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231 Bear Woods Trail " � . DAVIE COUNTY HEALTH DEPARTMENT • • ~' � • Environmental Nealth Section � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003606 Tax PIN/EH#: 5843-39-9209 SJ Billed To: Scotty Johnson Subdivision Info: Reference Name: Location/Address: Pineville Road-27006 Proposed Facility Residence Property Size: 13.271 acres ATC Number: 4071 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLIED 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 I 1 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: (Y�L/ Date: ,s �a/��I L'- CERTIITCATE OF COMPLETION %, ,.�V **NOTE** The 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. 7 �'�T r�� `�� o,,, �ovs�; s�y �f F� �S' CNqM4�2S q� 2� Ik 1 � l 2z Ctlnu►�� •z '�� -��T Cc�L R.�c i�v� (!o-i 3-ocn� C��GI� �!�-r D �caa�3� �Q `� ��-! - —�,�� arLg�Septic System Installed By: Environmental Health Specialist's Signature: Date: � ��O DCI-�OS/99(Revised) _ , DAVIE COUNTY HEALTH DEPARTMENT � � _. —+ • Environmental Health Section ' P.O.Boa 848/210 Hospital Street �� J S � ' _ ~ � NC 27028 ' � S�� , Mocksville, � (33G)75l-87C►0 � � � IMPROVEMENT/OPERATION PERMIT J� �b....�C�� Account #: 990003606 Tax PIN/EH#: 5843-39-9209 SJ Billed To: Scotty Johnson Subdivision Info: Reference Name: Location/Address: Pineville Road-27006 Proposed Facility Residence Property Size: 13.271 acres ATC Number: 4071 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHOWZATION 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?F� 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� Repair� .� System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Widtt�_��Rock Depth� Linear F� Other: �� 'iS stat��d i�t �5/1 NCAC 1 r .' �� Required Site Modifications/Conditions: aer,epte�+ �ystems may also be use 11�1PROVEMENT/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.t . :00 p.m.to 1:30 p.m. on t e ay of installation. Telephone#is(33O751-87G0.**** �vdS��C �`�� , e�`�S �m6 _ � � � � ar � �- �� s� �s � Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � . � ' � r^ , ,� ..� +� � - �.' ) 11 � � � !`� � � � � APPLICATION �OR SITE EVALUA7(ON/Ih1P OVEh1CNT PERhf C � ' Davie County Health Department EnvironmentalHea/th Section Ap� 2 x ��,. P.O. Box 848/210 Hospital Street � Mocksville, NC 27028 a,�j��O��Y; (336)751-8760 �AVIE�Q��Wtn/ ***IMPORTAN'l*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THS R�QUIRED INFOR1tiATION IS PROVIDED. Refer to tho INFOFtMATION IIULLETIN for inutructiona. L Namo to be Billed �L6// �/ J D//17�0l7 Contact Per�on Mailing Addra3s y�b. /�}d�( �`�� Home Phone ` � ��5 '�77' � u��1r� � csty/state/zxr �i'�rr'.�i'i�,�i?v//�f_' /�� Z 7'OS`�Jrauniaess Phono 3 .S� • �1�� S' �'�� Z. Nazne on Pezmit/ATC if Difforent than Abovo �C�� !i/L�`� Mailing Addresa City/Stato/Zip 3. Application For: � Site Evaluation �Improvement Permit/ATC ❑ Both 4. syatem to service: �Houae ❑ Mobile Home � Business ❑ Industry � Other 5. 