608 Bonkin Lake Rd DAVIE COUNTY HEALTH DEPARTMENT
. * Environmental Health Section
' ' P.O.Boz 848/210 Hospital Street /�d- �—�-"'� �
• . . � Mocksville,NC 27028 U
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900063 Tax PIN/EH#: 5823-89-66461m
Billed To: Larry McDaniel Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: see map
ATC Nurpber: 2833
**NOTE** This ImprovemendOperation 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
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\J�
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�/.l�/ Design Wastewater Flow(GPD)�f�4 Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt�� Rock Depth�„� Linear Ft.��(
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/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.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.****
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Environmental Health Specialist's Signature: J Date: ,��`��
DCHD OS/99(Revised)
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' • • DAVIE COiJNTY HEALTH DEPARTMENT
• . . � Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 989900063 Tax PIN/EH#: 5823-89-66461m
Billed To: Larry McDaniel Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2833
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: ��--/�'�
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system de�c 'be on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A, S 'o .1 00"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the sy t 'll function satisfactorily for any
given period of time.
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Septic System Installed By: �
Environmental Health Specialist's Signature: Date: �����t�
DCHD OS/99(Revised)
, �u-ru�uuN ruu �IIE tVAWAl1UN/IMPROVEMENT PERMiY dt AT �
� r Davle County Health Departrnent � �;� �; �� �� �
� . . Envfrnnmenta/Health Serdon �
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*♦*II�ORTAA1Tt** THIS APPLIC�TIdl� C1lNIPnT A� PR4C83� ONLE88 �I,L RE�It1►tl�'JT�',L N�LTH
IIIE�OR�ITION IS PROVIDED. Refer to the INB'ORMATION BOLLSTIN for '%��U`m
i. ��. co b. siiien 1�n i i'Y1�t�z.t�i�f�ui (c���s�-o�r�� n.r.«� �i l I ��:
�sis� ��, �O�X. 5�rl • s� raoas �� 9 - I
c�tiNar.ar.e�z:p YYl`c�c��iis l l� t�� �r JQ�g ans�. rno� ���(fl - '7S7- �d�.�
s. Ilams od f�eal.t/l►i'C i! Di!larant than 71b�wa .J�� �c- Ca.�rr,� ,� �Y1� 11 e�,
�is„Q �►ea�,. �5� �1 t3.�-iS I�J� cstY/aeate/zip ✓1�1 O ck S V��� , � �49�S
�. Applicatioa i'or: U Site EvalnatioA Q/Improv+ement permit/ATC D Bok2�
4. syatam to enrvtoa: 6'Honse 0 Mobile Homn U Snsinaas 0 iadnstry 0 Other
a. It Residenoe: f people '� ,� / 8adrooms ,�_ � Bathtoama !�j
Q'Distwasher 0 Oatbaqe Disposal 0'11ast�le�q Nadiins 0 8as�t/Dimbiaq 0 8aaeaoeat/No pltimbinQ
6. i! Bnainess/Indastsy/Ott,er: 8peaity tiype - - - ,- - � people / SiN�s
* Cca�odes f shoxers f nrinai� � Nater Coolers
IP TOODSEAVICB: # Seats $stimated Aater Os ga (Qaliona psr aaY) .
7. Tpp� of watar snpply: O Conaty/City YJ i�ell 0 Cca�wnity
s. Do yon anticipate additiow or e:pansiow of We fac,�llty Wis�riem 4 intendtd to urve! 0 Yea �No
If yea,wbat type'
'**IMI°bRTANT'•"CLIENTS�1lUST Cti11lPLETETHL REQUlRED PROPERTY INFORMATION REQUESTED
66LOW. Eltber a Pl.AT or S1TE PI.AN MUST BESUBMI7TED b t6e client �it6'fHIS APPI.[CATION.
, ry �3.o�X 4S�f.&�S �C n�x�
Property Dimension�. / X��•� WIt�TB D�tECfIONS(from Mal�sville)to PROPL+RTY:
Ta:Otfice PIN: # J��� ��- �L(Q�lil . l Q�� � '�O �« � � -'�-C;�.✓��n..�--�
Property Addrar. Road N�une�(1 �tn �`C� �D�.`�-�`- � �'c� �✓� �� `�
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C1ty/Zip �O Ck6U��Lo , �� �S�-f G� i2 G� - �-e��-- _ QO � �-Q
If ia a Subdivl��Oa provide informatton,�u t'ollowr. �o nk c.v� � P-� - lC�� � `�`���
e
Name: � l�.Q �'� L�'-�t '
Sect�on: Block: I.ot: Date Rvperty Flagged: � -a�-��
This is to certify that tbe information prnvided ia corrtict to t6e best of my knor►ledga I anderstand that�ny permit(�)
1s�ued 6errxfte�arr au6ject to aaspension or rtiwoeation,If t6e site plan�or tatended nae cbange,or tf t6e informatlon
submitted tn tbi�sppitcation i:�alaiAed or cbanged I,also,andersta�rd tljat I am re�pon�ble for a!1 dbargu Jnc�n�ed from
tlifs appllcatio,r. I,6er+e6y,gfve rnnsent to t6e Aaf6oriud Repnaentative o�t6e Davie Caunty Heslt6 Departmeat
to enter apon above described property locmted in Davie Connty snd owaed b?•
to condnct all tating procedu�+a�s necautry to determine t6e dte aitabilit�•.
