153 Glenwood Rd Lot 12 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003422 Tax PIN/EH#: 5726-57-8401.12
Billed To: Joseph &Dorothy Maino Subdivision Info: Meadowwood 2 Lot# 12
Reference Name: Location/Address: 153 Glenwood Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3930
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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE Y ARS.
Environmental Health Specialist's Signature: _ ` Date:
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 Arti le 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY 1§61aken iat the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC::27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003422 Tax PIN/EH#: 5726-57-8401.12
Billed To: Joseph & Dorothy Maino Subdivision Info: Meadowwood 2 Lot# 12
Reference Name: Location/Address: 153 Glenwood Road-27028
Proposed Facility Residence Property Size: see map
ATC Number: 3930
**NOTE** This Improvement/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 #People #Bedrooms_� #Baths
Dishwasher: K Garbage Disposal:Er Washing Machine:R! Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply _ Design Wastewater Flow(GPD)-L�P Site: New u Repair❑
LL f/
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width2 Rock Depth �-� Linear Ft�7D
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAY T- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Con ctN,,repr entative of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 .m. o 1: p.m.on the day of installation. Telepbone#is(336)751-8760.****
�i< -X6
� ls-e
e
r
Environmental Health Specialist's Signature: 11191alll,
Date: 4Z�x'4�z
DCHD 05/99(Revised)
r '
.'Nov 23 04 12: 13p davie county envhealth 336 751 8786 P. 1
APPLICATION FOR SITE EVALUATION/lAIPROVEMENT PERMIT&ATC
Davie County Health Department
Environmental fleaith Section
P.O. sox 840/210 Hospital St.roat
Mockoville, NC 27028
(336)7518760
***IMPVRTAHT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
XNFOMTION IS PROVIDED. Refer to the 7NFOM ATXON DULLETIN for instructions.
'J �
• 1. Name to be milled 5Se �] t3r ,�VT�DT7tA mat1710 contact Person �( .'pruJ_
mailing Address 13q Tpi(a C+ Roma Phone 55(o I
City/SeataJzZs„ MQc VAI'0 , PL r}, tb;L? Business Phone
21. Name on Permit/ATC if Vifferec t than Above M• IPP— `Barbe_r 0r2& j- rtjy-V--
Nailing Addreas Jgyickl Chi rid ���,,,c,,,LLLity/state/Sip
7. Application Yore ❑ Site Evaluation Improvement Permit/ATC ❑ Both
a, system to service: ❑ House Mobile Home 17 BusineaB ❑ Indust:ry ❑ 0thor
S. Type ayatem requestedi10 Cenvantienal ❑ conventional "dined ❑ i,mevative
6. It Residence: 8 People s Sedrooma P Bathrooms
Dishvashor
• arbage Diapoual washing Machine ❑Basament/Plumbing ❑Basement/N
o Plumbing
7. 11 Auaineae Sndust n /Mar: voiLYE Pe M Pao la N minks
Y Cose:+odes I stLoxers 0 Urinals S Hater Coolers
ZIP FOODSERVICE: . $ Seate EBtimatod Water Usage (gallons per day)
a. TWO of mater sypplye),County/City ❑ Well d Community
.9. Do you anticipate additiana or expansions of the facility this systens it Intended t0 serve?Q Yes �(No
Ir Yes,what type?
***JMP0'R71NT***CLIENTS Aft=COAfF2X7'8 THE PX,QUIRED PROPERTY INFORMATION REQUESTED
• - DELOIY. Either a PLAT or SITE PLAN MVS7'QESUBA11rTED by the client with THIS APPLICATION-
Property Dimensions: X 10 '< 1 o2Q X AR WRITE DIRECTIONS(from/Mocksvittc)to PROPERTY:
Tax Office PIN: # ��t'iC�li� 1GtlScw) — � anc&l I
Property Address: ItoadNarnc �S3 G)enkonoA Qa DL n D +
citymp 5 - C '14 =J
If in a Subdivision provide inroormatic-n,as follows:
Name: I 1 12et Am VV&
Section: 91 Block: _ Lot: _ Date home corners flagged: NOV._ 15OD -
;r This Is to certify that the inrarusation provided is correct to the best of my knowledge. I understand that any permit(s) 4,
Issued horcaftcr aro subject to suspension or revocation,if the site plans or tutonded use cleangc,or if the infornsation
submitted In t6ls application is falsified or changed. Jr,also,anderstdnd thatl am responsible for all charges Iticurred front r
this applicatlon. I,hereby,give consent to the Autltorizcd Representative of the Davie County 11cilth Dcparttneut
to enter upon above described property located in Davie County and owned by
600/904 dad VN110HV0 OEM 6280 866 9££ XVd ££:6I QllA 6009MAT
to eonuucc au tcscing p oceaures aS nccrisar) ro ueiernuae tae s:c�su airy. G��'jG�fiy�' '
DATE SIGNATURE
THIS AREA MAY BE USED FOR DI kWIKG YOUR SITE MAN(Include in of ttu owing: Existing anti proposed
property lines and dinunsiens, structures, setbacks, and septic locations).
