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418 Yadkin Valley Rd � � � ' DAVIE COUNTY ENVIRONMENTAL HEALTH ` � , , P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 REPAIR OPERATION PERMTT ,Acco�a�t �: 990005703 �"�x�IE�E.%�H#: 5872-39-3655 Bifle;d To: Mark Kelly �u�idi�i�iart lnfa: � Re��er�r�ce Rf�r��e: Addition-Permit - Loc�tiioniAd�r��s: 418 Yadkin Valley Rd-27006� - _ f�ropc�sei9 F��:i€ity: Residential-Addition � - Pfc��er�y�Si7e: . •5.011 Acres ��'��,��`TFie 66uance of this Operation Permit shall indicate the system described on the ATC 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. • . iSystem Type: S.T.Manufacturer �/� � r Tank Date Tank Size� Pump Tank Size System Installed By: � ' E.H. Specialist: /'+�il / llGlG1D"ate: 2 20 GPS Coordinate: �� l � � _ � � � �� 0 � � � �.�� , _ �- � ,� , � ��. � 8 � � �`� .� .M � �.� `t� � � � ��I �� V �_� ��d�l�� (Le� � T°,�y DCHD 11/06(Revised) , � , _ , DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 . REPAIR IMPROVEMENT PERMIT AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �kc�ount �: 990005703 Tax F'1N.%EH#: 5872-39-3655 �ifled T�: Mark Kelly Suk�di�ri�iorl info: � f�e:fer�r�ce �lani�: Addition-Permit LacationiAd�r��s: :418 Yadkin Valley Rd-27006' PropnsQd Facility: Residential-Addition Praper#y Size:� 5.011 Acres � ��*�`��This I�6Authorization to Construct(ATC)MUST 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 IP/AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat �the intended use change. ;, ____ ___ _ - Residential Specifications: #Bedrooms � #Bathrooms #People�Basement(�Basement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �C�'C. Type of Water Supply: ar,County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size�l�GAL.Pump Tank�� GAL. Trench Width�� Max.Trench]�epth��'� Rock Depth� Linear Ft. 'o��Z,5""/0 Site Modifications/Conditions/Other: ��a^ 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# 336 753-6780. ' `w � � C� �� .. ., . � H�rY q'•� , � � . f�° �►s� � ' � � , � � ' � � , , . v. .: , ..i. . , _ `� � f .� ' ' .� � � �t �` � ��,5 �'" ,� �ti . - e�s�`S �Rc�. t� Environmental Health Specialist � Date: 2� � DCHD }a/06(Revised) V`' n�w`��p� � ��3 . � ... } . . _ .._ . . ._ _ _ . .. . . � � , . ` ;I- . .. ,�/�.f� `_�� C� ~.i..;��, �, .��r .� '; , .,��, �" �� ' f` ,, ' �� f;�e�� dN 5�,�� -� , Davie County H�a1th Department ., . . �0�►s f� Environmental�Health Section ' „ . � �� . '`�1 P.o. BoX s4g . � C� # � ,�,5„ 210 Hospital Street O� �'t : Courier:# •09-40-Q��- ,�$ , �,.�sville,`�G�'��028�( # �'r�,t�jl�/ ' 1911 ' �� t�� -�.� ..i y' Phone:(336)-753-6780 ��ON-SITE ASTE�AT + � T.IFICATION F�:(33s>-�5�-lsao -�: (Check One) RepT �ement�r - Remodeling Reconnection 1 � ; Name:� � ��-��,�S� �C>�('�!�" '.Yf��? � � PhoneNumber � /�'5�� (Home) . • n � Mailing Address: �DY�\� �C) � � ; 3��- �.�� '��' (Work) ,, / � o_ � ��i��✓Vt� VV �' ..t1 '��^;�s�� ,,,� :'-. '�' EmailAddress:�'��.-�� L.� S�n�(�t�c��Ct: �G�''` , y _ ' .5", ' . ' �' " > �r ��•'^� {•,�.`��w 3,�, � �t�. ' 1 , � � Detailed Directions To Site: ►�e..