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235 Hearthside LnDAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 yq0� (336)751-8760 r IMPROVEMENT/OPERATION PERMIT Account #: 990002104 Tax PIN/EH #: 5798-81-9306 Billed To: William Cousar Subdivision Info: Reference Name: Location/Address: Hearthside Lane -27028 Proposed Facility: Residence Property Size: 5 acres ATC NuMber: 3208 **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 r1 #People 2 #Bedrooms 3 #Baths Z Dishwasher: 0"' Garbage Disposal: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial ElWaste: Lot Size&'91 ,3fi_ 1 S Type Water Supply I-)VDesign Wastewater Flow (GPD) —3(00u (ap Site: New Repair ❑ System Specifications: Tank SizeICUC> GAL. Pump Tank Other: 5 'b1SFi49Q Required Site Modifications/Conditions: •' TSTA- LL Dj r� GAL. Trench Width Rock Depth 12 -" Linear kpc'1 >zC-5, . u �i-S q O - C - W &j - ,J data. S t. -- 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.**** 0 -ro 4eAkTtr--A=' �FPeox. � �RFP-CPu� 2(onr oX. 1 JE -roNr.40 3Dffvw - OF � OQ 17 r� 1_.rC�l0J Environmental Health Specialist's Signature: DCHD 05/99 (Revised) /qn , �s 120' Date: �S ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002104 Billed To: William Cousar Reference Name: ATC Number: 3208 Tax PIN/EH #: 5798-81-9306 Subdivision Info: Location/Address: Hearthside Lane -27028 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 CONS IS V ID FOR A PERIOD OF FIVE ARS. Environmental Health Specialist's Signature Date: 7 0� CERTIFICATE OF-CnMPLETIO4 **NOTE** The issuance of this Certificate of Completio shall indicate the s esu has been installed in compliance with Article 11 of G. tE:�1Q Disposal Systems," but shall in NO WAY be en�nt�efthat the s: given period of time. t 21 1Z 7 J� Septic System Installed B : ).vell, l% Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Improvement/Operation Permit I .1900 wage Treatment and * 7 11 funct� satisfactorily for any �/� r r'2 -OZ Date: APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department EnvitonmentaiHealth Section 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. o 1. Name to be Billed /1�ym �J i' �lr Contact Person,,(�� Mailing Address Home Phone���%l City/State/ZIP lie W Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip "e-9 x-51, L -7 _6 a -.D L �� 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC 't�YBoth 4. System to Service: ❑ House @' Mobile Home ❑ Business ❑ Industry Q Other 5. If Residence: #People ` #Bedrooms � Bathrooms _ "ishwasher H -Garbage Disposal N-11ashing Machine O Basement/Plumbil-F' ❑ 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 "ell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V'fo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �� (► re S WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 6� I -A3 ue (04 e link C IL9- }' (n)o eorm+z er Ed Property Address: Road Name (i 0 l _c -T ©tai City/zip mQ{'y 11V1, aln-I I q T If in a Subdivision provide information, as follows: Name: Section: Block: Lot: 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 Davie County Health Department 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 /-/I- d ,9= SIGNATURE Sid �l / 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). F l e- Revised DCHD (07/99) 30 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. O Invoice No. Z'%3� 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department EnvitonmentaiHealth Section 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. o 1. Name to be Billed /1�ym �J i' �lr Contact Person,,(�� Mailing Address Home Phone���%l City/State/ZIP lie W Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip "e-9 x-51, L -7 _6 a -.D L �� 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC 't�YBoth 4. System to Service: ❑ House @' Mobile Home ❑ Business ❑ Industry Q Other 5. If Residence: #People ` #Bedrooms � Bathrooms _ "ishwasher H -Garbage Disposal N-11ashing Machine O Basement/Plumbil-F' ❑ 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 "ell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V'fo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �� (► re S WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 6� I -A3 ue (04 e link C IL9- }' (n)o eorm+z er Ed Property Address: Road Name (i 0 l _c -T ©tai City/zip mQ{'y 11V1, aln-I I q T If in a Subdivision provide information, as follows: Name: Section: Block: Lot: 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 Davie County Health Department 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 /-/I- d ,9= SIGNATURE Sid �l / 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). F l e- Revised DCHD (07/99) 30 Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. O Invoice No. Z'%3� 230 � 1 Q CN 5 Aon ix. ti'1 ) '�a 7357 F GA - t }�s�1i r it �� x !il � t t� �! �x•x �ap�! ����a 1 c�� i _s s i t j�}��• ,�� 000 ] pww • LPC 281 7,3�839- 0896 (1289) � (7.61 A) 1348 x224 592 (1 5 1) 64, _ 174 - J so 1.52 A �s 8772 •! -y � ;.241 T 764 s 281 K 4 rI tit k 295 ,.V ..:. .. .,'I I�vJ'I A .s.. ^•x�` kx.. lt.: t. .. _e }.. x .. �.,`.i ..., t,.:. .. .w .,�. 230 � 1 Q CN 5 Aon ix. ti'1 ) '�a 7357 F GA - t }�s�1i r it �� x !il � t t� �! �x•x �ap�! ����a 1 c�� i _s s i t j�}��• ,�� 000 ] pww • LPC 281 7,3�839- 0896 (1289) � (7.61 A) APPLICANT INFORMATION Account #: 990002104 Billed To: William Cousar Reference Name: Proposed Facility: Residence Water Supply: `-Evaluation By: On -Site Well Auger Boring DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation �` R R RMATION Property Size: P OPE TY INFO Tax PIN/EH #: 5798-81-9306 Subdivision Info: Location/Address: Hearthside Lane -27028 5 acres Date Evaluated: go Community Pit Public Cut SITE CLASSIFICATION; ra LONG-TERM ACCEPTANCE RATE: e l REMARKS: EVALUATION BY: Wp 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 Mineraloev 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) Landscape position I DEPTH groupHORIZON Texture Consistence Textur group Consistence Structure Mineralogy groupMineralogy Texture �^r�c�•��nQ.-�r.�r-moo Consistenceffi JWAS%" Mineralogy 1111111111tA�i� Fr' .L ' --O HORIZON IV DEPTH 11�1 0�1 0 wig. Ell Wj_ 91m, Texture group MoorIEN IMEN 0011 11wo—rom OMISSION 1M1M11MM1 Consistence Mineralogy—®®�- SOIL :����.�s-� CLASSIFICATION • e�NMM111"E2Mss111011011111111111 SITE CLASSIFICATION; ra LONG-TERM ACCEPTANCE RATE: e l REMARKS: EVALUATION BY: Wp 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 Mineraloev 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) t - Davie GountV)Yeal th Department Environmental Wealth Section PO Box 848 / 210 Hospital Street Mocksville, NC 27028 Phone: (336)751--8760 January 25, 2002 Mr. William Cousar 1126 Conley St Apt B Winston-Salem, NC 27105 Re: Site Evaluation - 5 Acre Tract/Hearthside Ln Tax PIN #: 5798-81-9306 Dear Mr. Cousar: As requested, a representative from this office visited the .above site on January 22, 2002. 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 to serve a three-bedroom residence. **SPECIAL NOTE: Due to poor soils and complex and steep topography on this tract, the area available for installation of the septic system is limited. Care must be exercised to disturb as little native soil as possible during preparation of the site. 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. Please have initial grading and clearing completed prior to making the request for a septic system permit. If you have any questions, you may contact our office at (336)751-8760. Environmental Health Section