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290 Leatherwood Trail
r \ ��+ J ,�w � . - DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section _ - P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003491 Tax PIN/EH#: 5769-66-9009 MH Bitled To: Mark Holbrook Subdivision Info: 2L�0(��{���i ( Reference Name: Location/Address: Leatherwood Dr�e�e-27028 Proposed Facility Residence Property Size: 5+acres ATC Number: 3992 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED 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 Treahnent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER C TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: ?��� Dat��e( ��'� 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 Treahnent and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any giyen period of time. c �a y� , � fi� �� tt'e � �� � �e , Septic System Installed By: �?1��� '� / Environmental Health Specialist's Signature:���/ Date: � ! DCHD OS/99(Revised) , . ' , ;.. DAVIE COUNTY HEALTH DEPARTMENT . � ,,.- � > ' Environmental Health Section ' P.O.Boz 848/210 Hospital Street �� ? .,� Mocksville,NC 27028 //�� (336)751-87G0 . �i IMPROVEMENT/OPERATION PERMIT � Account #: 990003491 Tax PIN/EH#: 5769-66-9009 MH Billed To: Mark Holbrook Subdivision Info: Re�ference Name: Location/Address: Leatherwood Drive-27028 � Propbsed Facility Residence Property Size: 5+acres ATC Number: 3992 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiJTHORIZATION 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 // #People�_ #Bedrooms � #Baths �. Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: � BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply e�/ Design Wastewater Flow(GPD) ��� Site: New� Repair❑ System Specifications: Tank Size��GAL. Pump Tank GAL. Trench WidthC�� �Rock Depth���Linear F�� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6°�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 of installation. Telephone#is(336)751-8760.**** ��� �� ,6 � ��� y�r`�s--����.z�� � � re�(�l��� �J �� U ��jP'�YJ,Py 6 /� �-�l� ��. � r : ;Q Q�v�rr�E� �-- � � . � Environmental Health Specialist's Signature: !� Date: 5 �� DCHD OS/99(Revised) ,� . � , , �. .r .. .� . � . . � .. � . ' . . . . . , ', .a. . ' ' . � � . .J � ^� 'r �v � Q hR +. .. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE � V � Davie County Health Department Environmenta/Hea/th Section �E� P.O. Box 848/210 Hospital Stree 9 2005 Mocksville, NC 27028 (336)751-8760 DtiNIRONII��rT _ �H ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE''REQLII .ED INFORMATION IS PROVIDED. Refer to the INFORMATION SIILLETIN for instructions. 1. Name to be Billed _�"'�(�`�(_�)'1'`�1,��5 ��� Contact Peraon �Qr(5 //Q/�/�0({� Mailing Address J-1� I I I('��'(1�(T�.rl �► Home Phone 33�0 /� "( � City/State/ZIP ��(1�� , N��� �g�p�� Businesa Phone 3Jc0 %�- J 2. Name on Permit/ATC if Different than Above �Ql(�� Mailing Addresa �C'�.�� City/State/Zip J�'(�� 3. Application For: ❑ Site Evaluation LK Improvement Permit/ATC ❑ Both 4. syatem to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry � Other 5. Type aystem requeatad: ❑ Conventional ❑ conventional modified ❑ innovative 5. =f Residence: # People 2 # Bedrooms � # Bathrooms � 4�Diahwasher �arbage Diaposal _ ❑Washing Machine BSasement/Plwnbing ❑Basement/No Plumbing 7. If Buainesa/Induatry /Other: verify type # People # 3inks # Commodea # 3howera # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gailons per day) 8. Type of water aupply: ❑ County/City � Well ❑ Community 9. Do you anticipate additiona or expansions of the