�- a�- @.' �U I �u r I�r`�n� .o ��c� ..l.,I� ,�, -�c., r .� ►^� ,��,-, . ; � v�i yA�l IC;,�. �, I:�Q., P c� • N<Sz��" �=l�A`C-rnY C��2 ��;��, r� ��,�>�> r R-� �I�-�' . Property Address: �i� �i��r��'t t,r l/r; I(,��t, -;�!ue � �GbC � ��• 2C� -J�fl�� ; . Please Fill In The Following Information A�qoqt T�e� STING Facility: �P�vi�U 5f ��AC� {,;; � ' Name System Installed Under.�,�lti��'e ��;�„ ��+� Type Of Facility: �1�5 .c�n-�:'T.�- ��_�.��.�1 Date System Installed(Month/Date/Year): (� I 1 D� T � Number Of Bedrooms: � Number Of People: ,� � Is The Facility Currently Vacant? Yes No If Yes,For How Long? i--. Any Known Problems? Yes (No .?If Yes,Explain:� Please Fill In The Following Information Abou�The NEW Facility: /�� ,�. n�, _/ / U '� Type Of Facility:��1,:��j(Ji� � �j�C3(�UO/�i?,S Number Of Bedrooms:_�_Number of People Pool Size: Garage Size: Other: �( Requested B • ate Requested: `� �$ /� ature) � For Environmental Health Office Use Only (Approvea� . Disapproved Comments: 'f;(;�'(�(:ti1�It , �./ /�!%��J ��r �'r �{';ilS/(�lt ��lc'1Il(��,� � �� : Environmental�HealthSpecialist��,��(�((F(�� I��!ii'Q, � � Date: �� 7l`// *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Chec Money Order # Amount:$ U • Date: � �� - � !il/lc � Paid By: � (/(%/�[.� � Received By: li ,�( Account#: ��,� Invoice#: � j , ` � � ��l�1�� Gcl;�► n-� �, � .�1 '•�� ' ' . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mceksville,NC 27028 ' (336)751-8760 � Account #: 990004145 Tax PIN/EH#: 5872-39-8664.H ' Billed To: Erwin Stainback Subdivision Info: ,�� Reference Name: Location/Address: �Yadkin Valiey Road-27028 Proposed Facility: Residence Property Size: 5.011 acres ATC Number: 4525 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater Systern 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 O�ice 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 CONST UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �/ Date: �f��!�/� �d Q f�'''�'�--� v �.. k CERTIFICATE OF COMPLE'TI N � E '�."�� /-/� -� �'l�� `� **NOTE** The issuance of this Certificate of Complehon shall indicate the s tem described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 1�OA,�' ection .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that th�system will function satisfactorily for any given period of time. d \ % �_ 3 4 '�. � �j'� � 1 <<C G(,G� 'S�Tay�S R.� '� �'�� ,�--�—___——�i/ \ � C4 w ,��c� f � � �� \ � \ V� �— � � � � \ � , �dG�a� J � �..� � ,=�.---r ; tb� .3�� 3..'-i� l lG�s... R,S�P ��` a� �� Or�� Septic System Installed By: �19 < - �� c �'�' ;�C�/��'� �.`/� 'G' � Environmental Health Specialist's Signature C. ,r'��1�/' Date: DCHD OS/99(Revised) . � � , . : , , - . _ . DAVIE COiJNTY HEALTH DEPARTMENT • , Environmental Health Section ' P.O.Boa 848/210 Hospital Street Mocl�sville,NC 27028 � (33G)751-87G0 ,' Account #: 990004145 Tax PIN/EH #: 5872-39-8664.N ' Billed To: Erwin Stainback Subdivision tnfo: L�� Reference Name: Location/Address: �Yadkin Valley Road-27028 . Proposed Facility: Residence Property Size: 5.011 acres ATC Number: 4525 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CONST UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /`1"/ Date: ��/� �d Q f��--� � l _ K CERTIITCATE OF COMPLE�'I N � E '�.