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361 Will Boone Rd . ' DAVIE COUNTY HEALTH DEPARTMENT � � Environmentai Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 Account #: 989900139 Tax PIN/EH#: 5746-99-2083 Billed To: Steve James Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility Residence Property Size: 125'x 568' ATC Number: 3883 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSUED 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 WASTEWAT T VALI -FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signature: ate: � CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. l 11� 1'J /1� �s �� \� S tic S tem Installed By: ��1 Y.J-'1'�l j � � _ eP YS � �,� �-�____.� Environmental Health Specialist's Signature: Date: / -C�� DCHD OS/99(Revised) , � DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section ^Q �` � `'� , � P.O.Boa 848/210 Hospital Street V `D �l,� � Mocksville,NC 27028 (33G)751-87C►0 IMPROVEMENT/OPERATION PERMIT Account #: 989900139 Tax PIN/EH#: 5746-99-2083 Billed To: Steve James Subdivision Info: Reference Name: Location/Address: Will Boone Road-27028 Proposed Facility Residence Property Size: 125'x 568' **NOTE�*�islm'rovement/ eration Permit DOES NOT authorize the construction ofa s tic tank P �p ep 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 M �`��,E #People #Bedrooms 3 #Baths L Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size (��'/"'��=5 Type Water Supply ��N� Design Wastewater Flow(GPD) �� Site: New�Repair� . ,� � System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench Width�' Rock Depth i2 Linear Ft.E�� Other: � 'd>�+�l�I(� �-�?� � Required Site Modifications/Conditions: � �e ��� �a�, ' �-t�' �Q� � �Qe..�? LI,,J�S INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFF'LUENT FILTER. RISER(S) IF G " BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department 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(33C►)751-8760.**** , I I�U X3�,"X-12" . I�p' � 1 c�c�' f��' @/ �� M ' ��`� ►z5 F,�.1 r 4�� � i Qt,J �— t'�. P��� '� k��U`-� ' F1s � 2g t� Env�ronmental Health Specialist's Signature: Date: DCHD OS/99(Revised) . . . .._.__� .`_. �' � , � � I�J � U V � , - APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER ATC � Davie County Health Department AUG 1 8 20Q4 Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ENVIRONMENTALHEALTH DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED IINI�ESS ALL TFiE REQUIRED INFORMATION IS PROVIDED. . Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Silled � (�r � �,/ � Contact Person S/cU�l�,�-¢S�f��e--�l�Qi�t� Mailing Addreas �(D g �(�/�/�'�/�/�� C�l /� Home Phone .7�ln� �I c7 '�� /�� City/State/ZIP /�/�d G�(Jfl��:/1/�- �����J Huainess Phone,/L,��`�D 7 "� 7��/ 2. Name on Permit/ATC if Diffarent than Above ���I� Mailing Address City/State/Zip �� 8" � " `r--s 3. Application For: IS Site Evaluation � Improvement�ermit/ATC � Both 4. syatem to service: ❑ House ��ile Home ❑ Business � Industry � Other 5. Type syatem requeated: IIYConventional ❑ conventional modified ❑ innovative 6. If Residence: # People � # Bedrooms _� # Bathrooms � ❑Dishwashar ❑Garbage Diaposal ,Icd�ashing Machine ❑Basement/Plumbing ❑Hasement/No Plumbing 7. If Susinesa/Induatry /Other: verify type # People # Sinks # Commodes Z # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallona per day) 8. xype of water aupply: �nty/City ❑ Well ❑ Community 9. no You anticipate additions or espansions of tlie facility tl�is system is intended to serve?0 Yes CcLD�o�I r,,. � : ;..: f : If ycs,�vhat type? ***IMPORTANT'�**CLIENTS MUST COMPLETE THG REQUIRED PROPGRTY INFORMATION REQULSTED BELOW. Either a PLAT or STTE PLAN MUST BE SUBA717'TED by the client with THIS APPLiCATION. / ! Property Dimensions: /��� ��4� � «'RITE DIRECTIONS(from Mocksvillc)to PROPERTY: Tax Officc PIN: # v � L�10'�go�d � � ���'��/�� �� �� � PropertyAddress: RoadName l,J'�\\�oC�..� Q�. Gv'���2Sd�� / l�i�� � 3��'�. � �7 City/Zip�i�4G� v . \\.._ �,� �i2i�� �� (/C . ��/�'� �tt�Yl� ��I p L`� --�.�1�— / � If in a Subdivision provide information,as follows: d� ��� � �C7 d �/ ' � � Name: Section: Block: Lot: Date Lome corners ilagged: �� � O� � / �/i�l �S o n L� c�.�.o,�.. Tl�is is to certify tliat tl�e information provided is correct to tl�e best of my knowledge. I understand tliat any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use cl�ange,or if the information submitted in this application is falsified or changed. I,nlso,u�iderstand tlrat I a�1i resparsible for al!cl�nrges irrcrrrred fronl [his applicatiar. I,hereby,give consent to the Autl�orized Representative of the Davie Couuty Health Department to cnter upon a6ovc described property located in Davic Coimty 1nd o�vned by to conduct all testing procedures as necessary to determiiie tl�e site suitabil' DAT� �'"�O �2 d Q 7 SIGNATURE ' THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of tlie follo�ving: �xisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Chargc Date(s): Client Notification Date: EHS: Sign given � � Account No. 9 9 0 0 3 �f Revised DCI-�D(OS/03 Invoice No. `7� `rr 9 � 0 ��� . o ��'`'`_� �:.��..- � c� �-^^-�"' ���� � �� �� �G C - � � . ,. � � ' DAVIE COUNTY HEALTH DEPARTMENT • � Environmental Health Section PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER RTIFICATION FOR DWELLING (Check O e) REPLA EMENT�REMODELING ❑ RECONNECTION o � � . Name: ��� G• c-�l I¢'/�'1� Phone Number: .�.3 6 �91^'� 'Z�/ (Home) Mailing Address: /l0�/ /!f/i/te �?�� �i� Q� . -� '�Zg �!�— ��� � (Work) OG/1 .• �e hJG. �,7� Z Detailed Directions To Site: ��� `� �' v � � l��G/i�O d�✓� `� ,/_��o�.'l�. `f�.�-�� � L��.`�— . Property Address: Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: Type Of Dwelling: Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People: Is T'he Dwelling Currently Vacant? Yes❑ No❑ If Yes,For How Long? Any Known Problems?Yes❑ No� If Yes,Explain: ' Please Fill In The Following Information About The New Dwelling: Type Of Dwelling//��'/� v� umber Of Bedrooms: Number Of People: a �� Requested By: Date Requested: ���Z��v� � ature) For Environmental Health Office Use Only . Approved ❑ Disapproved ❑ ' Comments: �, '� ' Environmental Health Specialist Date ' 'rI'he signulg 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❑ Check❑ Money Order� # Amount: $ Date: � Paid By: Received By: � Account #: Invoice #: . `,,,n c . . ��' � . � DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900139 Tax PIN/EH#: 5746-99-2083 Billed To: Steve James Subdivision Info: Reference Name: Location/Address: Will Boone Road-27�8 �� ,.,, { Proposed Facility: Residence Property Size: 125'x 568' Date Evaluated: U�7 Water Supply: On-Site Well Community Public ✓ Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 5 6 7 Landsca e osition .. Slo e% � HORIZON I DEPTH �- .