1715 Peoples Creek Rd (2) �J ►�-2'° _°�
_ ,� . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003056 Tax PIN/EH#: 5880-40-3420.D JL
Billed To: Homes by Jonathan Lee,lnc. Subdivision Info:
Reference Name: Location/Address: 1715 Peoples Creek Rd.-27006
ATC Number: 3908
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MiJST BE ISSUED 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 WASTEWATER CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 6 / Date: �
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900"Sewage Treatment and
Disposal Systems,"but shal!in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
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Septic System Installed By: . � cJ '�-
Environmental Health Specialist's Signature: Date: � '!'� d�
DC�-ID OS/99(Revised)
` , DAVIE COUNTY HEALTH DEPARTMENT ` U� �'�` ' ��
� � Environmental Health Section �
' . � � " P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)7S]-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003056 Tax PIN/EH#: 5880-40-3420.D JL
Billed To: Homes by Jonathan Lee,lnc. Subdivision Info:
Reference Name: Location/Address: 1715 Peoples Creek Rd.-27006
Proposed Facility Guest House Property Size: 14 acres
ATC Number: 3908
**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 THI5 PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type /� #People ! #Bedrooms_� #Baths �
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type� #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) �y� Site: New�Repair�
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt�� Rock Depth� Linear Ft.�S��
Other:
Required Site Modifications/Conditions:
IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G `�BELOW
FINISHED GRADE. ****NOT[CE: 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(33C)751-87G0.****
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Environmental Health Specialist's Signature: � � Date: J�/ `..Z �
DCHD OS/99(Revised)
. ^ Oct 14 �4 :54a davie county envhealth 336 751 8�86 p.i
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l� ^ _ �" ' AYFUGA r10N FOIt SITE EYALUATION!iMPrsOVEMENi PEIiM[T&ATC
D � � Davie County Heal2h Department
��� � � � - EnvlronrnentalXealth5ection
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� \\n � P.O. Box 848/2I0 Rospital Street
'. Mocksville, NC 27028
f � 't f336?751-8760
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� �OtiC,�E�,'(��L�' tt"IMPORT * THIS APYLICATION CANNGT 2S P80CE3H&C UN:+ESS ALL 84UIl2En I
`"Ep�� �,,�r{,r�,},1 ox ss ROVIDED Refer to tha INFORMATIO*I BIILLETIN tor astructions.
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� EO Se Ei11ad C� ( � ��" " Contact Parw /(n�/�� V
�Y�R�`„[C��'N. dYeea:-�S-� G�rSv�cC CLE"�v►�cn5�C. Nom� Dhnn ._
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. Clty/StaCa/LIP � Bu�in�s� 7Lor _
. ��:. Nane on Peralt/ATC S! DlGf�ze�t criau Abovr
.r..-Meiiing Addreaa _ Ciey/stnee/zip
"':�- �pplieatiop For�. L Site Evaluation ��sprovnment Permit/ATC G� 8oth
�g. syaean to sorvic�: R'xou/se Q K.obila Homs ❑ eusineee ❑ Indurtry O other
� LIS. Typ• eyetsa raq'ieatrdt U CO::vmticnai ❑ aoav�ation�l mcditioG ❑ innavative
E, I[/Raai6ence� /Y Peop12 ��/� il B�dreome ! A Bnthroome �_ J
r\('� � �Diahxasher -L]caZSege Dip=�eaal l7WasF.ing ltachina �sasamentlplwobiag ❑8aeoawnt/No Plumbing l�/�ryWC� J/-/TLG)
� �Q �/'"� iL Bu�lnecs/Induet.ry iothrr� veeity typa ,^, i DaoDl• A 31nka
\7 v 4 caamodw�„� i stwv�sa!` A 7xinala p�tatar Caolara
V � �
���� IF F04DSSRVICBs � Sea � Setimatad Wxtar Unagn (gallc�e par day}
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, p`�t
, �8. e ot vates ouDF�Y� Coti.nty/City ❑ We11 ❑ Coimnunity
���,�.��� s you aaucipata aaaieiona >r ezpansioas of the faci7ity t�ls system is lutepded to scrve?O Yes C3No
�V�R��E`G�)���y �rycs,w��n�q�vcz __ ._
**`IMP Ti1N1„*•CL[6?+TS MUSTC PLLTETHG RLQUIRED PROPER7'Y INFORMATION RL+QUSS7'GU
OW. Ithcr a PLAT or SiTE PLAN bf T BE SUBMITTED by tLe Nicnt wlth TH15 APPLICATION. �
p ' r ON
��Praperty D(mcnsions: i� � �� L�RITG D[RCCT'fONS(trom Mocks�•ille)to PROPER'I'Y: 0 �l s� L�!`7
✓�r�x orr��rt�v: u SS��So o��2 0 �r'��'G� C,�, �p./
r/Yroperty Address: Road Name 1�r P�i�r,� �,�E��v� KT l��v ���s�TG .
