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1235 Farmington Rd' �G1�• L � 9 `Gb DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900035 Tax PIN/EH #: 5841-59-8230.01 Billed To: Richard Short Subdivision Info: Reference Name: Richard Short Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 10.5 Acres ATC Number: 2446 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW FGN IS ALID FOR A PERIOD/OF FIVE YEARS. Environmental Health Specialist's Signatu e: A= Date: G t!p CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indi has been installed in compliance with Article 11 of G.S. Disposal Systems," but shall in NO WAY be taken asa, given period of time. / b1-Zo Septic System Installed By: Environmental Health Specialist's DCHD 05/99 (Revised) m descri on Improvement/Operation Permit OA, S on .1900 "Sewage Treatment and that a system will function satisfactorily for any tj 7 7 Lkv-mt� t' --T Date: . • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section DA, to -19-Ob • P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900035 Tax PIN/EH #: 5841-59-8230.01 Billed To: Richard Short Subdivision Info: Reference Name: Richard Short Location/Address: Farmington Road -27028 Proposed Facility: Residence Property Size: 10.5 Acres ATC Number: 2446 **NOTE** This Improvement/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 VSE #People 2 #Bedrooms 3 #Baths -2— Dishwasher: Dishwasher: e Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply tAV--L ._ Design Wastewater Flow (GPD) Site: New 2" Repair ❑ tr System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width Rock Depth /Z � � Linear Ft.6W Qi Other: -2_ (6 , fNSTAu--t'Jc'S j O.C. Mtn . Required Site Modifications/Conditions: IN)5TALL- p,J C y4 -W 0Q , kA�P lOv' Wim, Kad 5d OFG dPax IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this s tween 8: m. to_9I3SR.m or 1:00 p.m. to 1:30 p.m. on the day of installation. Tel hone # is (336)751-8760.**** 5E o Gn2w�, a�T 'n G j �G Z Al 910 L �`z D o_ Environmental Health Specialist's Signa e: Date: [JI -6 OLD DCHD 05/99 (Revised) • c rrr� r CC�CE�M APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Health Department Environmental Health Seddon I M, P.O..Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. A 1. Name to be Billed J / f Contact Person ' /27 ei Mailing Address d Q a Home Phone City/State/ZIP .fi ✓f,n�t� )e— /W Business Phone 2. Name on Permit/ATC if Different than Above c Talz' <—, Mailing Address 3. Application For: ❑ Site Evaluation City/state/Zip i 15 rovement Permit/ATC ❑ Both 4. System to Service: "use ❑ Mobile Home ❑ Business ❑ Industry 0 Other 5. If Residence: # People CL # Bedrooms # Bathrooms -2— hwasher ❑ Garbage Disposal J�148hing Machine ❑ Basement/Plumbing p Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Cho 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. / n Property Dimensions: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # �' y/��`� - $fid . OD/ r i /f>�S� PAr'11i.�.�r; Property Address: Road Name M. b!1) i C City/Zip t5 r-1, rm If in a Subdivision provide information, as follows: Name: Section: Block: Lot: fo Date Property Flagged: ©-9 free 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 D ounty H a.Depart ent 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 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 Date(s): Client Notification Date: EHS• Revised DCHD (07/99) Account No. Invoice No. ��� 1� r. APPUCAMON FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT -• , ! Davie County Health Department Environmental Health SeWon _ P.O. Box 848/210 Hospital Street Vockaville, NC 27028 1336)751-6760 EiIVIRONIAENTAL HEALTH `4**1'WCRrAHT*** THIS APPLICATION CANNOT BS PROCESSED UNLESS ALL ^RE INFORMATION IS PRMI�D'ED�. 'jRefer to /thee INFORMATION BULLETIN foor� instructions.. 1. flame to be Billed Gt,t� 1 ff nllC�.i'- t: Contact person( q Mailing Address r �-7 / ] • O—l�� �b/a n Baoe phone 336 /p%' city/state/Zip A cl an e,P , ./Irt' a --700 Business Phone 2. Bane on Permit/ATC if Different than Abavet,_-/"; /� e en n e�z� Mailing Address ,17)0 -fn e- 3. Application for: to Evaluation a. system to service: 511rouse 0 Mobile Home S. It Residence: # People City/state/Lip 0 Improvement Permit/ATC 0 Both 0 Business 0_Industry 0 Other # Bedrooms 1 # Bathrooms 0 Dishwasher 0 Garbage Disposal 0 Washing Machine O Basement/Plumbing 0 Basement/Bo Plumbing 6. if Business/Industry/other: specify type # People # Sinks # Coas,odes # showers # Urinals # Water Coolers Ir FOODS'i:MCE: i Seats Ratimated water Usageetgaiions per day) 7. Type of water supply: 0'C-0'U"n ty/City 0 r R -W6] 1 0 Community e. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes 0 No If yes, what type' _ ***1MP0RTAN7*** CLIENTS AlUSTCVJ1PLEIETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBhIITTED by the client with THIS APPLICATION. Property Dimensions: r� WRITE DIRE ONS (from Mockr4lle to PROPERTY: Tax Office PIN: 0 _ Y �- �3�,Q��� Property Address: Road Name /%71.L/ n d City/Zip _Ar y a— dy '/S ke). L c-� e_, If in a Subdivision provide information, as follows: Name: Scion: Block: Lot: Date Property Flagged: "This 6 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 reiponsible for all charges incurred front this appUcadon. 