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234 Meadown Glen Ln DAVIE COUNTY HEALTH DEPARTMENT J �b , • � " Environmental Health Section ��- �� P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 989900057 Tax PIN/EH#: 5812-04-4109 Billed To: Randy Grubb Subdivision Info: Reference Name: David Moore Location/Address: Meadow Glen Lane-27028 Proposed Facility: Residence • Property Size: 15 Acres q�� 1m b r: 2457 **NOTE*'�'1'his�mprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHOWZATION 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 ��J Article 11 of G.S.Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS �j,�'i- 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: ❑ Basement/No Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size /'_2S Type Water Supply 1..�0 Design Wastewater Flow(GPD)�� Site: New� Repair❑ System Specifications: Tank Size�al� GAL. Pump Tank GAL. Trench Widtl��p�� Rock Depth��Linear Ft. �, Other: � .� O �� 0�1/ --� D � Required Site Modifications/Conditions: � � 0 �4 � d .(,� —� INIPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6��BELO FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 .m.to 1:30 p.m.on the day of installation. Tele hone#is(336)751-876 **** � ,� �ty s�'-� �`� �`' J �- ��-��.�, �� o ' o �,�� . �� C� , - �� ,� , � �� 0,(7 �� I ' �� r � � � � ?c .. � Env ron tal Health Specialist's Signature: � _ Date: — — DCHD OS/99(Revised) , � , . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 98990005? Tax PIN/EH#: 5812-04-4109 Billed To: Randy Grubb Subdivision Info: Reference Name: pavid Moore Location/Address: Meadow Glen Lane-27028 Proposed Facility: Residence Property Size: 15 Acres ATC Number: 2457 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 WASTEW C STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ��7 —�� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion 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 guarantee that the system will function satisfactorily for any given period of time. 5; �� Oi /Opi / / � o � Septic System Installed By: i`� �r� ' Cv�,� , tJ Environmental Health Specialist's Signature: �' �- - Date: /� r�d -'�� DCHD OS/99(Revised) � , � L5 � 15 � V L�', APPLICATION FOR SffE EVALUATION/IMPROVEMEM PERMIT&ATC D ' Davie County Health Department „_.,. Environmenta/He+a/tfi Serction ,�;J � 3 c l;� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 � `�;;.. - .�. . � ***I�ORTANT*** THIS APPLICATION CANNOT HE PROCESSED UNLESS AI.L THE REQUIRED ]INFURb�TION IS PROVIDED. Refer to the INEORMATION BULI,ETIN for instructions. , 1. Name to be Hilled Contact Peraon G � Mailinq Addreae Home Phone � City/State/ZIP t Buaineas Phoae ��v"� �T 7 � 2. Name on Permit/ATC if Ditforent than Above C ` l.� Mailinq 11�ddreea City/State/Zip s. Appiication For: ❑ Si Evaluation �'Improvement Permit/ATC ❑ Both a. Btem to se�.