143 Mortgage Hill Way (2) • DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section �� ��/ � `' �
� ? , � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028 � �
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001724 Tax PIN/EH#: 5823-35-7807.02 ���
Billed To: Tom Kitchene Subdivision Info: /Y 3�/lO�l'JC'liy �
Reference Name: Location/Address: Four Comers Road-27028
Proposed Facility: Residence Property Size: 3.4 acres
**NOTE�*'Ttilbgriipro 8ment/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 PERMTT 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 �,/AG� Type Water Supply�_ Design Wastewater Flow(GPD) �(�� Site: New�Repair❑
System Specifications: Tank Size/D�l/GAL. Pump Tank GAL. Trench Width��Rock Depth ,/.2� Linear Ft��
Other:
Required Site Modifications/Conditions:
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 ofthis
system between 830 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.****
�
� r x
Environmental Health Specialist's Signature: '�/ � Date: � ��v(
DCHD OS/99(Revised)
. , _ - . ��
, , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 �
Account #: 990001724 Tax PIN/EH#: 5823-35-7807.02
Billed To: Tom Kitchene Subdivision Info:
Reference Name: Location/Address: Four Comers Road-27028
Proposed Facility: ResidenCe Property Size: 3.4 aCres
ATC Number: 2825
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). T'his 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 WASTEWATE O STRUCTION IS VALID FO ERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �l b `� �
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 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.
l
�7 � '
i5��
/�-�
/5"(�
Septic System Installed By: �C.J
Environmental Health Specialist's Signature: /�yca��/ Date: U `��`��. .
DCHD OS/99(Revised)
, ,- � � 6I
• . J Ai'('LICATfON FOR S!T€:EVALU�6Tf0f�/1��'iic�VEiti6�Nt'P�li�31f�ATC �Z�
Davie County Health Department
Environmenia/Hea/th Sertion
P.O. Box 848/210 Hospital Street
• Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BUI,LETIN for instruc�ions.
1. Name to be IIilled �/� (� j�L�G��1�� Contact Person
---_.___----
Mailing Addro3a j� LI. �)(�0[, ( � �� Home Phone �/�'� ~��%}7 T
City/State/ZIP ` �.'�1Y��,�N.;, JVV - s�[ (O��Z F3usineaa Phone `/(.�'� " ��7�J
2. Name on Permit/ATC i£ Different than Above � �
Hailing Address City/3tate/Zip l��
r
3. Application For: �Site Evaluation ❑ Improvement Permit/ATC �Both
a. syatem to service: �Fiouse �Mobile Home ❑ Business ❑ Industry ❑ Other
s. If Residence: # People 7i � Bedrooms � � Bathrooms �
�DishMasher I:I Garbage Disposal �Wushing t9ichine ❑ Basc�ussnt/Plumbing I:I IIuac�ment/No Plumbing
6. Z£ Buainess/Industzy/Other: Specify type # Peopla # Sinks
� Commodes G � Shoxern � � Urinala # Water Coolorn
IF FOODSERVICE: # Seats Estimated Water Usage (gallona per aay)
�. ��pe of water supply: � County/City ❑ Well ❑ Community
o. Do you anticipate additions or expansious of the facility this systecn is intcuded to sciv�? ❑ Ycs �No
If ycs,what typc?
***I�{1PORTANT***CLIENTS MUSTCOMPLLTETHE REQUIRCD PROPER'I'Y INFOItMATION IZI;QUL:S'I'ED
BELOW. Eithcr a PLAT or SITE PLAN MUST BESUBbtlTIED by tl�c clicnt with TIIIS APPLICATION.
Property Dimcnsions: ��'���� 4�•v �� • WRITE UIRECTIONS(from Mocluvillc)to PROPI:R'I'1':
Tax Officc PIN: #� �p� 3.3.� l Uv 7•�� (l/C�I 7'V ��� (��f , ��'�
Property Acldress: Road Name '��-���� �� ( L--� ('�'� C� ��Nr�S _
City/Zip �A��l�'� � � t'"p (�-�
�
lf in a Subdivision provide information,as follo�vs:
�
Namc:
Section: Block: Lot: Date Property Flagged: �` ^Z �`�!
