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166 Myers Rd . `� , DAVIE COUNTY HEALTH DEPARTMENT 'L . - ' Environmental Health Section / �g^ ° 3 P.O.Boz 848/210 Hospital Street � ' Mocksville,NC 27028 (336)751-87(0 IMPROVEMENT/OPERATION PERMIT Account #: 990002979 Tax PIN/EH#: 5852-79-3511.HF Billed To: Henry Freeman Subdivision Info: Reference Name: Location/Address: Myers Farm Road-27028 Proposed Facility: Residence Property Size:. see map ATC Number: 3618 **NOTE** This Improvement/Operation 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� #Baths� Dishwasher:� Garbage Disposal:� Washing Machine•N—� 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) Y�` Site: New❑ Repair❑ '/ `� �00 System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width ��h�Rock Depth,1� Linear Ft. Other: Required Site Modifications/Conditions: I]VIPROVEMENT/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 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(33C)751-87G0.**** ��P m�� e r�� `� .��,�.,�_� i�- �� r � .�o��w . . � Environmental Health Specialist's Signature: �l Date: J��'t� DCHD OS/99(Revised) � ' , � � � DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section -' P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990002979 Tax PIN/EH#: 5852-79-3511.HF Billed To: Henry Freeman Subdivision Info: Reference Name: Location/Address: Myers Farm Road-27028 Proposed Faciliry: Residence Property Size: see map ATC Number: 3618 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 YEARS. Environmental Health Specialist's Signature:�� Date:!! ��"�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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. � u0 `�� . �0 � `�� I � Septic Syste Inst lled By: �' � �•C/` .�- Environmental Health Specialist s Si ature: Date: �'�"d� DCHD OS/99(Revised) �, . - �� : p � � � OM � � , ; APPLICATION FOR SITE EVALUATION/IMPROVEh1ENT YERMIT& NOV 7 2Q03 ' Davie County Health Department Environmenta/Hea/th Sec�ion P.O. Box 848/210 Hospital Street EtlYfRONMfMp(,HEA�T}� Mocksville, NC 27028 Or1YlEC0UNIY (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED IINLESS ALL THE REQIIIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructionB. � / ! YYJ l. Nama to be Billed � Contact Person fff e»y/ Mailing Addreas Aome Phone ��'r City/State/ZIP "',S. �� 07 �� Business Phone �,�_� f� �p�— � �S 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation f�Improvement Permit/ATC ❑ Both 4. syatem to service:�7 House ❑ Mobile Home ❑ Business � Induatry ❑ Other 5. Type aystem requested: � Conventional ❑ conventional modified ❑ innovative t 6. If Residence: # People �_ # Bedrooms � # Bathrooms � �Dishwasher �Garbage Diaposal �Washing Machine �Basement/Plumbing ❑Basement/No Plumbing 7. If Suaineas/Industry /Other: verify type #� People # Sinks # Co�odea # Showers # Urinals 4 # Water Cooler3 IF FOODSERVICE:; # 5eats Estimated Water Usage (galiona por day> s. xype of water aupp�y: �I County/City ❑ Well ❑ Community �� 9. Do You anticipate a�dditions or cxpansions of the facility tliis system is iutendcd to scrvc? �Ycs �No # If yes,what type? � �� .; ***IMPORTANT?�**CLIENTS MUST COMPLETE THE REQUIRED PROPLI2TY INFOI2MATION R�QUGS1'GD BELOW. Eitl�cr a�PLAT or SITE PLAN MUST BE SUI1t�1ITTED by the clicnt with TIIIS APPLICATION. Property Dimensions: l��Y! �j� �� WRITE DIRLCTIONS(from Mocicsvillc)to PI20P�R'1'Y: T �- ' Tax Officc PIN: # 5`'��Z``7��,S/f ` �� / ,��/��r�.