169 Stony Brook Trail Lot 35 tip�
DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
.` --- P.O.Boz 848/210 Hospital Street 1 Z
Z
Mocksville,NC 270281
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002165 Tax PIN/EH#: 5820-22-4556. RB
Billed To: Richard Barefoot Subdivision Info: Northbrook 3 Lot#35
Reference Name: Location/Address: Stoneybrook Trail-27028
Proposed Facility: Residence Property Size: 48Y x 472'
ATC Number. 3079
**NOTE**This Improvement/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 PERMIT BEFORE INSTALLING SYSTEM.
i
Residential Specification: Building Type #People_ #Bedrooms 'l #Baths aC.s
Dishwasher:42,000' Garbage Disposal: ❑ Washing Machined Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seeatts�, Industrial Waste: ❑
Lot Size Type Water Supply IVI/! Design Wastewater Flow(GPD) VO�' Site: Nev,�,O'Repair❑
System Specifications: Tank Size&& GAL. Pump Tank%QQ�GAL. Trench Width; Rock Depth e Linear Ft.
Other: /9411 `gel
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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)751-8760.****
Lqo
nee
Environmental Health Specialists Signature: Date: / o Z
DCHD 05/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT 1
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 900002165 Tax PIN/EH#: 5820-22-4556. RB
Billed To: Richard Barefoot Subdivision Info: Northbrook 3 Lot#35
Reference Name: Location/Address: Stoneybrook Trail-27028
Proposed Facility: Residence Property Size: 480'x 472'
ATC Number: 3079
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). 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: �G� "'• 441ADate:
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.
Septic System Installed By:
Environmental Health Specialist's Signature:. Date: `
DCHD 05/99(Revised)
02/19/2002 12:04 SALEM CHEST SPECIAL 4 336 751 8786 N0.411 0002
0%%lam t6e2 13:15 13367662309 STAPLES PAGE 02/02
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APP" A"LtUN FOR SITE EVAU ATIOWPAPROVIA119 T pt wUNIT AT D �
Davla County Health Department
Enrilriol»e"WIf f/ei/dr-Sectioors
P.O. Box 846/210 Soupital Skeet
ltoe)caviJL2=, IRC 27028
(336)751-8760
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7. Typo ot: watax suWply: ❑ C.ovnty,/Ci.Vr Stell 0 cc"alwan1w
0. Do ya"anticipate additions or exponsionS of the Omility this aystcm is int m s¢rvo2 ❑'Yes )<No
Ifycs.what typCT
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"lAtPORTAN7-' CLIENTS UUSrC0MPl.E7"ZTHE REQ&(1JtCP PROPERTY INFORMATION REQUESTED
BELOW Either a PLAT or SITLLPLAN MUSTRESUBM/TI"E D by the_etient With 77fIS APPLICATION.
Property Ditne"s;ofts: �'X J� ` WRri'E DIRECTIONS(from Moc"010 to PAOPERYV:,
Tax* Yate PITY: tR��JS,��a��'��5(� _�(�f N• �� � � 1�1►'HSr
Property Addee_ts: Road Nate
citylziP
1f in a SubdN-Woos provide information,at;loltows:
Name:
i
Section: Block: Lot: � Data Prapecty p'laggcd:�lT'�
ec
This is to certify that tits:a6aru,*beat provided:s eora,eet to the best of my knowledgw 1 understand that any poranit(s) i 1Jt
issued bereafftr am sobjeer to suspension or MVOC4li00,if Ibc sift phos or intended use chaogc,or if Ifse information
submitted is this applicadnn Is fatalt:ad or cpaage4. !,a1so,wir4rentondMat!aim netpo0,+s141tjer B/I e%arres im4wr�djronw
this applieallon. t.hereby,give conscut to the ketharbEed Representative of ffie Davit County Health Department
to enter upon above described property located in Davie County and owls
to cooduct all testing procedures as aeccUary to deftrtpine the site So Pfyr
' DATE_ �d Z- SXGNA'7 URE
THIS AREA MA'Y BE USED FOR DRAWING YOUR SITE PLAN(Include all of the Eollowlag: EArsting and proposed
property linea and dimaasions, atructat`es, setbucia, and septic locations).
Site Revisit Chane
DAte(s):
Client Notification Date:
EHS:
i
i
Account Na
Revbcd DCHD(07/99) Invoice Na
1 _ v
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002165 Tax PIN/EH#: 5820-22-4556. RB
Billed To: Richard Barefoot Subdivision Info: Northbrook 3 Lot#35
Reference Name: Location/Address: Stoneybrook Trail-27028
Proposed Facility: Residence Property Size: 480'x 472' Date Evaluated: o I
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: 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
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 05/99(Revised)
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APPUCATION FOR SITE EVALUATION/IMPROVEMENF PERMIT&AT IE Q W
Davie^ounty Health Department D
EnvitonmentaiHMIM$*Von
P.O. Box 848/210 Hospital Street DEC 81999
Moaksville, NC 27028
(336)751-8760
***21�II�ORTANT*** THIS APPLICATION Cmew ==s= UNLESS ALL THE REQUIRED
INVORMATION IS PROVIDED. Refer to the nVORMATION BULLETIN for
"natruations.