�'�� ,� � /-/� -g �G� �Q� `� **NOTE** T'he issuance ofthis Certificate ofComplehon shall mdicate the s tem described an ImprovemendOperation Permit has been installed in compliance with Article 11 of G.S.Chapter 1�OA�Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that th�e`system will function satisfactorily for any given period of time. � \ �^ 34 \ . \ "rr�c u.�LI.. 5��5 �.`� �� C�'�� s� �+s _ ,J�C7'��rt` �f \ � � ��<< �. \ d� � � `,� � � � ��K 7— � � � � ►�--j-- j . ca' � , �� J�Gc�s-- .3li"R�S�� ` o n �'� ��k Dr�� Septic System Installed By: �1� � �� < �c Environmental Health Specialist's Signature. �%�.� Date: .��G —�� DCHD OS/99(Revised) . � , , � : •� , DAVIE COLTNTY HEALTH DEPARTMENT . , . Environmental Health Section � , P.O.Boz 848/210 Hospital Street r� ' , Mocksville,NC 27028 ""; .�� (33G)751-87C►0 I�'� IMPROVEMENT/OPERATION PERMIT ' Account #: 990004145 Tax PIN/EH#: 5872-39-8664.H Billed To: Erwin Stainback Subdivision Info: Lf�� Reference Name: Location/Address: '33t Yadkin Valley Road-27028 � Proposed Facility: Residence Property Size: 5.011 acres ATC Number: 4525 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AIJTHOWZATION 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 STI'E 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:l� Basement w/Plumbing:.� Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �r�� Type Water Supply� Design Wastewater Flow(GPD) Site: New❑ Repair❑ ` � System Specifications: Tank Size/��GAL. Pump Tank GAL. Trench Widtt�� Rock Depth� Linear Ft� Other: � ..c..-,._i: ?:. .7 acceaied Systerns may also r,� use Required Site Modifications/Conditions: I1�'IPROVEI�IENT/OPERATION PERMI LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF C,"BELOW FINISt1ED CRADE. ****NOTICE ta a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 9:30 a.m. 0 1:0 p. .to 1:30 p.m. o the day of installation. Telephone#is(33C►)751-8760.**** /l�0 �! �f�t� �/�d,j, ��P Pce� �'�'Q � Environmental Health S ecialisYs Si ature: ' / Date: P � �� DCHD OS/99(Revised) Sep 29 d6 01 : 42p davie oount� envhealth 336 751 8796 p- 2 • . ' APPLICATION FOR :�ITE EVALUATION/IMF'IROVEME T� 'I�'c , :��avie County Aealfh Dci�artment �' � Enviro�:mental Health ;�'�Ct[Oit P.O. Box 848/210 HospitaA Street OCr j = Macicsville,NC 2702::3 , ��Q� , (336)751-8760/Fax (33�7r�1-8786 ¢'��R0�1;4� T , Application For: ❑ Site Evaluation/in�provement Permit �j Authorization To Construct(A ��L7�n�,��j'}j�� / ` U(� ' ***lMPORTAN7'***THIS APPLIC.41'[ON CANNOT BE PftOCESSED Ur::LESS ALL OF THE REQiJIRED INFORMATION IS PROVIDED. Ref:r to the INFORMATION BULLETl'.'1 for instructions, _ APPLICANT INFORMATION _ Name to be Billed � V�1�a� S� J�l��1 G�� Contz�ct Person �Q�1T� ST��U�G�� Silling Address � � et�v, '��nwl 6 A _ �Qtsts Phonc CC� 3 —(,'T — 3 7 City/State/ZIP � �� (�(� 'Lg _. Busiiiess Phone 33 -.