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225 Seawall Trail • ,�. • -• DAVIE COUNTY HEALTH DEPARTMENT �, • ' Environmental Health Section `� P.O.Boa 848/210 Hospital Street �I�'�� Mocksville,NC 27028 (336)751-8760 Account #: 990003153 Tax PIN/EH#: 5778-79-7354 Billed To: Donald Seamon Subdivision Info: Reference Name: Location/Address: off baileys chapel-27028 Proposed Facility Residence Property Size: 7.612 acres � ATC Number: 4098 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONS RUCTION IS VALID FOR A PERIOD OF FIVE YE . Environmental Health Specialist's Signature: Date: �` CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovementJOperation 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: Qu�e,� �I�T� c��R , �► �� o��t -r�KS _----� ��_ � �� . � � � , T �. �'�W AIJ�.� 0 � � ;�� 12 � ti �i �)�Z �> 3 o y � 2b� � " . Q� �i�� '� Septic System Installed By: ��'J � Environmental Health Specialist's Signature: % ate: "r" � DCHD OS/99(Revised) � . DAVIE COUNTY ENVIRONMENTAL HEALTH ,�, � P.O.Box 848/210 Hospital Street _...._ .+. Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003153 Tax PIN/EH#: 5778-79-7354 Billed To: Donald Seamon Subdivision Info: Reference Name: Location/Address: off baileys chapel-27028 S��c�T,c� Proposed Facility: Residence Property Size: 7.612 acres ' ATC Number: 4098 Site Type:,�New ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A - Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms 3 #Bathrooms��#People � Basement.�Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �•�� Type of Water Supply: ❑County/City �ell ❑Community Well System Specifications: Design Wastewater Flow(GPD) -aoC�Tank Size �� GAL.Pump Tank ��'AL. „ 3�� ,� . Trench Width� � Max.Trench Depth Rock Depth �2 Linear Ft. f� Site Modifications/Conditions/Other: ��Qu— � �� ' ��""`�' �� —,� l c:�p' �,2t�c/1 I.�L�l� . 10' � 4�� 1..�•J�-� !S �_S i�.�I�Tlc�n1 �s..�3`� � Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 33 751-8760. A � L � � �v � 7 4` � a .�- ►°�`��rA'' ��, �. �� `t�STt� A5� �� c +�� . �'� �� c3�"� ,� � �, _ 1�Ta„s�+� IS � I � �r10 �Lj �.�� ` �2ad� v�IAL.L ,s� r /`W`w' . �,uo � '�, � ��I.��. I�jr t�.�.l.. M�a�lys .v "� �1;:'_1C?�,1 . . _ r�.qrST Qt��.. � As st�ted in �,5A N�AC 18A.1969(5� nccepted Systims r►iay also be use Environmental Health Specialis Date: �� 4,�� DCHD 11/06(Revised) - � • DAVIE COUNTY HEALTH DEPARTMENT S��L � : . � '. Environmental Health Section � � ,�,� 5 . P.O.Boa 848/210 Hospital Street � �, Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990003153 Tax PIN/EH#: 5778-79-7354 Billed To: Donald Seamon Subdivision Info: Reference Name: Location/Address: off baileys chapel-27028 Proposed Facility Residence Property Size: 7.612 acres ATC Number: 4098 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION 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 .S #Bedrooms y� #Baths ��S Dishwasher� Garbage Disposal: ❑ Washing Machine�Basement w/Plumbing: ❑ Basement/No Plumbin� Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste: � Lot Size Type Water Supply � � Design Wastewater Flow(GPD) �� Site: New❑ Repair❑ �. i System Specifications: Tank Size/�U�GAL. Pump Tank GAL. Trench Width ��i �Rock Depth_� Linear Ft,�� Other: Required Site Modifications/Conditions: INIPROVEMENT/OPERATION PERMIT,LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G"BELOW FINISHED G . * : Con � a r resentative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 9:30 a. .or 1• 0 p.m.to 1:3 p.m. llation. Telephone#i 3C►)75 ;8760.**** �1,�`LP ��?Ry �d O(�-� , P,,Sc,f��c,� � � - � ��e n �� ,�. � � vv - l� S � Environmental Health S ecialist's Si ature: � Date: �/ P b'� DCHD OS/99(Revised) 1 ` . " ,� , .�—j� �� . �'/ . � D C � ,� o � , , � � 'LiCAT10N C01j 517L•L-Vf1LUAT10N/lhiPItUVCAIL•Yf!'L'IIi191T S�l'CC Q///� I ApR � ?00 Davie Counfy Hea(fh Department "! 4 EnYrroanrenta/Healt/i Section . �ROIyM P•0. Box B�0/210 Ho�piL•al StrecL- v_ ��EfNTq�y�� Iioc}:3vi].le, PTC 2702II ��Nry � {33G)'/51-Q7G0 � ***IriPORTiINT*** TIiIS 1,PPLICATION C1INNOT DL PROC�SSLD UIdLLS5 ALL Z'iIL I:LQUIkLll • . I I2JFORMATION IS PROVIDED. Refor �o L-hn INI'OR2,JATION IIULL�TIN tor in.;C�:ucL'iont�. . • J 1. N�nc to be Dillcd ConL•acL- I'cr::on ___ ____ ____ bfailing Addre�� 7�, V . �x �?� Itoiuc Yl�onc 33 7 /0__^�p /t� City/Statc/ZIP !'7(�(.��il��-s� /f� �(3[J l'� Du�incna YhouQ 37J__,o2p�,� . .._. 2. Namo on Pcrmit/1►TC iE DifEercnt than l�bovc � �_____.__.,.... . . .. . Mailing Address City/SL•al•c/ZiPe� � ._.—.._..._.... ._._... . 7. Application For: L�Sitc �valuation � �TmprovemenL- Pe�.zuil/ATC ❑ UoL-L 4. system to service: Ll�f Housc � 2dobile Home ❑ IIusine�:s ❑ IndusL-ry ❑ OL-l�cr __ __ ___ ' '� . 5. Typc �y3tem zeque�ted: �Conventional ❑ conventional uiodificd ❑ innovaCivc G. If Residence: il Peoplc �_ U }3cdrooin� 3 II 15aLliroo,u:, ' � �.o� LrlDiahwaaher ❑Garbagc Diapoaal NJWnahing Diachino ODascmenL-/i�lwnbinJ L�'JD�::etnenL'/21u Ylwubiii� 7. IL Duaincas/Zndu�try /Othcr: vcrity Cypc !1 Pcople IF �ii�Y::: __ ___. . � Commodc� � Showcra 1f Urinaln Il t•raCcr Coolcru IF FOODSERVIC�: �� SeaL-n �IItimaCed Water U:;agc (gallon:� per day) �._.._�______. 8. Typc oP watcr aupply: ❑ County/City. �WcJ.l ❑ COI1llilUlllL"]� s. Do you anticipatc additions or espaiisious of(Uc facility tliis syS�CI111S IU�L'll(IC(I IU SCl'1'C?❑ Ycs ��u � Ir)'CS�11'll�<<)'j)C� . _ ***tAtl�ottr.��v1�**cL�Lrt�rs��tuszcantr�tLTL•riiL liLguurLv i�itoi�Lii•i•��i,vi�o�cn-i,t•i•ic�rr it�:�ui.5•ri:u �.�.') i3GLO�V. Isllhcra PLA7'orSIT�PL��N dlUSTIlESU/lAll77'ED by tl�c clicnc iti•illi'1'Illti AI'I�I,IG\'I'ION. 1'rojtcrl)'D1illC11S1UJ1S: �i l0 l � Q�1.