224 Ralph Rd .' �• •' . +• _.�_
DAVIE COUNTY HEALTH DEPARTMENT �
Environmental Health Section
r.o.Bog sasnio x�p���sr��t
Mceksville,NC 27028
(33G)751-8760
Account #: 990001384 Tax PIN/EH#: 5769-33-3123
Billed To: Vicky Bullard Subdivision Info: Z2�
Reference Name: Location/Address: Ralph Road-27028
Proposed Facility: Residence Properry Size: 7.35 acres
ATC Number: 3245
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 a e Treatm and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT VA FOR A PERIOD OF FI YEARS.
Environmental Health SpecialisYs Signature: Date: � �� Z
S� ��p CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis 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. ,�p�p-rl�-1,��,.J� LnS� i/
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Septic System Installed By:
Environmental Health Specialist's Signature: ate: �7 L�
DCHD OS/99(Revised)
'A� '. DAVIE COUNTY HEALTH DEPARTMENT ._. � .i.
' � Environmental Health Section Q� � Z3� '
_ P.O.Boa 848/210 Hospital Street
_ , Mocksville,NC 27028 � .,
(336)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990001384 Tax PIN/EH#: 5769-33-3123
Billed To: Vicky Bullard Subdivision Info:
Reference Name: Location/Address: Raiph Road-27028
Proposed Facility: Residence Property Size: 7.35 acres
ATC Number: 3245
**NOTE** This ImprovemendOperation 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type Ne�sc. #People `� #Bedrooms � #Baths Z
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: �
'�>.
Commercial Specification: Facility Type #People #People/Shift #Seats . Industrial Waste:❑
Lot;Size <' ��'��""�T'ype Water Supply ��-�-- Design Wastewater Flow(GPD) ��� Site: New�Repair❑ � I��
- ,/ �
System Specifications: Tank Size ��AL. Pump Tank GAL. Trench Width �o Rock Depth l 2-�� Linear Ft.'`�3�� ;
��
ocher: � �I sT�i�3T10� F�x��S, j,n�s'i"e.t-�- (��n1�:s � �2�• C. j+-��r�• �
Required Site Modifications/Conditions: �r�LL d^� C�7J � �� � �'+�% �=-t�=� �t �
�
U �
I]VIPROVEII1ENT/OPERATION PERMI LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW i
FINISHED GRADE. ****NOTICE: Co act a representative ofthe Davie County Health Department for final inspection ofthis ;
system between 8:30 a.m.to 9:30 a.m.or 1: 0 p.m.to 1:30 p.m.on the day of'nstallation. Telephone#is(33C)751-87G0.**** �
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nvironmental Health Specialist's Signature: a :
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DCHD OS/99(Revised)
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, APPLICATION FUR SITE EVALUATION/Ih1PROVEItiiENT P[R611T&ATC
,.� . -„ " Davie County Health Department
^ � Environmental Hea/th Section
P.O. Box 848/210 Hospital Street �^"''�
Mocksville, NC 27028 � � � a � �
(336)751-8760 �
r'��
***IMPORTANT*** THIS APPLICATION C1�NNOT BE PROCESSED UNLESS ALL TH� I
INFORMATION IS PROVIDED. Refer to the INFOR2�ITION BULLETIN for inst c ions.
� p�TFI
1. rrame to be silled `' ` �NV��ONNIEN��
_Y (C_k � ������ `('`C1 Contact Porson ����F;�t�_-_"^��.:
/�-- / ._,,..-..-,^",.' -
Mailing Address �qL��1�� �{Q�� (.—�i�/�'�, Home Phone �'
Ci ty/State/ZIP ��^�S(�1 �1�C. � � . Business Phone � ��� �P��
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
l�.�
3. Application FoLy�ti�Site Evaluation �rovement Permit/ATC CI Both
�
a. system to service: [�House p Mobile Home CI Business (=1 Industry ❑ Other .
5. Zf Rasidence: # People �� # Bedrooms 3 # Bathrooms ��
�bishrrasher II Garbage Disposal �Washing Machine CI Basement/Plumbing fl Sas�ent/No Plumbing
6. If Dusiness/Industty/Other: Specify typo �k People # Sinks
# Commodes !► Showers #f Urinals �i Water Coolers
IF FOODSERVICE: � Seats Estimated Water Usage (gallons per day)
7. 2�pe of water supply; ❑ County/City l�Well ❑ Community
, /�
e. Do you anticipate additions or cxpansions of tl�c facility tl�is system is intended tu scrve? Cl Ycs ��io
It'ycs,wliat typc?
***IMYORTANT***CLIENTS MUSTCONIPLBTCTHE REQUIRCD PRQPGRTY INFORMA'CION RLQUGS'fI;D I
(3GL01V. Cithcr a PLAT or SITG PLAN MUST BESUBMI7TED by thc clicnt with TIIIS APPLICATION.
