133 West Knoll Brook Drive Lots 14 & 15DAVIE COUNTY HEALTH DEPARTMENT,
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT ('
Account #: 990001691 Tax PIN/EH #: 5749-43-5798.15
Billed To: Jack Corriher Subdivision Info: Meadowridge Lot # 15
Reference Name: Location/Address: Sain Road -27028
Proposed Facility: Residence Property Size: see map
**NO I IJ* * This &proveme 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 #People #Bedrooms #Baths
Dishwasher Garbage Disposa)?I!r Washing MachinVEr Basement w/Plumbing;.� Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seeats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) "16 b Site: NewEl--"Repair ❑
System Specifications: Tank Size/ GAL. Pump Tank GAL. Trench Width��/Rock Depth�Linear Ft.j��ry
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT -
FINISHED GRADE. ****NOTICE: Contact a represer
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:31
1VED EFFLUENT FILTER RISER(S) IF 6 " BELOW
the Davie County Health Department for final inspection of this
the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature. Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001691 Tax PIN/EH #: 5749-43-5798.15
Billed To: Jack Comher Subdivision Info: Meadowridge Lot # 15
Reference Name: Location/Address: Sain Road -27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2796
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 WASTEWATA CONSTRU TION IS VALIP F R A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:6� Date: '� �2�
Ito
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion sha indi ate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of S. Chapter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken a a A7tee that the system will function satisfactorily for any
given period of time.
M0
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
�4' `� • Date: C?— (a V l
11 A TION FOR SITE EVALUATI ON/IMPROVEJ%I ENT PERMIT & ATC
Davie County Health Department
APR 1 7 2001 Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
ENVIRONMENTALHF�ETi{ (336) 751-8760
pAVIE COUNTY
1 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed
to �0 94- `7 / /`,-�+
'7t` - Contact PersonJ_
-,AI
Mailing Addrosa
Z/ 3 /C. Cz�Dz) eyJ�/C •
Home Phone
-2
City/State/ZIP
/41 ace rii(- i F IVA'
(
7 �J Business Phone
%f/ - S' 7 Z-
2. Name on Permit/ATC
if Different than Above /✓
L/4
Mailing
Mailing Address
% f(
Zi:tP
3. Application For:
1
t�Site Evaluation
C01 provemermit/ATC ❑ Both
a. system to service:
F� House ❑Mobile home
❑ Busin
s ry ❑ Other
5. if Residence:
# People
# Bedrooms _
# Bathrooms_
VDishwasher WCarbage Disposal WWashing Machine (7/Basement/Plumbing ❑ 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: ES/ County/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A 0
If yes, what type?
***IdIPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: --9<"7 �( /,Z 0
Tax Office PIN: # S>lle,
Property Address: Road Name,<Q-/ ✓�
City/Zip
If in a Subdivision provide information, as follows:
Name: X /I0 Ce'
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
!- 07r / 6/ A&V /S'
Section: Block: Lot: _ i� Date Property Flagged: t1
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 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 suitability.
DATE Cl ' /7' % SIGNATURE �rf
LX
TRIS 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. '
Invoice No.
1 APPLUCMION FOR SITE EVALUATION/IMPROVEMENT PERMIT do AIC
Davie County Health Department
�. Environment al Health Suction
P.O. Box 848/210 Hospital Street
Mocksville, VC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNbr BE PROCBSSSD UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. /tam to be Billed KE IJ nl E T N t- o -sr, e R L • FosTs2.
