170 S Angell Rd .�
• DAVIE COUNTY HEALTH DEPARTMENT �
' Environmental Health Section �
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001679 Tax PIN/EH#: 5749-19-7801
Billed To: Edward Barnhardt Subdivision Info:
Reference Name: Location/Address: S.Angell Road-27028
Proposed Facility Residence Property Size: 1.33 Acres
ATC Number: 3986
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 Buiiding Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Tr ent and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON IS ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur : � ate:
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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.
�.
����BVr�x�l
�a 1?D ���,�,�
`� ST � ��N-I r
��
K�1. I�-�
� S�ILd
���"
1��a1: 11-Z
Septic System Installed By: �� � �- esf�l
� v'
Environmental Health Specialist's Signature: ` Date: d ��
DCHD OS/99(Revised)
.
DAVIE COUNTY HEALTH DEPARTMENT �
. Environmental Health Section �
' P.O.Boz 848/210 Hospital Street / a s
� Mocksville,NC 27028 v2/�'y�
� � � � (33G)7S1-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001679 Tax PIN/EH #: 5749-19-7801
Billed To: Edward Barnhardt Subdivision Info:
Reference Name: Location/Address: S.Angell Road-27028
Proposed Facilitji �,Residence Property Size: 1.33 Acres
ATC Number: 3986 ��'
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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 Z
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑
� Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size ������ Type Water Supplyl� Design Wastewater Flow(GPD) L"Tv Site: New� Repair❑
' System Specifications: Tank Size��`�GAL. Pump Tank GAL. Trench Width��t Rock Depth 12�� Linear Ft.�r
Other: � �5T���J����
��/� �j� 5 ', —_� �
Required Site Modifications/Conditions: ����,u_�.J �_r�OvQ, I'�`� G�-- 'f�"• l..�a�, __C� ���
11�1PROVEM11ENT/OPERA'I'ION 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 9:3 a.m.or 1:00 p.m.to 1:30 p.m. on the day of installation. Telephone#is(33C►)751-87G0.****
• 'jp' � �f 5�
�b t,�,ZL_
I
�7�
�F��--a� �.I� ��
r
�,�sr ��r��'
'�• N��
r,�►`�j (°°, a � �5�
� q�� �
� qo' I
C/
Environmental Health Speci ist's Signature: Date: 7 fl�
DCHD OS/99(Revised)
� I `
:'. . �('^ � � � �
� v
Q 200�n ON FOR S1TL• EVALUATION/IhiPROVEhiEN7 PL"Rhi1T S�ATC �
�4 �p� 2 � Davie County Health Department
Environmenta/Hea/t/�Section
�Nj�N��jH .0. Box f34£3/210 Hospital Street
�N1R p��COUN�( Mocksva.11e, NC 2702Q
(336)751—E3760
***IMPORTANT*** TIiI5 APPLICATION C1lNNOT I3E PROC�SS�D UNL�SS ALL TFI� REQUIR�D
� INFOIZNSI�TION IS PROVID�D. Refer to L-he INFOR2•SI�TION nULLETIN for instruction�.
1. Namo to bo Dilled G�� � . � � Y Contact Pcruon L�W��
Diailing Addreuu (�j'/� ��-// v v� ,� ~ Ifome P2iono �/�J / J ��
�n �/ �/ /
City/State/ZIP j�G 7 ✓; ' I Q IIuaino�n Phono�..5 / �TL��
2. Nama on Poxatit/ATC iE DifEerent than Above
Mailiug Addroaa City/Stata/Zip-
3. Application For:��-Site Evaluation �7L1-Improvement Pcrmit/ATC ❑ DoL-li
4. syata�a to sorvico: ❑ Houae Ca'Mobile Home ❑ Busine�3 0 Induutry ❑ Orher
5. . 1ype ayatem roquosted: �Convontional ❑ convontional modifiod ❑ iniiovativo
6. If Rasidence: iF People �_ 11 nedroomn �_ �E Dathroomn �_
Oniahwaahor ❑Garbage Di�poaal lsdWashing Macliino ❑Dasement/Ylumbing ODaacment/No Plumbinc�
7. If Duainean/Induatry /Othor: varify typo A Poopla II Sinks
# Comsaoclaa # Showora N Urinal� IC Platcr Coolar�
IF FOODSERVICE: �� Soatu Etttimatied Water Utsage (gallona por day)
8. Typo of wator aupplys L�YCounL'y/City 0 Well ❑ Community
9. Do you anticipato addition� or espausions of thc fzciliry tbis systcm is intcudcd to scrvc? 0 I'cs �YNo
If ycs,ivl�at typc?
