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342 Longwood Drive Lot 37DAVIE COUNTY HEALTH DEPARTMENT ' " Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 LRZ &00001 Account #: 989900283 Tax PIN/EH #: 5861-59-5 9.37 BC Billed To: Bob Cope & Son Construction Subdivision Info: Redland Way Phase 2 Lot # 37 Reference Name: Location/Address: Highway 158-27006 Proposed Facility Residence Property Size: 0.85 acres ATC Number: 3894 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 Treatrpent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON IS V OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 11 i-nffikte the system described on Improvement/Operation Permit has been installed in compliance with Arti 11 o . Cha r 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be to as a g #& that the system will function satisfactorily for any given period of time. •0 Septic System Installed By:. ��c P Ys�, ' % Environmental Health Specialist's Signature: �';°'i`7 �/ Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT _ Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900283 Tax PIN/EH #: 5861-59-5239.37 BC Billed To: Bob Cope & Son Construction Subdivision Info: Redland Way Phase 2 Lot # 37 Reference Name: Location/Address: Highway 158-27006 Proposed Facility Residence Property Size: 0.85 acres ATC Number: 3894 **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. 1 Residential Specification: Building Type ay #People #Bedrooms #Baths 24Z-jz Dishwasher: d Garbage Disposal: M"" Washing Machine: Er" Basement w/Plumbing: Z Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 0 ' -s Type Water SuppI&jjrYDesign Wastewater Flow (GPD) SW Site: New Repair ❑ System Specifications: Tank Size 1000GAL. Pump Tank GAL. Trench Width L�fp Rock Depth NN Linear Ft. 22-�3 Other: �I.7�8-n--r,�uo --r1hTf*ti1=Ts_ �0iL -V1,U, " Xr& : :S "•,,I�a ai-ItLY1A Required Site Modifications/Conditions: W9M 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.**** - —Lid IS' 7� laa�"S f SIL -r Pdtil� (To BZ , Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Da 1,� CM>-, Name Address Z Mailing Address (if Email Address:] Subdivision Name r DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR Telephone Number Directions HW1j /5s, �(iZL t# (3-1 -1w, (-&,, Date System Installed v Name System Installed Under Type Facility (� Number Bedrooms Number People Served Type W ter Su ply Specific Problem Occurring jk/ !� ; Date Requested Info Taken By THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS Revisit Charge Date Reason DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR OPERATION PERMIT Account #: 990005551 Tax PINiEH #: D7 -080 -AO -037 Billed To: Ernest & Karen Warren Subdivision info: Redland Way Lot # 37 Reference Name: LocationiAddress: 342 Longwood Drive -27006 Proposed Facility: Residential Expansion Property Size: 1 Ac ATC Number: 6055 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T. Manufacturer Tank Date Tank Size Pump Tank Size Bedrooms System Installed By: Installer#: Date: GPS Coordinate: Environmental Health Specialist: DCHD 11/06 (Revised) Date: ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 REPAIR IMPROVEMENT PERMIT AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005551 Tax PINIEH #. D7 -080 -AO -037 Billed To: Ernest & Karen Warren Subdivision Info: Redland Way Lot # 37 Reference Blame: LocalionlAddress: 342 Longwood Drive -27006 Proposed Facility: Residential Expansion Property Size: 1 Ac ATC Number: 6055 Site Type: ❑New ❑Repair $LExpansion **NOTE** This IP/ Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any.building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use chance. Residential Specifications: # Bedrooms L4 # Bathrooms # People BasementErBasement plumbing E"' Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size TC Type of Water Supply: CJioCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow GPD) l � b Tank Size--Ei( AL. Pump Tank GAL. Trench Width _ Max. Trench Depth 2(r Rock Depth Linear FFt. LQ�� Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)753-6780. ON Environmental Health Specia DCHD 11/06 (Revised) lmpfilit ^ 00100:o� et� Ch Date: T -1 avie County Health Department Iivironmental Health Section P.O. Box 8,18 210 Hospital Street ENRON Courier # : 09-40-06 Moc•ksvillc, NC 27028 pp�1E Film (336) 7.53-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: Emest .4 Karen NAjorfito Phone Number 3%0- q'}o -4583 (Home) Mailing Address: 26 LonQW006 Df, 5?2Q-q14-3'159 (Work) AIyar,r Nc. 71oDt,14kID: ��loZ_-l-Q303 on LonqYvInJ lbn . [o Property Address: • 1 Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Rain C= -I- 50rS Con5frAle- tjhType Of Facility: F 5iamcc Date System Installed (Month/Date/Year): —t D, Number Of Bedrooms: `t Number Of People: �- Is The Facility Currently Vacant? Yes �� If Yes, For How Long? Any Known Problems? Yes 0 If Yes, Explain: , S7 Please Fill In The Following Information About The NEW Facili� Z%' Type Of Facility: 5 1 mi s: Number of People_ Requested By: Date Requested: -1,1 ( ignature) I For Environmental Health Office Use Only A proved Disproved Environmental Health SpecialistDate: *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 Paid By:� Money Order # Amount: M Account #: I _ _Invoice #:-- 1-G - -- '`Ai07, 10 4 - 46*(Ch) Iv r/3-56' 107 49 (Are)(Nv tb- •t CI �5' 1 9'25 " E 260_ 7g. 38 9'l,3" A.3s:o ' �C/) ) 3fi �. o 39 f43567 ft 39.726 sq. MCI � ►� � " '' � tN3� 1t 00 acres0.91 u� 37 . n3 Co - OD 4 tG n j cam; 'In 0.85 ozres C» ,$ CO 42.487 sq, ft-. 