236-248 Bonkin Lake Rd DAVIE COUNTY HEALTH DEPARTMENT �' N
" Environmental Health Section
� '. P.O.Boz 848/210 Hospital Street �� J '� �
' _ ' Mocksville,NC 27028 �oL � �� 7 �
(33G)751-87fi0 �. K�}
IMPROVEMENT/OPERATION PERMIT �
Account #: 990002755 Tax PIN/EH#: 5833-05-5959.C6
Billed To: Clifton Burke Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3580
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHOWZATION 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 I 1 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 �1131�Si #People 2 #Bedrooms 3 #Baths 2—
Dishwasher: �" Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementJNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �+"�1�`=S Type Water Supply w�� Design Wastewater Flow(GPD) �l�t.J Site: New U Repair❑
System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width ��� Rock Depth � Z�� Linear Ft. �0��
�
Other: s �ISI���1�•�J �3X�S � l N STAU..- i_.t.��S � o•c-• M►►J .
Required Site Modifications/Conditions: `P.��A�•- o-J ��*0�, ��P 15�C3�F �-�p�,�, �Z=� ��OFF W�:,u�
Ih1PROVEI�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G`°BELOW
F(NISEiED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C►)751-87G0.****
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En ronmental Health Specialist's Signature: Date: � �Z- l73
DCHD OS/99(Revised)
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' . • ' DAVIE COiTNTY HEALTH DEPARTMENT
• � Environmental Health Section
� P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990002755 Tax PIN/EH#: 5833-05-5959.CB
Billed To: Clifton Burke Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3580
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MLTST BE ISSLIED 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.1 0 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW S IS VA D FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa Date: � 22 `v.3
CERTIFICATE OF COMPLETION
**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,�s a antee that the system will function satisfactorily for any
given period of time.
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Environmental Health Specialist's Signatur • , Date:
DCHD OS/99(Revised)
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. � � � � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERh11T& �S � /�
• Davie County Health Department LS' O �
Environmenta/Hea/th Section �
P.O. Box 848/210 Hospital Street 1��,[�Y l
Mocksville, NC 27028
(336)751-8760 � '�403
��ROI'e,�
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TH '�
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruct
� �!— /� (_ � /�
1. Nazne to be Billed ��. f [�/L. /,J C.V^Jr� Contact Person �L� I ` o� /�U��
Mailing Address ,��7U c.� ' ` C�a-CL' t't4�� (S� Fiome Phone �j3.li '��oG"'�5 �A
City/State/ZIP CCem,�l o i1 S /���. 270/2- Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Addresa Cit /State/Zip
��-'�j"�yaT
3. Application For: Site Evaluatio Improvement Permit/ATC Both
4. syatem to service: H se Mobile Home Business Industry Other
5. if Residence: # People � # Bedrooms 3 # Bathrooms _�
,_\ �.
,.--•-�
Diahwasher Garbage Diaposal Washing Machine Basement/Plumbing Basement/No Plumbing
6. If Business/Induatry/Othar: Specify type # People # Sinks
# Commodea' # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay>
7. Type of watar supply: County/City ell Community
a. Do you anticipate additions or expansions of the facility this system is inte�ided to servc? Yes No
If yes,what type? "
***IMPORTANT'`**CLIENTS MUST COMPLETE THE REQUIRED PROPCRTY INI'012A'IATION RGQUGSTEU
BELOW. Either a PLAT or SITE PLAN MUST BE SUBAfITTED by thc clicnt with THIS APPLICATION.
Property Dimensions: WRITC DIRGCTIONS(from Mocksviilc)to PROPER'Tl':
Tax Office PIN: # ��3 3- 0 5 Sl s q e� l� ) IJ '-' �1 �y� '�"'�
Property Address: Road Name�t7n F-i✓ ���G�-,/� �ti A I�r r•� �• � •
City/Zip �-�� Z� ,�� p�ciL.�/
If in a Subdivision providc information,as follows:
Name:
Section: Block: Lot: Date home corners flagged: � � d�
This is to certify that the information provided is correct to the best of my knowledge. I unclerstand tl�at any permit(s)
issued l�ereafter are subject to suspension or revocation,if tlie site plans or intended use cliange,or if the information
submitted in this application is falsified or changed. I,also, understand that I am respousiGle jor all ckarges incurred fi•out
t/iis applicatiat. I,hereby,give consent to the Authorized Representative of tlie Davie County Hcalth Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE .,�1 �0.3 SIGNATURE)(
THIS AItEA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of t1�c following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
� ( � Site Revisit Cliarge
�,,Q/t. �..�.� n d"' J� L. L.JG. /�-� � S .•� Date(s):
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S�L�� ��/ �A �'' o�.��S Y�'�"�p �'a;ti �� Clicnt Notificatio��Date:
�,0 w/,c.ls..�s-� �� F h,�S �^,.�.-, S ,-F-�.. I'�a-�-� s'
rn� ✓�� EHS:
Sign given i✓� Account No. � �y--S
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Revised DCAD(07/99) Invoicc No.
