172 Myers Farm Trail , y' � , DAVIE COiJNTY HEALTH DEPARTMENT
Environmental Health Section �� �`� � � (��
� � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
• (33G)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001461 Tax PIN/EH#: 5778-58-9827.ah.
Billed To: R.A. Hewitt Bldg. Subdivision Info:
Reference Name: ' Location/Address: Myers Farm Trail-27006
Proposed Facility: Residence Property Size: 21.6802 acres
ATC Number: 2973
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
. system. An AUTHOWZATION 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 V� #Baths �,�
Dishwasher� Garbage Disposa� Washing Machine:� 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) C��� Site: New�Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width���� Rock Depth/1 r Linear Ft.'y�l��
Other:
Required Site Modifications/Conditions:
I1�IPROVE111ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
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)751-87G0.****
�
Environmental Health S ecialist's Si ature: ' ' � Date: �� �
p gn G� � �f
DCHD OS/99(Revised)
, � . .
, � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990001461 Tax PIN/EH#: 5778-5$-9827.ah.
Billed To: R.A. Hewitt Bldg. Subdivision Info:
Reference Name: Location/Address: Myers Farm Trail-27006
Pro osed Facilit : Residence Pro ert Size: 21.6802 aares
ATC Number: 2973
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLIED 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 WASTEWAT CONSTRUCTION IS V LID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �` C� `�U/
CERTIITCATE 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 .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 ti e.. �
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Septic System Installed By: ��N1,�A+�, �ilT� I� Di�JC�
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Environmental Health Specialist's Signature: ate: / _
DCHD OS/99(Revised)
09/18/2001 14:55� 940 3257 RA HEWITT BLDG 1�j02
, � � l�J � � �
, � ��
� TION FQJt S[TC CVA�UAT10iV/IMi'ROV[l11CNT PCMtIT&ATG
SEP j 8 2001 davie County Hea(th Department
. • Envirorrmer�tal Health Settion
� P.O. Sox 948/210 Hospital Street
• ENVIRONMENTAtHEAL� Mocksville, NC 27028
ppV1ECA�NN (336)751-6760
**t2liPOR7'ANT't=t THIS APPLICATION GlNXOT BE PROC�SSED UHI�SS AI.L THE REQUIRLD
INFORI+ATION IS RR��7IDEA. Refer to the IPYFORt�►TION BDLLETIN fo= lastructions. I
1. IIamQ io•� 6illed , , �_ Concaet Person 1� ,_
Mailing Addresa TT �ome 8nona 3 — o�o�
cicy�srate�zx� ,40�L�',�C1 NC a�-ool� aus�nas$ anon� 33�� 9�o- ar,�,�
2. tiama or► Pesmit/A2C if DiPferent thaa Abwe �/�'l��
lfaili.ag 7►dciross � City/scate/Z.ip :3�CJ T �
3. Agplicatioa F'or: i�Site Evaluafiiou 0 �provamc�nt Pe�it/ATC I I Both
4. syass� to sos.ics: �House O Mabile Home ❑ auainess I.l Industry ll Other
I
5. IP Residanea: i Peop2e � �f Bedrooms � ii 8athrooms � 2,
�Diab�rashez �Gar.bage Dieposal ���s�ing ,Sachino �Baseme�trp�mbl�g I! naeemenl•/No Plumsing
6. If &isiaesa/Ynduarsy/Otner: Specily Cypo � People � Sinl�
d Commndee � SAowora � uzinala N Hatar Coolurs
IF FoopSERVICE: # Seats Estima�ed Water Usage (qalio�s por aay)
7. Zype of vatar supply: 0 County/City �Well I1 Community
e. Do you antieipatc additions or cxpansiuns af tbc f•reility this systcm is iy�tcndcd eo scrve? �Y� I"I No
I f y�s.what typc? �'�'11'DOlY1 �' ����.rT�' [ /'D Gt�'t�OL !1'1\ _„�„
t�rJMPORTi1NT*;*CWEKTS MUSTGOd1PGL•TL•TIiE kEQUIR�D PROPCRTY 1N1�01zmn�l�lON lu�:QuLsr�u
B�LOW. EicLer a PLAT orSITE PLAiY MUS7'BCSU1;1�117TED by tLa ctient witli T1�11S APYLICA'I'ION. '
Pcoperty Dimcesions:
02�. t�p�oZ Q�eS 1VR1TL Dl[ZECCIONS(Crom Mockcviilc) tu PltOPl?Ii'1'1': �
Ta:OfficcPlN: # 'S�'� " ��' G}�oL�' �`vl,, $OI � �YnQ�FL2+�� �'{.t.fn
Property Address: Road Namc ��'e"�- m(��J'S {$�M I f4.c � 1'�f�'�- ! ,,�3��- D!1 �(j�.}- Qa 1Lh(�,',
City/Zip /}�l�(�,I)l�•_ ��'• o2�Da/c a�f 7 M� �S�j �{-D�1 i/� ��211�%
ltin a Subciirision providc inCor���atiou,us tollo�vs: �/I Q M��.�Il�-�- 0�'1 �Q�S r Q.Lm
Namc: 1'��� -I-�. I !lvvdJ/!.I i'DQd,1(�n�-It� c��'+ h f/�?�"
SctUort: Block: Lot: Dstc Properly Flaggcd:
This is co ccrtify tbat ttic informatioa providcd i�corrcct to thc bcst of my kuowlcdbc. l undcrsta�d tl�at yny permil(�)
issucd hcrcafcer ire subjcct to suspcnsion or reroc�lioa,if thc site plaus or iiitcndcd asc changc,o�if tl�c infor,u:�tiun
� submittcd in this ap�licatiun u falsificd or changccL !,al�o,rrndersla�rd ll�ar!a��t�espu�r�'iWcJur«1!cbor`�cs iucurrrrl fr��n�
rlris applieulion. t, hcreby.givc conscnt to thc AutUor'rced Reprasentvtivc of ihe D:�vic County ticaltli Uc�iurtme�tl
to cntcr upoa abovc dcscribcd property locslcd in p�vic�County and ownc�t by QQ-�{�i, � I�P�(:�2 �
ta condact aIi tcsting nroccdures as nccc�sary to dctcrminc il►c sitc suitabil .
