159 Northbrook Drive Lot 14 3 OPERATION PERMIT FGounty
ice use UnIV,
_ Davie County Health Department 7FRe umber 229981 -1
210 Hospital Street c3060Ao014
P.O. Box 848 umber
Mocksville NC r 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: North Carolina Custom Modulars Property owner: North Carolina Custom Modulars
Address: 1936 Hwy 64 E Address: 1936 Hwy 64 E
CRY: Asheboro !CRY: Asheboro
State/Zip: NC 27203 State0p: NC 27203
Phone#: (919)548-2033 Phone#: (919)548-2033
=i
Property Location & Site Information
-_F�Address/Road#: Subdivision: 'Northbrook Phase: Lot: 14
orthbrook Drive
sville NC 27028 Directions
--Hwy 601 N. left on Ijames Church Rd. Northbrook on
Y
Structure. SINGLE!FAMILY __.
#of Bedrooms: 3
right;
#of People:
'Water Supply: PUBLIC
*IP Issued by'` -2140 Nations,Robert *System Classification/Description:
_ 'TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS
*CA issued by: 2140-Nations,Robert SaproliteSystem? QYes 9No
_ Design Flow: 3.. 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes PNo
Soil Application Rate: 0 w 2 7 S
*Pre Treatment:
Drain field
N itrification Field 1 3 0 ° 9 Sp *System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines 4Instager: ray Poole
Total Trench Length: 3 3 6 ft. Certification#: 1862
Trench Spacing: _ 9 Inches O.C.
Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: 3 Inches
Feet Date: 1 1 / 0 7 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6Inches
Minimum Soil Cover a q Inches vApprovalStatus`
Maximum Trench Depth: 3 6 Inches ® Approved O Disapproved
Maximum Soil Cover: 2 4 Inches
CDP Fite Number 229981 - 1 Septic Tank County ID Number:
G3060A0014 �
Manufacturer. $h0af Lat.
STB: 760 Long:
Gallons: 1000
Installer. Ray Poole
- Date: 0 8 / 0 9 / x 0 1 6
Certification#: 1862
- ._.�._.... _ *EHS: 2140 Nations,Rout -
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
Date: 1 1 / 0 7 / 2 0 1 6
ST Marker El Yes � NO -
Reinforced Tank: ❑ Yes `L7 No Status
Approval
y® Ap roved❑ Dtsa roved
1 Piece Tank: -❑ Yes � No p pp
Pump Tank
--Manufacturer. Installer.
PT: Certification#:
Gallons; *ENS:
-_;.Date: / i / ! Date: I I -
RiserSeeled ❑ Yes ❑ No
RiserNeght: ❑ Yes ❑- N0 (Min.6 in.)
proval Status
Reinforced Tank: ❑ YeS ❑- NO
,A
p
- -
Approved❑ Dtsa'Drovetl
1 Piece Tank:- ❑.,Yes ❑___No_ -
-� Supply Line
Pipe Size. inch diameter Installer. -
Pe Length: feet Certification#:
*Schedule:
*EHS:
Pressure Rated ❑ Yes ❑ No Date: I /
Approved fittings ❑ Yes ❑ No
Approval Status
❑ Approved❑ DrsapproRV
ved
Pump
Pump Type: Installer,
Dosing Volume: Gal Certification#:
Draw Down: Inches *EHS:
*Chain: I I
Dater
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No
Approval Status
PVC Unions ❑ Yes ❑ No
❑ Approved❑ Disapprovetl
Vent Hole ElYes ❑ No
Anti-siphon Hole El Yes 0 No
22998'1 - 1 .G3060A0014
CDP File Number County ID Number:
Electric Equipment
NEMA4XBox orEquivalent [3 Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ No
Box Adj.To Pump Tank Certification :
_ ❑ Yes ❑ N o
Conduit Sealed ❑ Yes ❑ No *ENS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Ell
Approval Status
Ala rm Audible ❑ Yes ❑ No31
. �. -. . ❑ Approved Disapproved
Alamt Visible ❑ YeS ❑ No - , 7 -..
