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667 Deadmon Rd (2)�� Account #: 990003388 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/Z10 Hospital Street Mceksville, NC 27028 (33G)751-87G0 Billed To: Alexander Carswell Reference Name: Rex Kesiaence ATC Number: 4426 Tax PIN/EH #: 5747-83-0366 Subdivision Info: Location/Address: Deadmon Road-27028 rro AUTHORI�ATION 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 WASTEWATE CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: / Date: ��/�'1/�� CERTIFICATE OF COMPLETION **NOTE** 'The issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sh��AY hP taken a u �ee that t e ste 1 function satisfactoril for an �iven neriod of time. � ��'��hC �1 / :� .S�% y y Septic System Installed By: �.e. %� �J� i� /li� Environmental Health Specialist's Signature : ,!`r/.�' /� � Date: __ _ �'�9" DCHD OS/99 (Revised) f ,r � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33O751-8760 Account #: 990003388 Billed To: Alexander Carswell Reference Name: Rex �roposed Facility: Residence ATC Number: 4426 Tax PIN/EH #: 5747-83-0366 Subdivision Info: Location/Address: Deadmon Road-27028 Nropertv 5ize: .0948 acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental IHealth 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 VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � �`/l Date: �7�/32�j�/ CERTIITCATE 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 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sh �s a��uafa��lt�a t esyst v�fll function satisfactorily for any given period of ti �!"''s�' � � I �-�?S'�i3�CJV� � Septic System Installed By: � .� C� ,� ---r Environmental Health Specialist's Signature : ,/`T%%`Y �� Date: �'-�9"/�v DCHD OS/99 (Revised) , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87C,0 IMPROVEMENT/OPERATION PERMIT Account #: 990003388 Biiled To: Alexander Carswell Reference Name: Rex Proposed Facility: Residence Tax PIN/EH #: 5747-83-0366 Subdivision Info: Location/Address: Deadmon Road-27028 Property Size: .0948 acres **NO"1'E:�*'This�mpro4eme dOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALJTHORIZATION 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 ._� #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 Wastetivater Flow (GPD) �� Site: New�Repair ❑ � System Specifications: Tank Sizei� GAL. Pump Tank GAL. Trench Width ��Rock Depth%�� Linear Ft,� Other: �n .1969(5) acCepted Systems may also be used Required Site Modifications/Conditions: I1�9PROVEMENT/OPERAT[ON PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF G`° BELOW FINISNED 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►)751-87(0.**** Environmental Healt DCHD OS/99 (Revised) Date: �/✓/�/� ; _ � • ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D�� 2� ounty Health Department �-� �E�vi zental Healtli Section P. 848/210 Hospital Street -�}U�J � 2 2�Clo �ks`'ine, Nc z�o2s (33 8760/ Fa (336)751-8786 a+Y�Ror�� , , Application Foi ite Eval��ment Pe 't Authorization To Construct(ATC) � Both ***IMPORTAN7*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Contact Person ��r ��' N K�""'"'� Billing Address e > ` � Home Phone `; �l -- � S � — S�S Z � City/State/ZIP � �'i t _ � S �', �,��/,% ��j'),��Business Phone '��T �-- ��6 ��/_ 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. (Pernvt is a�6��h� with site plan, no expiration wit om leteplat.) Street Address �(?� � City : � ✓i ��e- Tax PIN# �%�%�3— (�(p��_ Subdivision Name Sect�on/Lot# Lot Size ��-%G./� _ _ Directions To Site: Q .f,/7U _ DR/f� ��lZI�`(i .��5 �IeQS� RGYI �5i d� D/l/ Date House/Facility Corners Flagged — - ` If the answer to any of the following questions is "yes", supporting documeri�ation must be attached. Are there any existing wastewater systems on the site? ❑Yes L7N Does the site contain jurisdictional wetlands? ❑Yes C?'1�10 Are there any easements or right-of-ways on the site? ❑Yes C3�No Is the site subject to approval by another public agency? ❑Yes C7No Will wastewater other than domestic sewage be generated? ❑Yes 8No � IF RESIDENCE FILL OUT THE BOX BELOW # People _�i # Bedrooms # Bathrooms _ _ Basement: OYes '�No Basement Plumbing: ❑Ye�o _ IF NON-RESIDENCE FILL OUT THE BOX BELOW Garden Tub/Whirlpool �1'es ONo 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 Typesystemrequested: nventional ❑Accepted OInnovative ❑Alternative ❑Other ` Water Supply Type: 0. County/City Water •• ❑ New Well ❑Existing Welf ❑ Coirununity 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 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 1 am responsible jor all charges i�sccn•red from this application. I he��eby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and rules on the above described property located in Davie County and owned by e�/3'YY1Q _ (�vt.c,�.o�r � 1. X� n .� �Property owner's or owner's legal represent ' -e x-l�-��.�--'�'— Date Si�n givcn Yes ❑No Revisc;d 2/06 j�jD �r►� � Siie Revisit Charge Date(s):_,__ Client Notification Date: _�_ EHS: Account # �y��__ Invoice # 0 ! � � . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT : � � '� � Davie County Health Department En vironmenta/ Hea/th Section � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL �fi II��,`t�� INFORMATION IS PROVIDED. Refer to the INFORMATION BIILLETIN for instructio 1. Name to be Billed C e• c�l.� �� Contact Peraon `,,1 Y3- 5 � Mailing Addresa � /v � Home Phona' /ii �/ City/State/ZIP ��-'/L l� �/Ua' O Businesa Phone 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: �Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. syatem to servicez ❑ House }�Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type aystem zequeated: ❑ Conventional ❑ conventional modified ❑ innovative 5. If Residence: # People �_ # Bedrooms �� # Bathrooms '�; 7 a. 9. ❑Dishwasher ❑Garbage Disposal ❑Washing Machine If Buainesa/Induatry /Other: verify type, ❑Basement/Plua�bing ❑Hasement/No Plumbing # People # Sinks # Commodes # Showers # Urinala # Water Coolers _ IF FOODSERVICE: # Seats Estimated Water Usaga (gallons per day) Type of water supply: County/City ❑ WHll ❑ Community no You anticipate addi iona or expansions of the facility this system is intended to serve? � Yes �o If yes, what type? ***IMPORTANT"�'** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: _ a�. _.�C / �e�� / Tax Office PIN: # � 7 �7_ � 3 ' � � �+ �' _,,;�..--- Property Address: Road Name :;�_ f�� , c�tyizip G DU.`.��.