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1099 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001265 Tax PIN/EH #: 5841-77-7913 Billed To: Charles Jones Subdivision lnfo:X%O g g Reference Name: Charles Jones Location/Address: Farmington Road -27028 M.- ..A r.. ..: C1... n --"i---- I 1UNU5cu racwiy. Residence Property Size: 4 Acres ATC Number: 2473 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 WASTEW RUCTION I VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: I **NOTE** The issuance of this Cert. has been installed in co(nl Disposal Systems," but given period of time. I - CERTIFICATE OF COMPLETION of Completion shall indicate the system described on Improvement/Operation Permit with Art' le 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and 1140 Ytakbn as a guarantee that the system will function satisfactorily for any �S t�p �6- > c"P� 00 P p,Y Septic System Installed By: 4'J P--) Environmental Health Specialist's Signature (' Date: o D DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT 1 t Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001265 Tax PIN/EH M 5841-77-7913 Billed To: Charles Jones Subdivision Info: Ir/Q ?-g Reference Name: Charles Jones Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 4 Acres ATC Nup�brr: 2473 **NOTE** This 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. Residential Specification: Building Type 140l% #People S #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: IR/ Garbage Disposal: M Washing Machine: d Basement w/Plumbing: M/ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industri11 fal Waste: Lot Size 41 WV -E -,-S e Water Supply�t( Design Wastewater Flow (GPD jCOC7 Site: New u Repair ❑ System Specifications: Tank Size 000GAL. Pump Tank GAL. Trench Width �(� Rock Depth 1 Z'r Linear Ft. &cu Other: �44-W Required Site Modifications/Conditions: I,457ALI, 04 C& f %OLle, 14OZ-0 %cS Drr / ( !, FL 60 t? rte' - i..IS 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.**** V) �i r Environmental ealth Specialist's we" - �PWW Q0L-- )CHD 05/99 (Revised) P2o$ ISo ?,�LL 5 pv1 VXJV4N _X o s O,T ,SSJI) _71tfO O 0 M�►� _ Date: C►� C "n) DAVIE COUNTY HEALTH DEPARTMENT �n d 7-11-0 v Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001265 Tax PIN/EH #: 5841-77-7913 Billed To: Charles Jones Subdivision Info: Reference Name: Charles Jones Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 4 Acres ATC Wmoer: 2473 **NOTE** isimprovement/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 INSTALLINQSYSTZM. AIJ� �! 67r Residential Specification: Building Type Hl7J�- #People S #Bedrooms #Baths Dishwasher: C'!r- Garbage Disposal: 19"- Washing Machine: 121 ",- Basement w/Plumbing: 121"�-Basement/No Plumbing: 13 Commercial Specification: Facility Type #People #People/Shift #Seats Industri] Jial Waste: Lot Size �A�-�S Type Water Supply C oyr-jW Design Wastewater Flow (GPD) 4�p Site: New 13Repair System Specifications: Tank Size1000 GAL. Pump Tank GAL. Trench Width3tj Rock Depth 1Z Linear Ft._&t)O Other: $d(1 ZSC.ta'S . 'Ji} �� PAN VALVE ' 40-1 )C'c-F MIX. uai Required Site Modifications/Conditions: I r�"�,L,l.. �J C.o�J I �s,J2, � `J t9f� 1.��, 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 gfiQstallatjo�. Telephone # is (336)751-8760.**** N !d VY ~ 0 0 - Environmental ealth Specialist's Signature: Date: 4 Oc7 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section %� P.O. Box 848 �>f' It (�% .