2140-Nations,Robert
_ .'Operation,Permit completed.by:
,._._ ___Authorized State Agent = Date of Issue: 1 1 0 7 20 :C 6 1
Owner/ApplicantSignature; www
_ This system has been installed incompliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal,15A NCAC-I$A 1900 of. Seq.,and all conditions of the Improvement Permit and
---.-Construction Authorization This property is served bye TYPE m G.
sewage septic system -
. v
Rule A 961 requires that a T TYPE III G.
q Type septic system meet the following criteria: -
Minimum System Review By The Local Health Department: N/A
--_ Management.Entity OWNER., T
Minirrium System Inspection/Maintenance Frequency By Certified Operator:
N/A _I
Reporting Frequency By Certified Operator. NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract .
. wkh a public management entitywith a certified operator or a private certified operator for the fife of the septic system.,
Rule.1961 requires that Type VI septic systems designed for a hometbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system. ___
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit fora system required to be maintained by public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing 01mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 229981 - 1
Davie County Health Department CDP File Number:
r
210 Hospital Street G306OA0014
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1
Olnch
Drawing Drawing Type:-Operation Permit- - Scale: . OON
Block= A.
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CONSTRUCTION ArUTHORIZATION
Davie county Health Department CDP File Number:
210 Hospital Street G306OA0014
P.O.sox 848 County File Number:
Mocksville NC 27028 Date: 0 9 / 1 2 / 2 0 1 6
Q Inch
Scale: . . . . Qslock
.Drawing Drawing Type: Construction Authorization QNJA
t
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CONSTRUCTION AUTHORIZATION '
Davie County Health Department t
210 Hospital street CDP File Number:
P.O.Box 848 G3060A0014
Mocksvlle NC 27028 County File Number.
la016
09 / 1a
Date: _ _
Click°below to import an image from an extemal location: cawing Type:Construction Authorization-j—,
io
i
IMPROVEMENT PERMIT For office Use Only
"CDP File Number 229981 - 1 ,
Davie County Health Department
County ID Number:G3060A00W
210 Hospital Street
._. '�. .. .- P.O. Box 848
Evaluated For. NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 9/12/2021
*NOTE TO INSPECTIONS DIVISION:-Building Permits cannot be issued with this Improvement Permit.
Applicant: North Carolina Custom Modulars Property owner: North Carolina Custom Modulars
Address: 1936 Hwy 64 EAddress: 1936 Hwy 64 E
City: Asheboro City: Asheboro
K .-.State2ip: NC 27203 StatetZip: NC 27203
- Phone 9: (919)548=2033 Phone 9: (919)548-2033
Progerty Location & Site Information
rddress/Road 9: Subdivision: Northbrook Phase: Lot: 14
hbrook Drive
le NC 27028 Directions
Structure: - SINGLE FAMILY 'Hwy'601 N. left on Ijames Church Rd. Northbrook on
#of Bedrooms: 3 right
4 of People:
*Water Supply: PUBLIC
System Specifications
nitialSystem
Provisionally Suitable
Minimum Trench Depth: 2 4r*bize-Classitication;
Inches
Saprolite System? Oyes ONO Maximum Trench Depth: 3 6
- Inches
Design Flow: 3 6 0 Septic Tank:
- 1 0 0 0 Gallons
Soil Application Rater 0 _2 7 -5 1-Piece: OYes ®No
- - - Pump Required: OYes (j)No O May Be Required
*System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: OYes ONO
Repair System Required:0 Yes ONO ONO, but has Available Space
Repair System
C
ite Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inchesil Application Rate: 0 x 7 5 Maximum Trench Depth: 3 6 Inches
*System Classification/Description: Pump Required: OYes Q No O May be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number 229981 - 1 County ID Number. G306OA0014
*Site Modifications 1 Q Open Fili Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan The Improvement Permit shag be valid for b years from date of Issue with a site plan(means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shag be valid without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one Inch equals no morethan 60 feet;that includes:the specific location of the proposed facility
O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or intended
use changes(NCGS 130A335(n).The person owning orcontrolling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,
reporting,and repair(.1938(b)}
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps. Signature; Date:
'Issued By: 2140-Nations,Robert Date of Issue: 0 9 1 a / a 0 1 6
Authorized State Agent: OValid without Expiration?