�: L�' House 0 Mobile Home ❑ Business ❑ Indust ❑ Other �sr ry 7� �i s. �f �tesidence: � Peaple �,_ # Bedrooms �_ � Bathrooms -��- B'Diahwasher ❑ Garbsge Disposal p'Washing Mschine ❑ Basement/Plumbinq ❑ Sasement/No Plumbinq 6. If Suainoaa/Znduetxy/Other: Spacify type i People i Sinka � Commodea � # Shoxers * Vrinala i Water Coolera IF FOODSERVICE: # Sests Estimsted Water Ussge (gallone per day) �. Ty�e of water supply: CG1"County/City ❑ Well 0 Community e. Do e�ou anticipate additions or ezpansions of the facility this system is inteaded to serve? ❑Yes E�'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: ��s WRITE DIRECfiONS(from Mocksville)to PROPERTY: Taa Office PIN: # , ��/� -G y y14� ��Oe��f�liYL /�, �U � Property Address: Road Name,�G'��J G��e �� /"G��e�OGtJ (��7� �� U City/Zip�`C'c�v�'/lC' 02�6�� C/�d G /�-. '-' G�/ J S�GfNL � If in a Subdivision provide information,as foliows: Name: Section: Block: Lot: Date Property Flagged: ,��=LdD�� This is to certify that the information provided is correct to t6e best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocatioa,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 joP all charges incurred Jrom this appl�cation. I,hereby,give consent to the Authorized Representative of t6e Davie County Iiealth 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 �--/Z- 2 D UC� SIGNATURE�T�y ; THIS AREA MAY BE USED FOR D1tAW1NG YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notificallon Date: EHS• Account No. �� Revised DCHD(07/99) Invoice No. -�� ' .�� .� � I � �� _ . �S � ; , � ��` AP I ATION OR SITE EVALUATION/IMPROVEMENTS PER � � �; Q�,� �n` � I � Davie Count Health De artment � �^ ��1 'lj ;. Y P ..� . � Environmental Health Section N�y 2 I ' � .� C'� P. O. Box 665 41997 ; d' � �o � Mocksville, NC 27028 F � f� �. � 3 c� , �: �' 1. Application/Permit Requested By � �. °. � Mailing Address Home Phone f �, , � � Business Phone aJ ' 2. Name on Permit if Different than Above 1�.�, �- A V"�T�- � 3. Application for: �.General Evaluation a Septic Tank Installation Permit i � 4. System to Serve: '�House ❑ Mobile Home ❑ Place of Public Assembly ' f: ❑ Business O Industry ❑ Other ,t� ��'�� ❑ Unknown ` �' cl�� ;. 5. If house, mobile home: Subdivision c�. G�, �YL- � Section Lot # �� ; ❑ BasemenUPlumbing No. of People � ❑ BasemenUNo Plumbing � No. of Bedrooms �\� [�.Washing Machine " No. of Bathrooms � �Dishwasher ` O� !� i ; Dwelling Dimensions `D�v "'t' ❑ Garbage Disposal ' ,. 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers � t No. of Showers ��l� '9�ater Usage Figures �: i 7. Type of water supply: ��Public �0 /�CJ�� ❑ P.r�vate � �,� ❑ Community ( �• �t .�9a-��a i r,� 8. Property Dimensions,� n1��.4� �� Sewage Disposal Contractor i i 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? s ' ; 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvementg Permits are subject to � revocation, if site plans or the intended use change. Effective October 1, 1989. `• P:OP�RTY I\POr I�IATION F.EQUIR�D: � Tax 0�'fice PIN i� � Directions to Property: S�S I�L•�� •`t��.� ' �1�Z� C �,,�,`�''p �� ,. P.oad ;1a:ne �Q,Q,�� ` � �bQ.��-cv�- �o �� ` Boh �f (if availaule) ; ��So�, � � s �' �- c�.�;� �Sr�.S�`r�A . ��. . i � 3 i � i This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges � incurred from this application. : �?�- a�1 � DATE SIGNATU � ; _ ' i CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY � MUST CHECK ONE: �1. I OWN the property. O 2. 