-Z � 4� �' Texture rou � Consistence � � � � Structure Mineralo HORIZON II DEPTH l i' Texture rou i Consistence �r� � 4--�S Structure 1� Mineralo � HORIZON III DEPTH 2- ' (o� Texture rou � f $'� 4 C Consistence F F Structure - Mineralo HORIZON IV DEPTH � ' Texture rou Consistence Structure Mineralo " SOIL WETNESS RESTRICTIVE HORIZON ' SAPROLITE � CLASSIFIGATION LONG-TERM ACCEPTANCE RATE . �, SITE CLASSIFICATION: EVALUATIOI�1 B 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 wi[h chroma 2 or less Classification-S(suitable),PS(provisionally 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I � b �u� ' ��� ��r� .: $ � ����i � ��'�� ���� � ��" . ;� ,� r�;�!�� �� ������� ; ��� �� � ,�� � � �gy'.�p p ^',� � . m� i ��.i � atx '''y.�y � �;�i :4 i ��,#�' �p � � 5 �� b�� d i Y " i �t�� d d �� ms V�M� � } �.15,1a% i i� w,+�. . �"� k p ,� `,� i � � . ,� � i7 I I �.i rc �,m i n i�., u �� x t 1 � q a' i . < � ��� , F a�e� '�q X �' i�a� ��urUi "i �� 8 ��. �ip '`� �'� o u9 �'.fi �/"' . S� f . � i .�i ��aa ������� � $:«. i� ���� ��a�ll M �i #" �c� 4 s, �PI i °i �,�f �� ��r�R I 6��4� `� § ��i (�n ;' '�,. ";� li�"1�i ��..� �,�`�„�+Tw��� ,a� ��. ... � �i "� � �s� ir��„ h��k�'i�� i�: i i �'d . �4� ���i �' � ' 'a� � �. �,v � ��i � � � �� � � � fi ��� � : � � � �s ���a, � ��� ��b � ��; fw� T i � ��� �i�' � ��it���e;r� Ni� 0�,�N v..���' .� ��.,� ». .�•.�: �. ( � � �+,�ay��(� i�' �T �F �,h�� �s. �s�,� . ^.� I � t�'�i: �� ��*"�' S� ' �: � a�,a? ;��� � i � ul�(I�a� 'I � W" z� +. .���. '�#�a�... g :.;,,� :Ei�� % . ��'� � �P..` �d��L .�.-�ii��i�s�i�� d.�i�t� 6 i �� . ��. �!� rs .II�"N rtai r � r� ��� u� E , u � 'a 'e � �tio ;,,g`���pu��,'; �''i �' ° i �f. i 8`� '� '��^ �.t" �IG�' �m^ ''�.�� 3�i�„ �i f�i ,i : � �� � � , . �. , r:: ��' �� , ;:,. � :. , . _ � I ...,.: . :. .. .. ..� ... , : ��. ... �..'�'.._ � _�,. '�:. .. _.'. . a :; . � .�.�.- .... . � , . � _ -- -- � .' � � � , , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 / Fax: (336)751-8786 August 19, 2004 Steven James 169 Tunentine Church Rd Mocksville,NC 27028 Re: Site Evaluation- 1.34 Acre TractJWill Boone Rd Tax PIN#: 5746-99-2083 Dear Client(s): As requested, a representative from this office visited the above site August 19, 2004 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 and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally,please have the property corners located and flagged prior to making this request. If you have any questions, feel free to contact this office at 751-8760. Sincerely, � . Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s) 08/33/2004 21:19 336284d219 CAR�INA FINI5HING PAGE �3 � � . ' � APPt1CA710N WR SiiE EVAu�ATt IMPROYFJNFNi PERMIT�ATC ' Qavle Couety He ItN Doputm�nt ' • �nvlranments/ ed/d►Sec+don P.O. 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Typ�ot �raar supply� �ty/City O 1I�11 � Cos'm�uRity f. ao� asnsniyae• aaaseton. or e=p�adoos nf thc faclt tbf�syatom t�tatcnJed to tetvel O Yes TJ.A►e-- I If ycs,�rhat rype? � • ••'IMPORTi1NT'•'CI.IEPPi'S MUSTCOMPL6TB7N� It6QU/RE,D PitOfBA7Y MROltMAT10N AEQUESTED HELOW. 8lthersPl,ATarStTEPLANblUStdBSUdAJ7TBDb thecNent wlthTH1SAPPLICATION. / Proptrty DlmOnstoaet /�V��,��� WRI'�'6 p1REGT10NS(trom Maksvlite�to PROPERTY: T�z O(tlee PfN: � �7 4f�9 9�o g 3 ��-,Ji,;J���! �e� %o a �r � lr�%/6soi.l� /�,/� % 3� Pro et Atldran: Road Namc � � c��Zp � �a•i�s e,v�1T. ,�,ad.%.�o.y.� _..' o'a f....k'� It�n�Subd(.(aton provlde InforauUon,at follo�rs: ��o�'� � q'3,�'' /` n.roe: Sectian: $lotk: Lot: Di�te I�ome eoraerr iTa�eds TL41s to certify ihat thelntormativn prorided ts eorreet to tu� bl3�OC�Iir Ipl01YICdCl. I llfldtYS19A{��llll Ally Plfflll�(t� B�ued hereatter�n�ubJeet to au�peneion or rcvocatloa,lf the Ite pinu or Intepded wc cuabte.or If ths fnfermallon iubrtdtted ip tlils�pplkatloa(�faltltled 0�chfb=ed f,also,un r,t�ond�hatlarM�rrpontlblaJoi apCl�a�er i+�curradJYax fhfi eppJleaiJow. I,herab�,�Ive cowent to the Autl,ortzad Aep cntstive of the Davle Countr Health Deparlment to epter upoa abor¢dutrlbcd properq lot�ted!n Dar1e Coun and owotd by to conduci ale teaito��rocedure�as neceuary to drtermGu the Ue sultaDu DATE_L�"I� ��04� SICNATU THlS AItEA MAY DE USED FOR D12A'W7NG YOUR SITE (�nelude all of tht fopowln�: EsiatiaQ and proposc� propertr Una and dimeatloaa, ttrueturec, eetbaelu, and apti io¢oeio�u�. • Site Itedait Charee �,�c(.): ' Qlent NoURcaUon D�te: EI35: Sftn�ivea Account No. Rcvised DCND(OS103 Invoic¢No. 06�23/2004 21:19 3362844219 CAROLINA FINISHING PAGE 02 ` . � DAVIE COUNTY HEAL7 DEPARTMENT ' � Environmental He: th SecNom �o s�aa�mo x� i:s�s� Mockavtlle,NC 270Z8 Phone: (396}75 76t} QN-STTE V1iAS'I'EWATE RTIPI ATiON FOft DiNELLING (Check e} RBPLA MBNT�R6MC DSLINC,o RfiCONNECTtON a r „� Neme: • c.�IF one Nunnber: ,.,,��Jx�' ""�a ''•t�/ (Home) Qi�' / r � �G 3�' r2�+ � �f 91 Mailirtg Addresa: � � �_____I" 'Y (Work) .�-. Oc� .� � hJG. � � Detailed Directions To site:�'� ` • i � � G+�✓� '� d«�i� `4 � ��.e'� �il7�- G L�/'� Property Addreea: Pleaee Fill In The Following I:tforntatlon Abaut The E�cisHng Dwelling: Name Sysbem Iruatelled Under: . • Type Of Dwelling: Dabe 5yabem Instatled(Mnnth/Day/Yesr): Nv ber Of Hedroems:l..N�acber Clf People: Is The DweWng Cttrrently Vacant? Yea� No O If Yes,For� w Long? � Any Krwwn PrablemsT Yes 0 No D If Yes,Explain: Please FiII In The Follnwing InfomtaHon About ThE New DwetlIng: Type Of Dwelli�g�//' �G !� r'I ua�ber Of Bedroo � Number Of People: a� ( Rec�uegted By Da,1be Requeebed: g''���--=•t�`� /; tII�TEE� " � . For P.nvironmental Heal Office Use 4nly � Approved 0 I)isapproved 0 ' Coazments• Envlronmental Health Specialiat Dade ' "The sig�ning of tkia fo=m by the Tssvironmentsl Health Stmif fs is r,o way i�trnded,aos akouki ba tak�os a ' �uaraat�e�e(ext+ended ar if�ntted)that the an-sltP wsst�ewater sysa wt1I function pro ly for an given period of tla�e. Paya�nt Cash 0 Check 0 Mot►ey Ordar 0 � ,_.Amouat s Deibe- . Paid 8y: Received) y: .- Account A�• t�vnfce q: 4.:.:,?