864 Fork Bixby RdDAVIE COUNTY HEALTH DEPARTMENT o`-- `7_ 1 % —
Environmental Health Section
' P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 g�q q pk-eji}C&(Pd-
IMPROVEMENT/OPERATION PERMIT i� f
Account #:
989900079
Tax PIN/EH #:
5778-38-0039.01
Billed To:
Ronald Jones
Subdivision Info:
ince Name:
Ronald Jones
Location/Address:
Fork Bixby Road -27006
ped Facility:
Residence
Property Size:
30,000 sq. ft.
kNOTE* selmpro49ment/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.
Specification: Building Type 0 oc-,aL #People #Bedrooms 3 #Baths -2—
: Er Garbage Disposal: ❑ Washing Machine: M"" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Size Type Water Supply(!OkYr `e Design Wastewater Flow (GPD) 34Site: New 12Repair ❑
em Specifications: Tank Size OCCGAL. Pump Tank GAL. Trench Widtli ly" Rock Depth 12! Linear Ft. 3C0
l
Other: I �STPAf3,OTio.•-t �X,4 l��i., c�Lt,I1LS O.C. M,a,3
Site Modifications/Conditions:
S,o" l4bo57. kc-taP W opF facp-
)VEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6 "BELOW
IED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
betwe 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.****
i-01
L
(1 �
, Mw
vironmental Health Specialist's Signature:
05/99 (Revised)
Date: 9 (k o
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900079
Billed To: Ronald Jones
eference Name: Ronald Jones
P oposed Facility: Residence
ATC Number: 2490
Tax PIN/EH #: 5778-38-0039.01
Subdivision Info:
Location/Address: Fork Bixby Road -27006
Property Size: 30,000 sq. ft.
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
OTE** 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 CONST U IS V ID FOR A PERIOD OF FIVE YEARS.
ironmental Health Specialist's Signature: Date:
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 I I 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. I
Septic System Installed By:
Health Specialist's Signature :
05/99 (Revised)
5
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC P O V IE
Davie County Health Department D
.' Enviwnmenta/Health Se+ctlon
P.O. Box 848/210 Hospital Street NOV - 4 1999
Mockaville, NC 27028
(336) 751-8760
***nW0RTANT*** THIS I• YPLICATION C UMM BE PROCESSED UNLESS ALL THZ REQUIRED
INFORMATION IS PROVIrAD. Refer to the INH'OMMION BULLETIN for instzuctions.
D /I Qn .i1.
1. Na= to be Billed VI V rL&L< cy • V Contact Person
1
Mailing Address J- _ Boma Phone �o
city/state/sxp r� P %i -C Business Phone 90
2. am on permit/ATC if Different than Above
Mailing Address City/state/Sip
9. V cation For: 21Site Evaluation 0 improvement Permit/ATC 0 Both
4. system to service: W House . ❑ Mobile Home ❑ Business 0 Industry 0 Other
5. If Residence: # People # Bedrooms 3 # Bathrooms �O _
Dishwasher O Garbage Disposal vaahinv Machine O Bassmant/Plumbing C] Basesient/No Plumbing
6. if Business/Industry/Other: specify type # People # Sinks
# Commodes # showers # Urinals # Rater Coolers
iF FOODSERVICE: # Seats Estimated Dater Usage (gallons per day)
7. Type of water supply: M'County/Cit-y ❑ well ❑ community
9. Do you anticipate additions or expansion of the bellity this system is intended to serve? 0 Yes o
this
to e
to c
DA
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQU/RED PROPERTY IN GRMATICN REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
perty Dimensions: . 3 d e ob ge 0, WRITE DIRECTIONS (from Mockn1le) to PROPERTY:
C=c/
011lce PIN: # -6-9%�- 3 - Q d 3 �/ o -a�L
_
perty Address: Road Name -
, p f
City/Zip tE %% 7�Jd6 1�� -
�p
a a Snbdk pion provide information, as follows.. Oh
Block: Lot: Date Property Flagged: // -S -:V
Is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
d hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the Information
fitted In this application is falsified or changed I, also, understand that I ant responsible for all charges Incurred from
rpplicadon. I, hereby, give consent to the Authorized Representative of the Davie County Health 13jepartment
ter upon above described property located in Davie County and owned by
educt all testing procedures as necessary to determine the site suttab .