facility this system is intended to serve? ❑Yes �'No If yes,what type? ***IMPORTANT'"**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with TFIIS APPLICATION. Property Dimensions: �1�-a-�� WRITE DIRECTIONS(from Mocksyille)to PROPERTY: Tax Office PIN: # s �`1—G-� "' l � � ' Property Address: Road Name�-�'�ti►�•� Tr�-w�� \��- ��G�'� City/Zip % If in a Subdivision provide information,as follows: , Name: � \ �`. Section: Block: Lot: Date home corners flagged: m � 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,a[so,understand tl:at I am responsible for�rll charges incurred from t/eis 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 to conduct all testing procedures as necessary to determine the site suitability. DATE � "O��-� ,�j SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(I de 1 of th low��: Existing and proposed property lines and dimensions, structures, setbacks, and septic locat' 1 ' Site Revisit Charge at ): � Clien tifi 'on Date: c��� �' �� _�',� E . �.- �� � q Sign given_ .�� � Account No. �`� ! Revised DCHD(OS/03 Invoice No. q '� � � � , � r . . , �R� . �� � � � 0 � � APPLlCATlON FOR SITC EVALUATION/IhtPROVEhfENT PER F� � � � Davie County Health Department . Environmenta/Hea/thSecGon �fAN 1 4 � 2005 P.O. Box 898/210 Hospital Street Mocksville, NC 27028 � (336)751–a760 ENVIRONMFMA�p DAVIE COUN� ***IMPDXTIINZ'*** T�iIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVID�D. Refer to the INFORtdATION BULLETIN for instructions. i. Namo Co bo Dilled �/rr.��/ ��„1tG� Contact Pernon 1 Mailing Addrena d CG� Homa Phone City/Stata/ZIP /'�'{UCi� ��d Z�IIuainoss Phono �y���G'� �s p 2. Namc on Pesmit/ATC if DifPerent than Above Mailing Addreas City/State/Zip r 3. Application For: �ite Evaluation ❑ Improvement PQrmit/ATC ❑ Doth 4. system to serviccs �Houso ❑ Mobile Homa ❑ Business ❑ Industry � OEher 5. . Type ayatem requested: ❑ Convontional ❑ conventional modifiod ❑ innovative 6. =f Residence: , i� People �_ # f3edrooma r�_ i} IIathrooms Y� A�iahwaaher GLJ arbago Di�posal F�ifias2i�iig Machino aement/Plumbing �Dasement/No Blumbing 7. I If Du�ine�s/Industry /Othor: verify typa # Poople # Sinks @ Coa¢aodas # Showera # Urinals � Water Coolars IF FOODSE$VICE: �� Seatn Eatimated Water Usage (galionu por day) s. Typo ot water supplys ❑ County/City �1 0 Community 9. ao you anticipato addiaioaa or cxpansions of tlic facility tl�is systcm is intendcd to scrvc?�1'cs ;: $�o�----- Yf ycs,ivl�at typc?, , , ***Il{iPORTANT"'**CL1GN1'S AlUST COhtPL�TL•TII� RIQUIRED PROPCRTY INI�ORMATION R�QUGSTCD . • BGLO�V. �ithcr a PLAT or SITG PLAN AfUST BCSU131�II7'TCD by thc clicnt �vitl�TlIIS AI'PLICATION. Q,i ... D Properly Ditnensions: � �i�—G� 1YIZITE DII2GCTIONS(from 11•Iocluvillc)lo YROPLItTY: T�x orr,��rirr: ����/0 9- ��- �O d 9� �� ,� � ,�v ��� �/' � �� � Property Address: Ro�d Namc,,�%����G{�vI i-�'i'ct/ G'" �`' c � � ctcyrr�n / f ��G ��.51��✓ �.-.���J �- . _ � 7� � . If in a Subclivision providc informa(io»,as follotivs: d�r� ����rro..�/ f Namc: ' �/Z<i �l�l Scction: IIlock: Lot: Datc l�omc coriicrs llaggcd: � � 6 5 Tl�is Is to ccrtify tliat tlic inforiiiatioti providcd is corrcct to tlic bcst of tuy Iaiotit•Icdgc. I undcrstaiid tl3at any perinit(s) issucd l�crcaflcr are subjcct to suspcnsion or rcvocation,if tl�c si�c plans or intenJccl usc cl�nngc,or ff tlic information subntitted In tltis application is Calsificd or d�angcd: I,also,«a�lcrslna�l lJratl anr responsiLlc for a11 clrargcs i�rcrurcd jran 11ris applicatiorr. I,l�crcby,give cotisent to tlie Autliorized Rcprescntativc of thc Davic County IIcaltli Dcplrtmcnt to cnicr upon abovc dcscribcd property locatcd in Davic County 1nd otiti'ncd by � tu couduct�Il tcsting proccdures as i�cccssary to dctcrmiuc thc sitc sttitabili . /� --._ DATr��/�/^/��� SIGNATUIt� � TIiIS AIt�A NIAY B�US�D TOR DRAWING YOUR SIT�PLAN(Lic a c follotivii�g: �xisting�nd proposcd property liucs�i�d dimensions, structures, sctb�cks, and scptic locations). /—'` � S : .7� Sitc Rcvisit Charbc ` f,.V/�� �" � Datc(s): �,�� / �y'� �:., ��`" C �� � � .. 