� �j . Property Address: Road Name__�� ' �/. �► , il`�� ' �� ,� City/Zip �i►�r.��.��c� �i>l�G�''�/t� �� %f'I�C/Q�" ,� If in a Subdivision providc information,as follows: ��" ,L)Q('� /`� /�DOl�l.S Name: Section: Block: Lot: Date home corucrs tlagged: ��— ��'� � This is to certify that the information providcd is corrcct to tlie best of my kno�vlcdgc. I undcrstand tl�at any permit(s) issucd hereafter are subject to suspension or revocation,if the site plans or intended use cliange,or if tl�c inform�lion submitted in this application is falsifed or changed. I,also,uiiderstand t/iat I aui responsiGle for al!clirrrges incurred fi•om this application. I,hereby,give consent to tlie Authorized Representative of tl�e Davie C unty Health Departn eul to enter upon above described property located in Davie County and owned by _�`'�j��Z��,-_l �,� e �j�P�� to conduct all testing procedures as necessary to determine tiic site suitability. DATE /1�� pf�p��_ SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUIt SITE PLAN(Iucludc ali of thc 'ollowing: Existing and proposcd property lincs and dimensions, structures, setbacks, and septic locations). ' Site Rcvisit Cl�ar•gc ' Datc(s): • Clicnt Notification Datc: EHS: Sign given Accouut No. �` � Revised DCIiD(OS/03 Invoicc No. � 1 Chonnel tron Betr�/1�'rtd Tax Lot 58 Tie Line S 89'20'28"E� Tax Mop C-6 �g.s�. n/f Charfes J. Nash ond wKe � Oro E Nash ' OB 46 O PG 95 � � — �X x IRS �x !RS � N 02°49'S0"E . ' x__ x x X X I —. �ra Fence for Tax Lot 58 E�crooc es Prope ne _�,� � �-'� 1 Porcel 2 � S 88"31'28"E f`f1 ' 25s.n• � f Part of Tax Lot 60 s as�zo�2s��E � � �- 6.743 Acres -!-/— 2�.�' '� ,��. � � . . iI � i Wiro Fence for Tax Lot 66A1 i I S 02°35'41"W Encroaches Properiy Une • � � 51.03' • ' � . — � r �104.92' i i 579.18' S 02•35'41"W 193.28' S 03•42'08"W S 03°39'41"W 209.83'S 03°43•06"W � � ��s 3/4"� i/2� oR � � I Fnd_ . ' Fnd T-9°�/°°p T-8o��coP /Ixle Fnd t i � �. � � � \ " I I i � Tax Lot 53.01 � � Tox Lot C-6 fi i i \ I Tie Une ' ' . I n/f Ricky Stutts N 89•39'16"W—� i i _ DB 199 O PG 3�/.3 2pg.02• , , ` , . \ I � �-- -�-._..— - -. - � . I �; ' - •� • � i - "+ ' ' � ' APPLICATION FOR SITE EI/ALUATI�JN/IMPROV�lriENi i'I�tziMiT&ATC. O � � /� � � , Davie County Health Deparfinent � % <S' a � Environmenta/Hea/th Section � �� " P.O. Box 848/210 Hospital Street �!-�/�/ Mocksville, NC 27028 Z c9 �O� (336)751-8760 Z ��R�N�'�f ***IMPORTANT*** THIS APPLICATION C�NNOT BE PROCESSED UNI,ESS AI,L THE RE '�;y�,�`A(jy � INFORMATION IS PROVIDED. Refer to the INFOF2MF�TION BUI��TIN for instructions. 1. NamQ to be Billed ��. R(7�� '� �o J� Contact Person �ij'� I Q �" � ( ��jj i� g �"�-S S�I e� l�0 ct r �� Mailin Address `� Aome Phone �� - d 7t} � City/State/ZIP W/f�h��l�" ✓CZ IP M U��n r��Q� Business Phone .�,5�p— � /J( -� 7 (J (� 2. Name on Pesmit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �Site Evaluation ❑ Improvement Permi.t/ATC Il Both 4. system to service: �House � Mobile Home ❑ Business ❑ Industry ❑ Other � 5. If Residence: # People � � Bedrooms � # Bathrooms �� Dishxasher �Garbage Disposal �Washiny Machine �Basement/Plumbing I1 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Peop1Q # Sinks li Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: �County/City ❑ Well ❑ Community s, Do you anticipate additions or expansions of the facility tl�is system is intended to scrvc? �Ycs �'No If yes,what type? ***IMPORTANT***CLI�N'I'S��IUSTCOMPLETETHL REQUIRGD PROPGRTY INrORMA7'ION REQUCSTGU BELOW. Either a PLAT or SITE PLAN MUST I3ESUBDII7TED by ti�c clicnt with THIS AI'PLICATION. � ti - - � Q �� Property Dimensions: �-�-- .