This is to ccrtify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued herea[ter are subject to suspeasion or revocation,if tt�e site plans or intended use change,or if tLe information
submitted in this application is falsiticd or c�anged I, also,undersiand Ihal l am responsible jo�a11 charges i�rcrrrred frriur
this application. I,liereby,give consent to the Authorizcd Rc�resentativc of thc lJavic Coavty IIealtI� llcj�arimcnt
to c:itcr apun aUove ciescriued pr�perty located iv llavie County and owned by __ __
to conduct all testing procedures as uccessary to detertuiue tlie s' ' b' ity.
UATL �vl7 '-�� SIGNATUR v»-- "�� -
TfiIS A.REA MAY BE USED FOR DRAWING YOUR SITE PI.AN(Include all of thc follo�ring: �xisting and proposcd
property lincs and dimensions, structures, setbacks, aud septic locations).
� . Sitc Revisit Chargc
> �""�r Datc(s):
�i��
�,� � Clicnt Notircation Datc:
;.
�5 ___._� EHS: �
��
� � 2
�Cj '. Account No.
l �
Revised DCHD(07/99) t Invoicc No. �
�
� �
�
DAVIE COUNTY HEALTH DEPAR'I'MENT
' . � ' Environmental Health Section
. � ;
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION�"'"'-`•�.�.� ..
�.,.,-�...._.�.. _
_ , . _..,^.�.. , _ - ��-
Account #: 990001724 Tax PIN/EH#: 5$23-35-'�807:Q�"�'�
Billed To: Tom Kitchene Subdivision Info: �
Reference Name: Location/Address: Four CornersRoad 27028
Proposed Facility: Residence Property Size: 3.4 acres Date Evaluated: � -I � ��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring i/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L. L
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH l�'' 6'
Texture rou '�A:'".
Consistence � 7 ���
Structure 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 �
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: -� OTHER(S)PRESENT:
REMARKS: I N��S-z!� !�'�� O L r :�
� 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-Sil[
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
Mineralogv
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 OS/99(Revised)
■���■��������������■����■■��■�■��■■��■��■��■�■■����■��■����■ ■�■■
■�■����■■■���■��■��■�■�����■■�■■■�■■���������■�������■■����■■■��■■
■�������■���■■����■��■���■�■���■�■�����■�������■�■\��■�■���/■���■
■����■��■���■■�■�■�■■�■��■���■�■ ■�■■■■■���■��■��■�����■■����■�■■
■■���■■����■���s000��o■�■�����■■���■�■��■■�■■�����■see�■■�������■■
■����■■�■��■������s�■��■��■����■��■��■�■■�■■■�■��■��■���■��■■��■�■
■�■■�■■■�■����■�■����■■�■��o�■��■����■�■■��■�■■��v�■�sae��■���■��■
■����■��■�mm■�■��s�■s■■�■■�■■■�■���■���■■��■��■��■�■■�������■�■■�■
■��■�■■�����■�■■■���■����■■■��■����■■■�■■■■■■������■�■�■����■��■�■
■�■�■�■���■��■■��■�■�■■�■��■■■es��■■���■■����■■�■��■�■■■■■�■■���■■
■���■��■��■■■��■�■�■■■��■■�■■����■■���■■�■■�■��■�■■o�■■�■����■�o■
■■���■■����■■�■■���■■■�t■��■�■�■ ■■���■��■��■��■��■�■■■��■�����■■