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'� • DAVIE COUNTY.I�ALTH DEPARTMENT : ''' 4 Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION _.____. ,' PROPERTY INFORMATION Account #: 989900098 Taz�PIN/EH#: 5769-66-9009 Billed To: Jimmy Barringer Subdivision Infa Reference Name: Location/Address: Leatherwood Drive-27028 Proposed Facility: Residence Property Size: 5+acres ' Date Evaluated: f�--�:��D_f'— Water Supply: On-Site Well � Community ` Public Evaluation By: Auger Boring v Pit Cut .. : FACTORS 1 2 g 4 5 6 '1 Landsca osition .L, Slo e% G HORIZON I DEPTH / t� 6� '/ Texture rou L Consistence SWcture Mineralo 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-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 oi 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-Slighdy plastic P-Plastic VP-Very plastic tructur 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 � tes . 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-gaUday/ft2 , DCHD OS/99(Revised) ` � ■�■ �/�����������■��■■����■���■���■������i�����/������■O��O������■ ■��■ ■ ■����■e��o■�■■���������■�����������������������■�■�o������a ■■ ■■ ■�����������■�����������■ ■�■��aoa�■��������■�o����������■ ■�5��� ■�C������■��■��������■��■�i��■��s����v��������■�■��������o■ ■���■ ■�■ ■����������■��■�■�������■���■���������■■■�����■��������■ ■���������������������o���■�■������■��������������■�������������■s ■����������■������a����■���■��■����■������■����■����■�■��■■���■��■ ■����_��■��o��■������■���������■�■��■�s�e�■���������■�������■��■�■ i�ii��ii�iiiiiiiiiiiiiiieasiiiiiiiisiiaiiiiaiiiiiioiiiseiiiaiiiiii 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' � • �i. � . � . . ' Y�,; - � � �� � � . � . ,� . . �`„'1�^�+yw'T`^'�'<� b , ��:�. t •�. �''.;<.'.�^e�'w�'�. . . �„� X Y ; �t k � �4 L -' `�� �� ,¢:� x� � � x � ��l?,��I�xC�tI1VT1���I��,T�IY��fi��T1E��NT���� 3,� ���� #,§ � � .x�„,�, r.�.,y� a. � .�.t�:�:;�..�...�~�«�' � Environmental Health Section P. O. Box 848/210 Hospital Street "' Courier 09-40-06 . Mocksville, NC 27028 R< � > � �.„� , t r "` -� ' � (336)751 8760' � �E` �""'.�.'`�� �� � �is� � P 'h� - � . 4 ,� a . ,... aa �¢ �, . �' �r �r�+,.er �• . . 3� 4.� �� �7r q��k i y�K KA°3 'S S S�/tx �'e '� �k� 'i �.,r 4�.F f 1 }p £ k �q -0 Sa K 'f 1, �, �'a.M ,� ,. . 1�+ b zh+ �"3'� £� E"�"Y+`9 Y S t ,Y �p Q� d 4 T . ,� F k ?��.k�, � M b �,�5�.�RA t 4X �r.�� f%4, Y� f ������{i%? q� y F b Y� �. p �, '' € �.:'�J �` s ,�' R, �'A�� ��� .,,'E y 4 a,y (' S'��{ {; , L �y;'-C 2'�`'" ,a"����� d.�-���� t ��g � z r�X� `,�,>e �.� i,��s3 k' �'A�' �.�g.. d; ,r.� f{ ,45�,a�" ,�� . „�.,y ,�d«,�,�r,°�. �,.� e � ,., �.,� � -�".. :. . � , :��� ,�� �,,,�a„`�,r;��»n�. ,��i� � �� January 26,2005 Jimmy Barringer 290 Leatherwood Trail Mocksville,NC 27028 Re: Site Evaluation/ Leatherwood Trail Tax Office PIN: #5769-66-9009 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, January 21,2005. Based upon the information provic�ed 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 an 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, � ,��'�t����. - Robert B.Hall,Jr.,R.S. '� . Environmental Health Specialist RBH/dlf Enclosure(s)