c;�Yr�n�D✓�lN�'� /l/C 27cb�
]f in a Subdivision pro.v.ide.infamc�tion,as foliawo;
Nan3c•
Sectiou; IIlcch:�� Lc+t: L�H:Cfe homccorncrsdn�Ted:��'ZD-�
Tliis is to certlfy(hnt the Infarm¢tio::provtded is correct to thu best ot my luiowicd�e.I understand that any pernilt(s)
lssued Itereafler nre su6ject to suspensian ar irovocadon,if ihe uic plans or in;ended use ctmngq ur 3C the informatian
subuut[cd ln thi5 applicat[un ic Cn151tiCd OT changctL I�ulsu,nrederatand dan I arrr reapoasibJtfar all ebarges lecurrrd fi�nu�
rr«.�v���r��rro�,. �,hercby,give cons;ni to tiie Autl�arizccl Representadve of the Davie County IIcalth Dopurtnwut
tu enlCr upon atx�ve deseribed proparty located iu Duv{e Counry and owned by
10 conduct nl!test[ng procedures as��ccessar,y to dcterminc ehc aftc sultability.
�DA7'� ��-J)`d Y-" �BTGNATUI2E�r��_� � CJ�-�
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THIS AItL+A MAY IIE USEA FOR 1)RAWItiG YOUR S1TE PLATf(Intlude al!of llic follawing: �slst[ng nnd proposcd
property lines nnd dtmcnsious, stra�:tures, setUacks, nnd septic]ocatlonsl.
SiFc Revisit Cl�argc
Datc(s):
Cl(ent Notificat(mi Dntc:
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Sigu glreu � Account No. �
Tievixetl ll G[D(05103 luvuiec Nu.
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APR (; ��r�� �,'� 710N•I�Olj St]'L• LYALUATION/lhlPltUVL•11J1:N'C I'LIL111�1'a Il'I'L' n� y
- . Davie County Health Deparfinent �
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EnYiroaare�ta/Hea/t/r Sectioa
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FNVIRONMENTALH[ALiH P•0. Box a4II/210 Ho��iLa1 StxceL �
DAV�ECOUNiY 11ocY.�vi].lc, 2iC 2702a
(33G)751-II7(i0
�,�� ***IrSPORTANT*** TIiTS 11PPLICEITTODi C11NNO:i' DZs' PXOCLSS1iD UidLLSS ALli `1'1tL iir:Quxi.Lv�� �
L INFOIZMISTION IS PROVIDED. Ret'or Co l:ha INI'OR23ATION DULL�TTN ior in�L-rucL'ion:� .
c���t, ..._._ . .. .
G , i. x�,� ro v� D�iioa �n;r���,C �. �t�rti�l�i� con�a�c r���o�, l�s�v_..____..._..
O � .
�;;� � 2dailing Addre�s j/L.rSfJu.J�-�-�1, ��' ' . lcauc 1�lionc.�.�G' �j.S`.�OtS� . . .
�� City/3tatc/ZIP /`�'!i/1:'LC"� � �' �' lluuincaa Nl�ouc _
2. Namo on PcrmiC/ATC iL' Dit'Eesent than 1ll�ove � ___,._._._._.... .
Mailing Addreas City/Stal•c/'Lip _._...
]. Application For: •valuation ❑ TinproveincnL 1'criuiL-/1�'1'C U 1��L-li
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4. Syatem to scr 'ce: �ouse ❑ 2Sob.ile Home ❑ Du�ine�:� ❑ :Lndu:;L•ry ❑ Ol:l�cl� ��
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5. Typc sysl•em requcsted: L�l Conventional ❑ conventional moditicd ❑ ii�novaCivc
G. If Residence: i! Peopl.e �! II F3edroom� �. � II L'aL-hroau:, I . .. ..
�Di�2iwaoher ❑Garbage Di�po�al ❑Waahing Afachino ❑IIa:;ement/YlwnbiuJ ❑t�a::c,uc,iC/tiu 1�7.u�ubin�
