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2687 Hwy 64E ►' '• � �ONSTRUCTI�N For ottice use on�v "� A(�'i'H�R�ZA'n0(� 'CDP File Number 120620-1 �°=s'"=�`� Davie County Health Department County ID Number.��05�- . � 'r�g 210 Hospital Street Evaluated For: ` EXPANSION � � P.O.Box 84$ Township: `` cf �/VI� �� ,,, '"� .`��• Mocksviile NC 27028 PERt,11T VAUO UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 1 / 0 1 / 0 0 0 6 Applicant: David Beck Prope�ty Owner. David Beck Address: 2512 E.Gamer Rd. Address: 2512 E.Gamer Rd. C�y: Raleigh . . C�Y= Rateigh State2ip: NC 27610 State2ip: NC � 27610 Phone#: �336)239•1428 Phone#: (336)239-1428 Propertv Location 8 Site Information AddresslRoad #: Subdivision: Phase: Lot: 2687 US Hwy 64 E Mocksville NC 27028 Directions structure: SINGLE FAMILY hwy 64 East, on the comer of 64 and Merrells Lake Rd. #of Bedrooms: 3 #of Peopie: 3 � *Water Supply: PUBUC Svstem Specifications Minimum T�ench Depth: Inches Site ClassiTicatan: Minimum Soil Cover. Saprolite System? QYes QNo Inches Design Flow: Maximum Trench Depth: Inches • Soil Applicatan Rate: Maximum Soil Cover. inches *System Classification/Description: `Distribution Type: Septic Tank: Gallons *Proposed System: 1-Piece: QYes QNo Pump Required: �Yes QNo QMay Be Required N�rification Field Sq.ft. Pump Tank: Gallons No. Drain Lines 1-Piece: QYes QNo TotalTrench Length: ft GPM—vs-- ft. TDH Trench Spacing: _ �Inches O.C. Dosin Volume: _ GaUons Feet O.C. 9 Trench Width: � Inches — gFeet Grease Trap: Gallons Aggregate Depth: - - - inches pre Treatment: ONSF �TS-I OTS-II Septic Tank Installer Grade Level Required: 0) �II �III �IV Page 1 of 3 CDP�ils Number 120620 - 1 co��ry i�Number:��000000s� r/ ❑ Open Pump System Sheet Repai�System Requi�ed:OYes ONo �No, but has Available Space eaair Svstem Trench Spacing: Q Inches O. 'Site Classification: — Q Feet O.C. T�nch Width: �Inches Design Flow: — Feet - Soil Aggregate Depth: Appl�atan Rate: inches � Minimum Trench Depth: 'System Classificatan/Description: , Inches Minimum Soil Cover. Inches . Maximum Tr�ench Depth: � 'Proposed System: Inches . Maximum Soil Cover. N�rification Field Inches Sq.ft. No. D�ain Lines *DistributionType; Total Trench Length: ft Pump RQquired: �Yes ONo OMay Be Required Pre Treatment: ONSF OTS-I OTS-II •Site Modiftcations � No grading or constNction activity is allowed in areas designated for system and repair without approval oi Health DepaRment. "Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsib�e tor chec{ung w�th appropriate governmg bodies in meeting their requirements. ThIs Auchorfzatto�tor Wastewater Systen Construction sh�ll b�valld for a p�son equal to the perlod d wlldity of the Improvenert Pemfit,nd to exceed ifve years,and mry be Issued atthe smetime the Improvement Pertnit Iswed(NCGS 130A,336(b)�,It the Installatlon has not been comqeted durfng tt�periad ot valldity of ths Constructlon Pertntt the IMortnadon wbmftted In the applieatlon fa a pennit or Conatructlon Auttsortzadon Is tound to haw been Incornc�talsified or changed,or fhe site(s altered,the permit or Construction Authortcation stuill bacane Inwtid,and may be susper�ded or revoked(.1937(g)).The person awning or oorrtrolling t�e systen shatt be responsible tor assuring compliance with the laws,n�es,and permlt conditions regarding systen locaflon,InstaUstion.opentlon,ma�tenanc�,monitaing,reporting and repalr (1938(bj). ApplicanULegat Reps. Signature Required? QYes �NO ApplicanULegal Reps.Signature� � Date:_ � � _ *Issued By: 22aa-Oa � Andrew Date of Issue: . � 4 / 1 6 / a 0 1 3 Authorized State Agent: Malfunction Log QYes OHa d Drawing Olmport Drawing TocaiTime:�NH:r��t,i� **Site PlanlDrawing attached.** PegB 2 Of 3 Hours 3 � �tinutes 5-11•GA DENtED �,�� ' ' IMPROVEMENT PERMIT � , Fo�off�euseo�i� ~ � CDP Fite Number 120620- 1 Davie County Health Department '�+~� '� County iD Number.��o000005t .