��--�—y -� �,1 ) � WRITC D(REC'T(ONS(from Mocksvi►Ic)to P1t01'lsli'1'1': � '�'Z 7 / ' r ��I y� /�. -�- � �� -�- (Q /1 Tax Office P11�I: #�Q�( �0.D �. -lO �� l0� J�� "V l�-�l � KJX�I�t 1 n U ' Property Address: Road Name �� I�I U(� (� ?5 � � ., � r - c�ry�z�p �o C 5 � � ( I 2 ��0�.� ��B�.Y j /1�,� Q p.o f�-,-. �� r lf in a Subdivision providc information,as foilows: � `� 1Vame: Scction: Block: Lot: � �, _ . Datc Property Flaggcd: � � This is to ccrtify t6at the information providcd is corrcct to tlic bcst of my knowlcdgc. I undcrstand that any permit(s) issued 6ereafter are subject to suspension or revocation,if the site pinns or intended use change,or if the information submitted in this application is falsified or changed. 1,also,u�rderstand tltut 1 arrt respo�rsiGle jur a1!cltnrges irrctrrrer/,fronr 1/iis applicatia�. I, hereby,give conscnt to tlie Autl�orizcd Rcprescntative of tt�c lluvic ounty I�calth epartn cnt to cnter upon above described property located in Davie County and owncd by � . to conduct all testing pr edures as nccessary to determinc the sitc suitability. DATE I aS SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: Existing and proposcd property lines and dimensions, structures, setbacks, and septic locations). Sitc Rcvisit C6argc Datc(s): Clicnt Notitication Date: �ris: � Account No. �� Revised DCHD(07/99) � Invoice No. ��3 �� •,� • DAVIE COUNTY HEALTH DEPARTMENT � � ' Environmental Health Section ' � Soil/Site Evaluation � • APPLICANT INFORMATION PROPERTY INFORMATION ' r..:_:��-��' .-. 990002138 >i--: - _ - _ . _ 5852-79-3511.03 ` ^;.��i;�: Dr. Robert Fox .�.��_.._ ' .. ...`�: <�.�.,� �'�,`crti�� ^;�-:;,,. �.:;�.�•;��.',•",�,� .,�� Highway 801 N-27028 �;.,.,,,��.� ��,�,.�, Residence or.,n.,;-;,, �i�c: see map �� ,,,,�,,.;,�d: ��D� Water Supply: On-Site Well 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 S' Consistence Structure Mineralo HORIZON II DEPTH y�' '� Texture rou Consistence � , Structure 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: 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 Mineralo�v 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 OS/99(Revised) , 5 . , , • . . .. , ` ID��I�(�OUNTY�I�LT�i D��T1��1'T ` : . __ _ . _..., ENV1�Oy1�iENTAL tlFALTN SfCT10�1 P. O. Box 848/210 Hospital Street . Courier #09-40-06 . . _. Mocksville, NC 27028 __ : , Phone #: (33G)751-8760 . February 7, 2002 � Dr. Robert Fox 325 Steed Court Winston-Salem,NC 27104 Dear Dr. Fox: On February 6, 2002 this office evaluated 3 sites aon a 13 acre tract of land that fronts NC Highway 801 and Myers Road in Davie County. Site 1 that fronts Highway 841 is classified provisionally suitable for the installation of a septic system. Site 2 is classified unsuitable for a septic system, however,this classification could change dependant on where the property lines are established. Site 3,that fronts Myers Road is classified provisionally suitable for a septic system. Before any permits are issued the exact house location must be staked off. , If you have further questions please feel free to call our ofice at AC336-751-8760. S incerely, /�02►'��'° Robert B. Hall, Jr., RS Environmental Health Specialist RBH: df r- . � . ° ' . • .. ____. _..___ , _. __ __ , __ __ __ _ ._ � �5»0 � e _ . _ _ _ . � (J.OB/�) � I � , 6�� (17 04A) 4943 � 6952 - � �^'r p�e� 89B2 7809 :2BB8 . °g,' t ! �' - ��` i � 1e� V ,i852 • � � C600000053 � �SRlasr._ . .. � _ '� . - _. ..,. . -MVCASAo�o- '. — _ ."