�/ Mocksville, NC 27028 / 6 (704) 634-8760 W` /'YAf C1, ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed C7119k le e o76Are,::5 Contact Person �14AVk--� Mailing Address Home Pho/9 7to1 X4`-3 City/State/Zip '7&Z-3 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC XBoth 4. System to Serve: [ ] House [ ] Mobile Home [ ] Business [ J Industry [ ] Other 5. If Residence: # Peopled # Bedrooms # Bathrooms. a [J l Dishwasher [)c] Garbage Disposal [)q Washing Machine [X Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: N County/City [ J Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes Dd_No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: M 61 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # Property Address: Road Name lt:;411%7l/l i City/Zip If in Subdivision provide information, as follows: Name: Section: Lot #: 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 intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. 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 / —WL wwzlo / tt nduct all tessfing p edures as necessary to determine the site suitability. DATE � S- / }� SIGNATURE / /SG L /!f /�, Revised DCHD (06-96) 9/v JUN 15 2000 EliVIR10tV1E GOUPJTY L1M �`I b Z DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAMEne' ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE y%a� LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z �- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence ; Structure l MineralogyF 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:PJ�f L,�iC'/fQP/ 6-'� LONG-TERM ACCE_��'�A-1V�RA7-0 : � REMARKS: f� 71411 I C' DCHD (01-90) EVALUATED 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 ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V127y 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 3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralomy 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 ................................ .NOON..=SNC..................... ■■■■■■!■■!■■■!■■■■■■■■■!!■■■■■■!■!!!■■■■!�■■m_ E��=■!■�■!■■EEn0No ■!■■■■!!■■!■■■f■■■■■■!■!■MM■EE■■!!!!ElEE!!!l�t1EE■E ■■■■■■■■■■■■■■■■ ■■!■■■■■■■■■■■1•i■■■■■!■!■■■■MEM■ ■■■! 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EMMMME!!!■=■■!■M■ll.. ................�.......................... ..............................................................■■■O MEMO :::::::::::C::::::CC:.:::: :::::.::::::::::::::::::::::::.a ■■■M■■■■■■■■■■■M■■■■M!!■�NIN■■ ■■MO!l�OO�===»e!■lMis■■MM■■■■■■ 1 pp :; _, ��tS�F laity ,' 'ot. �� • 1 . y pp :; _, ��tS�F laity ,' 'ot. �� • 1 14.05 29,65Ac 187. 5 k> >� — — 31 2Ac 1.O3Ac y`� �'n k{ d� _fIs) I_ 176 A,,, A � j ". I `';.4 A,9. 22 {, �i 1 r-�I CP a kin,1; (12Ac�• , a y, Y4c- ! •` 4r e Y n``* i N' • 1 'TC (22� 500 2Ck3.2L 16 �,f �: — .........( � � L�" y �; .. ,. F � i '� � • 1, 5 + � WO �a 6 PUDDING ; RIDGES ROAD �. 10 11 r61o.51 n c 56 AC n k+ oo 14 � 11 , � � 3 -,Ilk ��r� ` �6 • •�' 6�1u N 1 5 At(; N N �'` rz ( I �� co ' a r t •� rt � �.e. >W. wy ' k° •1 _. y 15j -PI '''�) /� � �I ... i 0. 9 A, 14.05 29,65Ac 187. 5 k> >� — — 31 2Ac 1.O3Ac y`� �'n k{ d� _fIs) I_ 176 A,,, A � j ". I `';.4 A,9. 22 {, �i 1 r-�I CP a kin,1; (12Ac�• , II 4, N' • 1 k•R ` ,"� p r `�c "C N,+, ;�, (22� 500 2Ck3.2L 16 l .,-300� I 14.05 29,65Ac 187. 5 k> >� — — 31 2Ac 1.O3Ac y`� �'n k{ d� _fIs) I_ 176 A,,, A � j ". I `';.4 A,9. 22 {, �i 1 r-�I CP a Davie County Health Department and -Come Health Agency EnvironmentafHealth Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 September 26, 1996 Mr. Charles G. Jones 1436 Irving St. Winston—Salem, NC 27103 Re: Site Evaluation/Furches Estate Farmington Road/Mocksville Tax PIN: 5941-77-7913/4 Acres Dear Mr. Jones: As requested, a representative from this office visited the aforementioned site on September 20, 1996. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of a modified, oversized on—site sewage disposal system. 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) cc: Jesse Boyce, Zoning Officer 0A