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942 Farmington Rd" • , n .. 1. - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 -t f q - I Account #: 990002675 Billed To: Larry ' hael Reference Name:-/.------) Proposed Facil�Residence ATC Number: 3405 Tax PIN/EH #: 5841-75-3686.01 Subdivision Info: Location/Address: Farmington Rd -27028 Property Size: see map 161 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 VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: iE1-�� Date: y `6) /_0 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. l 00 eIA6--4� 0 S Septic System Installed By: Environmental Health Specialist's Signature: A I Date: DCHD 05/99 (Revised) -•n DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street /A- ' Mocksville, NC 27028 •�� (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990002675 Tax PIN/EH #: 5841-75-3686.01 Billed To: Larry Michael Subdivision Info: Reference Name: Location/Address: Farmington Rd -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3405 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 BEFO) STALLING SYSTEM. Residential Specification: Building Type TJ #People #Bedrooms t/-4413aths Dishwasher Garbage Disposal: ❑ Washing Machine.;2 Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ e Lot Size tk Type Water Supply b Design Wastewater Flow (GPD) -�20 / Site: New;2r Repair ❑ System Specifications: Tank Size /OGb GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width Rock Depth Linear Ft 4 49 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 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.**** r Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) r PLICATION FOR SITE VALUATION/IMPROVEMENT PERMIT Davie County Health Department 1 � •�� Environments/ Health Section I "� f_tV1ROPIM;E.NTAEH� STH P.O. Box 848/210 Hospital Street NC 27028 4 fVVU�\FMocksville, (336) 751-8760`Ty ---***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 z"'eVZA% ML Contact Person Mailing Address /]/J yzz"6 �/ Home Phone �:�—g77-'QP%3 City/State/ZIP �{ S(/, � �%�Qa 3 Business Phone 2. Name on Permit/ATC if Different than Above,6fJ17 / Mailing Address City/State/Zip S,g/17,E 1 l- 3. Application For: ite Evaluation ❑ Improvement Permit/ATC Both i 4. System to Service: House ❑ Mobile Home ❑ Business El Industry 1 Other l'k'�J 5. I -'3' f Residence: # People # Bedrooms# Bathrooms %(1/Dishwasher ❑ Garbage Disposal [?(Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type` # People # Sinks # Commodes /_ # Showers # Urinals # 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 XNo 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: m� Tax Office PIN: # � y i' -7 5-3 6o4 � • O Property Address: Road Namc,�/%%i%r� City/Zip��'eL� i(/. ( . If in a Subdivision provide information, as follows: Name: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Section: Block: Lot: Date Property Flagged: ' 5� l/ 3 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 D�epartmf t to enter upon above described property located in Davie County and owned by vlGi 7 / to conduct all testing procedures as necessary to determine the si iitab_Uity. 111111 1F '1111111 1111111ill PM K 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). r' MA, R 2 G 2003 DCHD (07/99,Revised �� EN'JIRONMEPTAL HF1tLTH DMIE COUNTY ot�6� Cts Site Revisit Charge Datc(s): Client Notification Date: EHS: / Account No. Invoice No. 3 yy 1 3 ail 0 209 cm rn 1.000A N 0 1277 N 209 N w N (430) N A O 2.000A 1612 454 N w 0 402 U' 405 (1.77 A) 5115 418 N (1.96A) 5078 rn 7.27A 1786 co 0 rn (32.91 A) 4249 11.001A 3995 2128 2178 a� J50000003003 5841753686 14.967A WA )- evJh 3686 14.62A 3383 5.18A 3067 15�5 1843 0 0 (1110) 'APPLICANT INFORMATION Account #: 990002675 Billed To: Larry Michael Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation On -Site Well Auger Boring_ Property Size PROPERTY INFORMATION Tax PIN/EH #: 5841-75-3686.01 Subdivision Info: Location/Address: Farmington Rd -27028 see map Date Evaluated: Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 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: REMARKS: EVALUATION 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 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 DCHD 05/99 (Revised) e . 