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239 Towery RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street 4, Mocksville, NC 27028 t a i (336)751-8760 1 i' IMPROVEMENT/OPERATION PERMIT l Account #: 990002498 Tax PIN/EH #: 5727-76-1262 Billed To: Ed & Malissa Godbey Subdivision Info: Reference Name: Proposed Facility: Residence Location/Address:, Towry Road -27028 Property Size: 3.8 acres ATC Number: 3328 **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 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 s- #People Ll #Bedrooms #Baths Dishwasher: Ell" Garbage Disposal: ❑ Washing Machine: l2r-11- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 3•9AC ZS Type Water Supply (24'T -Y Design Wastewater Flow (GPD) FHCO Site: New 0" Repair ❑ System Specifications: Tank Size 10CC)GAL. Pump Tank GAL. Trench Width 3t;' Rock Depth Linear Ft. ��Ol Other: `'fs'(�lri o� ��x��! / SSI q r,L LI�LS 9 c7. C. rw l�✓. Required Site Modifications/Conditions: /N.S%gLi- &V GA 1oti2 i ;o �G�" L t-tiJi t4A/L=S IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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)751-8760.**** -* "X l L -"J "i —Ix-' i ri 41 �tJ�� M��•j LW L CA Aftox • iso S Environmental Health Specialist's Signature:r' U2 O DCHD 05/99 (Revised) ��• 1t,1U� Iej DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Account #: 990002498 Billed To: Ed & Malissa Godbey Reference Name: racmiv: Kesioence ATC Number: 3328 P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5727-76-1262 Subdivision Info: Location/Address: Towry Road -27028 bize: S.rs acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION W **NOTE** This Authorization for Wastewater System Construction MUST 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTE ON ON IS ALID FOR A PERIOD OF ;7 YEARS. Environmental Health Specialist's Signature. Date: /Z/ O; CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall has been installed in compliance with Article I 1 of C Disposal Systems," but shall in NO WAY be taken a given period of time. Septic System Installed By: an, described on Improvement/Operation Permit Section .1900 "Sewage Treatment and he system will function satisfactorily for any Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) 11uw u. uc Il:ama davie counts envheelth 336 751 8786 P•9 APPUCATION POR SITE F.VALVATIONAMMOVFMENT PVItMIT dr ATC-�f'-a►7,C'P �~ - t? 2— • • �O /I �' 1' David county Healthgor, He -( /"',/� Ertviroementrl althth SSeection 1 Mueb.illa. NC I7C28 (7041,f'i6760 —IMPpRfaNT"•••,TNISAIrMICATiONCANNOT Sig PROC8 MUNLM ALLTHE REQUIRED INFORMATION to PADVIDBD. I. Name to be 9illcd A * 1 j �&y Cpnlacl Prlcnn �. pa MeillnjAddtbs , 1 �.r TtaD N&wrl a CilylSragef ip "ed, 14 i ar- la y Butinan phone �3�e''�i'htiL-9ssi 1 ' 6 Z Nsntlow►emti✓ATCifDtRtonrtbanAbevc Mallin Addrtrs j"/ y ° f: Cioy/S1utl,Cip 3. Apprrcmien For " "Ieblte Evaluation Q Improvement Permh 6 ATC Z) Both 6. System to Serve: I' Howe O MobilCHome Other S. IIff RRetideaer. d People -,I-- o Bedfoome �-S _ d 8achrogrMt / Dishouher a Cwbage Disposal 'wa►bus Mucrua .21-Ga.rnid"Mumbms 0 Gusemem/No Plumbing 0 9 6. It 8mlieelalather: SPeelfy type 6 People a Sinks 6 Commode, 6 Showere 0 Urlamis 6 Wuurcootets If Foodlervico: 6 Snags Pattwnalad Mtata Usage Igallotu pv dayy ;lfJ 7. Type of watrt supply: C°vmyjCjjY] r well Ci Comrourky E. Do you 61196Pate additions of repaasions of oho facility thin .ywin Is Inlonded to serve' O Vex .a' -No Irytc, wbm type? PlowirrYiN RMATIom RE vioxv: see 1 RTANT - A n AT OPTMR r xopgRTY MU9T is SUdMI]TED WITH TIM APPLICATION. rMtreM Dtmeiteiont: I W"M DIRECTIONS (front .S�ir�'i I Meeker M) TO PIton/,RTV: Tui 0fuse PSN: 6 yL� F 1 owQ r roperry neer. Old Nama 1 It in SubdivWee proviso Inform6rinn. w. foflnwa; a 1lr�i j 1 / Section;• lot 0: TMs Is to c>;rtify Mal the infonnali0n provided is correct to the bag tit my knowktlge, l usidustattd that any pmail(s) is.wd hereafter on lmb)act to tmspension or revocation. if the file plena Or intended we change, or if the information wbethtM In this appticatios as J -`✓y falsHled or ebae/ed. I. alae_ undenland that I am responsible for all Chanes ineumd from Mui spplicalon. 