� � r�:� 210 Hospital Street �. .. , P.O.Box 848 Eva�uated For. EXPANSION ��,,,. . Mocksville � NC 27028 Township: Phone:336-753-6780 Fax:336-753-�6SO pERl.11T VALIO UNTtL' 4I'I6IZO'IH "NOTE TO INSPEC710NS DIVISION: Building Permits cannot be issued with this Improvement Permi� � Appticant: David 8eck Property Owner: David Beck Address: 2512 E. Garner Rd. Address: 2512 E. Garner Rd. C�y: Raleigh c�y- Raleigh ' State2ip: NC 27610 State2ip: NC 27610 Phone#: (336)239-1428 Phone#: (336)239-1428 Pro e Location & Site Information Address/Road#: Subdivision: Phase: Lot: 2687 US Hwy 64 E Mocksville NC 27028 Dlrections structure: SINGLE FAMILY hwy 64 East, on the comer of 64 and Merrells Lake #of Bedrooms: 3 Rd: �of People: 3 'Water Supply: PUB�IC S stem S eciflcations niti�al S_��ste�n *SiteZTassi �c�af'an: Minimum Trench Depth: Inches Saprolite System? QYes QNo Maximum Trench Depth: Inches Design Flow: Septic Tank: Gallons SoitApplicatan Rate: . �_P1e�: QYes QNo `� Pump Required: QYes QNo OMay Be Required 'System Classificatan/Description: Pump Tank: Gallons 'Proposed System: 1-Piece: QYes �No Repai�System Required:OYes ONo �No, but has Available Space Repair Svstem *Site Classification: , Minimum Trench Depth: Inches Soil Appl�ation Rate: Maximum Trench Depth: tnches *System Classificatan/Description: Pump Required: QYes QNo Q May be Required 'Proposed System: Page 1 of 3 � CDf�File Number 12Q620- 1 County 10 Number. ��0000005t xSite Modiflcations . ❑ Open Fi11 Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. zPermlt Condltions The issuance ofthis permit bythe Health Department in no wayguarantees the issuance ofother permits.The pennit holder is responsibls for checking with appropriate governing bodies in meeting their requirements. $�� P�an The tnpmvernent Permit ahal be vatld for B ywrs from date of issue with a site pan(means a drawitfg not neClssattty drawn to O scal�that shows t��exlsti�g and proposed property Itnes with dimcnslons,th�location of thefadlity and appurtenances,the st�e torthe proposed Wasu+waoer systiem,and th�Iocatlon otwater supplles and surfacewaters). P�at fie Improvemen!Pertnit shad be wlld without expintion with piat(mear�s a property surveyred prepar�ed by a�e�sLered land O surv�ryor,dawn to a scale ot onf inch equals no monthan 60 fee�that includes:tt�a speciiic location of the proposad fadlity and appurtenancas,the sltefor the propos�d WastewaLer systen,and ttw location o�water supplles and surtace waters. Plat also mtans.tor subdivislon lots approved by the Iocal planning authoNty and recorded wlth the counry regtster ot deeds,a copy of the recarded subdlvlslons ptat that Is acoompaNcd by a stt�plan that Is drawn to scale). The DeQartmeni and Local Ha�th Departrnent may Impose oonditlons on the Iswanceand may nwke the•permits tor taUure ot u�e sysean to sansy a�e conc�aons,the rul�s.or thls article Ttds pertnit Is subject to rewcation itthe sf�e pan,pa;or In�endeci use changes(NCGS 130A�335(�).The person owNng orcontroltf�g thesystem shatl be responslbie fo�assuring complianca wlth the laws,nAes,and pertnit oondfUons regard(ng sy:ten locanon„Instsllaiton,open�on,malntenance,monloarfng, reporting�and rep�r(.19s8{b}} ApplicanULegal Reps.Signature Required? OYes QNO Applicant/Legal Reps.Signature� Date: � � *Issued By: �aa-oayv�rait.Andrew � Date of Issue: � 4 / 1 6 � a 0 1 3 Authorized state Agent: OValid without Expiration? O Create CA? OHand Drawing Olmport Drawing **Site PlanlDrawing attached.** � TotalTime:(HN:��,�.,� � _Hours. 3 g u Inutes Page 2 of 3 Activdv Code_ S-7-IP'S denied(documented) • • � �/f"r ir r v i -�— s: i_ ... �_;r�:.�� f •� � � � , � `�.t � -� ' DAV1E COUNTY HEALTH DEPARTMENT � r, ��=k s ' ' ` `INIPRQYEMENTS PERMIT AND CERTIFlCATE QF G4NlPLET1QN "N4TE:Issued in Compliance With Article li of G.S.Chapter 130a Sanitary Sewage Systems - Permit Namber . Name --:..,_� ' �}_ .. _�+ _—.._ Date _.__ N� ' � � Location � � �.�.� _^—._ _�. _ . . . . � w ' _ _ .. _ .. _. _,7�f�'��G�S�i� ��i ��{�.