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134 Potters Ridge Dr Lot 1 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 �,, Account #: 990001592 Tax PIN/EH#: 5843-41-2948 Billed To: Madeline Sheeran Subdivision Info: Potters Ridge Lot#1 Reference Name: Location/Address: Potters Ridge-27028 _1 Pro osed Facility: Residence Property Size: see map (Z,5 ATC Number: 3047 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). 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: J�_ CERTIFICATE 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 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: G��%�U�1✓Yl., �r Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) . , DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section ' P.O.Boz 848/210 Hospital Street Mocicsville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001592 Tax PIN/EH#: 5843-41-2948 C.• n 1 Billed To: Madeline Sheeran Subdivision Info: Potters RidgeA Reference Name: Location/Address: Potters Ridge-27028 /� aa Proposed Facility: Residence Property Size: a2t{lets 12iai� 62 ATC Number: 3047 **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 l 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 Ae-1- #People #Bedrooms _ #Baths_L Dishwasher: Garbage Disposal:, Washing Machin 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 2r Repair❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width3C�Rock Depth 'Linear Ft. Other: ��-4&6- Required &-Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1: he day of installation. Telephone#is(336)751-8760.**** woo d �- r Environmental Health Specialist's Signature: 7�1Date: DCHD 05/99(Revised) e.SS r'- A TION.FOR SITE EVALUATION/IMPROVE6IEW PERMIT&ATC AWN ` Davie County Health Department EnVirnnmenta/Hea/tft.Sec[ion ' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENU��Qp�j\�0 (336)751-8760 V **IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to thhe/ INFORMATION BULLETIN for instructions. 1. Name to be Billed 14 ��'_ �l7 C �ontact Person Mailing Address s Home Phone City/State/ZIP �J usinesa Phone SO_"W 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 1 , House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: /# People # Bedrooms 4— # Bathrooms Dishwasher �bage Disposal ashing Machine U Basement/Plumbing 0 Baaement/No Plumbing 6. If Business/Industry/Other: Specify type People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: a County/City ❑ Well ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: _ 1M V4> WRITE DIRECTIONS(froip,MocMvillc)t6.-Pk i'EItTY: Tax Office PIN: # Property Address: Road Name_ » e. s city/Zip 611 ��, - C►-b� s So I t �J If in a Subdivision provide information,as follows: Name: a to-� �� d I3 �� R� pf 42/1 Section: Block: Lot: I�te Property Flagged: / 'U C�4 6'1 /T—f- This is to certify that the information provided is correct to the best of my knowled�e. I understand that any permit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred front this application. 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 to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lin s and dimensions' ' ' p )structures setbacks and septic locations). Site Revisit Charge i o IN Datc(s): Client Notification Date: EBS: L� R U u N Account No. Revised DCHD(07/9 Q2. �` /' v Invoice No. 0 `' JZ /L �a l�' ENVIRO1�'.IAE`lTAL HEALTH DAVIE COMITY �Tr4�L� 114/0 z / o? p Z � o wog, . ` ZW' X / O (T W En \ W -Pl. AC-C, �C-CC, W tT �J co N p O • r �� cw POTTERS R�� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001592 Tax PIN/EH#: 5843-41-2948 Billed To: Madeline Sheeran Subdivision Info: Potters Ridge Lot# 1 Reference Name: Location/Address: Potters Ridge-270288 Proposed Facility: Residence Property Size: see map Date Evaluated: A'. Water Supply: On-Site Well L/ Community Public Evaluation By: Auger Boring / Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Lt L Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH �! `� Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: d �� EVALUATION BY: 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-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-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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 05/99(Revised) J D k1rIE COUNTY HEALTH DEPARTMENT _..: ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 March 8, 2001 Madeline Sheeran 5200 Riverwest Road Lewisville,N.C. 27023 Re: Site Evaluation/Potters Ridge , Lot 1 Tax Office PIN: #5843 —41-2948 Dear Client(s): As requested, a representative from this office visited the aforementioned site on March 7, 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, Xoea&.ik4A. Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s) ;;• DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name '/��1�a7` S�7.2d D//'Gr/�/.�i,y'� Date '�3� 9'y N2 7 7 3 3 Location �i✓� _d�e Cf�P LLQ<'G'�.D� � i Subdivision Name No. Sec. or Block No. Lot Size S: 9 House Mobile Home _ Business _— Industry No. Bedrooms ��_— No. Baths __ No. in Family�-�2 _ Public Assembly Other Garbage Disposal YES ❑ NO ❑'' Specifications for Syste : /i Auto Dish Washer YES E] NO Z 4P/ y tO`•U Auto Wash Ma shine YES ['NO ❑ ` p, Type Water Supply *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. Gn If° 30143XY2 h� i Improvements permit by —A-11-1 — *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 — 2�!L4C-g&Aj S T t N\ Na - 45-fre FAc,J T Certificate of Com44ove 4eenlleed 6 Iq 'The signing of this certificate shall indicate that the system dhas 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 PERMIT p Davie County Health Department Environmental Health Section AUG - 6 193 P. O. Box 665 Mocksville,/N� 27028 _______________ 1. Application/Permit Requested By. Mailing Address SUd' /I / l�C�/�er1 du� ✓ c�•, �i,L's7�eti� SN��a, /l/C- �j(/� Home Phone c//r' ZZ 7- 97Business Phone 2. Name on Permit if Different than Above 4 3. Application/Permit for: ❑ General Evaluation eptic Tank Installation A�8b 4. System to Serve: ❑ House ❑ Mobile Home /" ;ll❑ Place of Public Assembly ❑ Business ❑ Industryy �❑ Other 5-9 ❑ Unknown 5. If house, mobile home: Subdivision l ' Section la" ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms " ❑ Washing Machine No. of Bathrooms �o ❑ 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 Lr� 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions 5 ac.ee-s Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2-1q-0 - 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:rm 1v "f/d nl ef ,/MVV v This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY Fand ECK ONE: ❑ 1. I OWN the property. �'2. I DO NOT OWN the property. ked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: ve consent to the authorized representative of the D vie ounty H alth 9epartment to enter upon above described cated in Davie County and owned by ,�j/�G► �Oj /' all testing procedures as necessary to determine said 's sui bility for a ground absorption sewage treatment al system. DATE SIGNATURE DCHD(12-90) DAVIE COUNTY HEALTH DEPARTMENT �p� ON—t�I Environmental Health Section Soil/Site Evaluation NAME [r�� U DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY ,1t/md,�' LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape positionSlope HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 4/sl Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE 77 CLASSIFICATION LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: /i;s EVALUATED BY: �Z/ 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-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-Finn 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-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 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(01-9o1 ■.■...............■■..■..■■.....■.......■■./■■■■..■..■.■■..■.■■■■ ........................... ................... .................. .................................................................. ■..■■■......■...■.■...■../■■■■■ ■■■■■■■■■■/■■■■■■■■■■■■■■■i■■■■■ iiiiiiiiiiiiiiiiiiiiiiisiiiiiiiiii=iiiiiiiiiiii■iiiiCiiiiiii'iiii=■ ■■.■.........■.......1�..........■..■..■...■.■1�:1■/■.. ■■■■■■■.■E■ ........................................■....... .■■■.■■■I.■.■■■.■ ........■...0■■..■....■■■..■■■■..■■■■u■ ■■■ ■■ n■■■■■ ■■■■■■.■ ...................................... ■■E.■■�■■ . ..■■■.■■■■■■■■ ...................................... ..■.. ..■.■.■■■■.■. ................................ ... 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BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)634.5985 August 11, 1993 Bill & Mary Ann Sweat 5320 Old Walkertown Rd. Winston-Salem, HC 27105 Re: Site Evaluation Pineville Road Dear Mr. & Mrs. Sweat: As requested, a representative from this office visited the aforementioned site on August 10, 1993. Based upon the information provided on the application for a site evaluation and after an evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr. , R.S. Environmental Health Section RH/wd Enclosures cc: George Wilson