1 Dp NOT OWN the property. � If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: t I hereby give consent to the authorized represen tive of the D 'e C Health pepartment to enter upon above described •; property located in Davie Counry and owned by � �A.�Y : to conduct all testing procedures as necessary to determine`said site's suita lity for a ground absorption sewage treatment ` and disposal system. i ; �`, �~� ATE SIGNATUR � � DCHD(1�93) 4 A l.i 1�1��.J \ r� W ��• v J r� Fred M. Lashmit � � D.B. 116 - 124' � � � �� . � , . Z � ^ ` • . � ' � ;� \ Cl �ry bo/ " 1�' , ^�ry��/ \ EIP . . . �q l �� ` GG �.. � �� n,» S'�e2j�4`S�f 1�`�' so �2?�3 �s��S s s.�� g \ v � 9 v 4 7,,32, N / h 1 O m R�� Porcel 38.01 Stephen S. Rich o W s D.B. 175 - 715 • ,m' w 1N y, �?� � � Ma � ''}r `��A `u tr � ' 15.0 0 2 AC �J s, � � Qo 2 o � � F I 2 � ��oe•b�� . � n -c "�s,�. � CC'1 y n ''�•�� .j��- �( I 8 : °' `� i r.° 'i � v � s � �i s,��8� I � �7 AO�, ba . 9Gs�, F ' � 4� S `"_� _ Pond y �, �46sJ, F`t ;� S`��S f N 75.?s �aPP�ox. location)m � �n � - t _ J�ry,p� ?7�4 4396ZS f 4 p 40'� p• � •x.. �f / c �O,�r - ,� _:Z..,�v, ,,�>,.N;; �S 8 O � E �. � . � . /•$D ^Nf; ""' '�9..».J4�,...T, w+ � 9� _E7P� =o=rya� � '7.006� ACRES �'. = N� � 4- a °'�� $: 0 � 6 � �:; � � � � � �a/�� y'ry,y w� �y `�'p,. �^ Yw. S�� ' `'�' �'9 `� 5°� ~zs 2 0.4 6 2 ACRE S o° Z''°�'��- y ^�Orys'��y^�� °�' �� 5�� Ja.,�* y �m � ?:� ti�b' e,ltr N �'f' N/p t Qp . . 1, ��iJ 'zs. vi �JJ+ ��q N *J� t8, `ttAd.. �5�16� � . ' � N .ti, O � n N �� .y ^ n ��'�ao�'�,6 . 3 vw".�' '.�' � . ^ v�i 0 � � 2 � � � � o Z � � m o 12.61 '7 ACRES 11 .032 ACRES �� 15.928 ACRES 0 ... a �.. ,��8.8�• _ � N 87•13'20"W � 7364.26• 285.46' ' .....__`� . �P 314.73' Nr� ' N 86•30'1p��y 302.71' EIP 135.76'EIP 161.50• � .,�� 677.44• N 86•47•20'ryy N 86•18'20' �found - I I I -�_. Parcel 2p John C. Hanes I � D.B. 42 - 340 ' I Parce1.20 I . John C. Hanes a o � �o D.B. 100 - 689 c� "n = . NS 1 Mm i -�I : I I c� o VD I NW� V O' V C .. :�- . : , �I . . . . , . � O vVim � p �m , I a0o I a�p ' . . � � . . f�.,y.r.�we�h�an w�ioMiw w Y�.y�i�.+�.u��M� � .. I . . � . � nwr�ti NW 1Jt,PoN 577.Na)(efMr},IM! �y�� I . • . . � � . ...w�v�y�d�n d�wh tiAee1��rwn 1Yw�MwnMle��eund I��seek es nelW , � � I . � � � � . . " . .��-.��IMl 1M r�µN M�dae�w eda/dM b�t:tQ�00:IM!tl�4 � • . . � � � � � Wot�s/rMwN Y��a�M 0.f.Q-70 a wwM�A.�'wRn�w.rn�,«�y�.. . . . . . . ... . ' . �R n�+bWlen ww�b�r w�wd...�. . . . _ . . � . I - � . M4 ��a �� lYY6 .. .. ' .. �. � - �•--- `,`��1►i�ini��,, sea�or ston, �� N C'qR0 ,� f . P `� Q.�� , �/ .p '' . . _� �� `��Q�G\STE9�;t'y �i 2s23 ' SEAL _ wow.e�wr.. =r L-2623 � " . ••920 S UR�.��''�• '� . _ ^�y�.c Ar�Y c P�f�y'�• . ; �.. . _ ��bllr�•.... ' � ^�••--•--,�, .€�.... ., � • � • � DAVIE COUNTY HEALTH DEPARTMENT ' #��nvironmental Health Section sECTtoN LOT ,,.,rt.....z, • � Soil/Site Evaluation APPLICANT'S NAME /'/lDQY"� DATE EVALUATED /,��5 � PROPOSED FACILITY ,�'� PROPERTY SIZE N �� SUBDIVISION ROAD NAME .v//�'l� Water Supply: On-Site Well v Community Public Evaluation By: Auger Boring ,� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition ,L ,(� Slo e% HORIZON I DEPTH �� ` Texture rou � Consistence Structure Mineralo HORIZON II DEPTH .