E �%' 'T /c 9 SIGNATURE Ct�
5 AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
erty lines and dimensions, structures, setbacks, and septic locations).
JUL 1 3 2000 (�
_ D
DCHD (07/99)
HEALTH
y �oL -
Site Revisit Charge
Date(s):
Client Notification Date:
EBS:
Account No.
Invoice No. lee S'
n ✓SQL .
ca-
0- a,o o
- — � Tmr Lot 79
P/O Tar Lot 80 I Tar hoop h7
\ Tor hoop 1-7 Ronald Bomsy
CB too O PG 74J
PK-No8 Found I
\ PK -11017 Set
in Awwlt Drive I 2&1/2- 93P
• Tato, L
S B7'iJ'55-E 467.20'
2241• \ Tar Lot 80
\ Tar Yap 1-7
780.62' \ and 11th 0 t
. \ Pauline D. Jones
OB 97 O PG 838
W-Mail
t S89.13J5E 275.88' 1'v/�
a ail.
\ N 21'S9'o
PK- Se IRS
e•• !% 278.0H'Tota1 S HE'0?'1-
197.8.:' 24638' Sava .aw.
N 86.38•-"c 31.50' °
1- EP u S 20.45'10"E�` IJ6.96•
1- EP o 78.19• Parcel 3 l— N i.. 2J'J5 N
Tax Loc 8201 �• \ Point 1.000 urea +/-
Tar Atop 0-7 it \
t n/f Dodd Ronald Lanning r"\ S 19'2A'70 --
and Wile :16.87' t 'iR5
:0-// Sonora Ann J. Lanninq\ `�•� \ g 95' Sato
(0 7J Acres me 684 $\ \ 30- aa ie�:E 2g',.0.
N••
1- EP 1' L7p Spire Set in Pine Stump
b 198.078E4,'00"w PK -Nae" Set
1 5 >r �
00,6.40'8`-"�' IRS S 19'35'55"E
'J'OD"W�jRS 198.09' i 5 8 25.00'
1- ufl
o—
518.70' N 87
Parcel 2 ` 296.39' \\
0.109 Acres +/- ` N 18•JS'...."»' \— S 21'14S -'
\\ 110.6E'
a ep •�
Tie Rod (Sent)
\
A65- AV
Ta: Lot 96
I t 5 6 115 Tor Mop 1-7
PK-Nac7 Sat ` \ .-\ n/f George Piazza
+/- \ and Wife
CL +/- SR 161 ; 1P,5-Placoa : Line Jib Pic=
OH 185 O PC 561
JO.23'
S i8108.10"E \
1so.3J• \ \\
PK-Ncii Se:
CL +,/ - S.R. 1611
1" EIP Found \ \ \
I Tar Lot 78
Tai hoop 1-7
I n/f L.B. 807ry
DB too O PG 745
1 5/8- ER 1- EP
S 87'72.40-E 259.14' 6
Parcel 4
16146 Acres r/-
1' EP by 5tone
in Base of Oak Tree
I
c
I
E7?6`- 38- 003 1
iar we t
Tar LI-8
ap
T-4b&r • um
87.41'20"£ 411.18' -
S 03'00'00-N'
559.93' Total
0
1' N 87'29140'"A L 5/8" E1R
Tor Lot 99
Tar Moa i-7
n/f Budais Foster
and Wife
Lok A. Foster
DB 186 O PG 1J5
51250' �
N 02'59'10-E
Ta Line
I
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900079 Tax PIN/EH #: 5778-38-0039.01
Billed To: Ronald Jones Subdivision Info:
eference Name: Ronald Jones Location/Address: Fork Bixby Road -27006
roposed Facility: Residence Property Size: 30,000 sq. ft. Date Evaluated: 9
Water Supply: On -Site Well
E ialuation By: Auger Boring
Community
Pit
Public Z
Cut
FACTORS
1 2 3 4
5 6 7
L ndsca a position
Slope %
H RIZON I DEPTH
T xture group
C nsistence
S cture
Mineralogy
HORIZON II DEPTH
T xture group
C nsistence
r -
S cture
b /L
Mineralogy
HORIZON III DEPTH
Texture group
C nsistence
S cture
M neralo
HORIZON IV DEPTH
Te ture group
C nsistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
C SSIFICATION
S
