219 White Dove Lane Lot 8Account #: 990003605
Billed To: Paul Churchill
Reference Name:
ATC Number: 4070
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
01z/q
Tax PIN/EH #: 5820-64-7656 PC
Subdivision Info: White Dove Acres Lot # 8
Location/Address: White Dove Lane -27028
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 CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: lywl Date: ,h /P s7—
W 3 bd✓aom
CERTIFICATE OF COMPLETION
aff
**NOTE** The issu�6f this Certite of Completion shall indicate the system desc�d 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.
LA42
Septic System Instal eAd
Environmental Health Specialist's Signature : Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
t Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 S
IMPROVEMENT/OPERATION PERMIT
-z/9
Account #: 990003605 Tax PIN/EH #: 5820-64-7656 PC
Billed To: Paul Churchill Subdivision Info: White Dove Acres Lot # 8
Reference Name: Location/Address: White Dove Lane -27028
Proposed Facility _Residence Property Size: 5.040 acres
ATC Number: 4070
**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). 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 #People_ #Bedrooms #Baths `f
Dishwasher: e Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type
#People #People/Shift #Seats
Industrial Waste:
El/�
Lot Size Type Water Supply
C o
Design Wastewater Flow (GPD) 0
Site: New M' Repair ❑
System Specifications: Tank Size/jGAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width Rock Depth --a Linear Ft.
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 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
R /o (vl
(C (` do
.. P
Environmental Health Specialist's Signature: /y, �/ Dater—�D Os� rG
DCHD 05/99 (Revised)
/J� J APPLICATIO FORSTE EVALUATION/IMPROVEMENT PE
/ J Davie County Health Department u
J_ % EnvironmentaiHealth Section
//y
i .0. Box 848/210 Hospital Stree APR 2 7 2005
Mocksville, NC 27028 L
(336)751-8760
EI "RONMENTAL 14rA In,
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL D
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. )
l'LU KLr e ,Yl e
1. Name
lee"
ed
Mailing Address q/ Home hone 33L / ` Gc // Contact ,Pe son y�C� c
oC �� (7' j P
City/State/ZIP S LL JXa�r n It— /� Bim= Phone t� /0 --
2.
J
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation Ximprovement Permit/ATC ❑ Both
4. system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People o2 # Bedrooms ;� # Bathrooms_
ODishwasher ®Garbage Disposal lashing Machine ❑Basement/Plumbing dBasement/No Plumbing
7. If Business/Industry /other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
S. Type of water supply: 0 County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes fd No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client witli THIS APPLICATION.
Property Dimensions: �� WRITE DI ECTIONS (from M villc) to PROPERTY:
Tax Office PIN: it
Property Address: Road Name C'c' +` '��� ` ✓e
City/Zip
If in a Subdivision provide information, as follows:
Name: ✓ e
Section: Block: Lot: Date home corners flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
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 an) responsible for all charges incurred frons
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 conductaIll tteo th gg procedures as necessary to determine the site suitability.
DATE%o�%/ OS SIGNATURE `'� �s�� ✓( iUiiCAr�O
TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Sign given
Revised DCIID (05/03
Datc(s):
Client Notification Date:
EHS:
Account No. e 0
Invoice No. ---I'2
t 1PERS� Pg•
P �,-[ BfloK 6 1 1
1 P
t Vol 1
1 1 1 k.Ot 1 1
1 1 t,01 15 1 1 1
LOT 66�'3
. ' _ . , ...,.,�. .. ; t" t ; 110•%? •
��•1g
192 11Q.00
t 8.
1
0.L__-- ..' ./'' '� 111.97
gp•111.99
'79 43
AREA = 5.040' CRE MSEL
ID 19
•.
1EL P • NA 85 ,� ••''' l6 Ls L4
� .••: .•.
S4W
/974
c
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & TC SFp
Davie County Health Department 30
EnvimmnenAVHea/th Section 43
P.O. Box 848/210 Hospital Street �4�`�Otiil9
. Mock (336 8760
1751N7028
M
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS ,P/�ROOJVIDED. Refer/to the INFORMATION BULLETIN for instructions.
1. Name to be Billed WL&q /C c ye- S Contact Person
Mailing Address YO 4& „1 �[� Home Phone
City/State/ZIP ,Cl�Ql SIL 1 /Q �, �� Q -6� Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Pennit/ATC ❑ Both
4. System to Service: �ouse ❑ Mobile Honie ❑ Business ❑ Industry ❑ Other
5. Type system requested: Conventional ❑ conventional modified ❑ innovative
6. If Residence: It People 'Z�' It Bedrooms # Bathrooms _Nl*�'_
Dishwasher []Garbage Disposal VW ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type It People It Sinks
4' —.
It Commodes It Showers # Urinals tt Water Coolers
IF FOODSERVICE:. # Seats Estimated Water Usage (gallons per day) _
8. Type of water suppiy:XCounty/City ❑ Well ❑ Community
9. Do you anticipate Tditions or expansions of the facility this systeui is intended to serve? ❑ Yes XN0
_S
If yes, what type?
