277 Riverstone Trail :��V,� _.�� DAVIE COUNTY HEALTH DEPARTMENT � ���GD
- � - ' Environmental Health Section
� P.O.Boa 848/210 Hospital Street
� - Mceksville,NC 27028
(336)75]-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000870 Tax PIN/EH#: 5861-51-5293
Billed To: John Wali Subdivision Info:
Reference Name: John Wall LocationiAddress: Riverstone Trail-27006
Proposed Facility: Residence Property Size: 3.6 Acres
ATC Number: 2266
**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
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type �,l�l��� #People 3 #Bedrooms � #Baths Z .5
Dishwasher: �� Garbage Disposal: ❑ Washing Machine: �� Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 3.(�,_/.�(�Q� Type Water Supply 1/���L. Design Wastewater Flow(GPD) �(c� Site: New�Repair❑
System Specifications: Tank Size��QGAL. Pump Tank GAL. Trench Width �c�� Rock Depth �2'� Linear Ft.��
o�h�: 2 �,s����o� `�� , t.�s-�4� ��.x� 9 0.�.
�. �
Required Site Modifications/Conditions: ��ST4U.. OrJ C�ID.J 1 OvfZ ��Q �� � J � �� F�o►+��
' v�-� .U,.S..�'
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 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: Date: /
DCHD OS/99(Revised) �
, - �.� �r�.
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/Z10 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990000870 Tax PIN/EH#: 5861-51-5293
Billed To: John Wall Subdivision Info:
Reference Name: John Wall Location/Address: Riverstone Trail-27006
Proposed Facility: Residence Property Size: 3.6 Acres
ATC Number. 2266
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSiJED 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 Trea ent and Disposal Systems). THIS
AUTHORIZATION FOR WASTE TER C IS V ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: l
CERTIFICATE OF COMPLETION
.
**NO �*� this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
`�'_JL�fijas been installed in com ' with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
=sf3f�b�i' "but shall in O WAY be taken as a guarantee that the system will function satisfactorily for any
� d of time.
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Septic System Installed By: -���'�'�Nl,
Environmental Health SpecialisYs Signature: Date: � _
DCHD OS/99(Revised)
- "�
,`'_��l") I I _ 3�-�� � � APPLICATION FOR SITE EVAUlATION/IMPROVEMEM'PERMR&ATC � � � � 1�( �
' D a vi e C o u n t y H e al t h D e p artment �
�£"N�I r v R Y V I. � J}-�`. _�_T� Envi►�nmenta�I He�a/th sedfon
� � B.o. eo� 848/210 8oapital Street NOV I 6 I999
�--' �n� �t � �' _d tR-Ti„ .
�O� . ��� ��',I D�_ Mockbviile, NC 27028
- __._ . _ __ . - .
(336)751-8760 �
ENVIRONMENTAL HEALT
��*I1�ORTANT**� THIS APPLICATION CAI�iNOT BE PROC�BBED UNLE88 ALL T�
IIZB�OR1rATI0N IS PROV=DED. Rafar to the IIZB'0�1TION BULLET=N !or instruatioas. '
s, ltam� to b� s.tu.d �b`1 N /U• �ll/(� �j - cos►taot r�rso� Tn h tii L/i//� �1
M.si� aaa�... d d o� GI/o o c//c.R.v, rpl som. r�,.(?s cl 9�d��'9-9s
Cit'Y/Stat�/Lip _/T�vH/�l C� ,/�/G�. ol �D U(o su.ia..a �o�.
f• Aatii Oi: �i�'IDiL'/�a�. SL Yi.ri�+�.:.. 'w..ra ti.ait�
Mailiaq l�ddr�u City/Stab/sip � .