■■����t�■�■■■��■�■�■�es�■��■�et■��■■�s�e��■��■����■��■�■���■■■�■■■
■■�■�■�����■���■������■��■■■�■��■��■�■�■��■■����■���■■�■�t�■���■�■
■■���������■■�������■����■■���t■■��■�■�■�����■��■�■�■■■■���������■
■����■���■�■����������■��■���■��■�■■���■��■��■�■��■��■�■�t■■■����■
■�■�■����■���■■�■�■�������t�■■�����■�■■■�■■�■����■��■■�■�t�■��■��■
■■�■�■���■�■■■■�■�■�■�■��■■■���■■����■■■�■■�■�e■�■■�■■�■���■��■■�■
■■�����������■■���■�■�■■■■�■■��■����■�■�■���������■■■■■■■�■�■�■■■
■�■����������■■■■�■■■�■■�■■�■��■ ■�■■■■�■��■�■��■�■■■■■�■■■■��■■■
■�����������■�■■■��■■����■■■����■����■■■�■■■■■■��■�■■■■■�■��■��■■■
■�■��■�����■■■■■■■�■��■■�■■�■���■��■�■■■�■■�■■■��■�■■��■�■��■■��■■
■■���■■���■■■■■■�■�■■■�■�■��■■■�■■■��■■■�■■■■■■��■�■■■■■�����■��■■
■����■■�����■■�■���■■■�■■■■��■■�■■���■■■�■■�■■■��■�■■��������■�■■■
■���■�■■■■�■�■�■�■�■�■�■■■■�■■■�■■■■���■�■■�■�■��■�■■��■������■■�■
■�■�■�■■■��■■■���■��■■■■■�■�o�■�■■�■�■���■■�■■■�����■�■���■�■�■■�■
■���■���■■��■■�■�■���■■�■�■�■■■���■�■�■�■■�■�■��■�■■■■������■■��■
■��■����■■�■�■�■�■����■�■�■���■■ ■■���■�■■�■�■�■■��■������■■■��■■
■���■�■■■■�■����■���■■■�■�■■�■■�■■�■���■����■■■��■��■��■���■����■■
■■�■�����■��■■��■�■���■�■�■■����■■�■���■�■��■�■�■■■�■�■■���■■���■■
■��■��■��■�■■■�■�■���■■�■�■■�■��■■�■�■�■�■�■■�■���■�■■�����■�■�■■■
■■�■����■■�■�■■�■■����■�■�■■��o�■■�■���■�■■�■�■��■��■■�■�����■■�■■
■��■����■■���■��■■■�■■■����■��■�■■�■�■�■■�■���■��■■�■■■■������■■�■
■�■■�■���■■■�■■�■���■�■e■■�■�■■��■�■■■�■■�■��■�■��■��■■����■��■��■
■�■���■�■■���■■�■�■���■�■�■■�■■■��■■�■■■�■����■��■■�■��■■■■���■�■
■��■■■■�■■■�■■■�■■�����■■■�■�■�■ ■�■�����■��■�■■��■�■■■■■■■�■���■
■��■��������■�■���■���■�■■■■■■■■�������■��■��■����■��■■■■■■■�■���■
■���������■�■■■���■■■�■■■■�■�■■■�■��■�■�■�■��■�■■�■■���■■■■■�■���■
■�■■�■�����■■��e■■■�����■�■■�����■■■■�■���■■�■�■■�■����■■��■���■�■
■�■��■���■�■���■■■�������■■■�����■■■■��������■�■�������■■■■����■�■
■■■��■■�■■���■■■■�■�■���■■�■��■■�■■■■�■�■��■■���■��■��■�i■■��■��■■■
■■���■■��■�■■■���■■�■��■�■�■�■�■��■�■■■��■�■n�■�■��■■���■■■�i■��■■■
�iiiiii�iiiiiii�iiiiii�iiiiii�iiiiii�ii�:�i�iiiiiii,�iiiiiiii�
■�■■■■��■■�■���■�■���■■�■�■■���■�■■�■■■�■■�■�■■�■�■■■�■ti■■■i�■■���■
■�■����■■�����■■�■������■��■�■�������■■����■�■����������i■�■i��■■■�■
■��■■■��■��■���■�■�■�■■�■�■■��■��■�■■���■��■��■�■��■���n���!��■�■■�e
■��■■■�■■�����■■���■■■■�■�■■�■�������■■��■�■■■■�■������n�������■■■
■��■���■■��■�■■■e■�■�■■■■��■�■�■��■�■■■�■■■�■■�����■■■�i�■��■■�■■■■
■■�■���■■■■■�����■�����������■�■■■■�■■■��■�■��■��■■�■■■��■■�■■■��■■
■�■■�■��■��■�■�■�■�■■■■�■�■■�■�■�■������������■�■■�■■■i��■�i�■����■
■�■�■■■��■�■�■�■�■��■�■�■■�■�■�■ ■���■■�■■■��■■�■��■■■!�■■��■■�■�■■
■■■��■■��■�■�■�■�■o�■�■��■�■■■�■■�■���■�����■�■��■��■�■���n■���■■■
■�■�■■���■�■■■�■�■ve■■■��■�■�■�■■�■���■■�■■�■■�■��■��■��■�i�■■����■
■�■■■■���■�■�■���■����■��■t■�■�■��■��■■■��■�■■�■��■�����■����■■■■�■