Nailing Address l 8 G 111APt-- T{2�� L/a.Jc Boma Phaas -704-54 -77c�8
City/State/LID tA0C -$V it -Lt , 1,1 •C- - :27oze Business Phone 33Co-1Z3-8F3S0
Z. Nana on Permit/A?C if Different than Above
Nailing Address
City/state/Zip
3. Application For: It Site Evaluation 0 Improvement Permit/ATC 0 Both
a. system to service: t3 House O Mobile Home D Business 0 Industry 0 Other
s. If Residence: # People # Bedrooms 3-� • Bathrooms Z
dishwasher 0 garbage Disposal Pliashing Machine O Basement/Plumbing U Basement/No Plumbing
6. if Business/Industry/other: Specify type • People / sinks
f Coommodes / showers # Urinals i /later Coolers
if FOODSERVICE: T Seats// Estimated stater Usage (gallons per day)
7. Type of water supply: 8'County/City 0 Well 0 Community
s. Do you anticipate additions or expansions of the facility this system b intended to serve! 0 Yes 0 No
If yes, what type'
***IMPVRTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either s PLAT or SITE PIAN MUST BESUBMITTED by the client pith THUS APPLICATION.
Property Dimensions:
135 X (a 9 I
X 1-7 3Y 5 E Z
WRITE DIRECTIONS (from Mocksvllle) to PROPERTY:
Tai Office PIN: 6
5-749 -
4-5- 519 8
1= A.sT ON V S � �w �1 C; 8
Property Address: Road Name !S (A t a Po a D
City/Zip'Nicc-Ks0 , 11= a1yZ O
If in a Subdivision provide information, as follows:
Name: MEAoowk(-0GE CPr�PoSeD�
Section: Block: Lot: )5
To ,,\&Q Roo -13 (sP, 1(o4) TURiI
RkG11T OP SAv" _ APPR-o O&S W)iLlr
TCS S t -M r3 p -A K \Ltd T
Date Property Flagged: 6, • a 8 - H
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 cbanged. I, also, andaxtand that I ani reFonsiblefor all charge Incamd frons
this appUc adom 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmemt
to enter upon above described property located in Davie County and owned by IVEw.VE7 24 _ L. Fo'&-r 1�
to conduct all testing procedures as necessary to determine the site sultabilih-.
DATE lo•Z8 -1991
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 (07/98)
Account No.
Invoice No. 902
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT 11NFORMATION
Account M 989900654
Billed To: Kenneth Foster
Reference Name: Kenneth Foster
Proposed Facility: Residence
Water Supply: On -Site Well
PROPERTY INFORMATION
Tax PIN/EH #: 5749-43-5798.15
Subdivision Info: Meadowridge Lot # 15
Location/Address: Sain Road -27028
Property Size: 1.97 Acres Date Evaluated: 545D)qq
Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
(i
L
Slope %
VTO
HORIZON I DEPTH
0.
Texture group
Consistence
IG,r 5
Structure
k
MineralogyI:
HORIZON II DEPTH
Texture group
Consistence
G: S
Structure
Mineralogy
`
HORIZON III DEPTH
2 --
Texture group
i5;0
G.t
Consistence
$
V -r
Structure
Mineralogy;
HORIZON IV DEPTH
Z -h
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
P S
LONG-TERM ACCEPTANCE RATE
3
SITE CLASSIFICATION: Ps
LONG-TERM ACCEPTANCE RATE: �•121
REMARKS: PAZ 5b1�16 Q Q:) Z
WDIMCM
EVALUATION BY: -1 N
-C M-1
OTHER(S) PRESENT:
F0
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
MON
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)
�•TION FOR SITE EVALUATION/16IPROVEAIENT PERMIT & ATC
D Davie County Health Department
APR 1 7 2001 Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
ENVIRpAM��o �� (336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer
N to the INFORMATION BULLETIN for instructions.
1. Ne--f
ame to be Billed ,TAC/C 0 / � r- / 'elor—lz- Jk Contact Person ��f��k C `� ~ K/ y4&1-' ✓ N
Mailing Address Z1'? X4D'�VDD e et • Home Phone
city/state/ZIP /1 ock •r4,/e- 14 IV- r- Business Phone? - •"917Z
2. Name on Permit/ATC if Different than Above L/A
Mailing Address /y /ld
3. Application For: L4'Site Evaluation
4. system to service: P House ❑ Mobile Home
5. If Residence: # People_
City/State/Zip
❑ Improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
# Bedrooms 3_ I Bathrooms_
[YDishwasher W Garbage Disposal WWashing Machine 6""Basement/Plumbing O Baaement/No Plumbing
6. I£ Business/Industry/Other: Specify type
# People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats ` Estimated Water Usage (gallons per day)
f
7. Type of water supply: f/ County/City ❑ Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes VINO
If yes, what type?