O Create CA?
CHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 229981 - 1
210 Hospital Street
P.O.Box 848
County File Number: G3060A0014
Mocksvilie. NC 27028 Date:
Q Inch
Drawing Drawing Type: Improvement Permit Scale: QBlock
QN/A
U
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C 'G FI Y I r
..........
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{
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 229981 - 1
P.O.Box 848 G306OA0014
Mocksville NC 27028 County File Number:
Date: LOA9 / I .1 / 2016
:° Click below to import an image from an external location:Drawing Type: Improvement Permit.___, ,
CONSTRUCTION ' Foe Office Use Only
f AUTHORIZATION *CDP File Number 229981 -1
Davie County Health Department County ID Number.
G3060A0014
210 Hospital Street Evaluated For NEW
.� .,,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 9 / 1 a / a 0 a 1
Applicant: North Carolina Custom Modulars Property Owner: North Carolina Custom Modulars
Address: 1936 Hwy 64 E Address: 1936 Hwy 64 E
City: Asheboro City: Asheboro
.StatefZip: NC 27203StatelZip: NC 27203
Phone#: (919):548-2033, Phone 9: (919)548-2033
Property Location & Site Information
F-Address/Road #: Subdivision: Northbrook Phase: Lot: 14
brook Drive
e NC 27028 Directions
"
Structure:' SINGLE F_ ' AMILY Hwy 601 N. left on Ijames Church Rd. Northbrook on right
_ ,.
#of Bedrooms: 3
#of People:
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
KSRdessification: Provisionally Suitable Inches
Minimum Soil Cover. 1a System? OYes ONo Inches
Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate:Y:O , a 7 5 Maximum Soil Cover: a 4 Inches
"System Class ification/Description: 'Distribution Type:
TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: g
Gallons
"Proposed System: 25%REDUCTION 1-Piece: OYes ®No
Pump Required: OYes @No OMay Be Required
Nitrification Field 1 3 0 9
Sq. ft. rj PumpTank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo "
Total Trench Length: 3 a ft ' GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 . Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 . ( Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: ONSF OTS-I OTS-II
Septic Tank Installer Grade Level Required: OI OII 0111 OIV
Dann 9 ^f'3
CDP File Number 229981 ,- 1 �', 'County ID Number. G306OA0014
' T r
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONO, but has Available Space
rDesign
System
Trench Spacing: 9 OInches 0.
ification: Provisionally Suitable — Feet O.C.
Width: Inches
w: 3 9 Trench _ ` 3 Feet
Soil Application Rate: Aggregate Depth:
a 7 5 inches
Minimum Trench Depth: a 4 Inches
*System Classification/Description: -
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS, Minimum Soil Cover. 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
- Maximum Soil Cover. a 4
Nitrification Field 1 3 0 9 Inches
Sq.ft.
No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 a ft Pump Required: C7Yes ONo OMay Be Required
� Pr@ Treatment: ONSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. r
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Pennit,not
to exceed five years,and may be Issued at the sametime the Improvement Permit Issued(NCGS 130A-336(11)}If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
inwild,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps. Signature: Date:_
Issued By:
2140-Nations,Robert Date of Issue: 0 9 1 a a 0 1 6
. ._ _.
