281 Bracken Rd . DAVIE COUNTY HEALTH DEPARTMENT
� ° • ' Environmental Health Section
� P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003641 Tax PIN/EH#: 5820-30-3703. HA
Billed To: Howard Adams Subdivision Info:
Reference Name: Location/Address: Bracken Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4158
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 CONST U ION IS VALID FOR A PERIOD OF FI ARS.
Environmental Health SpecialisYs Signature: � Date: �
CERTIITCATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with ' e o .S.Chap ection.1900"Sewage Treatment and
Disposal Systems,"but shall in NO AY be taken as a arantee that the s stem will function satisfactorily for any
given period of time.
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Se tic S tem Installed B : � � '� ✓ � e
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Environmental Health SpecialisYs Signature: /,�j/ Date: ��—
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �� ������° S
, '� ► P.O.Boz 848/210 Hospital Street
� � ' � Mceksville,NC 27028 � ��
(33G)751-87C►0 '
IMPROVEMENT/OPERATION PERMIT
Account #: 990003641 Tax PIN/EH#: 5820-30-3703. HA
Billed To: Howard Adams Subdivision Info:
Reference Name: Location/Address: Bracken Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4158
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALTTHOWZATION 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 T�IIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �f�7 #People #Bedrooms c.� #Baths��
__ Dishwasher:�1 Garbage Disposal: ❑ Washing Machine:I� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply�/�'� Design Wastewater Flow(GPD)=�'`-� Site: New�Repair❑��
I �'
System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width�� Rock Depth �.� � Linear F.
� �'t�t�d in 15A F,�� 18a.19i�9(5�
Other: �„�s���d d}��r r+a,��,�l�e I�� d�
Required Site Modifications/Conditions:
INIPROVEM11ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF C► "BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of ' County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.t . .m. on the f installation. Telephone#is(33C►)751-8760.****
/
��Je��
8`� �—
Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
. � �
, • t �• D �� li'� (5 I{ t[DPI I�A' =0R SITE EVALUATION/Ih1PROVCM1IENT PCR�S117&ATC �
Davie County Health Department /� �
„ En vironmenta/Hea/th Section . ____... .._� -<��
t��N — 8 2�a'j . Box 848/210 Hospital Street
Mocksvilla, NC 27028 /�� �p `��� ds
(336)751-8760 �
�`��:i0:;°.."Pc tTh1 HiJ'1T�3
A,�,-
*�' � i'S�cPFM� TION CANNOT BE PROCESSED UNLESS ALL THE RLQUIRED
INFORb1ATION IS PROVIDED. Refer to the INFORMATION BULLETI2d for instructions.
1. Namo Lo ba Dilled �1.���( �Cf�/y``� Contact Peroon
Mailing Addrasa �� �s �-�1 P�f"' � lioma PYione / �v�� l � v
CiLy/State/ZIP � '— S � � �--�/ 2� IIuaineDa Phono �i-Q--e-- � [ ! �2�
2. Name oiz Permit/ATC if Diffarent than Abovu
Mailinc� Addresa �y�at p �/ `
3. Application For: �CJ Site Evaluation ❑ Improvement Permit/ATC ❑ noth
4. system to service: �iouse ❑ Mobile Homa ❑ 13usiness ❑ Indusstry � Other
5. Typo nS•ntem requeuted: ❑ Conventional ❑ conventional modified ❑ innovativa �Dac�epted
6. If Re�idenco: �t People # nedrooms � �t IIathrooms �
Di�lr.�ra3her ❑Garbage Di�posal 4�Washing Machino ❑Basement/Pluml�ing ❑uaaemenL-/2do Plumbing
7. If Buuinesa/Industry /Othar: verify type # People �k Sinka
# Commociou �F Showora # Urinala 8 P7aL•or Coolere
IF FOODSERVICE: �# Seatu Estimated Water Usage (galion3 par day) .
a. Type ot wator aupply: � Coun�y/Ci�y �] Well � Community
/ �
9. no YoL anticipata adtlitions or expansions of thc facility tliis systcm is intcuded to scrvc? C]Yes � No
If ycs,titi�hat typc?
