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.
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S tic S tem Installed By: ��1 Y.J-'1'�l j � � _
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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.****
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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 ��'`'`_�
�:.��..-
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� � ' 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 suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD OS/99(Revised)
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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. Hox 848/210 ospital Stxa�t
Mocktv111o, NC 2T028
(336)�5 -8760
rtr,=yppRT11NT��'� TKIB 7�YLICA720N CJINNOT BS DRQCSSBYD VNLYSB �LL TS� REQQ=A8�
�ifORKI[TION I8 PROVIDm. Rfl�! t0 tbi Z?T7 TZaN SDLL�TIK tor in�truotions.
1. M�M co b� ylll�d • eowt�nt l�s�en�/f•//l�I•/YJ///��
uatlia4 �r��� �� /i�d � � 8aM YAoe� �fq" '!"l'��'o�g.�l
curlat.c./:ir oG 'f�/�7,,OG5�—�! +� swsA... �aoa..3.���y�/
a. �... oa ..�se/,zr t: uut.s.we w.n �nor•�C a
wilina iatr��� citrJ��se�/tiv .
�. Apylicaeion sor� f�sits zvalustiou O �sproo.�tst parmit/I►TC ❑ BotA
t. OY�t�� s�zvte�� O Soua• �oDil• Sotas � BwiAsi■ O Tadv�t.sy D oehar
' S. tyy� �71�ts t�Q+l��[�Q� W�eonr�atlowl ❑ eoa�� elonal swAlL1�0 ❑ 1��'+�r�
i. I! Auld�ne�� 11 FeoyL 7 H�dsoome �_ t DatLiooms a
�n1�Avsatar OCarbay� Di�posal 4JIfa�Alnp WCL� �OY�NaC/PiuwblaQ �AR�wat/No llw�b�e4
7. St �u�lwulIaAultry/Oth�N r�Cify typ� � � ! t�opl• • linka
� rp�pp�� Z � �ppr�r� * Orinsl• i Wtsr Lbal�rs
I! lOODSIAVZCi� � Ssat/ Xst� t�d Katsr II�•Q� (4�13on�y�s dar}
t. 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
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Neme: • c.�IF one Nunnber: ,.,,��Jx�' ""�a ''•t�/ (Home)
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Mailirtg Addresa: � � �_____I" 'Y (Work)
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Detailed Directions To site:�'� ` • i � � G+�✓� '� d«�i� `4
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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:
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