� �7c�� Subdivision Name _ —_ ; Lot Na. �� Sec. or Block No, _ Lot Size .— House ..... .�.-_ .. Mobile Home __.. 8usiness ...__ _. Speculation __ No. 8edrooms __.No. Baths __—_—._... No. in Family._�_�_ Garb.age Dispasal ' YES p NO L� . . Specrtir,ations 1or System. Auto Dish Washer YE5 [ Na '1 Y � . � • Auio Wa�h Ma^hine Y�S !� NO '� iYPe Water.Supply _ � .--._ _.. .. '7his permit Void if sewage system described below is nat installed within 5 years frpm date flf i5sue. This permiF is sub�ect to revocation if site plans or the intended use change. . 1 �� . Q l�' . , _ . . . l _ � � � .ff�.� - � . . �_��. , �- � ., , � � .. _ t�,� � � y�`'�` � . �{ ,t �t �' _ . . , � � �l• ��1 } y ��.i' � �• 1��' r'f L� � I J!'1 � �.v � f �ff� �J �` .. Im�r•��rement�� perrn.t by . ._--- --...�. 'G��:act � �epreserta►.ive af thc�.Davie Co��nty H�alt;� D�par,mtnt t��r `ina ir�;pection ot this system between 8:30- 9:30 A hvt r�r I A�J-?:3� �."r�. �n clay c' �:orn��':r.tinn. re�eph;.�n� N�mhPr 7�?4-63�1-5985. Final �nstaf�a��o� Jiagram: ' Syst2m In,ta'I�ri by �: '��v�� _ � ; �� s . � 3� _ 1�f� � �� . . . ' � ♦ •• '. -. � . (.._.... ..,.�� ' � � . - . � . , APPLICATION FOR SITE EVALtyATION/IMPROVEMENT PERM��D Davie Coun Environmental Health ��1 /y �„ `� P.O.Boa 848/210 Hospital Street ; `� ; Y Mocksville,N� Z�o28 MAR 1 �� 41 �33��s3fi�so�Faz�336��s3-16so � 20i3 �� r-�� pplication For. BL Site Evaluation/Improvement Permit ❑Auth9rization To Construct(ATC) ��'gthH�AL "i'{� �?"/ Type of Application. ONew System �Repair to F.�cisting System �Cpansion/Modification of F.�cisting System or Facihfy � � � � •"IMPORTANT"'THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED C � INFORMATION IS PROVIDED. Refer to the INFORMATION BULLE'1'IN for instructions. APPLICANT INFORMATION Name to be Billed D�� IJ Q� Contact Person QL�,vi� D�C/C� BillingAddress Sa? E• n Y' HomePhone �3(,- 3Q^ �y City/State/ZIP in�, C o1 (O10 Business Phone Name on PermiUATC if D�erent than Above 1 ,1 Mailing Address " City/State/Zip �V � ^ � PROPERTY INFORMATION *Date Housye/Facili Comers Fl ed // �iOTE: A survey plat or site plan must accomparry this application. Included:❑Site Plan ❑Plat(to scale) �� \ (Permit is val' for �qnths with site plan,no expiration with complete plat) � Owner'sName �Q.V'1�[�eC� PhoneNumber �3�"a39��y� �` �� Owner's Address t.l, w �I City/State/Zip 1'VI C tlCsw P. �' o �/0 � O �� PropertyAddress fo fI S City_ Mo�+]�v�/e Q� �� I� LotSize 3,g9p� TaxPIN# S"I 754�y8/ � � Subdivision Name(if applicable) Section/Lot# O� � � D'uections To Site: /I�� ,� �y( If the answer to any of the following questions is`�es",supporting doc tation must be attached. (�`� , �� Are there any e�sting wastewater systems on the site? �es❑ o � � Does the site contain jurisdictional weUands7 �Yes o �/" � Are there any easements or right-of-ways on the site7 ❑Yes o , \�� Is the site subject to approval by another public agencyl ❑Yes v�\ � Will wastewater other than domestic sewage be generated? ❑Yes o � I ` IF RESIDENCE FILL OUT TEIE BOX BELOW C��U #People #Bedrooms #Bathrooms Garden Tub/Whirlpool❑Yes o Basementt B'�es�No Basement Plumbing: GY�es �No. �� IF NON-RESIDENCE FILL OUT THE BOX BELOW � Type of FacilityBusiness Total Square Footage of Buildin� #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similaz facility water consumpUon) FOODSERVICE ONLY: #Seais Type system requested: �onventional ❑Accepted �Innovative ❑Altemative ❑Other Water Supply Type:�County/City Water �New Well ❑Existing Well ❑Community Well Do you an6cipate additions or e�cpansions of the facility this system is intended to serve7 0 Yes �4�10 If yes,what type? This is to ceRify that the information provided on this application is true and cocrect to the best of my knowledge. I understand that any petinit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie Co�mty Health Department to conduct necessary inspections to determine comp(iance with applicable laws and rul �e�d t I am responsible for the proper identification and labeling of property lines and comers and locating an�l r s g house/facility location,proposed well location and the locatioq of any other amenities. Property owner's or ownePs legal representative sig�ature . Site Revisit Charge 3'�.