1. Blase to be filled O/1F1. ��'%1 _e,g,�-V,e/YGT T contact r r•on rc. -.11 �
N"ling Address O �Cpl/LO - Noise Phone
City/state/sIP �L'Sl1/�- �1:C���-7d Z Nowin—s•• shone
Z. Ilene on Persit/UTC it Different than Above /�IC'f�i9/cd) D�• dL�c�i
Nailing Address � /YOI�' City/stat./si,p
3. Application ror: Site Evaluation 0 Improvement Pdbdt/ATC 0 Both
Le
s. systes to servioe: K House O Mobile Home 0 Business 0 Industry 0 Other
5. If Residence: 1 People f Bedrooms # Bathrooms
Dishwasher �earbagr Disposal V-rh•hing 1ftchins O sa•esent/Plusbing Q Naaeeenthto Plumbing
6. it sue Industry/other= specify type People # sinks
• i showers #"IIsinal• i Rater coolers
IT 1OODSERVICE: # Seats Estimated Water Usage (saums per fir)
7. Type of xater.supply: County/City 0 hell 0 Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ANo
If yes,what type?
***IMPORTANT***CUENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESURMITIED by the client with THIS APPLICATION.
Property Dimensions: 54z TI X WRITE DIRECTIONS(from Mocknille)to PROPERTY:
Tax Ofilce PIN: # 20—22- 55 j 3�� 60141 ��Z m�u�s f'itsT
1*ronfey49900k Z )z
Property Address: Road Name62r#36, /Y: 6909,e ere. 3 /—yd , D/y 1'Z�7F.s
CityiZipAoc,�SLILl /1�C�. _lam �u� f!�/1L=.� �o
If in a Subdivision provide information,as follows: /Y
Name: 0 AV 600/ 6�90I AW 7i?L oN
Section: ? Block: Lot: Date Property Maggedt 12 This Is 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 me change,or if the information
submitted In this application Is falsified or changed. I,also,understand that I ane responsible for all charges lncarred frons
this application. I,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 byic1}i4P0or/'
to conduct all testing procedures as necessary to determine the site sultab
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property Tines and dimensions, structures, setbacks, and septic locations
Site Revisit Charge
Date(s):
Citent Notification Date:
EAS:
QQ .
Account No.
Revised DCHD(07/99) Invoice No. l� l
S 87.51'57' E —► I
S 84 29 35• E--
467.88 299.93
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LOT #37 �� LOT
1 (5.224 AC.) "iA �� (5.6-4
N
+STONY BR
1 9� cp
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W Oale
In
Q
N ,/pop
in
LOT
Z (5.302�AC:)��'
LOT #41
(S.00a Ac.)
c
tn 1 I J
0C4
caw 1 o S 86.10'30!E 502.64 TOTAL r , 0 r0
� 0. _ .
oo •_ W s
p co°D QI j LOT #42 �Sp
Q 3 (5.425 AC.) �'4
w
� J I FB•
w LOT #35 i �U'(Y &
(6.304 AC.) 60
t N N ACCESS EASEMENT
CD FOR THE
PURPOSE
o o OF INGRESS EGRES
y
} frr
87'42,24' E 656.92 ?137AL - 39.4 . /b
s �
• •-+, W v ss
• O,t'� �S�60, X31 46•
g LOT #34
(6.076 AC.)
C2
z b -J
• LOT #33
y h~ (7.087 AC.)
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S 83.4838'
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
r Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000895 Tax PIN/EH#: 5820-22-4556
Billed To: Delbert Bennett Subdivision Info: Northbrook Sec.3 Lot#35
Reference Name: Delbert Bennett Location/Address: Stoney Brook Trail-27028 /
Proposed Facility: Residence Property Size: 6.304 Acres Date Evaluated:
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 l
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: 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
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 05/99(Revised)
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y DAYIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
(336)751-8760
December 16, 1999
Mr. Delbert E. Bennett
508 Dulin Road
Mocksville,NC 27028
Re: Site Evaluation
Stoneybrook Trail/Northbrook Lot 35
Tax Office PIN: #5820-22-4556
Dear Client(s):
As requested,a representative from this office visited the aforementioned site on,
December 16, 1999. 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 on-site 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,
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/msp
Enclosure(s)