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257 Hidden Valley LnAccount #: 990002662 Billed To: Russell Tesh Reference Name: Proposed Facility Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5729-18-0473 Subdivision Info: Hidden Valley Location/Address: Hidden Valley Lane -27028 Property Size: 10.49 acres 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 ermit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Se a Treatm and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA T NI PERIOD/ OF FIV/2)E ARS. Environmental Health Specialist's Signature: -If ate: /tif _/f _/_ V 11-r CERTIFICATE OF COMPLETION **j�jtOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 1 3``'/% has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and 40 Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any fro given period of time. lIp x��k w t 3F' � ,ID • iJ� (6. EEI 34 'YA V Septic System Installed By: L� Environmental Health Specialist's Signature:Date: DCHD 05/99 (Revised) 1, Account M Billed To: Reference Name: Proposed Facility DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 990002662 Tax PIN/EH M Russell Tesh Subdivision Info: Location/Address: Residence Property Size: 115�1/',o`1S v Y 5729-18-0473 Hidden Valley ..� Hidden Valley Lane -27028 10.49 acres ATC Number: 3904 **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 #People #Bedrooms - #Baths Dishwasher: 0"�' Garbage Disposal: ❑ Washing Machine: 0"'- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 10 ACUS Type Water Supply Design Wastewater Flow (GPD) � Site: New Repair ❑ System Specifications: Tank Size la&AL. Pump Tank GAL. Trench Width Rock Depth 1Z Linear Ft. 7E0 Other: 'o'►Si�► cT-tl>Ai,tL __n S Required Site Modifications/Conditions: '5 sT1 LL- c�1 C-3,`,iWZ, aS© ,% A i;Ll. IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISE S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department or 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 (gyp' �2i ✓� � f-7 rop 1©D' Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: c/ Account M Billed To: Reference Name: Proposed Facility DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT 990002662 Tax PIN/EH M Russell Tesh Subdivision Info: Location/Address: Residence Property Size: 115�1/',o`1S v Y 5729-18-0473 Hidden Valley ..� Hidden Valley Lane -27028 10.49 acres ATC Number: 3904 **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 #People #Bedrooms - #Baths Dishwasher: 0"�' Garbage Disposal: ❑ Washing Machine: 0"'- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 10 ACUS Type Water Supply Design Wastewater Flow (GPD) � Site: New Repair ❑ System Specifications: Tank Size la&AL. Pump Tank GAL. Trench Width Rock Depth 1Z Linear Ft. 7E0 Other: 'o'►Si�► cT-tl>Ai,tL __n S Required Site Modifications/Conditions: '5 sT1 LL- c�1 C-3,`,iWZ, aS© ,% A i;Ll. IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISE S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department or 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 (gyp' �2i ✓� � f-7 rop 1©D' Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: c/ --'—APP CATIO. SITE EVALUATION/IMPROVEMENT PERMIT & A C '•� vie County Health Department 20 vironmentaiHeaith Section ; /`} P.O. ox 848/210 Hospital Street ----J Mocksville, NC 27028 ( l ��EfN�StO�IEEf�ITH (336) 751-8760 i pAVfEC0U1�►� `� J ***I *** THIS APPLICATION CANNOT BE PROCESSED UNLESS A THEF' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for ins �'ii�sr HLII! 1. Name to be Billed�vSSetl L "/eS Contact Person�t�// Mailing Address/,;,, f �/�c� e�� .S Home Phone City/State/ZIP /%i: ., �` lew �C ,27/D) Business Phone 3yS Z1.2 -Al 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ,.,❑Site Evaluation ILS 4. System to Service: H'oouuse ❑ Mobile Home 5. Type system requested: L7 Conventional City/State/Zip Improvement Permit/ATC /❑`Business ❑ Industry ❑ Other ❑ conventional modified ❑ innovative .Both 6. If Residence: # People 117, # Bedrooms -7 # Bathrooms .Z Dishwasher ❑Garbage Disposal ew.shing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ElCounty/City ia" Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? WYes ❑ No If yes, what type? ala IC hn-t-4- wor/, S4ezo ***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: go X lge)o L,.