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157 Ponderosa RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001674 Billed To: Timothy Mitchell Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5823-54-6481 Subdivision Info: Location/Address: Ponderosa Drive -27028 Property Size: 5 acres ATC Number: 3579 **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. Residential Specification: Building Type #People &" #Bedrooms �� #Baths Dishwasher:: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply &,e l f Design Wastewater Flow (GPD) Site: New e Repair ❑ System Specifications: Tank Size/ _UGAL. Pump Tank GAL. Trench Width�6 Rock Depth -/,L/Linear Ft. Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: -eptaq a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m,o 0 . to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** A/'r Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001674 Billed To: Timothy Mitchell Reference Name: Proposed Facility: Residence ATC Number: 3579 Tax PIN/EH #: 5823-54-6481 Subdivision Info: Location/Address: Ponderosa Drive -27028 Property Size: 5 acres 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: �1�// Date: CERTIFICATE OF COMPLETION r% **NOTE** The issuance of this Certificate of Completion shall indicate the system d d T © ro�ment/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, S ion. 00 "Sevw e Treatment and Disposal Systems," but shall in NO WAYr t� �n s a guarantee that a syst wi fun ion satisfactorily for any given period of time. k p kl-f je r Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPUCATION FOR SITE EVALUATION/IAIPROVEAIENT PER&I1T & ATC Davie County Health Department- `� e�(4 Envirnmenta/Heal&SeCUOJ7 p� t P.O. Box 848/210 Hospital Street Z 0 2V I Mocksville, NC 27028 i �C (336) 751-8760 ENVIRONMENTAL HEALTH 1=11F COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 . Name to be Billed 1001d 1 d I FINE, MSI TC44� Contact Person 5AM- yj� 17 L75 { t; Mailing Address ��__lag , 4el-TO/Vn ��L-Igk)L(7 Home Phone—33(0-QRZ(!/� 2/ /(pl,^1/56 0 City/State/ZIP I O CV,511 u,6 A)C- 7WS Business Phone ��lo �L� J✓ ~/ 110� 2. Name on Permit/ATC if Different than Above Mailing Address City/Stat `� Zip / ✓%-4 3. Application For: Site Evaluation Improvement Permit/ATC U Both 4. System to Service: X House ❑ Mobile Home ❑ Business 20 Industry ❑ Other S. If Residence: # People_ # Bedrooms 3 # Bathrooms_ U Dishwasher ❑ Garbage Disposal XWashing Machine ❑ Basement/Plumbing 0 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 X Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo 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: Tax Office PIN: #160 a3 54 - 6 q81 Property Address: Road Name Paw�x-�cQs}� city/zip /r10C.L!SUII. (t' 0i0078 If in a Subdivision provide information, as follows: Name: WRITE DIRECTIONS (from Mocicsville) to PROPERTY: 6) 6,D1 N To SO/ (IIN't"L -5) ('�,�,v e<53rut-'l T wig �iNGrory — /t,i-e �21eeaT ons 19rangQ5,9 Section: Block: Lot: Date Property Flagged: O 0 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 front this application. I, hereby, give consent to the Authorized Representative of the Dam County Health Department to enter upon above described property located in Davie County and owned by <) j!�j 13, LOW6PY to conduct all testing procedures as necessary to determine the site suitabi ity. 3 l DATE /20o) SIGNATURE V" 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). n.`,e r L L e l-/ Revised DCIID (07/99) �-,-- 3 Site Revisit Charge Date(s): Client Notification Date: EHS: -7V Account No. QLS -7 Invoice No. a') 2 � , ` � � q N ♦� (289) N o � � �j� , . o � ` � INDEXED ON 5823.04 W ^ Z. . (153) O � . � � . . . .. . �% . . � A � i . � . ... � . � . h �� A . . �. - . !w .. . � I : �,.oSA> : �ao � Y'v N 2S6 � � �� P 2�88 � _ a v� _ �, : �n N � � � . :�. ; " 5763 ,so 60 �s !, `.. � � � (�) � h i � , i , ; � B300000075 , �_ ; , ; - �.os� � ; 6481 zca �� n DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001674 Tax PIN/EH #: 5823-54-6481 Billed To: Timothy Mitchell Subdivision Info: Reference Name: Location/Address: Ponderosa Drive -27028 Proposed Facility: Residence Property Size: 5 acres Date Evaluated: Water Supply: On -Site Well ✓ Community Evaluation By: Auger Boring A.--- Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 4-1 HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure h/ 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: / "_� 111A e'� , LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: ,,Qo&U OTHER(S) PRESENT: 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) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 April 18, 2001 Timothy W. Mitchell 128 Shelton Lane Mocksville, NC 27028 Re: Site Evaluation/ Ponderosa Road Tax Office PIN: #5823-54-6481 Dear Client(s): As requested, a representative from this office visited the aforementioned site on April 18, 2001. Based upon the 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. Slucerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s)