***IAfPORTANT"°**CLl�N7'SAfUST COhlPLCTLI'I1L: RL•QUIR�D PROt'�RT1'IIVl�OKA�Ie\TIOIV RCQU�STCD
--- BGLOIY. �ithcr a PLAT or SI7'I:PLAN AlUST!3G•SUIIAII7TGD by tLc clicnt �viUi T!IIS APPLiCATIOIY.
Property llitucnsions: l l�k ��- � / / � 1YKI1'�D[RLCTlONS(froiu Aludcsvillc)lu 1'liOl'GRTY:
c ����.�F—! '
i
T�xorr►��rirr: f����ll��,f��UJ�f �� � a �v /�/�i y �-�..�
�?� 9 -t9- '7�br
roperty Address: Road Nanic -� L /� r ,/1J ..� �--
i
City/Zip �OC;,��v�l��v ��� '�.-,� ^ ,, �
� / � � �
If in a SubJivision providc iuforliia(io»,as Collotivs: c�/ - �i/� � l_"� i"
Namc: . [�1) �,—� ,
!—�
Scction: Bloctc: Lot: Datc homc corncrs Aaggcd: o�-� s
Tliis is to ccrtify tli�t tlic inforinatioii pi•ovidcd is corrcct to tlic bcst of my IuioSti•lcdgc. I undcrstanJ tliat any perii�it(s)
issucd lurcaflcr:�re subjcct to suspcnsiou or rcvocntion,il tiic silc plans or tntcndcd usc cliangc,or ff(hc informaitou
subu�it(cd in tl�is application is falsificd or changed. I,�lso,uurlcrslanr!!lraf I anr respoirsiLlc jor rtl!clrargcs incrrr•rcd jrvn�
!lris applicatiotr. I,Itcrcby,givc cocisetit to tiic Autliorizcd Rcprescntalivc of(lic Davic Couuty IIcaltl�Dcpartmcnt
to cntcr upon abovc dcscribcd property locatcd in Davic Cowit}'and otiti�ncd by �
cu coi�Juct all tcstic�g proccdiu•cs as ucccssar��to dctcriuinc tl�c sitc suitabilitp.
� v�.
DATIs,��/,��/l/�� SIGNATUI2� t ���i� � /`��� - � l
TI�IS AREA I17AY B�US�D TOR DIZA�YII�IG YOUR SIT�PLAIY(Iucludc all of tl�c folIotiviug: �xisting and proposcd
property lic�es alid Jimcnsions, structures, sctbacltz, and scptic Iocations). �
' ; Sitc Rcvisit Cliarbc
��% 5 -��,� : nac�cs,: .
� ' f��� Clicnt NotiCcation Datc: �
.� bB,-�
� �IIS:
Sign givcn . �� A'ccount I�io. �
Rcti�iscd DCIiD(OS/03 Invaicc No. ��� �
-,,.�o �ota/ �:� � � (1 .82A)
N j� �� 8188
� (1 .71A) ; S3
2174 � (1 .54A) �
h`��° a �� 7130 �o�
�,
,
/ 2�� S3�
� (1 .21A)r
�/ 8901
i ��� '���
/; 4983 3os
� ��
�� 27p � G5100A000101
;
%� �� �0�
i� ti � .33A) ,�`�'
%� 7801 �`�
; , ,
l�/ S28J
, 3r2
0 200 �
� 2646 � (7.89A)
51 (4.40A) 0604 ,
(148) 4670
(1 .01A) � �
� ��
2520 ti °`
N
. � (2.78A)
` -. 2414
. j
�
1
Q �
�� �,,�.�;�2 Z- ��
�
� ��
� �
r
�
� f
f �
� �.ti ��
� ��
t
�, �
��
.�„�' ., ' i �--
�� c�� _ ._ --
�- ______
� � DAVIE COUNTY HEALTH DEPARTMENT
;� Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001679 Tax PIN/EH#: 5749-19-7801
Billed To: Edward Barnhardt Subdivision Info:
Reference Name: Location/Address: S.Angell Road-27028 �.