Site Revisit Charge
Datc(s):
Client Notification Date:
EIS:
Sign given Account No.
Revised DCHD(05/03 Invoice No.
59
a
OL�-
t nch S i
Deic-. 4D �n
foonoQ dDd MUM MINN 6280 866 9££ IVd WH QU WZM/II
o«rw hfEADO J10DOE
OD, SECTION'
rt• '.:• s R {.i.f.' 1 N.M. 7, PG. 1361_ - '75 c r
LO?' 5 1 LOT 4 1;Y •.I = 1 «•1 c
_ �q LOT 3 1 L i LOT f
4t IDOHnOD!'f'DDII'1510.\ 1
:•7..116: :, M:. filfi dJ'. t •� .
_•
t S 98' t
c4. YLADOW0109 SUED19ISIOY
1 i.s 4.2e rc is i:s �F.,�� t_ PL-RX 7.PC. 136 AC.-
3s�3 *v s M. • s ueft aF ZONED R-20
,�;,, 3 191. t 3�.-rr:s,wa •a.� `• s. 2a'r:a RSM .es
S aa•17-r«r d •K• mEa1PrG 129.19 ---
M c9
�J 5. "AREA= 0.945 AC. a g »RrR NO�s• C'
C
AREA= 0.9 9 AC. 'n 71 wta•a 7YH7 A10ER oa
v ;i 7• m 40.& t, .ROB"T C. ,Z6 1.7 IV.rc
2 MNOWM{C
ARX'4 ' d _ s.rova rax
EA_ 0.8b _ o_
Z ;s ••.`rJ../�'7j5�1 ' ay 9 r�>� / 5.IL AMxaWC 3r to
ea n�)•3z74.E',c DD Rq. 6' C7 0.9.56 LC
b
'm 14x44 'm Gi7E"'XO �i`'•ys'j6.c• ,0• s�.V �Ic R . v7
BARBARA W. BOWES .• �.,, s, \�/ � _ - ��Iss 6
6 ns'ar NE
ayT3 TI.-!`
swa3°E e
D.B. 179, PG. 65 ' 1.Sd Hece c
S^ 16, / q o� ' - �' Pri• e.sc'N,°n
g AREA= 0.706 AC. HSA` 4a
AREA- 0.809 AC. t IJjC 32 a a.3s news z
10- .6 ( i Is AU rmum z
a,�'' dj '° ► i' u.EACH✓X s0114 A"K
la 8E sun
i> g '>y 1 �•,�' Ts Me Op
AREA= 1.007 AC. y u#41(bRNt7
M.71HW A A FU Rt
Nm M
YS yrMs / � � i � .