1, hereby, give consent to the Authorized Representative of the Da p County Heallb Departm t to enter upon above described property located In Davie County and owned by a E_ to Conduct all testing procedures as necessary to determine the site sum ty. DATE _ _._ —7? SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PIAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. J5-y�4 Revised DCHD (07/98) Invoice No. %Zs� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME (01� 1 L I,Zv^-V-, rr PROPOSED FACILITY ti'tl 0 SUBDIVISION Water Supply: On -Site Well Community Evaluation By: Auger Boring ✓' Pit SECTION LOT DATE EVALUATED PROPERTY SIZE - %5 e� �3 ROAD NAME , — �f �"� 0 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH 0-10 04 Texture groupV L Consistence $ se k sssy5S5 Structure " -neI< IL Mineralogy ti4-'prA .X C5 1M X� HORIZON II DEPTH 14 to- Z -o -1 Texture group Z G G Consistence ; S 'F? S 49 Structure lL Sbk !SGV - Mineralogy M 1l001 (n i xc, V M 1 HORIZON III DEPTH I 20 - 30 1 t4 - Z4 Texture group LtS C_{ G Consistence F-. S K F,- 'S VF 1/ Structure v_ 6k I►/1 Mineralogy M t Y ---D Z 1 HORIZON IV DEPTH *2>2 30 Texture roup 1p Consistence I= V Structure MineralogyZ` 2` SOIL WETNESS RESTRICTIVE HORIZON 14 SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: v•y REMARKS: SaAu. "/y QL i✓aJr LEGEND DCHD (01-90) Landscane Position EVALUATION BY: s)661� IjS2�a OTHER(S) PRESENT: 6411 - 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 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 SC - 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 Davie County Wealth Department Environmental )Yealth Section Po sox 848 / 210 Hospital street Mocksville, NC 27028 Phone: (336)751-8760 June 2, 1999 Gail Bennett 117 N. Claybon Drive Advance, NC 27006 Re: 3 Site Evaluations - 13.87 Acre Tract/Farmington Rd. *Sites #1 and #2-5 Acres Each *Site #3-3 Acres Tax PIN: 5841-59-8230 Dear Mrs. Bennett: As requested, a representative from this office visited the aforementioned site on May 28, 1999. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, Sites #1 and #2 that have frontage on Farmington Road were found to be provisionally suitable for the installation of oversized, modified on- site nsite sewage disposal systems. Please be aware that house location may require setting a lift station for the on-site wastewater system. Site #3 was also evaluated May 28, 1999. This tract was found to be unsuitable for the installation an on-site sewage system for the following reason(s): Rule .1943 - Soil Depth; Rule .1944 - Restrictive Horizons. Due to the limitation(s) on these sites, this office is not aware of modifications or alternative measures that can be implemented at the present time to upgrade the classification from "unsuitable" to "provisionally suitable." Your application for Improvement Permits must, therefore, be denied. You have the right to an informal review of this decision by the Environmental Health Director of this office and also by the regional staff of the Department of Environment and Natural Resources. You should contact this office to arrange for this further review. You may also wish to obtain the services of a private consultant to collect site- specific data and submit such data and a system design to this office for technical review. A site may be reclassified to provisionally suitable provided written documentation, including engineering, hydrogeologic, geologic or soil studies indicates to this office that a proposed on-site sewage system or a proposed alternative system can reasonably be expected to function satisfactorily. The substantiating data from these studies must indicate that: A) The effluent(wastewater) will receive adequate treatment; B) The effluent(wastewater) will not contaminate any ground water or surface water; and C) The effluent(wastewater) will not be exposed on the ground surface or be discharged to surface waters where it could come into contact with people, animals or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition for a contested case hearing with the Office of Administrative Hearings, PO Drawer 27447, Raleigh, NC 27611-7447. A copy of a petition form can be provided to you on request. The petition must be received by the Office of Administrative Hearings within thirty(30) days of the date of this notice. The hearing may be held in Davie County. If you file a petition for a hearing, you must send a copy of the petition to 1W. Richard Whisnant, DENR, Office if General Counsel, PO Box 27687, Raleigh, NC 27611- 7687. If you have any questions, feel free to contact this office at (336)751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section enc(s) IN;