3. llpplioation Sor: [�''sit� avaluatioa ❑ Improv�nt P�rmit/ATC �^C�` Bo��
a. e�.� to s.z.so.: �ous� 0 Mobile Home 0 Business 0 tadnatry 0 Othar
a. _! Rssidance: ; Paople 3 � 8edrooms � f 8stbrooms ��
@�Di�hra�l�r O Garbaq� Di�posal �'Ir►asbiaQ Nacl�in� O Has�nt/pissb,inq L9��naau�nt/1Qo plvebiaQ
s. zr swsn.../z�dwcr�r/ors�.r: up.a�ry tpp. # a.op1• � ssak,
• Coaod�s � 8ho�nr� � Uri:tal� � Nat�r Cooi�r�
IF FOODSERVIC�: � Seats gatimatad iPatar Oaaq� �Qauon. p.r aay)
�. Typ� o! xster suppiy: 0 County/City [��1P�11 ❑ Commuaitp
e. Do yon anticlpste additlons or ezpansions of t6e facWtq this aystem ia tatended to eerve? ❑Yea @�I�o
u yes,wbat type? , -
. *"'IMPORTA/VT"**CLIENTS MiIS7'G�OMPLETETHE REQUlRED PROPERTY INFORMATION REQUESTED
BEIAW. EtWer a PLAT or SITE PLAN M[!ST'BES MITTED by cllent �vtth THLS APPI.ICATION.
a.s oayx��s'.y xss���`�x � /�G/�J
Property Dimenstons:�a 7, Y 7 ,D � � R+ DIRECITON3(irom McelovWe)to PROPERTY:
Taz Oflice PIN: # a�'�1-.t'1-s'� 9 3 ls"�' �As r• rc�r�,� 2� �,� s���v +B F r��l�� rn� �
Property Address: Road Name IQ�1/�'l�STnNE TR►�i 1 7"h�tir Tr,� �27' oi,� R�✓C'z25%o,��� T/�.
� � City2ip ���ANC� , d 7ao(� T�,/��v !F_Fi L/V TD c162�v��a v /�T lRl�� �
If in a Snbdlviaion prnvide tnformation,aa foltows: Pr�P�c�r�� (�i ��A(Z �F N�l o T- �A�E c�A 11'l.
Name: �'r.r ��✓cv tli� O F a�9!< T►��ES . .
Section: Biock: Lot: Dste Property Flag�al: ��' /�-�q
Thts�S to certify that t6e Informatton pravided i�correct to the beat of my knawledga I andersdtnd thst any permlt(a)
isaued hereafter are aabJect to awpeaston or revocation,if t6e site plans or intended aae change,or U t6e information
anbmitted in t61s appl�caHon i�fal�ified or chengaL I,also,anderstand tikat I ani nsponslble jor a!l cliarg�t Jncanrd from
tl�ls appltcatlo� I,hereby,give consent to the Aut6orized Repreaenbttv�of the Davie Connty Halth lkpartme�t
to enter apon above deacribed prnperty located In Davte Connty and awned by
to condact all testing procednres as nccesaary to determtne We aite saitabillty.
DATE /�' /�- �Y� SIGNATURE
THL'�AREA MAY BE USED FOR DRAWII�iG YOUR S1TE P ctade sU of the follawing: Faistlag and propoeed
prnperty lines and dLnenstons, atrnctnrea, aetbscka, and aepdc IocuHona).
� � Site Revhit Charge
�cs., Dute(a)•
.
