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1164 Cherry Hill Rd 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001303 Tax PIN/EH M 5755-62-9616 Billed To: Dan Cagle Subdivision Info: Reference Name: Location/Address: 1164 Cherry Hill Road-27028 Proposed Facility: Residence Property Size: 10 acres ATC Nu�p byr: 2519 **NOTE** Thls mprovement/Operation 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. i Residential Specification: Building Type�j� #People _ #Bedrooms --? #Baths Dishwasher: Pf Garbage Disposal: ❑ Washing Machine:. Basement w/Plumbing:j0"0' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size _ Type Water Supply Design Wastewater Flow(GPD) <L,�fZ Site: New Repair❑ System Specifications: Tank Size/OBD GAL. Pump Tank GAL. Trench Widtlr,� Rock Depth �jLinear Ft.<?&� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6-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 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** F Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001303 Tax PIN/EH#: 5755-62-9616 Billed To: Dan Cagle Subdivision Info: Reference Name: Location/Address: 1164 Cherry Hill Road-27028 Proposed Facility: Residence Property Size: 10 acres ATC Number: 2519 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,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALIDFORA PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �/, Date: y 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 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. Septic System Installed By: Environmental Health Specialist's Signature: f'yn�./i/ Date: DCHD 05/99(Revised) ' APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department AW _ 2000 Envinvnmental He+altb Seaon P.O. Box 848/210 Hospital street Mocksville, NC 27028 ENVIRONMENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed 1. CA A A3 F .G, 3-h- contact Porson 1 4 u O sa- SA iu eY'or46L Ls Hailing Address 11 ,61-1 6e"\4 did" 2J. Home Phone q q'� -5—,37 6 City/state/ZIP A&C k'-CW t(I t '"( X702 S2 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Lip 3. Application For: 0 Site Evaluation lh'Smprovement Permit/ATC ❑ Both 4. system to service: LYHouse 0 Mobile Rome 0 Business 0 Industry ❑ Other 5. --If``Residence: # People .2 t Bedrooms ..3 i Bathrooms Y�Dishwasher n Garbage Disposal (l-Washing Machine Prli�ssmsnt/Plunbing ❑ Basesent/No Plumbing 6. If Business/Industry/Other: specify type • People # sinks t Commodes i showers # Urinals # water Coolers IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ well 0 Community e. Do you anticipate additions or expansions of the facility this system is Intended to serve? ❑Yes "0 If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 8) AcR.S WRITE DIRECTIONS(from Mocksville)to PROPERTY: l Tax Oftice PIN: 7 - _ ' / 69 d Sou ('L'% �u C -r rat Property Address: Road Name tn�P� •I l�� C Ainh ro x L' 2 "A,1--q a4-� City/Zip ' ARCO-C—Aft Cko rses �a.�� c�:• If in a Subdivision provide information,as follows: a�" Name: n„_ Section: Block: Lot: Date Property Flagged: 1 a20o 0 This Is to certll,., 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 intended use change,or if the Information submitted In this application is falsilled or changed. 1,also,anderstand that I am responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davi County Health Department _ to enter upon above described property located In Davie County and own by 4� a e'is e J Z to conduct all testing procedures as necessary to determine the site suitabi Y. DATE V C) SIGNATURE & Tw THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dim- naions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notilication Date: EHS: Account No. // )30-3 Revised DCHD(07/99) Invoice No. b 1 / TOTAL-486.80 :042610'25' j N A�•41.,6. w � � .09 N 82•t0'25' W-�- NBP 55'42' W-m- � 395.67 460.71 376.18 p�O 1� f o 0 w m u tO � U N � O SSS• �► mmn p rJj�3l F -dNN - it" Z Xm 0 li P, � N t �r 1 • mp ny APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P r : Davie County Health Department �C V ~' 1�/ Environmental Health Section D P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Reque ted By ti3 ` A 6 Mailing Address � ,Q: C) Home Phone ` /. �'L r 72-7a:zd Business Phone 70q 7 3/-..2 314' 2. Name on Permit if Different than Above 3. Application for: PCreneral Evaluation ❑Septic Tank Installation Permit 4. System to Serve: ❑ House � „� ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No.of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public ❑ Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? *NOTE: Improvements Permits shall be valid 11110piim from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFORMATION REQUIRED: Tax Office PIN: # '6765-62- 960/0 PROPERTY ADDRESS, as follows: Road Name: C m—h-A� � \ city: Mocks \3\\\e, N.c SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1 , 1995. This is to certify that the information provided is correct to the best o y knowIdXIInderstand I am responsible for all charges incurred from this application. —�S 7 & DATE tRiNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2,the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193) `�\.;` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS PROPERTY SIZE led 14e PROPOSED FACIILTY ,/`YdtL�L LOCATION OF SITE Water Supply: On-Site Well i/ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 Landscape position 1 ,L. Sloe Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group ' Consistence Structure Mineralogy /.' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .� / SITE CLASSIFICATION: �_ EVALUATED BY: 'G LONG-TERM ACCEPTANCE RATE: 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-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V--.-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely fine Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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(01-901 Won i� �� ly'�fa: c IV P 0 IV 9oa � bb st dd rii �� '' �" r 996£b �✓ 29Z£ k �r'w.•i as £8'' y..: 0a 00�� ••^� � a Y �daK n� ' • � 1 ay �l'd' Wy?PE"Yr ,,�V,yyey�,.,. *; + 1V'1y`,v gY?�QP WY dna �"( it" a �Y„f•Y N M •. L .,r't p•� of � r � vik ai } yw � :. ra , t�, ""';w't # ..t�' °5 a1 R 4 Z.: � ;` �v1� '• N +��, Ivy k v f J y x YA A4 �.„� r .� � T�k� N X . �y w •�T{ �sowL / � L is oda SB r ,� {� Davie County Aeall Department - and Noine YfealtFr .fyency 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634-5985 April 17, 1996 Dan F. Cagle, Jr. P. 0. Box 1420 Welcome, NC 27374 Re: 2 Site Evaluations Cherry Hill Road/100+ Acres Dear Mr. Cagle: As requested, a representative from this office visited the aforementioned sites on April 11, 1996. Eased upon the information provided on the application(s) for site evaluation(s) and after the evaluations were completed, the sites were found to be provisionally suitable for the installation of an on-site sewage disposal system on each site. Before any permit(s) can be issued the appropriate application(s) mist be filled out and the house/mobile home location(s) staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr. , R.S. Environmental Health Section RH/wd . Enclosure(s) 73 , t 1