***Idll'ORT�INT"�**CLIGNTS AfUST COAIPLETE TII� RL•QUIRL•D PROPCR7'Y lNTOR1IIATlON RLQUGSTLD
I3I:I,OW. isithcr a PLAT or SITC PLAN-hlUSTBE SUB�IITTLD by thc clicnt �vitli T[IIS APPLICATiON.
Property Dima�sions: ��� � ""�'ti`— �VRIT�DIRGCTIONS(fron�lYlodcsvillc)to PROPTKTI':` .
,....._..................___.._______
Tax Officc I'IN: # 2—�' d"� ��3 � ���{
(_.._.�._.----�...n�,------�
I'roperty Address: Road Nam �- � — � ' S '�-- `�~"
City/Zip '
� S �
If in a Subdi��ision providc inforruatiai,as follows: �
Namc:
Scction: Blocic; L t: Dalc t�ome corncc•s flag�cd:�p � d S
�.�
This is to ccrtifj�tl�at thc information providc is ca•rcct to tlic best of my knowlcdga I undcrstand tttat any permil(s)
issued I�ercafter are suUject to suspensioii or revocation,if tlie site plans or intended use cl�aiige,or if tlie informatio�i
submitted in tliis applicatiou is falsiGcd or changed. I,nlso, trnderstanrl[hat I ani responsiGle for ail clrarges incrrrred frvru
1/ris appli�atiurr. I,hcrcby,git�c conscnt to tl�c Autl�oriud Rcprescutativc of tiic Davic County Ilcalll�Dcpartmcut
to entcr upon a�ove dcscribcd properfy localcd in Davic Cowity and oi��ned by
to conduct all tcstiug proccdures as ucccssary to dctcrminc tlic sitc suitability.
DAT� � ���� SIGNATURI; ����'�''���������1�"
THIS AR�A 11�AY B�US�D TOR DRAWING YOUR SITE PLAN(Includc aIl of thc fotlo�siug: Lxisting�ud propuscd
property lincs Znd dimensions, structures, setbacks, ancl septic locations). ,
'�� , ;,�.v Sitc Revisit Cl��rgc
�/
� D:ttc(s):
1.�= Clicnt Notircatioii Datc:
l�/� ,
��
G�� Li-is:
��iven '`� � �, ' Accouiit No. �� ��
�.�-r�-� (�}t�3 ) G�
^.IID(OS/03 5�,;�.cS' Lrvoicc No. �o � �
C9'�'`�- +
� r,.e�� ` tkL.� �� �cJ' ��-Z._.
i'��rc. !1,i� /
� ` DAVIE COUNTY HEALTH DEPARTMENT
� " �, . ► Environmental Health Section
" Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003641 Tax PIN/EH#: 5820-30-3703. HA
Billed To: Howard Adams Subdivision Info:
Reference Name: ! r.cation/Address: Bracken Road-27028
Proposed Facility: Residence Property Size: 1 ucre Date Evaluated: �--,��—DSJ
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 % ,o
HORIZON I DEPTH �� //
Texture grou � `S'G°.G
Consistence /
Structure 6/' �
Mineralo /�- !, '
HORIZON II DEPTH � << -Cl�j��
, Texture rou C.-
Consistence �
Structure � /1
Mineralo -, '
HORIZON III DEPTH y �i.., s
Texture rou
Consistence �R/
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
i._ n�_dccape Position
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-F1ood plain H-Head slope
Tsxtur�
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
�IQiSt
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS -Non sticky SS -Slightly sticky S -Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
,S.tili��.l�
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
MineraloQv
" 1:1,2:1,Mixed
LYQtes
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)
TAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Revised)
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Environmental Nealth Section
P. 0. Box 848/210 Hospitai Street
Courier 09-40-06
• Mocksville, NC 27028
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June 15, 2005
Howard Adams
1345 Bridgestone Road
Winston-Salem,NC 27127
Re: Site Evaluation/ Bracken Road
Tax Office PIN: #5820-30-3703
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on,
June 13, 2005. 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 installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Constrz�ct 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, , �
. ,������.....��•
Robert B. Hall,Jr.,R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)