-11—��] Namc on Pern�ibAT'C ifDijferent thar�Above _ Mailing Addre�s City/Stat::/Zip PROPERTY INFURMATION _ NOTE: A survey'plat or site plan mi�st:cccompany this application. �^31 (Perntit is valid f�o•r 60 on s w:c�site lan, no expiration with comp'�:te plat.) / Street Address_�A(�K,rl I Q K 0 � City � . Tvc P1N#�S 7 2 3 a ' �b�� Subdivision Name F { S� �� 5ec;ion/Lo # Lot S'ze a d( ReS Direc ions To Site — �p d � 0. �. • 5 R SYv t�� P � (�a � A 0�C�1 A e �/ Il�t 4, ctJ '�r- ' - Date House/Facility Comers,Flagged_. 17 • If the answer to any of the following qves':ions is"yes",suppotting documentat on must be attaclied. Are there any existing wastewater systems on the site? ❑Yes�No Docs the site contain jurisdictio�ial wetlands'? OYes No Are there any easements or right-��f-ways on the site? ClYes�1No Is the site subject to approval by.inother public ugency'? U Yes)j1No Will wastewater othnf ihan do�ne:;ric sewage be generated? OYes�INo IF RESIDENCE FILL OUT THE E��OX BELOW ��— #People 2 #Bedrooiiis #Bathrooms � Garden T'ub/Whirlpool �lYes ❑No _ Bascmcnt:�Yes ❑No Basement Plumbin�: �Yes ❑No _ IF NON-RESIDENCE FILL OUZ''['HE BOX BELOW Type of FacilityBnsiness TotaI Square Pootagc:of Building #People #5inks #Commodes #Showers # Urinals Estimated Water TJs:�ge(gallons per d:ry) (Attach docum::ntation of similar facility water consumption) FOODSERVICE ONLY: �f Seats Type system requested: �Conventional 7Accepted 17Tnnovative �Altcmai ivc ❑Olher Water Supply Type:�l County/City Watec ❑ Ncw Well O�xistir;�Wcll ❑ Corn�nunity Wcll Do you anticipate addicions oc expansions��f the faeility this system is intended lo scrve? ❑ Ves �1 No If yes,what type? _. . This is to certify that the information prov:ded on this application is true and co::rect to the best o£my Irnowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocatior.if the site is altered, the intended use changes,or if the information submitt�ed in this applic:�ri�?n is falsified or changed_ I underst�r�r1 that!arn responsi/�le far all charges incurre�l jrom this application. [hcrcby grant right of entry to the Authorized Represent��tive of the Davie County Health Department to conduct necessary inspections to determin�•compliance wit�j a�pl' able laws an�3.rules on the above clescri6ed property located in Davie o ty and wned by �RW'1?�► � 5 tIS AN STA+T�1�p t,��_. , � _— Site Revisit Charge Prope o er's or o��ncr's legal represe�ktative signature Date(s): �0 ��j�� Client Notification Date: Date EHS: Sign givcn flYes ❑No Ac�ount#S � /� Revised 2/06 Invoice# � • . � _,� ' • .. ' � ' � � �j'� � � _ � . .r: �►t-� �— . n� • ` . . F. .n� �s.s � r-� � n.v '1�O '. . �,s /. �e� . � • �� . 6-) . � � '� ` 78d �' _i . /' $ t E ] � � �� 776 I J / � - ,�`,._.. � 1��_a F-f � / � � �a!��. � K-? �'� � �� --__ �n� 00�� " �e�'o9 8 Q� p � 79A , .. dl.A- � E-1 ' a �SS �� . • Y � �M,i . i. I _ • � � . � a PP �_ �3 � �� , o-� °� ��'� � � . , asa , v-e ;� _ 0 - �� e�a . / ��' . � � . o-� / . � �ss '�� . -z � . �- / - e , i� .� . �v _ ��-- � �'1� � � � S �� . cz� �-i . o-z � -_ i / ' . �'� . � - • iT� � " � � . .