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370 Oakland Avenue Lot 106DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990004094 Billed To: Butner Real Estate Investments Reference Name: Proposed Facility: Residence ATC Number: 4510 ?& (p_5_ -0(e Tax PIN/EH M 5708-05-1924 Subdivision Info: Oakland Heights Lot # 106 Location/Address: Oakland Avenue -27028 Property Size: 1/2 ac AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED bythe 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: // 7 —,t�7-1 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permi 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. 1:t,k,p l 1.. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 4 ),r, 0 C DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004094 Billed To: Butner Real Estate Investments Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5708-05-1924 b �a Subdivision Info: Oakland Heights Lot # 106 Location/Address: Oakland Avenue -27028 Property Size: 1/2 ac ATC Number: 4510 **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 QP #Baths Dishwasher: P1,11, Garbage Disposal: ❑ Washing Machine:•8"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Co Design Wastewater Flow (GPD) CJ L)l Site: New ❑ Repair ❑ i/ System Specifications: Tank Sizc` VOGAL. Pump Tank GAL. Trench Width � Rock Depth Linear Ft. t?W Other: As stated in 15A NCAC 18A.1939(5) Required Site Modifications/Conditions: accepted SystOM May a,- -h used 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.**** hoy s } l�' Environmental Health Specialist's Signature: Date: Gv DCHD 05/99 (Revised) �$ I R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department gEP Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 A ication For: re ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) 'Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed fi✓�.c t k lh �F,f;, .,,, Contact Person Billing AddressX 2,3 41 s se Ac Home Phone City/State/ZIP —,4 cL,44�CC At c.:. Z 7oy L Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) .S7 v'rI q 2 - Street Street Address ZZ4,& Y CityA'v - . b.; /j�c Tax PIN# �•y4•r� 7 SubdivisionName j f, Section/Lot#�/� („ Lot Size_ _, 4e _ Directions To Site: _� Lj f -j %�4,,,:t Ate. /-"� . 42„ a Date House/Facility Corners„Flagged !j — s--:- a& If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? &Tes ❑No Does the site contain jurisdictional wetlands? ❑Yes G� Are there any easements or right-of-ways on the site? ❑Yes R?No Is the site subject to approval by another public agency? ❑Yes RrtQo Will wastewater other than domestic sewage be generated? ❑Yes W?, b IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _, # Bathrooms 2 Garden Tub/Whirlpool ❑Yes ONd Basement: ❑Yes 2K6 Basement Plumbing: ❑Yes Cho IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Fa ility/Business Total Squ Footage of But ' leiz; �� People 4— #Sinks # Commo s ,,t :��Showers # Urina Estimated Wate sage (gallons pe ay) (Attach doc entation of simila cility water con mption) FOODSERVICE O 1 #Seats Type system requested: P�&ventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 2 ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. 1 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine com liance with applicable laws and rules on the above described property located in Davie County and owned by , , f f,,�, �� �,T're, •�/� �v74te Property owner's or owner's legal representative signature f -as= 9 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given 4s ❑No Account # Revised 2/06 Invoice # 125 7599 �p • ,��`� 0576 295 7500 6h stip ry 2496 ❑ u� 200 u� w 9410 0460 0 157 .95 N 01 ❑ 0247 8217 �o o 82295 ❑ 209 7149 0137 �ti s �p1 2164 b 6161 �'��' 9110 ❑ ❑ Abp ��s ��61 8022 ❑ 2001 ���► ���j 1112DA0007 ' 7945 1924 'mss ❑ ��� � app ?o p0 6867 0847 ��y app 9833 app �� 9b 8786 app �p�b 7640 11 6563 401 (6.44A) 7210 0 4479 8 9 14 15 6 6: 5114 ❑ \ 17 ¥NO . . ® © Iry Aj Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street - Mocksville, NC 27028- (336)751-8760/ Fax (336)751-8786 Improvement Permit September 22, 2006 Butner Real Estate Investments 293 Jesse King Road Advance, NC 27006 Re: Oakland Ave Tax PIN# 5708051924 Dear Mr. Butner This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. System To Serve: 6C, Wastewater Design Flow(GPD)<�4C/ Valid: 2"5—Years ❑No Expiration System Type: ❑Conventional OAccepted ❑Innovative ❑Alternative ❑Other. Site Modifications/Permit Conditions: Asstated in 15A .eke j �tt. os-ni i.p.letter 7/06 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004094 Tax PIN/EH #: 5708-05-1924 Billed To: Butner Real Estate Investments Subdivision Info: Oakland Heights Lot # 106 Reference Name: Location/Address: Oakland Avenue - Proposed Facility: Residence Water Supply: On -Site Well Property Size: 1/2 ac Date Evaluated: o Community Evaluation By: Auger Boring / Pit Public V Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % G HORIZON I DEPTH 61 Texture group C Consistence Structure Mineralogy 4'/ HORIZON II DEPTH f Texture group Consistence .(V - -Structure Structure Mineralogy�'- HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 100> LONG-TERM ACCEPTANCE RATE jZ SITE CLASSIFICATION: , LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: I / A 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 CONSTSTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3Yet 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 Nato 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 05105 (Revised)