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128 Abbey Ln _ � � ��. . • � , • ' ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 990001$67 Tax PIN/EH#: 5&43-36-3399.02rs Billed To: Raymond Simpkiss Subdivision Info: �Z� ��j��v� ��/Qi Reference Name: Location/Address: Pineville Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2942 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 WASTEWATER CONS UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: Q`—� �7 —�— � �- � f� , �D�1�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article I 1 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. /`O r:�--Q � �`� p/ `/ �0� 0 /oo � l00 � � I�s� � ��y � Septic System Installed By: � D`-'�i Environmental Health Specialist's Signature: r�''l� �'``'— Date: � /�— C7 � DCHD OS/99(Revised) � , , DAVIE COUNTY HEALTH DEPARTMENT . . , , Environmental Health Section • ' � ' � P.O.Boz 848/210 Hospital Street �� --, � Mocksville,NC 27028 / (336)751-87C►0 � IMPROVEMENT/OPERATION PERMIT Account #: 990001867 Tax PIN/EH#: 5843-36-3399.02rs j�� Billed To: Raymond Simpkiss Subdivision Info: Reference Name: Location/Address: Pirr�wi+�e-Fiead-27028 /��`� � Proposed Facility: Residence Property Size: see map ATC N��b�r: 2942 **NOTE** "I�is mprovementJOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply�_ Design Wastewater Flow(GPD)� Site: New t� Repair❑ � System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width,��Rock Depth f' Linear Ft.�� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)iF G"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.**** � 1^ Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � � � . . � ,� y�� C1 � . . LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC AUG Davie County Health Department � 2�� Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street ENVIROiJMENTAL HEACiH Mocksville, NC 27028 DAVIE COUNTy (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORI�TION IS PROVIDED. Refer to the INFORI�,TION BULLETIN for instructions. � 1. Name to be Billed ��T��I�(/��2�/��GIJ� Contact Person y3'`=� Mailinq Address y t/� L(j( /Aj•��• �� ' Home Phone � City/State/ZIP jA/J�J/ f,,✓ ,_f'�L�jyJ /✓� Z� �G,) Business Phone ^ �.�, o�.<< 3 �5— 19��" C2o ��s. 2. Name on Permit/ATC if Different than Above � Mailing Address City/State/Zip 0 3. Application For:�Site Evaluation ��Timprovement Permit/ATC ❑ Both a. system to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: ri People � # Bedrooms ,� # Bathrooms Z �Dishnasher ❑ Garbage Disposal �washinq Machine ❑ Basement/Plumbing fi Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gaiions per day) 7. Z�pe of water supply: ,�ounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes �No ' If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eit6er a PLAT or SITE PLAN MUST I3E SUBMlT7'ED by the client with THIS APPLICATION. 4 Property Dimensions: �--e-e /'—�--�o WRITE DIR�CT[ONS(from Mocksville)to PROPGRTY: � Tax Office PIN: # ��`f�- � � - � � ��- � �-- y� ri �ll /Y1�'�!��I/��d. Property Address: Road Name y� ��2� /',�4�h1��,/T"� G��-ri�r c�cyiz�p Td i�i�v,�v�l� �,� �'un.� �.��f lf in a Subdivision provide information,as follows: ',$�U'G�- � /'Y! �' j!� �i j3�1''.�I Gi✓. Name: ,�-~'z-''(_ Z 4 '� ` Section: Block: Lot: Date Property Flagged: � � � This is to certify that the information provided is correct to the best of my knowledge. 