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Property Din�cnsions: �� J S �v �VRIT�DIRGGTIONS(from Mocic�vilic)to PKOPI:(i"1'1':
Tax Officc PIN: # S ��o / � 3 J l Z3 (�� �l1 ;� Le-�� a n W�l��'`�'
Property Address: Road IYamc !�� I,P �1 �q � , � ( ���
City/Zip_ / 'I DC IG1' [/ � ��t \ ��
If in a Subdivision providc information,as follows:
Namc:
Scclian: 131ock: Lot: Datc Property rlagged: CJ �Q ��
'tliis is tn ccrtify that thc information providcd is corrcct to thc bcst of my lcnowlcdgc. 1 undcrst�nd tl�at any permit(s)
issucd hercaftcr are subjcct to suspension or revocation,if t1�c sitc plans or intended usc cl�angc,or if tl�e inform:itiun
submitted in this application is falsified or cl�angecl. I,a1.so,u�rderslruld t/rn!!ant rc��n�rsiGlefi�r n!/c/rarges incrrrrc�d jron�
, 1/tis upplicatiar. (,hcrcby,givc conscnt to thc AutLoriud Rcprescntativc of thc Davic County Ffcaltl� Dcpartmcnl
lo cntcr upon abovc dcscribcd property locatcd in Davic County and owned by �_^.
to conduct all tcsting proccdures as ncccssary to dctcrminc tl�c silc suitabilit
`
DA7'[: Z SICNATUR� .
THIS A[iCA MAY B� USCD FOR DRAWING YOUR SIT�PLAN(Includc all of tl�c following: Cxisting and proposed
property lincs and dimcnsions, structures, setbacks, And scptic locutions).
Sitc Itcvisit Cl�argc
Datc(s):
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Revised DCH (07/99) �`�"�— Invoice No. ��� �
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
,-. �. ' Soil/Site Evaluation
+ APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001384 Tax PIN/EH#: 5769-33-3123
Billed To: Vicky Bullard Subdivision Info:
Reference Name: Location/Address: Ralph Road-27028
Proposed Facility: Residence Property Size: 7.35 acres Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo %
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEP'TH
Texture rou
Consistence �
Structure
Mineralo
HORIZON III DEPTH
Texture rou
Consistence -
SWcture '
Mineralo - �
HORIZON IV DEP'TH
m Texture rou
Consistence
Structure
Mineralo
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky
SBK-Subangular 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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NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slighdy plastic P-Plastic VP-Very plastic
t ct re
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular 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
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�� T�avfe Coun ealth Z7e artment
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Envlronmental,�fealth Sectlon
Po Eox s4s/slo xaspiral screet
Mocksville,NC 27028
Pho� (336)751-8760
September 14,2000
Vicki Bullard
294 Split Creek Lane
Mocksville,NC 27028
. Re: 2 Site Evaluations-
12.9 Acre Tract/Ralph Road
Tax PIN#: 5769-33-9442 . v �
Dear Ms. Bullard:
As requested, a representative from this office visited the above site(s) on
September 13, 2000. Based on the information provided on the Application for Site
Evaluation and after the evaluations were completed, both sites were found to be
provisionally suitable for the installation of an on-site sewage disposal system.
Before a representative of this office will revisit the site to issue an Improvement �
PermidAuthorization to Construct,the appropriate application must be completed in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
If you have any questions,you may contact our o�ce at(336)751-8760.
Sincerel � �
��
�
Jeff G. Beauchamp, R.S.
Environmental Health Section
enc(s)
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. . �- • . APPLICATI�I FOR SRE EVAWATION/IMPftOVEMENT PERMtT&ATC [S � [� p�/ �
'' e:! �` Davle County Heaith Department D
Envr►ronn�r�ts/He�a/�fi Se�on
p.o. Box 848/210 Eospital Straet au� 2 s 20�0
. Mocksville, NC 27028
. . (336)751-8760 .
***I?lPQR?AIQZ'�'�* Tfl28 APPLICATION CANNOT HE PROCE3SED UNI.L33 ALL TFiE REQVZRED
INFORMATION I3 PROVIDED. Refar to the IN8'ORMATION BULI,ETIN for inatiructiona.
1. x.�.. to b. 9ill.a �j C��'�� �J��`�..,� ccntaot r.r,on V ►e��� 1�u��..�V
lsailia4 1►�ddr��a ��1�l �C,��� reY'�,� 8oma phon� ���'�(� W�'c Q A+v��L.
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cs�/st.r../s:r �,�c�S v�, �t� llV G nu.�.., rhon.
2. Nw oa ?�rait/1►TC ir air!•srnt thu� 11bow
Nailinq Addr��� City/Stab/zip
3. l►�rpliaation �or: Sit� Rvaluation D =mprovement Permit/ATC O Both
a. sy.t�.a to s.rvio.: �ous• � Mobile Homa ❑ Huainass O =nduatry 0 Other
s. z= R.�sicl�na�: f p�opl� _,,,�_ � Bedrooma �_, i Bathrooma �_
Di�hMaa�r Q Garbaq� Dilpo�al rB'Ka�hinq ltaohi�o U Sa��nt/BltsbiaQ O Has�s�nt/No Plvab
6. Z= Hu�in�s�/Zndu�try/Ot2��rt 8p�aity typ� � p�opl� � eink�
• C000d�• i 8Aox�rs i Urinal• / Mat�s Cool�r•
I! S'a0D8ERVICB: � S�ats Eatimated Water Dsaqo t�ioa• p.r a.y)
�. Z�p� o! xater suppiy: O couaty/City �1 0 Co�ity
e. Do yon aaHcipate addiHona or ezpaa�iona of t6e facility t6is system!a inteaded to aerve? O Yes 0 No
If yes,what type?