1 HEALTH TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC 1 1V li_�,) oti' l_ Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 3: I ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Bii'led V Contact Person 1 / 1J lr`l ((XATG �1 Mailing Address r (J 1 h0 & 0^3 'l Home Pho e jam) / % �—I -:2 �J / City/State/ZIP / y ot% V sings SPhon �3/0) % 15 }CJ 2. Name on Permit/ATC if Different than Above A S A-8,by �-� Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Y, Improvement Permit/ATC evBoth 4. System to Service: 1l3 House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # BathroomsZ El Dishwasher CI Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers 7. 8. IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) Type of water supply: K'County/City ❑ Well Do you anticipate additions or expansions of the facility this system is intended to serve? POSSiGLe_ If yes, what type? iy U (�S -kry El Community ❑ k6slC❑ No I***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: /l~/EZ31 S4=C61 __S'8y I -- 2 S-_�? � S � /QQ Property Address: Road Name f—AeA&•��X' City/Zip If in a Subdivision provide information, as follows: Name: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Section: Block: Lot: Date Property Flagged: Q �d 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 to conduct all testier procedures as necessary to determine the site s ' dity. j 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: Account No. 1 Revised DCHD (07/99) Invoice No. A. r ''' G� t� 7 APpIICAiION FOR 6t1'P EVAl1)A'nowiMPROYEMENT PEarr fit ATC C�l Davie County Health Department l• 11''. EnWmnmenta/ MmIdr $&Wbn Y.O. sox 040/210 Hospital Street Moakovillet NC 27020 (936)751-9160 15? OU E D 0-7 3.,00 ***n0Cat=WX*** sass "PLICA -Z-10" CiunWr = sR0=88= U=ss ALL Ttsm mauxnxn Iri1on&TION IS PROVIM. Refer to the INI"O1tI UZOH BU=TIH for instruotions. contact. 2,6266A�— (//�..TJU 1. Nage to be sL11.d McLlLise addr.me Li l'� ve Yl Rom >w up1 19tl on -S3 cLty/state/axx► W—S ,, nl C 91102 aueie.e..iso,. f��7 q �{. ` 9 e. Neale on v arlt/arc La niteeraat thea abere ttaiiinp Addaees char/state/alp a. Application cors GK it;.e 'valuation 0 improvetsent Yerdit/Ams ❑ Roth e. ares:.s to aernioes 8'1touse 0 Mobile Home 0 Business ❑ Industry ❑ Other a. If.Residences MM People - 4 Bedrooms _ + B-atthhrooms U'DaWaSbur l9�aarbape bLapo.al �Ri hien Ilaobine o V..tJV.1.t . q,iaaia V.. 11...bind s. If suaiMea/Snduetxer/otAest specify type I "to i sink. commodes 0 sswMeaa M Dsinel. � _ ! water eool.ra Ir rwolERVICB: N seats Estimated Water Usage (capons p.r day) 7. Type of Nater attpplys A-66.mty/City 0 well ❑ Community e. no you anticipate additions or expanslons of the facility this system h Intended to serve? B'fres 0 No If yes, what tytset , Li W1 4 0.QQ� • SO Ym2 ***IMPORTANT*** CLIENTS bfWCOMPLErSTHE REQUA[ED PROPERTY INlrORMATION REQUBB7'ED BEIDW. Either a PLAT or SITE PLAN MUSFAESEMUnTEi1 b the sliest with TtlIS APPLICATION. NN Property Dimensions: , lWgo� / O - / 3 /�C- WRITTEE�D• iR�ECTtONNS (ftvm MocltM le)� to PROPERTY FRVK =" q0 AN a S01 Tax Office PIIVc i .S 8 y 177 to 3 o I ' 1rr 1� t� ' _1151J �,T�s � Property Addresst Road Name F6 AaK, r1 s�� n 9 U GL citylzIp If In a Subdivblon provide Intortsation, u followrs oibota Names $eetloss Blockt Lots bate Property FlagRsdt This b to certify that the lafbrmation provided b correct to the beet of my knowledge. I understand that any permit(#) Issued hereafter are subject to suspension or revocation, if the site plane or Intended as change, or If the Information submitted In this application b hlslfled or changed 1, sbo. understand that 1 am respoinibltfor all charges lncsrrtd f Yost tkb eppllcadox. 