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227 Mr Henry Rd (2) , •+ , DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section �' . r.o.Bog sasnio x�p�t��st��c � Mocl�sville,NC 27028 (33G)751-87G0 Account #: 990003633 Tax PIN/EH#: 5717-43-9239 Billed To: Jason Hampton Subdivision Info: Reference Name: Location/Address: 227 Mr. Henry Road-27028 Pro osed Facility Residence Property Size: 2 acres ATC Number: 4106 . AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction ML1ST 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 C STRUCTION IS VALID FOR A PERIOD OF FIVE YE� Environmental Health SpecialisYs Signature: Date: U S CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A, Section.190 "Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarant that he syst wi function satisfactorily for any given period oftime. `.1e1 , ' �r � �� , � � � �� , � , _ �_ , � Se tic S stem Installed B : 6 � G/ � �/7C�C� P Y Y � � �Environmental Health Specialist's Signature: ` �� Date: � DCHD OS/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section �,�. �-� � -3-- � �� , � •,. ' P.O.Boa 848/210 Hospital Street • � Mocksville,NC 27028 . (336)75]-87C0 IMPROVEMENT/OPERATION PERMIT � Account #: 990003633 Tax PIN/EH#: 5717-43-9239 Biiled To: Jason Hampton Subdivision Info: Reference Name: Location/Address: 227 Mr. Henry Road-27028 Proposed Facility Residence Property Size: 2 acres ATC Number: 4106 **NOTE**This ImprovemendOperation 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 ith Article 11 of G.S. Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). IS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHAN�E. c WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALL �� . Q� 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 Type Water Supply G Ll Design Wastewater Flow(GPD) Site: New❑ Repair❑ � .� �� System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth �.Z Linear Ft� Other: � . +� , in RCAC 8A. �39 5 Gc, l ��t,J� �/ `��U�g� ��12c .�tems may a�o � u�e / Required Site Modifications/Conditions: l�Gv` � i/ Il�'[PROVER1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:3 or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33()751-87G0.**** i �� f �ro►� � an p �a�� - � - �� _ � -� . . Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) . � . � , � '' ' �� '. � (�ji.'� � p � c' ICATION FOR SITE EVALUATION/IhiPROVEhfENT PGih11T&A7C � � � .G � :Davie County Health Department �r� � Environmenta/Hea/th Section � �I� � ��QY 2 � Z��5 P.O. Box 848/210 Hospital Street • Mocksville, NC 27028 :�� (336)751-�760 � Qd1(lROiJMINTAE NF.R!?t! * PPLTCATION CANNOT BE PROCES5ED UNLESS ALL TIi� R�QUIR�D INFORBSATION IS PROVIDED. Refer to thn INFOR2dATION IIULLETIN for inuL-ructionu. 1. Namo to be Dilled �R J(�� ['�(�� (7"�Q� Contact Per�on cJC3hy�1 �, �� Mailing Addres� � f � xome Phona�lD� �tQ��a��3 City/State/ZIP IC� ,� � �� Duainena Phone 2. Name on Permit/ATC iE Di£Eerent than ]�.bove G ^ DSailing Address City/State/Zip / r� -- 3. Application For: Site Evaluation ❑ Imp ovemen� Permit/ATC ❑ Both q. system to service: O House I� Mobile HomQ ❑ BusinQsa ❑ Indus�ry � �i r � �,n�— . 