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, •. . DAVIE COUNTY HEALTH DEPART`MENT
� • � Environmental Health Section
. ,
• Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002755 Tax PIN/EH#: 5833-05-5959.CB
Billed To: Clifton Burke Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map . `S� �
R-.����'.
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% Z�
HORIZON I DEPTH .(c�
Texture rou (_.
Consistence 555
Structure
Mineralo
HORIZON II DEPTH Q- ?�
Texture rou
Consistence
Structure
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE a.2
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: � ��� �µ �"�o �
�'� 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)
. o • r
• �,' ' � ,�� ., ✓ APPLICATlUN FUR SIrC EVALUATIUN/1119PIiUVE1'dENT FLfi191T ' � � Q LS
'� . Davie County Health Department [� ����
.. ' Environmenta/Hea/th Sec[�ion (� � � ,� �
• "' P.O. Box 848/210 Hospital Street �! ,; OCi� � � L�`�i
Mocksville, NC 27028 "�t '
(336)751-8760 � E��`' ,' ,��;��?;;�;•1T�L HENLTN
D!\�IE COUN?Y
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI,ESS AI,L��TH� R�QUII2�D
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. !�
1. Name to 'be IIilled / ( � N��/�J �� N`+ �.�� Contact Person _____ __ __ _.
Mailing Address �� /lc'� 9/Z— Home Phone
City/State/ZIP �y �'' i,d /� //� . /'" � IIusiness Phone
T—
z. xame on Pormit/I�TC if DifPerent than at�ove �i��� .S�/�+�'
�
Mailing l�ddress d lri)" ���/� Ci�y/State/Zip �e[��`� �f �E�
3. Application For:�ste Evaluation ❑ Improvement Permit/ATC Il Boi:h
4. System to service: �House ❑ Mobile Home ❑ Business I:l Industry IJ Other
5. If Residence: # People �_ # Bedrooms ,3 !� Bathrooms z
I�Ifishxasher O Garbage Disposal VT Washing Machine ll Basement/Plumbing II IIasement/No Plumbiny
6. Zf IIusiness/Industry/Other: Specify typQ # Peoplo N Sinks
N Commodes # Showers fl Urinals A Water Coolers
ZF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Z�pe of water supply: ❑ County/City �ell II Community
s. Do you anlicipatc additions or cxpansions of thc facility this systcm is intcc�dcd to scrvc? ❑ 1'cs I�-�7o
If ycs,wl�at typc?
***lh1PORTANT*** CLIENTS bfUSTCOAIPLETETHE R6QUIRCD PItOPLRTY (NI�OIiMA'I'ION K�QUIsS'1'IsD
I3GLOW. Eithcr a PLAT or SITE PLAN�YfUST BESUI3M/7TED by tl�c clicnt wiU�7'Ii1S Al'PLICA'1'ION.
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I'roperty Uimcnsions: J ' �'` • � �d k � `�U �VRl7'G llIRLC'1'IONS(from Mocicsvillc) tu PIZOI'(�.IZ'1'1':
Tax Officc PIIY: # �c�'33� O S J� J J� 8 ° � !'✓� � ���
PropertyAddress: RoadNamc�D�.C.in� �i�� /L�( r---� �� � �`''t/G'� �,,�, ��
c�cy�z�� /'h���s t/i/l �- �o� � v� �o�-,��-; �,� �d •
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If in a Subdivision providc information,as follows: �^"�i-, �".L /���'�/� 5���� !����
Namc: < �!(/e //�6 S� (� Cf F�4
Scction: Block: Lot: _� Dalc I'roperty Tlaggcd: 6 6
This is to ccrtify that thc information providcd is corrcct to tlic bcst of my Icnowlcdgc. 1 undcrstand tli:it:�ny per�ait(s)
issucd hcrcaftcc are subjcct to suspcnsion or rcvocation, if tl�c sitc plans or inlc�idcd usc changc,or if tlic infuruiatiun
submittcd in tl�is application is falsi6cd or cl�angecL I, also,understarrd thut I anr respousiGlc fi�r a!l drurgCS'RlCrrrrer!f'rom
tltis appliculio�t. I, hcrcby,bivc conscnt to tl�c Auti�orized Rcprescutativc of thc Davic County F[caltt� Dcpartmcnl
to cntcr upon abo��c dcscribcd property locatcd in Davic County and owncd by
------.....___--.._
lo conduct all lcsting proccdures as ncccssary lo dctcrminc tl�c sitc suitability.
