The URL can be used to link to this page

610 Four Corners RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Sectionf �/� �� • • P. O. Boz 848/210 Hospital Street / Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT t 990002051 582430-7261 Brenda Whitaker 610 Four Comers Road -27028 Residence _ see map 3053 **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 CONTR'AC/TOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _,M,#People .2 #Bedrooms _ . #Baths 9_ Dishwasher: xf Garbage Disposal: ❑ Washing Machine:, Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size _ jAc Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size/16_ GAL. Pump Tank GAL. Trench Widths o" Rock Depth Linear FfDD Other: Required Site Modifications/Conditions: 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.**** p� a S�r`l Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account 9: 990002051 Billed To: Brenda Whitaker Reference Narne: Tax PiPviEH Y : 582430-7261 Subdivision Info: Localion!Address: 610 Four Comers Road -27028 Proposed Fac lily: Residence Property Size: see ma ATC Number: 3053 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: G� 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 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," buts all�n NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: 6`%2 -E)L----, • do APPLICATION FOR SITE EVALUATION/IF�7PROVEI1fENT PERMIT� Davie County Health Department y QS Environmental Hearth Section V P.O. Box 848/210 Hospital Street NOV5 2001 Mocksville, NC 27028 (336) 751-8760 EI+YIRO,.:a,HFALTH r'-- � ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIREIi' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed &✓�"n (V /� r �C(if r Contact Person J-Wy� , Q� Pe �i Mailing Address 9 s(J i I a,} k -,P L Home Phone 01 City/State/ZIPS C./(Jt'�/ � h( �-� %(J Busin // essl) /rJ Phone / (a - �7 lam 2. Name on Permit/ATC if Different than Above �/� ►� I �S 'Q— �1 fa .t �— Mailing Address City/State/Zip 3. Application For:Site Evaluation ❑ I��Ccf& ovement Permit/ATC ❑ Both 4. System to Service: ❑ House tP Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms IQ O Dishwasher ❑ Garbage Disposal k7 Washing Machine ❑ Basement/Plumbing 11 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 )d No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # S$ ;a H - 3 U - 7 ;I �' ( Property Address: Road Name //'/L/) / 6 u r C3 d rye 'Q r City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: X�60/ / -to rn Irl t a � o, vni/.2 1-o Fau rCnt-m a Y4 IL_� - u r vi �t ,)'- ,fir , e_ ed- e vac f I -f 0/1' 1/ e Date Property Flagged: )/ /`/ 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 Die County Health Department to enter upon above described property located in Davie County and owned by eduja rd P -e -eJ to conduct all testing procedures as necessary to determine the site suitability. DATE /� /S 4 / SIGNATURE Z- "IrIA/kid THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and propose property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Invoice No. / is r� L9L9 V99'6' £5000000£8 RlT41•l l l i nPIZ- -- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002051 Tax PIN/EH #: 582430-7261 Billed To: Brenda Whitaker Subdivision Info: Reference Name: Location/Address: 610 Four Comers Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: //',2€"I Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupC 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: A4 /Z 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■eye■■■■■■■■■■■■■■eee■e■■■■■e■■■■■■e■ ■■■e■■e■■■■■e■e■■■■■■t■■■■■e■■■ecce■■e■■■■e■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■u■iii■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO MENNENMENNENMONESEMENNENiii iii■■■■■■�i■■■■■■ ■■■■■■ ■■■■■■ ■■e■■■■■■■■■■■■■■■■eee■■■■■■■■r�■■■■■:��■■e■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ecce■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■ �■■■■■■■e■■■e■■■■■■■■■■■e■■■■■■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ iii■■■■■e■■■■■■■ ■■■ ■■■ �'_--cj-e� -__ _. DAME couNn' HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Riocksvilie, NC 27028 Phone #: (336)751-8760 November 28, 2001 Brenda Whitaker 169 Biltmore Lane Mocksville, NC 27028 Re: Site Evaluation/ Four Corners Tax Office Pin: # 5824-30-7261 Dear Client(s): As requested, a representative from this office visited the aforementioned site on November 28, 2001. 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 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 off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosures