1056 Pine Ridge Rd , DAVIE COUNTY HEALTH DEPARTMENT
� ' Environmental Health Section �
� P.O.Boz 848/210 Hospital Street �`�� l� d 3
.
�. Mocksville,NC 27028 ��
� (33()751-87C0 � � ��G� �ZL z--
IMPROVEMENT/OPERATION PERMIT
Account #: 990002761 Tax PIN/EH#: 5745-13-2271 MP
Billed To: Mary&Gary Peacock Subdivision Info:
Reference Name: Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.04 acres
ATC Number: 3525
**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 REVOCATTON 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� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply� Design Wastewater Flow(GPD) <. !� Site: New�rRepair❑
���p�; �� i�
System Specifications: Tank Size�=(�,�""AL. Pump Tank GAL. Trench Width�� Rock Depth�Linear Ft.�
o�h�: ��.)1 ��,� U��v c
Required Site Modifications/Conditions:
IM11PROVEI�1ENT/OPERATION PER1111T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G "BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe D �e 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 ay i t llation. Telephone#is(33C)751-87(0.****
�
�
Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
� DAVIE COUNTY HEALTH DEPARTMENT �
� , .
` Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990002761 Tax PIN/EH#: 5745-13-2271 MP
Billed To: Mary&Gary Peacock Subdivision Info:
Reference Name: Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.04 acres
ATC Number: 3525
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 FI YE S.
Environmental Health Specialist's Signature:� �G/ Date:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system de ibed on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130 , ctio .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the s em will function satisfactorily for any
given period of time. `�` ,;^P �
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Septic System Installed By: i' /
Environmental Health Specialist's Signature:���� Date: (�' ✓
DCHD OS/99(Revised)
• �i.—��,y,""''"�"���
' , ;;+..,.� [4 � � �
��,. A. TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
`, � 9 2�0� Davie County Health Department
',+ ,� !,��j�( � Environmenta/Hea/th Section
5J �.: P.O. Box 848/210 Hospital Street
,L�1� Mocksville, NC 27028
�1Y1R�N��,pUxS'( (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 `�' ..QC�[�C� Contact Person �Ql� �C
Mailing Addreas � Home Phone �.d y— µ g�y
--r-
City/State/ZIP ��/P��,�� �1e � '/�/�. Business Phone ''"•a•.
2. Name on Permit/ATC if Different than Above
Mailing Addresa City/State/Zi
(�-(' � ��-.,
3. Application For: Site Evaluation cJ Imp ovement Permit/1�T� Both
��Y-ig __�__. , -- -- �
4. system to service: House �Mobile Home Business Industry Other
5. If Residence: # People _� # Bedrooms � # Bathrooms .2 '�Z
/�bishwasher Garbage Disposal Washing Machine Basement/Plumbing Basement/No Plumbing
� �
6. If Busineas/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
a. Do you anticipate additions or expansions of the facility this system is intended to scrve? Yes No
If yes,what type? ���dC�
***IMPORTANT'r**CLIENTS NIUST COMPLETB THE REQUlRED PROPERTY INI+ORMATION R�QU�STGD
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by tl�e client witli TI[IS APPLICATION.
Property Dimensions: � � 7 �t.r-�� WRITC DIRGCTIONS(from Mocksvillc)to PROPGRTY:
Tax Oftice PIN: #3�7 ys- / 3 — �� � � ��� 5 � �ru-S� �R..r� a�'
Property Address: Road Name Pi n✓ R�d�,c.�R,,� . �° � S � a r. ' /�h���...�+�
. �� •
City/Zip I'h a c-KS�� 11�a. ,l ✓ L'T1.. �r.-► e� ' �-o��f�v �'.
If in a Subdivision provide information,as follows: .� S ►ws� ��.i'}' 7'- � �3 d" �+'��'
Namc: D r� L
3-,..
� Z� � 7-
Section: Block: Lot: Date home corners flagged: —_�
� e� �— �"2h�.�
4.��� �a/�' �.�.�•. ,�c,�
This is to certify that the information provid��ect to the best of my knowledge. I understand tliat any permit(s)
issued hereafter are subject to suspension or revocatio�i,if the site plans or intended use change,or if tlie information
submitted in this application is falsified or cl�anged. I,also,w:derstand diat I au:respousiGle for al!chn��es ir�curred fr�om
t/ris applicatio�:. I,hereby,give consent to the Authorized Representative of the Davie County I-Iealtli Departme�it
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE � t I ro � SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include a of thc following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
4.� ,/" � / /u `` O / ` Site Revisit Charge
/,� ��_�. �,� ��/
C � v l Datc(s):
( 'r-3a r7t3o) — L��.J � �' � a -0 �
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�"� � Ciicnt NotiFcation Datc:
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Sign given Account No. a 7 � �
Revised DCHD 07/99 Invoice No. �� ! / v
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� " ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT
J�. �' • �
' , . . Z � Davie County Health Department � � �Z�pZ„
n � , � � Environmenia/Hea/th Section "
���`� r P.O. Box 848/210 Hospital Street
� Mocksville, NC 27028 E N`J I RDA VIE COUNTHI'Et�L T H
� (336)751-8760
***IMPORTANT*** THIS APPLICATION C,ANNOT BE PROCESSED UNLESS AI,L THE REQUIRED '
INFOF2I�TION IS PROVIDED. Refer to the INFORN�iTZON BULLETIN for instructions.
1. Name to be Billed c�✓1 CY u Contact Person (��� (V�G`{�
Mailinq Address r�6� P.�.-? Q`��j.Z. h� Home Phone `�T J �a`7!'/
� )
City/State/ZIP r'��C�� ��I � � Jti •�. Z7���j Business Phone '�'—"---
2. Name on Perm:i.t/ATC if Different than Above
Mailing Address City/State/Zip
3. Applica.tion For: J�Site Evaluation ❑ Improvement Permit/ATC ❑ Both
a. system to service: � House [� Mobile Home ❑ Business ❑ Industry ❑ Other
� 2
5. If Residence: # People '� # Bedrooms 3 # Bathrooms � �Z'
IW Dishwasher ❑ Garbage Disposal C�F7ashing Machine ❑ Basement/Plumbing f.l Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
ZF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: C�''County/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INrORMATION REQUGSTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the clieot with TNIS APPLICATION.
4
Property Dimensions: l•l�� /��� WRITE DIREC"I'IONS(from Mocksville)to PROPGR'1'Y:
Tax Office PIN: # S 7 t(S� � Z2�� �D 1 S {-d �'rr"�c�-� Co�;r��Qn
0
Property Address: Road Name P��. Q��� ��� `ad� S L-s' � M :�w
�,ty,Z,p �a�����Ir �rv.�, �-�..�f � -�; ,�� ��
�— ,. n � p
lf in a Subdivision provide information,as follows: �c�7" � -(US''� (d� -1'•�"
Name: �.��5 � ` `� f
Section: Biock: Lot: Date Property Flagged: l- o � a%Z-
This is to certify that the information provided is correct to the 6est of my knowledge. I uaderstand that any permit(s)
issued hercafter are subject to suspension or revocation,if thc site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,uitderstaitd tltat I ant respo�rsible for al1 clrrirges i�rcurred fro»r
this app/ication. 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 owncd by
to conduct all testing procedures as necessary to determine the site suitability. ►
DATE_����'�d� SIGNATURE ��v YYti C,'�_
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and pro�osed
property lines and dimensions, structures, setbacks, and septic locations).
Sitc Revisit Chargc
Datc(s):
Client Notitication Date:
�
EHS:
' Account No. ��� �
Revised DCHD(07/99) � Invoice No. ��� � �
tc�` �. ��
" , DAVIE COUNTY HEALTH DEPARTMENT
' • •, '• Environmental Health Section
, � ' Soil/Site Evaluation
' � APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002102 Tax PIN/EH#: 5745-13-2271
Billed To: Ron McDaniel Subdivision Info:
Reference Name: Location/Address: Pine Ridge Road-27028
Proposed Facility: Residence Property Size: 1.04 acres Date Evaluated: /- � 3��
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 ` �i
Texture rou L ��
Consistence
Structure
Mineralo
HORIZON II DEPTH �� ��`�
Texture rou
Consistence " i
SWcture / �
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: e OTHER(S)PRESENT:
REMARKS: (�(/��-S� ��/"/ �i/Oj "'�"� �
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-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloev
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 OS/99(Revised)
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, D�YI��OUNTY�I�4LT�I D����TbI�NT. _ ' , � ,:`
_ . .. _ _. �
ENVIROIVMENTAI HEALTH SECTION
P. O. Box 848/210 Hospital Street -
Cour�er #09-40-06
Mocksville, NC 27028
, -i
Phone #: �.(336)751-8760 _ `, .
_ _ _ . . . .._.._:.a
January 24, 2002
,
� _ �
Ron McDaniel
1068 Pine Ridge Road
Mocksville,NC 27028
Re: Site Evaluation/ 1.04 acres Pine Ridge Road
Tax Offce PIN: #5745-13-2271 �
Deaz Client(s):
As requested, a representative from this office visited the aforementioned site on
January 23, 2002. Based on information provided on the Applications for Site Evaluations
and after the evaluation was completed this site was found to be provisionally suitable for
the installation of a modified, oversized on-site sewage system.
Before Improvement Permit(s)/Authorization(s) to Construct can be issued the
appropriate application(s) must be filled out and the house/mobile home location staked
on each site.
If you have any questions, please feel free to contact this office.
Sincerely,
/��'�t���d�i•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/di
Enclosure(s)