LONG-TERM ACCEPTANCE RATE
V t
CLASSIFICATION:
3 -TERM ACCEPTANCE RATE:
LEGEND
Landscaue Position
EVALUATION BY: _ �` KI,
OTHER(S) PRESENT:
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
05/99 (Revised)
V
DAVM COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P. 0. Box 848/210 Hospital Street
Courier #09.40-06
Mocksville, NC 27028
Phone #: (336)751-8760
November 17, 1999
Mr. Ronald G. Jones
185 Livengood Road
Advance, NC 27006
Re: Site Evaluations — 2 Sites
Fork Bixby Road
Tax Office PIN: #5778-38-0039
Dear Client(s):
As requested, a representative from this office visited the aforementioned sites on
November 17, 1999. Based upon the information provided on the Applications) for Site
Evaluation(s) and after evaluations were completed on the sites, both sites were 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 on each site.
If you have any questions, please feel free to contact this office.
Sincerely, p/
A4*e'
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/mp
Enclosure(s)
DISTANCE
48.04'
26.30'
PK—Nail Found
in Asphalt Drive
ea
Tie Line \
S 23°57'08"E
180.62'
2&1/2" EIP
0
Tax Lot 80
r
Tax Map I-7 CDW Part of Tax lot 82.03 I
n/f J. Wade Jones �
and wife Parcel 2
J I
Pauline D. Jones oS 88°38'37"E
DB 97 ® PG 838 w 56.77'
1/2" EIR L 1/2" EIR I
O PK—Nail Found
o_
-0 0
-)313
a� `
= O
k � �
W
.�3 � N -.A
END-,
R — Center Una
CL — Center Une
EP —FAv of Pavement
FC — Face of Curb
PP — Power Pole
ht Pole
H — n Hak
— Ro rus
CH — Chord Distance
P 0 — Part of
L-1 I
S 89°13'35"E 275.88' 1 & 1 /2"
22.1' 0
S o . nW
O UU"
u
�un9 Part of Tax Lot 82.03 � I
g Masonry !
Foundation Parcel
3 �
0.772 Acres
C�
PK—Nail 17,6' A. 9R
Found
286.25' S 86°��P�
Site
�a
a�
! Urengood Rd
�a11�+ RO SR 1810
't �e
Vicinity Map (Not to Scale)
NOTE:
This property is subject to all easements, right—of—ways,
streets and assessments, if any, as the some may appear of
record in the office of the Register of Deeds, Cleric of Court,
Town or County Tax Office or which may have been acquired by
prescriptive use. This survey is subject to arty facts that may
be disclosed by a full and accurate title search. NOT furnished
as of this date.
This map or drawing and any accompanying
documents are furnished to the person(s) named
thereon and no alterations or use by others
is permitted unless authorized by
Grey Engineering, Inc.
Map not for recordation.
Precision 1:10.000+
PK—Nail
` Foundation Survey:
Tax lot 82.02
Ronald G. wife
Jones
�
Tax Ma 1-7 and wI
n/f Barbara J. Lanning Sandra J. Jones
and husband
David Ronald Lanning Part Tax Lot 82.03
DB 205- -@.---PG 783 Taxx Map I-7
Deed Book 320 ® Page 74
• ' 0.772 Acres +/— by coordinate computation