1 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,uitdersta�td tltat I am responsible for al!cJrarges i�rct�rrerl jrom this application. I,hereby,give consent to the Authorized Representative of the Davie County Healtl�Department to enter upon above described property located in Davie County and owned by to conduct all te ting procedures as necessary to determine the site suita ' DATE I SIGNATUI2E THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc ali of the following: Existi�g and proposed property lines and dimeasioas, structures, setbacks, and septic locations). Site Revisit Charge � r _ Date(s): � �� v.�._ Client Notification Date: — � _ ��- ' � EHS: �'�-`-� `�- g � Account No. Revised DCHD(07/99) � I Invoice No. � 7 � � �-� � �'`� V � , . . . , � ,,• , t ri � � , - . . . . _._...,.. „ _...___ ... . .- _.,..._...., D��I� ��U�CY�i�L - , ,,: . , � T�€ I��,,,��tT1V��NT �.°;, : . �..�....,�.'; ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospltal Street Courier #09-40-06 Mocksviite, NC 27028 Phone #: (336)751-87G0 July 23 , 2001 Boger Real Estate " 5248 U.S. Highway 158 Advance,NC 27006 Re: Site Evaluation/2 sites Abbey Lane/Pineville Rd Tax Office Pin : # 5843-36-3399 Dear Client(s): As requested, a representative from this office visited the aforementioned site on July 23, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, ��e Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di 3 SfC unmorked � •t7 foo0 r ate � W z • RUTH DIETZ '�,s. IN- EDGE GE O scale —� �� ih OF FAVEMtNT , D.B. 337 Pc. 188 VICINITY MAP _ ( S OS'2523,0 O8• M 68.73 i i I r� placed 30' SNArN a v Ir r "J1 ' rr � I � I � !r o r � r II< I M I ; 1 ry 1 RO 1 � I � I 1 j I I I I oFEssio .i2 B.C. BROCK Jr. ` _•QQ' SEAL�� •� - n fl D.B. 75, PG. 251 �` 1 = = L-2527 ' Z� <9 it 1 I Ir r � I , li I, GRADY L, TUTTEROW, CERTIFY THAT UNDER I' MY DIRECTION AND SUPERVISION, THIS MAP 1 WAS DRAWN FROM AN ACTUAL FIELD SURVEY 1 Ii MADE BY UTT ROW SURVEYING COMPANY. I 1 , I1 --- ---- ---- --- ------------ _S ---- ' PROFESSIONAL LAND SURVEYOR L-2527 f AREA = 0. 263 ACRE3 8-1 4 a TUTTEROW SURVEYING COMPANY J, unmarked JOHN W. FROST 124 SOUTH SALISBURY ST. Po,n MOCKSV ILLE, N, C. 27028 r , D.B. 330 PG. 99 (336) 751-5616 W, `. %o r N ti 50 25 0 50 100 150 new �� 73.43 r j ran N 83.39'07• V I r new ron Ir I SCALE IN FEET r PLAT OF SURVEY FOR, 1 o DOUGLAS H. CO UNCIL REVISIONS SCALE, 1' 50' ApPROM 1w WA N&M DOUGLAS H. COUNCIL = JULY 13, 2001 GILTDATEP 0011.00l! WB 92 E—148 BEING 1.737 AC. OF THE DOU" 114. COUNCIL PROPERTY (0.8. 172, PG. 381) 1 n ex at nq Ni 0.253 AC. TAKEN FROM THE DOUGLAS H. COUNCIL PROPERTY <W6. 92 E 148) REF: D.B. 120 , PG. 148 FARMMGTON TOWN",DAME COUNTY, NORTH CAROU NA. I TAX MAP REF.' 8-5 PARCEL 34 do p/o PARCEL 42 ~05 �� '> 20301-3 ._% . • . "�--_�w,.,.,_,_„ """""� ' LICATION FQR SITE EI�A�UATION/IMPROVEMENT PERMIT&ATC - • n' r,, � �� . �C,,, l��,t�_,.,.......- •��•� Davie County Health Department Q � � Environmenta/Hea/th Section �n i P.O. Box 848/210 Hospital Street ' J��- � I �� Mocksville, NC 27028 `�; , .,� �... - , ,;Ll'rl (336)751-8760 �i.ii� �,� ***I,NIE�OI2TANT�'�* �THIS APPLICATION CANNOT BE PROCESSED UNLESS AI�L THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BUI,LETIN for instructions. 1. Name to be Billed �nQ p� ��/q' �STL)�� Contact Person ��Oq e v Mailing Address �� S V�S� d/y /�� Home Phone /9 p" 7 7.