291 Leatherwood Trail DAVIE COUNTY HEALTH DEPARTMENT
- ,
- � Environmental Health Section �`�-lo-ol
. . r.o.Bog sasmo Ao�p�tai s��t
� Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT �
�g�L�eo��ef'� ��
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Account #: 990001228 Tax PIN/EH#: 5769-66-6826
Billed To: Bryan Barringer Subdivision Info:
Reference Name: Bryan Barringer Location/Address: Harrow Lane-27028
Proposed Facility: Residence Property Size: 5.13 Acres
ATC N�u�pber: 2745
**NOTE** Thls ImprovemenbOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYST'EM 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 T��INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �O�. #People #Bedrooms s� #Baths 2
Dishwasher: �Garbage Disposal: �Washing Machine: n Basement w/Plumbing: 0 Basement/No Plumbing: ��
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size�•i3 �`�SType Water Supply ��-�— Design Wastewater Flow(GPD) c�0� Site: New�Repair❑
,� � r
System Specifications: Tank Size���GAL. Pump Tank GAL. Trench Width� Rock Depth �Z Linear Ft.�O��
Other: � �'3TfL+°�T'v 'J `��7�� � {t�1�T11.u�- 1.�,��S � �o•c. �..,�J.
Required Site Modifications/Conditions: �'���L�- � Go�.iR��� � 15'� ��, {�P �,op' C-Qo..� �-u-
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie 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 day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: � � t�
DCHD OS/99(Revised)
. . , �ap �..�o• ol
•- ;• DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001228 Tax PIN/EH#: 5769-66-6826
Billed To: Bryan Barringer Subdivision Info:
Reference Name: Bryan Barringer Location/Address: Harraw Lane-27028
Proposed Facility: Residence Property Size: 5.13 Acres
ATC Number: 2745
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This 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.190 Sewage Treatm t and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON V D FOR A PERIOD OF FIVE YEARS.
/
Environmental Health SpecialisYs Signature: ate: D
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 guazantee that the system will function satisfactorily for any
given period of time. Qp-
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Septic System Installed By: ' `C 0�
Environmental Health Specialist's Signature: ate: l D �
DCHD OS/99(Revised)
,� ,;� , APPLICATION FOR SITE EVALUATION/IMPROVEMENT PEAMIT&ATC
� � •• Davie County Heaith Department � � � � � � �
� . " y Envirvnmenta/Hea/Mr Seaadion
.
. P.O. Hox 848/210 Hospit.s]. Btsaet � _ $ 2000
. Mockaville, NC 27028
. (336)751-8760 " j' - 7`o l .
. ENVIRONMENTAL HEALTN
***�ORTANT+r** THIS 71PBLICATION CANNOT �.Pli0Ca88�D UNI.�S$ lILL T
INH'01t�ATION IS PAOVIDaD. Ro��r to the =N�'ORbATiO�ti HU�.I.�TIN !or iastruatioae.
�. �... � e. s���.d � r r '� r ��f`��t �,� �o'rI� /�.� :
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�. Nae� oa p�saih/]1TC i! Diil�r�at tt�aa llbov�
NailiaQ 7lddru• City/6tat�/=ip
�� �'��- ctiS,Fe,� 3-�-o�
3. l►pplicstion For: p"Site avaluation ��O�mprovem�nt P�rmit/I�TC � Both
a. eY.t.. to s.r►so., 8�ous• � Mobile Home ❑ Husinoss D Iadustry Q�p Other
�,(' V✓
s. �t Resid�nae: i people 1 Badrooms _�'� '� � Ba�throoms �2
B'Diihwuls�r 8' �iarbaq� Di�po�al B'fta�hiaQ Nanhia� O Haswat/Pluabis�q �8aawnt/No pl�mbiaQ
6• t! su�in���/Indu�try/Oth�re Sp�oily typ� � �opl� f eiiilc�
+ Co�od�� 1 BhoM�r� � Oriaal� ! N�t�s Cool�z�
IS a'OOD$ERVICE: � SAAts EO��tAC� NAt�= Oa�Q� (4alloas p�r daY)
7. Typ� o! Mater supply: 0 Couaty/City B'N�11 ❑ Coadmunity
e. Do you snticipate Additione or e:pansions of the fncillty thia syatem la Intended to eerve? 0 Yes �
If yea,w6�t type?
***IMPORTANT"**CLIENTS MUSTCbMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or 31TE PLAN MUST BE SUBMITTED by t6e elient w�tth THI3 APPLICATION.
