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108 South High Field Road Lot 34fo d/,Z-j-6b DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900259 Tax PIN/EH #: 5870-69-0403.34 Billed To: David Mallard Subdivision Info: Windemere Fams 2 Lot # 34 Reference Name: Location/Address: Beauchamp Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2622 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 WASTE W CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ham--- Date: /O '-?O —6L) 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. 16 Septic System Installed By: Environmental Health Specialist's Signature: �CU—� �� Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ('4- (- Z 7 D J Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)7.51-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900259 Tax PIN/EH #: 5870-69-0403.34 Billed To: David Mallard Subdivision Info: Windemere Fams 2 Lot # 34 Reference Name: Location/Address: Beauchamp Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2622 **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 #People #Bedrooms { #Baths Dishwasher: M- Garbage Disposal:' Washing Machine: E17 ----Basement w/Plumbing: B----"Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size t t Type Water Supply Design Wastewater Flow (GPD) ?i(QO Site: New Repair ❑ System Specifications: Tank SizA� GAL. Pump Tank GAL. Trench Width /' Rock Depth L2� Linear Fta` Other: Required Site Modifications/Conditions: 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.**** e. �a fo yo' 10` Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: IQ -030 -0v r/ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department En vironmenta/ Heath Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 OCT 2 5 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billedt/!i S.�/ Contact Person Mailing Address /�9 r>:�2,c_��p��(�� C=.•+ , Home Phone city/state/zip lC i4. C, 7o L__3 Business Phone 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: ,rA Site Evaluation mproinvemssent Permit/ATC ❑ Both 4. system to Service: 5e House ❑ Mobile Home ❑ Buse ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms_ # Bathrooms 3 Dishwasher Garbage Disposal iLd Washing Machine ,t4 Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: J2r County/City ❑ Well ❑ Community 8. 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 COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # 6 Y70— 0 ©�-3 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: -OV`,O aW6i 'P �i�.p/•',�_ WRITE DIRECTIONS (from Mocksville) to PROPERTY: Section: �— Block: Lot: J' Date Property Flagged: / Z �d 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 the site su' ility DATE �O �S= O O SIGNATU r 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). 0 Revised DCHD (07/99) p1-6 PZ -S ( Z Cot1�/U 1� Site Revisit Charge Date(s): Client Notification Date: EHS: 'I y 11 Account No. Invoice No. 5a -// 13M/ APPLICATION FOR SITE EVAWATION/IMPROVEMFM PERMR & ATC Davie County Health Department Env/tronmental Health Sectfon P.O. Box 868/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ; AUG 2 5 1999 ***nwcRT7tNT*** THIS APPLicATIOM cunw = PROCc8t3BD UNLESS ALL THE AEQUIMCD IMM MIITION IS PROVIDED. Refer to the 11M MIITION BULLETIN for instruations. 1. Mame to be Billed WEMIN.1 DCJCwf,-nJW C"VAWI contact person ) G6tyaCY Mailing Address t2L3% 9-EyNaknw RO. soay shone 336•'116.IWO \Ai city/state/sip 1N1rdA-5ALtV% ,tic 211010 Business shone 336.111- d6"I$ 2. Maas as pewit/Arc it Different than Above gelling Address 3. Application for: W"Site =valuation a. system to services B Houses O Mobile Home City/stag/sip 0 Improvement Permit/ATC C Both 0 Business 0 industry 0 Other a. If Residence: # People # Bedrooms i Bathrooms 0 Dishwasber 0 oarbage Disposal 0 Washing Machine 0 Basement/plumbinq O Bassment/Mo pinmbiaq 6. if Business/Industry/Others speoifr type # Commodes # showers # people # sinks # urinals # hater Coolers XV 1O0DSERVICE: # Seats Estimated Water Usage tgallons per day) 7. Type Of Wat4r supply: 0 County/City 0 Well 0 Communiy e. Do you anticipate additions or expansions of the facW ty this system la intended to serve? 0 Yes Elko If yes, what type? ***1MP0RTANT*** CLIENTS MAST CIOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tai Office PIN: it Property Address: Road Name /,1 �'� a 1,���/�'• Cltylzip WRITE DIRECTIONS (from MockrAlle) to PROPERTY: POAMT-i CA If in a Subdivision provide information, as follows: Name: IUocMfM 7 a"p-M-S OJMAP Section: ?/ Block: Lot: 5a Date Property Flagged: This is to certifj 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 ibis application is falsified or changed 1, also, understand that I am responsible for all charges incurred front this appi1cadom 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. t i -PROARN- TMS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the Mlow1'ng: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): I Client Notification Date: 1EHS: Account No. Invoice No. p i ON PUCE 663 37 T FENCE C�RNPR LAWRENCE L. MOCK BY WILL REF:D.B. 49 P9. 8 '44 I / � * • _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Brant Godfrey Proposed Facility: Residence Property Size Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5870-69-0403.34 Subdivision Info: Windemere Farms Sec.2 Lot # 34 Location/Address: Beauchamp Road -27006 See Map Date Evaluated: 9 Community Evaluation By: Auger Boring Pit Public •� Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH - "-,b Texture group CL_ Consistence G . S S (9 Structure G MineralogyI : I HORIZON II DEPTH Texture groupG Consistence Structure =Gk Mineralogy I. HORIZON III DEPTH • U 2 - Texture rou Texture + Consistence i,.�Cr Structure P• i k MineralogyI HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: � REMARKS: LEGEND Landscape Position EVALUATION BY: CC"GGC :OAL C� 4J "P 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)