-., . ' � �• - . / o� � v .� N �_ � . Q rl` 6 . / � µ-tQ . o-t . �i � �s eeb . B.. . �.i ae� A��V . /l . e� . __ � sr�.� / � � / . � . e/� o,� . -" �. / . �- � � � _ - ' �e p . Q . � , , �,� - . / � - oQ . ��o�.`"' •� � �� Q' � . az J � ' �e � ° �. __ . 25oa e / p � �0 � Q : IH� , �� P �� . 99J / �CO 'Q 839 � . . a �-a O R EE.! . . �7.7 �� • j� p:' + 'l/ 'T s � C . T / �. �A '� h(�� Ta� t�+rT ' _ � . PRGPEF�TY LII�E - / _ � � • � ~ PP � saa - PP \ OverYaead l.aa1 .Aq^v.lce P1�cr'. L/ne � � � � � - . • ( Ot�e Fb+re+• CoJ � / - � • ' IRQV STAKE . . . .30 ' �UKE� POwER EASEMENT � � �",m. ,� ' ' , :' . . � � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � �2 ', �" " " P.O.Boz 848/210 Hospital Street U-� , Mocksville,NC 27028 Y] a'3� . 1� (33G)75]-87(0 IMPROVEMENT/OPERATION PERMIT • Account #: 990002836 Tax PIN/EH#: 5872-39-8664 ' Billed To: W.Wayne Frye Subdivision Info: Reference Name: Kate Holmes Location/Address: Fred Bahnson Drive-27006 . Proposed Facility Residence Property Size: see map ATC Number: 3512 **NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 #Bedrooms �� #Baths �-`� Dishwashe� Garbage Disposal� Washing Machine� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size Type Water Supply L '� Design Wastewater Flow(GPD)�� Site: New�Repair 0 / ' y� c/ System Specifications: Tank Size/ d� GAL. Pump Tank GAL. Trench Widtt�� Rock Depth �� Linear Ft.�� Other: Required Site Modifications/Conditions: Ih1PROVEI�9ENT/OPERATION MIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G "BELOW FINISHED GRADE. ****N IC • tact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a. . 1:0 .m.to 130 p.m.on the day of installation. Telephone#is(33G)'751-87G0.**** � , ,� � a� �,� �s � �� F Environmental Health Specialist's Signature: � - / Date: �� / DCHD OS/99(Revised) ,° . .• • . . . DAVIE COUNTY HEALTH DEPARTMENT � 3 � � Environmental Health Section � ' 23 � . �, `�. - ., . . �fpC ,� D P.O.Boz 848/210 Hospital Street � , Mocksville,NC 27028 �j � ' (33G)751-87C►0 �L IMPROVEMENT/OPERATION PERMIT ' Account #: 990002836 Tax PIN/EH#: 5872-39-8664 � Billed To: W.Wayne Frye Subdivision Info: Reference Name: Location/Address: Fred Bahnson Drive-27006 • Proposed Facility: Residence Property Size: see map ATC Number: 3512 **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction ofa 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�` #Bedrooms� #Baths ..-�, Dishwasher:�Garbage Disposal:� Washing Machine:�� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size � � Type Water Supply (r� Design Wastewater Flow(GPD)-�� Site: New� Repair❑ / System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width� Rock Depth 1„Z Linear Ft.��/ Other: Required Site Modifications/Conditions: I1�IPROVEi�'IENT/OPERAT ON PER1�11T LAYOUT- APP FFLUENT FILTER. RISER(S) IF 6 "BELOW FINISIIED CRADE. ****NOT • Contact a representativ o e Davie County Health Departrnent for final inspection ofthis system between 8:30 a.m. o : .or •00 p.m.to 1:30 n the day of installation. Telephone#is(336)751-87G0.