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323 Bootleg Alley" DAVIE COUNTY HEALTH DEPARTMENT , � � Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000898 Billed To: �Iliam Davis Reference Name: William Davis � Proposed Facility: Residence IMPROVEMENT/OPERATION PERMIT /�/,r=�< �%��3 —UG Tax PIN/EH #: 5745-247619 Subdivision Info: Location/Address: Cemetery Street-27014 Property Size: 6.88 Acres **N����iibgmprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERNIIT 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 ��OOsv #People �_ #Bedrooms 3 #Baths � Dishwasher: � Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: Q� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ �i�i.�.� Lot Size �i��-�� Type Water Supply Design Wastewater Flow (GPD) 3Cd-' Site: New ��Repair ❑ System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width �4�� Rock Depth �Z�� Linear Ft. �� q� Other: �� �k� , ��J S'� l.L.. Ca••g �S I f�•C. • Nti t�J . Required Site Modifications/Conditions: r E� G@+JT�Q� �'� �D� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 u BELOW FINISHED GRADE. ****NOTiCE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** �a.c1�• 1..�,.�� �� n.� I"l�' �0 �� 01 s 12tD� x��� �.,2�, �� �32 t�l�: � �� L�t'o.c. � � � Zo' � � 'F�►,,-� l�' 2 ,r �,, �z�' � 4n. •J n� . l+ Environmental Health S ecialist's Si a e: Date: ( l l9' Ov r � DCHD OS/99 (Revised) Account #: 990000898 Billed To: William Davis Reference Name: William Davis Proposed Facility: ResidenCe ATC Number: 2293 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5745-247619 Subdivision Info: Location/Address: Cemetery Street-27014 Property Size: 6.88 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MLTST BE ISSUED 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 WASTEWATER CONS7'$i�E�j�03V IS V,f�LID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs CERTIFICATE OF COMPLETION Date: � / `� O **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. � � ��X��x�z,-' �,� t\ �,��y,a � r 1 � c� �2v' ` ; , � + ��-j- /�, � �' 3 ` : � z� . `��y � �-Ot� .� , Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) • APPUCATION FOR SITE EVAWATION/IMPROVEMENT PEHMR & . Davie County Health Department "_ , � Env�lronmenta/ He�/th Sedfon � 8.0. Bos 8�8/210 8ospital 8tzset Moakevill�, NC 27028 �• �p� G�-�� f� (336) 751-8760 �z * * * I1�ORTANT+t * * TH28 71P� I2ilfORMATION IS BRGVIDED. 