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838 Mr Henry Road Lot 2 & 3DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002224 Tax PIN/EH #: 5716-76-2163 Billed To: David Taylor Subdivision Info: South River Farms Lot # 2 Reference Name: Location/Address: Mr. Henry Road -27028 Proposed Facility: Residence Property Size: 10.20 acres ATC Number: 3261 **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 Av-� #People #Bedrooms � #Baths Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type /. #People #People/Shift #Seats Industrial Waste: CILot Size Type Water Supply e' Design Wastewater Flow (GPD) � Site: New,12-"Repair ❑ System Specifications: Tank Size GAL. Pump Tank _ GAL. Trench Width � Rock Depth.22 Linear Ft.�j'OZ Other: 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 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** C.� Health Specialist's Signature:'Wa26 lf� Date: DCHD 05/99 (Revised) Account #: 990002224 ,Billed To: David Taylor Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5716-76-2163 Subdivision Info: South River Farms Lot # 2 Location/Address: Mr. Henry Road -27028 Property Size: 10.20 acres ATC Number: 3261 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 WASTEWAT O TSTRUCTI N IS VALID FOR A PERIOD OF�F,I`VE YEARS. Environmental Health Specialist's Signature: i Date: �(j ZL 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 i l 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: DCHD 05/99 (Revised) Date: i ® ❑ 0 0 Curve Radius Chord Bearing and Distance Arc Length - - CONTROL CORNER a-, a r ; Cl 814.94' S 4° 24' 16° E 194.86' 195.33' 0 9 39 g g 9 o C2 814.94 S 4" 41 17' W 63.30' 63.32'. S 19' 43' 12" E 217.09' a H ~ lz .m v I LOT SR 1143 95.04' I S 87. 53' 59" E — 1134.15' 1039.11' g8 OMBINED AREA LOTS 2 & 3 g 4 10.20 AC.+/ z I— ---- LOT 2 — 9g�4 >-A ------ 100 YEAR FLOOD LINE _ AS SCALED FROM PANEL 370308 00038 U S 3. 49' 05" W g3 O r g a 12s LOT 125.97'N 103.00' N? 1090.83, 7 $ 1090.83' �Yl' { Q ' N 87' 53' 59" W 1193.83' I SOUTH N ° RIVER LOT 4 age$ y VICINITY (no Scale) xaaN g a o 3 y A (U sit Jz?� R y»hj \A v�S L�� SIM P • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATIONPROPERTY INFORMATION Account #: 990002224 Tax PIN/EH #: 5716-76-2163 Billed To: David Taylor Subdivision Info: South River Farms Lot # 2 Reference Name: Location/Address: Mr. Henry Road -2r7/928 Proposed Facility: Residence. Property Size: 10.20 acres Date Evaluated: p/i2 Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut Consistence DEPTHHORIZON H ®®®®® SITE CLASSIFICATION:_ EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope rFS - 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 r CL -Clay loam SCL = Sandy clay loam SC S - Clayandy , SIC 7Silty clay CCONSISTENCE 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 -tern acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) M OEM APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department Ell vironmentaiHealth Section P.O. Box 848/210 Hospital street Mocksville, NC 27028 (336)751-8760 Name to be Billed Mailing Address ~City/S.tate/ZIP Name on Permit/ATC if Different than Mailing Address City/State/zip n 3. Application For: %Site Evaluation ❑ Improvement Permit/ATC Both. 4. System to service: El House Mobile Home [I Business��ltt ❑ Industry 11, Other S. If Residence: # People /. I q Bedroomsq Bathrooms II Dishwasher 1:1 Garbage Disposal T�Washing Machine LI Basement/Plumbing 1.1 Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People ° # Sinks N Commodes it Showers # Urinals 11 Water Coolers IF FOODSERVICE: $ Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ 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? IMt'UK7illVT*** CLIENTS MUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED RELOW. Either a PLAT or SITE PLAN MUSTBESUBM17TED by the client with THIS AI PLICATION Property Dimensions: 9�.-� / - N - I �' I l / WRITE DIRECTIONS Crom Mocksville) to fROI'IsR'1'1': Tax OMd IN: # S �NNn� Z x&A&U 0 mr. Property Address: Road Name lftffi rn Q, 61 - J5�' 6�IYn% F. If in a Subdivision provide information, as follows:' .LAI / IL..�I�� r section: Block: I Lot: Date Property Flagged:• This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc 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, anrlerstand that I mu responsible for all charges incurred from dmfs application. 