**** ��e9 �'h . �/ ��7�� 1�,� o��'s �� / �i- 1 �f D,r'S r�f� F s�t � Environmental Health Specialist's Signature: Date:,/"-�� DCHD OS/99(Revised) , � . , . . DAVIE COUNTY HEALTH DEPARTMENT . ' Environmental Health Section � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 ' (33G)751-87G0 � Account #: 990002836 Tax PIN/EH#: 5872-39-8664 Billed To: W.Wayne Frye Subdivision Info: Reference Name: Location/Address: Fred Bahnson Drive-27006 • Pro osed Facilit : Residence Pro ert Size: see ma ATC Number: 3512 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLTED 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 C NSTRUCTION IS VALID FOR A PEWOD OF FIVE YEARS. _% Environmental Health Specialist's Signature: Date: ,, C�RTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � • ' � Jure 37 03• 04:33p davia county envhealth 336 %S1 8786 p.2 �� .. � ., � � . � p � � � � . . APYUCATION FOII SlTE EYALUATION/lMPROYEAIFM i'Gtk11T&A]C Q � � ' Davie County Health Department ' ' Environmenta/HBa/d�Sedian � tl�� ,� � • �,� P.O. Sox 848/910 HoepiCal 8treet �UI�� Mocksville, NC 27018 � � (336)751-8760 F1VVl r, INr R21117TON IStP&TOVIDIDp�RetexN�CANI�YQT7SIFOpRDdAT ODT BULLBTIN for i�tru4tions. �AVIEC A��lH vl. uaw w b� s111�a ��6,r Fit+1E Ot'afA1J�11[Coatact Y�rioa,�Il�.Vl(A�.�A.II�_ � �.wiunQ xaa:.�, i�a � 4 f uo� r000. ��3-�2 L 4 ,� csh�lacac./ur .`.v !J G. ^��0'3-(_ awsn rnow 4�3• �'Z�'4 �3. Maw oa Aoznit/]1TC!t Diftarant tban 7�bov��_� � 7 � italliap 11ddr�as �J�I �� W�t�sMi City/stat�/iSP _. ��K��...L�._�...Z�da` ✓ - ,r]. Jppliucica ror� .�Sita Svaluatioa �� 1�Improvement Permit/ATC �IIoth �t. aystaa eo s�rvie�� Y�ous/� O 1Sobi1• Rouw O Sutiaeis O Iadustzy � Othcr �S. lyp� syat�m raQu�stad� C7 Cosvwtional Q coav�nClowl moditiad ❑ imovativa � � 1 .r6. ZL R�sidmeee � Paopl� � t Bodroams .�_ tf Dathrooms 7i � �'"' �Diahvuh�r OGarbaq� Diiy;aal �xaahSaQ IsachSa� �Saaoaaat/YlunYing �aasomvno/No Dlu+ubing 7. IL Dusiwss/Iadustry/Oeh�rc v�rity Cyp� i Pooyl� t 81ak� f Cosmod�� I 3Aowra ' t IIriaala ! Nataz Coolora TT p00DSE3NICEi # Seat� Eatimated Water IIsaQs IOalion� ynr�iqy) • ��. �yp� oL wt�r wyply� i4 COIIUty/C�.ty � ❑ W011 � Conmtunity �. uo you aactciyac. aa�tsons or czpaustout of Uic fadUty Uils s��stcur Ls tuccudcd to sc:rvc?0�ca 0"�u v Il7et,�v4at typc? "'lAfPO��:Sf�YT`t'�LIE�' COAIPLETCTI�E XL•'QUlK�EDI'ItOP�IYfYINFOItMA7'IONIZIiQUCSI'I:D 9 DELOW. tqieraPi.ATorSITEPI.A fUSTBBSUDhII7TEDbylhedlcat�rilu'ftiISAPPLICATtON. �°;�y �i'roperty Dimensious: WKi'fE DlltECl'IONS(f�uw hluclariUc)�u 1'ItUPEIYI'1': �p� �V�,u�vyJ.L�✓ � �o "rax orr�rur: a Z-3 a`�4 �-r � ..�3-- � _ _ __ . _ �o T.cFo � ra m . �roputy Address: Road Name ' �. — — - - — t�i r' 80 � TL��T 3�� V� c�cr�a— �-o Y/�du.i�f� If in�Subdivision pruvidc jpfurma:ion.as follows: �� '['j{.r-x/ (?��/.E.r- rr.��: �i4hY..�,�J4�-�•.� � SccUoa: Block: Lot: atc uoa�c corucr�A1��cd: � l . -- �L �� { Ki�-ti.T'd �d�TG O w� et�N'r Thls Ls to eertify that lhe Information providcd b eorrect to tLc bcst of my kuotirlcdre. I uuJcrslauJ l��t auy pcn�ul(�) issucJ 4creaffer are sabJcet to suspcysJon or revocatton,lf thc ttte plaus or Intended usc d�ange,or tf Ihe Informatlou �.I u y T Yezio�..To :u6nuttcd io ikis appUtation is fakitic:d or chanecd I,also,uadars�wiJf/rat I vui�aspoustblc jur u!!c/ivncr uuurrr�f jruw �-„r .� �� tlits appilcarlan. I,hcrcby,glve eousent to t�e Authortzcd Rcprescntative ot tUc Dav c C�ounty I.iguli! llcparlmcul ��""' � lo entcr upon abovc dcscr(bcd proper�y loea�ed!n Davic Couaty aaci owucd by /�/��-` +t��titES,,,, ._ __,, L�SC-swErGj" � lo coaduct all testinp proccJures as nrcessary to deterwine tl�c slte su� tli �. L/DATE ��Z'f I�� --SICNATURE� ` , Ti�1S AREA MAY BE USED FOR D.ItAWINC XOUR S1TE PLAN(Iucludc aU ot t6o follotirtn�t fizistiur apJ proputud properly lina aad dlmeatlons,struciur�s,sctbacks, aad upUc IocaUons� Silc Revisit CLar�o , Dutc(s): . Cticut[�IoUIIr•rUon llau: EliS: SI�o�ivw Aecount No. �-.�' a / VD �a--('�'� v3 &evised D Sf0.3 � ' inveicc 1Vo. �� '� . � �b �• �-��.,.., SITE Z be FRED BAHNSON FARMINGTON o RD, a TOWNSHIP }�. i q/4 ww�b� PP. KINDERTON g01 VILLAGE' \ / N 87-52-38 E Bart B, Bshnson ; , 70.76' kvn D. B. f 92 a t P. 18 3 1 \ REFERENCE D A V I E PO/^M COUNTY _ ---�Pp•�N g 4-3 5- 10 E l20 at p.114 _— - Power L�"°�- --�- ' Iron to Iron er\ \ S 34-07-00 E 60' 0. EASEI T C.IN -�— E 2 9 1. 6 ' g 0, Total 700. 00' WER C _ PP. 8.4_35- 3 2 5• \ RoW 30 ! DYT�— N \ PO1NB� 5 2 4. 0 8' Iron to iron \ y .� cn � V �.� IPP` E: cn .� `\ \ �,-a erg' p�Power�-rl 8 4- 36- 10 E—T ` E a • o Iron } 0 Iront o` ENt 2 a q \ 7.4 5' 5 8 6. 9 0' Total E _ ERE K E 5 S E A✓- E M 500 0 I�• 1�� \ ; \ , a 6 EGRE55 �I u� EI N G K E S S. / �. , 1�40� A� FL IN ? F b15q 0 A �" , ►� O � ` �� PA�/F� 00—�F �� 1016 1 1 b l T �f T a mCli ��\��r .� o 50- � � A �Z `c / p ACMES , Q "� dor, �s F �3A. � 'r w b N a,Lr�e N a36g. AC 11/2 Sty. ,per F N 31-� Frame '�! o `G' `�F A6.� �� \ tg O � iron at 1 ^° X470 /1�', 3� asp► TRACT A 0 1 \, $ Cd / a' Ino,at �� q 6� y 5.059 AC N 24'1 W ,� / N a b cv /� 22 Beech 1 y v � 152.34 Q / TRACT A 8 .167 AC � -F � � j -S 26-33-50 C) 7oa60' 60, l6' 410. 7) Toto/ 4Ae �� 1g o. q 6. / 3 50. 55 Iron to Iron PROPERTY ADDRESS: ca 4 -29-,40 W 6a 18' 473 FRED BAHNSON ROAD , 318 53 6. 6 7' ADVANCE. NC, 27006 (iti 81.0 u S 61 6 3/ ti^ -4 /�� B/aakar B. Strand 20 4 /j�jD. B. 3331 jvt P. 668 6Q,s o ��/ S26-33-54 ?, 100. 64' -4 O� !,y 169- 93 Total / -4138. g0' 31.03' 00 38 `�?>. 348- 02' 5 17. 9 5' i( �_�_ S 83-3 6- 17 W. \`\\ O IRON FOUND 3 14 saki Steel Pin Na// Co/in Hopk/ns � \\\�\ � 0 so' soo' 200' D. B. 3 0 9 s t P. 111 \\\ SCALE: 1"= 100' • IRON PLACED '1"O.D. GaN. Pepe � \�\ 1 GENERAL NOTES SURVEY F O R Q — ALL: CIH, ROADS, DRIVEWAYS, POWER LINES, AND MOUSE LOCATIONS KATE H. HOLMES ARE FRGMAND ARE INTEGRAL TO TN/5 BOUNDARY SURI/PY/MAP. THF GREE K6 SHOhfN ARE LOCATED AGGURA7FL.Y WHEN THEY ARE W/TH/N 50' ( OF THE BOUNDARY LINES Showing The Partition Of That Property Presently NORTH CAROLINA. FORSYTH COUNTY `�� — 77-ElNTEF.'IORGREEK LOCA TlON55, ANDTIE LAKE ARE PLOTTmFROMDATA Recorded In Deed Book 198 at Page 207 At The �\\`��CA.9 %, �0INTAX AND/ORGUAVHAPS Davie County Register Of Deeds Office I certify that an I surveyed the property �.