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190 Channel Ln� � _. - A• ��L Account #: 990001454 Billed To: Eugene Holley Reference Name: Proposed Facility: Residence ATC Number: 2648 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (33G)751-8760 Tax PIN/EH #: 5820-940113 Subdivision Info: Location/Address: Channel Lane-27006 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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, ion .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT STRUCTION IS VALID FO PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � - i Date: `� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of G.S. Chapter 13 , Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a t the system will function satisfactorily for any given period oftime. �n� , i" i� /D � Septic System Installed By: �xJ � f Environmental Health Specialist's Signature :�� Date: S�/—S ` �% DCHD OS/99 (Revised) _ .� , . . ., , ", ' � . /��f��ln✓ �G',li/9J'f �� '�' Account #: 990001454 Billed To: Eugene Holley Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)75]-87G0 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5820-94-0113 Subdivision Info: Location/Address: Property Size: Channel Lane-27006 see map **N07'�* * Ttii b�mprove�in$ nt/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 ,�J.�� #People �� #Bedrooms l #Baths � 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 � Design Wastewater Flow (GPD) _�� Site: New �Repair ❑ System Specifications: Tank Size��%� GAL. Pump Tank Other: Required Site Modifications/Conditions: ll GAL. Trench Width3� ��Rock Depth � Linear Ft,� IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFL ENT FILTER. RISER(S) IF 6" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Da 'e ty Health Department for final inspection ofthis system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day ation. Telephone # is (33G)751-87G0.**** a i� /`�E--�-r � � I .�� J �' ��y�I ��,,ol ` � � ' Environmental Health Specialist's Signature: Date: �r� ",� DCHD OS/99 (Revised) � e� j�� ' y -. ' } . 1 ` � 1'� �� j ri'� APPLICATION FOR SITE EVALUATION/IMPROYEMENT PCfiM1tIT & ATC � (� �� Davie County Health Department ('O��r y ��/;� I Environmenta/ Hea/tfi Section {5 ` U" � P.O. Box 848/210 Hospital Street � �� `,� �� tC� � Mocksville, NC 27028 vfry,�1' � I (336)751-8760 .G'��p_3v_ c� c� - �. � �� Mi� r ocr i 8 �7�0 / ***II�ORTANT*** THZS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nama to be Billed �/�e /% (�/ /�� Contact Person Mailinq Address ��(� y /�/ � /7 �/ Y �Q(%� /� Home Phone % -7 Q " 3 3 � J _ City/State/2IP �Q (�� / � � (� /� � � /0��7 Business Phone 2. Name on Permit/ATC i£ Dif£erent than Above Mailinq Addsesa City/State/2ip 3. Appiication For: Site Evaluation F� Improvement Permit/ATC ❑ Both a. sy8t� to sarv��e: 0 House yYMobile Home ❑ Business ❑ Industry ❑ Other s. =f Residence: # People �_ � Bedrooms _� # Bathrooms � K Diahxasher II Garbage Disposal `i'Washing Machine ❑ Basement/Plumbing O Base.-aant/No Plumb�g 6. If Buainesa/Industry/Other: Specify type # People # Sinks _ M Co�des # Shoxers # Urinals # Water Coolors IF FOODSERVICE: # Seats Estimated Water Usage (qallona per a$y) 7. �ipe of water supply: I�County/City ❑ Well ❑ Comnunity e. Do you anticipate additioas or expansions of the facility this system is intended to serve? If ycs, what type? ❑ Ycs f�10 ***IMPORTANT*** CLIENTS MUST CObiPLETETHE RLQUIRED PROPERTY INFORMATION REQUESTI:U BELOW. Eit6er a PLAT or SITE PLAN MUSTI3ESUBb1I77'ED by the client with THIS APPLICATION. Property Dimensions: � � Tax Office PIN: # E'�� —�% �— � j �� Property Address: Road Name��„-v,e C. �`a-^ s City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (trom Mocksville) to PROPGR'TY: /� �O / fa C�T �i � /i�c�. �U C�G�h�/ Gn. %�r��e�� d �I e r�-��,,,f.. '' , ' �� e� m�rk�er,0 ,�. r'� � �,,,�- S'. � e-� �F �/� c? a. a1 Date Property Flagged: % d ^ % }� " �(� This is to certify that the information provided is correct to the best of my knowledge. I understand that Any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intendcd use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am re�Ponsible for a11 char�es incurred jronr this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Depurtment to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATG /Q � �� OO SIGNATURE t� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) �l ��d � i �✓ � ��3 � � Site Revisit Charge Date(s): Client NotiGcation Date: EHS: Acconnt No. � �� °�3'�° ° � 3 5. ✓e � J41 Invoice No. -t- /�S �'� iS ��-3 j� �./ o n. a.