�i X�� Cllent Not�catton Date:
� 3
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o `�° '�i �� � ; � ~ �,�
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-Revised (07/99) �R���I� !� R��� �'�� � Invotce Na ���y
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ROXIMATELY 8000' NORTH
ER.SE�OSR�1832C HWY 158 LESTER� R. ALLEN
.. AND WIFE ELMO�D �1iI.Y a�
. - ' RACHEL W. ALLEN ' .. . tc�Tx� n. BYERLY ac
. DH 139 PG 853 DH 160 PG 254
� DB 112� PG 630 ' ��
'3 7b'23'44" E s 83'S4'38" E � ,. E DB 111 PG 695 � � a
, . 126.05' ��P97.77 � �1 2 3� 17--- S�e'OlI s y4�s. 'S 8'2•03,,2cJ„ �ii • _
. » `� �----8���04 oo�e�• E ia�61. E 12
� 68'3212 *e -= � � � . S 81 � . E
138.81' -`'�--"�9:30 �\ �6 02
N 79'32 27". W�'�� IP � �,���\�� 31 so,NIP 87.Q8� $ 89'31'17" E �
282.30 (TOTAL) F 37.18 \�\ � 2 pl� , 9.0
IE GENE ALLEN ' � Nqoe.00Q4�W\'�\\ \ +''r NIP �. esy�� zeo.so
3 64. PG 631 � \ '� ; 1 � 4
� 83 PG 601 ,, � � � ,/. ��►`�, LOT 2 . NtP
- , � _ ..- �.� 17.000 ACRES � �
M , ,� �� e"� : ��BY� COORDINATE o.100F N�
� o� e - ,�,� ,' METHOD
� �/ � �'�y��' i` NIP�fs},s � (INCL °-LOTS 2A&w ) LOT 2B •
" ' a �
AT 3 / FIP � � s' �5�� . �.451 ACRES
0 ACRES • � � � 9 NEW 30' ACCES3 �� • '
IORDINATE ' `� `�O EASEMENT �, �i '
�rxon .w � . � LOT 2A °� � �
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/m� • I � �
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/� F N� `� o . 51a.3s FOUND
, ��e - � f�
���y� FI ��m: 0 5 59'22„w NIP � MONUMENT
z S7
t 4 , FIP 82•3 q» E . ,
ACRES NIP 788.�7'
RDINATE
HOD � �
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�RY x. FOSTER o 39. 022 ACRES . . �
I 154 PG 683 �z BY COORDINATE '
METHOD � � ;
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FOUND •
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' MONUMENT
�xT , N 829,�p 2-��_ v�
0 T E s; 424.02 w 1459.17'
i'HLS SURVEY INCLUDES ALL LANDS OF BILLIE G. ALI.EN A3 DESCRIBED
�r nA a� pr a�t n� Trrr. n��+m �ntT�*T�. nr.ri4TRV
�� ��` �": DAVIE COUNTY AEALTH DEPARTMENT
' � Environmental Health Section
Soi]/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 99000Q870 Tax PIN/EH#: 5861-51-5293
Biiled To: John Wall Subdivision Info:
Reference Name: John Wall Location/Address: Riverstone Trail-270
Proposed Facility: Residence Property Size: 3.6 Acres Date Evaluated: � �1r Z�i'
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring K� Pit Cut
FACTORS 1 2 3 4 5 � 6 7
Landsca osition L L,_
Slo % � S �7.0
HORIZON I DEPTH d -(2 p- p - � — �
Texture ou L L Gt.
Consistence r$ SS N �
Structure �Z L
Mineralo /�` ' �
HORIZON II DEPTH I L! . ! - Co
Texture rou C c
Consistence '$ r: S (� S
Structure iL /Y1 �M M
Mineralo ; 2'! 2- . Z:
HORIZON III DEPTH -/ � - 2 (,� - Z
Texture rou G+S Sc�
Consistence ' -s'
Structure gk
Mineralo M,I . h�. �
HORIZON IV DEPTH 2!�� 2 .t
Texture rou
Consistence 'j
Structure '
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION J S
LONG-TERM ACCEPTANCE RATE o,
SITE CLASSIFICATION: QS ���% T L�JD���r EVALUATION BY: ��f" ��u��f.�a Q��..�
LONG-TERM ACCEPTANCE RATE: C�2 OTHER(S)PRESENT: �3t�►-�.�1 I.�A.�.L.
REMARKS: � �� HA� �c.'irJ L�1i�� h/1�,Qu.��z
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
truct r .
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
ote
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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