� . _ Da�s) Client Notification Date: . Date • EHS: Sign given ❑Yes�No , Account# �Q�2��,-i Revised 11/06 Invoice# !i� 7 �-f.^ri�A�c}��`�Rt'it."�-..,�.�..,�,�,a..e{:.4�7'�C'l`+:��,.''3''�'+�r;�'�y�"'..r; �;t M�- �-.t�vt^ ��—r ::.-��c- ;5^saE:,„r�x�-.�e�;_;ra'J a�^,.-�;,q" x.�-;.Yx's.x�grn''u a 4cz.=2''iz:"�-.,1��. ' -�, -.�x- �"� •,�j� � ,��(r.. �.._,j � _ � t�� ` � �,� , r. � .t/'�'� - �'�`6 tt; ��t'�*"�y � �� i Y o . ` . . . � � . . . ' , . , ,: � , , � . . s ��I` ,� � �`�'c _ , . . . : ' :. . , . , . . ' . � ., `� ��.� �' ' �A�I� ��9� �IEe��S�(`� ��G�46�JL�14 � ' . � � �� i� .�� .a � '�' .eri„_: ... �;F' . -� , - . '_ _: i j- , j. � M ,�� , _ �OM�ROV�MEN'TS PE��9Y �1��•��8��'� �F� C��L�L�49�1� . _- :� . ��;, � : �, �. . . �k �ry�` *NOTE.rlssued in Compliance UVith Article,l l of G.$.Chapter 130a ' -. � �� . �, �1"�Sa�ta'ry�,Se�a�Sy��"� �..}� ,�,�,�v �''�= �.,9'�-��'`��' . , �� P . �.. �'� �' � �'�� r t Name :� �`�,�*� �'" Date , � }, f � � - �� ". '�o � n ' ts _ ��`: � �G'% ��. ��i'r.r�S`r �,dl�, ,f",��Jr�'rOe�'f� ��%r'x.,�`:�,,./''/�1��,�" ./l`� �.��'-��'� -,."�s s.�• ✓�+'`' a�;�', . � LocaUon� � � - . �° - p — - . � �..,._,:,�,.----�r -, ' � �f �,j �, ��lf� � C��.�� -��, p��a .. . f VtJ � ' �' , ,, .. t , £ ' � , . U _ , , . •_ .• ,. . . . . :: ,, . , . , ; . , , ; : T 2 , _. �w:.... ,< _ - �' - � .. ,�Subdivision Name " ` . = Lot No --- ,_� : Sec or Block No. ° , ' r- . � , . � n °Lot Size - House. �� Mobile Home —,- ��F Business _ - 'Speculat�ion �� -' ,No. Bedrooms. � .No. Baths .—�� 'No. in Family � _ �`'� . � . �. � � _ ' .� . .: � �-. �� Garbage Disposal; YES 0 NOu � � � Specifications� for>.System � Auto Dish Washer.: ° YES .� NO� ❑ �' � ` �� .� � � ��,� ,;�"��r`« ` � d � � Auto Wash Ma^hine YES�,� NO 0 p�'��r'�! r� � . �; �� TYpe�Wate� Supply — . . . --- . . , - :�. . ,. r,,� _ ,�_ � "This permit Void if sewage system described 6elow is not installed within 5 years from date of issue. ,x, = s " This permit iS subject�to revocation if�site�plans or the intended use change,. � � - '•` _ . � � ; �.. , . , . � , . .:•, . . , . ,. , . . . � - . • V ., �*� a��i�.�'�' ' . , , _ . . . .-- . . . . . - . 4 � . . . �� s t . ., ' . . _ _ „ _ ' ` x . . ._ . - . .; . . . ,: :., . T, ; � _ n.: : .. o � .. �. . . . . _� , � . _ . . � 6 ., : , . . .. , . � ... �.. . . ,. . . r , ye �. � '. . , . d ;I. , . � �j¢� , _ _ . .. i_ .. _ k . ' . ^ ' �� .,� � , .. , � � • - � _ . „ , , . . _ .. : , : . . . <' _ . . • .:. . .. r - . • � g �. : . � ¢y t � ` � " . ,- - � . . F l �� . i��1, i• i..�..�,i. � . " > k . - . . ' . � .. , . . . . ' 1� �`�i �' .- . _ " , . ... ` .. �' . : f .. ..W . ' . - . . . .,�... .. , c . . .. . . - . . . N. : .. ' .. ". . _ .. . - . � � , _ .. a . , . .. . .�. . � � � - > � . . . � ', . . . . . .. . .. . .: ��-, . � . - : . . . . . �. . � �� . . . �.. . ..f . ,. .. - - ' . ii � .. _ + 'o '�.e . . . " 4 . . . • ^' ' ,. ' . . , . . .� � � .. .. � _ � �.. '. .; `� - , . , . : , /y .. L, . .t �,..��.�^ 1. ..- - . ., �. ./ � '�f j�y� �i � , � . .. � . � . ... - , . . � - .�'�*T ��w.,��' . i �� , . � . �,.�., � � � �� . � , � -------�� , �' . �� s�'� � . . , _ — - . � . � ° . . .; � �, .,: �- � 3 . " f ' j . 3 F � .- � , t.�� (! , - _ . �( � . �P�� r � ' � . : _ .r I / . . �,t ' � 3/1_ , o. - . �.,t . i' p y v� ; ; . � K � • > > . , . . t ,, . , . ,.. • �; � . �_ . , . � � - . � . � - � s � :� 7 �G _ n' . , V _ . . .. . . ..4 . .. y ... . , b. �� - � . . � . . . . . . . . � . . ..a, �� . . - - - . ' , ..._ .- .. - . . � � _ ,. . ... �. . . .. . _', . . . - . . . ..�. ' . ' ��' - . � . . � � -, .., . '. . .. . . .� .�. ' " . . - . �. , - . - r , : ; . . ,. • . ; , �. . , ; .