*�"IMPORTAN7'�**CLIENTS M(lST'C�OMPLETETHE REQUJRED PROPERTY INFORMATION REQUFSTED
BELOW. Eit6er a PLAT or SITE PI.AN M!!ST BESUBMI7TED by the client with THIS APPLiCAT10N.
P�operty Dimensiods:�nQO SCS 1., �[?k �f( � a(X.��p WR1TE DIRECfiONS(from Mocktville)fo PROPERTY:
jCa$7JC 3/ O
TA:Oftice PIN: # S�1 Li-�3 3 'CI`1 `1 � ��a �,�w h ls Y�i4�s�f - � "D i✓
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Property Address: Raad Name o��� ��\'��,o.� ��,,,?,ti r4?`?QR IC m� ' � ��
City/ZIp wlot�,CS�,►�,� �.`7a1X l, � � h'�
� V In s Subdivisioo provide lnformsH�,aa tdlawa:
Name:
Sectioo: Block: Lot: Ihte Property Flagged: �—���Csf�
_T6b is to certify that the information provlded is cornct to t6e best of my knowledge. I anderstand t6at any permit(a)
L�aed 6eresRer are anbject to=n�penaioa or revocsHon,if the site.plaas or intended oae change,or it the intormation
snbmitted iu this sppllcation is falsttied or c6auged. I,also,anderstand lhat I am tesponsJb/e jor e//cbarg�s lncurr�d from
Ibls app/Icatlon. I,6ereby,give consent to the Anthorized Representative of the Davie onnty H It6 Departmeat
to enter npon above described property locsted in Davfe Conaty and awned by c:w e Y
to conduct ail testing procednrea as neceasary to determine t6e site suitability.
DATE SS' ,��' 27 SIGNATURE 1 �
THI3 AREA MAY BE USED FOR�DRAWING YOIIR STTE PLAN(Inclnde All of the lollawing: EzisNng and propaeed
property lines and dimenslons, atractnres, setbacks, and septic locations).
Site Revisit C6arge
Dste{s):
� Client NotiticsHon Date:
EHS:
Acconat Na � ��
Reviud DCHD(07/99) Invoice No. �a
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• � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heaith Section
Soil/Site Evaluation
APPLICANT INFORMATION , ; ; `' � PROPERTY INFORMATION
Account #: 990001384 � Tax PIN/EH#: 5769-33-9442.02
Billed To: Vcky Bullard Subdivision Info:
Reference Name: , Location/Address: 208 Ralph Road-2702
Proposed Facility: Residence PropeRy Size: see map Date Evaluated: � Ov
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut �
FACTORS 1 2 3 4 5 6 7
Landsca e osition d
Slo % _'
HORIZON I DEPTH �=' ?� .—�p �--
Texture rou
Consistence � �. —
, Structure C(L
Mineralo _ � ,
HORIZON II DEPTH ' �/�
Texture rou
� Consistence '�
Strucfure
Mineralo : 1 `
HORIZON III DEP"TH y�
Texture rou �
Consistence . ;-5
Structure - �
Mineralo �: : � �
HORIZON IV DEPTH t }
, Texture rou �
Consistence
' Structure
Mineralo
SOII.WETNESS :
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION -C
" LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY. - �
. l ,
LONG-TERM ACCEPTANCE RATE: �•� OTHER(S)PRESENT:
REMARKS: �Lt'QIaJ�' �l.�k�-'�{��W� _
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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic �
Mineraloav
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
DC�ID OS/99(Revised)
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.. ;' ' •
T�avfe Gounty,�fealrh De,�artmenr
Erlvlronmental,7�ealth Sectlon
Po s�s4s/no x�i�s�c .
Mockaville,NC 27028
Phon� (336)751�6760
t
September 14,2000
Vicki Bullard
294 Split Creek Lane
Mocksville,NC 27028
Re: 2 Site Evaluations-
12.9 Acre Tract/Ralph Road
Tax PIN#: 5769-33-9442 � o �
Dear Ms. Bullard:
As requested,a representative from this office visited the above site(s) on
September 13, 2000. Based on the infom�ation provided on the Application for Site
Evaluation and after the evaluations were completed, both sites were found to be
provisionally suitable for the installation of an on-site sewage disposal system.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Constivct, the appropriate application must be completed in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
Ifyou have any questions,you may contact our office at(336)751-8760.
Sincerel '
��
�
JeffG. Beauchamp,RS.
Environmental Health Section
enc(s)