106 Bramblewood Ln � j
; • t� ' DAVIE COUNTY ENVIRONMENTAL HEALTH
t , P.O.Box 848/210 Hospital Street
• Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Accr�unt #: 990000687 "��x�I�€,�EH#: 5823-33-9323-#2
BiElc� To: Cynthia Lyons Suf��ivia1011`1f1�0:
�e:fer�r�ce P��n�e: LacatiortiAddr�ss: Bramblewood Lane-27028
F'ropc�sQc9 Fa�;i€ity: Residential - �co��rty Size: 18.18 Acres •
a�TC Nu�tber: 5817 j;
**NOTE** The issuance of tbis Oper�tion Permit shall indicate the system described on the ATC has been installed
in compliance with Article l l.`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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� System Type: � S.T.Manufacturer�rlG��i�i� Tank Date� ��Tank Size�QD�
Pump Tank Size /l�C7Q j2���
� Q���1
System Installed By: e f`�Q E.H. Specialist: � ate: /��l
GPS Coordinate:
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DCHD 1 1/06 (Revised)
� ' DAVIE COUNTY ENVIRONMENTAL HEALTH
= ' � ' P.O.Box 848/210 Hospital Street
� � , �, Mocksville,NC 27028
� (336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
�cc�u�t #: 990000687 �"�x F�INiEH�: 5823-33-9323-#2
�ille;d Tc.�; Cynthia Lyons S���i�i,-ion Ir3fz�:
R�fer�r�ce P�ar��e: E.ocationiAdr�r��s: Bramblewood Lane-27028
f�ropc�sec9 F;��:iliEy: Residential Pro��� �z�: �18 18�cres
�C, 5g1, it��ype: ew epair ❑Expansion
���*�F��`�This����horization to Conshuct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
' Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential.Specifications: #Bedrooms�#Bathrooms � #People�Basement� Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size ��i�. Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)���Tank Size1�GAL.Pump Tank�GAL.
Trench Width� Max.Trench Depth�� Rock Depth� Linear Ft. U����
Site Modifications/Conditions/Other: �ZP��I.J[��
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m:on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist ' Date:
DCHD 11/06(Revised)
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, ' --'• � + Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990000687 Tax PIN/EH#: 5823-33-9323-#2
Billed To: Cynthia Lyons Subdivision Info:
Address: 108 Bramblewood Lane Location/Address: Bramblewood Lane-27028
City: Mocksville Property Size: 18.18 Acres
Reference Name: ,
Proposed Facility: Residential
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
� construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Permit Type: Lg.New ❑Repair ❑Expansion� w��Permit Valid for: I�S,S Years ❑No Expiration
Residential Specifications: #Bedrooms_�#Bathrooms � #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):_E� Type of Water Supply: f�County/City ❑Well ❑Community Well
Site ModificationslPermit Conditions:
S stem T e LTAR
Initial � �d
Re air y'v Q . `Z
Site Plan �
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Environmental Health Specialist Date (
' i.p.I 1-06
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� APPLICATION FOR SITE EVALUATION/IMPROVEMENT ��ZMIT & ATC
Davie County Environmental Health �.:,����
P.O. Box 848/210 Hospital Street
Mocksville,NC 27028 �uN Z � 2���
(336)753-6780/Fax(336)753-1680 �Y�
Application Far: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Botti�—�
Type of Application: ,�1ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
(33b �-ao��
Name lf�-�1iQ i� r'�.S ContactPerson�Q��pr, y4�pP_�,
Address I O amble_�.mc� r Home Phone 33(v- �� - �►9�1
City/State/ZIP V�l������/���e��,�G �'"7 c�a�C Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ed
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan �Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name}� � � � Phone Number�33c_o>441��Cn ti 4�.
Owner's Address_ "$��,r.��1�2wZ�o L.,r. City/State/Zip��I�Sv,1,� � hY'.
Property Address r-c�b � City��«,,,1 l�.
Lot Size �g .�`� Tax PIN# "� 2 - � 3 3
Subdivision Name(if applicable) Section/Lot#
Direetions To Site: �QO I - , O t'� �'l3� - � �� �(`c� h�n<< �c-��cf
If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? fYes • No
Does the site contain jurisdictional wetlands? Yes ✓ No
Are there any easements or right-of-ways on the site? J Yes No �Ou3�r' ���e�
Is the site subject to approval by another public agency? Yes ✓No
Wi(1 wastewater other than domestic sewage be generated? Yes �/No
IF RESIDENCE FILL OUT THE BOX BELOW
#People �_ #Bedrooms �� #Bathrooms � Garden Tub/Whirlpool ❑Yes ,�No � .
Basement: ❑Yes o Basement Plumbing: ❑Yes No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Buildin� #People
# Sinks #Commodes # Showers # Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: ❑Conventional ❑Accepted OInnovative �Alternative ❑Other
Water Supply Type: LR County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �
If yes,what type?
_ ___ _._ . _ _..._... . _.._... _ . _ _ _
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereafter arG subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
la rules. I understa hat I am responsible for the proper identification and labeling of property lines and corners and
1 cati nd flagging o s aki ouse/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
�Property wner's or owner's legal rcpresentative signature
Date(s):
� � � ' Client Notification Date: __
Dat • EHS: ---
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Re��ised 11/06 �L � !.�s�3 "� � Invoice# -� *
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htonclay,June 27 2011
cv *i•WAI2NINC:THIS!SNOTASUR EYl�"'
p This map is prepared for the inventory of tesil property found within this jurisdiclion,an is crompiled from recorded deeds,plats,and other pubiic
� records and data.Users of this map arc hcreby�iotified that the afvrementioncd pubil prmary information soi�rees shouid be consulted for
w veriscation of the info:matian containcd on Ihis map.l�he County und mappLig comp. y�ssume no Iegal respoiuibi3it,y for the infor,nation
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• •• ;• ',�' • •� DAVIE COUNTY HEALTH DEPARTMENT
y ' '� Environmental Health Section
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Soil/Site Evaluation
APPLICANT I FORMATION �' INFORMATION
Account #: 990i Tax PIN/EH#: 5823-s�'��
Billed To: Cy thia Lyons Subdivision Info:
Reference Name: � Location/Address: Bramblewood Lane- 70 8
Proposed Facility: Re idential Properly Size: 18.18 Acres Date Evaluated: �_!_ ��
Water Supply: On-Site Well Community Public X
Evaluation By: Auger Boring Pit_X Cut
FACTOI�S 1 2 3 4 5 6 7
Landscape position �
Slope % �
HORIZON I DEPTH
Texture grou
Consistence �
S tructure �
Mineralo �
HORIZON II DEPTH
Texture rou
Consistence
Structure
Mineralo I
HORIZON III DEPTH �
Texture rou
Consistence �
Structure
Mineralo
HORIZON IV DEP'TH
Texture rou
Consistence
Structure �
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZ N
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPT CE RATE
SITE CLASSIFICATIO : EVALUATION BY: .��
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LONG-TERM ACCEPT CE RATE: -� OTHER(S)PRESENT: /��'I „`�P'P_
REMARKS: ` G
LEGEND
T,andsca�e Position .
R-Ridge S -Should r L-Linear slope FS -Foot slope N-Nose slope �
CC-Concave slope V-Convex slope T-Tenace FP-Flood plain H-Head slope
Texture .
S -Sand LS -Loam 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
('nN�I�T+,N ,
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VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
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NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP Slightly plastic P-Plastic VP-Very plastic
Struc.ture
SC-Single grain M Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic �
Mineraloev
1:1,2:1,Mixed
lYotes
Horizon depth-In inches '
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(� nsuitable)
Soil wetness-Inches fro 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)
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sca.E�i• - 60' 113134 °�'ES TH�I[llSVII1E N.C. '27980
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• DAVIE COUNTY ENVIRONMENTAL HEALTH 4
• ' " f " P.O.Box 848/210 Hospital Street
, � � J Mocksville,NC 27028
(336)753-6780/FaY#(336)753-1680 '
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
�c�t�ut�t �#: 990000687 T�x F'I�fiEH#: 5823-33-7506-NEW
Bille�T�: Cynthia Lyons S�f��ivi�iart Inf�: '
f�efer�E�ce P�a��e: New Permit Issued LocaiioniAd�r�s�: Bramblewood Lane-27028
f�rn�c�s�ec9 F���:ility: Residential . T��r��r�r�.y Size: 1 Acre
Site Type: ❑New ❑Repair ❑Expansion
a�TC t�umber: 5784
**NOTE**This Authorization to Construct(ATG)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site ptans,plat
on the intended use change. ^
Residential Specifications: #Bedrooms #Bathrooms � #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
� Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: �County/City ❑Well ❑Community Well
System Specitications: Design Wastewater Flow(GPD) Tank Size GAL.Pump Tank GAL.
� Trench Width Max.Trench Depth Rock Depth Linear Ft.
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this,system between
8:30—9:30a.m:on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist • • D�te:
DCHD 11/06(Revised) .: ` �
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• • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County �nvironmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax (336)753-1680
Application For: ❑ Site Evalu�tion/Improvement Permit ❑ Authorization To Construct(ATC) Both
Type of Application:`�Ie�v System ❑Repair to Existing System ❑Expansion/Modification of Existing Sy tem or Facility
`�
***IMPORTAN7*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION '3sb- y�Z-ZoB�
Name ��A[T{-�( /k ��(S� �,l{�J�f J Contact Person��-��J1� ��-``.-
Adcti•ess +OS `�Yri'���41lZ?c�� �... Home Phone '3 3�, �(1-f v- (o)G�l-(�
City/State/ZIP �nC(�SVI L I_�C_ l�C c�"7(�o1a Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORIVIATION *Date House/Facility Corners Flag ed s.3d�//
NOTE: A survey plat or site plan must acco�npany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pernlit is va d for 60 months with site plan,no expiration with complete plat.)
Owner's Name �'��In.i� L�v�s� L`(���5 Phone Number
Owner'sAddress�p� t3�M�i�� t,jpOt� L,/}N�Z City/State/Zip ��1LSv��t1�Z ML 2.� oZ�S
Property Address-�3p ��ti•Z c n ���� City �./�pLILsV��t�Z N L
Lot Size��C� Tax PIN# �23- �j- J�Q(o
Subdivision Name(if applicab e) Sectio /Lot# �n /
Directions To Site: �Q� �. jq� �{ QD l c�q�rl, c�uJd DN Kf�'�"i7��
7
If the answer to any of the following questions is`-`Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? Yes �[No
Does the site contain jurisdictional wetlands? Yes �No
Are there any easements or right-of-ways on the site? Yes No
Is the site subject to approval by another public agency? Yes �/No '
Will wastewater other than domestic sewage be generated? Yes �J No
IF R�SIDENCE FILL OUT THE BOX BELOW
# People �T #Bedrooms �_ #Bathrooms�_ Garden Tub/Whirlpool ❑Yes 1No
Basement: OYes C�10 Basement Plumbing: ❑Yes L�10
IF NON-RESID�NCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building � #People
# Sinks # Commodes #Showers #Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
�Nater Supply Type: �Cotu�ty/City Water 0 New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this sysfem is intended to serve? ❑ Yes i No
If yes,what type?
Tilis is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any pennit(s)or ATC(s)issued hereafter are subject to suspension or revccation if d�e sitc is altered,the intended use
changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to deterniine compliance with applicable
la �s and rules. I u erstand that�I am responsible for the proper identification and labeling of property lines and corners a�id
l in an flaggi g or staking �h house/ ciliry location,proposed well location and the location of any other amenities.
�� � " Site Revisit Charge
Prop rty wner's r owner' legal epr sentative signature
Date(s):
�_ �7— � � ClientNotiticationDate:
Date EHS:
Si�n given C]Yes L�No Account# V 10�1 _
Revised 1 1/O(i Invoice#
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GoMAPS� - Davie County NC Public Access - �
� WA7ERSHED STRUCTURES _
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***WARNING:THIS IS NOT A SURVEY!***
This map is prepared for the inventoty of real property found within this jurisdiction,and is compiled from recorded
deeds,plats, and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.
• DAVIE COUNTY HEALTH DEPARTMEN'f P� •/G�9q
• �� ► Environmental Health Section
• . � . P.O.Boa 848/210 Hospital Street
,
Mocksville;NC 27028
(33G)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000687 Tax PIN/EH#: 5823-33-7506
Biiled To: Cynthia Lyons Subdivision Info:
Reference Name: Cynthia Lyons Location/Address: Bramblewood Lane-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2128
**NOTE** This Improvement/Operation Pecmit DOES NOT authorize the construction ofa 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 LS 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 M -�01�t #People Z #Bedrooms�_ #Baths Z
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size , `�K� Type Water Supply��^� Design Wastewater Flow(GPD�(� Site: New�Repair❑
System Specifications: Tank Size ���('AL. Pump Tank GAL. Trench Widt��� Rock Depth 12� Linear Ft�O��
Other: Z �'1���T1o..� ��� , (IJ`'�TDJ.�� L.i►S�cS �,O.0 .
