255 Baileys Chapel Rd (2) DAVIE COUNTY HEALTH DEPARTMENT -�
� . _' Environmental Health Section �
� - �' P.O.Boz 848/210 Hospital Street
1 � '
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000889 Tax PIN/EH#: 5779-241794.b2
Billed To: Cherie Yarbrough Subdivision Info:
Reference Name: Cherie Yarbrough Location/Address: Bailey's Chapel Road-27006
Proposed Facility: Residence Property Size: See Map
ATC Number: 2994
**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
PERMTT 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 rT #People� #Bedrooms `J #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 �a Design Wastewater Flow(GPD)—C� Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width ����Rock Depth��Linear Ft�aU
Other:
Required Site Modifications/Conditions:
11�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROV EFFLUENT FILTER. RISER(S) IF 6`�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ft vie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m. o he a f installation. Telephone#is(33G)751-87G0.****
�
Environmental Health Specialist's Signature: Date: ��-�/'"� �
DCHD OS/99(Revised)
• � DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 99q000889 Tax PIN/EH#: 5779-241794.Q2
Billed To: Cherie Yarbrough Subdivision Info:
Reference Name: Cherie Yarbrough Location/Address: Bailey's Chapel Road-27006
Pro osed Facilit : Residence Property Size: See Map
ATC Number: 2994
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MiJST BE ISSLTED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 WASTEWAT CONST CTION IS V LID A PERIOD OF FIVE YEARS.
�'
Environmental Health Specialist's Signature: � Date: �j j�f ��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate of Complet' n s all in icate the system described on Improvement/Operation Permit
has been installed in compliance with Art' le of .Chapter 130A,Section .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WA be ken a guarantee that the system will function satisfactorily for any
given period of time.
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Environmental Health Specialist's Signature:�—T�� Date: p2��`�� ,
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DATE__ L2/2 I 9 9 BIGNATURE �
TH13 AREA MAY BE 11SED FOR DRAWQIG YOUR STPE PLAN(Inclnde sU of t6e foUowin�s E�W�and pr�opa�ed
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., DAVIE COUNTY HEALTH DEPARTMENT
' � ' Environmental Health Section
•� � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000889 Tax PIN/EH#: 5779-241794.02
Billed To: Cherie Yarbrough Subdivision Info:
Reference Name: Cherie Yarbrough Location/Address: Bailey's Chapel Road-27006
Proposed Facility: Residence Property Size: See Map Date Evaluated: ���
Water Supply: On-Site Well Community Public d��
Evaluation By: Auger Boring `� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �C...
Slo e% `
HORIZON I DEPTH
Texture rou
Consistence (
Structure
Mineralo
HORIZON II DEPTH ( �' C �
Texture rou C'
Consistence
Structure /L �%
Mineralo
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: ��C�
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-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
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
DCHD OS/99(Revised)
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D�1lI� �OUNTY�I�I.T�I D����T14i�NT
Environmental Health Section
P. O. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
(336)751-8760
December 10, 1999
Cherie Yarbrough
204 Autumn View Drive
Winston-Salem,NC 27103
Re: Site Evaluation
Bailey's Chapel Road
Tax Office PIN: #5779-24-1794.02
Dear Client(s):
As requested, a representative from this offce visited the aforementioned site on,
December 9, 1999. 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,
/����•���'
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/msp
Enclosure(s)