5. Type ayatem requested: ❑ Conventional ❑ conventional modified ❑ innovat�o � • 80 6. If Residence: 8 PQople �_ # Bedrooms _�� ! Bathrooms �� ❑Diahwasher ❑Garbage Diaposal �Waahing Machine ❑Ba3ement/Plwnbing ❑Dasement/No Plumbing 7. If IIusinesa/Induatry /Other: vorify type # People I{ Sinks # Commodes� # Showora 1p Urinalu It Wator Cooloru IF FOODSERVICE: �� Seats Eatimated Water UIIaga (gallons per day) 8. Typo of water aupply: ❑ County/City � Well ❑ Community 9. no you anticipate addiriona or expansioi�s of tlic facility tliis s}�stcni is intcndcd to scrvc? ❑Ycs �No •. _ If ycs,tivliat typc? ***IIIIPORTANT'`**CLIGNTS d1UST C0�11PLL•TETHG REQUIRLD I'ROP�RTY INrOR11-IATION R�QUGSTCD BELOW. Citi�cr 1 PLAT or SITIs PLAN IIfUST BESUBAfI7TED by thc dicnt with TIi1S APYI.IG�TION. Property Dinicnsions: �� 11'RIT�DIRLCTIONS(frmn lYlocicsviilc)to PROPIsR'1'1': Tax OfCcc PIN: # ��- !�7 3 =l o� �j� �U b� ��Q.� --t 1��1�1 h�� Property AdJress: Road Namc�rl �lr �?Y�)�'�.t, R� bt� �'� �'tl� i� �-�- C3-t`t �{� . � , c;tyiz;n��, v L\l�, rJ�2�� o r1 �-�.��- ICin a Subdivision providc ii�form�tion,as follotivr. Namc: Seciion: Blocic: Lot: Datc liomc coriicrs tlaggcd: � c� C�`� Tliis is to certify tliat tlie information provided is correct to tl�c best of my la�owledge. I undcrstand ll�at any peruiit(s) ''' issued liereafter are subject to suspensiou or revocation,iC tl�e site plans or iiitendcd use cliange,or if tl�e ii�fori�iatio�i submitted in tliis application is falsiGed ur cliangcd. !,alsu,u�ul��rstanJ tlrat I au�respnrrsiGle fa•a!!cJrarges iiicrrrrecl jrunr r��s�rr�r�Rr,o,�. I,licrcby,givc conscnt to thc AuUiorized Rcprescntativc of thc Davic Count �I-Ica1tL Dcpartu cnt to cntcr upon abovc describcd property Iocatcd in llavic County and o�vncd by �� - 1'�1�1'n�� to coiiduct all tcsling proccdul•cs as ncccssary to dctcrii�inc.tlic sitc suitabilit}�. DAT� ' �"3 V ^ u S SIGNATUIt� �� . � TIiIS AIZ�A MAY B�US�D rOR DRAWING YOUR SIT�PL (Includc all of tlic fullo�ti�ing: �aisliiib aud proposcd property lincs and dimcnsions, structures, sctbacics, aiid scptic oc:�tions). , Sitc Rcvisit Cl�ar�;c , Datc(s): Clicnt NotiGcatiou Datc: �IIS: � / Sign givcn �� Account No. �(O Rcviscd DCH (OS/03 � Inyoicc No. / o � � ��`�./�r/� � / l�, � � �� , �� -��. .�. :, ^��P�.�j��.wr (251a) ��C/ .:, ° �ava�n; � +7 ezes i� r sxo� �� \ < ��) � ��'.nsos �ze bo,�l .. °�� tiigi. ..��. ' . . � sscs �i m 0 � . .. � � . �. . .. � r � ��: 4� ...:�. . . . .. O��. .�� ... �. .. OQ J�IGGiNSROAD Qtn..�'`�-�-�� r O ` � v'/Y P .A� Oq�� S R� ,,, .q . �8.9Dn� Cq ��s:.,� � . P� � 1 � ,._. � . � � �'"� � .. O � * 4,�� I �,� y R r " O " y ,.�., , � � s �ss s <, � .�« � Rr/ �w � �� '�`� � � z ii�ti��v�� °� .� � � ; � � �: , • ;. `� '�' '�. , M :.„ :�. ":: � ;:...:� Lta.oan� ��. �DX '' .:�:� • . . ..��i ��..� . � � � ' $ �7AV1E >� 7' r � � RCADEMY FtD �zsas„ x a _ � 8501 A1 � 21EY.� � ^ i6�i^" ... . \ :� � ...�¢ . � � . / r. e, � \ � 7$p . lat 2^w1 : + � .,., � ",�..�� UP sase , / i � _ � ` r,�%� \ . cS�M.) .. �' � .. .. � � . ,. �� , y46 ... � e ., . �.� � —.� ' .lz oenl � � . '• � . . az: .�. ,` 0 . . .. � p � .. � (ii�rq . .a � - _ �203 � . . �2 ' v .. �, A � .. .. � . 5 . ? ' _._ I po ...., t3s.t � q� �S r 7 I � . . . /� 3�.osAi � 225 . . / .... . �� ,,, . . 227 '� sz»� � �k „ / p ; `p ' t10.MAj I ��P . �.. en: . ��.. � � � � � ... . (s ssa) ls 6v,). . .. .. ... . 'b. � � ��263 mos . . � . � . ,/ .. � asn � ! � �63 � ' \ / , i / .. � � . . . . � � `I�Asq � ` � y . t�i � � � �� r � � �_ >e.., ... ., . e. (I6WA) . � � � / . 