� %i/C �?d� If in a Subdi ' ion provi �nformation, as follows: Name: " Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners flagged: �a �� y � This is to certify that the information provided is correct to tl�e best of my knowledge. I understand that any permit(s) issued t►ereafter are subject to suspension or revocation, if the site plans or intended use change, or if thc information submitted in tl�is application is falsified or changed. I, also, tutderstn�:d tliat I ani responsible for all charges ii:cirrred fro�n t/tis applicatio�r. I, l�ereby, 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 the site suitability. DATE �D � �V — D 4 '� SIGNATURE �— 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). Site Revisit Charge C��— �s�-�� Sign given �� Revised DCHD (OS/03 Date(s) Client Notification Date: EHS: Account No. � �O Invoice No. �� 2. �, C . i � � , . , . . t . �. ' ; a � � 1 T x. ( q . � . .' L f Y� � � i . ` ; , r �. 4 � � �w �`��<��'4.�e � s • �. . �� d� ` �5 .t�c'r :,r �s?_•'', ��.-1 , . � +rL ~� . . . P h` i L Kw r„ ' . ... 5 . K . ..,T ..�; M., k . ` t _ � +� � �T. . ._.. � ✓ ' � ��rf t : \ i; ; f t f { Y ) L ^� j ! Y x , � ` . f �� ~ `y .� _ `T ` r ' .-�.: 't • v♦ �ii . . � �. . I�. s r, '1 . Y `. > t ' i � z �{ � ` h . . . ., . ' � :-, L�.. . t .: ) _ . ?'� � . s .y :/ . , • r , i .. . . . : , . .. ,.. y z. . . L.'i ... , � . .:j }' . , . . _ . . . . . . . . . . _ ., � �. t . � ' . . , t, . � _ . ' +,. . . . . , � . . . . � t. �a . `{ . .. ' . ' . . , �� f ' X' . w y . . � '� ` ' . , .' . . . . , ' , 'y, i. _ _ .. . . . .. - , .:,.. , �, ' � ' _ ,. .. • , , .. + • .. . , , . ,. , _ , . ,. , . , . . . , . , • � .. . , -. + . , . . . �: - _ . . , • ` .. . . , . - , . . . . , �• _ . , ,, , . .- . :, o ; � � . .. .. ,,�^ . . • •• ' • . �'i.. . . ' � .. � . . ' ,. . ` , . - . . .. . . � . , • � , . . _ . �c . . ,. . ' _ ' ' . . . . _. � , . . . , } . . . � . . . �. , , . . � ' .. � - ; � � . + . ` . . . IRs . . �,2 � .. t . . . _ , . , . . P1at�ted�Sto[ie Fnd . ' • . ._ . . "`""�' . . . ' , . � . � � ' � . ' ' , �: � '. • . �. . ' �Parcel 1 � �. � � � , . ; �:Tax �t s� ;`:' :: Part `of Tax Lot 49 • � ' :Tdx`: �Aap K-5 ' �:. ; ; n/f :Jotu� � Hugh Gcaves . Tox MoR:K-5 .�.� jS. ' , ., DB 188 O PG 507 . 0.948 Acres .+ c'' . � • - . /= � . . - �11 � ' � � . . ` . � • . � `• � , . : . , -. . : . . : . ' -� � . ... . , ' - . ' . . - ~C 4 � � , I . , '.� ' ' . , . ,. ' . , . Parce� 2 -. ,�s , ; : . . . � �, ; � 1 Part of' Tax � Lot 49 . . " . . ' per :, cn Tox ;MaP. K 5 . ._ . P9 3 O PG 45 ' 0.512 Acres + � r- x ,� - . . /_`� i � ..—wor.n wins F«,ce ` �. ` . cA � . ' � � . . . . `Q - 1�`'`+ . . Houae .� ' : ; � IRS • x . . , . : . \ ' ��6 A ` `, ' ' • x . ' ' ; .� ' - �Rax Fenc+ . , �.'. • •• - • _ �` 1 . X' • . . � � ' . �� •. . ` � � � • � ��: : � � . . . `` ' _ . . . . . ' . . . - . . .. ` ` 0 ' DAVIE COUNTY HEALTH DEPARTMENT � ' • . Environmental Health Section `N • ' Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003388 Billed To: Alexander Carswell Reference Name: Proposed Facility: Residence Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5747-83-0366 Subdivision Info: Location/Address: Deadmon Road-27028 0948 acres Date Evaluated: //lI�Y Water Supply: On-Site Well Community Evaluation By: Auger Boring � Pit Public r% Cut HORIZON I DEPTH Texture group Consistence Strvcture 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 ACCEPTAr SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R- Ridge S- Shoulder L- Lineaz 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 