1. lv.a. to b. ssu.a ��� �... cshr/4tat./s:p r/ //' ; �c�c�a� DEC 91999 'T�L�S Ztea CATION C7INNOT E� PROGlCSS�D UNL�88 71T+L Tiia REQUIRED R�ler to th� INFO�IAT=OTi BOLLETIN for instruations. � / / ! ,Cr � /��' t� �.'O�lttOt �t�OII L/l _� if � 1 �' � w/' l . sC� 9�l H�. �. �(�;�3� �� _ �/ -- — _ _ � � , suairs�.. s� ��� �37�' Z. 1taa� oa parait/11SC i! Di!la=a►t thaa 1►bors NailiaQ 11ddr��• City/Ytab/!ip a. l►ppiicatioa l�ors CY81ta lvalua�ion 0 Improv�maat p�rmit/1lTC � Both �. sY.c.a. to s.s�.w� �ous• O Mflbile Home 0 Busia�sa 0=adustsy 0 Oth�r s. I� R�sidu�c�: f P�opl� � � Sedrooms � • Bathrooms �_ i�hMuhar O Oasbaqr Di�po�al fl tha' hin� llaal�ia� 0 Hasa�nt/pl�abinQ O Das�at/No plumbinq 6. zr swsn.../xaaustsy/ot,Asr� Bp�ai�r Lypa i P�opl• � sisilc. / Coa�od�• i Bhox�r� � Uriaal• i Rat.�r Cooi�r� _! �'OOD8l�RVIC$: �.S�ats $stimat�d 1Pat.�r Daaq� tv.u�• r� �y) 7. Typ� o! Mat�r �upply: 0 Couaty/City [1�►«ll 0 COmmusiity e. Do yoa snHcipate addlHow or espanelons of the facility thia �tem is intended to urve? ❑ Yes �Io If yea, whAt typ�T **"IMPORTANT"** CLIENT3 MUST C�OMPLETETHE REQUIRED PROPERTY INFORMATION REQUFSfED BELOW. Eit6er � PLAT or SITE 1'LAN MI/ST $�SUBJ�ATTED by t6e ellent w�ith THI3 APPLICATION. Property Dimensions: '�' UC� /` t0`�/ �-F ("'•" "`•`"�VVVRITE DIRECI'ION3 (trom Mock:ville) to PROPERTY: TA:OQice PIN: # � / y:� -" a�— ��'J � 1i.+6� `SG'eU � : �f�� .�e� ��� r-�� Property Addreas: Rosd Name L:C i�'t t'- Y"Y�lJ1 i!`" �ic� d� ``��� �w �a�� � City/Zip r �C G� �'ln.� � ��'-�- ��F-f�c%v ' %i�t2 U in � Sabdtvteion pcavtde Inform�Non, �e tollowe: �� �, �u, �Ffi►2- «Lw1 � NAme: � Sections Biocks Lot: Da e Property Fb�eds �r� -' ��'� This is to certitj� t6at the InformsHon praNided b correct to the beat o! my I�awledge. I andcratsnd t6at Any permit(�) iasned hereaRer �re enbject to �o�pension or revocallon, if the eite pl�ne or Intended as� change, or if t6e intormsHon aabmitted in t61s applicaHon Is falstfied or c6anged. t, also, aadcrstand that I om responsl6le jor all clFarg lncurrtd jroni tbls appticatlon. I, hereby, �ive conaeat to t6e Aat6orized Repreaentative of t6e H t ent to enter apon above deacribed property loated la DaWe Conaty and awned by to coudoct ap teatin� procedares �u n�ceasary to determine t6e dte �it�6it�ty. ,!� � � � G DATE °�' ' SIGNATURE THIS AREA MAY BE U3ED FOR DRAWING YOtTR S1TL PLAN (Iaclade all ot t6e folta�vin�: E�eNn� and proposed prnp�rty Ilna aad dimensiona, etrnctnrea, eetbscks, and aepHc locstione). Sih Revbit C6�rge Dats(a): Clfent NoHBcalloa Date: EHS: Revised DCHD (07/99) Acconnt Na . T ,� Involce Na ���0 C�f" y, f, } . J \ . - j , _ �4�' } F . � �.f h . � � :�, Y� { �� a '{ * +<:t���t� � ' • TF� `�p ,: ,� �.� .�� �, ;, . � , . � 5I ,j ti ' � �a � ,. 0 4! t t � * , . S� .`��, =;�,`. , � N . ,.-�� . .�' . ¢ �4�:. `s� - -;: . . • �� . �� e R� . t. � cv ':` 36p 9 . �� �r `.t� .��.tti,�54 �., `� ��'{.��� `��,.,� } � F' `'� �� :� • • • �,* � 15 � �� � 47�.s SEE MAP ,� , � r �:� � , �. � a ..,688 AC � " � ,f� � 1 r � � � ,� � � , ' �� .,, . , �:� � . 