3610 n �� , G � 26ik I � T . urz , � � , � p w�w*��d��il��id�� _� ' � .�..� ��y �� .a�.v� ..�. � y � m�� . � �0�) � . .�� g � . :�. � � a4 . � � . .,i ; .: :, a, � .�.. .� N9�. ,a'j. � / BY�RLY� � ��,� � , , CHAPEL RD ,�a'� . , � ^�'"~ � �� - '.ni�'ai ». w' ��ma . .� . . ' �sezn� . � ° �naal , �. � .. .. � � � �q. . orm �:i � . . / a_ ty �lessA� � � �P^9 � .. / . . � �� 1.tTt� F . � � `�,� bK1�'��. '` ry �� ..•sssr. t su� � \a�� rli� � � = d+� � "lii � a ii n`O Siiti��sa ' �� v; I � o � 'RL APEL°RD ', � -� z.,b,+,; � B � � � � ,�.a 1 159 28A) � R. .� . 0�95 . �+^ . � , , ' /� ''� Of'�� ,� .,WI'.DE;'� � �. / `, �C�aS i=..' ` is esn� ��m�'`w �,; �m, �iI,P�Gi^ � t� �ii � � � ��x� ,: , =., � �� , i '� ��i a' `� .... . eso' . �. ' �- . . : " nl t,�!i�i wi f�. �2 M 1 .. . DAVI�COUNTY H�ALTH D�PARTMCNT � ' ' • Environmental Heaith Section . Soil/Site Evaluation APPI,ICANT INFORMATION PROPERTY INFORMATION Account #: 990003633 Tax PIN/EH#: 5717-43-9239 Billed To:� Jason Hampton S�tbdivision Info: Reference Name: Location/Address: 227 Mr. Henry Road-27028 Proposed Fa�ility: Residence Property Size: 2 acres Date Evaluated: _�g�S� Water Supply: On-Site Well �� Community Public � Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% � � HORIZON I DEPTH �� i Texture rou C Consistence /� Swcture �o � Mineralo �� HORIZON li DEP'I'H ` �� Tcxture rou Consistence - i f Swcture �L Mineralo ; HORIZON III DEPTH f� G`� Texture rou Consistence Structure Mineralo L�' / ' HORIZON 1V DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCGPTANCE RATE � . SITE CLASSIFICATION: 4� � EVALUATION BY: ��.� L/ LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND � Landscaac 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 Texturc 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-Ficm 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 Structurc �SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic V�Iineralo�y 1:1,2:1,Mixed ote 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-gal/day/ft2 I�Cf In OS/99 (Rcviscd) ...........................................................��..... ................................ ......................... . ... ................................�3.........................._.�... .......................................................... ■ . ■.■ ...................................................■.■■�..�■ ■ ......................................................■■�.... ■C .......................................................■�.... 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Box 848/210 Hospital Street � Courier 09-40-06 • Mocksville, NC 27028 �Os� -�,-��" '�3 � �� (336)751 8760�� r '�� F � >:4 � � 1 �� ' * ` } �:._x..:... .:....m.�....�.w.n,.o.,.w.+�...�...�,v�L.....v.___...��_....ssva.o.,,4.:s�...r....�w,...�,�me,..:<...�......,.�,..........v.......�u.,a�...<_.....�..,.. d�ti„r.bw....,+.E._._ June 9, 2005 Jason Hampton 227 Mr.Henry Road Mocksville,NC 27028 Re: Site Evaluation/Mr. Henry Road Tax Office PIN: #5717-43-9239 Dear Client(s): As requested, a representative from this office visited the aforementioned site on,June 8, 2005. 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 an oversized modified 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, , .. ��'��8. ��• Robert B. Hall, Jr.,R.S. Environmental Health Specialist RBH/dlf Enclosure(s) �