Authorized State Agentts����- - �.._. Malfunction Log Oyes
a
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health PAID
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 Date;
(336)753-6780/Fax(336)753-1680
pplication For. Site 7valuationtimprovement Permit C Authorization To Construct(ATC) ,Both b Q
Type of Application: bisew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT'"**THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION /
Name A) t t C D/�u l� C/ �e h2 a4 f"fContact Person
Address — Home Phone
City/State/ZIP r oh O Business Phone
Email Email: /1GCA(,r7'1)pit ygv 3 �Q as . oAk
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included:u Site Plan UPlat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name Phone Number
Owner's Address City/State/Zip
Property Address r ro o 1C OP, City.
Lot Size TaxPlN#
Subdivision Name(if applicable) ivorlh L Oo Section/Lot#
Directions To Site:
If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes.VNo
Does the site contain jurisdictional wetlands? Yes yNo
Are there any easements or right-of-ways.on the site? Wes No
Is the site subject to approval by another public agency? _Yes�lo
Will wastewater other than domestic sewage be generated? Yes PrNo
IF RESIDEN E FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool I IYes No
Basement: ❑Yes J2NO Basement Plumbing: !]Yes ,)tNo
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 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
Type system requested:XConventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type:YCounty/City Water ❑New Well ❑Existing Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes 9 o
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 permit(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
orst�king the hou /facili location,proposed well location and the location of any other amenities.
`/014' � Site Revisit Charge
Property wner's or owner's legal representative signature
Date(s):
Client
d [� Client Notification Date:
Date EHS:
Sign given I Yes❑No Account#
Revised 11/06 Invoice#
*�70T970 7
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4 LOT #14\ \\ LOT #15\�\ N es.WV. E 436.9 14x00 a n`°"»o°eww c«n�b-0 .e a ceni.M.nr�M bl
(1.094 A0.) ` {1.093 AC.) \\� 1 / L�. • 23.00 71.94 _ • ,,,yry rowt bu e.e��, eiM yo1
LOT J32 so tft:Nomronoac nw'�"a"id
(2.329 AC.) `�\\ ti �r \\•/, �Mi a f y
*WFW�%WE CM"BOARD OF COMMSIONERS
LOT X21 do ,{1j m �' CURVE DMIA RAD
.4� (0.994 AG) _ LOT " n c1 taro3'i4• ,40.
\ ,�r \ \\ d� LOT X22 w C2 i6a*' 4W
: (0.7x0 AC) LOT #24 La^ c3 r1a 21• 446
p'4C�,\ ? ° S`� W (1.223 Ac.} cis toriaiati1
p, C6 11'39.20• 4914
¢�Rp` \ LOT X13 �' rip. �• , H CONTROL Q C7 836'11• 491.
FOS (0.733 AC) 2 9 4.. o f ! cow9x
C3 4?30.00• 23.1
of a: cio u�z°4ris 50011
`� A,�'6tS��,�� �� (rhf�w 6•J g b� 9 aD 0.49• V C12 �'26'W 50J
C14 24.2zs9,'3221
• 511
4 �+ cis 24ro1.43• 346.•
T 30 T' !� c i 423C00� 2Z
LO
COURT
p i # �cp4 A LOT 25 cis 10.30.07• 501
LOT 12 (0.698 Ac.) r y ct9 sr1T4a• so.
g�� _CM__. (1.104 AC.). C20 .72.33'34' 301
(0.747 AC.) / ' • LOT 29 f +o•ummr 1 ��� C cx1 7~3x• 501
(0.700 AC.) 1 1°'T C24230.00•
C233- 1803.39' 106:00:
o (`, • C24 1739'x9• 406!
LOT 028 w i h Cts V32:33• 406:
4x0 / ,s ,►� (0.799 AC.) LOT #27 L y C26 383344• 386.1
(0.705 AC.) S LOT X28 ,�.� r C27 COStr 38L
/ LOT #31 A ffi (0.x35 Ac.) 'H'�s +
:OT #11 / / (0.799 Ac.) `•$ _
0.696 AC) '�r,� _ •� H
let°Ry"1" / !0x00 10x00 100.00 00
Noy
_ _ I co"m 00 99.931 33lE' Y 9E8.93 100.00 70.00 100.00 2 gd OWNERS
A��O' �OORt&R 1 1 M�
almoo EUCEN.