1�pe system requested:�Conventional ❑ conventional modifiod ❑ innovaCivo • 6. If Residence: � Paople � # nedrooms Z # IIaL-hrooms � �Diahwasher ❑Garbago Dispoeal �Wanhing Machine ,,�Ba�ement/Plumbing ❑Dasement/No Pltunbing 7. If IIuainoas/Induatsy /OEher: verify type A People t� Sinka # Coaaaodea� # Showera # Urinala 1{ Wator Coolera TF FOODSERVICE: # Seats Estima�ed Water Usage (qalione por day) 8. Type of water aupplys ❑ County/City �Wall ❑ Community 9. Do you anticipate additions or cxpansions of tl�c facility tliis s}'S�Ctll 1S lI1fC11(ICd lo SCI'YC? �YCS �lvo iry��s,�Yt�at cyn�� ***IAIPORTAN7�**CLIL''NTS r1fUST COAIPLETE'I'I1C IiCQUlIlCD I'ROP�It1'Y IM�OI2I1'IA7'lON RLQUGS'tCll I3GL0\V. Githcr a PLAT or SITI;PLAN AIUST Bl:SIII1AlIT'fL•D Uy ll�c clicnt �vitl�TIIIS AI'PI,ICATION. I'roperty Diuicnsions: �� ' 1VR1TI;DIRGCTIONS(from Mocltsvillc)lu PROPI:K't'1': �Tax Officc PIN: �� '3�3��2C� �"l ��l � Tb gd/ , ��'� �. D✓/ PropertyAJdress: RoadNamc , J , �Gr�i��N /�� _ /v/'�1 �• O�l City/Zip /°i11P vi//P �d . �S o �.��oX / �,; If in a Sul�division providc informalion,as follo�vs: G3r�� v✓rl /!. Orl o�i'r1`/'oti� Go p�,/�,/,0%x, Namc: % M�. o�- jvrn �. o.� r'.,�� G�f��✓� Section: I3locic: Lot: Datc hanc corncrs 17aggcd: b' v�7 6 � w Tl�is is to ccrtify tl�at thc information providcd is corrcct to ll�c bcst of my ICIlOIYJC(I�C. I undcrstand lhat any permit(s) issucd lureafter are subject to suspension or revocation,if the site plans or iiiicuded use cl�ange,or i[tl�e iiifoc•matioi� sub►uilted in tliis applicatioi�is falsired or changed. I,nlso,rurrlerslnad tha1l a�n respousiGle fvr nl!clralb�es iacrrrred j•um tlris applicalion. I,l�crcby,givc conscnt to thc Autlioriud Rcprescutativc of thc Davic Couiily IIcaltl�llcpartn►cnt to cnfcr upon abo�•c dcscribcd proper(��loc�ted in Davic County aud oti��ned by to conduct all lcsling proccdures as ncccssary to dcicrminc tI�c sitc suitability. � DAT� ; �� SIGNATUIZ� �� : � TIIIS AIi�A MAY B�US�D rOR DRAtiVING YOUR SIT�PLAN(Iucludc all of tti�follo�ti�in�;: I:xisting and proposcd property liiics and dimcnsions, structures, setbacics, �iid septic locatiocis). �� -7 . Silc Rcvisit Charbc � �`��'� , Dalc(s): �✓v"" L _ �� Clicnt NotiGcation Datc: L,z.c1L� �HS• , , � Sign givcn �� < u �� l � Account No. � �v � Reviscd DCHD(OS/03 Iiivoicc No. � � _ _ _ __ _ _ ' � ��, e ,� — C� �� -�-�' �--� � .-� , , . . . . . �-�,,..�-_.�--� �� y�i � �� ,� ,5zo> — � i �ISTED IN YAD! �I -r ,�2� `. LISTED W � �„�� , �� . (4.66A) . � '� ` � � YADKW COUNTY y"' � . . . I 913 . . . '. 3h 2101 I p22n� � I 8314 � � / — � 13 71A — � � ` � � , ' > (15.01A � � 4153 629 (330) 19b 207 ;.��4�� . I '� g e��.°.��:;�:�. � � � � . ��O , ,. '. (8.98A) y 5970 pez I � �mr ,;,.;:a� � , � ,� �;,.,� „ ' t ? ��B � � EL: t q� " . ?A3 219 i58 :�I3 �. '� � ;7.08A) 1 4389 � � � f 2000a � � . 1365 f�>� � � � . � . (18.<30A) . .. . ¢ . . � . 1116 (17 OEiA} � 5112 � zos (5006 r�^ I �;a.;; �052 3.610A 7607 .� � O � 1.00OA � i ', `� �daa,i. , e;5�.��. _ — . . _ .__ _ _ _ _ - _.. �� Fi�yr 27 OS 09: 43p Scotty V. Johnson 336-677-2888 p. l r ` . � ' , , , . . • ' ' ` � r�r�....�.......'. ..p 'ti`.�'.. . �> . .,1,,,` , rj!��N''1 ..�. l��r. ENVIRQNMENTA� HEAL7H SECTIUN . P. 0. liox 848/210 Hospitai Streol __. Courier K09•40-06 , Mocksvillo� NC 27028 �:..; �.,:...�,�.. , .- -r.-�;�r�y;;'� .r. �..,,. •,� ..., � :?w�!:�::k�«�., :�,:;�'.�`.��:��.;+;y�,".:�c�,.;:�:a�t��.�R�tW1piA��;,;::(�30)7.81-8760 � , � July 10,,2002 .,t: � . Harold Waync Smith � . 