1085 Williams Rd ` . . o DAVIE COUNTY ENVIRONMENTAL HEALTH �
, P.O.Box 848/210 Hospital Street � �\��
' Mocksville,NC 27028
� (336)753-6780/Fax#(336)753-1680 (�\ti
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REPAIR OPERATION PERMIT
Account #: 990002796 Tax PIN/EH#: 170000004501
Billed To: Melissa Long Subdivision Info: •
Address: 1085 Williams Road LoptioNAddress: 1085 Williams Road-27028
City: Advance property Size: 6.206
Reference Name: Melissa Long
Proposed Facility: Repair
: **NOTE**The issuance 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. -
System Type:�_S.T.Manufacturer C' Ti� Tank Date_� Tank Size �
Pump Tank Size_�! --��
System Installed By: ��l��p E.H.Specialist: Ir � (,l�(X,Date: ( �?��
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GPS Coordinate: '
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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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
,Ac�ount #: 990002796 r•�,r:,:;;.��..; ;� ,= '��x P`��lEH#: 170000004501 ..
�illec�To: Melissa Long :��:i:::;: .`S�abdi�ri�on lnfac .
Refer�E�ce Nan�e: Melissa Long �?:.:;:;, �:: P,..::€.�ca��r�lAddress; 1085 Williams�Rbad-27028 " ,
E'ropUs�;r! Facility: Repair ��r��-,.,� �,.:,� � ,��:: ,; ��e#�Siz�: 6.206 -
ATC NuE'itb2� 5836 ,` ;�:� ;��'::�' =� Site Type: ❑New�Repair ❑Expansion
**NOTE**This Authorization 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 AUTHORIZATION TO
CONSTRUCT IS VAL�FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change. �
Residential Specifications: #Bedrooms�#Bathrooms #People i' Basement� Basement plurnbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size . �(, Type of Water Supply: C,1�ounty/City ❑Well ❑Community Well
i � �y��
System Specifcations: Design Wastewater Flow(GPD)�� Tank Size � I� L.Pump Tank��%rJ�"J GAL.
1< << � 7 �
Trench Width� Ma�c.Trench Depth� Rock Dept�,__��_ Linear Ft. �pp` �
1 �
Site Modifications/Conditions/Other: ��,��R ��
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30— :30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist 1 ' Date: � � G�} �
DCHD 11/06(Revised)
. � . � •
Davie County Health Department
�Ps j� Environmental Health Section � ,.��, ,
�^ : � P.O. Box 848 �'�
C�
~ � ,5,, 210 Hospit��l Street • �
O U �'t Courier# : 09-40-06 "• '1911
Mocksville, NC 27028
Pl�one:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680
(Check One) Replacement Remodeling Reconnection
Name: ��.�, � ���I��js G� I�,Q�Q Phone Number q�� - �J7�O (Home)
MailingAddress: ��"�j_�����(,tMS �'�r (Work)
��\Q '�(S VI ���.���� Email Address:
Detailed Directions To Site:_ �Q't E — �(''� �C'� ,U(�t�l��t 1'l� ^ �'(^�
�[�l i 11 i�►^nS �� `�-h Q:r� `�� rn�1� � r1 ri�I�.f-
Property Address: ��� W l I I i Ct rl�,5 ►�l�• � ..L�� C����o� ���(7�
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ('� �p��, Type Of Facility: �I W
Date System Installed(Month/Date/Year):�;�� Number Of Bedrooms: � Number Of People: �
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? es ' No If Yes,Explain: �7CL-�e.�^ ��r�. ,p �.�e� �-y1�'�.�c S��'�-� (`; ��r��,
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: c 1��1��Q��►G�,e_ Number Of Bedrooms: � Number of People �
Pool Size: Garage Size: Other:
Requested By: ��t� �/�,�' Date Requested: �(�, �� � �
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
omments: �
Environmental Health Specialist " Date: ����p��Q//
,
*The signing of this form by the Environmental Health Staff i m 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:
� T�Account#: �I 7 (!' Invoice#:
� �,. �.p .�] � r/� ���
� ��,C� � DAVIE COUNTY HEALTH DEPARTMENT �j�� �
��� �, Environmental Health Secdon
�� ���y 1 � ^�d�3 PO Box 848%210 Hospital Street
� ,
. ..,��. , �. co
�ViRON�'nE`y�At r1 LT� Phone: (336)751-8760
p1V1EC0U�+
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION 0
�
Name: �c����,SC.l Lo na Phone Number: ���- ��G�t�� (Home)
Mailing Address: 1 I�j � �, 1 ti� G Y7l 5 �({ _ (Work)
A<i�,'��n c e; 1�_C . �o��
Detailed Directions To Site: L`i 1���i �l1� � i��r ���'�5 �[�. �o� t�'C�'Y1 I 1�f`��5 l�� 1�f� '�'[.lf Y1 ��P�-�- o fl
Far I�Q�,tihv �cj.�b�s�cl� F"�rl� ��eD����r�c���� rn;l�s r.n (e,�-1- �n(;I1;�t,^r►� Qc�
�-h�.� �'Z �r1 r�c;h}--.