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SITE CLASSIFICATION: � �j�% �� ��A�� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �• � OTHER(S) PRESENT: REMARKS: ���IZiZ (��OSc� 'jZ) Goca �L1Sy-c/2-.r..f pI' 1-FtC�1-F�� v�Ll3�, 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 -�lightly plastic P- Plastic VP - Very plastic Q�� �o .y�' ` ,� Struct re ,� �,p' SC - Si le grain` � M- assive CR - Crumb \GR - Granular ABK - Angular blocky SBK - S angulaz b�ocky PL - Platy PR - Prism�tic i� `S 1:1, 2:1, Mix d� Notes Horizon depth In inches Depth of fill - In 'nches �� Restrictive horizo - Thickness anc� i5�ch r Saprolite - S(suitab ), U(unstutable) Soil wetness - Inches�orriland surface to fri Classification - S(suitable), PS(provisionally LTAR - Long-term acceptance rate - gaUday DC�ID OS/99 (Revised) \ � ` , ,\ � �� Z� V 1 _� � land surface �� . t � water L/ � ��� � � es from land surface to soil colors with c oma 2 or less , U(unsuitable) x %�-� ■ ��■■����■��■��Se■■■■�■� ■�■■����■����■�i�O■■��I ■�■■��■■�����■■�■�■■��I ■■���■■■��■�■�■�����■■� ■�■■���■v■o�■�■�ee��■�� ■■■■■■■■��■■■�■��■��■�� ■��■����■�■�■����■■■■■� ■■��■���■�■��■�����■■■� ■�■���■���■��■�■��■■■■� ■�����■���■■■��■■�■■�■� ■■����■��■■��■■�■�■■�■� ■�■■■■�■■■■■■�■■�■■■■■� ■�■■■■�■�■■�■�■��■�■■�� ■■�■�■■■����■������■��� ■■ ■��■�■■�■ ■��■■���■ ■���■��■■ ■��■■■��■ ■■■■■���■ ■�■�■��■■ ■■■�■��■■ ■�■��■��■ ■■■■■■��■ ■■�■■■�■■ ■■��■■��■ ■■■�■■■�■ ■■■��■■■■ ■����■�■■ ■■■��■��■ ■■���■■■■ ■����■■■■ ■�■�■�■■■ ■��■�����■����::::�::��■������■����������■�■■■��■■■■■■�■���■■■ ■��■■�■■■■■�����■■��■��■■���■ ■����■����■■��■■�■■■■■■■���■��■■ ■■�����������■�■�■��■��■■���■��■■�■�■��■■■■��■■�■�■■■■■�,■■■■■�■ ■����■■����■�■■�■�■�■■��■�■��■��■■��■■��■��■■�■��■■��■■���■■�■■�■ ■�■■■■■■■■■■.���■�■��■■■■�■��■��■■■��■■�■■■■■�■■�■■■■■■��■■��■■ ■�■�■■�■�■�■������■■�■■�■■�■�■■�■■�■��■�■■�■��■■�■■�■■■�����■■■ ■■■■���■■■■���■■�■�■o�■��■�■�■■��■■■��■��■■■■�■■��■■■�■�■■■■■■■ ■�■�■■■■■����■�■���■■■■��■■■■�■■�■�■��■■�■�■■��■���■■■�■�■■���■ ■��■■■��■���.■�■�����■■����■��■�■■�■�■■�■■■■��■����■■■���■■��■ ■■��■■■��i������■■■�■■�■■�■�■■ ■���■■�■����■■■�■■�■■�■■■�■■■■■■ ■■��■■■�■c�������■■■�■��■�■■■��■■■��■■�■■����■■��■■�■�����■■■■�■ ■�������■��■�■■■■■■�■�■■■�■�■■�■���■■�■■�■��■■�■■■�����■�■■■��■ ■■���■■�■��■�■�■■■■�■■�■■�■�■■�■■�■■■■■■�■��■■��■■�����■��■■��■ ■���■■■������■��■�■����■■�■�■■■■����■■�■��■��■■�■■■����■���■��■ ■�■■■■■■����■�■�■�■■�■��■����■�■■�■�■■�■��■■■■■��■■■■���■���■�■ ■■■■■■�■■�■■■■�■�■�■e�■��■■■�■■�■■■■�■■��■�■���■��■■■■�■■■��■■■ ■�■■■■■■■�■��■�■�■�■■�■■�■�■��■�■■■��■��■■�■��■■��������■■■■�■ ■■�■■■■��■■■�■������■�■���■■■ ■�■■■��■�����■■�■■■�■�■�■■■■■■■■ ■�■�■■■�■��■�■�■�■��■■■■��■■■�■■�■�■■�■��■�■■■�■■■�■�■■■�■■�■■■ ■■■���■■■�■■�■�■��r���r�■■��■■�■■�■■�■■■■r:�■�■■■■■■■��■■■■■■■�■■ ■���■�■���■■e��■����■■n���■�■�■■■■■■■■�r�F�■��■■■■■■■�■■■�_�■■■■ ■�■���■�■�■��■�■�c�■�■�i�■■�■�■■�■■�■■■■���t�■��■■��■■���■■ �.