- 1oa � eaa �S� re:1 t+051 �mi �_�� ; 600000053010 C600000054 : 4664 - . , ('I.SIA) rv 56�o cs000000�ao2 rz�a� 7.�SA C6�0005 2513 � i T. _ C600000058' . a . S:e o. ' �i � . . �. r � � . . , . � G6D0000056 C60000006601 ' ' OQ � � 5:7A � 1760 ' C600000060 , � i � - _ 6A ' eo - 6ea9 -�1 � � . - . , . . - .`'�>e. . . � � f , g " � � cs000�o41� , . 7fi 10 N I 1 � I . � (W.o�nl, � . � iJ.]2A i 95N 1 2580 (t875P.) t10.97A) . ' 79�1 �d37 � . �. ■ '` � d (].Zl A) i 1008 , ,� a , . . s. . . ._ (�e8A) 8S0_ ' (1.78Ai �� . � ! OeSd �ea�" ee�i . R — _ .. �� ,.:i..eo��.. — ^ , . . . . .. -• . . �.. .. ' � �r^'� .._ . .. I ao _o�, .. ..Q,. ,._ •.r' ` �,z�A� ; l . , „ . � �s�q I ...,_._, . ._ ._ ..�. ...�... .._ ... __- -.,- � _ i _ . . .. ..., 5692 ; . \I 5�29'� i 1475 1 % . • �� 9aa2' '. . ' . II ��(°�`�.S' �� .. ; , I ZO 397d ;,11'73c1 N019NINN3d ESE6LSL9cE ZD�SO ZO�Z/8�/T� — _-- I �.�U��.�:, �;��a�''�'�.'' :��:��.�.�� :�'��'`�'�'a��;I�',.� Environmental Health Section . . �� P.�J. �30:�: �48/210 Ho�pital Street Courier#09-40-06 �iocl<sville. NC 270'� Phone#: (336)751-8760 Fax#: (336)751-8786 Mav 28. 2005 He�1rv Freeman 1 Ct M�-ers Road Mocksville,NC 27028 Re: Site Evaluation Tat PIN: �852-79-0�32 Dear Mr. Freeman , As requested, Robert M. Na.tions, RS; Em�ironmeiltal Health Si.�ecialist with this of�ce oii Ma��21, 200�, evaluated the above-referenced property at the site designated on the plat/site plan tl»t accoi�ipanied��our improvement pernlit application for a 4 bedrootn residence. Tlle evaluation��as done in accordance��ith the la�vs�nd niles governing «•aste�cater systems in North Carolina Genei-al Stattite 130A-3�3 and related statutes and Title 1iA, Subchaptcr 18A, of the Nortl� Carolina Admii►istrative Code, Rule .]900 arid related nllcs. Based on the criteria set out ii1 1iA, SLibchlpter 18A, of the North Carolina Administrati��e Code, Rules .1940 through .1948,the evaluation indicated that the site is tNSUITABLE for a ground absorption se«-age s��stcm. Thercfore, �•our requcst for an improvemcnt permit is DENIED. A cop��of the site evaluation is enclosecl. Tl�e site is unsuitable based on the follot�irig: Rule .1940 Topography and Landscape Position Rtile .19�1 Soil Characteristics Rt�le .19�2 Soil Wetness Rule .1943 Soil De��tll Rule .194� Available Space These severe soil or site limitations could cause premature svstem failure; leading to tlle discharge of untreated se�eage on tl�c ground surf�ce, in surface��aters. directl��into grouud«�atcr or inside vour stn�cture. The site evaluation included considcration of possible site modifications, and modified, i�movative or altenlative s��stems. Ho«�cver, this office h1s detern�inetl tl�at none of thc abo��e options will overcome thc severc conditions on this site. P,possible option inigl�t bc a systcrn designed to dispose of sc��age to anothcr area of suitaUle soil or off-site to �dditional property. For tlle reasons set out abo�•e,the propert�� is currentl��classi�cd IINSUITABLE, and an improvcment permit shall not be issued for this site in accordance ��ith Rule .194g(c). Ho«-cvcr. tl�e site classif ed as IJNSUITABLE ma��be reclassified as PROVIONALLY SUITABLE if «rittci7 documentation is providcd that meets the rec�uircments of Rule .19=��(d). A cop�� of this nile is encloscd. You i��1��l�irc 3 consultant to assist t�ou if'��ou «°ish to try to dcvclop � plan undcr��llich vour site could be reclassified