1 1 I I I 1 DELDER9
• j � j I I I I
LOT 2 i LOT 3 i LOT 4 t LOT S LOT 8 LOT 7 i LOT 8 f LOT 9 i LOT 10 !
1 1 1 NORTHBROOK - PHASE ONE
PLAT BK. 6 P 124 Nom; C
LOT 1 I 1 I 1 ei i i
0 - von stoke round DAVIE 4
DAME COUNTY HEALTH DEPARTMENT -
ENVIRONMENTAL HEALTH SECTION
P.O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone#: (336)751-8760
March 19,2003
Shuler Building
142 Shuler Road
Mocksville,NC 27028
Dear Mr. Shuler:
On March 14,2003 a representative of this office evaluated Lot 14 in the Northbrook
Subdivision in Davie County. At the time of this evaluation a road tile discharge was observed
on the middle front portion of this lot. This surface water has created a gully that poses severe
limitations in regard to septic system installation.
Before specific approval or denial of said septic tank permitplans to correct this surface
drainage must be submitted to this office and the work completed. At that time this office will
evaluate this lot and make a determination as to the suitability of installing a septic system.
If you have further questions,please feel free to call this office.
Sincerely,
Robert B.Hall,Jr. ,RS
Environmental Health Specialist
RBH: df
y
� `VC E
APPLI�CAYI N FOR SITE EVALUATION/IMPROVEMENT PERMIT.&ATC
Ld03 ;aJ Davie County Health Department
i!; MAR '" EnVltwnmental Health Section
P.O. Box 848/210 Hospital Street
ENVIRONMENTAL HEALTH Mocksville, NC 27028
DAVIEC
OUNTY (336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for /instructions.
1. Name to be Billed <�,X I C,- d;�yi/1�i.7y Contact Person e",
Mailing Address �f4,? S/�V/�j ,Pct Home Phone
City/State/ZIP '0C1 a7Oxy Business Phone �y/� 70zz-
2. Name on Permit/ATC if Different than Above
Mailing Address City/state/zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC QBoth
4. system to Service: R-ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms �—
94--Zishwasher M--darbage Disposal P'fa'shing Machine ❑ Basement/Plumbing M Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# 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 this system is intended to serve? ❑Yes CYNo
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either'a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /Do 4 P/-O>- WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # 1i S Q b 3 -V)8 D/ Nm-68 As A-41-
Property
Property Address: Road Name 110 1 Nva i+l breo��- ��C rn mss. �i• 12-� /io rn,•�.c
City/Zip IJ,C', ,*4p7-F 1'�fC lvl- r+� �jyr 4,k to r4o Lz 6)-
if in a Subdivision provide information,as follows:
Name: Xlor't 6uco�--
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 am responsible for all charges incurred from
this application. 1, hereby,give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by 00,Stne 8enne4 Erb
to conduct all testing procedures as necessary to determine the site suitability.
DATE -7-0 3 SIGNATURE
THIS 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):
Client Notification Date:
2—`_ `-J .tiff-Q—�-� EHS•
(J
Account No.
Revised DCHD(07/99) Invoice No. 3 '
(, Sy�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_ LOTS
Soil/Site Evaluation-
APPLICANT'S NAME � d.L°K DATE EVALUATED
PROPOSED FACILITY ', l� PROPERTY SIZE
SUBDIVISION ,�fh� /�d�/'an ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position (/
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
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 RATE
SITE CLASSIFICATION: �c� EVALUATION BY: i
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 i 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(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)
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nM
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Q u €
�• Davie County Health Department o
Environmental Health Section SEP I 8 t
P. 0. Box 665 11
Mocksville, NC 27028
ENVIRONMENTAL
DAVI
1. Application/Permit Requested By ✓y�
Mailing Address //�aG CS - ►
Home Phone !29,F#7 2 7 Business Phone '
r, P
2. Name on Permit if Different than Above
3. ApplicWion/Permit for: General Evaluation " ❑ Septic Tank Installation
4. System to Serve: house ❑ Mobile Home ❑ Place of Public Assembly F
❑ Business ❑ In wn
5. If house, mobile home: Subdivision Ivo � l�Raa1KS!ton Lot#
❑ Basement/Plumbing
No.of People ❑ Basement/No Plumbing
i
No. of Bedrooms ❑ Washing Machine
No.of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
1.
