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448 Deadmon RdAccount #: 990001598 Billed To: Norman Carter Reference Name: Proposed Facility: Residence ATC Number: 4434 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 D ►.� Tax PIN/EH #: 5747-52 �83 Subdivision Info: Location/Address: Deadmon Road-27028 Proaertv Size: 12.49 acres 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �C,% Date: C.��(Ci/� ?k CERTI�ICf1TE.O�COMPLETION **NOTE** The issuance of this Certificate of Completio has been installed in compliance with Article Disposal Systems," but shall in NO WAY be given period of time. (�it:���I sr� c�w�..�tC ��� �a�� 1��� ���4 y� Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) a� 1 ;a�e the system described on Improvement/Operation Permit .,hapter 130A, Section .1900 "Sewage Treatment and uara�tee that the system will function satisfactorily for any � ` � � F���1 �I�.1, h \�� ,�,��� I�S�fled �� ����� � �� � � -- = i`�l�t S �J \ �.J �� 3�' I�1 �s���<< �� c�;� i3e ' I6� , DAVIE COUNTY HEALTH DEPARTMENT ' E' e� Environmental Health Section P. O. Boz 848/210 Hospital Street ' Mocksville, NC 27028 (336)75]-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990001598 Billed To: Norman Carter Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5747-52-3483 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: 12.49 acres �v �a�A � :� �/ ATC Number: 4434 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AiJTHOWZATION 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 � #People � #Bedrooms � #Bath��.2 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 Siz�G�d GAL. Pump Tank GAL. Trench Width�:���' Rock Depth ��Linear Ft�pa Other: As stated in 15A NCAC 1E3A.2969(5) Required Site Modifications/Conditions: accepted Systems r�ay ��so b� used I1�IPROVEMENT/OPERAT[ON PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW FINISFIED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (33C►)751-87G0.**** � � Environmental Health S ecialisYs Si ature: �4� '/ 1 r �► DCHD OS/99 (Revised) ll� D e/`t-� � Date: � �2� /�r � , . , � - • APPLICATIO R SITE EVALUATION/IMPROVEMENT PERMIT & ATC �,� � �j � Davie County Health Department �,� [� � Environmental Health Section �,� P.O. Box 848/210 Hospital Street •' i,, J�N �� 2006 - Mocksville, NC 27028 �-'-' (336)751-8760/ Fax (336)751-8786 R A�HEALIN Permit L�7'Authorization To Construct(ATC) ❑ Both "'�IMPORTAN7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed �' Q.V� l�L� ��� Contact Person Billing Address ` ,s- / -�U�- Home Phone - 5pi City/State/ZIP `')'� ���-5 /Ji l� il1 L- Q270a t� Business Phone <,lf,i `�j'%35 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address City Subdivision Name Directions To Site Tax PIN# ,� �% �% -S� - .3 `�c�'� Lot Size «.�ti,;.. '�f, �C anr.l �� Date House/Facility Corners �Flagged G(� If the answer to any of the following questions is "yes", supporting documer��fion must be attached. Are there any existing wastewater systems on the site? f�'%es ONo Does the site contain jurisdictional wetlands? ❑Yes � Are there any easements or right-of-ways on the site? ❑Yes C� Is the site subject to approval by another public agency? ❑Yes 1�10 ' Will wastewater other than domestic sewage be generated? ❑Yes G3�No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms � #� Bathrooms � _ Basement: � es ❑No Basement Plumbing: Q'%s ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Garden Tub/Whirlpool I�1`Yes ❑No Type of FacilityBasiness 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 systemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: Ca'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 (�'rIo 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 pernut(s) or ATC(s) issued hereafter are 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 understand that I arn responsible for all charges incurred �fi�om tlzis application. F'hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to conduct necessary inspections to eternune compliance. /with applicable laws and rules on the above described property located in Davie County and owned by Q(' t1R ,T�(,1t�,rG'!� - �LL-�'= - Prop rty owner's or owner's legal representative signature ����-'_� � Date Site Revisit Charge Date(s): Client Notification Date: _ EHS: Sign given CiYes ❑No Account # ��T � ��1� Revised 2/06 Invoice # S.SZ 3 w , �'"n.��,, � '�� L``ti''^^``.^^ � � � l'� t5 S¢ � r � � i � NOV I 3 � _ . , ;. Et� �`JiiE;li� - _ - ',��Ttl � D��t`! F� ,;, il i,�?