as PROVISIONALLY SUIT:ABLE. You have a right to an informal revie�G� of this decision. You mav request an informal reF�ie«� bv the environme»tal health sl�pervisor«�itl�this office. Yoil ma�- also request an informal revie�� bv the N.C. Department of Environment ai�d Naturll .Resourccs regional soil specialist. A request for informal revie«�must be made in��riting to the D�`�ic Count��Health Dcpartment, Environmental Hcaltlz Section. You also have a right to a fornlal appeal of this decision. To pursue a fonnal appeal, ��ou must filc a petition for a cont�ested case hearing�vitli t1�1e Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get�cop��of a petition form. ��ou may�vrite thc Office of Administrltive Hcarings or call the oftice at (919) 733-0926 ar from thc OAH web site at �v«1v.ncoah.con�/forms.siitml. The petition for a contested case hearine must be�led in accordance ��vith the provision of North Carolina General Stahrtes 130A-2� and 1�0-B-23 and all otlier applicable provisions of Chaptcr 1�OB. N.C. General Statute 130A-33� (g)provides that your l�caring �vould be held in the county�vhere��our propert5� is located. Please note: If��ou ��ish to pursue a forn�al appcal; you must file the petition farm�vith the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETI'ER. The date of this letter is {DATE}. Meeting the 30 da�� deadline is critical to vour right to a formal appeal. Beginning a fornlal appeal �i�ithin 30 davs «�ill not interfcre«�ith�ny iilformal revie«•that '��ou might request. Do not�vait far the outcome of an�� infortttal revie«- if you ��ish to file a formal appeal. If votii filE a petition for a corrtested case liearing with the O�ce of�dministrative Hearings, � ��ou 1re required by la�v(N.C. Geueral Statut� 150B-23)to send a copS� of��oL�r petition to the North Carolina Department of Ei�vironment and Nattiral Resources. Send the cop��to: Oftice of General Coutisel,N.C. Deparnlle�It of Environment and Natural Resources, 1601 1�1ai1 Sen�ice Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to Davie Co�mt_y Health Department. Sending a copy of��our petition to Davie Courit��Healtll Departmeilt «�ill NOT satisfi'the Icgal requirements in N.C. Gcneral Statute 1�OB-2� that��ou send a copy to tl-►e Office of General Counsel. NCDENR. � Plcase call or�vrite this office if you havc an��qLiestions or need anv additioual assistance, as follo«�s: Telepholie number: (336) 7�L-8760 Davie Count��Health Departmcnt Environmental Health Section P.O. Box 848 Mocicsville.NC 27028 S.inccrel��, �� ' u•'�''%�%�`�� , Robert M. Nations. RS Environmental Health Specialist � /df Eilclosure(s): Soil-Site Report Rule .1948 Invoice 7i,Ab4'� Ai�dD RUi:.�S �'Q� 5��%�G�7'I2��4TMENT AND DISPOS�L S�'�TE��►S 15A NCAC l8A .19Q0 Rizle .19�4b .1948 SIT� CL�55IFI��TI�N (a) Sites classified as SUITABLE mav be trtilized for a gro�md absorption seti;�age treatment and disposal system consistent�vith these Rliles. A stutable classificatioii gen�r�lly indicates soil and site conditions favorable for the operation of a ground absorption se«-age treatmcnt and disposal sS�stem or have slight limitatious that arc readily ovcrcomc b��proper design and installation. (b) Sites classified as PROVISIONALLI� SUITABLE may be utilized for a ground absorption se�vage treltment a.nd disposzl systen� consistent with�tllese Rules bLit have moderate limitations. Sites classified Provisionallv Suitable require some modifications and cu-efiil � planning, design, and