No. of Lavatories No. of Water Coolers
r
No. of Showers Water Usage Figures
7. Type of water supply: LB"Public T. ❑ Private ❑ Community
8. Property Dimensions t , #G aXzzzQL Sewage Disposal Contractor 7
9. Do you anticipate additions//expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
yy
Directions to Property: 0 C'�YV a� C&ix t/
This is to certify that the information provided is correct to the best of my knowledge,and I understand I am responsible for all charges
incurred from this application.
/ f49 6--,
DATe 0 SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative of the Davie County Health Department to enter upon above described
cated in Davie County and owned by
all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
system.
DATE SIGNATURE
DCHD(12-90)
61.14'S7• t CENTER OF BRANCH IS
N 7*874• E S g•104 1 ems, r 1. /PROPERTY LINE � S X6.09'37• 1
4124 N 33.!6•SS•E 310.8! 2 65. '4'
N 38.33'011 E 46,94 BOOM •%hwbF Y V t"
Q\' 29.43 S%•23' 2.. d I
J, 4- + 00NiN01• y�,al yh,nyi,t 1:
N 533.33'39' E 131.2E •r -y �i00L ' OORNER r6A ev free oene.nt w
37.81 `� *�4ar lr,� {jAr,.!{ pparlm aaw•nw amw on
N S 10.3 139• E /• eIp2b
ICA'�•6 N 60 1 3/E \\
VWNER
�`' 0• N 32*04'06• E \ o �. LOT18 �R > f .L
63.1 �S \\ \ , �, (1.279 Ac) - LOT fig ��� C
OWNER
N 39.14'39' E •\ \ \\ i (2wow" m
290 AC.) tai L hb! -1*
110.31 \�0 \ \ =NaRrlieaaac PtkSE 2
Mh,a•0•e1
to enMen
e d eall0w.e.6bbA d
J` \y \�g> hm or o,en.d9el a tworda end e,e
found meM eo.h alh w eM
(9.14'39' E ♦ G`V u' \ o �•y - - aenmuon.p9wT e.Mt 119,h w h�wMiolta►
101 o0 \ \ �` \ \ '�'Sr. LOT #17 th.I ro< I a eil.e,�naa,end fa n.
0.942 AC.) •�0^ + •••� .•P•�1•n foe d.eW d.perhdgerb,wnt
NOT
\ 4 LOT #20 COMMM� °
M A PERarOR APP OFiaiwaM&
SZ� \ \ o \y ♦Aity \ \\ ;
(2.913 AC.) LOOTN JO SU 0.nM ON FOR MMUT04 OF
T ♦ \FYr� s`\ LOT #16\\ \ A bry chic DAVECOUMY NEnLTN OFFICER
\\(1.162
ovu
ELN \\ \ \♦\\ \\ S 6�. - axnFu�T[of rrrReY wve CO.eouesaNva
S° bT X14\ \ LOT 15\ \ lO��S!• N 93.30'87• E 436.94 140.00 L Cal soon,=V,rm
\ \ �' 1 /�` 9 Jo P 171.94 a n,.Dan.C•bwd a b e);;dgpc•vu"iW.i.nr.h.r.y.