***IMPORTANT ** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the elicit with THIS APPLICATION.
Property Dimensions:, en-- "7,0
Tax Office PIN: #JCS by - --;� (0S
Property Address: Road Name �v V( J
City/zip Yy)r kS�t ►1 'kq
If in a Subdivision provide information, as follows:
Namc: �Jb die LC--y-e;
Section: Block: Lot: _
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
k1e,
Date liome corners flagged: d
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use cliange, or if the information
subtnitted in this application is falsified or changed. I, also, understand that I ani responsiblefor all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth 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 J A 6 ZO 3 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Cil UI -4-- tx,C
Sign given
Revised DCHD 05/03
0 SS SLS �C.
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. y
Invoice No. ��
Turmov SUKP=YIIiG C031PANY
127 -LIBERTY CHURCH FMAD
MOCKSVILLE, KC. 27028
(704) 492-3616
50' EASEMENT
8 9
7
11
;EMEW 12
6 13
io
MAP SHOWING DMSION OF:
WHITE DOVE ACRES
MAY 12, 1997
REVISED: JULY 21, 1997
300 150 0 300 600 900
SCALE IN FEET
24128--1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990002939
Billed To: Michale Graves
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
PROPERTY INFORMATION
Tax PIN/EH #: 5820-64-7656
Subdivision Info: White Dove Acres Lot # 8
Location/Address: White Dove Lane -27028
Property Size: see map Date Evaluated: Z9-1-6_3
Community
Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1 2 " 4 5 6 7
Landscape position
.L
Sloe %
/
HORIZON I DEPTH
e6
Texture groupf
L°
Consistence
Structure
Mineralogy
HORIZON II DEPTH
ii
Texture groupG
G
Consistence
v •,
Structure
14'-' J•
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:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:� L
OTHER(S) PRESENT:
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)
October 3, 2003
Michale C. Graves
248 Allen Road
Mocksville,NC 27028
Re: Site Evaluation/ White Dove Lane
Tax Office Pin : #5820-64-7656
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on
October 1 , 2003. 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 an 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,
A4144 & 6A1041 -A.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/df
• '� APPLICATION FOR SITE EVALUATIONAMPROVE ET -!-C
—,
' Davie County Health Department I
Environmental Health Section
P.O. Box 848 OCT I 01997 '
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1
Name to be Billed
Mailing Address r b
City/State/Zip Y' [ fit" (-ta � 4 l) Q- c; z;q
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person P 1 LXX
Home Phone n 4- -7 X 9 x
City/State/Zip
3. Application For: t<Site Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: ` House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People #Bedrooms # Bathrooms Dishwasher. Garbage Disposal
VWashing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [ ] County/City ItA Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes A No
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERT INFORMATION REQUIRED:*** IMPORTANT ***)&=&W OF THE PROPERTY MUST BE
_ 3 -- �% , D + SUBMITTED WITH THIS APPLICATION.
r grty imensions: ��• - WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
/C i
R(Iffice PIN��
Property Address: Road Dame ( �►Ls�. `�•l.;tl L-(�QJ��`� ) ►L>�y��
City/Zip y yv; `kt)
If in Subdivision provide information, as follows: ! -
Name: —A)ht h-, i4w Aa
9 ,
Section: Lot #: ;
This is to certify that the information provided is correct to the best of my knowledge. 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 from this application. I, hereby, give consent to the Authorized
Representative of the Davie Copnty Health Department to enter upon above described property located in Davie County and owned
by = to ccojndduct-all testi g roro�dur s necessary to determine the site suitability.
DATE [b g `1-) SIGNATUREC0C�-� � 7 /�l
Revised DCHD (06-96)
THIS AREA AIAY 13E USED FOR DRAIVING YOUR SITE PLAN:
eS Lt7U�
TUMMM SUiIP ING COMPANY
127 -LIBERTY CHURCH ROAD
MOCKSVILLF, KC. 27028
C 704) 49?-,_Kl f%
5
SD`'D
y
3
50' EASEMENT
6
7
13
12
/ -'\50' EASEMENT
9
11
5dL
10
MAP SHOWING DMSION OF:
WHITE DOVE .ACRES
MAY 12, 1997
REVISED: JULY 21, 1997
300 150 0 300 600
SCALE IN FEET
JOB NUMBEPc 241 iH�-... y
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME SArA PAL,-
PROPOSED
AL —
PROPOSED FACILITY H DSS`_
SUBDIVISION w wl y - AC S
Water Supply: On -Site Well
Community,
Evaluation By: Auger Boring Pit
SECTION I LOT
DATE EVALUATED
PROPERTY SIZE ,, S. W�C ea -
ROAD NAME W\\ Y Q4j7
Public
Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
D - Z
0-:2-7-
- 2ZTexture
Texturegroup
Consistence
5
Structure
CR_
AA k-
Mineralogy1
HORIZON II DEPTH
Z -
2Z
Texture group1
Consistence
;
Structure
!3 k
5
Mineralogyl;
HORIZON III DEPTH
7
4 f
Texture groupSa
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
0
n
SITE CLASSIFICATION: U
EVALUATION BY: c-�--%►-�1�
LONG-TERM ACCEPTANCE RATE: 0. O' -7 F2d47- Laocr OTHER(S) PRESENT:
cK
REMARKS: �ACIL 1 R. F iTt2-_Q_ .tirl> CtAy . r I
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 (01-90)
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• Davie County Health Department
and Home Heafth Agency
Environwnta(Heafth Section
P.O. Box 848 / 210 HOSPITAL STREET
• COURIER #09-4-06
MOCKSVILLE, N.C. 27028
PHONE (704) 634-8760
October 15, 1997
Sam P. Hall
P. 0. Pox 294
Mocksville, NC 27028
Re: Site Evaluation
White Dove Acres/Lot 8
Tax PIN: #5820-64-9480
Dear Client(s):
As requested, a representative from this office visited t -he
aforementioned site on October 14, 1997. Based upon 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.
t
If you have any questions, please'feel free to contact this office.
Si41y, I
Jep, R.S.
Environmental Health Specialist
JP/wd
Enclosure(s)