1, bereby, give consent to the Aui wh*d Representative of the Davie County 11"Ith Department to eater upon above described property located In Davie County and owned by to conduct aH testing procedures as necessary to detersebse the site suitability. DATE ' i — SIGNATURE f---= THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the foliowingt Existing and proposed property Una and dimensions. stmetura, eeibscka, and septic loctd wt ii APR 5 2000 ENVIRONP,9ENTAL HEALTH DAVIE COUNTY., Site Revisit Charge Dato(e)i Client Notification Datet G EHSs Account No. �v jol 1A 3. C, 4F 2 14.05 (5) 29.65Ac (32.75Ac) NI '%..,,7 I . 1 —3647 N.- 8 "2. S. R 143 2 :321 jr- N L LQL 67. n 20 WO 17 2Ac •A 2)9.22. I U-6 Ac toO A,44 9 Aj 4 9 23 479 u_D 17.01 449 A Mwz-,iv", it 44, i 6u?_ (37.5 Ac 0 (TR 24 29 'E Ac - a 20 Go 4AC cOta A 14 2�7 can rt cs ,g APPLICANT INFORMATION Account #: 990000765 Billed To: Carla Kiker Reference Name: Carla Kiker Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5841-76-3011 Subdivision Info: Location/Address: Farmington Road -27028 Property Size: 10-13 Acres Date Evaluated: /F -� Community Evaluation By: Auger Boring [/ Pit Public v Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 7 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: loe'oy'�--'--i "L.e' e2l !'/O 61, (� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: % OTHER(S) PRESENT: REMARKS: � �Gr �j�� 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 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 DCHD 05/99 (Revised) 4�` 6091 2A 250A 9030 9 n MRA) w rA 151 7 4.01 7955 9915 297 los ` Mac ChA 4 his 3692AI 203A/ q 4 w U 0.779 C A C' r 5115 � :l J > - h ' C. 1 EnB > 4 U L This map is for PERC TEST I d. and BUILDING PERMIT purposes ; only. The Davie County Tax Administrator's Office u anB2 assumes no liability for any information contained on this map 2 ArA w u, 5 � CL � Un ChA MrC2 01 (t96A/ GnB2 c 5078 ; 7 N ' a COUNTY-ID:125O0O0O030 7.. ` ) n ChA h ArA •�• September 08,1999 3:54 PM (2o.aoA1 ' 0699 EnC Parcel Identification Number 5841-76-3011 DAME COUNTY HEALTH DEPART14 M ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09.40-06 Mocksville, NC 27028 Phone #: (336)751-8760 October 7, 1999 Ms. Carla Kiker 413 Rivertree Lane Winston-Salem, NC 27103 Re: Site Evaluation/Farmington Road Tax Office PIN: #5841-76-3011 Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 6, 1999. 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 a modified, oversized 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, xog;*t Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/mp Enclosure(s) 4.18A- 400 . 8A4 4 � f � P11 i.. n ti N 5; � t r , y e 731 201 i 215 73i O a i V 27. 4p23 2 Ai}A 2 F, rill", 0 2.50A 4987 6. 15A 9915 , (2075) ✓ So l— a .r: ^.,.,a .ter••.. ch 'ga "s wel ✓i � ✓ ij s Y.F. f {46.59A} 4249 ✓Ya � . y � / 2127.93 Tot q ' 0 14.96A 3686 //&i �' ✓J / W . / O Oil m 'f4.62A 3383 pp pp �J 4 a�J 34 53 / Pl f l xs'a �g'g'•f•,, ae / w , ��tf 3067 77 (20.80A) 0699 30 (4.88A) 3434 '�� ✓fit .�'"'' � ��/„u;,.,;. � � (15.58A) 1242 �� „ 832 (230) (1.90A) L 0078 i (2.03A) 3692 209 N 1.000A o 405 1 77 97 2nq N 9177A No 51''15 m 0 (32.91A) 4249 w (429) N 1 1.001 A • 3995 N rn 2128 9519519 0 .. -� 5841/53686 452 l�, a� , �,r E50000003003 D 943 . , oC � i� 14.96A U p 3686 w 2.000A w 1612 i KIKER KENNETH B 454 �'_ 402 92 s C,A,�� USS Q.( o n IN e 917 X27 s8 �, 14.62A N (3.07A) • co 3383 1312 s rn90 0 418 4.94A 11 _ (lllp 934 ) s3 3.40 N (1.96A) 8182 5.18A W 5078 3067 7.27A 892 115j 75 1786 L /� N / /TSI A/.�e /� O C,�' �' • so DTT 7-7