Proposed Facility: Residence Property Size: see map Date Evaluated: � 2 '��
Water Supply: On-Site Well Community Pubiic �
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L.l L-
Slo e% � 3 ' �
HORIZON I DEPTH f] • � �� �:`
Texture rou � ^ G-+—
Consistene� .S� ' �SS
Structure S 1� � '
Mineralo � -�'�C�" � -
` HORIZON II DEPTH le_?-ZO -2 / -- D
` Texture rou C. � G
Consistence ; S �� ��
Structure • S-�v"1c ,-1�
Mineralo '
HORIZON III DEPTH �3 Z" -3Z - C7
Texture rou � - c�'.+S�r�CSc�. G FSt
Consistence _f '� SS s/ r S
Structure 5� Syk'
Mineralo S�;,Q �...,�C.
HORIZON IV DEPTH �tyt "'' '�ll� �!U
Texture rou Cs�) /<�'�l'�c ��
Consistence . �'
Structure
` Mineralo u'X
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � • (�- O-.��
SITE CLASSIFICATION: P S EVALUATION BY: ����-�`�
LONG-TERM ACCEPTANCE RATE: ����'��� OTHER(S)PRESENT:
REMARKS: �}Tj? �L�� Qp�_ ,..�x.L'� ��
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 day loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
� CONSISTENCE
Mois
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
1:1,2:1,Mixed
Note �
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 OS/99(Revised)
■�� � ■����������������������������������������/��0��������/�■
■�■ �����■�\���������������������������������■�������������■ ■■
::��: ':'::::C:::::::C:C:C:C:::�::::::::::::C:::C::C::::::::C�::
::'�:.:A:::::::::::::::::::::::::C::::::::C:::::::::::::::::::::::
■�����■ ■�������������■�■�■�������■������������������a�������■���■
.....=.0..........................................................
:C•:• •:':CC:::::C:C::C:::::::::::::::::C::C::::::::::C::::C::C:::
_:�.���:C:C:::::C:::::C::::::::o�i::::::::::::C:::::::CC::::::::::
...0.. ...........................................................
■���� �������t����������a������������a����������t���������������■
■���■ ■�����������■■������������������������������������������■�■
■���■ ■���������������������������������������������w�����������■
■ ■■ ■�■������������a■����������■������■������������������������■
■■ ■�■ ■����■�������������������■��������������������������t�■
'.�.. ...0..................... ................................
__:::: :C::::::C:::::CC:CC:C:C::�::::::::::::::::::::::�:::::::::
:::C':C':::::�::::::C:::::C:::C::::::::C::::::::::C::::C::::CC::C:
C..........................................................
...0 ��...........................................................
..... ...........................................................
:::::=:C:::::CC::::C:C:C::::::::�:::::::::C:::::::::::C::C�:C:C::
..... . ..........................................................
....... ..........................................................
........ .................................................... ....
......�.0..................................................�. ....
:::C'. .................................................... ......
■_������������w���������������������■������������o����������■
■�A■ ■ ■������6�=========------w.t�������t����■�t���■�����/����■
■��■ ■■ ■������11■���■�����■��7�.I1�.1►7��������������������■������■�■
C■/�//����������I�i����������L�li!�1�[►.��������������i��������/�AA����■
... .........�................................��...........�......
....gEs.........�.................................�.................
.... ..........�......s..........................�.................
■���■ ■����������������■�������e�����������������ei�����■����������■
■�=���i��������������������������■t����������������i����������������■
�i�iiii��iiiiii�iiiiii■�Ciiiiiii�iiiiii�iiiiii'�iiiiii�iiiiii�
iii��i��������������������■��������������■�������i������■���������■
■�����■ ■�������t��������■�■��������������■������i����������������e
.......C........�.................................�.................
■�A�/�A//�������1���������������������►r7�����►+����I�����������A����■
■�■ ■�����������I/��������\���■��!■��■���9�Li�z�����1����������������■
■�������������■�I����■������ier�■ ■���:�fil.LJi■���I�������������■��■
■■ ■��I������■���I��������������Z/���������■�������f����������������■
■��■ ■������■�■�����■������cr'ait�������������������i����������������■
■ ■■ ■���������������t�i������������������������������������A����■
iiiC���iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii«iiiiiiiiiiiiiiiiiiiiiii��ii
.... �..........��............�...�;.�...��.�........�.............■...
