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332 Howell RdDAVIE COUNTY HEALTH DEPARTMENT /rG Environmental Health Section Soo P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900441 Tax PIN/EH M 5822-65-8236.0000E Billed To: Ray Mayberry Subdivision Info: Reference Name: Ray Mayberry Location/Address: Howell Road -27028 Proposed Facility: Property Size: **N07 E**'Tliisbginproveein nt/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 ))t/� M li #People 2 #Bedrooms 3 #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size -7 • 4q"SType Water Supply L�Eu-- Design Wastewater Flow (GPD) 7�koD Site: New M Repair ❑ System Specifications: Tank SizeICCOGAL. Pump Tank GAL. Trench WidthaJ ' Rock Depth JZ" Linear Ft.TC�U' Other: J7 —)-)Pop P I N-C'•S. I'JsTALL_ L-1 A5S 91o•C. 0,14. Required Site Modifications/Conditions: 1 K-)S-MLL oa uo-foolz l soa-t � vk-=P I& 01-F 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 da of installation. Telephone # is (336) 51- 760.**** -Pp—op. 1.1 rJ "j n.-ri�D2 3s' * LZ0'TUQ Ploo'sloj MOST' i�G L' ©t Aj -�T0i,) .jT TIS O r- *ite'p Sd FP-�)A',-- OC -u, Environmental Health Specialist's Si ture: Date: �//Woo DCHD 05/99 (Revised) t Account #: 989900441 Billed To: Ray Mayberry Reference Name: Ray Mayberry Proposed Facility: ATC Number: 2449 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5822-65-8236.0000E Subdivision Info: Location/Address: Howell Road -27028 Property Size: 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 CONU N IS LID FOR A PERIOD OF FIVE YEARS. Environmental 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 11 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. 1 \UV Vol I5�• \ six r i CPO 47 ° r y Septic tem Installed By: �J L NS Environmental Health Specialist's SignaturDate: . / 7:�— I - 1 W2`,� > DCHD 05/99 (Revised) APPUCAIIION FOR SITE EVAUTAIION/IMPROVEMENT PERMIT & ATC U Davie County Health Department D 0? -V9 Envlronmenfof Healfh SmWon FEB - 8 1999 ��r Y P.O. Box 848/210 Hospital street X-cokwurlille, NC 27028 t% �//l (236) 751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***IIyPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN fore instructions. I . name to be Billed Gt Contact Person d GL e zy^ CD le �c � Address %d Hailin H % g cmm�ty��S/f°s�e city/state/zIP /je rh rvy-ep y -,.S (�BC /�✓,C . A/P'(12miness Phone Z. Name on Permit/ASC if Different than Above Hailing Address r,_ /i .n --,,o f, S ��° City/state/Zip (� �e' .++ r•,. /� S!f/'C ®/ .� 3. Application For: U site Evaluation 0 Improvement Permit/ATC IF Both 4. system to service: ❑ House Uk tobile Home 0 Business 0 Industry ❑ Other s. If Residence: # People i # Bedrooms t # Bathrooms 0 Dishwasher 0 Garbage Disposal 911 asking Machine 0 Basement/Plumbing �v0 Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # sinks #Commodes # showers # Urinals # Hater Coolers IF FOODSERVICE: i) Seats Estimated hater Usage (gallons per day) 7. Type of water supply: 0 County/City @'i�iell 0 Community s. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 -No U yes, what type? ***IMPORTANT*** CLIENTS AIUSTCODIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBlifITTED by the client with THIS APPLICATION. Property Dimensions: WRITF,,DIRECTIONS (from Mochsville) to PROPERTY: Tai Office PIN: 11,51r;a. — Tom, 3 `Kt7 ) C4 k Nc 4 /Paz Property Address: Road Name 4 n %�� .! �t -� L. e� Cityalp—/fidCTe"e/i IV- 21028'-LpA/e/ f�c� m• �e 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 ani responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie Coun Health Department to enter upon above described property located in Davie County and owned by ,,=art �r y to conduct all testing procedures as necessary to determine the site suitability. DATE 2 - SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR'SITE PLAN (Include all of the