�; , . . - . �� ;Improyements p�ermit by'_ -- — , � C�ontacf ` . . T , , , . . - ' a representative of the Davie .County Health Department_ for final insoection, of th,is system,,between 8:30- ` E. _. , .,: � ` pr � 5 , , ., . . . , . ��. Y P ' ,.., ., . � �� . .� ' . ..+ , � � � . ,_ :;. 9:30 A.M.'or 1:00-1�30 P:M. on da of com leti�n. 7elephone NumbPr 704-6 4=5 �y` Final lnstallation-�Diagram.: � . �.,� � System.lnstalled by,^ ��•��'��'' *y' . - � .- � . � . . . . . . � . . . . . . . .a.+ . 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'w �. . , ' � k ° Certificate of�Completion:�- . - . „ . . „ - D _ , ��; - �` ate �� ' �� 'The signing of ihis certificate shall indicate that the system described abo,ue has be.en �nstalled�in compliance with. �� = ��:thenstandard,s set forth in the above regulation, but;shall m NO way be taken;as�a guarantee tFiat_the sysfem will function ;. � `..�.satisfact'orily=�for any gi`ven.period of time. ` _ ; -F ' , -- ,. . � _ . _ _ , . , � . _ � - , . . . , ,. ; ..,. .. f •-�.,.. '�"*c �¢ �1?s ifis, r�.;Gne.y.e ,r^+.� r �:.xwk,q;p�.�^f+y�=c :�y,e:.;-�.,.,..w,.'�j�e-•,r,�w-ar_vswug+ue r � •m,'_v �� ^'�� s;t;„:�' . �� , � 4�� ,` '�i1 . . � . .f �" �.Ay�. � "'gf M' -i, „F+ y-,.. �4i'� -,My ,�R� ^1 n t _ . . . F - : ��, '` � _� ,� �,y-�V��f F--�� 1- ;_.;,,�� .� j � . �� "�'d x' r ;,_��,,� ar�4��_- .� :, . . �, ^G`�`�-.x, ��.��i�'�,�. ' t : , .. � .:: ��'�0� �'�� rMi� ��d��(' 4 �2��'�- ,�.' ; ,. ,. pc� ' � [,�, ; � � _':./��^T.,c �-�. <,'__�y�� B.fr��C�R��I��_ ..�I��R�04�� C��8��. O� COM��B�� .. -. . � . , . . . .. .. . �� , "� +r....,,� e�1` : . " - r� NOTE'Issued.in Compliance With Article II of G.S.Chapter 130a � "" ' {iSanitary,Sewage Systemsy,e..' ?. P�P�9� � �P �:,; � ', ��4;��r�,�a�''..GY�.s'�''.�".��.,�� ,�'/� Date ��..� r�'��' � �� Name � � . �o � � �C��f�'i+��,�y+�3i!�i!..5�+ .�r''s�i �'�.�l��i:J`^r f�f{�fi6�!`^•Ji�„/fO�Y , �!� �;i- ,%'�/ ' .CM'ss.:.-�!"`� >�t" ' �- .� " Location_�� _ - , � , � l - _ �,.-r- _ .,,�.-.� � / d� !� /��/� Of , � � , . -,1�,.�{t%� � F.��.�`! �I y �Q��,� _ . , ., � W T _ , Subciivisi -• • � . . . ;• � _.�.:.��.r � � �on Name ��' 'Lot No. ° .Sec�or Block�No. " " - � �,,.-• ; 1=� e r r ' Lot Size House —T— Mobile Nome � '�` Business__ --��'Speculation ° ° No.-Bedrooms �` No. Baths `� No. in 'Family _ ,� � � .. _ 1 . .:� Garbage:�Disposai; ; •YES �. , NQ • .� , � ' Specifications for S stem: �� § . Auto Dish Washec YES �� Np �_ , y ��,,�'��'��y'' �'� ,��;� �` ' r . . Auto;Wash Ma hine YES�,,[J NO p ��r��-, t. �%•. . . . - � �ype Water 'Supply" � - ' --- , . . , - _ , ' � � � ,. , `This permit Void if sewage system described below is nof insfalled'wifFiin 5 years from date of issue. n �,, �" This permif is subj.ect to revocation if site plans or the intended use change. , f ., . , . ��''" . A. ` ' u , .t�� , . ', � ""' i.'� ��x � - - •• . . . � •4,_ , ,. . l.� ' .. - � . ~. - . � .. . . . .. . . � � . �• +`j . . . � " .. �. . . . ' . . . . � . !� . : . +'�. . ' _ <. . . - � , . � . . ' � � . , u . . . . , ; . . , ,. . • . . . � y� � ' . 3� �� .. , • � � ... � . - _ " . .. . _ �� " _ „ . ' ,_ �• ., . . . . ,�3 tl� ��f�lt4� f``a ��w ' f. . � � , . . . . � . �. bi � . . . . y . a . ... . .� . . .. . . . .. .. . .. ..�c e., �. . . . . . " , � . . ,. � .. � 1 ` ' : . . .� .` : � ` f , "r. , j � , ..� r. c f..�� ... �. , . ... �'� , . ,i .. . .,� ,�,. , �, ,_ . . �� 4 � .. " � .. ` � . . . � �_ :.. . .. '. . .. .. � �uw�� . � .. � �� . . ' � f�. . ...' .. �. ..�.�,� } �.4 � �'�'I {� , . ��; . .. .. I�E _�`,�'?��' � � :. ` ' �, - „ ,.. ' ., , . _ , ,,,, �:�/ •._„ a „ , •` - � _._, , ; :,, .. . . d � : • � . ,. �.. ._ � ! � , . .: . � _ . ,. �. , :_- � , p�i „ j � . �; , . F;. . C . .� :�'.'� �� . , . �o �o .,�� ` (. �:: . � -� � . � . . . � . �. . � . i� ` . . ,��: •. Improvements permit by -- — , ,� - � -. „ p , y p: . 'Contact,a re resentative of the Davie Count Health De artment for final insoection of this system between 8:30-' �>_� -�:�:9:30 A.M:- or 1:00-1:.30 P.M.