2�0 Woodlcc Drivc . � Advance,NC 27006 Rc: Sitc Evaluation/off Pincvillc.Roa� . T�ix O�ice Pin : '�t 5843-39-9209 � Dcar Clicnt(s): � As requcstcd,s rcprescntative from this ofrcc visitcd thc aforcmcn�ioncd sitc on July 9,20U2. Bascd upon the�n.formation providcd on thc APplicutio��jor Site Evaluation and aRer a�t eva�uation was completecl on the site,the silc w;is found to bc provisionally suitable for the installation of an on-sicc scwabc systcm. Bcforc anlmprovement Permif/Autliorizatio,e 10 Construct c�n bc issucd thc approp�iatc aPplication must bc filled out and die housclmobilc home toc��liun staked off., If you have:u�y questions,plcasc feel free to contact tl�is officc. Sincerely, . � . .�'.�.t��.��- . � ' Robcrt B.HaII,Jr., R.S. Environmcntal Hcalth Specialist RH/df . . �, . . . � . l `��a �� 'Q� � AP�'LICATION FOR SITE EVALUATION/IMPROVEhtENT PERM1tIT&ATC '. � �'�� Davie County Heaith Department s i i :� , _Q � - •� Environmenta/Hea/th Section E�� '�" � ' � � . � �� ' ' P.O. Box 848/210 Hospital Street T,� . ' Mocksville, NC 27028 �t�y�ROtdP�,lEPfiAL FIEJ1LTIi (336)751-8760 ` DAVIECOUN?Y ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AI,L THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORI�TION BULLETIN for instructions. ,_l- C . 1. Name to be Billed � Q�(� �� LX��-� J rn � �� Contact Person (,J C,Lk v� �, �✓YL� r�J Mailing AddrQss a a a �.C�L l� � L C C'_ �� 1"• Home Phone `�/��— Y-`t'�f� .� City/State/ZIP ��1/(.�Y�L..e _ /t C___�,_[��{� Business Phone R `6 ��d d 2. Namo on Permit/ATC if Different than Above �. Mailinq Address City/State/2ip 3. Application For: i� Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. sYstem to service: � House �1 Mobile Home 0 Business ❑ Industry 0 Other 5. If Residence: # People � # Bedrooms �_ # Bathrooms � I�( Dishwasher fl Garbage Disposal 41�Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbinq 6. If Business/Industry/Other: Specify type # People � Sinks H Commodes N Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Esti.mated Water Usage (gallons par day) 7. TypQ of water supply: ❑ County/City � Well ❑ Community a. Do you anticipute additions or expi�nsions of the facility tl�is system is intended to serve? ❑ Yes [9�No Ifycs,wl�at typc? ***IMPORTANT*'�*CLI�NTS MUST CONiPLETETHE REQUIRED PRQPERTY INrORMATION REQUESTED I3EI.OW. �itl�cr a PI.AT or SITE PLAN MUST 6ESUB�LII7TED by thc client witl�TH1S APPLiCAT10N. Property Dimcnsions: /3 . �7( � �VRITE DiRGGTIONS(from Mocksvillc)to PROPERTY: Tax Officc PIN: # S� �-� "'"�� -9 �� I �o✓T l� o n �-G sM i n�' t� � R u Property Address: Road Namc b'� �;h e J i l l e �c� ,t.�-F�U C1, ei n� l/I �� R�• c�cyiz�r dvio�ksd��L�e a 1�� G� 1 ►�-.� ►� —�- Tu►2 n P►`� Ff-� If in a Subdivision provide information,as follows: Q� �l�l �� ' J�`� ��'r lYamc: �.bU�r .DrccC }� wcJ-c- Scction: Block: Lot: Datc Property Flagged: 7- .�- d 1 Tl�is is lo ccrtify that thc information providcd is currcct to thc bcst o!'my knowlcdgc. I undcrstand that any permit(s) issucd hcrcaflcr are subject to suspension or rcvocation, if tl�e sitc plans or intcndcd usc cUange,or if tl�c information submitted in this application is falsificd or cl�angeci. I, also,rutderstnitd lhn!I am respo�isib/e for a!