�8 City/State/ZIP _�'[��//1q./r Q e /�� Business Phone _9 9 8� �� 2. Name on Permit/ATC if Di££erent than Above �)/Lf /�1�S Mailing Address A�6 6eN � �NC City/State/Zip f�� 'L�$V i 1 I c /� ' ` • � /�.W 3. Application For: �Site Evaluation ❑ Improvement Permi.t/ATC ❑ Both 4. system to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People ,L # Bedrooms �� q Bathrooms �_ �Dishwasher U Garbage Disposal �Washing Machine ❑ Basement/Plumbing f.l Basement/No Plumbing 6. If Business/Industxy/Other: Specify type # People # Sinks q Commodes # Shoxers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (galions per day) 7. TyPe of water supply: � County/City C] Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intendcd to scrve? ❑ Ycs �I No Ifycs,what typc? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INTORMATION REQUESTED QELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with TH1S APPLICATION. I1 Property Dimensions: � � WRITG UIRGCTIONS(from Mocksvillc)to PROI'GR'I'Y: T:�x ort;�� [►v: #__�g�3 � ' 3 9 �� — �r��I ;��a�o�r Q c! �'�r� �b be� C.N �?J� PropertyAddress: Road Namc � � r f C � ✓ A► 'i�C ON 'I�C�/�'� �� c�ryiz�n�v(n c ks v,'/!r h/�C J7o�__�b v�ve� a� �4-� �.�. L�v •4 p � If in a Subdivision provide information,as follows: __�✓ I�.i i N e�.�aN 1T� � Namc: Section: Block: Lot: Date Property Flagged: �,� —�c� -' �-% � This is to certify that thc information provided is correct to the best of my knowledge. I understand that any permit(s) issued hercafter are subject to suspension or revocation,if thc site plans or intended use change,or if thc information submitted in this application is falsified or changed. I,also,u�tders�nud t/rat I nnr resparsible fi�r�ll charges incarred front t/�is app/icntio�r. I, hereby,give consent to the Autl�orizcd Representative of the Davic County Hcalth Department to enter upon abovc described property located in Davic County and owncd by to conduct all testing procedures as neccssary to detcrmine thc site suita ity. DATG �'�"� I �" D� SIGNATUR � THIS ARGA MAY BE USED FOR DRAWING YOUR SIT�PLAN(Includc all of thc following: Existing�nd proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Clicnt Notitication Date: � �HS: Account No. � l" Revised DCHD(07/99) Invoice No. �l ZO ,�� ; . •� . ; . . � ' DAVIE COUNTY HEALTH DEPARTMENT . • � Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 0 DATE EVALUATED � "��'J � PROPOSED FACILITY PROPERTY SIZE �� SUBDIVISION ROAD NAME �s�rU�6/�. Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � 1 Texture rou Consistence � Structure !�. Mineralo ,'C� ( � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ' , SITE CLASSIFICATION: � EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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-Subangulaz blocky PL-Platy PR-Prismatic MineraloEv 1:1,2:1,Mixed No es 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-gaUday/ft2 DCHD(01-90) . _ W , . � . . .. . ....., ., ._. . _...;,. _..., ..: _. ..�.,,.,., ,; I��.11l��1U�VT7�ii�I.T�€ I��i��tTlv��I'F `� ; ..:.._ __._. .___ _ . _.._ .... . _...._ _ . ENVIRONMENTAL NEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC :27028 Phone #s (336)751-876Q July 23 , 2001 Boger Real Estate � 5248 U.S. Highway 158 Advance,NC 27006 Re: Site Evaluation/2 sites Abbey Lane/Pineville Rd Tax Office Pin : # 5843-36-3399 Dear Client(s): As requested, a representative from this office visited the aforementioned site on July 23, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site,the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked of� If you have any questions, please feel free to contact this office. Sincerely, ��• Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di