202 Seawall Trail � _.. DAVIE COUNTY HEALTH DEPARTMENT
� '� Environmental Health Section
• ' P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990003695 Tax PIN/EH#: 5778-79-3915
Billed To: John Waller Subdivision Info: �-t,,,r�y��-�
Reference Name: Location/Address: Baileys Chapel-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4165�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his 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 CONSTRUC ION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: � �
� � CERTIFICATE OF COMPLETION
**NOTE** T'he issuanc..�e��this 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. � .�
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Septic System Installed By: �
Environmental Health Specialist's Signature: � � / e: 7 `��
DCHD OS/99(Revised)
,
DAVIE COUNTY HEALTH DEPARTMENT ��,�
Environmental Health Section
� � � P.O.Boz 848/210 Hospital Street ��
. � -� � , Mocksville,NC 27028 �� s
� (336)7S1-87G0 �i� 'J�� O
!
IMPROVEMENT/OPERATION PERMIT
Account #: 990003695 Tax PIN/EH#: 5778-79-3915
Billed To: John Waller Subdivision Info: ��y��,`-�(�
Reference Name: Location/Address: Baileys Chapel-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 4165
**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). THLS
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:f� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: �
Lot Size Type Water Supply�jL Design Wastewater Flow(GPD) [P� Site: New❑ Repair❑
i�
System Specifications: Tank Size,1�0� GAL. Pump Tank GAL. Trench Width��Rock Depth �� Linear Ft.C��
Other:
Required Site Modifications/Conditions:
I1�IPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW `
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.**** '
�
�
Environmental Health Specialist's Signature: Date: �� `f��✓
DCHD OS/99(Revised)
• � � - ' ' . APPUCATION FOR SITE EVALUATION/lh1PROVEM1tENT PERM1tI T� � � � � �
. �. Davie County Heaith Department
• Environmenta/Hea/t/�Section ,��� .. 2 �j
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-6760 �IRONMENTALNTMEAUti
***IttPORTANT*** THIS APPLICATION CAIVNOT BE PROCESSED UNLESS A ED
INFORMATION IS PROVIDED. Refe� to the INFORMATION BtTLLETIN for instructions.
Namo to be IIilled ���I� �.t�a�,C{Z, Contact Pornon '�c �-. r-,P_ �a�p..,J�t� �n�a���,
. �Mai ng Addresa �1 02[.Q f�R.c,n o�-Ly� C[ft,�rv� K�l, _ Iiome Phone �Lo(t ��l 3�
�/State/ZIP ��dNonS, /UC 1'Z� !1 BffBtnaae Phone J d�n ��"��f�1�'l(
,/l. Namo on Permit/ATC if Differeat than Above �..�1��. �I'1�-- 39 5`�
�iailing Address City/State/2ip
t� Applica�ion For: Site Evaluation �provement Permit/ATC ❑ noth
c.9,/s atem to services L�iouse � Mobi1Q Home ❑ Iiusiness ❑ Induatry ❑ Other
�5/. Typo aystem reguestod: ❑ Conventional ❑ conventional modified ❑ innovative p ac Cep ted
6 If itesidence: , N People �_ # Badrooms _� � Bathrooms _�
'/ODi�hwasher �arbage Diaposal Qfsashing Machino ❑Dasement/Pluu�ing ❑Dasemant/2do Plumbing
7. If Duainesa/Induatsy /Otherz verify type # People S Sinks
# Commoclea # Showere # Urinala I� Wal•or Coolera
IF FOODSERVICE: #� Seats Estinlated Water Usage (qaiions par day)
�Type of water supply: C�County/City ❑ Well 0 Community
9 no You anticipatc additions or cxpansions of tlic facility tliis systc►n is intci�dcd to scrvc?�Ycs �'l�io
If y�cs,�rl�at typc?
***lA1PORT�INT't**CLILNTS MUST COhlPLETL•TII� REQUIKLD PROPCRTY INrORMATION RGQUGSTCD
I3GLO�V. Eithcr a PLAT or S1TG PLAN J�fUST BE SU6htITTED by thc dicnt �vitli T[(IS APPLICATION.
ro cr(y Dimcnsions: / �— RIT� fron�Modcsvillc)to PROI'CRTY:`
C, �
Tax OfGcc 1'IN: # ���O '�/"J /�� lD� ,�g4� �+ �e�C�i 4 . �, Ra. � �w�N1
P perty Address: Road Name�,t �1t1 S �/�� �cD� . (M �`o�.�- o-r 6A:��..`s
��ty�Z,P � o� ��. ��.�� a��,� �a�+ �
�in a Subdivision providc inforniation,as follows: (��,,,����r, 1 a,,.. 2�a� :r �'��-�-n o�
Namc: '
Scction: Blocic: Lot: atc liomc corncrs llaggcd: `��a �05
Tl�is is to ccrtify tl�at tlie iuformation provided is correct to tl�c best of r»y knotivlcdgc. I undcrstand tliat any permil(s)
issucd I�crcaftcr are subject to suspensioii or revocation,if thc sitc plans or intendcd usc cl�angc,or if tlic inform�tion
submitted in this application is falsircd or ct�anged. I,also,tu�derstand tliat I anr responsiGlc for al!cliargcs i�tcrrrrcd froui
tlris applicatiou. I,hcrcby,�givc consent to tl�c Autl�oriacd Rcprescutativc of tl�c Davic County Iicalll�Dcpartmcnt
to cntcr upon abovc dcscribcd property locatcd in Davic County an� otivncd by
to conduct all tesling procedures as necessary to deter►nine tl�e site suitab'ity.
