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768-772 Fork Bixby RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900373 Tax PIN/EH #: 5778-26-8858.000E Billed To: Jackie Knight Subdivision Info: Reference Name: Jackie Knight Location/Address: Fork Bixby Road -27006 Proposed Facility: Property Size: ATC Number: 2103 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 WAST EW d ON IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa .- Date: �ZI 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 uar ntee that the system will function satisfactorily for any given period of time. r 10 'x `^••11 O � V 1 `3 0 t kir Q S ITS o Septic System Installed By: Environmental Health Specialist's S DCHD 05/99 (Revised) Date: 10 In k q DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900373 Tax PIN/EH #: 5778-26-8858.000E Billed To: Jackie Knight Subdivision Info: Reference Name: Jackie Knight Location/Address: Fork Bixby Road -27006 Proposed Facility: Property Size: ATC Number: 2103 **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 M, VW 'N-" #People 2 #Bedrooms 2 #Baths Dishwasher: 11 Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: D Basement/No Plumbing: El Commercial Specification: Facility Type #People #People/Shift Industrial Waste: 13 Lot Size Ni/--�� /� Type Water Supplr—,D Design Wastewater Flow (GPD) ,�.�#/IS''ea��ts 2� Site: New Repair 171 System Specifications: Tank Size IMOGAL. Pump Tank GAL. Trench Width:S(� ' Rock Depth �,Linear Ft.700' Other: I lh'51'b 6011 o e-�s Required Site Modifications/Conditions: ` V Id c(P— gypE. "4e. Fu-` rle�-) (1k• IiOAG S 1 oFf= IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Co resentative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a. • o t m. on the day of installation. Telephone # is (336)751-8760.**** 1 210, Tv 0 Pot lo! M1N I12c,P. L,►A Environmental Health Specialist's Signature: DCHD 05/99 (Revised) .4 Date: klq (336)751-8760 LI7� ***ZWORTANT*** THIS APPLICATION CAMM BE PROCESSED UNLESS ALL THE T-MQV11 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructiona. l. Name to be Billed , i (tf %0- Contact Person =..2. C.VF,C P Nailing Address k0, ox /S Name Phone 7'%0 -':�o�S--z" City/state/LIP ",� VR6lc p- NC. %0 0 U Business Phone y. Name on Pewit/AMC if Different than Above �arnc 4.5 Oho ✓i v Nailing Address City/state/zip `-- 1lva;aat-: a Both 4. system to service: 0 House Mobile Home 0 Business 0 Industry 0 Other s. If Residence: IF People _ 0 i Bedrooms _i2 _ 4 Batbrooma 0 Dishwasher 0 Garbage Disposal 0.1washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing S. If Business/Industry/Other: Specify type f People / Sims • Commodes i Showers 4 Urinals • dater Coolers IP FOODSERVICE: # SeatsEstimated slater Usage (gallons per day) 7. Type of water supply: Lha/County/City 0 well 0 Conmaunity a. no you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes 0' 0 If yes, what type' *".3fP0RTAN7"' CLIENTS MUST COMPLEMr." ".2 REQUIRED PROPERTY INFORMATION REQUESTED iBEIIM. Either a PLAT or SITE PLAN MUST BESUB1iMED by the client with THUS APPLICATION. Property Dimensions: 578'—Z�L'twojzTsn Office PIN- t3 Property Address: Road Name rc' k --6"y City/Zip ALuar o ;I-?n0b If in a Subdivision provide Information, as follows: Name: c Section: Block: Lot: Date Property Flagged: j Z 4 - .a -� This Is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit($) rued hereafter ars subject to suspension or revocation, If the site plans or intended use change, or if the information sulimitted in this application Is falsified or changed I, a&-; !;nAawfand that J am reapomMlefor all charges irrcunrd f vm this application. I, hereby, give consent to the Authorized ..,presentative of the Davie County Health Department to enter upon above described property located In Davie County and owned by acv4, .4- Q CLrrMn : .70. )�n to conduct all testing procedures as necessary to determine the site suitability. .::+visna ur+.Z THIS AREA MAY BE USED FOR DRAWING YOUR SITE P (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and eeptic locations). Revised DCHD (07/98) Account No. -31.3 / Invoice No. # �10 ��a.%• ' I V D1 S• CD S, T 8858 Sys 187 (145) %V This map is tar PERC TEST and BUILDW , PERMIT purposes only. The I ie County Tax Admin ator's Office assumes n ability for any information stained on this map COUNTY -ID: 170000009701 January 19,1999 8:38 AM Parcelle ntification Number 5778-28-8858 I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME "4 l DATE EVALUATED PROPOSED FACILITY M, 1` PROPERTY SIZE SUBDIVISION Water Supply: On -Site Well _ / Community Evaluation By: Auger Boring Pit ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L e_ Slope % �p HORIZON I DEPTH J - Texture groupG z Consistence - 5 Structure tC Mineralogy HORIZON II DEPTH -4V Texturerou $C Consistence 19 r ' S Structure�'� ie_ Mineralogy ; HORIZON III DEPTH - D Texture groupts� Consistence 5 Structure k Mineralogy• f HORIZON IV DEPTH Texture group$: Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION (JS aE LONG-TERM ACCEPTANCE RATE '��E SITE CLASSIFICATION: �) t f�IEVALUATION BY: fit` I LONG-TERM ACCEPTANCE RATE:lW'� OTHER(S) PRESENT: J� —914A I t REMARKS: I�IAVn� �IL� Nd1L �t4�tl��£jS tNrilc�7� W164l- LE-A096W 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 - Subaneular blockv PL - Platy PR - Prismatic Mineraloa 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 - gaVdaylft2 DCHD (01-90) 1 . ■■ ■■ ■ ■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■ ■M■■ ■■■■� ■■N■■ ■■NEM � .o■■ SERIES ■ ■■■■MM■■■ ■■■MM■MM■ ■■■MM■MM■ ■■■M■M■■■ ■MMM■■M■■ ■■M■M■MM■ ■■■MM■MM■ ■MMMMM■■■ ■■MM■M■■■ ■■■■MM■■■ ■■■■M■M■■ ■NNOM■NN■ ■ ■ MONO ■O■■ ■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■►��■■■■Mirk■■■■■■■■■��!ii�� ■■■■■■■■■■■■■■ ii::.i■i'i■■■mo■Mom■om■ENNENMENNEN� ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ �■iii■i■■■■■■■■■■■■■■■■��■■■■■■■■■■■■■■■■■ ■ ■ r�f�iC�%■►■■■\1■�1■11■■�/f ■■ ■■ ■■ ■■ ■ ■ ■ Davie County Wealth Department Environmental Wealth Section Po Box 848 / 210 Hospital street Mocksville, NC 27028 Phone: (336)751-8760 February 9, 1999 Ms. Jackie Knight PO Box 15 Advance, NC 27006 Re: Site Evaluation -1 Acre Tract Fork Bixby Road Tax PIN #: 5778-26-8858 Dear Ms. Knight: As requested, a representative from this office visited the aforementioned site on February 8, 1999. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, you may contact our office at (336)751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section enc(s) f I