1, hereby. fir -c consent to �^ • S r the Authertsed ReprueolOve of the Davit Comply Health Depari end to enter opal above described ptoperty, Ioceted in Dote Caunly and owned by 2)Qq j, f.- b"V to coaduq an mune pmeedurea { c J as necessary io determine the pts sitto ility. DATE 2 0 S1tiNAT(ikL Revised DM (06-96) Y Li Lot - 4 1 u oa Ado r ti APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section P. O. Box 848 Mucksvilic, NC 27028 (704) 8760 ""IMPORTANT"" .THIS APPLICATION CANNOT OF PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Contact Person t u Mailing Address 854 1 /4rr J -:Z -g loo Home Phone 52kZ,--909-Z:E" City/Statemp k1ArkS1►1 % tjc--7-I,aZ.i Business Phone 336^�'7L 6tf� 2. Name on Permit/ATC if Different than Above Mailing Address City/Statc/"7_ip 3- Application For./Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: ^ House O Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms _-_,.3- # Bathrooms 71--5 u Dishwasher C3 Garbage Disposal Washing Machine -01—Basement/PlumbingC1Basetnent/No Plumbing 6. ,If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals it Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. 'type of water supply: County/City 'Z`Wcll ❑ Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ,�No If yes, what type? PROPERTY INFORMATION REQUIRED: "* IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Acap''t 1 WRITE DIRECTIONS (from �,�,�.�,. 7--U-1 Z ., (P2- 1 Mocksville) TO PROPERTY: Tax Office PIN:15� 1 t2 ci�w perty Add ss: oad Name 1 I 1 • If in Subdivision provide information, as follows; t 1 v Name: 1 ti 1 Section: Lot #: 1 - 1 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are 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 J /� and owned by 004A'�/t _ �I . /r+N to conduct all testing procedures as necessary to determine the site suitability. DATE -( Z SIGNATURE 4-7 Revised DCHD (06-96) a,4 Co C6 "S �P DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section,, Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 9900024?3 Tax PIN/EH #: 5727-76-1262 Billed To: Ed & Malissa Godbey Subdivision Info: Reference Name: Location/Address: Towry Road -27028 Proposed Facility: Residence Property Size: 3.8 acres Date Evaluated: Water Supply: On -Site Well / Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % o HORIZON I DEPTH ©- (o r- M ILl Texture group Consistence TrS Structure k Mineralogy( / HORIZON II DEPTH (p • Z - Texture group Consistence Structure Mineralogy HORIZON III DEPTH 727 _q Texture group ,_} Consistence gS Structure S Li Mineralogyj HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 03 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: n.3 EVALUATION BY:��5zA�Ae_P OTHER(S) PRESENT: REMARKS: c M n L%'u ' 6 ¢%_kyL %`4 IA?p e +. ' r"� •l b.-" (--(42 � � Qtu c 2 L q 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 - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 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 - gal/day/ft2 DCHD 05/99 (Revised) No N -- a — e L nwH Bf7F : T T aft T n nnL� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336) 751-8760 / Fax: (336) 751-8786 November 19, 2002 Ed and Melissa Godbey C/o Swicegood Wall McDaniel Realtors 854 Valley Road, Suite 100 Mocksville, NC 27028 Re: Site Evaluation - 3.967 Acre Tract/Towery Road Tax PIN#: 5727-76-1262 Dear Mr. And Mrs. Godbey: As requested, a representative from this office visited the above site on November 18, 2002 to perform a site evaluation. Based on 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. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization 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, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp, R. Environmental Health Section Enc(s)