1, hereby, give consent to the Authorized Representative of the Davie County II 11th Department to enter upon above described property located in Davie Count and b A Y Y+ltl/ to conduct all esting procedures as necessary to determine the site s itabilit % DATE, L SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existingand proposed property lial5s and dimensions, structures, setbacks, and septic locations). l`Site Revisit Charge Date(s): l gQsClient Notification Date: O Uu y Revised DCHD (07/99) tf F/ S I'r J c- I ✓ e- IV EHS: Account No. --)-q Invoice No. 3/3 3 IMPROVEMENT PERMIT DAM COUNTY HEALTH DEPARTMENT IMPROVEMENT PERMIT and OPERATION PERMIT i **NOTE** This improvement permit DOES NOT authorize the construction or installation'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. j (In compliance with Article 11 of.G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME laX- PROPERTY ADDRESS++� wpITF2,707r DATE V1'-1#( SUBDIVISION NAME Stt7R ifiG/ l!/O LOT NUMBER SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION-. BUILDING TYPE /446YP #BEDROOMS # BATHS 4g�L # OCCUPANTS 6ARBRGE DISPOSAL: Yes/Na COMMERCIAL SPECIFICATION: FACILITY.TYPE # PEOPLE _ # PEOPLE/SHIFT i. # SEATS _ INDUSTRIAL WASTE: Yes/No LOT SIZE fir' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TAW SIZE n/6RL.QPUMW TAM(/_ BAL. TRENCH WIDTH 3 " ROCKDEPTH LINEAR FT.' OTHER REGUIRED SITE MODIFICRTIONS/CDNDITIM #**THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING.THE SYSTEM. #*CONTACT R REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 R.M. OR 1:00-1:30 P.M. ON THE DRV fF INSTALLATION. NE IS (704) 634-8760. OPERATION PERMIT ST IN TALLED BY flmm y AUTHORIZATION N0:" **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED'RBOVE IVIS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 1308, SECTION .1900 "SEWOiE TREATMENT AND DISPOSAL SYSTEMS', BUT SHALL IN NO WRY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 10/95 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS IT Davie County Health Department .IUL 2 6 1996 Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By K e L 0 6 tAl 1cle&c t R i G K eaR Mailing Address 3 14 r Rkmc.14 s4. Home Phone 4iq - SS o1 �i 6 (,,,',ICL G/�-oue. f11, C, a'?0 3 Business Phone 704-5 SS-3�%2% 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation 4. System to Serve: R mouse Installation Permit ❑ Mobile Home i ❑ Place of Public Assembly ❑ Business ❑ Industry /� El Other ❑ Unknown 5. If house, mobile home: Subdivision Jo t ik eiUCA- 1-afLM Section Lot # 3 i ❑ Basement/Plumbing No. of People -� ❑ Basement/No Plumbing No. of Bedrooms LTVZshing Machine No. of Bathrooms a y� C"ishwasher Dwelling Dimensions �!� r X oZg t ❑ 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 1 No. of Lavatories No. of Water Coolers I No. of Showers WaterUsageFigures 7. Type of water supply: ❑ Public F Private ❑ Community 8. Property Dimensions gg r 1143, Sewage Disposal Contractor mid 6Qn4eit- 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes D -<O 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: Go !o �l6< <Ka1 --II0� Ra��cd5c Rely Wketic `i F Q4 u r ;'OTa NA-, MAR R4 l urtu R"3 �+ MMM 80 S6 t p� *& -7 Le1h7' s;SN P2a��"�Y eL CQJAIIJI e. ;IAS Tax Office PIN: #S'%/(p-75--a96 PROPERTY IADDRESS, as follows: Road Name: Me. kled&eV Rd, City: N.C. SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. 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. 7- 18-9(o DATE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. E-2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner ora person authorized by the owner: I hereby give consent to the authorized representati a of the Davie ounty Health Department to enter upon above described property located in Davie County and owned by'd 1I I ay Le2 to conduct all testing procedures as necessary to determine said site suitability for a ground absorption sewage treatment and disposal system. -7-1S-9 &P & --�.. -P 1_ -- DATE DATE SIGNATURE DCHD(1i33) ti wim YADKIN RIVM io scale) ' . • - t 7R 1 1 'A..J N 87' 53' 59' W 1193.83' . 1 LOT 4 Cl 814.94' S 4° 24' 16" E 194.88' 195.33' C2 814.94' S 4° 41' 17" W 63.30 63.32' ,�- as' -,+ i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ��Gi�� DATE EVALUATED /& Ak ADDRESS PROPERTY SIZE�)/��'/- PROPOSED FACIILTY fir LOCATION OF SITE 1r Water Supply: On -Site Well _��_ Community Public P Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 Landscape position L Slope 1 HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group e"— IC Consistence Structure Mineralogyt HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION /45 LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: iEue he, LONG-TERM ACCEPTANCE RA REMARKS: /XJB�i Zr DCHD(01-901 EVALUATED BY: �/ PTHEFJS) 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 -Heed 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 I Structure SC -Single grain M -Massive CR -Crumb GR -Gran ular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mi neraloa-v 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolile - S(suilable), %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