�� r ����`�r � IN FOR SITE EVALUA�ION/IMPROVEMENT PERMIT & ATC Davie County Health Department Envir,vnmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORN�,TION IS PROVIDED. Refer to the INFORI�ITION BULLETIN £or instructions. l. Name to be Billed Contact Person Mailinq Address �� C% �/J i/ 1'�q ��' �� �,n ���/.Q Home Phone City/State/ZIP � `�(,)C /C � L/t `I�Q � "( e��(���� Business Phone � � � � � �v / 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: E�''Site Evaluation ❑ Improvement Permi.t/ATC ❑ Both 4. system to service: [�ouse ❑ Mobile Home � Business ❑ Industry ❑ Other �- � 5. If Residence: # People # Bedrooms .---� # Bathrooms _� �Dishnasher ❑ Garbage Disposal L�lashing Machine ❑ Base�ent/Plumbing f] Basement/No Plumbing 6. If Business/Industry/Other: Specify type R People # Sinks # Commodes # Shoxers # Urinals # Water Coolers IF FOODSERVICE : # Seats Esti.mated Water Usage �galions per aay> 7, R�pe o£ water supply: O�County/City ❑ Well ❑ Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Yes L�]'No ***IMPORTANT*'�* CLIENTS MUS'7'COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI7TED by the client with THIS APPLICATION. Property Dimensions: 1 d+ l� � Tax Office PIN: #.� 7 L% ?' s o� �' � �� $� Property Address: Road Name �ect w�- v� City/Zip lf in a Subdivision providc information, as follows: WRITE DIREC'I'IONS (from Mocksvillc) to PROPGRTY: (�0% J` f'o ,C��c1 Man �� 1'/� ,���1�5 6 �� ���;h� C/o � C�� SPe �- � � ��.� � k 1� � 1,�.� � Name: -j �k �s-�- ` Section: Block: Lot: Date Property Flagged: � C�Yc S������'�o�' 6 -� � This is to certify that the information provided is correct to the best of my knowledge. I anderstand that any permit(s) issued hereafter are subject to suspension or revocation, if the site �lans or intended use change, or if the information submitted in this application is falsified or changed I, also, understand tkat I am responsib[e jor al! c/rurges incurred fronr this application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth Departmcnt to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the sitc suitability. DATE �� / � '� ,� SIGNATURE � ��� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existi�g and proposed property lioes and dimensions, structures, setbacks, and septic locatioas). � , �-- 1-,��( ---5� �- . � �C - f r,. � �� cc.-� /� /�L a� O c�.��'' T�t_ � �� � �c� u �,o / p J' Revised DCHD (07/99) . Site Revisit Chargc Datc(s): Client Notification Datc: EHS: Account No. Invoice No. �OJ �/ � J_3v-u/ �J-�e � �(S81 - . � � v� �. . - y ¢ co � m �i m m m W �y�' g � m o� m N N � m ' � � " � ; � ., • . (4b6) .. °� OSZ (OLA (SLl) OC 0 (LZt) ' (20L) (SOL) . _ _.. O ._, �5� _ __ .Io 13G) " . , , ' ._. .. _. � � .... ,_ _.. ._ Q� 3NA08lllM .. ' WILLBOONEROAD _.' __ : , .�t151 :... 9py _ . � i � . . .. ... � O y ' � : � � � . O � � � �� ��° `�� N Q r O O . O � � N � � � $ M rn � O 0 . CO^ � �O � � O ap C' � �-' � O � '�O Ocn � O � v Y O � O �r� OO m M...� ,^� � 9es` p Q^,� J v� tC) m � ^' O� p ��3 00� o oo� o Nv o� hp p Y `�' Y o � o o �� � Y Y Y Y ., .o ,� �e � r M t y Y � �9 �E �S sE `, ' O 9fS O N O p �o, �W p '� O� . --_� !' 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001598 Billed To: N�an Carter Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5747-52-3483 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: 12.49 acres Date Evaluated: j� - I 9-°/ 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 Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � 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 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 - Subangulaz blocky PL - Platy PR - Prismatic Mineraloav 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 - gaUday/ft2 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'. . +. . : ...� ...vr.� _.�� .....«....-... . � ..... ...�.�.�. _..,r...-.,. ._�...p�w....._»,^-s.�.�.. �....�...�. q++r• . ^. " � .. .. . . . . , __ , D��II� COUNTY �i�LT�Ii D��'.��tTbI�NT ' _ __ ...�..�._ ._: . _ .. .�.. � . _..,._ .. .�. ._.. . ..,_..... . _._.. .: _...�..�_�..... _�_� .�.. ..... ._.. �.�. ._ . .��w.s.� , ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street - Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 November 20 , 2001 Norman Carter - 229 Springhill Drive Mocksville, NC 27028 Re: Site Evalution/ Dedmon Road Tax Office Pin : # 5747-52-3483 Dear Client(s): As requested, a representative from this offce visited the aforementioned site on November 19 , 2001. 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 Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. � If you ha.ve any questions, please feel free to contact this office. Sincerely, /�a���/��,. Robert B. Hall, Jr., R.S. Environmental Health Specialist .. � � 0 : N�Urr �oM/ \A251 // 112v � ��'� 0198 «.,T • . ,�Zol � � � l `�rn� 9183 0 - - . I .s� � . l,��ol ��� 8087 (4.33A) � 5180 �o '�� `2601 �� 7062 �. �'� ' � 6958 _� a� a � 1g2 d'j . 7 6� 1 (5.71 A) 1606 �i �; � 4193 1993 > .� g (2.35A) M 5649 148 201 0 � 6417 201 � 5397 � 201 0 � 6208 �o M i � �9S 5908 � �37� (273) 2886 �2S 6807 , �°o �3`�J 3890 r�,� �,�° 5706 °