289 John Crotts RdDAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section /
• P. O. Boa 848/210 Hospital Street `� �// ll o /
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001186 Tax PIN/EH #: 5748-83-0810mp
Billed To: Mary Pegram Subdivision Info:
Reference Name: Location/Address: John Crotts Road -272028
Proposed Facility: Residence Property Size: 1.05 acres
ATC Number: 2697
**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 DO rv\ V-% #People #Bedrooms 3 #Baths :2. ��-
Dishwasher: 0"- Garbage Disposal: ❑ Washing Machine: Er�- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type//11 #People #People/Shift #Seats Industrial Waste: CI
Lot Size -OS Type Water Supply�,ptVL�Design Wastewater Flow (GPD) 2-�00 Site: Newe Repair ❑
System Specifications: Tank Size[lJl-('AL. Pump Tank GAL. Trench Width Rock Depth Linear Ft. 300,
Other: 1-'`�T�f?,�TIO�
Required Site Modifications/Conditions:
t
5 09::F AA- I.
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED JEFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the D vie 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 y of installation. Telephone # is (336)751-8760.****
cp�
r
J
y
o.
'�.TO
aVL?ov� -7j.
bw N
c'
r
}
F2otz T'
Environmental Health Specialist's Signature:
CHD 05/99 (Revised)
--d t.} t- j
C�'f1 !�, �
GIOt
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001186 Tax PIN/EH #: 5748-83-0810mp
Billed To: Mary Pegram Subdivision Info:
Reference Name: Location/Address: John Crotts Road -272028
Proposed Facility: Residence Property Size: 1.05 acres
ATC Number: 2697
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 WASTE CO N IS FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatu e: Date: ! S
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.
la
L ,off
i
�✓<
(✓ 4.0
Septic System Installed By: 1LQa
Environmental Health Specialist's Signature : Date•
DCHD 05/99 (Revised)
EVALUATION/IMPRO
APPLICATION FOR Davia County Health Department PERMIT & AT
Eni ironmenfa/ Heath S& on "'
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 L., `--
(336) 751-8760
ENVIRONMENTAL HEALTh
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEREQU "
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed C" W • r&rfl Contact Person 1 1 �L � (r'
cP
Mailing Address jk4/� l Home Phone
City/State/ZIP 0ief'yNvroAS . 1 VL+ Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: ❑Site Evaluation sImprovement Permit/ATC ❑Both
4. system to Service: ❑ House Mobile Home ❑ ��Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms 139-1
Dishwasher ❑ Garbage Disposal 1 Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type
# Commodes
# Showers
# People # Sinks
# Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: , County/City ❑ Well ❑ Community
�
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes (/No
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: - C)5 4(24-e,5 WRITE DIRECTIONS (from Mocksville) to PROPERTY::
Tax Office PIN: #t1 %yg- g.3 _ � gl � Nw�t 64C /- 01) Aey)A AlgkCi)
Property Address: Road Name n kscz?l»en Ua-h o &ate
City/Zip &&k6k lk- .2'720,ek � ✓Qt?�11� fob Doh %)'Re -f-
If in a Subdivision provide information, as follows: X10 6)1) orete i C 7"ek 8/y1al
II
Name: - f' 4- ejuded
Section: Block: Lot: Date Property Flagged: 0"-7
{,bme bd�4n xi II Lx--, /did cel` 6y
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 L• p r pJt LLC
to conduct all testing procedures as necessary to determine the site suitability. ty�nsr� �rc'-A-YN , m the ,
DATE- - L -/)I SIGNATURE
T
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include 1 of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
• 1E/J
Revised DCHD (07/99)
c'Zua4/�-
I%
EHS:
Site Revisit Charge
Notification Date:
Account No. `
Invoice No.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Suction Va 8 2000
P.O. Box 848/210 Hospital.Street
Mocksville, NC 27028
(336) 751-8760 ENVIRD VIE OUNT EALTH
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for
j�instructions.
1. Nass to be Billed—Pp r /C -"Slim( -G4 t contact Parson T �"� W/ -CrcA- Q
Mailing address 5q 114 ,) l.t�'t4n yAappn1d- L n, Home Phone -22-3(- N 'I 1pr2- 19 y 1
City/state/ZIP W l to Jen -� iCI'1'l +v �C 1(03 swine. ((P��'h�'one`aJ1 � `�- 3o a %
2. Name on Permit/ATC if D�i(ff(e�reenjt, than �Abo�vs -S.�c yy-, ,-j � —RkAV\ Carr\cr V\e,(ITs
Mailing Address � l 14 U `� oil u,%Y 6 L6 , City/state/Zip
3. Application For: "ite Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to service: X House ❑�tMobile Home ❑ Business ❑ Industry ❑ Other
S. If Residence: # People tet^ # Bedrooms # Bathrooms
Wbishwasher hVearbage Disposal U4ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type
# People # sinks
# cc # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: • W" ounty/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system Is intended to serve? ❑ Yes %-No
If yes, what type?