Property Address: ���''�� �+���Gt'Yt_S R('�.
�-
Please Fill In The Following Information About The Existing Dwelling:
� �� � i
Name System Installed Under: m Q.at LO r1Q Type Of Dwelling: '
Date System Installed(Month/Day/Year):�'�� � 5� Number Of Bedrooms:�_Number Of People:�!
Is The Dwelling Currently Vacant? Yes f� No❑ If Yes, For How Long?�j�j'�-I15
� Any Known Problems?Yes❑ No C� If Yes, Explain:
PIease FilI In The Following Information About The New Dwelling:
,
Type Of Dwelling: `i;����f,<I P� Number Of Bedrooms: Number Of People: �
Rcquested By:� � Date Requested:� 10 _
(Signature) . �
For Environmental Health Office Use Only
A roved Disa roved ❑
PP PP
Comments:
Environmental Health Specialist
�� Date � l�'��
"The si�nutg of this form by the Environmental Health Staff is in no way intended,nor should be taken as a
�uarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.-
�3 3d � �4
Payment: Cash❑ Check' Mor�ey Order❑ # Amount: $ ��� Date: ���l,�–%
Paid By: _�1 - :JC f���i Received By: t�L""��'�'— _
Account #: ��.-- � 7 � �'� Invoice #: - `P r� �J
/
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�G , „ . . . . Yd
.�.� ' �,���� h , ' ; -� � a
� -" ` ,.'=� � ('' � DAVIE COUNTY HEALTH DEPARTMENT ' p-t �-� ��
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `��p
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems .����=�'�'s"v�� Permit` Number
Name_�[.[�L_���a'-'S'S�/�"���r��r�: ��"�/y'_ � Date ./ -/I� - ��.5� �� � g � C�
���/' r
Location -�j `���/ ./`�-.c� .,��,�,/;�/� ';/ �' `�/ ��/��- r F/ �� /-�j /i� /lr;,f
,!��� ��'
Subdivision Name Lot No. Sec. or Block Na
Lot Size���'S� House Mobile Home �_ Business __ Industry
No. Bedrooms �..�—.No. Baths �.__ No. in Family�_ Public Assembly Other
Garbage Disposal YES � NO [�'
Auto Dish Washer YES ❑ NO Q� S�cificati�s f�, Syst�m: „
�l'G'1iC�G: 1,�. �„/,1-��'��'
Auto Wash Ma^hine YES �' NO ❑ • '�v
Type Water Supply — ��1 ---- `-rU�� .�.��J,;,��
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
,.__..__�._.
�`
Improvements permit by _���L�
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by —1�� /��c,��l ��
D � '
�----- ��
�
_.�..__..e,__..--
!
