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619 Pineville Rd DAVIE COUNTY HEALTH DEPARTMENT ����/�� a `-1��.`b _ • ' � Environmental Health Section � •• P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)7S]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001429 Tax PIN/EH#: 5843-26-1384.00OE Billed To: William&Kim Jones Subdivision Info: Reference Name: Location/Address: PineviAe Road-27028 Proposed Facility: Residence Property Size: 9.95 acres **NOT�*��'�iibgmpro se�m2endOperation 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. Residential Specification: Building Type �'J' #People �_ #Bedrooms � #Baths� Dishwasher:� Garbage Disposal: ❑ Washing Machine:K� Basement w/Plumbing� Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��,Type Water Supply� Design Wastewater Flow(GPD) Site: New❑ Repair❑ �. � � System Specifications: Tank Siz�,�GAL. Pump Tank GAL. Trench Width �,� Rock Depth� Linear Ft.�i Other: ��'`✓ 300` Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)'751-87G0.**** / � V � � � 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 (336)?51-8760 Account #: 990001429 Tax PIN/EH#: 5843-26-1384.00OE Billed To: William 8�Kim Jones Subdivision Info: Reference Name: Location/Address: Pineville Road-27028 Proposed Facility: Residence Property Size: 9.95 acres ATC Number: 2602 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 I 1 of G.S. Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER S UCTION IS VALID FOR A PERIOD OF FIVE YEARS. � Environmental Health Specialist's Signature: . �� � 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 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 give�period of time. � �� � i� .�O ' . �'C�� �TO� �� X,3�ox� g., �U' 3 •�+�i S ev o'T— �1 l7 e�rn P�-� -.�i �bQ�t� ',�'sP�r��.� �m�� p�`� �-� ���-= �� Septic System Installed By: �� - `�'�-'�'`-r� Environmental Health SpecialisYs Signature• Date: � ' DCHD OS/99(Revised) � � c� a�� , APPUCATION fOR SITE EVAUlAl10N/IMPHOVEMENT PEAMR b ATC D . � '� Davie County Health Department �Cr . • • �. Envl�onmenta/Heur/th Se�cdon �" 2 20�0 � p.0. Box 818/210 �ospft.al BtsNt . Moalcsvill�, NC 27028 � • (336)7�51-6760 . ` �*�I3�OiRTAH?*** TH28 �IPpLICl1TIOit t�QNO? Bm PROC�88�D �INLE88 IILL '1'Ht I�EQQIAaD INrOR�ATiOti I8 pttOV2DED. tt�ls� to th� IN�"OIt�ATi02i BVLL�TIN for iastxuations. 1. 1R�� t0 L� s1u�M��LI.\L�M E. ���M�... T O�JrcS CO�IttOt �=�04 W��_��4� �G ��7)� �cai� �... \o�_u������.s-�.Q tZa ao.. aboo. � cihr/�at.�sir aov n�c_c_ n�c �-,co� su.ia... �on. •3a� - 3ss a- aloa� c.� Z. Ila� oa D�sait/J1SC i! Di!l�synt th�u 71bo�� 5 A t�n E �3l� h 3 Z-"a.-133 11ai11nQ �ddr��• CitY/�tal�/iiy �. f►p�piiastioa tors Sits ivalustioa �Improvsm�at p�r�oit/7►sC 0 Both �. sY.w to s•r.io.� �8ou�• O Mobil� Bom� � 8usia�ss � Iadu�tsy O Oth�r a. �! it��idu�c�: f p�opi� �_ ! S�drooms � _ f Hathrooms � �Di�bxaal�r O Oasbaqa Di�po�d �ttashinq 14dhin� �Sas�nt/Ol�sbioq 0 taawnkMo plvmbinQ /� 6. St �usia���/2adu�lsY/Otlur� �ai!? kYP� � �opl� f tiak� � Coo�od�� i �Aow�s� � IIsiaai• � 1/sbr Cool�r� Ir ��00�lssRviCs: � s•at. satims,t�a xst�r Uaaq. 1v�1� w= �r� �. Typ� o! �at�r suppiy: �Coutity/City 0 N�il 0 C�aity e. Oo yoa saHcipate�ddiHoo�or eipaudont o[t6e t�eWty t6b ry�tem b latenda!ta krve? 0 Ya �8'No If ya,wbat type? ***IMPORT.lMI"'**CWENTS MIJ�ST C10MPLETETNE REQUIRED PItOPERTY INFORMATION REQUESTED BELOW. Either a PI.AT or 8ITE I'LAN Mi1ST BESUBI�TTED by the cllent wit6'fU13 APP1dCATlON. Property Dtmenfiow: �� �S �� R+R1TE DIRF.CRONS(trom Mak�vQle)to PROPERTY: Tai08icePIN: � 5��3-a� —�3$� ���e ✓��1� `K� . a,� i o�-, ,,,, c-.