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150 Laurel Brook Ln S. as r :["r•'.i «. 4� Styr:. '4 �-'' 6„r: .t. ='i�r e• •�µ`a—`d xJ.i.-�>.n, >..d..� _ `w.c.•+- .�Y'w '^w'a. �;;,:•.r -.:y..:., Pormittee's. DAVIE COUNTY HEALTH DEPARTMENT lyime: .. lj o' Environmental Health Section PROPERTY INFORMATION P.O. Box 848 .Directions to�property: / 014- .) 1��►4 &I • Mocksville,NC 27028 Subdivision Name: Phone#:336-751-8760 Section: Lot- ^1 2­ Section: FOR:, CSV- , -sr 64 WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION AUTHORIZATION NO:. "r O A Road Name: Z **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County.Building Inspections , Office when applying for Building Permits, (In compliancS with Article 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION /do q— o—J • IS VALID FOR A PERIOD OF FIVE YEARS. NV EALT P ST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE ��ut)S�#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIALL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE✓r"'t'IPE WATER SUPPLY 1 - DESIGN WASTEWATER FLOW(GPD) NEW SITE.--- REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Jc LINEAR FT. OTHER I lS rQ t�tJT t�J '7� REQUIRED SITE MODIFICATIONS/CONDITIONS: �� i 5 ' . IMPROVEMENT PERMIT LAYOUT, , -n t"' . , 13 D7T . SOIL 'n S�STi •. C-.P�c-1� F'i "Tui 1 T **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH D ARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. . OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DOHD oasoz(Revised) aW.* .-t a✓•'�'w � lw-,....La«K� ... - .. -✓ r'N`�'` §. Hca'+ x..�,.«i:.r��..K,....<r r....�a- ., "4 �i.'.,,5�.,,_,,..�_ y.,' ..h.r` tees.- + - DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section- PROPERTY INFORMATION P.O.Box 848 r , Di �Cti t s t iropertq: ta,C'14-+--$ V���� " Mocksville,NC 27028 Subdivision Name: �-r� �`1'-G'►� r Phone#:336-751-8760 f ,tel w,�F- ;�� ..� Section: Lot: .} AUTHORIZATION FOR t�l• U WASTEWATER Tax Office PIN:# - SYSTEM CONSTRUCTION "`fAYfTHORIZATION NO: 2450 , A Road Name. I�L 'L�," tp: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliant with Aiticle l 1 of G.S.Chapter`130A,`Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) - ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 0Z IS VALID FOR A PERIOD OF FIVE YEARS. V EALT` SPE ALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE —1,0) ;_#BEDROOMS L� #BATHS'+•�' #OCCUPANTS 1 `" GARBAGE DISPOSAL:Yes or No i COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE-' "TYPE WATER SUPPLY Lt 1- DESIGN WASTEWATER FLOW(GPD) � NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.l ?� OTHER' REQUIRED SITE MOD NS: IMPROVEMENT PERMIT LAYOUTrN • fr + G) � 3 ' b t b COT' StA I`k T' **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH D ARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT:., SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: w*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. ncEm ovaz(Revised) `� 7.3 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME fJL WItS � PHONE NUMBER .�2t ADDRESS b "Ly2'L�"1-l?QjVQ14- L-tJ SUBDIVISION NAME LI�� L `�►� LOT# "Z DIRECTIONS TO SITE DATE SYSTEM INSTALLED 02 NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS L/ NUMBER PEOPLE SERVED 3 TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING DATE REQUESTED f INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1193 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 8481210 Hospital Street MocksAlle,NC 27028 (336)751-8760 Account #: 990001754 Tax PIN/EH#: 5863-57-1695.042 Billed To: Rodney Wilson Subdivision Info: Laurel Brook Lot#4-2 Reference Name: Location/Address: Griffith Road-27006 Proposed Facility: Residence Property Size: 5.310 acres ATC Number: 2861 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" N Z,4'— S VALID 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 descn n lmprovement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A, .1900"Sewage Treatment and Disposal Systems,"by�shall in NOWAY betaken as a guarantee tem will function satisfactorily for any given period of time. "i c 0 itpJ V6 Q� ta o Af t r yoj a o S opo — �. L�,.