164 Longwood Drive Lot 21DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
` • P. O. Boz 848/210 Hospital Street
• Mocksville, NC 27028
(336)751-8760 pa -7 a 9_ U
IMPROVEMENT/OPERATION PERMIT
11.-30
Account #: 989900573 Tax PIN/EH #: 5861-59-5239.21
Billed To: Glenn Johnson Builders Subdivision Info: Redland Lot # 21
Reference Name: Location/Address: Highway 158-27006
Proposed Facility: Residence Property Size: see map
ATC NuMber: 3207
**NOTE**, This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or anywastewater.
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.5
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 ��_ Design Wastewater Flow (GPD) Site: New2Repair ❑
System Specifications: Tank Size /OdbGAL. Pump Tank
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APP
FINISHED GRADE. ****NOTICE: Contact a representative
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 Fli
GAL. Trench Width �� Rock Depth��� Linear Ft.�(�
iVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
vie County Health Department for final inspection of this
the da f installation. Telephone # is (336)751-8760.****
r
Environmental Health Specialist's Signature:WDate:
P gn
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900573 Tax PIN/EH #: 5861-59-5239.21
Billed To: Glenn Johnson Builders Subdivision Info: Redland Lot # 21
Reference Name: Location/Address: Highway 158-27006
Pro osed Facility: Residence Pro ert Size: see ma
ATC Number: 3207
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, ection .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT C NST UCTION IS VALjP FQR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: ✓ Date:
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
g?ven period of time.
�tl
o� N
7
sS
4
Septic System Installed By: AK /1600
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
VJ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT
�y- Davie County Health Department I 7
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville NC 27028
(336) 751-8760 ENVIR E HEALTH
DAVIAVIE COUr COIIiJ?Y
***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 �l�`/r s� jJy </r/ SOrI /�i///�,�/O)�'�S -i /,C, Contact Person �2l�t ri
Mailing Address ��! 6 (/r/ �G2/IOSi /� N Home Phone 5/G -Ao ` J fes✓ S
r l�
City/State/ZIP d// %� L. 7C/d� Business Phone 33 6- 9yT%
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: El Site Evaluation B'Improvement Permit/ATC ❑ Both
4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. IfResidence: /#'People �� # Bedrooms
/_ # Bathrooms a /
4'f Dishwasher 47 Garbage Disposal [-rVashing Machine ❑ Basement/Plumbing ❑ 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: County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Q'N0
If yes, what type?
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
2-1
Tax Office PIN: # ((o t - 51-5 L �, 9. gg
Property Address: Road Name
City/Zip
If in a Subdivisions%provide information, as follows:
Name: ke 61 �ay
WRITE DIREC1CTIONS (from
/M�occksville) to PROPERTY::
✓�� 7D��/9,2 C� /ef�j <v� vssS
111,951-1 le, At' -Z'
IeA �7 �Z � Xle.) 7' e) P1
Section: Block: Lot: Date Property Flagged: r4,a tl W)"- 'S. �--
, Q
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 aff 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 site suitabPity.
DATE `2 SIGNATURE _ w�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN
property lines and dimensions, structures, setbacks, and septic Ioc,
Revised DCHD (07/99)
of the following: Existing and proposed
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
}
Account No. • S� o O "l'�77 A
Invoice No. � L--
APPUCAIION FOR SIZE EVAi_UAIION/ IMPROVEAIENT PERMIT & ATC
' t Davie County Health Department
Environmental Health Set oil
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PP.(=SSZD UNLESS ALL T
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i
. , _I , - / . 1 /7 i)
1. Name to be Billed
Hailing Address Q
City/State/LIP c
2. Name on Perait/ATC if Different than Above
Contact Person
Boas Phone
f
F'4 2001 J
REW
IRED
Business Phone
Nailing Address City/State/Lip
3., Application For: ®'Site Evaluation ❑ Improvement Perait/ATC ❑ Both
4. system to servioet O House ❑ Mobile Home 0 Business 0 Industry 0 Other W,�.,...
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ washing Haohine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Othert Specify type # People # Sinks
# Cottmodes # Showers # Urinals # water Coolers
IF rOODSERVICE: # SeatsEstimated Water Usage (gallons per day)
7. Type of water supply: 9-County/City 0 Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes 0 No
If yes, what type?
