248 Bonkin Lake Rd • DAVIE COUNTY HEALTH DEPARTMENT
,` , � , Environmental Health Section
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 � �+ �
(336)751-87C►0 f� � /" //— �
✓
IMPROVEMENT/OPERATION PERMIT
Account #: 990002596 Tax PIN/EH#: 5833-05-5959.JW
Billed To: James Williams Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3440
**NOTE** T'his 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 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: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size�S ��C Type Water Supply-�'�� Design Wastewater Flow(GPD)--���� Site: New�Repair❑
System Specifications: Tank Size%GAL. Pump Tank GAL. Trench Width � ��Rock Depth��Linear Ft.�U
��i/
Other:
Required Site Modifications/Conditions:
I1�IPROVEI�1ENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G ��BELOW
FINISI�ED 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.r4-ta- . .m. i ay of installa ' . ele hone#is(33C►)751-87C0.****
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Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
"r ' � ` DAVIE COUNTY HEALTH DEPARTMENT ��-'J
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(33G)751-8760
Account #: 990002596 Tax PIN/EH#: 5833-05-5959.JW
Billed To: James WiAiams Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3440
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). 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 WASTEWATER CONS UCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �
CERTIFICATE OF COMPLETION
**NOTE** 'The issuance ofthis Certificate of C s a m ica i��described on Improvement/Operation Permit
has been installed in compl' e with Article Chapter 130A, ion.1900"Sewage Treatment and
Disposal Systems" s all in Y be taken as a guaran at the ystem will function satisfactorily for any
given period of time. ��j
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Septic System Installed By: � / �
Environmental Health Specialist's Signature: i�- ` Date: �`/ ` i f
DCHD OS/99(Revised)
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, . D 'v u � TION FOR SITE EVALUATION/IMPROVEMENT PE(iMIT&ATC
Davie County Health Department �0 5 �-
] 2003 Environmenta/Hea/th Section
A�R P.O. Box 848/210 Hospital Street � ��'� � � g „ 3 Z�'
Mocksville, NC 27028
FNViRONMENT�-HfA�'TH (336)751-8760 �-e bt�t � Y y_ 6 G ���,
ppV1EC0UNTY
ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AI,L TFIE REQUIRED
INFORI�,TION IS PROVIDED. Refer to the INFORN�,TION BULLETIN for instructions. �
1. Nama to be Billed�}�,✓JCS [/v 1(.L�lQ6Q/� Contact Person �"-j�/yJ�-S �if//ui�4l3�1s
Mailing Address Z b Z� ��/�Nl��Y �oI Home Phone�,3(vl T(i�- �W S-�
City/State/ZIP rQ �J/1!�/�l� NC. o�.7a�— Business Phone �33�5� �-�o(p— Q(p(p`7
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. A.pplication For: �Evaluation �mprovement Permit/ATC ❑ Both
4. system to service: �House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People Z # Bedrooms � # Bathrooms 3
dYDishxasher G1�Garbage Disposal �Flashinq Machine ��Sasement/Plumbing fi Basement/No Plumbing
� 6. If Business/Industry/Other: Specify type # People # Sinks
1f Commodes # Showers # Urinals N Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. R�ipe of water supply: ❑ County/City 9�T+Tell ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to scrve? ❑ Yes B�PPo
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
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Property Dimensions: �/�/�ie�k• �'�S� 1'C �S-a0' �VRITE DIRECI'IONS(from Mocksvilie)to PI20PLR"i'Y:
Tax Office PIIY: # .5833 -- as- - s�s 9_ .i w -r,�v�/ ,y�,� �o i ,� �o ��✓,. roi
PropertyAddress: RoadName �Q��� �f-� �t� ![i�PN .Pi-rL� aiv �O/ 9t foo /�Aa20sC
City/Zip/J/�D�S✓i��� NC. �3 /hiGES 7�0 ��N�/N ���' �e►�
If in a Subdivision provide information,as follows: %l.e1l! Lf oiv /.3oN�iN �.� ����o,���
Name: (�UICL /�� ON �� � �ur✓7��5 L,4rvD SSNS,
Section: Btock: Lot: Datc Property Flagged: �7"! S? �0.3
This is to certify that the information provided is correct to the best of my knowledge. I 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,understand t/tat I ant responsible for a!!chnrges incurred from
tlris application. I, hereby,give consent to the Authorized Representative of the Davic County Hcalth Departmcnt
to enter upon above described property located in Davie County and owned by /�/�, ��4MS �NSNre;c� �niv,v,,��j
to conduct all testing procedures as necessary to determinc thc site suitability. � f'
DATE �7��J 3 SIGNATURE ��8n1� O. �f/�..�•-�-.->
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAIY(Include all of the following: Existing and proposed
property lines and dimensions, st tures, setbacks, and septic locations).
�S �,C�� �o � Site Revisit Chargc
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'- • DAVIE COUNTY HEALT'H DEPARTMENT
, Environmental Health Section
. Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002596 Tax PIN/EH#: 5833-05-5959
Billed To: James Williams Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map Date Evaluated:
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
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
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Lineaz 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
Mineraloav
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)
.� .
.•'� , . ,.� • � APPLlCATION FOR SITE EVALUATION/IMPRUVEMENT PCRh11T& �-'' =--��
' � Davie County Health Department � �
� ' Environmenta/Hea/thSectron � ��T 2 3 �.�.:': ?
P.O. Box 848/210 Hospital Street a
Mocksville, NC 27028 ---- -�-�-�""'=""'�
EraviF;o,,��,�;iT,;�_!�°,_����
(336)751-8760 pq,_IF i�;)�4wi� _
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFOFtMATION BULLETIN for instructions. !
1. Name to be Billed �� N�r/`� /-�-f`� � Contact Person ��OS��
Mailinq Address ��//t-`� �/Z- Home Phone � �y� 3�`7 ] � �
City/State/ZIP ��'�y�,t/ f��/� . /�' �-- Business Phone �G( 9� 0� f y / '`
2. Name on Permit/ATC if Different than Above �✓��e J�l�+�
Mailing Address 6�� �/��" city/state/zip �.rn!`„i �'�/F
3. Application For:�'rte Evaluation ❑ Improvement Permi.t/ATC Il Both
a. system to service: f�House ❑ Mobile Home ❑ Business ❑ Industry Cl O�her
s. IP Residence: # People �_ # Bedrooms 3 # Bathrooms Z---
I�shwasher ❑ Garbage Disposal !`1 Washing Machine LI Basement/Plumbing II IIasement/No Plumbing
6. If Business/Industry/Other: Specify typo # Peopla # Sinks
�I Commodes �i Showers # Urinals 8 Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. 7.�pe of water supply: ❑ County/City �11 LI Community
a. Do you anticipate additions or expansions of the facility this system is intcnded to scrve? ❑ Yes [$-A�}o
Itycs,what typc? �;
r
***IMPORTANT***CLI�NTS MUSTCOd1PLETETHE REQlIIRED PROPLR'fY INFOIiMA'I'IOtV I2GQU[:S'I'GD
l3EI.OW. Eithcr a PLAT or SITE PLAN�L1UST BESUI3MIT/'ED by tl�c clicnt �vith TIiIS'�11'I'LICATION.
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Property Dimcnsions: � � - � �d � �`'U WR17'G UIRGC'I'lONS(fro�i�Mocicsvilic) lo PliOI'l�;lt'1'l':
Tux Officc P1N: # �533�os S?S� -6 a�l !'✓ /�� ���
�.--� p /�
Property Address: Road Name���,C..in� �a��( � l= � �l �/: � /,�''t/� �a�� /Cc�
Clty/ZI� /'�J`7�S �/�` �`r- � �D� � !N� �OA-,�S-� �y� �d '
T
If in a Subdivision providc information,as follows: �^"/�'��, ��. N��'f�t� 5�.,�c� d�%��
Namc: / " "/f/� a s� e .C�F-.t/�e
_ �� �� � �
Scction: Block: Lot: � Datc Property rlaggcd:
This is to certify that the information provided is corrcet to the best of my knowledgc. I undcrstand tle,�t any permit(s)
issucd hcreaftcr are subjcct to suspension or revocation, if the sitc plans or iutendcd use change,or iF tlie inforu�ation
submitted in this application is falsificd or changed. 1, also,�urrlerstaud Ilrat 1 a»r responsiGle for rr/!c/nuges iucrrrred f'r��nt
a,;s a�ni;�ar�o,t. I, hcreby,give conscnt to the Autl�oriud Represcutativc of thc Davic County ticaltl� Dcpartment
to cntcr upon abovc describcd property locatcd in Davic County and owned by
to conduct all testing prcecdures as ncccssary to dctcrminc thc sitc suitabilily.
DATE Z.3 �Z�6� SIGNATUI2� i�� —__.
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: �xisting and proposcd
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Rcvisit Chargc
Datc(s):
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� •�� DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
- ', ' ` SoilJSite Evaluation
APPLICANT 1NFORMATION PROPERTY INFORMATION
Account #: 990002020 Tax PIN/EH#: 5833-05-5959.A
Billed To: Hunters Land Co. Subdivision Info:
Reference Name: LocatioNAddress: Bonkin Lake Rd.-270 8
Proposed Facility: Residence Property Size: see rrtap Date Evaluated: �� �O�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit � Cut
FACTORS 1 3 4 5 6 7
Landsca e osition L L-
Slo e% �l
HORIZON I DEPTH a—t o O—
Texture rou S� �1� L
Consistence F'r , gSP SS
Structure G!Z
Mineralo
HORIZON II DEPTH �� 1 Co 1 O�3
Texture rou G�- -
Consistence ��sd V
Structure A3 �1L a-
Mineralo 2� 2 � ; 1
HORIZON III DEPTH 1 —Z'7 3 2—
Texture rou -} � •�c �G
Consistence
Structure SQ��
Mineralo �
HORIZON IV DEPTH
Texture rou �
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 5 S
� LONG-TERM ACCEPTANCE RATE �j.
SITE CLASSIFICATION: � ��.i1�-�J� EVALUATION BY: � 'T""
LONG-TERM ACCEPTANCE RATE: �� OTHER(S)PRESENT:
REMARKS: �`w� �,� �VL� ���� S+ �
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 day 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
Mineraloav
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-gaUday/ft2
DCHD OS/99(Revised)
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Z�avie Gounty,�fealth Z7epart`merrt
Errvtronmental,�fealth Sectlorr
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 approximately 2001inear feet per
bedroom, or 6001inear feet for a three-bedroom residence. Additionally, a pump station
may be required. This is subject to change as actual desi�n 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 makin�this request.
If you have any questions, feel free to contact this office.
^ Sincerely,
.��
-,
JeffG. Beauc p, R.S.
Environmental Health Section
Enc(s) -