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2428 Hwy 601 N Lot 4l ` • r HEALTH DEPARTMENT RELEASE �yA w5TA7E o. Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Joshua S. Lambeth Address: 2428 US Hwy 601 North City: Mocksville State/Zip: NC 27028 Phone #: (336) 429-3051 PERMIT VALID 0 6/ 1 8 �, a 0 1 9 / Property Owner: Joshua S. Lambeth Address: 2428 US Hwy 601 North City: Mocksville State/Zip: NC 27028 11h one M (336)429-3051 Property Location & Site Information Address Hwy 601 North Subdivision: White Dove Acres Phase: Lot: 4 Road # Mocksville NC 27028 — SINGLE FAMILY Township: `Structure: Directions # of Bedrooms: 3 # of People: Hwy 601 north to White Dove Acres, house on right 'Water Supply: PUBLIC Basement: F� Yes ❑ No Type of Business: Total sq. Footage: No. Of Employees: 'Proposed Improvement: -Pool ch&vctm Remaining 750 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes O No Applicant/Legal Reps. Signature: 'Date: "Issued By: 2140 -Nations, Robert "Date of Issue: 0 6 / 1 8 / D 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** - ® Hand Drawing O Import Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 139080 - 1 County File Number: Date: 06/18/a014 O Inch Scale: O Block ":_ft. O N/A Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release Page 2 of 2 CDP File Number: 139080 - 1 County File Number: Date:. 0 6./ 18 / 2 0 14 �CE�vEv CSD 't 0" - IS3 - 6780 avie County Health Department Environmental Health Section P.O. Box W 210 Hospital Sweet Courier # ; 09-40-06 Mo&wil1e, NC 2702$ ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconn"on Faye - 7S316e0 Name: 4 t7"h e1'hono Number. y2 - ?a J-1 (Homo) Mailing ,Address: aYk�r. Al. iG O/ N V6 ;-yo– 3 77V (-c.• /%Zee<� " 'c w�. ,v-6,, y7 d Z e Detailed Directions To Site: /0 Dl - IV ZD IV . kc- op, L--t•.. 5 � op'YL, !Cl_+f�� .ati. It 6y A i�.�i•91A1 Property address ,.-, 71 o / 117sG s 7a 4e- 7VZ _ 7 x y Y Please Fill In The Following Information About The EXISTING Facility: / .✓ t d,rG Name System Installed Undcr:.Ge�i,Ci�r•�y�.a � � G'S 'Type Of Facility: Gate System Installed (Month/Date/Year):! –�5 f �0 d a Nunnber Of Bedrooms; _Number Ot'People:___�_` Is The Facility Currently Vacant? Yes 5 if Yes, For How l,ong7 Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The ,NEW Facility; Tpe Of Facility: wC o Number Of Bedrooms:3�Number of People Pool Size Size:2 Y —Other: Requested BY: DateRequested: Signature) For Environmental Health Office Use Only Approved Disapproved _ a ON 1p g lI Poe &% g � jA) e V110 Environmental Health Specialist Date: *The signing 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 ort -site wastewater system will function properly for any given period of time. j Payment. Cash Cheep honey Order # Amounts Date:_ Paid By: Received By: - Account #: '�`(� V Invoice #: A4 DAVIE COUN-W RFkL•TH DEP ARTitiENCT Erivirormental Health Section �} �U P. O, Boa &484210 Hw lk � ��ospital Street t! Mcickst�le ?r'C 27023 (336)751-8764{} Account #: 990001094 Billed To: Ron Lambeth Reference Name: .Joshua Lambeth Proposed Facility: Residence ATC Number. 2389 Tax P(NJ'EH #. 582CJ-54-4319.04 Subdivision Info: White move Acres Sec.1 Lot #.4 i Location/Address.- 'Hwy. 801 M-27028 Property Size: 1 Acre's AUMORIZATION FUR mksrEWATER SYSTEM CO VSTRUC-nON'' **NOTE** This Authorization for Wastewater Syste=i Construction lvfUST BE ISSUED by the Lurie County Envircximenui Health Section prior to issuance of any building penitis). This Form/Authorization `tunrb--- should be presence to the Davie County Building .Inspe#ions Office when applying for building permits) (in compliance with Axtick f E' of G.S. Chapter 130A, Wastewater $, stems, Section .19tt0 Sev age Treatment and Disposat S}—,ems). TFRS AUT%IOWZA'I"fON FOR WASTE TR QN IS FOR A PERIOD OF M'E YEARS. Environmental Health Specialist's Sip a#urDat a s CERTIR( ATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system descriW on Impnn�=nent`Ope,:atior has been 'installed in compliance with Article 1 t of G.S. Chapter 130.A, Section. t900 "SM -Age Treatment an Disposal Systems,"but shall in NO WAY x taken as a guarantee that the system Kill fimctinn satisfactrraiq iiiiiijik given period of time. r --t u 0 i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street MockrAlle, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001094 Billed To: Ron Lambeth Reference Name: Joshua Lambeth Proposed Facility: Residence Tax PIN/EH #: 5820-54-4319.04 Subdivision Info: White Dove Ac Sec.1 t#4 Location/Address: Property Size: **NOTE** Ttiisbgmpr38oveeme nt/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 1ja0S;1-- #People I #Bedrooms -3>— #Baths Z- S Dishwasher: M Garbage Disposal: M Washing Machine: G!r Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size I ACQ.L Type Water Supply C60ASTyDesign Wastewater Flow (GPD) _ D� Site: New Repair ❑ System Specifications: Tank Size 1OOGAL. Pump Tank GAL. Trench Width 3C, e � Rock Depth 12 11 Linear Ft. Other: Z T) CDP . l t-AS-fA't_.l_ UAC�> q 'p .C. + o t, . Required Site Modifications/Conditions: `^ie� D.