/ckrrrges inct�rred front flris applicntio�t. I, I�ercby,givc conscnt to thc Autl�orizcd Representativc of the Davie County Hcaltl� Dcpartmcnt to cntcr upon abovc clescribed property located in Davie County and owncd by to conduct all lcsting procedures as ncccssary to detcrmine the sitc suitAbility. DATC 'J-S G� SIGNATUR� �L) _ TH1S ARCA MAY BE US�D rOR DI2AWING YOUR SIT�PLAN(Include all of tl�c following: Gxisting and proposcd property lincs and dimensions, structures, sctbacks, And scptic locations). ' Site Revisit Cl�arge Datc(s): .-�:_... ,�..,�,- .._.._ ..... c�� , � � �� 1 � '� � `ti S '�nyif� } ``1 � ""'..JKfY lJNE EF , � , �SCAL.ED FROAf.DAVIE COt1MY 7AX FdAP) ' • -_.. . . � � . , _... , , .� ) Z w E'ip . \ aK � . _�' o S g`4-52,�, e � c! " ,,,�2 r'�. 919.35 1291.68• a Rebor Set 10 � •. � 127.01' � BUFORD S��{iTH � ^ Grcnitc 145.32' � Monument � �v � t�8 6� PG 42�'. � te ` W �� U (> 5.000 p,cres (O�AD) i � � ��_ �� 0 � r' /`• � � �o � b A z � � � O N � � _ � _--—--____ zoa.ss� �; '� 420.43' 1 13.2713 ocres � Gro:�te N 8543'38' !y � � o µ=�nv�nent � --- 1 p N 8515'S3 :-. t 4 � W Eip � b W v 4 1 a n �,�, Zo m I �: a ri o . ; �- �� ro � i _ z z � �-!. REL� �tGRAVES � ``' CENTERLfNE OF PROP05ED ' i � � 30' ACCESS & UTlU1Y EASEM��,tT ' �8 36 PG 356 ' _ _ -- ._ -- - _ , i �o � �� Z � l � C-3 � I r '� ` � c-2 / � �� , � � � N , . ,__ _ .-_�.__- ._ �\ � /� � G�,� � N � � � �/ � /� `�1 4�03•�+(j j��/ �p�-, U, . t � � r3G.�-3 E-, __ � " � � 1 ' � \ —1— —289.04' ----c��i0.005tt 58.26' 149.4p• . � -- 1 EIP O STONE � ' o c ��-�3��g- E _ � \ ; N 88 13'S$" W Rebar Stone ; � � � `� � _ � � � 561.94• i Set � N 8629'. � �o � ' 1 SE� DETAIL \�� -i�� 1 I • + z � �. , � I � • ' f i t �- - � � N r � .&a• tC.z;�i I � � . _..,., 1 � �a 2 �4go' , ' r ! : , `, e� � sror:e � �: ..,_... � ; i i _ - . , , . � i � , . � � � � t J ` , ' JAMES DAV1D �LUS � t � , � - • r,o ,�no n,^� . , , . , , , � DAVIE COUNTY HEALT�I D�PARTiVI�NT . . • • • � � Environmental Health Section _ � Soil/Site Evaluation AI'PLICANT�INFORMATION PROPERTY INFORMATION Account #�: 9900b2354 Tax PIN/EH#: 5843-39-9209 Billed To: Harold Smith Subdivision Info: Reference Name: Location/Address: off Pinevilie Rd-27028 Proposed Facility: Residence Property Size: 13.2713 acres Date Evaluated: 7`��.2 Water Supply: On-Site Well L,/ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH !i . Texturc rou �� Consistence Structure Mineralo HORIZON II DEPTH G `� � - Texture rou Consistencc Structure < / � Mineralo HORIZON III DEPTH � Texture rou Consistence Swcture 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-Tenace 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 SRK-Subaneular blockv PL-Platv PR-Prismatic y ., K + I y �. , . _ � � . ,�'��,� 'wg; ,�z t ,�TM�,�1��rCQu��'��1��.��r t ' e;�1�)�` 6� .�.:+.�i� w�, .w.a.r.,,..�.w.� r,�,Lns..� T�..a. (s.«..�.. . . . ... .,.,5., ,.,>n , i tu.....�n r..(«�i7 ' '� ENVIftONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-OG Mocksville, NC 27028 �. .: ` Phone �#: (336)751-8760. �•. July 10, 2002 ' Harold Wayne Smith 220 Woodlee Drive Advance,NC 27006 ' Re: Site Evaluation/off Pineville Road Tax Office Pin : # 5843-39-9209 Dear Client(s): As requested, a representative from this office visited the aforementioned site on July 9, 2002. Based upon the information provided on the Applicatio�i 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 Improventent 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, .��'�t��• Robert B. Hall,Jr.,R.S. Environmental Health Specialist RH/df