*,%*IMPORTANT"** CLIENTS MUST COMPLETETIIE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Ellher a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 6 15>4e, r�-15 4
Tax Office PIN: # 1?Z 57, %1
Property Address: Road Name /1t L 5
City/zip A111191✓ee. ,V_L,97W
If In a Subdivision provide Information, as follows:
Name: p
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
-1;4� - D- 7-/9 I i X'l
Date Property Flagged:
This h to certify that the information provided Is correct to the beat of my knowledge. I understand that any permlt(s)
Issued hereafter are subject to suspension or revocation, If the site plana 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 testing procedures as necessary to determine the alto suita Ility.
DATE — `> f� SIGNATURE -
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includ all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
I Client Notification Date:
I EIIS:
Account No. ' '� cc
Revised DCHD (07/99) Invoice No.
APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Account #: 989900136
Billed To: Westview Development Co.
Reference Name:
Proposed Facility: Residenc Property Size:
Water Supply: On -Site Well
PROPERTY INFORMATION
Tax PIN/EH #: 5861-59-5239.21
Subdivision Info: Redland Lot # 21
Location/Address: USHighway 158-27028
see map Date Evaluated: -7// D/
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH
Texture groupC
Consistence
` S
Structure
5 )~
Mineralogy
HORIZON II DEPTH
Iq - _S
Texture group
C 1+
Consistence
r--, S
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
FC' S -SS
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
S
CLASSIFICATION
VS
LONG-TERM ACCEPTANCE RATE
.3s • (2.
SITE CLASSIFICATION: 1 15
LONG-TERM ACCEPTANCE RATE: 0,3S -,c,4
REMARKS:
LEGEND
Landscane Position
EVALUATION BYE
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)
D
g sq, ft
8 Ac.f
'20' 13" W
74' Total
6
N
Ln
J
0
0
0
W
O
m
7'(Total)
l 299.93'
N 87'1904" W C32
0.691 Ac. t
��
�
238.07'
86'02'48" E
'
32,129 sq. ft.
Q h
N
259.01
L)0.738
,rn 10' Public
Ac.t
�'2g" E 15'
O
5 g0.51'17' W
NM
(D
0
ft.
I 21
N1 `� Easement
30/ Typical Setbacks
30,466 sq.
I
F'W.......... Floodway
V
/ Interior Lot
0.699 Ac.f
n 31,020 sq. ft.
I
1. There are no N.C.C.S., U.S.C. & C., or other Geodetic
survey monuments within 2,000 feet of the site.
horixantal
I
`U, 0.712 Ac.t
I
3. All bearings shown
or plat bearings as noted
244.99
I I
N 83'53'32" E
J� 44,892 sq. ft.
1.031 Ac.t
r,
242
S 86'20'13" W 310.6
l 299.93'
C
1
6 10' Public
o
n
'
a
35,349 sq. ft. Utilities
'
32,129 sq. ft.
Q h
0.811 Ac -t Easement
L)0.738
,rn 10' Public
Ac.t
�'2g" E 15'
o
5 g0.51'17' W
3 Utilities
-1235-79 /
N
0
316.g3
N1 `� Easement
30/ Typical Setbacks
W
I �
F'W.......... Floodway
V
/ Interior Lot
30'
CD
r / 19
36,438 sq. ft. '�
33,33 sq. ft.
U`
0,765 Ac.t 5
0.837 Ac.ttoll \ o_ta \
15' `U C) %g1
26 3 0 V-' 30'/ N6
Zg1 `'A
S '15Typical Setbacks \ a ¢• ��
15� g5 Corner Lot \ N d 1 8
� 2 32.175 sq. ft.
8
0.739 Ac.t
N 03'03'02" E r'�S 59 sq.
30 ft.
4001 \ `-.110'x70' Sight
"
p \ . 0 � 0.702 Ac.t 3
33 O a, � Easement
o. 25' 2 cs Zq�
30,870 sq. ft.