Required Site Modifications/Conditions: _�1S��/�.�,j� Q� Cp�Ti�L�Q� ��1 �[j ��- f� (,,-1 n��
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(33C)751-87G0.****
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Envi �' ntal Health Specialist's Signature: ate: � 9
DCHD OS/99(Revised) �
� • � , DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
y P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G}751-87G0
Account #: 990000687 Tax PIN/EH#: 5823-33-7506
Billed To: Cynthia Lyons Subdivision Info:
Reference Name: Cynthia Lyons Location/Address: Bramblewood Lane-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 2128
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). 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 CO TION IS V ID FOR A PERIOD OF IVE YEARS.
Environmental Health Specialist's Signatur : �� Date: � �i ��
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article i l 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.
Septic System Installed By:
Environmental Health SpecialisYs Signature: Date:
DCHD OS/99(Revised)
�(]` �i/���� . �'� APPLICATION FOR SITE e:►ALUATION/IMPROV�fENT PERMIT&ATC D � � � � � �
�� • Davle Cou�ty Health Depa�t:n�nt
/�i� ���•� ��5� Environm.enta/Hea/ifi S�Yio.n JUL 2 0 1999
���� P.O. Box 848/210 Ho�pit.E.i Street
Mocksnille, NC 27€f28
(336)751-8760 Et�VIRDAVIE COUNTNIl�LTH
; ***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
� INFORMATiON IS PROVIDED. Refer to the INFOkMATION BULLETIN for instructions.
1. Nams to bo Hillad �� ^ •�. J Contact Porson V�� P�
l�lailing Addreas b l ew L 8ome Phone 3�� -1`t� b L-1 T
City/State/ZiP 1 A ►(�(�SV(�1� , IV(' � t��lQ Suainass Phono ���p / l(�� "l ��
2. Nama oa Pormit/ATC if Differeat thari Above
Mailing Addroea City/Stats/Zip
s. i�,ppiication For: ❑ Site Enaluation ❑ Impronement Permit/ATC oth
a. syst� to sen►ico: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other
s. if Residence: � People � 8 Bedrooms � # Bathrooms v�
❑ Diahwaehez O GarY�ago Diapoeal �Washing Machine ❑ Hasement/Plumbing ❑ Sasament/No Flumbinq
6. If Sueinoee/Iaduatsy/Other: Specify type # People # Sisilca
A Commodes � Shoxera # Urinale � Water Coolere
IF FOODSERVICE: # S@ats Estint8ted WAter Usage (gallons per day)
�. Type of water supply: l� County/City ❑ Well ❑ Community
e. Do you antic's�ate adciitions or eapansions of the facility this system is intended to serve? ❑Yes ' L�No
If yes,what type? _
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION TitEftiJESTED
I BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by t6e client with THIS APPLICATIOI�.
Property Dimensions: �",/�G! � WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax OtTice PdN: # s�'� 3— ��- 7���, ���/� �C�/.� /p u1s/ ��f�
P!�operty Address: Road Name��y/��/�(dfaDC�' h�. GU �� �! �� -' �G� ��S�"
� c;ryiz;p ./�o�`l �I�'� ��02�' Gf�,-��u���.� �'�l'u���.
If in a Subdivision provide information,as follows: �/�G�1 ��«�� �� Gr�1����.
Name: / �/t� JP� !j�'1�U d,:�� /�'O?/�`'C .
Sectio�: Block: Lot: Date Property Flagged: ������
,�'his is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issa�:�hereafter aee subject to sus�ension or revocaHon,if the site plans or intended use change,or if the iuformalloa
submitted in this applicatio!�is falsified or chaaged I,also,understand that i am responslble for all charges incurred from
thls application. I,hereby,gsve consent tm�1�e Authorized Repces�:±ative of the Davie County Health Department
to enter upon abov�described property located in Davie County and owned by
to coaduct all testing prceedures as necessary to determine the site suitabi
DATE� 1- oCD- -'I� SIGNATURE
THIS AREA MAY BE USED FOR DRAWIIVG YOU�€.SITE PLAN( nclude ll of the following: E�sti d proposed
property lines and dimensions, structures, setbacks, and septic loca
Site Revisit Charge
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, � , '� � DAVIE COUNTY HEALTH DEPARTMENT
' , • , . , Environmental Health Section
• •' � Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000687 Tax PIN/EH#: 5823-33-7506
Billed To: Cynthia Lyons Subdivision Info:
Reference Name: Cynthia Lyons LocationlAddress: Bramblewobd Lane-27028
Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: ��5�
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% 37
HORIZON I DEPTH -1 ��- �
Texture rou G G
Consistence Fi �
Structure Df�Y iL
Mineralo I i�'7 M�
HORIZON II DEPTH �3 � -
Texture rou L�
Consistence
Structure Agl� IL
Mineralo �1 7 Urf�
HORIZON III DEPTH 3�,+ +
Texture rou �c �
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION PS t��j
LONG-TERM ACCEPTANCE RATE O.2
SITE CLASSIFICATION: 1 — EVALUATION BY: ��'� ,r�v�t�����
LONG-TERM ACCEPTANCE RATE: Y�•� OTHER(S)PRESENT:
REMARKS:
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
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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ENVIRONMEN�AL HEALTH SECTIUIV
P.O. Box 848/210 Hospitai Street
Courier #09-40-Ofi
Mocksville, NC 27028
Phone #: (336)753-G780
June 23,2011
Ms. Cynthia Lyons
108 Bramblewood Lane
Mocksville,NC 27028
Re: Bramblewood Lane
T�PIN: 5823-33-7506
Dear Ms.Lyons
As requested,Andrew Daywalt,Environmental Health Specialist with this office and Kevin
Neil,Regional Soil Scientist on June 20,2011 evaluated the above-referenced properly at the site
designated on the platlsite plan that accompanied your improvement permit application.
