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114 South Hemingway Court Lot 25DAVIE COUNTY HEALTH DEPARTMENT Account #: 989900317 Billed To: Glory Home Builders Reference Name: Proposed Facility: Residence ATC Number: 2758 Environmental Health Section �� I P. O. Boa 848/210 Hospital Street � /��� j j� rj- Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5789-14-2674 Subdivision Info: Covington Creek Lot # 25 Location/Address: HEMINGWAY COURT -27006 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 WASTEW=CNSTRUCTION IS VALID F R A PERIOD OFF FIVE YEARS. Environmental Health Specialist's Signature: Date: dM OF COMPLETION **NOTE** The issuance of this Certificate of Complet n hall indicate the system described on Improvement/Operation Permit has been installed in compliance with Articl 1 k of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY beas a guarantee that the system will function satisfactorily for any given period of time. 7 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: ��%� V a " 11141IJ I 0 1►II 11 @. I_ WA UNT.1 0 W.7419,4ru l_ N i . • ' • • Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900317 Tax PIN/EH #: 5789-14-2674 Billed To: Glory Home Builders Subdivision Info: Covington Creek Lot # 25 Reference Name: Location/Address: HEMINGWAY COURT -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2758 **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 o Dishwasher: X Garbage Disposal: ❑ Washing Machine:." Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /J #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply C Design Wastewater Flow (GPD) Site: New V!( Repair,❑ System Specifications: Tank Size/j�(Z GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Widtk_� Rock Depth Linear FtkfjQA 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 0 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mockaville, NC 27028 (336) 751-8760 MAR 2 020 ENVIRONMENTAL HEALTH DAVIE COUNTY ***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 Contact Person / Mailing Address/' /IY// cJL' Home Phone jb City/state/ZIP C �(�'/i!J ti%ON i , / �/' C • 'y�� Busineaa Phone /, ^N ��z V 2. Name on Permit/ATC if Different than Above Mailing Address City/ �State/zip 3. Application For: ❑ Site Evaluation e -improvement Permit/ATC ❑ Both s. system to service: r0 house ❑ Mobile Rome ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms ,- # Bathrooms -� Dishwasher n Garbage DisposalHaahiag Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: specify type # People # sinks # Commodes # Showers # Urinals # Hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ well ❑ Community e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? ❑ Yes d2bie If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED" BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. 1- .17- Property Dimensions: Tax OMee PIN: # �:2 Property Address: Road Name #Cyi City/Zip —A e, Uo 6 If in a Subdivision provide Information, as follows: Name: r—t-19 rre Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 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 bereafler 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 aU charges incurred from this apptication. I, hereby, give consent to the Authorized Representative of the Davi County Healthpepartment to enter upon above described property located in Davie County and owned to conduct all testing procedures as necessary to determine the site suitability. DATE _ ` �O SIGNATURE 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). Site Revisit Charge Date(s): Client Notification Date: I EHS: Revised DCHD (07/99) Account No. rt tl �, 3V Invoice No. 13. rAl — — — — — — — — — — — — - Ilo WiFL 00NNA CO 2 (7- R 4 2 L-. 13 1106.36' _100.98' 6 5. 8 9' Q C 273.23' S 88'53'59 W 1t6.7_2' - TOTAL ' C -P 24 2"W 20' PUBLIC RD. 50 R/W R 1W (C3) 50, Pi 88- 53 59' E C A 125.13 co viNCTON :I)( 1-- 12 �5 � : bi Uf-L I -N 0) N 83* 24' 1 x --------- CL ,:L 10 C,4 A.6 C4 LL- '2',36 lo -i Z fC) ocJ3' V) 6 .22 o go ;7) 321 o�CZ t., R,j ZD 5-) w 00 277.97' 14 89'58' 113" W n -- — — — — — — — — — 7 307,B3* S t19* 5' 43" E C4.Ic 01 - — — — — — — — — — — — — — — C3 C2 L 06 ri rl 2 2 Cl -10 - /741 1GD 4T) - -j ZAJV) N Y (\i C\ 42 WCT, v Q 6 7 j r clZ Q & J22 —r,0 `D, 71 8'12' 5(—,, 2513 1-- CORNER 81 4 1' --3 111:4T V5 " —5�- CONTROL 00 Q 5) 3 4 Q 9:) N 8 0 w PL A y APPLICATION FOR SITE EVALUATIONAMPRO'VEMENT PERM' Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 1 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TAjH`E RE U/I-RyE1-D/IfnN�FORMATION IS PROVIDED. Name to be Billed vVJD rti+E C Contact Person �1 c.�i <►f Mailing Addressf�L//��� i[ // ) >! �� C� Home Phone City/State/Zip J'tuaiu Ct? Nf! . 27oc)(Business Phone 18/3,391k I 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For. M45e Evaluation (] Improvement Permit & ATC,� [ ] Both 4. System to Serve: [ ] House [ •] Mobile Home [ ] Business [ ] Industry [ ] Other % O ± SU a I V i.S iO •J 5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal [ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/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 [ 1 Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ lq-o If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Mr+ 0� 60 44, ORCC-e [ WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # s 789 - d�-4/— - Property Address: Road Dame city/zip AV) 2?00 [ cs w��e �� l44ers If in Subdivision provide information, as follows: Name: 2 ' ' � r Section: Lot #: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter ar subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified o changed. I, also, understand that I am responsible for all charges incurred from this application. I. hereby, give consent to the Authorize ve of the Davie County Health Department to enter upon above described property located in Davie County and owne Iry Revised DCHD (06-96) all testing procS�IuFs as necessary to determine the site suitability. 1111: AIT; 1 ,11c1/ LIE 11 FU jolt 1)1t,111'1N6 J0111? .k;111 PIAN: ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT. Soil/Site Evaluation APPLICANT'S NAME�� �' DATE EVALUATED e _4�r PROPOSED FACILITY PROPERTY SIZE =&�/ 61 SUBDIVISION ROAD NAME 2ffa Z Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit i Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence i Structure /C - Mineralogy V HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 77 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: A EVALUATION BY: LONG-TERM ACCEPTANCE RATE: l OTHER(S) PRESENT: REMARKS: r � �'%% /� f�J' /�l� le ,4a2�1 Wiz/ a 04 Y 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 soii colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD (01.90)