Property Dimenstons: J . �� ,/�e.j G � WRITE DIRECf10NS(from Mockaville)to PItOPERTY:
T.:om��Pnv: a :��G 4 GG � �a C� � � L' .�e�7� o� �'r,v�.7�r�Y
Property Address: Road Name JE�I��"'!^iCr� /�iY � �2�/ /1 ,�t` �, �" ' P>•f/ ��4 r�Dt�f��
City/Zip �?OCt�J!/i�.�� /l�� .o��� ��� l�-�- ��.D�
U ln A Subdiviaion provide information,ae foltows:
Name: :
SecHon: Block: Lot: DAte Property Fl�gged: ' lo `��'2��
Thi�ls to certify that the tnformstion provided is correct to the best otmy Icnawledge. I anderstand th�t any permit(a)
issaed hereailer�re aubJect to euspenaion or revocalloa,U the ette pl�us or intended eee c6snge,or it the InformaHon �
aubmitted in this sppBcsHon is fslsitted or c6enged. I,also,undtrstand that I ant responslble jor all cba�ges Incurred jrone
tbls appllcatton. I,6ereby,give conaent to the Authorized Represent�Hve of the Davle Connty�esl`��partu�ent
to enter upon above deacribed property located In Davie Coan and mvned by�/� � D K/
to coudact all teeting procedara ne necess�ry to determtue the tte saltab [ty.
DATE ,�" �f'" �� SIGNA
TH1S AREA MAY BL USED FOR DRAWIIVG YOUR S1TE PLAN(Incl e sq of the follo�ving: Eztettng and propaaed
property Itaea and dImensions, atractarea, aetbacks, �nd eeptic IocaH .
: Site Revislt Charge
. Dste(s):
Client NoHticattou Date:
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_ Account Na .2.2� _
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Revised DCHD(07/99) �''�N - ' Invoice ������
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''' ' ����� � � DAVIE COUNTY HEALTH DEPARTMENT
i `�
' �• �' ' ' Environmental Health Section
� Soi]/Site Evaluation
� APPLICANT INFORMATION � PROPERTY INFORMATION
Account #: 990001228 Tax PIN/EH#: 5769-66-6826
Billed To: Bryan Barringer Subdivision Info:
Reference Name: Bryan Barringer Location/Address: Harrow Lan�27028
Propose„�,,,�acility: Residence Property Size: 5.13 Acres Date Evaluated: fi 2� D7
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring � Pit ` Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L' ' � �
Slo % o
� � HORIZON I DEPTH O • V a � � v
Texture rou C t� �- L'L-
Consistence G� .SS 5 r
Structure � 5 1L k .
Mineralo M�� h^�� ,tvti,,�'�
: HORIZON II DEPTH — 1�!- - 2 . I �-- I Z-
Texture rou C k
�r ,Consistence Fi % -P �
Structure . i� � (1
Mineralo nti : I ��t �
HORIZON III DEPTH t -t1' - � - � �
Texture rou S: C'� S
Consistence , N F� �
Structure k
Mineralo w�� vv�.�,
HORIZON IV DEPTH , �� 22- 3
Texture rou -
Consistence � � Fr S SP
Structure 53k �'
Mineralo I� ►'��;��
SOIL WETNESS
RESTRICTIVE HORIZON •
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 4�• Z-
SITE CLASSIFICATION: � EVALUATION BY: � ���-I4M�
LONG-TERM ACCEPTANCE RATE: D•�L , 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
ois
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
Mineraloev
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-gaUday/ft2
DC�-ID OS/99(Revised) _
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17avie Gounty,�fealth 17e�artmertr
Ermtrvrrmerrtal,7i�ea1 th Sectlon
ro s�s4s/no x��r�s�c
Mocksville,NC 27028 '
P1,one: (336)751-s76o
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June 28,2000 .
Bryan Barringer
820 Duckview Court
Winston-Sa1em,NC 27106
Re: Site Evaluation-
5.13 Acre Tract/Harrow Lane
Tax PIN#: 5769-66-6826
Dear Mr. Barringer:
As requested,a representative from this office visited the above site on June 27,
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 oversized,modified on-site sewage disposal system
Shallow soil depths and poor soil characteristics on the site requires that the septic
system be sized at approximately 2001inear feet per bedroom,or 8001inear feet for a
four-bedroom residence. This is for reference only, as actual design and dimensions of the
drain field will be determined at the time an improvement permit is issued.