� ,.� _ _/
Certificate of Completion � .�`' fi Date � ���S
'The signing of this certificate shall indicate that the system described above has been installed in compliance with '
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
, -„ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE IM�'�'•�>`'�.��;.���ti�d+
t ' f • Davie County Health Department � +
�� Environmental Health Section O��' � � ��`�`'}
l� P. O. Box 665
Mocksville, NC 27028 -�------ ------ �
, � `7���G1�-5�� ,�
1. Application/Permit Requested By 1�. �O �� �SS F�� �--0 �1Q�����
L
Mailing Address d3�M�Ii�n �� � Home Phone �d - �
1 v I�kS1/i � �(�_, �.0 . c�-7('��� Business Phone G�����o�'� ��
2. Name on Permit if Different than Above �`���ss���2��
3. Application for: �General Evaluation �eptic Tank Installation Permit
4. System to Serve: ❑ House C��fobile Home p Place of Public Assembiy
p Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot #
❑ BasemenUPlumbing
No. of People � ❑ BasemenUNo Plumbing
No. of Bedrooms Ga'Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: C�Y('ublic �D�gDd,,o�.`�-� p Private ❑ Community
�J�f 0
8. Property Dimensions � / / �« Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes [.�Vo
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: �b ��i i es e a s� o n l��I -�-u r r, � C'�►rl �O f k l7 i X�y
C C hurc l-� �2 c 1. 0 3 m � Ie 5 I S+l lar d �c�.� e�1 r�oc,d o�, I �e-�--l-V�� �I l �'c�.m �d-
-�i�r5� -�V�o S O�'Y Y�J h i�e- h o c_.t s�e o n '�� ►� �G In f ,
L�i��tic�-� CL-�
�2.�-a.-�y o��-c� �� B`�-� ��
C,Qic.Cl�- �:U/�/�`�2� b� - � ��v
!
�,%Z�I.�.�:�„`-- 8��-2.. � �
���
� '
This is to certify that the information provided is correct to the best of my knowl dge, and I understand I am responsible for all charges
incurred from this application. '
�alac� Iq�
ATE IGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPEFiTY
MUST CHECK ONE: ❑ 1. I OWN the property. � I DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by �c.l n►'1 i P�. L o r,a
to conduct all testing procedures as necessary to determine said site's suitabili or a ground absorption sewage treatment
and disposal system. _
� a ac� q - ` ` �,
DA E ' .. _ SIGNATURE
DCHD(1�93)
� � �^
� : - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME � DATE EVALUATED �o� ����
ADDRESS PROPERTY SIZE ��I��OJ'G ��
PROPOSED FACIILTY //�� �(�,�27+P LOCATION OF SITE l/1//��ii�r l/Z!/
Water Supply: On-Site Well Community Public `�
Evaluation By: AugerBoring �/ Pit Cut
FACTORS 1 2 3 4
Landsca e osition L ,L
Slo e 7. — — —
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH � � f 3 �
Texture rou � C`
Consistence �
Structure /c � l
Mineralo /.'/ /,'
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASS.LFICATION
LO�IG-TERM ACCEPTANCE RATE , ,:�
SITE CLASSIFICATION: � EVALUATED BY: � /C�/�
LDNG-TERM ACCEPTANCE RATE: � � OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge 5-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
�ICL-Silty <;lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-V��y 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
Structnre
�C-SYr.gle grain M-Massive CR-Crumb GR-Granular ABK-AnBular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mi neralo�y
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 w etness - Inches from land surface to free wate� 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(01-901
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(Davie Courrty .�lealtl�i (Deparlmerrt
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21O HOSPITAL STREET I P.O. BOX 665 .
MOCKSVILLE,N.C. 27028
PHONE:(704)834�5985
December 29, 1994
Jeffrey & Melissa Long
2s5 M�dison Rd.
Macksville, NC 270�8
Re: Site Evaluation/Williams Rd.
Dear Mr. & Mrs. Long:
As r,equested, a representative from this office visited the aforementioned
site on December �9, 1994. Based ��pon the information pr,ovided 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 systen.
If you have any questions, please feel fr•ee to contact this office.
5incerely, :
�������� .
Robert B. Hal l, Jr�. , R.S.
Environmental Health Section
RH/wd