DATE S �.�^a � SIGNATURE r � �
THIS AREA MAY BE USED FOR DRAWING YOUR SITL PLAN(Wc all of t6e�oilowing: E��aad�rnpos..-d
pro�Pty iina and aimen:ion�, strnctar�a, utbacks, and�eptic IouUona).
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� APPLICATION FOR SITE CVALUA7101!/IM1IPROV�h9EiifT Ij��7i1 i�lt3C �i'�.
� �� Davie County Health Department �2 2 2u�1 ; ��j
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l� 1 2 Environmenta/Hea/t�i Section (,�,�
�J fs� �S� P.O. Box 848/210 Hospital street ENVIRONI�1E
��Q ���' Mocksville, NC 27028 DAVIE NTAI HEALTH
�G (336)751-8760 COUNTY
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***IMPORTANT*** THIS LICATION C1INNOT BE PROCESSED UNLESS THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFOR2�ITION BULLETIN for instructions.
1. Name to be Dilled � 1t.TTF+ 1 � � Contact Peraon
Mailinq Address ���� �Y�,��� �• Home Phone RU3" G�r����C(�'(
City/State/ZIP �0� ��� `]� .� 1��� Businesa Phona �i�jy��7S�— �����(� ,
�.
2. Name on Permit/ATC if Different than Above
Mailing Addresa City/State/Zip
3. Application For: fl Site Evaluation ❑ Improvement Permi.t/ATC ❑ Both
4. Syatem to Service: �HOUS2 ❑ Mobile Home ❑ Business 0 Industry ❑ Other
s. If Residence: � People �_ # Bedrooms _,,�_ # Bathrooms �.S
Fd Dishxasher ❑ Garbaqe Diaposal tI"Washing Machine AYHasement/Plumbing U Dmaoment/210 Plumbing
6. Zf Buainess/Snduatry/Other: Specify typo # Paoplo II Sinka
Y Commodes # Shoxers � Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallona por aay)
�. Type of water supply: ❑ County/City �Well ❑ CommUnity
e. Do you anticipate additions or eapansioas of the facility this system is intended to scrve? ❑Yes G�'1Go
If ycs,what type? h1/�t
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPGRTY 1NFOItMATION ItEQULS'I'GD
BELOW. Either a PLAT or SITE PLAN MUST BESUI3MITTED by the client witl�TIIIS APPLICATION.
Property Dimensions: WRITC DIRGCTIOiVS(from Mocksville)to I'ItOi'LIiTY:
Tax Ofiice PIN: #� - �� - ' �rr�C,t. ���.� �r�n f t� �-�v �,.�:� �0 I, (uv',r�
�3�{-OU060 0�0
Property Address: Road Name �� ;c �� on�v �-�u o , M �
C;ty/Zip � �iirn I��r� E,S`'�iG I��. ro�loiJ �SS�C
i
If in a Subdivision providc information,as tollows: � t -�r rtp�ta . /?� ,,rp,�c'. �I.� n �ic l �
Namc: b k.+n f' ��, -� �i n,t. I�.'�"'.
Section: Block: Lot: Date Pr�perty rlagged:
This is to certify that tt�e information provided is correct to the best of my kaowle.dge. I uvderstand that s+ny percnit(s)
issued hereafter are subject to suspension or revocatioa,if the site plans or intended use ct�ange,or if tl�e infor►nation
submitted in this application is falsified or changed. I,aJso,understand that I am responsible for aJl charges incurred from
this application. I,hereby,give consent to the Authorizcd Representative of tl�e Duvie Cuunty Health Dcpartment
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determiue the site suitabili
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLA.N(Include all of the followin . �aisting and proposcd
property lines and dimensions, structures, setbacks, nnd septic locations).
�6�.Si�-, Sitc Rcvisit Ct�argc
1��l+�tSC. A�tr ¢. �+.�-'h I,r�i`�- �:�.�[krr� �c�Aw'�—�S�_ Datc(s): '
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���� j�� p�.. �"'� o� 1�S�G'N1+--' g�0� Clicnt Notification Datc:
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Revised DCHD(07/99) � � Invoice,No. � � ` �,
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- � � ' " DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
• ,� �' . ,, . . Soi]/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001544 Tax PIN/EH#: 5823-89-6646
Billed To: Jeffrey Miller Subdivision Info:
Reference Name: Location/Address: Bonkin Lake Rd.-27028
Proposed Facility: Residence Property Size: �acres Date Evaluated: �-ly '��
7
Water Supply: On-Site Well b/ Community Public
Evaluation By: Auger Boring �/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition .L L
Slo e% G
HORIZON I DEPTH �� ��
Texture rou CL G�4
Consistence
Structure
Mineralo
HORIZON II DEPTH �`" �6�` '�
Texture rou C
Consistence /
Structure iJ fl� e/ J�
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: cP EVALUATION BY: �/1
'
LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT:
REMARKS: ���.i ���' ��� a ,��'�° �
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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- ; D��II���lUIVTY�I�I.T�Ii D��ik�.T1��NT .: ..._>�,.:�
ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksvilie, NC 27028 �
Phone #: (336)75i-8760
April 18, 2001
Jeffrey A. Miller
1460 Farmstead Road
Rock Hill, S.C. 29732
Re: Site Evaluation/Bonkin Lake Road
Tax Offce PIN: #5823-89-6646
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
February 6, 2001. 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 installatian of a modified, oversized 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,
�i�!�,t�.' : /��.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s)