��- . Property Addrea�: Aoad Name (?�NEv�►-� l��. �h a 4 s� i S S� o w-a-� � Clty/Zip �'RQm�t��-c�N Ii in�Snbdlvbion provide Inform�don,a follmvr. N�mes &cHon: Blceks Lott Date Propettr Fia�eds �� ��' �`�� � This b to eertiPy t6st the Iutbrm�Hon praWded b eorreet to t6e bat oi my knon►led`a I andenhnd t6at f�ny permit(�) laeaed hereafter�re eubJect to tmpenelon or revocadon�i[the dte pisai or lntended ase cLsn�e,ar If t6e tnformeHon �abmiHed ln t6V sppllcaHon is bisqied or chan�ed. l,aiso,anderston�l tliot I oni nsponslble jor a/l cliarge.r lncameA fi+vrn tlils appllca�lon. I,6ereby,�ive consent to the Aat6orized Repraenhttre of t6e Davie Coantp Halth Department to enter npon above deacMbed property loc�ted in Davk Comty and m►ued by w�tx.�ar� e aN� K�rn �..• So�t�s to tondact�11 talin�pro�eaora u occe�as�►�o aetermme we.ue.atabwh. DA'fL � �-c�z_da SIGNATURE K_2. �a,,�� THl3 AREA MAY BE U3ED FOR DMWQIG YOUR$iTE PI.AN(Inclade�Il of t6e follo�ings L�tin�and propaed property Iina and dimensioai, �tra¢tara, retbaclu, �nd updo locadon�). Site Rcvhlt C6ar�e Dste(�): Client NoNUcallon D�te: LR3: Accoaat Na � � Revissd DCHD(07/99) ��..c:�•s� c.oJ��c.� �4''�``�s � so Invoice N , �< � � � o � n {../C-S Oc_+JJ@1�s Ca+> M'�'� W eC1y '"C1-<C. �`%. e _ � �� � �,V A�..11AZ'o� `'FOci "Z�1c:.. S\TE ,1 o f-�" � 3 t V" J X�t-C) E�l A Lv�q�c�:s S. w� `„L,►�M E . �ca�S � 3 z- � C-� _ I � '�'�''1 �� ��vkcs C�l aq� -a a aa .�..,� Oc� Be2. �3�:�-ac�a� -t� �,�Sr � P►NEVI E. ; „ , , � ,�. ,69 �ZBo � . �� R��D � 6271 �� 1087 0 � � � - (194) � • � N 4 �22 1097 o �oo 289 zo ( .78A) (417) N 3987 90 N 9072 '' ��so� ' 2 '' � � 8981 13 � 8 � DAVI E r?� � COUNTY � °� � 238 � � � 7881 N 00 7�9 M � �52 1564 B500000022 � `8�261384 D �, 5671 M � � � � � � 2537 169.61 9.95A ^ � 1384 (��.2sA� w � D ti ��2.52A� a296 7138 . .-. � � � .� i APPLI('AiION FOR S11E EVAWA110N/IMPROVEMEM PEflMIT&ATC � � ��� �� Davie County Health Department � � (� � � � [� � Environmental Nea/tfi Se+ction ' /`/J� P.O. Box 8�8/210 Hospital Street " MAY - � I� SV Moakaville, NC 27028 � ,� (336)751-8760 � �E�"JIROP,I!?^E�iTI�L HEALTH •*�Il�ORTP.NT*** THI9 APPLICATIdN CANNOT P�E PROCESSED LJNLE33 ALL T�tE-REQUI�tED��"'��-' INFORMATYON I3 PRO�TIDED. Refer to the INFORMATION BOLLETIN for iastruations. 1. liama ta be Billed �✓G�r'^�S ►JY`�v� Contaat Perao�nJ�""'��' d� �.Z_ �1��\ !l�.ilinq Address Z7i?i3 '�'d rrK�..,� (/C`• sama p'hone ���?J.S� S ���G 21 csty/state/z�r �1>GrCS !t*,`o G�'JG_ 2rJ r��� Bnsiness phone 7 �� `Z-D I l� Z. Nams on permit/1►tC i! Di!lerenb thaa Above 1lailing Addreaa CiLy/Btate/Zip �. Application Sor: Ni"Site Evaluation ❑ Improvement Permit/ATC �°Both 1. sy.tam to servsce: �House ❑ Mobile Home 0 Bnaiaeas 0 Industsyt 0 Other e. If Residence: i People � # Hedrooms � # Bathroom.s �- 0 Dishwasher U Oarbaqe Disposai 0 NashinQ 1lachine 0 Haament/plumbinq 0 Bas�mrs�t/No piumbinq 6. i! Bnsiness/Indnatry/other: Specity type � Beople � Sit�s • Caa�odea f 8hoxers � Uriaals N Nater Coolera IP FO�D3ERViCE: . � seats Bstimated itater tJsaqe (Qaiions per aay) 7. Tppe of water supplp: �Conaty/City' 0 i�ell ❑ Coa�unity e. Oo you�nticipate Additions or e:pansion�ot t6e facility thi�ayatem ts iotended to serve! ❑Yea � B yes,w6at type2 "*'�MFORTANT'•'CI.IENTS JI![IST C10AlPLETE THG REQUIRED PROPERTY 1NFORMATION REQUESTED BELOW. Elt6er a Pi.AT or S1TE PI.AN MUST BESUB�tITTEU 6y We cllent wtt6 TN1S APPLICATION. Property Dimensions: / �• b �C'''�s LWRITE DIRECfIONS(from MocW�Wlie)to PdtOPER1Y: Ta:Oftice P1N: #,��'�'3 ,� b �.3�u.