\`•c\`..•••..Ro /'� — THE Sob YEAR FLOOD PLAIN/5 PLOTTED FROM DAVE COUNTY TAX MAP5 AND IS FARMINGTON TOWNSHIP D A V I B COUNTY N. C. shown hereon that the error of closure is 1 / 50,000+%��oQ;.•'t�68S/o'•..01 NOT CERTIFIED TO BE CORRECT 3Y TH15 5URVEYOR that the boundaries not surveyed are shown as dashed o + •ti lines plotted from information found in Davie County_2.4� �r:�= — THE 5I/1BLdEGT PROPERTY GURR__NMY HA5 AC-CE-55 TO A PUBLIC ROAD VIA FRED SURVEYED B Y: W A Y N E NORTON SHEET OF Tax Moos• that this moo was prepared in accordance = 14 41 ;= BAHNSOM DRIVE(r -Y YADK/N VALLEY ROAD),A PIRNATE ROAD W/THA �•W H• LAND SURVEYOR SURVEY with G.S. 47-30 as amended. = S r 4r. - 60 RIGHT-Or—WAY, RECORDED-IN DB .114 AT P. 375, THE 50JMERN END OF DRAWN BY: 3450 York Road MI7WSS MY HOC AAV SEAL THIS DAY OF .KNE 2003. �� '�'yO O.••?� K W,H. COMPLETED: �,,..�� WHICH Wi45 SUBSEGIUEN7LY 2�r'tLIGNED WITH THE AFFECTED PURTION BE/N6 '� •. SURv:• RECORDED Winston-Salem, •'••••••• REVISIONS Ph. 336-765-7872 MAP NO. PROFESSIONAL LAND SURVEYOR -" YN E I►i► `` — 7TE fie5TERN R16HT-OF-WAY' I.NE G)F YADKIN VALLEY ROAD l5 AL50 THE 1�57F7?lJ E-Mail: whorton 0 rr.com B01WARY OF THE 5U3LEGT FWV=ERTY,AND 15 RECORDED IN L2.8. 6_5 AT P. 512 'POPEP T Y x .-3 7f Air-- --� � ►� 5�:' O D S - x733 �Z?f A H-2T\I`T / %�0 � 01 70.3 / 773 �- eH-1 �_ x732 / 73.E x 76.0 X76 0 x 725 / ix x 77b 1.7 x K-2 /77 9 � 1_-X n EIL J-1 UO ' x E-I -' 665 kx 80 x FF 1143 - x 95b n / ~ x 852 = x D-z i � J / /. =r'• -f . .L— ��s 87.083.3 ��i •y x -3 i / r ` O D J r X A x C-2/ / ♦ 763 � x A- 0` O z N-1 Q 0 /o x� i• ' 287., �' � np QST / 60 f Ile. 8 �I �' c /xO vJ x8-7 x96.1 / 963 93.7 / x 80b 1 % / ♦/ / / p ♦ i x 83 92B / x IN a x 0-e x 8-3 29(s 999 . x14 9 d 0 / 83.9x2 .T O /�� !p Q 729 Rj a x 99.7 (p Q x aa.1 x �- _"`-"�_ x 00 x eo.f TOAD LIMIT g'A � ti .. PAOPERTY L7W LO )p — PP PP _ Overhead Local Service PbMer Line � / l OL*e Power Co.1 .30 ' DUKE- POWEP EASEMENT LO MON STAKE — — — — — — ( QEARED ) BENCH MARK ELEV-100.00 TOP PI / 295.52 ^ � ': ' DAVIE COUNTY HEALTH DEPARTMENT � ' �. ' � Environmental Health Section , _ � ` � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002836 Tax PIN/EH#: 5872-39-8664 Billed To: W.Wayne Frye Subdivision Info: � Reference Name: Location/Address: Fred Bahnson Drive-27006 � Proposed Facility: Residence Property Size: see map Date Evaluated: �—/�d`� Water Supply; On-Site Well Community Public � Evaluation By: Auger Boring ✓ 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 �{ Y�� t Texture rou � Consistence Structure � / / 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: �l�i�I 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 p(astic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloav 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-Inc es from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(•uitable),PS(provisionally suitable),U(unsuitable) 1 � LTAR-Long-ted L�,ice rate-gal/day/ft2 _ - - - - ,- - �accep y,� � evised) � � . �