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /r ' I" &r. -S
Tai Office PIN: #. ff 2 !tg —'9:3 0 16
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
MLJa Co* C. -/a 13CACA C�urc-, RD.
Property Address: Road Name Za9 J-0nne(DA$QD i3eAcf C6mL R.D — 6ecomcs5 3-okn G[Z.C*i' tZ D
City/Zip fi\bg'-KSU i t k'&.4h,-( C urcl- P..A 4-u r s 1-4 Con4 ,n LJ
Q -102a
If in a Subdivision provide Information, as follows: of-%. Solnrn Croom at) 4.0c. Wu5c-0►Z L&4
Name:
Za9��kn Cro 16 JiDi vRcav4 Lot -t"Crnq
vc,54Z, P -p 73 so.' roQcc-4--,r3l
Section: Block: Lot: Date Property Flagged: `b' 141 - O O
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 Ith Depa ent,
to enter upon above described property located in Davie County and owned by �t�rl ..J -r. erl Ct ` J e -t r -S
to conduct all testing procedures as necessary to determine the site sujt4ility.
DATE'- /<s -ool� !00 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SFFE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
��sT:.9co
Revised DCHD (07/99)
-&V
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. ` c�
Invoice No.
UK
E6Z
WO
(6CZ)
OLZ
Z9£9
(vs,a)
EL'Y LY
Davie Countv Wealth Department
Environmental ,Meal th Section
Po Box M / 210 Hospital street
MocksvWe, NC 27028
Phone: (336)751-8760
August 28, 2000
Mrs. Pat Garrett
5914 Cottonwood Lane
Winston-Salem, NC 27103
Re: Site Evaluation -
1.4 Acre Tract/John Crotts Road
Tax PIN #: 5748-83-0810
Dear Mrs. Garrett:
As requested, a representative from this office visited the above site on August 24,
2000. 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.
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 note that the septic system for the existing dwelling at 289 John Crofts
Road encroaches on the 1.4 acres that is proposed to be cut out of the parent parcel. A
deeded easement for this septic system should be included in any real estate transaction if
there are no plans to move the system.
If you have any questions, feel free to contact this office at (336)751-8760.
Sincerely,
Jeff G. Beauchamp, R. .
Environmental Health Section
enc(s)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
'APPLICANT INFORMATION
Account #:
Billed To:
Reference Name:
Proposed Facility:
Water Supply
Evaluation By:
PROPERTY INFORMATION
990001369 Tax PIN/EH #: 574883-0810
Pat Garrett Subdivision Info:
Location/Address: 289 John Crotts`Rd-2 028
Residence Property Size: see map Date Evaluated: 95 9 Dr7
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1 2
3 4 5 6 7
Landscape position
L
t,
Slope %
3 Zo
HORIZON I DEPTH
O ' 14 e;'
D —10
Texture groupii
Consistence
SS
S
Structure
G�
Mineralogy
HORIZON II DEPTH
Texture group19C
C
Consistence
F SS RSP
S
Structure
S
Mineralogy
HORIZON III DEPTH
Ill- V0
Texture groupG
f
Consistence
;SO
Structure
S_P
e-
MineralogyI
HORIZON IV DEPTH
b
Texture groupS
Consistence
Fr
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE ID
SITE CLASSIFICATION: 'OS
LONG-TERM ACCEPTANCE RATE: o - d
REMARKS:
EVALUATION BY/�
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)
■■
■■■■■
■EN■■
■■NE■
■EN■■
MESON
■EN■■
■■■■■
MEN
MEN
■E■
■
■
■
■M■MM■
■M■■M■
■E■MM■
■M■MM■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■E■■■■■■■■■■M■■
E■E■■EM■■MME■■■
■■EMME■EMEMM■E■
■■M■MEM■MEM■MM■
■■M■ENEME■■■ME■
■■MME■■MM■MEME■
■EMEM■MMEME■E■■
■EME■EMEMEME■■■
■■■■MEMME■■E■E■
■■■■MME■M■MMEM■
■■O■■M■M■MMEME■
■MME■MEM■M■■M■■
■■■M■ME■■M■E■■■
■EME■EMEM■M■■M■
■EMEMMEM■■E■ME■
■MEMMEME■■E■■E■
■EM■MEMM■■■E■■■
■E■■M■■■■M■M■■■
■■■■■■E■■■■■■■■■■■■■■■EONO N■■ ■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
momom liiiiiiiiiiiiUNo
■■■■■■■IIS■e■■■EN■■■SNE■■■■L►.1'zllf.`JL�::iYIZ�J■■■■■■■■■■■
■■■■■■■11■■■■■■■■■■■■■■■■■car■■, ■■•■■■■■■■■■■■■■■■
■■■■■SSIISNS■■■ME■N■e■■■■■■■■■ ■■■■■Sm■■■■1'r7%1■■■■
■■■■■■■11■■NNS■■■■E■■■■■■■■■■■■■■■■■■■■■■■■11■■.i■■
SEEN
moos
■■■■
■■m■
NOME
■■E■
■■N■
■■■■
OMEN
■■E■
NOME
■
■