�� lYR1TL•'ll11L�C1'lUi`(S(fruui 11•lurl:s��itic) (u t'1ZUl'l:l:'I'1': _ � � -��- �.__._ �e� t:�z orr«i'iN: �� ?�'- 7 s- � 3S y - �i�ce �O�l ��a t Proper[y Address: Road Naiuc � ��N ! �:� , c�cy�z;P ��1e o�,, T/�-n.�i�� If i�i a Subdivisioii providc infornialion,as f�llotivs: � ��_ � � �. .��-02 1�'auic: ' ' � � � �IJ�- '�" �'g� � �/ _ � Scc(iou: B1ocIt: Lot: Datc lioiuc corncrs tlabbcd:__a�� '��- �- � � '��' Tliis is to ccrtify tUat ilic iuformatiou providcd is corrcct to tlic bcst of uiy luiotiti•lcdbc. I uiidci•sland Wa(any per�uil(s) issucd licrcaftcr are svbjcct to suspcusion or revocation,if tlic sitc plaus�r ii�tc�idcd usc cL:uibc,ur if tl�o iufor,u:�ciou submi(tcd in tl�is applicatioti is f:ilsiticd or cliaiibcd. I,also,uiidcrslaur!lllrrtl uur rcapuira•iGlc fur uJ!clrrr�3�cs iircru•r�•d.jrr,ur . 11�is crp��licutiuir. I,hcrcb}�,biti•c couscut to ttic Autlinri:ccd Rcprescula(ivc of Uic 1)aric Cuu»(}'IlcalUi 1)cp:u•Uucnl tu cntcr upon aboti•c dcscribcd pruperty localcd in llavic Couuty aud�iti•uccJ by _________ tu cuuduct:III 105I111�Jli'OCC(�UI'l`S 1S!ll'CCSS:iry lo dctcrtiiinc llic si(c suitabilil�� Dn1•L � —' ? " � f SIGNA•rvzu; � � TIiIS AREA 117AY 13�USi;D TOR DRAWING YOUR SIT�PLAN(Iuclucic all uf Uic fullotiviub: I;xisliiib:uid propo�ccl proper�y lincs and dimciisiotis, structures, sctbacics, and scptic locations). � � ��.p Silc ltcvisi( Cluu•�;c � -_-{%� . llatc(s):— -- / �.: � _ � ��, �� Cliciit Nolilicalioii D:ilc: �'� ; /n J�` �us: ` � Si i� ivcn � � �h'� �� • ; Accouiit lYo. �� S 3 1, , � s s . . .�.�.c.. -��/� �., .,Ci� . '� ��,r rl • 338 , _ + �L� � N � � � 5.80A 3916 � � N � \\ � � ,t`, 44 � _, � �� -� � X, � � ^� �� %- 1 C.':Qt'r �� /� . 5.80A ' � � �� 3472 � � � V O O 7.61 A 7354 � � 0 ; � 323 1725 �°•� '•��.�� .: � . r � ; � ��R� � a S ` us"� 1 � a �� I`� �� [ 1 i.. . . r�i�}�� tYwrt,; "+ tw`�" �,i -� � � �`�,,.r E "`��a`�"�` ' � � � ' �a a ,�`�.Ji kr �, bm�� 1� L° '�d + � �"' ° ��,c � +Y� i �6W1€EY °H§,y�N�a� tif� tl '«s•ni' t �„"x2�ti � � 6RP�+z�� ,i. 1 � w� � U1CFy ��*pi9 /�p�. k ' a� �B'(IX�y ��'hl�i)Sµ�"! ` �( 4 . .5�6��s ,�i��"`!.L�. . I}'��'��(�Fu�� '�7��%�:' i G � �� e �: ,L � � X,xrv�yj� �}µ�F��'��=o�,��8�i"'��a" $�I`�1..''� ��k+'��I i i i� m °r��,�#i � :a�� .. r a •� . • r, h4�� L� ' ¢,a as:�,�"'��..:' � . .... . _":, . .,. � � �, i , _ r�.cre��? . .._ n.� . �'` .. . ._. �. � . .��.:. _ . : . �:...� . x.. .,.... , - #..:. � - .. . . . . . . .. .. .,�-:: �.-..... . . � . �...� 42.11 A 6504 \ _ _ _ , . ��w, , � DAVIE COUNTY HEALTH DEPART'MENT ' ' . • Environmental Health Section ' • ' . Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003153 Tax PIN/EH#: 5778-79-7354 Billed To: Donald Seamon Subdivision Infa � Reference Name: Location/Address: off baileys chapel-27028 Proposed Facility: Residence Property Size: 7.612 acres Date Evaluated: l7 d.