installation in order for a ground absorption se�vage treatment and disposal system to fiinction satisfactoril�•. (c) Sites classified LJNSUITABLE have severe limitations for the installation and use of a • properl��fi�netioriing groLmd absorption sc«•age treatment and disposal s��stem. An improvement permit shall not be issued for a site �vhich is classified as IJNSUITABLE. Ho�ve��er, where a sitc is UNSUITABLE, it ma}� be reclassified PROVISIONALLY SUIT'ABLE if a special investigation inciicates that a modified or alternative svstem can be installed in accordance��•ith Rules .19�6 or .19�7 or this Section. (d) A site classified as UNSUITABLE mav be used�or a ground absorptior� se�vage tre�tment and disposal system specifically identified in Rulcs .19>j, .19�6 or .:19�7 of this Section or a system approvcd under Rule .19C9 if written doct.imentation, including engineering, �l�iydrogcologic, geologic or soil studies, indicates to thc local healtli department that the proposed system can be espceted to fiuiction s,atisfactoril��. Sucli sites siiall be reclassi�ed as PROVISIONALLY S[JITABLE if thE local health department determi��es tliat the substantiating data indicate that: (1) ��t-ouzid absorption system c�r1 be installed so that the effluent�vill be �ion-p�tl�ogenic. non-infectious, non-toxic, and non-hazardous; (2) the efflucnt�vill not coiltaminate gro�indtivatcr or surface��ater; atld � (3) the effluent��ill not be eLposed on the ground surface or be clischarged to surface��aters �vhere it could come in contact«ith people, animals. or vectors. The State sl�all revie«�Che slibstantiating data if req�iested by tl�e local health department. Historv Note: Authoritv G.S. 1�OA-��5(e): �ff. Jul�� 1 19g2 Amended Ef£ April 1, 1993: Januan� 1_ 1990. .1, '; - 5-�g� j'Y)/t• l-�p�vt/k� I.�� . . � � d� b�,y,� _ , - , �''�I'�t +_ '' � TE EVALUATION/IMPROVEMENT PE ATC ��l! _, ;�l5 � - �, avie County Environmental Health ��. c�O ➢'� � ' � '� P.O.Box 848/210 Hospital Street � r - �.� � S 4 R�=�a?��-•� Mocksville,NC 27028 � , �"`"� �.y 336)751-8760/Fax(336)751-8786 . , .��we+�{�S� . .4`-, . �9. i� Appli �on r'�-`t�; "te=�va1� errccnt-Permit' ❑ Authorization To Construct(ATC) ❑ Both Type pplicatio •� w System �Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION , �, � Name to be Billed ` ^ � �/_'�'/9��•--� Contact Person �c`'.�r Billing Address�//� f,^�;,�=;�i l� Home Phone �.;�.r�J ��C�'�� G'� Ci /State/ZIP /1,�i-�� ty /� i�i�/� l-��". �?C�� Business Phone -� ``-'.T'�' � � j �t, Name on PermidATC if Different than Above D i �Gf� ' � f.%'�n, /'l' � j �A� O Mailing Address nG .e City/State/Zip ;;� '�ty/� PROPERTY INFORMATION *Date House/Facility Corners Flagged J� i5 �� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan at(to scale) (Pernut is valid for 60 months wi�h site plan,no expiration with complete plat.) Owner's Name S� � � � '� G� /U: ,, Phone Numbe�3.1�6 ��-'9,/��f` Owner's Address '-7 • � , City/State/Zip/"' � , /I�(� c� ' Property Address ' l y City /�,,��%��lA Lot Size�/��-��. Tax PIN#__,��o?? S!�2 Subdivision Name(if applicable) Section/Lot# ,5�,� Directions To Site: _Qi�� ,l � ' ` 7`P1`.cs�"��/��t'-�r�� ,r�� j` ,�''lf/ i��9r�.r�� /�� .