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THIS AREA MAY BE USED FOR DRAWING YOUR SiT�PLAN(Includc all of tLc following: Cxisting anQ pruposcd
property lincs and dimcnsions, structures, sctbacks, und scptic locations).
Silc Kc��isil Char�;c
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• DAVIE COUNTY HEALTH DEPARTMENT
'. . � � ° . Environri�ental Health Section
' Soil/Site Evaluation
� '" � APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002020 Tax PIN/EH#: 5833-05-5959.B
Billed To: Hunters Land Cq. Subdivision Info:
Reference Name: LocatioNAddress: Bonkin Lake Rd-2�702��8 �
Proposed Facility: Residence PropeRy Size: see map Date Evaluated: _/�/� ��
—.�7—
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit f Cut
FACTORS � 1 2 3 4 5 6 7
Landsca e osition �
Slo e% s (p $ r�
HORIZON I DEPTH -L�
Texture rou � C�
Consistence l5 SS S
Structure
Mineralo
HORIZON II DEPTH AZg' - � 32
Texture rou
Consistence L• V YG , 5V
Structure
Mineralo .�► � "
HORIZON III DEPTH 2�— l 3z �4
Texture rou ' �'-a,
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 1� �j �j
LONG-TERM ACCEPTANCE RATE �'j,Z �Z
SITE CLASSIFICATION: � � � '"�.�'-�'�� EVALUATION BY: �9'"'"�
LONG-TERM ACCEPTANCE RATE: �' � OTHER(S)PRESENT:
REMARKS: v �� `"Q�� �� "'`���,��
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
Mineralo�v
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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�avie Gounty,�fealrh Z7e�artment
Envlronmental,�[ealth Sectlon
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
October 31, 2001
Billy Joe Sams
Hunters Land Co.
PO Box 712
Yadkinville,NC 27055
Re: Site Evaluations
2-S+Acre TractsBonkin Lake Road
Tax PIN#: 5833-OS-5959
Dear Mr. Sams:
As requested, a representative from this office visited the above site(s) on October
26 &29, 2001. Based on the information provided on the Application for Site Evaluation
and after the evaluation(s) were completed, the site(s)were found to be provisionally
suitable for the installation of an oversized, modified on-site sewage disposal system.
Due to shallow soil depths to rock,topography and poor soil characteristics on the
sites, we will require that the septic system be sized at approxirnately 2001inear feet per
bedroom, or 600 linear feet for a three-bedroom residence. Additionally, a pump station
may be required. This is subject to change as actual design and dimensions of the septic
system will be determined at the time a permit is issued.
Before a representative of this office will revisit the site(s) to issue an
Improvement Permit/Authorization to Construct, the appropriate application must be
completed in full and submitted to this offce. The location of the facility the system is to
serve must be staked off. The property must be surveyed prior to making this request.
If you have any questions, feel free to contact this of�ice.
� Sincerely,
�� �
Jeff G. Beauc p, R.S.
Environmental Health Section
Enc(s) �-
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DAVIE COUNTY HEALTH DEPARTMENT �
Environmental Health Section
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P.O. Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336) 751-8760/Fax: (336) 751-8786
May 29, 2003
Clifton Burke
1175 S. Peace Haven Road
Clemmons,NC 27012
Re: Site Evaluation-
6+Acre Tract/Bonkin Lake Rd
Tax PIN#: 5833-OS-5959
Dear Mr. Burke:
As requested, a representative from this office revisited the above site May 29,
2003. 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 oversized, modified 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 in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
If you have any questions, feel free to contact this office at 751-8760.
Sincerely,
��
Jeff G. Bea p, R.S.
Environmental Health Section
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