� Water Supply: On-Site Well +� Community Public " Evaluation By: Auger Boring � Pit Cut �z�� FACTORS 1 2 3 4 5 6 7 Landsca osition L Slo e% � o � HORIZON I DEPTH r �� -r << "� Texture rou Consistence �' V Structure r Mineralo ! HORIZON II DEPTH ' <f '� � � ^ '� Texture rou C G Consistence /' Swcture / Mineralo r- .�r � — 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 L L � SITE CLASSIFICATION: � EVALUATION BY: 5'l G � . LONG-TERM ACCEPTANCE RATE: THER(S)PRESENT: REMARKS: �' - � � �� LEGE � • 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 day 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 MineraloQv 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) � • . . . • ' . _ � . a � . ► k<R�*+ '�*a.'T?"�.,�.+��' �+�.-r,}+��„+r--� *s+;,� -: rx'?7Q:.t'�;.;4 S""'''�.'°it.^ .�i a ".•=^•vy�1"� �+e + y��.^7 . r�� _"4 S a��.t d'xEv*``�r..:, r +%" �.r � A' �.�a cm. . �N�St"2 a.:. . ��'..�`�.��,�� __��:��.��I��CE}UNTY��iI�LT�:g��'�k�ThI�N`T=�i��r��:,��rr�,�; �� Environmentai Heaith Section � - P. O. Box 848/210 Hospital Street Courier 09-40-06 Mocksvilie, NC 27028 �+�+'�^�n .�, � ..�. �t�-.r � � c'"3 � i . .'�"'�-q'.°'�'�� k �J��f'�rs� �.F.ht�¢r, t(336)751 87602 Fte. r : .y � �.r€'"P�t xz "-' �a'�1� �.2yrY�+..�y�. . i� X�� 4.1 � q?7. �,}G%1 A4 �. k'+P � { 1 ,Gf?s a i ira 7 * 4 q 2�F 3 t v �""it��5 rY3� .. �� x ti...i ' �- `� '+' �+ � � „� '�5y4 L`ZY,�&i,-��,� yx.. 4N; '!;""#"i�v '.��.a '��Y��+ �f �r� �3 '�''s� t+ �+Y� "�£"�„us-�d" -�.a"H'S�'%r z # �:k n� ,b�. . i�, ��3 x� •r t�.-�i� �.. ^� � , s _e�, � � s" b ,s,`f4st��S � � )r :a,..'u �T- d +��a'�,"'"�v�� aw.� � .,i 1 ��s +�i. s i fl � ax r t t - s 3 r iMt : r-o-v .�`'�'y �. - "?t� c,._...`"�N`'.1 wa?a�-r'4'� �i �'k�'�i v�wy L ,� z c [ �:� F r �'-.,'�'�. �S�,r� t 1,r�.i ac S.��,x r,� a 't t��£�3 Y�'�'x`"?� . . . �i,..� ,�....o+a�r.,.��:�.4._.3�.J,,.,,..,r..., . . . .. .�r.e�...,a 5��?��3 t�tt�'.e.�.� �.�K.ri�i�.�:�r`,�:.k�a.*n..''�...�'�_.�.,�..n�,4�.v t„�:. � � May 12, 2004 Donald Seamon � • P.O.Box 341 � � Advance, NC 27006 . Re: Site Evaluation/ 7.612 acres off Bailey Chapel Road . Tax Office PIN: #5778-79-7354 Dear Client(s): � As requested, a representative from this office visited the aforementioned site on, Apri120;2004 on a 7.612 acre tract of land that you own off Bailey Chapel Road. The soil conditions on the part of this property along a ridge are provisionally suitable for a septic system,however, space is very limited and topography complex. It is our suggestion that you try to obtain more property along the ridge that adjoins Mr.Barnes. If you have questions please feel free to call this office. , Sincerely, /�a��. Robert B. Hall, Jr.,R.S. Environmental Health Specialist RBH/dlf . Enclosure(s) �� , "� _ � ��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)