���■�■ ■�■■■■■�■�■■�■�■uw■■�■n�■���■■�■■���■■��■�i����■��■■■���������■�■ ■�■�■�■����■�����n■■��t��■�■�■■���■���■��■��■■��■■��■■■■�����■■�■ iiiii�iiiiiii�iiiiiii�iiiiiii '�iiiiiii�iiiii�ii�iiiiii�iiiiiiii� ■�■■■■���■�■����■�■■��li■■■��■■■������■■�■Ilir■■�■■����■■■■�����■■ ■■■■■■�■�■�■�■■���■■�■l1��■�■�■■�■■�■�■■�■I1��■■�■�i'��■■■�■■���■ ■������■����■■■��■■■■■����■■■�■■��■���■■�■�����■ws���L��:a��■■■■■e ■��■■■�■■■�■■�■��■�■■■[1���■■���■���■■�■■■11■���f:�iil��G�������■■■ ■■�■■■��■■■�■e■■�■�■■■il■■��■■�■■■�■��■�■■P.����C ::s�� ��;!■����■■■■ '■���■���■�����■�����■�[I���■�■��■■�■��■�■■11�■�■�■r11i�iC���■■■����■ I������■�■�■�■■�■�■■�■■11■■■■�■�■■�■■■■���1#�■��'��::C�CCC�'.`_�■■■��■ i�■�■■�■■�■�■�■��■■■■■■���■�■�■ ■■■■���■�■n�■���■iRaea■■■■�■■■■■■ i�t�■■��■���■■■■■■�■■����■■■���■■�■■���■��■���■■■�■ic�����■■■��■■s■■ i�■■■��■■�■�■�■�oe■■■�■���■■�■�■���■�■�■■�����■��■i�■��������■■��■ i■■■■���■�■■N■�■■����■e�������■■��■�■�■■�■■���■�■��■���■��■��■��■ ■�■ ■�■ ■■■ ■�� ■■■ ■■■ ■ ■ll��■■■�■■��■�■��■��t�■■■■i�■■■��i+■��■■�■ 17[I��■�■��■��■■■■�■■�/I■��■�i��■■■l:���■■■G !![I�■■�■��■■�■�■■�■■■/1■���■�1�■■�li�■�■■■� !l11��■�■■ ■�■■■■��■���■■��■�1■■■■���■�]■■■ y�l■�■■■��■�■■�■■■■I,�■■��■���■■■■■�al�■L' ■LI���■■■�\�����■�■■I/■■■��■■��■���■■[VF��■ ■�!■��■■■■�■��■�■■��1��■�■■■���■G1■■!4f■�L ■fl■■�■ ■1',1�■�O ■1'1■�■■ ■1'1���■ I■11■�■■ ■��■�■■�■�■�■11■�■■ ■��■■■■�■�■��11���■ ■■�■�■��■��■■11��■■ ■■�■����■■■■�II■��■ ■�■�■�■�■����11■■■� ■■■■■�■■�■�■�IIG��■ ■�■�����■■■■�riiiii ■�■■�■■��������■■■ ■■■■■�■■�■�■■■■■■■ ■��������■■■�����■ ■�■■�■■■��■���■��■ � ■ ■ ■ ■ ■ ■ ■ ■ Davie Gounty,%Cealth De�artment Errvirortmerrtal ,�fealth Sectton no s� s4s / Zio x��� s�c Mocksville, NC 27028 P4wne: (336)751-8760 January 3, 2000 William Davis PO Box 947 Cooleemee, NC 27014 Re: Site Evaluation- 6.88 Acre Tract/Cemetery St. Tax PIN #: 5745-24-7619 Dear Mr. Davis: As requested, a representative from this office visited the above site on January 3, 2000. Based on the infomzation 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 Due to some complex topography and expansive, clayey soils on the site, location of the residence may require setting a lift station The better soils were towazd the neighboring cow pasture. Please keep this in mind when siting a house location. Before a representative of this office will revisit the site to issue an Improvement PermitlAuthorization 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. Sincerely, JeffG. Beauchamp, R.S. Environmental Health Section Enc(s)