� Cej,3TQ3Q V-OEP IS: a41C- Opt) --Es, kCQf jc OCC RC -e. LOS IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) 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.**** ko.t- vzh3") U r--cS 0A)7 of -Dr–A'V3 ,n max. o , 4� O— S<7L�b Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: Cb DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital street Mocksville, NC 27028 (336)751-8760 Account #: 990001094 Tax PIN/EH #: 5820-54-4319.04 Billed To: Ron Lambeth Subdivision Info: White Dove Acres Sec.1 Lot # 4 Reference Name: Joshua Lambeth Location/Address: Hwy. 601 N.-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2389 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 WASTECO2 TR ON IS FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur :7 Date: 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. IOo x&",x1Z-" Septic Sys stalled By: C ' Environmental Health Speciaii More :i DCHD 05/99 (Revised) Date: '///0 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A L5 Davie County Health Department Environmen!a/ Heafth Secdon APR "-7 2000 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONIAENTAL HEALTH (336) 751-8760 1 DAVIE COUNTY I ***I14PORTAIVT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed _/t d ,,,) (^ 4, / - m 6 eL Contact Person Z�SV� U 10 p" L -AV � Mailing Address _ ISO ii0f\�IP- f VC, Home Phone 336- 3S7 -525/O City/State; f3P LL'ar� ori I Business Phone _ 3,�6 -r?,S 1 -56��7 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: ❑ Site Evaluation 4. System to service: 0 House ❑ Mobile Home 5. If Residence: # People �- City�/ tate/tip CtiTImprovement Permit/ATC ❑ Both ❑ Business ❑ Industry ❑ Other # Bedrooms 3 # Bathrooms 2 Y2- 6 Z p Dishwasher ❑ Garbage Disposal C Washing Machine N Basement/Plumbing 0 Basement/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: M County/City ❑ Well ❑ Community 8. 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 SUB1:i1TTED by the client with T HiS APPLICA T iON. Property Dimensions: 152111 HI -O X /62. 12 '/ 300.00 WRITE DIREAC'TIONIS_ (from Mocksville) to PROPERTY: Tax Office PIN: # Property Address: Road Name G o.1 N O V A "d City/zip I' o&sy,1lr , 77o2Q, If in a Subdivision provide information, as follows: Name: W k ko Dove- AC t-oe) Section: �- Block: Lot: Date Property Flagged: A p c �l —4-:3-200r) 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 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 suit bili DATE 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). Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EHS• Account No. D / Invoice No. S� • DAVIE COUNTY HEALTH DEPARTMENT -y ' Environmental Health Section Soil/Site Evaluation NAME ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE LOCATION OF SITE Water Supply: On -Site Well _ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Z_ Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupe C Consistence Structure i S Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE - CLASSIFICATION T=( LONG-TERM ACCEPTANCE RATEE SITE CLASSIFICATION: des LONG-TERM ACCEPTANCE RATE: i REMARKS: DCHD(01-901 EVALUATED BY: -.bra _/ 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 :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 NF -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure .3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralo¢► 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 RALEIGH GLASSCOCK io (BY WILL) c� (5663 3b!1 E �250.66 _ N �15.89 300 ;4Q : � • y S :g jN 1%_0 e9 ,� . p5 cn 29• 1 \. 81,70 ov� y o A�RfS s3.5gp A N 282 043, y N 65:10%49...x. .. CRES 91 y 281.00 N 25 plooS7, 300.00 u a S 65.10 4 A 4' ~ tycck ............................�. �' Z RUMMp,GE g �n o N y El 206 pg• 2p6 •- i o p •B. L4 L3 L2 0► / O o 0 1.5 UTILITY & PRIVATE ACCESS FOR THE PURPOSE FEAS fMfCNfjT •0'�gvE INGRESS dE�:Z11- 6 r.os�G" 3s•�.. _ Q •10'4g� E .. �S s2.21•. Q� N O 325' g�'utlUtY. easement qWQ±± : 50• b►�• ... ......... �'rE EDO 8, R r � onN •� 3 r3 1 X2., / a o 1.076 2C 2 79 0 A W a c o RE •96 Thy i �� .g vr N 63: 23,08• = O � � = 323.22• o y 4' 678 ACRES S DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section l W'0:7// Soil/Site Evaluation NAME �` ''0:7// DATE EVALUATED /lJ _� ADDRESS PROPOSED FACIILTY Water Supply: On -Site Well PROPERTY SIZE / t LOCATION OF SITE _ /O Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position C. Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 1� y Texture groupe G 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 C SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: i REMARKS: DCHD (01-901 EVALUATED BY: 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 :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 Structure 3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mi neraloity 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 ■■■■ ■■m■ ■mm■ ■■■■ ■mm■ ■■m■ ■mm■ ■m■■