540 Juney Beauchamp Rd „ . �-,(,�.
' • • ' DAVIE COUNTY HEALTH DEPARTMENT
' , Environmental Heaith Section
� _ P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990002078 Tax PIN/EH#: 5861-52-7021
Billed To: Todd Rumple Subdivision Infa
Reference Name: Location/Address: Reece Way-27006
Proposed Facility: Residence Property Size: see map
ATC Number: 3166
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,S ion.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATE C N TR CTION IS VALID F A PERIOD OF FIVE YEARS.
� � ` � _ � �
Environmental Health Specialist s Signature: ��� Date: � ''7 If
�'�' ,�J��O�v�f'
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementlOperation Permit
has been installed in compliance c e o . Chapt 130A,Section.1900"Sewage Treatment and
Disposal Systems,”but shall in O WAY be taken as a gu �that the system will function satisfactorily for any
given period of time. .��3a
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_ Septic System Installed By:
Environmental Health Specialist's Signature: Date: /lf����
DCHD OS/99(Revised) -
DAVIE COUNTY HEALTH DEPARTMENT
. Environmental Health Section / � v
� ' � P.O.Bog 848/210 Hospital Street � K � � ( �
� . �� Mocksville,NC 27028 �
' (336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002078 Tax PIN/EH#: 5861-52-7021
Billed To: Todd Rumple Subdivision Info:
Reference Name: Location/Address: Reece Way-27006
Proposed Facility: Residence Property Size: see map
ATC Nurr�ber: 3166
**NOTE** This ImprovementlOperation 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
PERNIIT 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:� Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste:0
Lot Size Type Water Supply Design Wastewater Flow(GPD) 'L�Q Site: New� Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width��Rock Depth�/Linear FtvGC!
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6°�BELOW
FINISHED GRADE. ****NOTICE: C presentarive o vie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day o ' stallation. Telephone#is(33G)751-8760.****
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Environmental Health SpecialisYs Signature: Date: � "'�.�� ��
DCHD OS/99(Revised)
. ' • , . /�� � � �1.�.�Gl
/
,; D � U� � 0 � � PLICATION FOR SITE EVALUA710N/114iPROVFMCNT PERI4�IT Sc ATC � ,
Davie County Health Department � � �
i ��(� �1 Environmenta/Health Section � `f�
" I ' ��u� :p.0. Box 848/210 Hospital Street �/a�'
Mocksville, NC 27028 �j�l/
ENUIROVh1ENTAl HEALTH (336).751-8760 U .
DAVIE COUN?Y �
***ZI�ORTANT*** THIS APPLICATION C1INNOT BE PROCESSED UNLESS AI�L THE REQUIRED
INFORI�,TION IS PROVIDED. Refer to the INFORI�+.TION BULLETIN for instructions. '
�" lr1 '� ��I� I Dc% 12�►,�Pl�
1. Name to be Billed � �C' U Y+'1 , Contact Person
Mailinq J�ddress � � �n �(��-+�/rr,'� F� �' Home Phone ��(� - 7J � ��'{ � /�
City/State/ZIP mQ��� . /�(.(�L� L 7��.� Business Phone ��L� � �7 ! -'�_�C7 �
�/ �l �� 1
2. Name on Permit/ATC if Different than Above /��F�111 L-'T h i. � ���G n_,�-�-� �i !t
tsaiiing �.ddress � �� .J,�nP�i Vl'c:��yr1-,n��1 City/Sta Zi �c1 J�n('s !\�,C' �� D D�
/ 1� �j /
X 3. Application For: � Site Evaluation �dv �t�rmit/ATC ❑ Both
. / � J
4. system to service: �" House ❑ Mobile Home 0 Business ❑ Industry ❑ Other�
5. If Residence: # People � # Bedrooms / # Sat s �
Gl Dishnasher Q'Garbage Disposal Cd'Washing Machine ❑ Basement ing ❑ Basement/No Plumbing
6. If Business/Industsy/Other: Specify type J 9 People Ik Sinks
� Commodes # Shoxers # Urinals t Water Coolers
IF FOODSERVICE: # Seats Esti.mated Water U3age �gallons per day)
7. Ty�e of water supply: 4�'County/City ❑ Well ❑ Community
s. Do you anticipate additions or eapansions of the facility ihis system is intended to serve? ❑Yes p�o
If yes,what type? -
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTEll
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMIT7'ED by the client with THIS APPLICATION.