s 7.M N
, .4. .. 1
y VAS E{�' YG 66
�b4 MEADOW
LEGEND
D R7CflARD DL. I �,•N I l O"ER ------
121, A EUCTWCsL eoa
L �-
pC 653 j - "� p.=WAXER VALVE
1 r't°a7: OELts 111OK ." C'+aa0 T,,4t:tR1 CHORD BRC.. •�"•�••, _ VC K;
H U 10:41'13' w.eo .19• 62.55 $0.15 s Sr0Y33-E 1•trent' Uat Na Dar-�Y Swath O.W,.el ?:
cl .03403' 30.00 ^1.38 73.7T 1791 N K13'15'[ 1 - � NO�� �
ri iai;:35; 59.Oo 43.62 42.43 73.13 s 4r w 4' fib^Y >rIARTuI L do DREASe4 [ o
0. `x.N 7434 6147 4691 Nat• 1e•:W':• With M;0d b_ tart one C.MMU tr WAII4 twd
L 9szs's4 saw 44:14 74.57 sass N u•. b+ww bR a jw0muw w tlw wtsetr ane te. 1360 JERICHO -K
c.arrunc z; W06'W W00 35.03 4444, 1821 s h•18'46•t .. .. . .oma.w(ovd,lo 4wrpy.RHC,wen eitterle cod MOCKSv1LLE. NC 27 0
atMoa,urla7 Not NI.Dye rn Otw. 7� h C 0}4b3' 30.00 .2..34 73.72 12.11 N 65J2.4r V '} mRatiero.[xctoT w tW tealn 4.wch-.1L.5en, 536-75 r-51;a e
wt.lsen hot«an tlelool.ttt+,oy*m?a ,i�i1?,C/!!3�•• rA 3140'3a' Sarq ,8.13 . 18.43 9.09 S 3374'07' :!-1 is Qefi6b 0e Wa er!Nali aad ew Bm+WOo
P.•+i,be a4«d tlesaHNien roondad Ie ,eb+ "�J,.'y co )3,47.46' SI a7 60.27 ir.13 30.59 N 1;35'3,'C'' eaa VN i7A1 �•
°49. .Nc.)(o!„«);8m1 Na :�'j`ykE4:Iq�a,s-2W a7^0'x• 5t., 53% 4+52 79.74 s IOYa'O,'E �''1 rtl;COM tN7 fs!01 ao17 OepeAmatN.
.l a",M w.<Nery+nd.etM o•ha«e j 4 �,��'2 ` HNI!OHCGWE Nf1TjpEt YN13 OER117)CATE DOES NOT
don IouN w tet.tool-7-Dn...J30:lea! r Ci:b, .. . ... M�F
COIS7011lC'4.HN71tNT nR 4trowv= -4444
w
TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Health Department
Q ti0�2
Environmental Health Section
F 2 Q P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
�tJM �uN� (336)751-8760
VAR F,�
***IMP T*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
I TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed / ��[j�� /�2 �L� Contact Person / j. Zc-6 �,0/L,!{�tJ�_
. _ ^ /
"Mallin Address tG OaLlt CfHome Phone —'T-
City/State/ZIP
T-
City/State/ZIP 1�17QC-I-f c/i &C
C Z 7d,ci�usiness Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ite Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to service: ❑ House e<obile Home ❑ Business ❑ Industry ❑ Other
5. I£Residence: # People # Bedrooms 13 # Bathrooms
{Dishwasher LI Garbage Disposal f aching Machine fl Basement/Plumbing 1.1 Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Slater Usage (gallons per day)
7. Type of water supply: B-<ounty/City ❑ Well ❑ Community
o. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes G1-w
If yes,what type?
'IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
� t
Property Dimensions: .Y2 ,j cx,
2--.-WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN:
Property Address: Road Name �elcl,•.Lpnt / ( — '
City/zip� /4C. G f 4.14/l,5p //�iil U�•('
If in a Subdivision provide information,as follows: l > �–
Name: ///E.4 6Ol,�J QtX� "`�1 ��1d til _� /" /t��YDC✓c/�C — V 4✓ '�`_ ':f
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 ani responsible for all charges incurred from
this application. 1,hereby,give consent to the Authorized Representative of the Davie Couiity=Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testi g proce ures as necessary to determine the site suitabili
DATE 3 / — SIGNATURE
TIIIS 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):
1
Client Notification Date:
EHS:
Account No.( 7 v "
Revised DCHD(07/99) Invoice No. ��
- � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001004 Tax PIN/EH#: 5726-57-8401.12
Billed To: Martin Lee Barber Subdivision Info: Meadowwood Two Lot# 12
Reference Name: Location/Address: Junction Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ? Pit r / �— # Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence if;7
Structure
Mineralogyl ,'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RA
SITE CLASSIFICATION: EVALUATION BY: 1 /
LONG-TERM ACCEPTANCE RATE: L/ OTHER(S)PRESENT:
REMARKS: IV �o
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(provisionall sui a e U(unsuitable)
LTAR-Long-term acceptan rate-ga day/ft
DCHD 05/99(Revised)
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■E■■■■■■■■■■■■■■■a►�■■■■■■■■■■■■■■■t�■■■■■■■■■■tri■■■■■■■■■■■■■
MEMNONMEMNON EMEW"M iMEMNONNOMMEMMEMEME
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■MEMO
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
SEEN
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■