�: A „� Pur►P TANS. Dort- - Septic System Installed By: l Environmental Health Specialist's Signature: V k-/ ate: l7Z DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT / • Environmental Health Section fc( -2- P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001754 Tax PIN/EH#: 5863-57-1695.042 Billed To: Rodney Wilson Subdivision Info: Laurel Brook Lot#4-2 Reference Name: Location/Address: Griffith Road-27006 - Proposed Facility: Residence Property Size: 5.310 acres **NOTE*N'1'hI mprov8ement/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 flok)SE #People 3 #Bedrooms L4 #Baths 4'5�' Dishwasher: Garbage Disposal: Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift `#r,Seats Industrial Waste: Lot Size 5.3 �� Type Water Supply � . Design Wastewater Flow(GPD) LP8� Site: New Repair System Specifications: Tank Size1000C'AL. Pump Tank ICWGAL. Trench Width Rock Depth 12 Linear Ft. Other: l�I ST-& Tip,) J�V�S, /,JS7-4 U,- O•C, nt?'-j. Required Site Modifications/Conditions: IJ JTI\LL- 0-) C.O^j TW ii Y—--f 10,©(T P L'IjZ, tit 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 betw 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#is(336)751-8760.**** SR-AsN geX, APP¢oc, �80� (ZzV 1 Sc� Cstap :!* x l$ Iv x }�aJse N ckP °' 49tox 14D' Z Environmental Health Specialists Signature: Date: 5/-5)/0) =o DCHD 05/99(Revised) I lop P ig � • Pea uLie �, i M LICATION FOR SITE EVALUATION/IMPROVEM1IFM PE-IINIIT&ATC Davie County Health Department Envirwnmental Health Section MAY 1620 P.O. Box 898/210 Hospital Street Mocksville, NC 27028 ENVI DAV E COAL HEALTH j (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. (Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �y�D AtM C \W' ��/� + Contact Person {q,()q�Q 1 1 Mailing Address I S Gh ny,�' ��1 Home Phone 1 6-70A City/state/ZIP Y-1�U►�(1L IVC ��t ](o Business Phone �336) 345-aa8 g 2. Name on Permit/ATC if Different than Above 4 S0.MQ_ Mailing Address City/State/Zip s. Application For: �2 Site Evaluation l�mprovement Permit/ATC B�Both a. System to service: V House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People f Bedrooms 14 tt Bathrooms q . ❑ Dishwasher ❑ Garbage Disposal VWashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Induatry/Other: Specify type I People It sinks to Commodes f showers # 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 ko If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE RL•QUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: - ® G p WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # ✓r8lo 3'.S? '!d 9 fy i�- �• 0 ?01 t } Property Address: Road Name (;(f t �l T'/1 U4 by�DI44-1-,o n! ?D I J-D City/Zip If in a Subdivision provide information,as follows: 3 rw� Its a ry I-/.,,&-r-U ddLvl ) Name: !