■�■��■��■■���■������■����■���■��■�■■�■■■��■�����■�■■�����■����■■■�■
■�■■�■�t�■���■�■�■■���■�■■�■■■��■�■■���■■�■�t���■��■���i���,�������■
■■■��■�����■■■�■�■��■�■��■■■�n���■�■����■■�■��■��■��■��■i■��i����■■�■
■�■��������■■■���■����■�■�■��■����■��■■��■■■■�■■�■���■i��u����■■�■
■�■������■�■■���������■�■�■v�n��■ ■��■■■�■■�■■�■��■����i�■►��■■■■■�■
■�������■■�■���■�■����■�■■■■�■�■■�■��■■■�■■�������■���■i�■�■■■■■■�■
■■������■■�����■�■���■■�■�■��■�■��■��■■■■■■�■���������■i���■■■�■■�■
■■�■��■■�■�■�■�■�■��■�■�■��■�■�■��■��■■���■■�■�■�■■����i������■■���■
■■�■■�■�■■�■��■■�■����������■■■■■■■■��■■■�■����■■�■■�■�i■■i■■■■■■��■
■��������■�■■■�■�■���������■■■�■■�■■�■■■��■■����■■■■�■�i■�i■■�■■■��■
■■■■■�■■■■�■���■�■��■■■��■�■�v�■■�■■�■�■■�■�■■���■■■����■�i��■■■■��■
■�■■�■��■■�����■�■��■�■■■■�■■■�■ ■■�■�■■�■�■���■���������i���■��■�■
■��������■�■■■■■�■■■■■■■�������■ ■�����■■■■■■■�■�■■����■�������■■�■
■�■�■■■■■■�■�■����■������■■■■■■■��■■�■�������■■■■��■■■��■�i■����■��■
■■■��■■■■■�������������■�■■■■■�■■��■�■�■■�■��■�■■��■■■��■�i�■��■■■�■
■■■�■���■����■����■���■■■■■�■■�■■�■■■■■■■■■■�■�������■i�■�i■■■■■■■�■
■■■�■■■������■�■����■�■��■■�����■�■■�■�■��■��■��■�■■����■�i■�������■
■�■����■■���������■��������■�■������������■■�■■���■������i����■���■
■■�����������■�■��■�■�■�■■�■�■�■■��■���■■�■��■��■�■�����lJ■■■���■�■
■■�■■■■■■■■��■■■�■�■■■■���������w�■�■���■�..�.����......�■�\����■���■
��t����� ---��
■�■�■��C�------��i�i���■■■■■■■�����■■������������■��■■���■�■■�■�■
■t����������������■■����■��■�■�■■�A■��■■■■�■���■■���■■■�■■■�����■■
■�■������������������������■�\��/1■I��■�■���■■■����■���■�■��■■■■■�■
■■■■■■■■■■■��■■■�■��■■■■■�■■■■■fr6l,[1�■�■�■���■�■■■■�■���■■����■■■��■
■■■�������■��■■■����■�����■��■s�i\%■■■■�■��■■■���■�■���■���■■�■■■�■
■�■�■■■■��■■�■�■■■�■■■���■�■�■�■■�■■�■�■�■���■■■■��■��■t■■�■��■■�■
■�■�■��■■■■���■■����■�■���■■■■■�■■�■���■■■■■■��■■�����■���■����■■■
■■■��■�■�■�����■�■������■�����t■ ■■■■■■■�■■���■������■�■■■������■
■�■����■■���■■■■����■■�■■■■��■����■■■����■�■����■�■��■■■������■�■
■■■��■�■�������■�■■■�����■���■�■■���■■��■�■���■�■■■■■■■�■■��■����■
. r . . �
.
D��I���1UNTY�I�LT�I I�����T14��1VT
„.. _..., �.. .. ,. ...: .__... �. .. _.... .� .._., ,.�.......... ,. ... .._. . ,...._,_... �_. . .. .. r . ., ..���.�..,.....�ba
ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-Ofi
Mocksvilie, NC 27028
Phone #: (336)751-8760
May 10, 2001
Tom Kitchene
P.O. Box 1549
Clemmons,N.C. 27012
Re: Site Evaluation/Four Corners sites 1 and 2
Dear Client(s):
As requested, a representative from this offce visited the aforementioned site on
May 8, 2001. Based upon the information provided 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 a modified, oversized on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mohile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
/�a�'����d�'•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s)