According to your application the site is to serve a {DESCRIPTION,ex: 3 bedroom,residence}
with a design wastewater flow of {360 GALS.} gallons per day. The evaluation was done in
accordance with the laws and rules governing wastewater systems in North Carolina General
Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina
Administrative Code,Rule .1900 and related rules.
Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative
Code,Rules.1940 through.1948,the evaluation indicated that the site is UNSUITABLE for a
ground absorption sewage system. Therefore,your request for an improvement permit is
DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the
following:
• .1943 Soil Depth
• .1941 Soil Characteristics
These severe soil or site limitations could cause premature system failure, leading to the
discharge of untreated sewage on the ground surface, in surface waters, directly into ground
water or inside your structure.
The site evaluation included consideration of possible site modifications, and modified,
innovative or alternative systems. However,this office has determined that none of the above
options will overcome the severe conditions on this site. A possible option might be a system
designed to dispose of sewage to another area of suitable soil or off-site to additional property.
For the reasons set out above,the property is currently classified UNSUITABLE,and an
improvement permit shalt not be issued for this site in accordance with Rule .1948(c).
However,the site classified as UNSUITABLE may be reclassified as PROVIONALLY
SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d).
A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to
develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE.
" You have a right to an informal review of this decision. You may request an informal review
by the environmental health supervisor with this office. You may also request an informal
review by the N.C. Department of Environment and Natural Resources regional soil specialist. A
request for informal review must be made in writing to the Davie County Health Department, �
Environmental Health Section.
You also have a right to a formal appeal of this decision. To pursue a formal appeal,you
must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714
Mail Center,Raleigh,N.C. 27699-6714. To get a copy of a petition form,you may write the
Office of Administrative Hearings or call the office at(919)431-3000 or from the OAH web site
at www.deh.enr.state.ne.us. The petition for a contested case hearing must be filed in accordance
with the provision ofNorth Carolina General Statutes 130A-24 and 150-B-23 and all other
applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g)provides that your
hearing would be held in the county where your property is located.
------- Please�ote:-If�ou-wish-to-pursue-a-formal-appeal,-you-must-file the petition-form-with-the--—
Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The
date of this letter is {DATE}. Meeting the 30 day deadline is critical to your right to a formal
appeal. Beginning a formal appeal within 30 days will not interfere with any informal review
that you might request. Do not wait for the outcome of any informal review if you wish to file a
formal appeal.
♦ • � f
If you file a petition for a contested case hearing with the Office of Administrative Hearings,
you are required by law(N.C.General Statute 150B-23)to send a copy of your petition to the
North Carolina Departrnent of Environtnent and Natural Resources. Send the copy to: Office of
General Counsel,N.C.Department of Environment and Natural Resources, 1601 Mail Service
Center,Raleigh,N.C.27699-1601. Do NOT send the copy of the petition to Davie County
Health Department. Sending a copy of your petition to Davie County Health Department will
NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the
Office of General Counsel,NCDENR.
Please call or write this office if you have any questions or need any additional assistance,as
follows: Telephone number: (336)753-6780
Davie County Health Department
Environmental Health Section
P.O.Box 848
Mocksville,NC 27028
Sincerely, Gy/�- ��/T (`
wl � .J
Andrew Daywalt
Environmental Health Specialist
Enclosure(s): Soil-Site Report
Rule .1941 and 1943
AD/bl