■��� ■�����������i������������,������r.�����������„����������������■
.... _�..........�...........�;���.��.�.............�.................
■��■ ■�������■�i�����■���s��■u������■����t�a�����i■������■��������■
�����������������i����������s��������■�������������i����������������■
■��■ ■��������■��i������■�������■���������■■������■i����������������■
■����a����v��s���������������������i��������������ii������������t���■
■ ■■ ■��ov����t�����■��������■���������■�������o��i����������������■
■ ■�����■�����������■�������■�������,��■�����������i����������������■
■ ■����������������������������■ ����������������i����������������■
■�������t�����■■����■�■�����������������■������■�i���■������������■
■��■ ■�����������������■���������ii���������������i����������������■
■��������������������������■�■�������������■������i�����■�■����■���■
■��■ ■�������������■���■����s��■����o�������■�����i����������������■
�����������������������������������►.�������►���������������������������
■����_�■���������i��������������:����■�����������■�i■����■��������■�■
■���� ■�����■����i�����������■■���i�■��■����■`����i■■������■��s����■
C:�:::':C::::CC::�::::::C:::C::::�::::C::::��'�,::C�:::C:::::::::::C:
.... C..........��.........................��..�...�.................
....��...........��.........................��.....�.................
■��■ ■������■����11���■����■�■������������■��I■i���l���■�■����������■
■����������������1/�■/����������������/����■�I�■���I����������������■
■�e��■/���■����■�11����������■����■\�������■�I�����I����������������■
�����/��/!t�l�����/1������������\�������������I I,!l���I������������/���■
■��\���l�r`ttir���/���I��������■�����������■����I�fi�■�I�■����A���A�����■
■������►!'r'IOi��Iili's����1��\����������■ ■��������■I���■■I������������■���■
■�������1��1���Iil�cii���s����■�����������a�������t�����i����������������■
— -----�..�.or���������V,��,���
(3.42A)
�`'��,_. • 5741 � ��
. . `',-`.,`' `� 1`-
. �
S�4 /
��� .
4557 `�� '
�
318 °� �
1 6
5
�
4427 � � '
0 � 474 '
� �
�
� �
``___----_. �'
�
� 8 � �r.,� —___
`� � �� � �''��'� � �
�� ���� (2.43A)
� � ,��.`� � 0219 �
� � S6� � �
,
� ��
4 ota� `
� ��, (1.82A) :
'� O 8188
.71 A) s38
�
2174 , ,� A) I
��'��� � ���� �������'`� � � �° -�
.. ��
,
�' ��� `�' ' � i
�c:'�
Pr`� tr o S s3�
�'" (1.21A)�
,� 8901 0
�� PCC2 ^h �
4�83 �o
1 s
��"�'° �
ty�1 ' RnD
/ ��'.
4�� CeB2 I �i�.3�A� � ',, ��� � �
, 1 7sa�
� �s
� �a
� � �
�
� �
� „ �
----�___. ,�
00 ;,.,,�,,
o,
46 � ' /�""� (7.89A) / ,
4.rri �
���� � o
0604` 3
51, ' 4.40A} 2
3} .�1{670 �
I � ��
� 3 � �
� �
�
N (2.78A}
2414�
�
��` �
� �
,-_----�-----223 .
�
L � '
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO �ox 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760 / F�: (336)751-8786
February 3, 2005
Edward Barnhardt
678 Main Church Road
Mocksville,NC 27028
Re: Site Evaluation-
1.33 Acre Tract/S. Angell Road
Tax PIN#: 5749197801
Dear Client(s):
As requested, a representative from this office visited the above site February 2,
2005 to perform a site evaluation. Based on the information provided on the Application
for Site Evaluation and after the evaluation was completed, the site was found to.be
provisionally suitable for the installation of an on-site sewage disposal system.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct, the appropriate application must be completed and
submitted to this office. The location of the facility the system is to serve must be staked
off. Additionally,please locate the property corners prior to making this request.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
Enc(s)