�T� S�I��QS GNATURC
TFIIS AR�A MAY B�US�D TOR DRAWING YOUR SI'fE PLAN(Includc all of thc follo�ving: �listing:tnd proposetl
property lines ana dimensions, structures, setbacks, and septic locations). �
Sitc Rcvisit Chargc
�� . Datc(s):
' � Clicnt NotiCcatiou Date:
�HS:
� �
Sign givcn� . Account No. J�� �s
� ;
Reviscd DCIiD(05/03 Invoicc No. »�- �
���
, "� _ � ���PPLICATION FOR SITE EVALUATION/IMPR�VEMENT P �C
. . •°• �� Davie County Health Department `' ' '�
� � � � ;$
� ,N :�•���� CQ Environmental Health Section �`�` ` ��� "�� ;;��
: �c.
1 �� �Q ` (p� P.O.Box 848 � �t "�_
� 1 � � � Mocksville,NC 27028 � � � �4�
a v c�ee.
�'�f �"h r� a� ��e �- (704) 634-8760
� ...
-' be��pt� %►^ t�'t or�'� nS
****IMPORTANT**** TI�IS APPLICATION CANNOT BE PROCESSED UNL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �o1�n In�h��.e.R Contact Person 7oH�n (�J���e,C
MailingAddress i`1��+ ��a�c��r 1^c..,,�-rr� �c�l HomePhone �,°110, `7Co(...-'1�135
City/State/Zip C,\-�,Mm�nS; NC, �70��- Business Phone �°�ia��7C,(.-')�13�
2. Name on PermidATC if Different than Above
Mailing Address City/State/Zin "
c•�,(,�Q �._.� _,_ . r._,
3. Application For: [./jSite Evaluation [ ]I�p oveme� ntFermit�ATC [ ]Both
4. System to Serve: [�]House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People a #Bedrooms�_ #Bathrooms a• [vj Dishwasher[ ]Garbage Disposal
[�]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/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 [,/J Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [./jNo
If yes,what type?
PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ��� a�►�� �WRITE DIRECTIONS(from Mocksville)TO PROPERTY:
Tax Office PIN: #�j'7?5f -�_- 3`� I�J ; �v�{,,� `�-c.� �d�� �n u�c1� f:c��
Property Address: Road Name � 11- ��" �'�`�au�s � '�u�►�t �e��. �u v�✓t le;�,�+ r>v� �3�`�1�'n n.,s
City/Zip (�.��e.c., a'taol� ; �c�. � c��.� e✓io�.
�
If in Subdivision provide information,as follows: �
�
Name: �
, . �
�
Section: Lot#: �
�
This is to certify that the information provided is conect to the best of my knowledge.I understand that any permit(s)issued hereafter aze
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 from this application. 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 owned
by to conduct all t�g�res as necessary to determine the site suitability.
DATE I-5��r1 SIGNATURE
Revised DCHD(06-96)
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J . . DAVIE COUNTY HEALTH DEPARTMENT
:� � ' - ' Environmental Health Section SECTION LOT
., ,
' SoiUSite Evaluation
APPLICANT'S NAME �T//9/ls�r DATE EVALUATED
� ��
PROPOSED FACILITY ,� PROPERTY SIZE_ V , O � �
SUBDIVISION ROAD NAME G�h��1.r L�i�G�dd j�
Water Supply: On-Site Well v- Community Public
Evaluation By: Auger Boring i/ 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 C�- G
Consistence T
Structure iG
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:_�f�
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-Tenace 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-Granular 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
DCFID(01-90)
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�� � � :- - � � �' �avie Coun �CeaCth �e artment �
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� � and.�-Come�-CeaCth�l.lgency
�nvironmentaC�Lealth Section
+ P.O.Box 848/210 Hosrrra�STFleEf . 4 '
1 M COURIER#09-40-06 I
� � � MOCKSVILLE,N.C.27028 � � �
� PNONE:(704)634-8760
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� February 14, 1997
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; John Waller �
' 1726 Brandon Farm Rd. .- `
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;
Clemmons, NC 27012
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Re: Site Evaluation/Williams Road
Tax Office PIHc �5778-79-3915
Dear Mr. Waller:
As requested, a representative.from this office visited' the
aforementioned.site on February 7. 1997. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to;be provisionally suitable for the
installation of an on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
� Sincerely, y
� �`
. ��.��������
Robert B. Hall, Jr., R.S. ,
Environmental Health Section
RH/wd � - �
Enclosurets)