DA7'C�I(�I�I StGNATU�tL
TH1S AR£A MAY BE USED FOR DRAWII�iG YOUR StT�P�A,lY(Inciudc nll of tl�c follo�ring; Gsistin�und proposcd
properiy lincs and dimcnsions, strvctures, sctb�cks, and sc�Nc Iocations�
' �' Sitc Rcvisit Chsr�;c
nacc(s):
��� ' Clicnt Notificatiou Dutc:
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Account No. I �E �
Rcviscd DCEiD(07/99) Imoicc No. �-S 1� ✓
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pg 123 PG 845 � � DB 75 PG 288/ I
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1 A N I T. W. BARNES �
/ / D B 1 6 3 P G 8 1 9 I C. C. B A R N E S I
� 1 I D B 75 PG 288 / C. W. M I N OR I
I D B 6 3 P G 5 2 1
IRON FOUNO 1 I � I I
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S 8 3°19'SO"F �� r f, DB 166 P G 4
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1���F- � �p �= 55" TWIN POPIAR N I F I
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,� °° " � \ !
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, ' 300.0p
� 200.00' SET N SET ' �
�ri 3 22186 AGRES . p,p��g p�gq{ 4�9.95' �R� ;i Pow- 42.1135 ACRES �� �
. � `,���e 325.42'
� V P �J M.ARKLAND � � � 1.3532 Z �,qRRY S. MARKLAND �' p I
� Q o `% ACRES N � D.B.IB9 PG.361
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� �+� D.B.IB9 PG.359 � �A �o �� A� 2.5671 ACRES � QI �
0 0 . � 3�e- � ^
D r rm N /� ��
`� 349_93' -
421.1a. m �' f N � �/�
S 63'03'17"E� 200.00' �% �
30.00' - S 83_0377-E 61.89' , O
IRON PLACED - - y � ROAD
- 5 83'0317-E 347.44' e ��' o 0
IRON SET Z7695� 30.53' 3p,53' •'i� 5 46'S0'16"W O
78.6�t 2�ao. 30 EASEMENT 3o.ir 39.10' CEME7ERY o �
I pXLE FOUND � .F 33922' --- I'
595.67 r---, N w
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a IR�N FOUND "�
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19 5 cn
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J. E. PEELER `n �
i I DB 92 PG 38 � � �
a pg 81 PG 313 11
RnNALD D. JONES � N � V
C.�,�3. 186 PG. 127 I z 239.58' �IRON PLACED
_ _ IRON P��� N 84°06'05"W
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� ' �� „` ' DAVIE COLJNTY HEALTH DEPARTMENT
� ' � � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001461 Tax PIN/EH#: 5778-58-9827.ah.
Bilied To: R.A. Hewitt Bldg. Subdivision Info:
Reference Name: Location/Address: Myers Farm Tr�il-270 6
Proposed Facility: Residence Property Size: 21.6802 acres Date Evaluated: 2 �
Water Supply: On-Site Well � Community �'ublic
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition ,L �,
Slo e%
HORIZON I DEPTH l� �i
Texture rou ,S` ,(�
Consistence
Structure
Mineralo
HORIZON II DEPTH �� ?�'
Texture rou �" �
Consistence ,- I
Structure /l ` /�
Mineralo � �� ��
HORIZON III DEPTH
Texture rou '
Consistence
Structure
Mineralo •
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Min�ralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SIT'E CLASSIFICATION: �� EVALUATION BY: � G�
�'
LONG-TERM ACCEPTANCE RATE: -S 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
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
Mineraloav
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-gal/day/ft2
DCHD OSl99(Revised)