� '` 3 "" Texture rou Consistence r Structure 9 / L 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 i' � SITE CLASSIFICATION: EVALUATION BY: �G�f LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: v`lcs'Q ,�.Q�� G�' .Ol�?�PiIcE� 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 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 DCHD(01•90) � � APPLICATION FOR SITE EVAi.UATIQN/IMPROVEMENT PERMIT &ATC • � _1`?�vie�Coun��'�ealth Depart�ner.t ` -T-----�-�_�� _____-_- , - �^ � � 1; ` „ � - ,Environmental Health Section� � � -• � - � , � �- � ru �. 4�,,�'' P.O. Box 848 -- � £ �N�� ,; ,, �' _ �� -;, Mocksville, NC 27028 • (704) 634-8760 :, ��-£A5�. 5/G�. ��,�g � . . .... . _. _..�i-�a-97 �.;'� : . ��'�'�IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL �--�� •� THE REQUIRED INFORMATION IS PROVIDED. GYl oa�E �br�'na. �oo2C �on nct. I�1 oo2C 1. Name to be Billed Contact Person Mailing Address �� g� ��Q��eG��S�' Home Phone `� �� - 7� � � d 3 2� City/State/Zip ��E m M a n s �C � 7U�Z Business Phone �� r ��'� � �� 2. Name on PermidATC if Different than Above ��LG �Gti L c7 ,�T LG9iC-"� i7.�1!� Mailing Address City/State/Zip 3. Application For: [ �te Evaluation [ ]Improvement Permit&ATC [ ]Both 4. System to Serve: [�House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People � #Bedrooms� #Bathrooms�-3 [''�ishwasher[ ] Gazbage Disposal [✓�Washing Machine ['�Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/Other:Specify type �� #People #Sinks #Commodes #Showers #Urinals #Water Coolers If Foodservice:#Seats Estimated Water Usage(gallons per day) 7. Type of water supply: [�ounty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [�'No If yes,what type7 � , '��' E I THER A PLAT OR S Z TE PLfIN PROPERTY INFORMATION REQUIRED:***IMPORTANT**�;��OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions��P� ��--'r- �W TE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # �1s �� d S� _ /D� ��''��1 T� ��f�E,�rY G N. 2C'l� ��'-t' ��"1 PropertyAddress: Roadl�Tame -� n�C�'��%�J �h • � � mE�C.eio�J Ln. ►'�o 2;� LL-E � � .2GlG� � `� i� - d��G 1 t-t .� City/Zip , �, If in Subdivision provide information,as follows: � � `i3�L h�- ' Name: �'�'� � 5 � , Section: Lot#: ; 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 t�i�}'�Q� Sh�`'/�`''�' to conduct all testing pr c ures as necessary to determine the site suitability. 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Salisbury St. Mocksville, HC 27028 Re: Site Evaluation/Meadow Glen Lane Tax PINts) : #581�-04-4109 Dear Client(s) : � As requested, a representative from this o�fice visited the -� aforementioned site on November 25, 1997. Based upon the informat:ion , provided on the application for site, evaluation and after the evaluation was completed, the site was f ound to be provisionally suitable installatiu:, ,�: an on-site sewage disposal system. If you have any questions� please feel free to contact this office. Sincerely, � �Q�� ' �� / `�O� � � Robert B. Hall, Jr. , R.S. Environmental Health Specialist RH/wd Enclosure(s>