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129 South Hemingway Court Lot 37Account #: Billed To: Reference Name: Proposed Facility: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 989900317 Tax PIN/EH #: 5789-14-8249 Glory Home Builders Subdivision Info: COVINGTON CK 2 Lot # 37 Billy Joyner Location/Address: HEMINGWAY COURT -27006 Residence Property Size: 3/4 Acre ATC Number: 2870 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 WASTEWA CO CTI I ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu e: Date: �p O 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. �� 3C,X14� rr ttil to. 'TAI . 3o �A Z� 30' to ¢i Septic System Installed By:t�- Environmental Health Specialist's Signature: Date: 7 DCHD 05/99 (Revised) IF APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 AT JUN -6 20 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 _i //y J C� l//!� Mailing Address I `�n !' OYJe-�UHome Phone City/State/ZIP Cze />I Mdk::) t , A)7 2- 70/ Z Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation City /state/zip 13'Improvement Permit/ATC ❑ Both 4. System to Service: use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms �- # Bathrooms is. -Dishwasher X3�Garbage Disposal � washing Machine 11Basement/Plumbing V1 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 e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 9 -No -- 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. Property Dimensions: /�� X �� WRITE DIRECTIONS (from Mocksville)) to PROPERTY: Tax Office PIN: #1 ' / Property Address: Road Name Me- * r ;r. yLLA C7 , City/Zip �,fyarrL If in a Subdivision provide information, as follows: Name: v ,` Y l Joh Gee k Section: 2==,= Block: Lot: Date Property Flagged: U �� 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 suitability. DATE _ �- Q1 SIGNATURE _!/��t., t 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). I -I Site Revisit Charge Revised Revised DCHD (07/99) �bZL- it,) NTOCC Date(s): Client Notification Date: EHS: Account No. D 3 I rl Invoice No. 3 3—� APPLICATION FOR SITE EVALUA "ION/IMPROVEMENT PERMT Davie County Heu:th Department Environmental Healt!s Section P.O. Box 848 Mocksville, NC 27028 (704) 634-8760 ! ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REgUIRED INFORMATION IS PROVIDED. 1. Name to be Billed • H6 ^4 E S Contact Person L A 'a��'` Mailing Address PI) �� if l tl >! �� o � Home Phone City/State/Zip ,06 U�t+J C� 2L Oct( Business Phone _ �''y77:Z. �8/3-,39/P'r/+�1 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip i 3. Application For: ite Evaluation `-7 !! [ ] Improvement Permit &ATC [ ]Both 4. System to Serve: [ ] House [ -] Mobile Home [ ] Business [ ] Industry [ ] Other % o+ ut�tY�t T u�S iynJ 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 [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [V]'No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: A)a t 66&C, IMCCe ( —:WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # S789 - 9-41_ MAUI A � u � � �S� IL+ �, �� i9G{ J4 n; 4q -e Property Address: Road Dame �� j �TO� r t' 1( / int r — wg2s S lol e t City/Zip Q. ca-nSS =Cam nde I j IW 4ers ; If in Subdivision provide information, as follows: Name: r Section: Lot #: h" % 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 tive of the Davie County Health Department to enter upon above described property located in Davie County and owne pw'. I Revised DCHD (06-96) SIGN all testing proceoWs as necessary to determine the site suitability. MIS :ti;T'.1 ,1111/ L;r, U rD III: PIAN: DAVIE COUNTY HEADH DEPARTMENT Environmental Health Section SECTION_ LOTS' Soil/Site Evaluation APPLICANT'S NAME�n PROPOSED FACILITYY �! SUBDIVISION Al/i /I 1v / e A% r C elt Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit t/ DATE EVALUATED e7 +? d PROPERTY SIZE ROAD NAME �t� '00(yy-) Public 11� Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH i Texture group Consistence Structure AC / 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: ' REMARKS: DCHD (01.90) EVALUATION BY: OTHER(S) PRESENT: LEGEND 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 s Plione: (336) - 753 - 6780 Davie. County Health D Environmental Heald P.O. BOX 848 21.0 Hospital Street Courier # : 09-40-06 Mocksville, NC 2702 (-�talJ �j Qy iit�►- .�..w. b- rel t) " ft%e&dl 405 fi- � �0 IUB 1►7C�M`I ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name:��_ob;,, i Sl aonotx Acc'av's 0^_ Phone Number 336 - 7qo SS S79 (Home) Mailing Address: S• t W7t �3� �� `1"(Work)! vavlGC K) C- "-1 oc> So Detailed Directions To Site:W �I ?C> rt ( l� ��sU"Q'►�!L �^ Coy' n � 3rd o n Lzf4 0 2 3"-�J-f%c/�14 6L-, f t-, Property Address: li'L l U•rA � fiance Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Q C5TPType Of Facility: 4-6fY�-c- Date System Installed (Month/Date/Year): L(?A__N.m.ber Of Bedrooms: _Number Of People: Is The Facility Currently Vacant? Yes No Any Known Problems? Yes No If Yes, If Yes, For How Long? Please Fill In The Following Information About The NEW Facility: Type Of Facility: T C'o Number Of Bedrooms: Number of People Requested By: (SaL LIQC6Date Requested:_ (p I I (Signature For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist (_lU tZOW A AAI&JM Date: (012Z.6010 *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: Pa C Money Order # r Amount:$ 0 Date: =Z'0 Paid By: Q/'S0 Al Received By: 06� t (/► � �/ /!� �� C Q,�/• dW 5 Account #: S5-7-5' Invoice #: 7.1114 -