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 - gaUday/ft2 DCHD OS/99 (Revised) � ■ ■ ■��■ ■��■ ■��■ ■�/�■ ■�■�■ ■�■�■ ■■ ■■ ■■��■�■�■��■��■ ■■��■��■��■ ■■■��■��■��■ ■��■��■��■��■ ■��■■��■■��■�■■��■��■��■�■��■�■�■��■��■��■��■��■�■ ■��■��■�■�■��■�■��■��■��e�■��■��■�■�■ ■��■�■��■■\��■��■■��■■��■��■��■��■■��■■��■ ■�■��■��■��■��■��■��■�■ ■��■��■■�■��■■■��■■�■�■��■��■■��■�■��■■��■ ■��■��■�■��■■��■■�■��■�■��■■�■��■��■ ■��■��■��■■��■��■�H■��■��■�■ ■��■��■��■t��■�■��■n■��■��■■��■�■■■�■■�■�■■ ■��■��■��■��■��■�■��I.y�s��'A7�■��\��■■■��■ ■■��■■��■��■��■��■��■�'�J��A�■��■■��■ ■■��■�■■��I�1?�I■��■1%11��■��■1��1�!i��■��■■ ■■��■�■�■��■��■�I[U��1�1��■��■7��■r��■��■��■��■ ■��ei��i�n��ri��■ ■��■��■��■��■■��u■��■�■��i��■��::__:�■��■■��■ ■■��■�■��■�■��■■��i�■��■�■ ■��■��■�■�■■��■ ■��■�■��■�o■�■�i�■��■�i��■■��■��■��■■��■�■ ■��■��■��■��i�■��■��■�i��■��■��■■��■■��■��■��■ ■��N��/��I��I"l��■��■��■ ■��■■��■��■��■��1>��I�!�C�i�.:��■■��■��■��■■■��■ ■■��■�■��■��■��!�i��■��■■��■��■��■��■ ■��■�■��11��■��■��■��■��l��■��■ ■�■��■��■I1��■��■ ■��,��■��■��■��■ ■��■��■■��■��■■�I\■��■■ ■��I■��■��■�■��■��■�■ ■��\��■��■�■��1��■��■��■�I��■��■��■��■��■��■�■ ■��■�■�■�■��■■11■■��■■��■�■■��I■■�■��■��■■��■�■■ ■■�■�■��■��■�I�■■��■��■��I��■��■��■■��■��■ ■��11��■��■��■��■ ��iiiiiii:��■�■��■��■�■��■■��■��■ -��■■��■��\■�■��■■��■�■ ■��■��■��■��■■:ii��■■�� ■��■��■��■��■��■��■ ■��■��■■��■■■��■��■��l��■��■��■�■��■��■��■��■■■��■ ■��i/�l��■��■��■��■�■ ■��■��■�■��■��■�■■��/��■��■��■��\■��■��■■��■��■��■�■ ■��■��■��■��■�■�■V■��■��■��■■■��■��■��■■��■■�■ ■��■��■■��■�■��■��■■��■��■��■��■��■■��■■�■ ■��■��■�■/■�■��■■�■��■■��■��■■��■��■�■ ■ ■�■■■ . _ • ; . . • � , _ ..�,�,.,.-...��.�,. ,.�-. . , . �� .,..�...� ��"��W:� �:t�..�.��:.�..�._ ,�.. .°��k�g� CE�UIVT��I�T�I��Z��i�'Tl��l�'f �.=��,.��.. ° >� �� Environmentai Health Section � P. O. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 � � .. . . . , � �� .:(336)751=8760 �' , . , '� November 4, 2004 Alexander Carswell 1346 North Main Street Mocksville, NC 27028 Re: Site Evaluation/ Deadmon Road Tax Office PIN: #5747-83-0366 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, November 3, 2004. 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 have any questions, please feel free to contact this office. Sincerely, ��!��8, �/�1�,. Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s) .� � , � e County Health Depart�nent �ronmental Health Section P.O. Box 84$ 210 Hospital S t�-eet Courier # : 09-40-06 Mocicsville, NC 2702$ rjC��/ �11i - //l�� :: (336) -�3''3- 67$0 ;, Fax: (336? - 753-1 G80 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection 1ame: �� s��/ •' Phone Number Y✓/✓ j�i Home � ) vlailing Address: /f 2� � ��% �� 4 G�� (Work) �i �� Property Address; �� jp`j %�� r}'IDn Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: � 1�"��/+�(i� � Type Of Facility: ��rn � �` �� Date System Installed (Month/Date/Year): . Number Of Bedroorns: �Number Of People: Is The Facility Currently Vacant? es No If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: �C�I � N Number Of $edrooms:� Number of People ,Pool Size: ge Siz Requested By: ( igna re) App/ roved � Comments: Environmental Health Specialist Other: Date Requested:_ For Environmental Health Office Use Only Date;�Z�ZZIZ<-"� �' ,�— �'• " '-- ��-� ��•�;Y�nmPntal Health Staff is in no way intended, nor sho«ld be taken as a gtiarantee