�on .day of completi�n. Telephone Number 704-634-5985. � _ . ° }� — --- � , � - .i= " Final Installation Dia ram: . System Installed by / ��•�� . 9 , : , � , , . , , ; , . a . � � � �� . . . . ';`l '' " _ ' .. . �<j �". . .. � �. ' �, '. � . , . �,��>,�� . ° ` �+,� ° , . � � . ; . , ; , .a.. _ , k Y� , " � '� �, , . : , , ' . , � ` . . . . �= c .�F . P T„{ -�°� . � � - r . � � �� , �;. ` _� . . i ,. t\ :,:-- n , � . , � .. ,r " , .,, _. :. � . .. � :t '', . ..., ' ' . 4 . . . . _. ..�..�� .. ' . . ) f. � .. .� . .�1� r.0 "�`� � . ' h _. , . (.T . .. . .. - , . ' ,*�.�q� � ' J � rt.. , ' . , . . . ,�.. ... � . �yy . ., . . , �, ,,�l , : �, . • .�' ,� � . � � . � �, : �,�,� � � �; _ - , ._ . � : . , .. . � �.�: � , , � .. r �. ` ;,� � _ . . .:: ,. , < `� ,�- ��,,� 3 . ._ �- � . : = � � Certificate of=Gom letion ,- Date � , �.� p � � . - u ' � _ . ,. . ..�,«.�.,, , 'The signing of this certificate shaU indicate that.the system described abo,ve�.has; been installed in�compliance wi4h . ��; the;standards set forth in the._above regulation, but shall in NO way be take'n,as�a guarantee that the system will func4ion, � satisfactorily�for:any given'period of time. `° � "�� - . , � - � i � � ` , > � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation API'LICt1RI'g'I1�1FOItli�gt�'Y'�01�1 �ROPER'g'X I1�TF'ORl�i[A'Il'dORT Account #: 990006035 Tax PIN/EH #: J700000051 • Billed To: David Beck Subdivision Info: Reference Name: Location/Address: US Hgihway 64 E-27028 • Proposed Faciliry: Residence Property Size: 3.891 Ac Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit / Cu[ FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slope % HORIZON I DEPTH — Y Texture grou C Consistence 5� - , r Structure $ �� 1Vlineralo R�D HORIZON II DEPTH Texture rou Consistence Structure IVfineralo HORIZON III DEPTH Texture rou Consistence Structure 1Vlineralo HORIZOI�t IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTNE HORIZON SAPROLITE CLASSIFICATION LONG-TERIVI ACCEPTANCE RATE , SITE CLASSIFICATION: F' � EVALUATION BY: CJ� ��''�"�-� LONG-TERIVT ACCEPTANCE RATE: �• � OTHER(S)PRESENT: RENTARKS: ILIE�IEI�II� 1Laundlsca��e 1Posikiom� 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 � � 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 � ��NSRS']C�N�IE � VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS -Non sticky SS - Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP- Slightly plastic P-Plastic VP-Very plastic �txuchuxe SC-Single grain ivi-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK- Subangular blocky PL-Platy PR-Prismatic 1�[inexa�lo�v 1:1,2:1,Mixed oRes 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 OS/OS(Revised) ' , � - ' � . . . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation t�P �,YCA1�I'I'IIVFOR1i�A'TIOIV PItOPEit'I'Y IliTFOitli�[A'Il'I01�1 Account #: 990006035 Tax PIN/EH #: J700000051 • Billed To: David Beck Subdivision Info: Reference Name: Location/Address: US Hgihway 64 E-27028 • Proposed Facility: Residence Property Size: 3.891 Ac Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ./ Cut FACTORS 1 2 3 4 5 6 7 Landscape position � Slope °lo HORIZON I DEPTH — � Texture grou G Consistence 5� � ; r Structure g �c Mineralo ��D HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERIvI ACCEPTANCE RATE � SITE CLASSIFICATION: .P EVALUATION BY: C�� '�� LONG-TERNT ACCEPTANCE RATE: �• � OTHER(S)PRESENT: REIVIARKS: ILIE�IEhY�D A,a��x� 1Po itio�x 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 � 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 ��N�n�7C]EN�JE � VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS-Non sticky SS -Slightly sticky S- Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic � SC -Single grain IVI-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic l�iuu�xaao�v 1:1,2:1,Mixed �� 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/daylft2 DCHD OS/OS (Revised) i". .. � � � � � ' � , - - � �� Davic County Health Dcpartmcnt ��•� 210 Hospital Strcct p � �- r-¢. P.O. Box 848 � � � Mocksvillc,NC 27028 �• ••o.