-Vax Office PIN: # 57 -1 - Property %Z Property Address: Road Name f/d61c, 6-,e- City/Zip -►c City/Zip If in a Subdivision provide information, as follows: Name: ,L- I j d' n 0,( ( -t Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: On to & eA- Oma► y/o%%,.U.e�l/�-, ��n� _ bD�oQcl/"r /Date home corners flagged: /,F Oef ,,9,e/ 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 _421'- ee'r L` to conduct all testing procedures as necessary to determine the site suitability. DATE O y SIGNATURE X 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). Sign given Revised DCHD (05/03 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. g� � 10 Invoice No. �� %'"'Pt") SW A _ -1 . r, � �nv �L 3 Zo g Mar 17 03 01:46p davie county envhealth 336 751 8786 p,1 • E C E Is APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Q U Davie County Health Department LJ Envitvnlnenta/Health Section P.O. Bots 84e/210 Hospital Street MAR 1 9 2003 Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN forins ructions. ENVIRONMTALHEWH IIAVIF- OIINlY 1Z Name to be Billed /�In 5"CG11 Tes<, C L Contact Person /S� ca, AW Mailing Address] zkN onak ✓ T r Nome Phone / OL/7 �/ �7 / ✓ City/state/ZIP 11,h/ 7S*;1 )Gi /Z101 Business Phone 3 " 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For:_ '%ite Evaluation 0 Improvement Permit/ATC G Both ,tee4' system to service. i8'House ❑ Mobile Home ❑ Business 0 Industry 0 Other ,/s. If Residence: # People '.L # Bedrooms # Bathrooms z ,_-y Dishwasher LI Garbage Disposal Jk washing Machine U Basement/Plumbing kl Basament/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) _T- Type of water supply: 0 County/City Well 0_Co+mmurt ty ,tee. Do you anticipate additions or expansions of the facility this system is intended to serve? X Yes PrNo If yes, what type? 41b^/< S�cNO 40 ,,,14, Alt L **_*IMPORTANT" CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED LOW. Either a PLAT or SITE PLAN MU�STBESUBMITT'ED by the client with THIS APPLICATION. Property Dimensions: /01 t/ 2 /7•/nC4X--V WRITE DIttECfIONS (from Mocksville) to PROPERTY: - a Otfice PIN. # 517 Z 916 0 y% 3 J R w V O ✓Property Address: Road Name 1-1/G4' /ein VCt l*4 1,4n.e —r- yyl, L (�J� "(/f'1 city/zip LCL ile IVC '-11 /7' elct.Piy, I %Ci ZI6�r 7, (Af in a Subdivision provide informat/ias follows: Name: �L 0.(�� Y ~� 0 y —^T (,` O P N tR. s a t* iu �•a � iv o Section: Block: Lot: to 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. 1, 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 accessary to determine the site suitability. vDATE/rj-42iC.vL c�3 SIGNATURE 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. �- Revised DCHD (07/99) Invoice Na All r I 3 r t ,Aq*o Pd S I re eP Hp n t, <- 1300 ' . w \ �flti/ t,'rr�(, c �N 0 +� e> DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336) 751-8760 / Fax: (336) 751-8786 March 27, 2003 Russell Tesh 125 Derende Street Winston-Salem, NC 27107 Re: Site Evaluation - 10 Acre Tract/Hidden Valley Ln Tax PIN#: 5729-18-0473 Dear Mr. Tesh: In 1994, the above site was evaluated by a representative from this office. A return visit to the site on March 26, 2003 verified that the area of your proposed house was adjacent to the area that was evaluated in 1994. At that time, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Due to steep and complex topography and low, flood plain areas on this tract, the area for the septic system is limited. Care should be exercised not to disturb the soil in this southwestern corner of the tract. 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. Enc(s) If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section 110 5.13 A 2�� ' 22 5.13 A J 7587 il[ D E. -N 10.49 A5 0473 241 221 (103.24A) 4641 5.13 A 3069 e 5.13 A 6078 201 5.13 A 9098 (87.7. 