following: E sting and proposed property lines and dimensions, structures, setbacks, and septic locations). CAL -P i4� f:va "Yo T- -70 (P - `70(P - SD' -3x> Revised DCHD (07/98) MAY 3 12000 P A Account No. Invoice No. (D T ACT 7 AREA = 12.1976 ACRES NIP 349.98 �-i TRACT 8 AREA = 7.8844 ACRES M EIP 0) N \� Lo dam' \\ O. cc cc W CV 1 O � 1 (n h ��. o j c/l O PIP262.02 3 S 000 39 04" E S: ^ N 000 39' 04" W 211.33 iV, MARKED o v TREE c�j 7 NT O) M ^, Q N SR 1419 oN 1 ti BURTON L. TRIVETTE _ Oo O 0 QN M DB. 118 PG. 216 NIP ._� NIP W— .. - 267.96 ` O 1 , N 08° 56' 39" W joM w °, m v) M G M OEIP 7 S ,070_p '7C 57 yy -+► '� NIP �.. �363 +� AXLE J co C U J Q f0 co TRACT 4 TRACT 3 TRA C T DAVIE COUNTY, HEALTH DEPARTMENT Environmental Health:•. Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �AqDATEEVALUATED 1 � PROPOSED FACILITY Nn PROPERTY SIZE '' SUBDIVISION ROAD NAME Aoi )0 0,ii Water Supply: On -Site Well ' Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4' 5 6 7 Landscape position SlopeIf VV HORIZON I DEPTH O - 4a O .: (O Texture groupGL SG:.- LL Consistence 5 Structure C L Mineralogy rh as HORIZON II DEPTH = CS'G, 1 .40-7-0 Texture group' r- Consistence , Structure Mineralogy M,yO&-p M1 '� D nnt�ovs► HORIZON III DEPTH Texture groupsG Sa n Consistence ellI,ty Structure S. Z Mineralogy M I Napt HORIZON IV DEPTH Texture groupr Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE - SITE CLASSIFICATION: �r� 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 'CON ISTENCE 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 L�7 " VXt/ Sz1QQ 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(01-90) ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■s■■■EE■�I■■■■■■■■■■■■ ■■!■■■■■■■■ESI■■■■■■■■■■■■■ ■■■■■■■■■ME■SIE■■■■■■■■■■■■ SSSS■■SE■M■■11■■■■■■■■■■■■■ ■MSM■■■■■M■■.■■■M■■ �lMENNENMCIMMEM ■MM■ME■■M■■II■■■ME■ ■■■■e■■■■■■UMM■■■■ ■MM■MME■■EMIAM■■M■■ ■■MMM■MM■M■IMM■■MM■ ■■MEM■■MEMM'■■■MME■ ■■M■ME■ME■MNEME■■■ ■M■■■ME■■MEMEM■ME■ ■E■■■MM■■■■■M■■M■■ ■N■■EMME■ERI■MEME■■ ■■MMM■■■■MII■■■MM■■ ■M■■MM■■MMIIMM■■■M■ ■MMMM■■■MMII■MMMM■■ ■■MM■■EM■ENEM■■E■■ ■E■■E■E■■■IN■E■■■■■ ■ME■■■■■■■I/■■■EMS■ ■■■■M■■■■■■■■■■■■■ ■■E■■!■■E■ME■■E■E■ ME ME ■E■ME■■■■■■■■ ■■■MEMS■■M■■■ ■■M■E■■■■■■■■ ■■■■■■■■r■■■■ ■■■■■■■■■!NmMM ■■■M■■■E'SMUM■ ■E■■■■■■ MMEME ■ ■■ ■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ SSSS■■■■■EEE■■■■■■■■■■■■■■■■■M■e■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■SSSS■■■11■■■■■■■■■■■■■■■■■■■■■■ MEMS■■■■■■■■■■��■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ISN■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ESE■■■■■■■■■■■■■■■■■ ■■■■I�IM■SSSS■■■E■11■■■N■■E■■■■■■■■■■■■■ SSSS■■■■■■■■■■■t�■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■��■■■■■E■■MEE■■■■EEE■ ■■■■■ME■■■■■■ESE■■ti■■E■EN■■EEE■■Ee■E■■ NEMS ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ 0 MENNENMMMMEM1VAMMIMMM ■■■■■■EMM■■■■M■■E■MUMM■■■ ■EN■■ SEEMS ■E■E■ ■E■E■ ■■■■■ ■E■E■ ■■■■■ ■EN■■ ■E■■■ ■E■■■ Davie GountVNealth Department Environmental7(ealth Section Po sox 848 / 210 Hospital street Mocksville, NC 27028 Phone: (336)751-8760 March 16, 1999 Ray Mayberry 1435 Lewisville-Clemmons Road Clemmons, NC 27012 Re: Site Evaluation -7.88 Acres - Howell Road Tax PIN #: 5822-65-8236 Dear Mr. Mayberry: As requested, a representative from this office visited the aforementioned site on March 12, 1999. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to beprovisionally suitable for the installation of an on-site sewage disposal system * * SPECIAL NOTE: Due to some complex and steep topography and soil wetness conditions on this tract, the area available for installation of the system is limited. Additionally, placement of the house may require setting a pump station. 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, RS. Environmental Health Section enc(s) 1L4�� Yn 3c�� L 3 i�LIo F. 0 14 lam. 3� 1 hm