�;.:.►• . Phonc: 336-753•6780 Fax: 336-753-1680 North Carotina Public Heatth 0 4 / 1 7 / � 0 1 3 David Bcck 2512 E. Garncr Rd. Ralei�h,NC 27610 *RE: Appllcation for Impro�•ement permit for: Tax Lot: �`Tak Block: Property Site:2687 US H�vy 64 C, Mocksville,NC 27028 . �. _::,. Health Departinent.File No.:_120620- 1 - Dear David Bcck; The Davic County Hcalth Department, Environmcntal Hcalth Division on o a I�i o I � o i a evaluated the abrn�e-referenced prop�rty at the site designated on tlie pladsite plan that accompanied your improvement permit application. According to your application die site is to serve a SINrLE FAMILY with a design tivastewater flow of�gallons per day. The evaluation was done in accordance�vith the la�vs and rules govemin�«aste�vater systems in North Carolina General Statute 130A-333 includin$related statutes and Title 15A, Subchapter 18A,of the North Carolina Administrative Code, Rule. 19U0 and related rules. Based on the criteria set out in Title ISA,Subchapter 18A,of the North Carolina Administrative Code,Rules.1940 through .1948,the evaluation indicated that the site is UITSUITA.BLE for a ground absorption se�vage system. Therefore,your�quest for an improvement pennit is DE1vIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the follo�o�ing: ❑UnsuitaUle soil topography and/or landscape position(Rule.1940) gUnsuitable soil characteristics (structure or clay mineralogy)(Rule.19�1) Unsuitable soil�vetness condition(Rule.1942) ❑Unsuitable soil depth(Rule .1943) ❑Presence of restrictive horizon(Rule.19�) ❑Insu�'icient space for septic system and repair area(Rule.1945) ❑UnsuitaUle for meeting required setbacl:s(Rule.I950) ❑Other(Rule.19�6) These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated se�vage on the ground surface,into surface�vaters,directly to ground�vater or inside your structure. � The site evaluation included consideration of possble site modifications,and modified,innwarive or altemative systems. However, the Health Deparnnent has determined tl�at none of the above options�vill overcome the severe conditions on this site. A possible aption might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. ,. � ' , , '• ; . For the reasons set out above, the properry is currently classified iJNSUITABLE, and no improvement petmit shall be issued for this site in accordance�vith Rule .1948(c). Hotivever, the site classified as Ul'�T5UITABLE may be classified as PROVISIONALLY SUITABLE . if�vritten documentation is provided that meets the requirements of Rule.1948(d). A copy of this ivle is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under�vhich your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an infoimal revie�v of this decision. You may request an informal re�rie�v by the soil scientist or environmental health supervisor at the local healtl� department. You may also r�quest an infotmal revie�v by the N.C.Deparnnent of Environment and Natural Resources regional soil specialist. A request far informal revie�v must be made in�vriting to the local health departmen� You also have a right to a frnmal appeal of this decision. .To pursue a fomial appeal,you must file a pe6tion for a contested case hearing�vith the Office of Administrarive Hearings,6714 Mail Service Center, Raleigh,NC 27699-6714. To get a copy of a petition form,you may�vrite the Office of Administrative Hearin$s or call the office at(919)431-3000 or from the OAH�veb site at http•lhvww.ncoah.com/forms.htrnL The petition for a contested case hearing must be filed in accordance�vith the provision of North Carolina General Statutes 130A-24 and 150&23 and all other applicable provisions of Chapter 150B.N.C.General Statute 134A-335 (g)provides that your hearing�vould be held in the county where your property is located. Please note:If you�vish to pursue a formal appeal,you must file the petition