�r��-� If the answer to any of the following questions is"yes",supporting documentation�ust be attached. Are there any existing wastewater systems on the site? ❑Yes C�'N�o Does the site contain jurisdictional wetlands? ❑Yes C��I�Q/o Are there any easements or right-of-ways on the site? ❑Yes L�13��o Is the site subject to approval by another public agency? ❑Yes CC�'1Q�o Will wastewater other than domestic sewage be generated? ❑Yes C333�o �IF RESIDENCE FILL OUT THE BOX BELOW #People —�� #Bedrooms � #Bathrooms ,� Garden Tub/Whirlpool L�r1�s ❑No Basement: C+�fes ❑No Basement Plumbing: �s ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Typesystemrequested:. �Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Q"No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. � � .u? 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",iY.f... �� Y' .�,.✓.,:,f. ,,,�'i,:� .. . . � i '� .�r�� r . � . ,� �" � ' , r . �," ', ' GoMAPS -Davie County NC Public Access Page 1 of 1 . , Davie County, NC - GIS/Mapping System �9Vt� Click HereTo Start Ouer Quitk �earch:(County ID [ � '+� �1 ��m,_ n ' ✓�w �-' f\ J I � � � ,Actiue Layer. ❑Use MaP TPS GIS �aU tz� � � �' ,,;�'' � �,° PARGELS (Map Tips Available� ,�'� Map Layers � R�sult� � s J : I a� ¢ R� ` a , ;, � :° t ,+� � F�» �� # ' ° ' •..�,..a: ��.._.. --�=``ARBOR LN� �� ; `b� -� ��4 �� , -�---- ��--�—•�-�— � �4 � �ti � t 'qib �� '�'r. ,A -..,yc._+J'��. k� �� „ 3 1 A � � �' ,�" ';?, •�-'�'t � � �,��. �} �# � f �� '� r' ,.<»� f. 2� � q; . '� .APPLE. CRE5-RD �' Q �,,.. a �;, : ,�--, �;,:� '�"�� `d y R+ �F tk �„�" ��.� �o- 'y;� figQ �� 2 � ,,# � r. `a,a st <$y� � 't <� � ' `� � �`;. �, ;�-� � :�: - �- ,� �4� z �� HtNY�6Q1-�' `� � �; �� y ;._ �'` .., M. z�'� -�.�.. � O � mmm, '••^�-;=d." �...,�� .".::":.:: b� � . mb 4� 4j � t: � � � Q 1 W ...t J w 3,," � ��' � f � T)� � �, � }r� � 4° �a o26i �'� � � ;; �'�' / http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129... 5/8/2008 � , 9 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPL 6��1I3b�FQ��N Tax PIN/EH#: 585��R��Y INFORMATION Billed To: Henry Freeman Subdivision Info: Reference Name: Location/Address: Myers Road-27028 Q Proposed Facility:, residence Property Size: 10.98 acres Date Evaluated: � � —�Ci' �. r _ _ Water Supply: ' On-Site Well Community Public � 1� Evaluation By: Auger Boring Pit Cut �� FACTORS 1 2 3 4 5 � 7 ak� Landscape position ,� (._. : (� �L-, � C_ Slope % ` � - HORIZON I DEPTH L�- ! C')-- '" U ^�� - J 6'�` Texture grou C , C L �, �`� L G Consis[ence � �¢'v � � ,��r Structure � � Q g L � �iCr...� ,� . Mineralo �(' .y '� HORIZON II DEPTH r -�/ - '` — � Texture rou G G Consisterice G , Stnicture , � ` /�t p�ti� k°( Mineralo �� /) HORIZON III DEPTH Texture rou ' Consistence - Structure Mineralo HORIZON IV DEPTH Texture rou Consistence � Structure . � Mineralo SOIL WETNESS �� RESTRICTIVE HORIZON ,f- `��' o�(c I'�� SAPROLITE CLASSIFICATION n �/S) LONG-TERM ACCEPTANCE RATE � �► �. (�, o= SITE CLASSIFICATION: �,�, I/� S L(. � �u G�"/r� EVALUATION BY: �J i v �'f\�t� C� S LONG-TERM ACCEPTANCE RATE: '� OTHER(S)PRESENT: ( "t�"'F'�I/l� REMARKS: LEGEND Landscape Position . R-Ridge .S -Shoulder L-Linear slope FS -Foo[`slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Text re S -Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam GL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay GONSISTENCE NIQis.t VFR-Very friable FR-Friable FI-Firm VFI-Very finn EFI-Extremely firm YY�� NS -Non sticky SS - Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Str�ct�re , SC- Single grain M-Massive CR-Crumb GR- Granular ABK-Angular blocky SBK -Subangular blocky PL-Platy PR-Prismatic bIineralo�v 1:1,2:1,Mixed lY�tr� Horizon depth-In inches � . � . 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