�� �h�v. �J� /�'�L, �;vrN�N5 �✓u� �"'�3' Prnpert�Addre�a: Road Name �� �.�✓�-JC P f�o�. �s �tl ,l� �vr �71" w�ye City/Zip�ij,r�U�Sv,�� �/.L- � S�ar�e ��/ `� � t-C�- r,b�hv `� `� �I ' � If 1n a Subdivision prnvide informatfon,a�followa: LS �r� ���^ ,�, �� d�c% u Name: �rDY. qdf�� '�'J �/�S 'r'v" �_ y�l u � 5ectfon: Block: Lot: Date Property Ftagged: � � �� Thi�is to certity fhat t6e intormatioa provided is cornect to the 6est of my knowledga I undecstand that any permit(s) issued bereafter are subject to au�pension or revocation,if the�ite plans or intended use cBange,or tf the informatfon submitted in tbia Application is talsitied or changed I,also,understand tQrat I o,�„espons�ble for ai!cliarges l,rcr�rred fronr tlils app[fcatiwn. i,hereby,give consent to the Authorized RepreaentaNve of t6e Davie County Health Departmer�t to eoter upon above described property located in Davie County snd owned b�- �✓��- �-�a� �,�v L to condud all te�ting prncedures as neceuary to dMermioe t6e�Ite auitabilih�. DATE �/,�/�1 SIGNATU Y� - TflIS AREA MAY BE USED FOR DRAWING YOUR Sl1'E PLAIV(lnclude all of t6e tollowing: E�ating and propo�ed prnp�rty lines ssnd dlmensfona, structures, setbacks, and septic locations). Accouat No. `s'S/� Revised DCHD(07/98) Invoice No. � �� �� �/�-/s� .. . ,� ..' '--�_�_ �Y . �� - ` � .. . ` }•� � i - ' . - 13 �2 � ._T 8 - - . 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' i =� _ �' f j .� N ( • - ` � .. ) 1 n � -- � , , � . . , ' � : � � � DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section SECTION LOT SoiUSite Evaluation � �/ �,�' APPLICANT'S NAME .E�/O�i�� DATE EVALUATED S !���� PROPOSED FACILITY � PROPERTY SIZE O�c' SUBDIVISION ROAD NAME �h� L', /� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �( '` � � Texture rou G Consistence � Structure li 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 3 SITE CLASSIFICATION: � EVALUATION BY: ` LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: O � ^� 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 oist VFR-Very friable FR-Friable FI-Firm VFI-Very firtn 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 otes 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) . . I,� , ; .' . ' - DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P.O. BOX 848 MOCKSVILLE, N.C. 27028 336-751-8760 May 14,1999 James Brock 2223 Farmington Rd. Mocksville, N.C. 27028 Re: Site Evaluatio�10.6 Acres Pineville Rd. Tax PIN#5843-26-1384 Dear Mr. Brock: As requested,a representative from this office visited the aforementioned site(s)on May 13, 1999 . Based upon the 1�ormation p�ovided on the application for the site evaluation and after the evaluation was completed,the site was found to be provisionaliy suitable for the installation of an on-site sewage disposal system. Before Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the home site marked. If you have any questions,please feel free to contact this office. S� C ' � cp, � . Robert B. Hail,Jr., R.S. Environmental Health Section enc: