118 Woodberry Trail . �
• _ ,
Da�ie County Health Department
��►s f� Environmental Health Section . ,
�� ;- � r.o. BoX s4s �
-� , ,
� , ,5,,, 210 Hospital 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: ��2 `��m� U'" `�Phone Number �"(L/7 Home
PS �331� 9�i ( )
Mailing Address: (Work)
Email Address:
D ai d Directions To Site: '�i' ��� � �?ie�- v � /� /� ���""
L �e N� � � a a 1
��7ov6o6 i�t7
Property Address: �! C� �c9 c,��.�✓' zr-/L�y 72/�i��. ' UG.I�s�� �YC.'-� ��•G.
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under•�/�2y Si/?}yJ�o� Type Of Facility: �'o�s�
Date System Installed(Month/Date/Year): '��0� Number Of Bedrooms:�Number Of People: 7
Is The Facility Currently Vacant? Yes � If Yes,For How Long?
Any Known Problems? Yes (�o� If Yes,Explain:
t_�
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: ,j�0l7.�9��(��IC�I NCJ Number Of Bedrooms:�Number of People
Pool Size: Garage Size: ���`�•�1(lZ'Other:✓`��li-�',� �jr�Qc, -
Requested By�� ���'���� Date Requested:�Z� �°Z
(Sig�e)
For Environmental Health Office Use Only
Approve Disapproved
Comments:
Environmental Health Specialist ;� �a, � Date: �
*The signing of this form by the Environmental Health Sta�' 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.
j Payment: Cash eck Money Order # �,�� Amount:$ � Date: � o�
Paid By: Received By: (Nv� ,
Account#: �rJ�Q Invoice#: ��
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� � r DAVIE COiJNTY HEALTH DEPARTMENT
Environmental Heaith Section
P.O.Boa 848/210 Hospital Street
� Mocksville,NC 27028
(33G)751-87G0
Account #: 990003540 Tax PIN/EH#: 5860-10-9062
Billed To: Gary Simpson Subdivision Inf.o:
Reference Name: Location/Address: Pamela Lane-27028
Proposed Facility Residence Property Size: 5 acres
ATC Number: 4024
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,Wastewate�Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS ,
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
j �j��/ s
Environmental Health Specialist's Signature: �G� Date: < /�6�
�� ,�
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation 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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Septic yste Installed y: L r f� � �� /�'�-
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Environmental He�R�S ecialis s Signa e : Date: � i
1�� ` I I -
DCHD OS/99(Revised)
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, � . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)75]-87G0
Account #: 990003540 Tax PIN/EH#: 5860-10-9062
Billed To: Gary Simpson Subdivision Info: %G8 W��d b e�l y, r���
Reference Name: Location/Address: - 8
Proposed Facility Residence Property Size: 5 acres
ATC Number: 4024
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**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). 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
/
Environmental Health S ecialist s Si ature: � � Date: �����
p ' � �� �.
CERTIITCATE OF COMPLETION
**NOTE** 'The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation 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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Septic yste Installed y: G r f � �� " �'�
Environmental He��S ecialis s Signa e: Date:
��� � ��
DCHD OS/99(Revised)
� DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section
� • P.O.Box 848/210 Hospital Street �� Y_yt, ��
Mocksville,NC 27028
(336)75]-87f►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003540 Tax PIN/EH#: 5860-10-9062
Billed To: Gary Simpson Subdivision Info:
Reference Name: Location/Address: Pamela Lane-27028
Proposed Facility Residence Property Size: 5 acres
ATC Number: 4024
**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). THLS
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: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply���,�]�` esign Wastewater Flow(GPD)� Site: New❑ Repair 0
�' ��
System Specifications: Tank Size JeI9aGAL. Pump Tank�GAL. Trench Widtlt� Rock Depth�_ Linear Ft.��
Other: Gs-` �to 7 S b
w ♦ t
�Cop#ed Systems may also�bQ ��
Required Site Modifications/Conditions:
I1�9PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF C►"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:(�0 p.m.to 1:30 p.m on th ay of installation. Telephone#is(33C►)751-8760.****
P�w�r � � � � ��-��� �� ��
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Environmental Health S ecialist's Si ature: � { Date: � ��
P �
DCHD OS/99(Revised)
� ' ' DAVIE COUNTY HEALTH DEPARTMENT
. ,� ',t_ • Environmental Health Section
' ' P.O.Boz 848/210 Hospital Street r J, ��� 5�0 �
' Mceksville,NC 27028
�0`
(336)75]-87C►0 '
IMPROVEMENT/OPERATION PERMIT
Account #: 990003540 Tax PIN/EH#: 5860-10-9062
Billed To: Gary Simpson Subdivision Info:
Reference Name: Location/Address: Pamela Lane-27028
Proposed Facility Residence Property Size: 5 acres
ATC Number: 4024
**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 I 1 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 ,T� #People � #Bedrooms� #Baths o�_
Dishwasher:� Garbage Disposal:� Washing Machine� Basement w/Plumbing:� Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��' Type Water Supply_��� Design Wastewater Flow(GPD) �� Site: New,� Repair❑
�
System Specifications: Tank Size`�GAL. Pump Tank GAL. Trench Width��''Rock Depth� Linear Ft.�b
Other:
Required Site Modifications/Conditions:
INIPROVEMENT/OPERATION PER1�11T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF(" 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(33()751-87C0.****
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Environmental Health Specialist's Signature: Date: ff y���
DCHD OS/99(Revised)
� . -
. - . • . DAVIE COiJNTY HEALTH DEPARTMENT
' Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87(►0
Account #: 990003540 Tax PIN/EH#: 5860-10-9062
Billed To: Gary Simpson Subdivision Info:
Reference Name: Location/Address: Pamela Lane-27028
Pr ert Size: 5 acres
ATC Number: 4024
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST 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 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: ��
CERTIFICATE OF COMPLETION
**NOTE** The 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.
Septic System Installed By:
Environmental Health Specialist's Signature: �' Date:
DCHD OS/99(Revised)
i
.� ��I� + ����� l Qj��zo�. �!i/����l�i!� /
� i� �-;r��-APPH R SITE EVALUATIUN/IMPROVEMENT PEAMIT&ATC .— / �-' V
' - . • � ` /
��-�-•����;'�" " . . Davle County Health Department /�
� � l.�AR 2 6 20a1 Envrronmenta/He+a/thSec�fon � �J � _ y�
. . Sox B48/210 Bospital Stxeeti ,� � V'�
Mockaville, NC 27028 • � �
Q�Vi'r,0',:FTITAL NFAL1t1 (336)751-8760 � �/�J��
D,'1VIECOUMY � �
***II�ORTANT*** THIS APBLICATION CANNOT BS PROGa88aD UNI.Lr88 ]1LL THS RaQUIRaD
INFOR�ATION IS pROVIDaD. Refer to th� 22IH"ORt�1TION BUI.L�TZN for instruatione.
� / ) �-q `� �
1. 11w co b. aill.e.�-a !A/ u�� �i'rl?.�D.�TI�V , co�.r.Roc r.r.on �Ir�1C��l� , `c. , c��
,,.t�� �... ����'�als����d ( ��2-i���) s�. �.
'2S(- o i O �
citir/atat../sxp�FQ�f`T Gv1v /7/, C a�'!IJ �!� su.iA.,. �on. �-tv�(.�-1
. lTaw on ?�sait/11TC i! Di!l�r�nt than 11bov�
ltailiaq I�ddr�a• '" � � ���Sa
jZP r�.s,[�..c s -�—�s-
3. �ii�►raon ffo=: ite avAl.uation 0 Improvem�ent 8ermit/ATC ❑ Both
i
a. e�.t.w to s•r.sa.: House ❑ Mobila Homa O Huaineea ❑ induatry 0 Oth�r
s. 2! Residenco: � Faopla ,y� � Bedrooms �� • Bathrooma �
Di�hxuh�r 0"Carbaq� Di�po�al Nuhinq Naohi� D'Ba�i�a!/plvabiny O Das�aant/tto pl�mbiaq
6. _! awi���/Indu�tsy/Oth�rt Sp�aity typ� � P�opl� i 81sk�
i Coa�od�� � BboM�r� } Orinale i �fwt,�r Cool�rs
IS a'OODSI:RV2CE: � 3eats lEstimated 1later Osaq� tvaiion. p.r a.Y)
7, Typ� ot xater supply: ❑ Cotuity/City �'"11�11 ❑ Coma�unity
e. Do you anticipate additiona or e:panstona of the fi�cWty this syatem is intended to aerv�? 0 Yea 0 No
If yea,w6at type?
***lMPORTANT**"CLIENTS MUST CbMPLETETHE REQ(lIRED PROPERTY INFORMATION REQUESTED
� BELOW. Elther�PLAT or SITE P1.AN MUS1'BE SUBMITTED by the dlent w�ith TH1S MPLICATION.
�',C,�sy
Property DImensions: ��5��. �i 7 X 7�/J(����- WRITE DIRECTIONS(trom Mock�ville)to PROPERTY:
X 3`(�i �`S�i�i�[ �3 5 � /�
TA:Ogice PQV: # ��(�� i o �i (� (�'�— ��..��, /5��'�4 S�''/t' l�'� �.l����J
PropertyAddres�: RoadName f /\�Y-�.� � (�w4.� It�-`t� '" L" d`'J �`t�w�4��'fO�'�"`�
� City/Zip 1' i o�,�.'.Sv���'e- lUC �7c1�.8�(,R e�2 ��' U•� (--�vc.�f►�J�w�
V in a Sabdiviaton provide InformaHon,aa followe: ��J.�� ` �1\ �O� ���e.i�v� ���
Name:
Sectlon: Block: Lot: Date Property Ftagged: 3� l� �!
Thl�is to certlty t6at the informatioa provtded L�correct to the beat of my kamvledge. I anderstand that any permit(s)
Isaacd hereAtter are subJect to ewpension or revocaHon,i!the ette pluns or lnteaded ase c6ange,or it t6e InformaHon
anbmitted In this appltcaHon i�faL�ified or chAnged. I,olso,anderstand fba!I am responslblt jor all charges lncumd jrom
tbls app!lcatlorr. I,6ereby,give conaent to t6e Aathorized Repreaentative of the vk C°�°ty HealW Depsrtment
to enter npon above deacribed property tocated in Davie Coanty and mvned br ��'�cv�o' �o n.> rJ�e 2
to condact all testing proccdares Aa ntcesasry to determin�the site taltubWty.
DATE � ���� � � SIGNA �
THIS AREA MAY BE USED FOR DR�►i�VIIVC YOUR STTE PLA.t`1(Inclune all of the follo�ving: EziaNng and propoeed
property Ilnes and dimenaiona, stractarea, setbacka, snd eeptic Iocallons).
Site Revistt Charge
'G,c� Date(s):
� �✓'� � ��� CUent NoNIIcstion Date:
►� � ��s
1 /���' EHS•
t-� '''���s � �.��,_ y��° s `
� ,,� (
� � �,5�t ����� Acconnt Na � '` � �
� y� ^� � '�_
RevLud DCHD(07/99) �.C�`�� `- Invoice Na � � ! �'',�a.c�
/ �
��� 3/�(n 5 �� � 3Syo
� � ' ���, -1. , _ . 1 l �
� �r� S-� << 7 ,:2s�-�- �
� ��'v o S�r/�1� X� •
'�fCT��`: ���./� N � �. �U Y�d
s
4'as �6 ''tib
i
20A) (70.14A) �cb /y��Y
3866 a 9817 p,si
x �TQ�N �e� �,��
8 ��i �i'p
q0
(73.024) (31.44 A)
4733 8765
.,c� ��s
� 3686
�
(4.63A)
9404 Y
S
im
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MSap
2.29A .
5191 ,�
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INDEXE ON 5860.03 �. �
. � - �
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'' _ F �K'.. �(/ .
� . � � � 3 � � �'
. � - G70 000 �i05 � �='° � � � � _
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• • � ,• DAVIE COUNTY HEALTH DEPARTMENT
.' ` �� . �_ • _ Environmental Health Section
� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001664 Tax PIN/EH #: 5860-10-9062
Billed To: Ira Simpson Subdivision Info:
Reference Name: Location/Address: Pamela Lane-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: �/-? -d��_
Water Supply: On-Site Well �` Community Public
Evaluation By: Auger Boring b/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition L L
Slo e% �
HORIZON I DEPTH " �{•�
Texture rou C L G-
Consistence
Stcvcture
Mineralo
HORIZON II DEPTH / '' ` "
Texture rou "
Consistence
Structure G/
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: !/'�l'���/� t/l�/fJ/�'fo'�C�l��v'�f' EVALUATION BY: �S�d✓`�
LONG-TERM ACCEPTANCE RATE: ,. 2 OTHER(S)PRESENT:
REMARKS: !J - : -/`��'� �k` �`C �✓►/
LEG ND
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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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 OS/99(Revised)
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k k D��II��0►U1VTY�I�LT�I D����tT��NT �
ENVIRONMENTAL NEALTH SECTION
P. O. Box 848/210 Hospital Street
Cou�ier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
Apri13, 2001
Ira Wayne Simpson
6065 Balsom Road
Pfafi�ovm,North Carolina 27040
Re: Site Evaluation/ Pamela Lane
Tax Office PIN: #5860-10-9062
Dear Client(s):
As requested, a representative from this offce visited the aforementioned site on
Apri12, 2001. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site,the site was found to be
provisionally suitable for the installation of a modified, oversized on-site sewage system
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
,��!���.��.
Robert B. Hall, Jr., RS.
Environmental Health Specialist
RH/di
Enclosure(s)