> >S\ 0.709 Ac.t 30, �D'
A*%•50. R 31,282 sq. ft.
sr>
pN� %$�'�° l\\ 0.718 Ac,t$
,071 sq. ft. 1g rf 6�% 01 y `r' 'r� 40
,071 h2
966 Ac.t Coy `� �gR• 10'x70' R �, r-o�
10' Public N f V"f Sight Easement
Utilities 1 J \
v p`�'�' 10' Public Utilities 0;
Easement r' `1 \ Easement
g �4 30,605Osq. ft.
s 236 0a C22 "p\ 0.703 Ac.t \ ate\
O 8" a
15
30.701 sq. ft.
W,695 sq. ft. N J�\\ 0.705 Ac.t
0.934 Ac.f 0r' .•�
v. 10' Landscape
ro cy!,13 �\s�3` Easement
31,718 sq. ft.
35,101 s q. ft.
0.806 Ac.f
10' Landscape
Easement
/ S1b2
O'�_10'x7O' Sight
' Easement
CP
O �
J.K. & L.M. MCCULLON
0.6. 54, PG. 432
4
�t �C
G
10' Public
Utilities
Easement
o�
Location Map N. T. '
c0 cr
LEGEND _
Q h
EIP.........Eris ting Iron Pipe Found w/size
NIP......... New 3/4" Iron Pipe Set '
a
Stone ..... Old Planted Field Stone Found
I
REBAR..... Existing Steel Reinforcing Rod
found w/size
o
0.......... Control Corner
W
I �
F'W.......... Floodway
V
NOTES:
I
1. There are no N.C.C.S., U.S.C. & C., or other Geodetic
survey monuments within 2,000 feet of the site.
horixantal
I
2. All distances shown on this plat are
ground distances, unless otherwise designated.
on this plat are based on deed
3. All bearings shown
or plat bearings as noted
I
4. Total Area 40.22Ac.
5. Total lots Phase I - 41 Lots
Average lot size - 0.89OAc.
6. Lots 12, 13, 15, & 16 have rega Lie access
oaarr.mt to NC filly 158.
7. Zoned R-20
I
8. Minimum building setbacks:
Front.... 30'/Side.... 15'/Back.... 30'/Side Street .... 25'
9. Public Streets, 20' wide ribbon pavement
10. Public hater Systems & Private Septic Systems
I
11. All utilities underg'rou'nd
I
NOTE :
I
This survey is subject to any facts that may be
disclosed by a full and accurate title search, NOT
furnished me as of this date, and may be subject to
I
easements, rights-of-way, restrictive covenants,
the same may appear of
assessments, if any, as
in the Office of the Register of Deeds, Clerk
record
of Court, Town or County Tax Office or which may
I
have been acquired by prescriptive use.
Redland Way
Phase 1
Oumer:
Westview Development Company
2631 Reynolda Road
Winston-Salem, NC 27106
(336) 777-0078
SCAB : 100Zoo
loo 0
I
F1F. ,n )PORK BY CHECA BY:
Davie County Health Department
'0�►s f� Environmental Health Section
P.O. Box 848 •
C�
,S„ 210 Hospital Street
O U �'� Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: t � ut/v% Phone Number 35!• 1(4 5 q S z_ (Home)
Mailing Address:11-1 zn( (Work)
, G�ya,, C' �(C 2 `77()[P Email Address: (��41���) (� �(�,a�1t:�ti� 1����1��c st�tc, CO
Detailed Directions To Site: ( 4 D IJG..r-c( .tet-_ JCA_1L lc qtr L bxk n (-�)6-6.1 �r-
Property Address: l t, Lk 1._ x,.:) -o,- r( �,>- C� U o.• c � ( C. ?-10 DLP LO I //-z
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: /��/ `/�� 5 6 Type Of Facility: p a Sc_
Date System Installed (Month/Date/Year): % j2 Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?.
Any Known Problems? Yes If Yes, Explain:
Please Fill In The Following Information About The NEWFacility:
Type Of Facility: , -tF— ,'�t 4a K > Ct Number Of Bedrooms
J
Pool Size: // Garage Size: Other:
Requested By: �� i,�t1 l lr� Date Requested: 17- 0 t Z
Number of People
For Environmental Health Office Use Only
Approved Disapproved,
Comments:
Environmental Health Specialist Date: �• S -
*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 # Amount:$
Paid By:
Account #:
Received By:
Invoice #:
Date:
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