•'S • /� w c-l.. . �- a. �40000000904 Zo7 m G400000009 .� � _, 5820940113 � v7 �,��.s e; � � \� o � ( �,� � � j- �!.y�� ob� ��p V�O . . . . �. � . � . s � �i5 � 147 • � 363 0 461 0 /// 4•6 i - � , . DAVIE COUNTY HEALTH DEPART'MENT ,- . �:• � Ernironmental Heaith Section � ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001454 Tax PIN/EH #: 5820-94-0113 Billed To: Eugene Holley Subdivision Info: Reference Name: Location/Address: Channel Lane-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: i� o'� 1i� �'iq C Water Supply: On-Site Well Community Public (� Evaluation By: Auger Boring_� Pit Cut HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence �.-------- tcn� 1 nii. i i v n I.LHJJli'11,H 11V1V SITE CLASSIFICATION: _i�T> LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 MineraloEv 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 DCt-ID OS/99 (Revised) ii ii ■■ ■■■■�■ ■�■■■■ ■�■■■■ ■■■■■■ ■�■��■ ■■■■�■ ■�■�■■ ■��■ ■��■ ■��■�■ ■■�■■■ ■��■■■ ■■�■�■ ■■�■■■ ■■■■■■ ■■■■■■ ■■�■■■ ■��■■ ■��■ ��■■■ ■ ■■�■■ ■�■■■ ■�■�■ ■�■�■ ■■■�■ ■�■�■ ■�■�■ ■�■�■ ■�■�■ ■■�■■ ■■�es ■■■�■ ■■��■ ■�■�■ ■■■�■ ■■■�■ ■�■■■ ■�■ iii ■�■ ■�■ ■�■ ■■■�■ ■��■ ■��■■ ■��■■ ■■�■■ ■■�■■ ■■�■■ ■■■��■�■■■�■ ■��■��■��■�■ ■■■��■��■ ■■��■■�■��0■■ ■■�■��■��■ ■■�■��a■e■■ ■�■■��■�■■��■ ■�■�t�■�■■��■ ■■■��■■��■�a■■■■■■■■�■ ■■��■�oo�o��■■�■��■■ ■■■■��■■�■��■��■ ■■��■■■�■�■■�■��■■■ ■��■��■■�■��■■�■ ■■■��■��■�■■�■��■■■■�■ ■��■��■�■■�■��■■■��■ ■��■��■��■■■�■■�■■��■ ■■�■■■e��■�■■■■■��■■��■■ ■�■��■��■■��■��■■■�■■ ■�■■�■��■��■■��■■�■■ ■��■��■■�■■��■■��■��■ ■��■��■■��■��■■�■ ■■■��■��■��■■��■■��■�■ ■■■�■�■■��■��■�■■■■■■��■ ■�■�■■■■��■��■■��■��■ ■■■�■�■■��■��■■■■■�■■��■ ■■��■�■■�■■■�■■��■■ ■■��■�■��■■��■■■��■ ■��■■■■��■■�■��■■��■■■ ■��■■■■��■��■■��■■■ ■■�■■��■�■■��■■■■ ■��■��■��■■��■�■■��■ ■■��■��■■�■�■��■■ ■■�■■�■�■■��■■■■��■■ ■��■■�■■��■■■■■��■■■ ■■�■■��■■��■�■��■�■ ■��■��■■■■■■■�■ ■■�■�■��■�■■■■��■■�■��■ ■��■��■��■■��■■■■■��■ ■��■��■■�■■��■■��■■ ■�■■�■�■■�■■��■■■■■■■■■ ■�■■■■��■��■■��■■■�■��■ �iiiiii�iiiiii�iiiiiii ■��■�■■�■■■��■■■■��■ ■��■■��■■�■■■■ ■■■��■��■■��■■■��■ ■■��■��■��■��■■�■ ■■■��■■�■■��■�■��■ :�■��■��■■��■��■ ■■��■�■��■■■��■■■■��■ ■�■��■��■■��■��■ ■�■�■��■��■��■■ ■�■��■��■��■��■��■ ■■■��■��■��■■■■��■ ■��■■■�■��■■■■■■�■ ■��t��■■��■■■■■�■ ■��■��■■�■■�■��■■■■■��■ ■��■■■■■��■�■■�■■��■�■ ■��■■�■��■■■■��■■ ■��■�■■■��■■��■■ ■�■�■■��■�■■��■�■■ ■�■��■■��■��■��■�■ ■�■�■■��■■�■■��■��■�■■■■ ■��■■■��■■�■■��■■■■ ■■��■■�■��■��■■■��■ ■■��■�■�■■��■■�■■■■■�■ ■■■��■�■■�■■��■■■■��■ ■■��■��■�■��■■�■■■■�■■ ■■��■�■�■�■■�■��■■■■■��■ ■■■��■��■��■�■■��■��■ ■��■■�■��■�■■■�■��■■■ ■�■■��■��■��■■��■■■ ■��■■��■�■�■■■�■��■�■■■ ■�■■■��■■■��■�■■��■�■■■ ■■��■■��■�■■��■��■■�■ ■�■■■��■��■��■ ■��■��■��■■■��■■�■ ■■��■■��■■�■■■��■■�■ ■■■�■■��■■■��■■�■��■ ■■��■��■�■��■■�■■■�■■�■ ■■�■��■■■■■��■��■■■�■■■■ ■��■■■��■■■■ ■■■��■■��■■��■■�■■■■■ ■��■■��■�■��■■■■■■■■■■■■ ■ i ■ "E r �1� Y �� r�U� ��.l�l.�� l��i�� ENVIRONII9ENTAL NEALTH SECTION P. O. Box 848/270 Hospital Street Cour�er #09-40-06 Mocksville, NC 27028 Phone #: (336)75i-8760 October 23, 2000 Eugene Holley 1064 NC Highway 801 N Advance, North Carolina 27006 Re: Site Evaluation/ Channel Lane Tax Office PIN: #5820-94-0113 Dear Client(s): As requested, a representative from this office visited the aforementioned sites on October 20, 2000. Based upon the information provided on the Applications for Site Evaluations and after evaluations were completed on the sites, each site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Authorization(s) to Construct can be issued the appropriate application(s) must be filled out and the house/mobile home location staked on each site. If you have any questions, please feel free to contact this office. Si�cerely, � � jiJ��G/. � . Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s)