Property Uimeosions: ' 9���"����oZ����f X ����9�X�3�WRITE DIREC'I'IONS(from Mocksvilic)to PROI'LRTt': y
Tax Office PIN: # ���f� � / �� �, �W��i �sd �??wc_��S <�e��•�-�on S
Property Address: Road Name �.�t LQ . _ln��„L., ��l„�- cih 1 �r�p,, �t'�t c� r f,-,4�'(
i � �
City/Zip�'1T�/t!n .+� :�,7��(o ��c �.�1 (Jv� 1< � _�n t•J c+�,/
,�( If ia a Subdivision provide information,as follows: �°J✓►<� G l /; G'u ) p I ����.� c� ] D'{�
Name: � ! S Ov� �.� /'�
Section: Block: Lot: �1('Date Property Flagged: 1 � r �'�� l
This is to certify that the information provided is correct to the best of my kaowlcdgc. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the sitc plans or intended use change,or if the information
submitted in this application is falsified or changed I,also,understand 1/:at 1 am responsib/e for al!clrarges i��currerl froin
this application. I, hereby,give consent to the Authorized Representative of tlie Davic County Healtl� Departmcnt
to enter upon above described property located in Davie County and o�vned by �� e nn�-�1� I�. I��F�cQ t�
to conduct all testing procedures as necessary to determine the site suitability.,
�
DATE I '�,`�� "' O I 51GNATURE �� . /�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: Existing and proposed
property lincs and dimensions, structures, setbacks, and septic Iceations).
Site Revisit Charge
�� Date(s):
`� � Client Notification Date:
4,'�`� ��� .
�� � .. . EHS:
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.. . . Account No. �� (_
Revised DCHD(07/99) Invoice No. �`P��2
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IitiHt ttto pr�perta• ilnc_ , tarat nf ail structnrPs nrr ar.r.ur�tn�}� ahnu•n hcrcon: that na at;�ictur� li�catcd on thla pr��perU�
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D.B. 132�- P. 591 � D.9. 29-P. 103 .
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. `tliat thc prvperly lines and l��calion of al1 struclures are �ccur�lely sl�o�vn l�creon; Ihnt uo stnicture lucnted on thls property
cneroaches nn �ny �djac��nt slrc•�•1 �n• prii����rtY. and Ih:�l no slrucltn•�• on �djna���l �rro�mrl}• eucronches on U�e pretnises
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`� MIC{-IAEL LEE NO01<ER
PARCEL JS U.D. IGI- IZJ
ELMO AV-L"RY BYERLY 3
D.8. 160 -254 _�� 'cn
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. tound 191.96 . � � . v<°°
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PARCEL 5 . TnX MnP F-7, CHnR�ES MICHAE� wA�L, 0.6. 160-a96
PROf'E�TY OF
I�CENNF_TH P. DUNCAN and JOY R.
LOT NO. �7•�� Mqp pF DAVIE COUNTY TAX MAP E-7 BLOCK NO. �
144 759 �ARMING7UN iOWNSHIR
� • • � � � � �• OCE 0 BOOIC I 5 5 pAGE 5 2� D AV)E COUNTY� N. C.
SCALE: 1 INCN- -I OO FEET 2 Q 6('j_F
JO� NO
�OVTN[11N •woto ►niHi • •u�r�r CO:WIN�TON•1AL[Y N50�'i �
'
,• , DAVIE COUNTY HEALTH DEPART'MENT
. � - � •� � � Environmental Health Section
. • Soil/Site Evaluation
� APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002078 Tax PIN/EH#: 5861-52-7021
Billed To: Todd Rumple Subdivision Info:
Reference Name: Location/Address: Reece Way-27006
Proposed Facility: Residence Property Size: see map Date Evaluated: �.2''��''�J
Water Supply: On-Site Well Community Public v
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition L.
Slo % �
HORIZON I DEPTH `
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH y�' 1i
Texture ou �'�
� Consistence ,-
Swcture � /
Mineralo ,- /
HORIZON III DEP'TH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEP'TH
Texture rou
Consistence
Structure �
Mineralo
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
truct r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
otes
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-tertn acceptance rate-gaUday/ft2
DCHD OS/99(Revised) �
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�:..�...�..�..�r.__.� _D��li��OUNTY�i�I.'T�I�DE�tT1VI�NT ...��.�:,,..,.:.�`�a
ENVIRONMENTAL HEALTH SECTION w� �
P. O. Box 848/210 Hospital Street �
Courler #09-40-06
Mocksville, NC 27028 ._
' 'Phone #: (336)751-8760 ' . ';.
December 13 , 2001
Todd Rumple �
126 Summit Drive
- . Mocksville,NC 27028
Re: Site Evaluation/Reece Way _ �
Deaz Client(s):
As requested, a representative from this o�ce visited the aforementioned site on
December 13,2001. Based upon the information provided on the Application for Site .
Evaluation and after an evaluation was completed on the site,the site was found to be ".
provisionally suitable for the installation of a modified,oversized on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate ?
application must be filled out and the house/mobile home location staked off. .
If you have any questions, please feel free to contact this office. �
Sincerely,
�a�'�����• .
Robert B. Hall, Jr., R.S.
Environmental Health Specialist -
x�-va� .. ._
Enclosure(s)