Before a representative of this office will revisit the site to issue an Improvement
Pernu�/Authorization to Construct,the appropriate application must be completed in fult
and submitted to this office. The location of the facility the system is to serve must be
staked off.
If you have any questions,feel free to contact this office.
Sincerely,
JeffG. Beauchamp,RS.
Environmental Health Section
Enc(s)
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" ; r APPLlCATION FOR SITE EVALUATION/IMPHOVEMENT PERMIT&ATC D
`' ' Davie County Health Deparbnent
� � . . Environmenta/Nea/thSe�ction AUG 2 8 Z0�0 ";
P.O. Box 848/210 Hoapital .8traet (I��
, M�ocksville, NC 27028 V
,, (336)751-8760
� �.�
*�*I1�ORTANT*** TIiI3 APPLICATION CANIVIDT BE PROCE33�D VNLE38 ALI. TH8 RLQOIRED
2NFORMATION =S PROVIDED. Refer to the INE'ORMIITION SULLETIN for iaattuctioas.
1. Na,.. !o b. 9slloa '� i � contaot r.r.oa,
Mailiaq 71ddr�es f ��� . / Sam� phona .
ciht/atat�/LZF � N L�, (" . ��b�lvLll 9usiA.sa phon�
2. Nam� on �rmit/!►TC if Di!l�r�nt than Abow Co I'�'II O�_ C. .0 I�l./'��-�/l
Maiiiaq 71dd=oss City/Stata/Lip
, 9. Appiicatioa For: 0 Site Evaluation 0 Improvemsnt Parmit/ATC Both
a. s�� to so��: 0 House ❑ Mobile Home 0 Hnaiaasa D Indnatsy ❑ Other �
a. _! Rsaidence: # People . � Badrooma � i Hathrooma �. �
�
❑ Dishxash�r �Garbay�a Disposal O lrashiaq Mschin� �Has�st/plvabiaq I] Haswat/No plw�biaQ
6. I! Buainots/Induatsy/Othor: Spooily typo • �oplo � 8inkt
i Co�o�s • Shox�rs � Vrinalt � Nat�r Cool�r�
IF �'OOD3ERVICE: # Seats Eatimated 1Pater Uaage cQ.sion. r.= d.�r)
7. Type of xater supply: ❑ COuaty/City ❑ i�Tell ❑ COmmunity
e. Do you ant�clpate additions or ezpansioas of the faclllty this ayatem is intended to aerve? 0 Y�.s 0 No �
If yes,whst type7
***IINPORTANT'k**CLIENTS MUSTCOMPLETETHE REQ[lIRE'D PROPERTY 1NFORMATION REQUESTED
BELOW. Elt6er a PLAT or SITE PLAN Ml1STBESl/BMITTED 6y the cllent wlth THIS AP'Pi.ICATION.
Property Dimensions: Vr a /.� �rG`� WRITE DIRECI'IONS(trom Mceksville)to PROPERTY: '
Taz Oi'tice PIN: # ..�a��v� ��a� (�?l�� ' r
Property Address: R�ad Name j��,rr F�J �l� �//�24- :�rL/
r / '
City/Zip � �d i�!� ��. .
�7��
If In a Subdivision provide informaHon,as follows:
. ,
Name:
Section: Block: Lot: Date Property Flsgged:
This is to certify that the Information provided is correct to the best of my knowledge. I nnderatand tLat any permit(a) ^
issned hereaiter are snbject to anspension or revocation,N t6e slte plans or intended ase c6ange,or if t6e informatlon ��
aabmitted in this applicaHon Is falsitied or changed. I,also,understadd that!ant rtsponslble jor oll charges lncamcd front ��
th�s appllcadon. I,hereby;give consent to the Anthorized RepcesentaHve of the Davie Coon Hea De artment
to enter apon above described property located in Davte Connty and mraed by �,(�� �� 6/� j
to condnct all tesNng procedutea as necessary to determine the eite aai ty. r
DATE ����5 ��� SIGNATURE - r�)
Y
THIS AREA MAY BE USED FOR DRAWIl�IG YOUR STTE PLAN(Inclad of the foUowing: Eiisting end propoac�l p�
property Ilnes and dimenstons, atrnctares, setbacks, and aeptic IocaHona) � �
Site RevLt[t Chsrge
Date(a):
� Client Notllicallon Date:
�� � � • EHS:
� 1
� ' Accoaat Na I g �
' 5�,�'
Revised DCHD(07/99) Invotce Na ���,�
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