114: A APPLICANT INFORMATION Account #: 990002662 Billed To: Russell Tesh Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size PROPERTY INFORMATION Tax PIN/EH #: 5729-18-0473 :subdivision Info: Hidden Valley Lot # Location/Address: Hidden Valley Lane -27028 10.49 acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % 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: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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) J6 I, ' 5 N ti AREA = 5.130 ACRES o E� D ,x ... Y!Z C�— iron AREA = 5.130 ACE ---------.----------oma —'-- 010 YaJ.4; �• — o ^ 10 .490 ACRES 1 X 1 .J ` a �• ID inJ - / - Q O n AREA = 5.133 ACRES ARE.,.= 5.133 ACRES , AF 0 11 336.60 331.00 - � � � .,�,,• Kms. i APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERM TRECEIVED (�' 1 Davie County Health Department �1 Environmental Health Section JUL - 6 19% U 1 P. O. Box 665 oc vll - -- - M ks i e, NC 27028 ---- 1. Application/Permit Requested By Mailing Address O,QNiP Home Phone X14 , iV I G. Z;702 b' Business Phone 2. Name on Permit If D111ferent than Above 3. Application for: General Evaluation ❑ Septic Tank Installation Permit �� 4. System to Serve: C+1'House"s- Awa Mobile Home - ❑ Place of Public Assembly O Business ❑ Industry ❑ Other ❑ Unknowr;7r,,4 % 5.' If house, mobile ho e: Subdivision �� Section -k:" wpa k,, 1,L- #A VC a ,vE AZO L o 7 ❑ Basement/Plumbing -X Pe 'S ZvP lr� S FITY 4- 7-,e ocra No. of People ❑ Basement/No Plumbing No. of Bedrooms 70 ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No, of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water, supply: ❑ Public ❑ Private ❑ Community 8. Property Dimensions �- Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the faciiit� tis sytem is intended to serve? ❑ Yes ❑ No if yes, what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: liLo-Al This is to certify that the information provided is correct to the incurred rom Is application. _ Q DATE of my knowledge, and I tpoerstand 1 am responsible for all charges IGNATURE CONSENT FOR IT - FV&,L)ATl0NIQ IM DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I QM the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 said site's suitability for a ground absorption sewage treatment and disposal system. DATE WHO (1/43) SIGNATURE • '' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME . �I%LDATE EVALUATED ADDRESS PROPERTY SIZE ;71we T PROPOSED FACIILTY ' LOCATION OF SITE /Q �✓ �` �� Water Supply: On -Site Well Community Public Evaluation By: Auger Boring I Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % HORIZON I DEPTH Texture group /7Z f4l Consistence Structure MineralogX HORIZON II DEPTH f z r 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 S LONG-TERM ACCEPTANCE RATEI SITE CLASSIFICATION: �'� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: REMARKS: �L�f - ow"yG LEGEND PRESENT: 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(01-901 Davie County Nealtli DYSen artment and Naive .�leallFicy 210 HOSPITAL STREET P.O. BOR 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634.5985 September 239 11994 James Nance 1568 Cornatzer Rd. Mocksville, NC 27028 Re: 2 Site Evaluations Hidden Valley/Tracts 9 & 10 Dear Mr. Nance: On September 15, 1994, this office evaluated tracts 9 and 10 in Hidden Valley off Allen Road in Davie County. Soil borings on tract 9 revealed a provisionally suitable soil on the upper left side; however, it appears that part of the tract lies in a flood plain. Before specific approval can be granted the house or mobile home placement must be estalished and that immediate area evaluated. Soil borings on tract 10 revealed a provisionally suitable soil. It appears there is room for two septic systems to be installed on tract W. Before specific approval can be granted the house or mobile home placement must be established and that immediate area evaluated. If you have questions, feel free to call. Sincerely, Robert B. Hall, Jr., R. S. Environmental Health Section RH/wd .Enclosure cc:. Jesse Boyce, Zoning Officer