438 Bonkin Lake Rd . • ,�c��—
- • -` •' } • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900502 Tax PIN/EH#: 5833-09-7067 8�5833-08-6518.00OE
Billed To: Michael Smith Subdivision Info:
Reference Name: Nancy Collette Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: ReSidence Property Size: 8+ Acres
ATC Number: 2591
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLJED 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.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE ON TRUCTION IS VALID FOR PERIOD OF FIVE YEARS.
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Environmental Health Specialist's Signature: �1 � Date: !�`" �-'�U
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate ofCompletion 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.
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Septic System Installed By: ����_ _��N-
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Environmental Health Specialist's Signature: � e:
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT �d—��' �/�- - ° v
• Environmental Health Section C/�cJ
' ��• ' � ' ' P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900502 Tax PIN/EH#: 5833-09-7067&5833-08-6518.00OE
Bilied To: Michael Smith Subdivision Info:
Reference Name: Nancy Collette Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: 6+ ACres
�TC N��p b�r: 2591
**N TE** "1'hls mprovement/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 /
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing:� Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 'fa% Type Water Supply /( Design Wastewater Flow(GPD) �__�� Site: New PJ Repair❑
,, �30D ��
System Specifications: Tank Size�QGAL. Pump Tank GAL. Trench Width� Rock Depth�Linear Ft.�
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Departrnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: i � Date: lb' �/"(`�i� �
DCHD OS/99(Revised)
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Scale:l"_ *"••«"•""• January 29,1999 2:31 PM
,�� �G,��` APPU[:A110N fUlt SIIE EVAWAiIUN/IMPIiOVEMENT PEAMIT&
r •�� ' • � Davie County Health Department o � [� � � � [�
O�'�6 � l � Envfidnmenta/Nea/th Sertfon
( l� �� P.o. Box 8�8/210 Hospital 3treet
� �� �` �o��iie, Nc z�oae .IAN 2 9 1999
D�
, �l 1336)751-8760
� � ENVIRONh1ENTAL HEhLTH
***ZMPORTANT*** THI3 APPLICATION CANNOT 8E PROG',ESSED UNLE33 �t�Y �
INFORMATION I3 PROVIDED. R�efer to the INFORMATION BULLETIN for iastructions.
i. Nama to be stiiea 1'�'1 j C�n4 P � c�1'h \ �� contaat neraon /�+�'�� -�o!l/.�
Mailinq )lddreas �G� UGUK•�1 \`e �O 1 ' '�GI�S Home phone �s�' � �9 L. .
C_ty/3tate/ZIp��—� �(.� Q� Buaineas Phone
2. liame on Pe=mit/l►TC i! Different than Above l e"'� v! ,�
n /� r
Hailinq Addreaa � U(�(��1��J 1�(� �i� City/8tate/Zip �'� � ,C_ , �
3. Applicatioa Sor: � 3ite iEvaluation 0 Itr,�rovement Permit/ATC oth
4. sy.r.em to service: �ouse ❑ Mobile Homa O Buaiaeaa ❑ Industry ❑ Other
s. If Itesidence: i People _� # Bedrooats � � gathrooms �
U�'Dishvasher 0 Oarbaqe Disposal lNiashinq Hachine 0 Baaement/PlumbinQ ❑ Baae�ent/No Plumbinq
6. I! Snaineas/2ndustry/Other: Specity type • peoQle � Sinta
f Co�odea � Bhoxnra # Urinals • Nater Coolera
IF FOOD3ERVICE: � 3eats Estimated Water Usage (qaiions per aay>
7. �rpa of Nater supplp: [�3' Connty/City 0 Hell 0 Co�uunity
e. Dc:you Anticipate additions or e:pansion�ot t6e facility t6is ayatem is intended to aerve! ❑Ye� �f'IVo
lt yes,what type!
***IMP�ORTANI'•** CLIENTS 11lUSTCODlPLETETNE REQUIRED PROPERTY iNFORMATION REQUESTED
EELOW. Eit6er a PLAT or SITE PI.AN hlUST BESUBl�tIITED by the client with 1TilS APPLICATION.
,�,� . , � �°�;�, �33 - o�- �l� - y�'��
v."'rciii�i�tic��UN3(frnm Moc{csv111c)to PROPERTY:
,.r�_____ .��3 �
Tas Oitice:��lV: # �.��'•`3� -- !� � �����`�004��lv0/iv -�f�'al— �GF� ./3o�v,l�'=--
Prope�iy Addreya: Itnad Name__�O'(1 Y�Y� (��� ��, � /� '
�/'IZu C� ?�ZoL�
City/Zip �
If in a Subdivision provide information,su followa:
Name:
Section: Block: Lot: Date Property Flagged: 2— �"'9 � �
This is to r.ertify that the information provided i�correct to the best ot my knowledge. 1 understand tbat�ny permit(s)
issued hereafter are subject to suspension or re.wocation,ff the aite pians or Intended use cbange,or if the intormation
submltted in t6is application fa falsit�ed er c6�wged I,also,understand that I am responsible jor all churgu�rcrrrred from
this applicarion. I,hereby,give conaeot to the Aut6oriud Repreaentative of t6e Davie County Healt6 Department �
to enter upon above described property E,.dc�ted in Davie County and owoed b��
to conduct all testiag procedures aa neces��ry to determiue t6e site auitabilih-. ,
DATE �����' � �'I SIGNATURE � �
� THIS AItEA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include xll oi t6e followiag: E:isttng and proposed
property liue�and dimeusion�, structures, eetbAcks, and aeptic locatfons).
--- qg�9
Account No. �°Se Z
Revised DCHD(07/98) Iavoice No. b�
-- � �'�r���'/ '
�ii�*i� /7�1v �
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V �� � '`: `"� �' � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME S '`�' ///� DATE EVALUATED ��lS /��
PROPOSED FACILITY ,�- PROPERTY SIZE ��}7-G
SUBDIVISION ROAD NAME �i-1,��`Y'�il��
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring � Pit 'Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L .L�
Slo e%
HORIZON I DEPTH C'c �' /�'�'
Texture rou L
Consistence
Structure
Mineralo
HORIZON II DEPTH /��` ��
Texture rou G
Consistence l' i
Structure JL -
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 � , Z
SITE CLASSIFICATION: �=C�Z{, �' �O'�C' EVALUATION BY: ��G'/
v
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS: OL/'�(��7����1d/Y/ '�-� � � ��
� 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
oist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
et
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
Mineraloav
1:1,2:1,Mixed
otes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-T'hickness 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(01-90) �
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 848
MOCKSVILLE, N.C. 27028
336-751-8760
April 19,1999
M�. Michael Smith
865 Yadkinviile Rd.
Mocksville, N.C.27028
Re: Site Evaluation/Acreage T�act
Bonkin Lake Rd.
Tax PIN#5833-08-6518
Dear Mr. Smith:
As requested,a representative from this office visited the aforementioned site on
March 15, 1999. Based on information provided on the Application for Site Evaluation
and after the evaluation was completed,the site was found to be provisionaily suitable
for the installation of a modified,oversized on-site sewage disposal system.
Before a�epresentative from this office can issue an Improvement Permit,
Authorization to Construct you must contact this offlce and set up a time to meet an
Environmental Heaith Specialist on the site.
If you have any questions,feel free to contact this office at 336-751•8760.
Sincerely,
��'���,�'��.
Environmental Health Section
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