312 Stroud Mill Rd DAVIE COUNTY HEALTH DEPARTMENT �'� ����'
L ! ' Environmental Health Section -3T�i�
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
� (336)751-87G0 �
IMPROVEMENT/OPERATION PERMIT
Account #: 990000798 Tax PIN/EH#: 4798-55-1336
Billed To: Joe Barkley Subdivision Info:
Reference Name: Joe Barkley Location/Address: Stroud Mili f2oad-27028
Proposed Facility: Residence Property Size: 5.5 Acres
ATC Number: 2212
**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 PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type 'I�.1�OMG #People�_ #Bedrooms 3 #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 ��QC'�� Type Water Supply In��.t..� Design Wastewater Flow(GPD) 'zi� Site: New�Repair❑
System Specifications: Tank Size�n00 GAL. Pump Tank GAL. Trench Width�lo�� Rock Depth 1Z� Linear Ft.3C`O�
Q�
other: I '�1 S�Q,►P�-r��•J �t� , l�.�ST4.� l��S 1 a•C.
Required Site Modifications/Conditions: ���LL O� GQ.ITOJ2�, K� QT �'z1�T � � F�o�n W�
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW :
FINISHED DE. ****P10TICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
t . 0 a m to • .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: 27�
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DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPART'MENT
Environmental Health Section
r.o.sog sasnio x�p���st��t
Mocksville,NC 27028
(336)751-8760
Account #: 990000798 Tax PIN/EH#: 479&55-1336
Billed To: Joe Barlcley Subdivision Info:
Reference Name: Jce Barkley Location/Address: Stroud Mill Road 27028
Proposed Facility: Residenc:e Property Size: 5.5 Acres
ATC Number: 2212
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 Sewag reatment and Disposal Systems). THIS
AUTHORIZATION FOR WAS TIO LID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa e: Date: j� ZC.
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
Di Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given peri f time.
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Septic System Installed By: I�'/��� � � �'�'�'�-
Environmental Health Specialist's Signatur : Date: ff
DCHD OS/99(Revised)
ENERGYUNITED ELECTRIC MEMBERSHIP CORPOR:ATION
I.�oe �)ac K �Gtr K(e�f hava requested EnergyUnited Electric.
Membership Corporation grant me perrnission to locate my septic:tank and lines extend onto the
EnergyUnited transmission right-of-way as recorded in my deed L fully understand. that
EnergyUnited may need to use this right-of=way to maintain theirpowerlines atany given time:I.
also understand that I must assume full responsibility for any damage that might occurto my tank
. or lines due to their right-of-way. I also must assume the understanding that EnergyUnited may
leave tracks on this right-of-way that they cannot be responsible.for.
I �D e ��a c K �O�r K I e_�l also lrnow that-when I sign this form I ,
understand that EnergyUnited EMC is not liable for any damage that might occur on this right-of=
way.
Signed By Property Owner
Date __��� � � � �/
STATE OF NORTH CAROLINA,COUNTY OF �Q�(1 ei _
I, ` i' n �• �r a Notary Public.for 1.?�Vi�
County,State of North Cazolina,do hereby certify that � )D e �J a C K �G�'K J
Personally appeazed before me this day and aclmowledged the due execution of the foregoing
instrument.
Witness my hand and official seal,this�day of OG'�DbU , 19 q9
My commission expires ,Z'j 2- �2 D�3
�•
No Public
_ ' 4 {� , arruuAllUN FUR SIIE EVALUATION/IMPROVEMEM PEflMIT&ATC . .
' �� Davle Couaty Health Deparbnent �
.' - � L Envi�nmen�/Hew/ifi Se�a6�on D � � � �YJ [�
��� � ��� G�I P.O. Hox 849/210 8ospits]. Strs�t
� .� ��r Mocksville, pc 2�o2e � • SEP 2 9 1999
OCT 2 5 tigg9 p����/ 1336)751-8760
/ T—
• S PLICATION CANNO? ffi PROC�BB�D VNLE88 ALL T RE �r tNTA1 HEALT �
RMAz=OTt . Reler to tihe II�E'ORMATION HULL�TIN �or instrua IE COUNTY •
�. �.,. � �. �.�.� � � �� �'' k ��t �.� ���e `�Ar.,� ,t��►x.�/� ` .
�� �... ��k'��Q� �a.. �. o — �� �j
cstr/ae.ti./a:p �r r�a r.t,r � �� a—�3 Y sa.s�a� rhas. D U — 4
Z. Naa. on p.sai!/Asc sr asrr.r.nt 11i.a 71bo.• -`
ltailiAq I1�ddsy�� CitY/sta�/Eip .
3. l►ppliaation Sor: �Sit� avaluat.ion 0 �mprov�t Bsrmit/7►sC � Soth
4. e�.t� tio s•s.iw: 0 Hous� � Mobile Soms O Busin�sa 0 taelSistxy O Oth�r
s. _� Rasid.na.: t Beople �J- ,_ � Bad�cooms � � Bathroams �
�l Di�hrasls�r 0 oarbaq� Dispo�al �ltashinq Naahi� 0 Haawnt/plm�bie�q O Euu�a!/lto plmbiaQ
6. t! !lwit���/Zndu�try/Oth�rs 8p�ai�Y tYP� � p�opl� f Biaka
� Ca�mod�� � 8how�r� � Vriaal� • l/at�r Cool�r�
_!' S'OO�DSERV=CE: � Saata $atimat�d 1Pat�r Osaq� cQauon. r� �r)
�. s'yp� o! Kat.�r suppiy: . 0 Couaty/City 1�, 1f�11. 0 Commuaity
e. Do yon anttcipate Addittona or eipauaiona of the facWty thia aystem ia intende�to rsrve? O Yas !D No �
uy�a,w�t cy�t
_ ***IMPORTANT"*"CWENTS MUSTGIDMPLETETHE REQUIRED PROPERTY INFORMATION REQUF.4TED
BEIAW. Eit6er a PLAT or 31TE PL�AN MllST BE Sl/8MITIED by the clknt wtt6 TNl3 APPIICATION.
Property Dimenstons: H G' L�s R+RITE DIREC'I10N3(irom Mockaville)to PROPERTY:
Taz O�ce PIN: � 7 S t't w� �e�t � . 7v�r� r I�h� �►�.
Property Addrea�: Road Name r�u� ,�� l � �c'l. �[� 1 1 e-F-f- a r ��-r�,,�c� �� I �
� City/Zip �� . �Y i v� t.J t4„� D r ►i'i ci 1.�"
If in a Snbdtvision provide informaHon,ts foilaws: Aer�s S -�t6 rr� �S'� r t�l� h���$� ov� �P`�.
Name: '�i r c! � b"'� v � 1-C �'f'. �Z 14t��eg .
Sec�i�a: Block: Lot: DAte ProPerty'Fla�eds �-
Thi�is to certify t6st t6e inlormaHon provided ia correct to the best oi my knan►ledge. I anderabnd t6�t any permit(a)
laaaed hereatter are aabject to aaspenaton or revocadon,lf t6e eite pisns or G►tended as�c6enge,oc lf the informeHon
aabmitte�l in this appllcaHon L�fuL�ttied or changed. I,also,anderstand tA�at I arrt responslble jor ap c6arget lncamed jrone
tbls appllcatlon. I,hereby,give consent to the Aathoriud Repreaenbitive of the Da te Connty Halth lkpartment
to enter apon above deacribed property located in Davie Coanty and mnttd by ��e �-C� +� (�
to conduct�U teating procedara as nec�aaary to determlae ths�ite�oitab .
DATE �— �� � q 9 SIGNA
THL4 AREA MAY BE USED FOR DRAWIIHG YOUR S1TE P (lncla e sll of the follo�ving: Eitating and p paeed
property 11nes and dLnenaiona, atractar�s, setbacics, �nd updc locstiona�
. �pLt,�.�.��..� ` 8ite Revialt Charge
� �a �a k� �' �, Datae�;
�: �.-�.
' ��PP,�� c�
m �
_ � ' � �.� .� Client NotiBcaHon Date:
� _ � �� �.
, � � �.
�,. � EHS:
��� ,�veu �a � �` G
. Accoant Na / a
�o�.. �-�-�7 � /D0�
Revi.ud DCHD(07/99) Invoiee Na
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:�...�.:
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. ...,, • DAVIE COUNTY HEALTH DEPARTMENT„
Environmental Health Section
� Soi]/Site Evaluation
APPLICANT INFORMATION; . ' � " , PROPERTY INFORMATION � •
Account #: 990000798 Tax PIN/EH#: 4798-55-1336
. Billed To: Joe Barkley " 8ubdivision lnfo � ,
;
Reference Name:�<Joe Barkley Location/Address: Stroud Mill Road-27028
• Proposed Facility: Residence Property Size: 5.5 Acres Date Evaluated: �D t� _
Water Supply: ` On-Site Well `� Community Public
Evaluation By: Auger Boring `� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition [,
Slo e% �
HORIZON I DEPTH O - (o '
Texture rou G�- C�
Consistence �SS S S
Structure CIL
Mineralo �; 1 ; : I
HORIZON II DEPTH - t CP — �
Texture rou C G
Consistence ; j (a '
Structure )<
Mineralo t : ► ; � : �
HORIZON III DEPTH ) - Z- -
Texture rou ��r C�
Consistence r
S Wcture
Mineralo ; ( I. � � F .
HORIZON IV DEPTH -i _L1
Texture rou �yc��
Consistence SS S
Structure (L
Mineralo � ; �
SOIL WETNESS
' RESTRICTIVE HORIZON .
� SAPROLITE s -
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE �
SITE CLASSIFICATION: EVALUATION BY: �--���)/a-K.:1 �
�
LONG-TERM ACCEPTANCE RATE: �'�J OTHER(S)PRESENT:
REMARKS: �� � C�v�TZ Q�cx t..�,,Z- �,r '
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
truct r
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
DC�ID OS/99(Revised) �
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17avie Gounty,�-fealth Z�eparrment
Envlrorrmenral,�fealth Sectton
ro�X s4s/no x��c�sc�t
Mocksville,NC 27028 '
I'hone: (336)751-8760
October 15, 1999
Mr. Joe Jack Barkley
187 Hayes Street
Harmony,NC 28634
� Re: Site Evaluation- �
5.5 Acre Tract/Stroud Mill Road
Tax PIN#: 4798-55-1336
Dear Mr. Barkley:
As requested, a representative from this offce visited the above site on October
15, 1999. Based on the inforn�ation 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,
Before a representative of this office will revisit the site to issue an Improvement
Pernut/Authorization to Construct the appropriate application must be completed in full
and submitted to this offce. The location of the facility the system is to serve must be
staked off. Due to the proximity of the existing power lines to the proposed house
location, written permission may be required from the power company to install a septic
system undemeath the lines.
If you have any questions, feel free to contact this office at (336)751-8760.
Sincerely,
JeffG. Beauchamp,RS.
Environmental Health Section
enc(s)