3 0.97 ocree 133.38' 1 38.68' S 04'37'44" yy fi52_ nd) 32#(TotGj) milia W: Pe troy D.B. 337, Pg. 697 PIN 5862615567 Zoned R-20 299.72' `sem I N —' 00 Cn APPUCAIION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC r-- tv ount Health Department E C E 0 V E nmental Health SeWon Q6.' P.O. 848/210 Hospital Street I 2003 kaville, NC 27028 n' (336) 751-8760 FEB 1 9 * ** IilP T1iN't �EIVVIn ' i i . T ION CANNOT BE PROCESSED UNLESS ALL iNFORMA ION IS P$Q�1E$i&EIIG Refer -' o the INFORMATION BULLETIN for 1. Name to be Billed V,,4 o ?t, Contact Person k� Hailing Address ,� tG�� / f Hose Phone _ ' City/state/LIP CIIII c-. �. , Business Phone 2. Name on Permit/ATC if Different than ]Above JUN i 41120,91 : RE D ruotfk'i4f8NMEN --4MCOUM Y Hailing Address City/state/Zip 3. Application For: USite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: douse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People ! Bedrooms 1 Bathrooms ❑ Dishwasher a Garbage Disposal ❑ Mashing Machine ❑ Basement/Plumbing ❑ Basemant/No Plumbing 6. If Business/Industry/Othert specify type People / sinks i Commodes i showers i Urinals 4 Mater Coolers IS ]FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of Mater supply: td'County/City ❑ Well ❑ Community e. 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 MUST COMPLETETUE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with TRIS APPLICATION. Property Dimensions: 5 fie, r -e5 Tax Office PIN: # -31 Property Address: Road Name Clty/Zip A611JIlluled, MZ 91—W, If in it Subdivision provide Information, as follows: Name: "-pp 14, Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 75 fz!�— D-7-1,91 4-/Xzo/ 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 am responsible for all charges incurred from this applicallon. 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 sults Ility. DATE y�� 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) 1 Client Notification Date: I EIIS: Account No. Revised DCHD (07/99) Invoice No. 4 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900136 Tax PIN/EH #: 5861-59-5239.37 Billed To: Westview Development Co. Subdivision Info: Redland Lot # 37 Reference Name: Location/Address: USHighway 158-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: .-g !7 Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % Ix Z9 HORIZON I DEPTH 0-11,0 Texture group S CL Consistence Structure Mineralogy ( " HORIZON II DEPTH D Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure K MineralogyI' I HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE r...,.,-. n: • 11- AAm .T_ C/ CAI AT TTATTrIXT DV- IA&L I /if LONG-TERM ACCEPTANCE RA REMARKS: LEGEND OTHER(S) PRESENT: 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) a' 31 ' y 41 t . 42.145 ft. 3 �. �• at7em , .. u? 0.97 x !sem '� f i A Ems'► � r. C-4 : A • �rC ijo l ' 4 ,r� 60 s st � � tai 34 11 W. 46(Oh) ,�• .56 9 2. '(Are) O'W 260 76' GO (D6 ur a• Vit' 39 cv ,l fes- -4 Loco J' � sq. 92 6cr.� ►�? ,-- N 43.567 9q. Q d r . ��_ l .00 ' acre i 37 ter" - jODKa s rt ) a d Q mss. •`. v 0.85 orxe� a� 38 `Sri 42,487 ft. O 0.97 ' S O4f37'4,400 138.60 . 652-32"(Totat) 299.72' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PEI Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ECCE WE nn t; OCT ` 7 2004 1 UU L ENTR( 1,11 P!TA1 HEATH ***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 Ad� ti'7'S/�f/) Contact Person U "%N{ �Y Mailing Address�Q �'j� ! /4�'l/ Home Phone 1� 0, City/State/ZIP l�n`�'(/Ve e- Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: (, Site Evaluation i13 Improvement Permit/ATC [I Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ® conventional modified 11 11innovative 6. If Residence: # People # Bedrooms J # Bathrooms) QDishwasher pGarbage Disposal V]Washing Machine ®Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes y # Showers _ 2 # Urinals # Water Coolers IF FOODSERVICE: # Seats 8. Type of water supply: Uf County/City Estimated Water Usage (gallons per day) ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? 'IMPORTANT` CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: I/S %�� Lcc� i� WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: it �81 / - % 5-.;, 3 7-3 7 8C /� cr Property Address: Road Name ic^k y r% LJI�ZZ City/Zip If in a Subdivision provide information, as follows: Name: �{'X I -rd Ltxt y Section: Block: Lot:_ Date home corners 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 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 thesite su' bility. DATE / / �, SIGNATU THIS AREA MAY BE USED FOR DRAWING YOUR SITE PL (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Sign given 1:`4 Revised DCHD (05/03 Date(s): Client Notification Date: EHS: Account No. '�'f5 Invoice No. �� ,