frnm�vith the Office of Administrative Hearings�VITHIN 30 DAYS OF7HE DATE OF 7HIS LETTER. The date of this letter is 04/17/2013 . Meeang the 34 day deadline is critical to your frnmal appeal. If you file a perition far a contested case hearing t�ith the Of�ice of Administrative Hearings,you are required by la�v(N.C. General Statute 150B-23)to serve a copy of your petition on the Of�ice of General Counsel,N.C..Departrnent of Health and Human Services, 20011\riail Service Center,Raleigh,N.C.27699- 2001. Do not serve the petition on your local health department. Sending a copy of your petition to the local health department�vill not satisfy the legal requirement m N.C. General Statute 150B-23 that you send a copy to the Of�ice of General Counsel,N.C.Department of Health and Human Services. You may call or write the local health depariment if you need any ndditional information or assistance. Sincerely, ENVIRONMENTAL HEALTH DIVISION *,R$ 2244-Daywalt.Andrew Environmental Healt Specialist luater and Waste�vater Section Encl.:(Enclose copy of site evaluation) (Copy of Rule.1948) . v' ' � . r ' / � � � . . • . � � �. . . � � 15A NCAC 18A .1948 SITE CLASSIFICATIOti {d)A site classified as UNSUITABLE may be used for a ground absorption sewage ireatment and disposal system specifically idenrified in Rules.1955, .1956,or.1957 of this section or a system approved under Rule .1969 if�vritten documentation, including engineering,hydro-geologic, geologic or soil studies, indicates to the local health department ihat the praposed system can be expected to function satisfactorily. - Such sites shall be reclassified as PROVISIONALLY SLJITABLE if the local health departrnent determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent�vill be non-pathogenic, non infectious,non-toxic,and, non-hazardous; (�) the effluent�vill not contaminate gound�vater or surface water, and (3) the effluent�vill not be exposed on the ground surface or be discharged to surf'ace waters tivhere it could come in contact�vith people, animals,or vectors. The State shall re�rie�v the substantiating data if requested by the local health departmen� � History Note: Authoriry G.S. 130A-335(e); Eff. July 1, 1982; Amended Eff. April l, 1993; January 1, 1990. � Parcel#: J700000051 Page 1 of 1 v��r� Davie County, fVC - Basic Estate Search � .� o��c Davie County Web Site •(��uc��o�cG� I�e�9 I��g�ge 5e�rch V'�x �iIB S��u�c� ��1��S��rc9� l� View Propertv Record for this Parcel View Ma�for this Parcel View Tax Bill Information ��e�cel#:]700000051 �ccoun4#: 8305246 ��rerer SngoPmation Y�x Coc➢es DILLON KATHLEEN J ADVITAX-COUNTY TA 687 E US HWY 64 FIREADVLTAX- FIRE TAX MOCKSVILLE NC 27028 I�Po � IInfforav�agion To�nrwshB Land (Units/Type): 3.891 AC FULTON ddress: 2687 E US HWY 64 ��ed%nfocvnaYion Local�onin Date: 07/2015 Book: 00994 Page: 0646 lat Book: 10 Pa e: 216 �e a!�escri tion �8R1 .891 HWY 64 5767596481 f�ro e b�inees �eau9�iuo : 11163 �3CIF: 1 05 �uoa0: 39 81 P9�u��g: 152 49 5sess�a8: 152 49 ��1f�PP��' Sales%nformation ko. �ooCc ��Q�� Pqonth Ve�r Sns4rument Qual/fDnQual Ser�proded �rice 00049 0645 05 1950 WD Unqualified Tmproved 0 00829 0152 06 2010 WD Qualified Improved 165,000 00994 0646 07 2015 WD ualified Im roved 151 OQO View Propertv Record for this Parcel View Mao for this Parcel View Tax Bill Information G< If8��8dP99 g0��SIC��lPCil ,411 information on this site is prepared for the inventory of real property found within Davie County. AIi data is compiled from recorded deeds, plats, and other pubiic records and data. Users of this data are hereby notified that the aforementioned public information sources should be consutted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County, its emptoyees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or implied, in fact or in law, including without limitation the implied warranties of inerchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnetlView.aspx?prid=1454794 6/22/2016