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184 High Meadows Road Lot 26DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 # (� Account #: 989900283 Tax PIN/EH #: 5870-69-0403.26 Billed To: Bob Cope & Son Construction Reference Name: Proposed Facility: House ATC Number: 2810 Subdivision Info: Windemere Fams 2 Lot # 26 Location/Address: 221 High Meadows Road -27006 Property Size: 1.276 Acres 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 WAT O STR CTION IS VALID A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �� 61/ 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. n NJ Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: !q _ Environmental Health Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900283 Tax PIN/EH #: 5870-69-0403.26 Billed To: Bob Cope & Son Construction Subdivision Info: Windemere Fams 2 Lot # 26 Reference Name: Location/Address: 221 High Meadows Road -27006 Proposed Facility: House Property Size: 1.276 Acres ** *NTnbetr: 2810 NfiE is mprovement/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 7 #Baths S Dishwasher: 0� Garbage Disposal: ❑ Washing Machine: 0"' Basement w/Plumbing: Pr Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats IndustrriaEll Waste: Lot Size Type Water Supply �� Design Wastewater Flow (GPD) .jw1d Site: New;2alRepair ❑ System Specifications: Tank Size � GAL. Pump Tank Other: Required Site Modifications/Conditions: . • it GAL. Trench Width Rock Depth Linear Ft. IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative oft avie 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. o to4y of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: tW. Date: DCHD 05/99 (Revised) PpP Z 5 201 FOR SITE EVALUATION/IMPROVBIENT PERMIT & ATC Davie County Health Department Envirunmei7tal Hea/tfi Section .O. Box 848/210 Hospital Street t Mocksville, NC 27028 J� (336) 751-8760 *IMPORT "'*'THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED FOP 02MION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 8,9h &pe-- C."nS4, Contact Person LI -4V (' Mailing Address ?(J AK 116a Home Phone 2 I� � f City/State/ZIP (/� eery �� a' [Q%/ Business Phone ! t 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City/State/Zip Improvement Permit/ATC Cl Both 4. system to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other I S. If Residence: # People --� // # Bedroom�s # Bathrooms �- � IVbi��shxasher Garbage Disposal L�YWashing Machine 4/Basement/Plumbing (l 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: L5'County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes D No If yes, what type? ***I41P0RTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 7eG aQ s p Tax Office PIN: # Tc lo / _ O �O 3.4 Property Address: Road Name p -g-/ City/Zip AJ -104 �L7& If in a Subdivision provide information, as follows: Name: Ll.*"Ilje ae%r 1—zurM5 Section: O. Block: Lot: A(a— WRITE jDIRECTIONS (from (MJocksville) to PROPERTY: Date Property Flagged: L,//..)— 5,/6 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 cuter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE % �o�g r 0 SIGNATURE J� - 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 (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: ') it 5 -) Account No. Invoice No. �'� 1 1 `� r: 5o 129 Ac. 0 .278 XPi �.(- QI O 1 16. 49 - 340. -n. -- nTA1..= 482.1 S 66 2t' 30 ° v HIS MEAL o Ws R Wf)A-,AID TOTAL= 4 82, l 9 N 8b • 22'3;8" E .. n. 95 - - 16$124-... - . .120.00 _ _ 1 .00 APPUCATION FOR SITE EVALl1AT10N/IMPROVEMENT PERMIT & ATC�� Davie County Health Department Enidrunmenta/Health Sectfon `! P.O. Box 848/210 Hospital. Street � � AUG 2 5 1999 Mocksville, NC 27026 (336)751-8760 111' ii. •. * * * IMPORTANT* * * THIS APPLICATION CAMM BE PR=SSZD UNLESS ALL TH REQUIRaD IN MMWION IS PROVIDED. Refer to the IMSORtUTION BULLETIN for instructions. 1. flame to be allied WEs;ytNJ DCJEWP.;AW CO-MPAWI contact Person ) GoopaeY Moiling Address 2L31 94y)JGt-nA JZ0. Hose Phone 336 0.1.,008 city/state/s=P "mc 2110j, nosiness Phone '136-111- 001R Z. Rase on Permit/Azc it Different than above Wiling address !. Application ror: M Sits Evaluation s. system: to Services a/Houses O Mobile Hone S. If Residence: ii People City/stab/sip 0 Improvement Permit/ATC 0 Both O Business O Industry 11 other t Bedrooms s Bathrooms 0 Dishwasher 0 Garbage Disposal O washing 1lachins 0 Basement/Plumbing O aasement/no Plumbing 6. It Business/Industry/Other: specify type i People f Coasodes I showers f Urinals f sinks i water Coolers It >!MSERVICE: # Seats Estimated Yater Usage (gallons Per day) 7. Type of water supply: 0 County/City 0 Well O Co=wniE!" tty a. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes Ef 1Vo If yes, what type? ***IMPORTANT*** CLIENTS MUST CIDMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: S� Tai Office PIN: # �d �U in-' 416J Property Address: Road Name /J�c uc 1/��/�'• City/Zip22%C WRITE DIRECTIONS (from Moclwille) to PROPERTY: ,MO&5 CNwU1 to I?Aodt 6W 8E4Vd 4MP„%'/'- pKpAt-XTV o. -J L'cm . H In a Subdivision provide Information, as follows: F Name: 1AXA 7 E911 0 c';O rXAP Section: �/ Block: Lot:=2co Date Properly Flaggedt 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, understand that I ani responsible for all charges incumd 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 suitability. THIS AREA MAY BE USED FOR DRAWERG YOUR SITE PLAN (Include all of the f lowingt Existing and proposed property fines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge J Date(s): I Client Notification Date: I EHS: Account No. Xyc Invoice No. /06p 0-1 1 X_1-5 i f � 4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION —, -V, LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY Al— PROPERTY SIZE SUBDIVISION ROAD NAME Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1, Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH -� Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: i REMARKS: s?'V ' 0'4D Ca7 DCHD (01-90) Landscape Position EVALUATION BY: hla71' 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