7. SL Duainc�s/Indu�tiy /OL•hcr: vcriLy l•ypc If l�coplc f! :;inl::: _, __..
# Commodca � 1! Showcra �f Urinaln i1 19aCcr Coolci� __ _._..__. .
IF FOODSERVICE: �� SeaL-u E�tintatcd WaL-ez U:;agc (�allonn per cln��) _.__.____ __
a. Typc oL watcr 3uppiy: ❑ CounLy/City ❑ Wc�l ❑ ConuuuuiLy
9. Do you anticipatc addition� or C11?aASi011S Ur tI1C r:lCllity(11iS S)'S1CI11 i5 1ll1C11tIC(1 (U 5CY1'C': ❑ �'C1 ❑ 1�u
!f��cs,titi'LaL t},pc? . ----.--
***111IPOR'li1�V,f�**CLill`!'fS�31USTC0�11'LLTt Tlli: 1LG�UlItGU YIt01'Llt'1'Y li�ll�Olt11�1�1'1'lON !tliLU1;5`CI�:tJ--�.- I
13GL011'. I:i(hcra PLA7'a•SIT�PL�IN r1lUSTIICSU11rltl7"7'GD by tl�c clicnt titi�illi'1'lliti r1I'1'I,lC�1'1'ION. _ �
/ <►ciz�s
I'r'u��er(}'llitnCn�iUns: � "— __.� IYKI'1'i.11litl;Cl'lUNS(Il'uu�1llucl;svilic) tu l'1tUl'l:Ic'1'1':
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Property Address: Road Namc /7��L�£ ,- C,E'if,E�
City/Zip ��vAi.y�c.
If iu a Subdivisiou providc ii�l'ornialion,as fuliotivs:
1\`auu: � �
Scc(ioii: B1ocI.: Lot: Datc lioii�c coi•iici•s ll:ib�;cd:_`���p r�
Tl�is is lo ccrtity iliat tlic iiiforciiatiou providcd is coi•rcct to tIic bcst of iiiy Ittiotivlcdbc. .i uitdcrs(.tiid (!ia(:ui��pci•Jiiil(s)
issucd licrcaf(cr are subjcct to suspcusion or rcvocatioii,if tlic sitc pIaus or iucc,�cic:Q usc cl�anbc,ur if(lic iiil�oi•ii�:i(iuu
subiuittcd ici tliis applicatioti is f:ilsilTcd or cliai�bcd. I,also,underslai�rl durt I uur res7�u�rsiGlcfor•«!!clrur�es irrc�u•r�•�/jr«rrr
tlrisupplica�iu�r. I,licrcb)•,biti�c conscut to tIic Au(tiorizcd Rcprescn(ativc of tlic-f�:ii�ic Cuwi(��IIcal(li 1)c��:u•(uicnl
tu cntcr•upui� aborc dcsci•ibccl pruper(��loca(cd iii llavic Couiify a�id utiti•iiccl b}�
tu cutiduc(all lcs(in�proccclures as ucccssary to �c(criniiic tlic sitc suita�' it �
llA!'i; 7' SICNATURL �
TIiIS AREA I1�AY liE USI:D TOR DRA.WIIIIG YOUR SIT.0 PLAN(Licl dc aIl�l tl c fut tvit b: � •' liub�uicJ prupuscc!
property lincs and dimcusious, structures, sctbacics, and scptic locatious .
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NS-Non sticky SS-Slighdy 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 OS/99(Revised)
� � � � � �' DAVIE COUNTY HEALTH DEPARTMENT
, : .
� Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME o�- ��`/t� DATE EVALUATED ��f6� L/
PROPOSED FACILITY �L/6(j S,O `r/ �Cr'i/1�'I PROPERTY SIZE 7 C�
SUBDIVISION ROAD NAME ��E���c �'�Y�
Water Supply: On-Site Well Community Public L�
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition �
Slo e%
HORIZON I DEPTH -/ y
Texture rou �
Consistence
Structure
Mineralo
HORIZON II DEPTH " ` ��
Texture rou �
Consistence
Structure GC <
Mineralo /�.
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLI'I'E
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE e . �
SITE CLASSIFICATION: �� EVALUATION BY:
�
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND �
Landsca�e 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 frm
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-gaUday/ft2
DCHD(01-90)
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' ENVIRONMENTAL NEALTH SECTION .
P. 0. Box 848/210 Hospital Street
� Courier #09-40-06
Mocksvilie, NC 27028
� _ _. . _. . __ _ _ _ _ _
_ _ _._ _ _ _ _ _ ._ _
' Phone '#�: (336)751-8760 , ' , .
Apri121, 2004
Kenneth Lapiejko �
P.O. Box 123 � "
Advance,NC 27006 � �
•Re: Site Evaluations/4 sites on Peoples Creek Road
Tax Office Pin : #5880-40-3420
i
Dear Client(s): I
�
i
As requested, a representative from this office visited the aforementioned site on
April 16,2004. 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 a 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,
/�4�������,•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist ,_
RH/df "