-4'Ph'w 0&L 0-,D a XC 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 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 QpA, to conduct all testing procedures as necessary to determine the site suitability. DATE J� D( SIGNATURE K—v) 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): b 3 r Client Notification Date: EHS: Account No. � Revised DCHD(07/99) Invoice No. t1. N�4,3$ E EIP IP Q _ 7 LC TA} pc� 433 95 S\p �'s E TSP � s .r-woys. CSF` N7A�348 sd, �� ooeo. or F� 35 0 Sp pS. " court. NPS ` EIP Z 00 ^ F ,cgdred by --r V . C4 cs WIn Or ^oY De N �isbed 20'40'35"E I Z z 90.25' NPS N21'39'34"W TRACT 1 TRACT 2 /40.60' AREA = 5.310 ACRES AREA = 5.365 ACRES DB 318 899 HANES CONTRACTING INC. NPS N53'39'09"W DB 318 899 PART OF LOT 4 PB 7 PG 106 ANPG 899 38.30' PART OF LOT 4 PB 7 PG 106318 PART OF TAX BLOCK 670106 LOT 4 OF PB 7 PG 106 N47'23'27E,� NPS PART OF TAX BLOCK 870106 LOT 4 OCK 870108 LOT 3 32.82' NPS NIP N35'21'04"W •' 59.31 h N53'51'1 4"E NPS C ! / 41.26'✓ OF NPS STRFTCy �n N18'47'41"W 38.55' 4 N30'20'29"E NPS PROPERTY LINE BEGINS FOLLOWING 56.77 / 3�v "s �/ ��CENTERLINE OF CREEK AT THIS POINT 4, N o g 33 pEIP NIP NPS N719.07 "E n EIP 39.07'(1) < \ OR, n HIS PLAT WAS DRAWN UNDER AFF EY MADE UNDER MY > 3 DED IN DEED BOOK 318. N68•� IP ' SURVEYED ARE SHOWN AS 'ION FOUND IN DEEDS AS �Sg 5"W Nf{y O <o 3 u� AS CALCULATED IS g�' N68.�C�HF P _h N ?D 1N ACCORDANCE WITH G.S. 0 6 DAVID M. HANES CONTRACTING INC. 3p D h PHIS 4th DAY OF MAY 2001, DB 159 PG 229 00' = I DB 92 PG 540 245 N7 '36' LAND SURVEYOR TAXD BLOCK GB7 LOT 40 / 5 "w S13?1'I EIP EIP 60•F 60.08,"WI (r NIP / 4p 0— EIP 76 35"w 7NAL LAND SURVEYOR, DAVID M. HANES CONTRACTING INC. / HE FOLLOWING DB 183 PG 694 THAT CREATES A SUB- / TAX BLOCK B7 LOT 49 4REA OF A COUNTY OR ANCE THAT REGULATES I -VOT NUMBER I LC NOTES TAi I. RAW ERROR OF CLOSURE 1:10.000+, MISCLOSURE WAS DISTRIBUTED BY COMPASS RULE. 2 AREA DETERMINED BY COORDINATE COMPUTATIONS. 3 DASHED LINES REPRESENT INFORMATION TAKEN FROM DEED OR PLAT 4 DISTANCES SHOWN ARE HORIZONTAL GROUND DISTANCES =12 (No 4 REB.AR ��,_-�� ')THERWISE NOTED) UNLESS NO-5D OTHERWISE ocrFRFK!'cc • DAVIE COUNTY HEALTH DEPARTMENT • "� Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001754 Tax PIN/EH#: 5863-57-1695.042 Billed To: Rodney Wilson Subdivision Info: Laurel Brook Lot#42 Reference Name: Location/Address: Griffith Road-27006 Proposed Facility: Residence Property Size: 5.310 acres Date Evaluated: 2 9 d/ Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 4 5 6 7 Landscape position L Slo % '20 ET_HORIZON I DEPTH 2 -t Texture group 5C-L, SCI. L Consistence 55 SP pr r Structure Mineralogy1 1: HORIZON II DEPTH 2lip 217- 1W Texture groupQ Consistence G: 19. Structure '5M4 A7kAW Mineralogy I; I Ml v)(&,) 1) HORIZON III DEPTH I Texture groupc Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS . san RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION $ LONG-TERM ACCEPTANCE RATE O' Eq SITE CLASSIFICATION: EVALUATION BY: C.4 d LONG-TERM ACCEPTANCE RATE: D -OTHER(S)PRESENT: 5 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) ■■■■■■■■■■■■■■■■■■■OO■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■M■■■■■■ ■■■■!���■■■11�!alit:�Y■i■If��J■■■e■■■■■ii■■■■■■■■■■■■■■■Nee■e■■■■■■■■■■■■ ■■■■■■■■■■■■■■1�:��s���■■■■■■■■■■■■■■■NOON■■■■s■■■■■■■■■s■■■■■■■N■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■: ■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■e■e■r�■■■s■■�■ass■■■■■■■■■■■■■■■■■■N■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■��■■■�.�■■■■■\\■■■■■■■■■■■■■■■■■■■■■■■■■■■■NONE ■■■■■■■■■■■■■■■■■■■■■■��■■■\■■■■■■e,■■■\■■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■Nee■■■■■■■■■■■■■■■■■■■■■n■■■■■■■■■■■en■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■!■■■■■Ii.■u■1�1■NOON■■■■e■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■N■■■■■�r■■■■■■11■Il■■■NOON■■11■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■s■!e■■■■■■�■■■■■NOON■■11■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■�Ir,■e■s■■■■■!■■■■■■■■■■■■NOON■■11■■■■■■■■■■■■■■■■■■■■■■■ ■■NOON■■■■■■■e■■■■■N■■■e�==�:::�� :�::�■::�■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■�::��■■■.,sae■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■E■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■