(1.094 AC.) (1.096 Ac.) ♦ \ . tiV /� moo «��sa1 wNORR1 t.PW�sE 2 ��
LOT X32 '\\\
(2.329 AC.) DAVE COX" COM=ONM -_
\\ �rr�(•�� 7 0g�/ w/ ��� IgM ��
LOT #21 ,p'' ,+j CURVE DELTA RAD
LOT #23 y ^ c1 lrO3'14• 449:
LOT #22 (0.960 A0.) a:w C2 1x03'14- 448:
LOT 24 w C4 YT42'io- 446.
: (0.750 AC.
• ¢ i .\\ 0� \ ) m (1.225 AC.) O c6 1v1s2s• 4011
'OGCc LOT 13 d+ `N Q. Ce 1,•39.20• 4e 11
�.`xS C7 w3a'1a' 401.!
(0.753 AC.) ", 2 9 Je.°',emp. �i / CORNER
ca 4x50'00- 251
�RF�Fo�ti \ �00�' �/, f�i�°�d � Its b br•z�0a a= cio e4i'riar• 55001
• c11 '64'23'06' 301
eL"Il'0' 64
�� �� _g 4 U C12 25'45' 501
dzl�e�°b••�•n cJ p Cl a F=0 C13 2'209•b2• 33
J�, r \ / ✓ �F b f ~ Cts 24'01'43' 346:
COURT C17 475000• J48255
LOT,.#30 c, �c LOT #25 cis W39'07• 301
\ / le ( 21� t > C19 537'1745• 301
LOT #12 �CE3__ (1.104 AC.) 020 7163.34• 5301
(0.747 Ac.) �Sc` / // r ' ��LOT X29 J/ ewsE,wEENT F -cu- $ C21 7rso'35'00' 251
f I C23 IlrOv5O• 251
(0.700 Ac.) c23 ,so3•aa• 406:
LOT 128 w > ` C25 1139133• 406:
Cts 432'33' 406:
(
o.7a9 Ac.) LOT 27 " C25 3633.44• 3a6:
�4.4e•38. c7b ': '� (0.705 AC.) g LOT #26 y,�.`� � c27 ro3'1a• 366.
Y / LOT #31 i 4 (o.ass Ac.)
OT 11 / / (0.796 ) `''c
/ $rc} _
;0.696 AC.) , , � � wo�
• �' o
FrSEE 1 100.00 100.00 100.00 �� 93.00 100.00 100.00 70.00 Om MOO 00
1Sgpo- 1 1h o' 000NTROL0 Nmol N 99.33'12• Y SM93 fe&93 U OWNERS --
Y E15.9O �' 1 1 CORNER f ( I I I I r EUCEN.
s I l f ( ( ( I I ( DELBER7
1 I I I 1 I ! I 1
LOT 2 i LOT 3 i LOT 4 ± LOT 5 LOT a LOT 7 ' LOT a i LOT 9 j LOT 10
NORTHBROOK - PHASE ONE
LOT I 1 I PLAT BK. 6 Pg. 124 f j Nom. DAVIE t
1 1 l O - Iron stake found
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• Soil/Site Evaluation Q - p
NAME DATE EVALUATED / 1 1 y 1
ADDRESS '�\4\' PROPERTY SIZE ` co ' lk� 4-Q6 j
PROPOSED FACIILTY �t-t a J 54 LOCATION OF SITE 0
Water Supply: On-Site Well _ Community Public
Evaluation By��._(--Auger Boring Pit ✓ Cut
FACTORS 1 2 3 4
Landscape position
Sloe % -IS
HORIZON I DEPTH Lv
Texture group L
Consistence
Structure
Mineralogy :►
HORIZON II DEPTH
Texture group
Consistence F
Structure
Mineralogy �L
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 RATE �
SITE CLASSIFICATION: v S ' EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: \1Lk OTHER(S) PRESENT Named NP
REMARKS: 1�e7` `�.o•�•��� 1�G�D a` See�Cl�.W� Cs' - ` e7 uv. a Ji��
LEGEN
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 :lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vc-y 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
Mi neralojcy
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(01-901
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