17 2.M7 Acres (oW) W0 48'x --------------------µ 0 '12_29' E----- ----- - 2( e' i I iz 1,41 j - 1.905 Avw &nd � t��0 10' tnwrr 1 40' s- - 275.W- _ 40' o , 1.742 Aces (drnd)cot N ,' �;� �• ply AN DSSO q Rebar Found 271.W 19 1161 Acrw (d„ ad) Lx 20 � J59 Acrm (d N (lvw E 201.08• 62.40' 1 1` 314.13• N = 4DOW Rio �' Pti6,Gc Ri9r5f 4f lYor � f 5 f 7/7 Z 4I.— — ,/�'" vas �' ✓ ` ie County Health Department /9 1 6j �V/db Environmental Health Section I .. P.O. Box 848 C•' 210 Hospital Street Q U�, Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CER. FICATION' C/ (Check One) Replacement Remodeling Reconnection a Name: 0- 11 v(si l K -e ( Y L' P -o Phone Number 1,3 U -7 S bb aim (Home) Mailing Address: ) 9k M t' a ! ahay ) �Q n ofII -_ ( Work) Y�UCKS V -C.-4 , C 70 � Efrhail Address: (' C Yl u � ct`? ty I vd S 131 n_ m Yt-e- Detailed Directions To Site: 1 S" ziL4r � 0: /uaf-a/ e -y? (J�t (j �� oU `SQ. 0 Property Address: � �' �� P QCi (Jud �� .(b V- tVP i i�-i 6 dl -/S v-t...LLe t UX a 10 Please Fill Irt-The Following Informatiron About, The, EXISTING Facility: Name System Installed Under: l,' /n /— ��c,✓� D s Y %� �' y �j a �,%Q, ) Type Of Facilit : , Date System Installed (Month/Date/Year): bS Number Of Bedrooms: V Number Of People: Is The Facility Currently Vacant? YesNNo If Yes, For How Long? 4 11, (� Any Known Problems? Yes S If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: /l0 O / t / Number Of Bedrooms: Number of People. Pool Size: /'-1 X ' Garage Size: Other: Requested By: ; L� �J P Date Requested: �U (Signa`t=)— For Environmental Health Office Use Only pprove Disapproved `Pr AYI �I QN-T CL 0 Se Comments: � 1CJ -t Tb Cl Environmental Health Date: 15— ► 2 - ) y *The signing of this form by the Environmental H(ilth 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 # Amount:S. Paid By: ami Received By:_ Account #: va Qy Invoice 4 C� l