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: = 9D X /7 -DO l WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # S7G, el _ U 3 - 5-7 % ' ' 1 i �I �i1,�7 Ulm A l)0 r14r AZ, /-
Property Address: Road Name 1 r a
City/Zip
If in a Subdivision provide information, as follows:
Name: AM X--Vw 1('/,0Ce'
Section: Block: Lot:
CoT(' i el '[/1✓I,✓ Ir
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 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 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 conduct all testing procedures as necessary to determine the site suitability.
DATE (l D / SIGNATURE CZ/ �
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. Z,6
Invoice No.
APPUCAIION FOR SITE EVAWAIION/IMPROVEMENT PERMIT do ATC @ Vv
Davie County Health Department D
Eav/ronmenfa/Kea/Ifi 21%cdon
P.O. Box 848/210 Hospital Street JUL 1 1999
Mocksville, VC 27028
1336►751-8760
***nWCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer
y to the INFORMATION BULLETIN for/ instructions.
P4 C-
1. Maas to be Billed KE N T NL . O sire R o�Kt Contact Version N A1E T H L • FOSTE 2
Mailing Address A PLA� T{2e� LaNE some phone 704 - 54(v-7 -7 9 8
City/State/LIP "•C-- :1702e Business Phone 57J( --IZ3-8850
2. Name on Permit/ASC It Different than Above
)&ailing Address City/State/Lip
J. Applioation For: it Site Evaluation 0 Improvement Pesmit/AT'C 0 Both
4. system to Service: B House ❑ Mobile Home ❑ Business O Industry 0 Other
S. It Residence: # People _ # Bedromas ,3Z # Bathrooms Z
S Dishwasher 0 Garbage Disposal Wgi; hinq Machine 0 Basement/pinabing 0 Basement/No plumbing
S. If Business/Industry/other: Specify type # people # Sinks
# Caemodes # Showers # Urinals # Nater Coolers
IF FOODSZRVICS: p Seats Estimated Hater Usage (gallons per day)
7. Type of water supply: County/City 0 Well 0 Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes 0 No
If yes, what type'
***IMPDRTANT*** CLIENTS AIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PIAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: 135'A 80o x 1'13 X ro91
Tai Office PIN: # 5749 - 43- 5-798
W111711 DIRECTIONS (from Mocksville) to PROPERTY:
LAST O N V S i-�w•w � S 8
Property Address: Road Name 15 A' -3 Po A o To S ►N s 0 RoN o i s R 1(o 43) Tu P,"
City/Ziprcc-Ks,J,115 91y`LS
If In a Subdivision provide information, as follows:
Name: MEAnnyJP t.OGE � Pr�poseD�
Section: Block: Lot: 14 -
RIGHT ON SA -,-J - A.PP0.px 0.eaW11LC-
TU S (TF n r 1
Date Property Flagged: G -,A? - 94
This is to certify that the Information provided is correct to the best of my knowledge. 1 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 ro pousible for all chargers Incurred from
this appUcation. 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmer•&
to enter upon above described property located in Davie County and owned by tf�CAy&-rii _ L. F4sT E R,
to conduct all testing procedures as necessary to determine the site suitability.
DATA. G • ZS - I991
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed
property lines and dimensions, structure, setbacks, and septic locations).
Revised DCHD (07/98)
Account No.
Invoice Na
f -I qi- a -d' -4'i
DAVIE COUNTY HEALTH DEPARTMENT
.. Environmental Health Section
- SoiVSite Evaluation
APPLICANT INFORMATION
Account * 989900654
Billed To: Kenneth Foster
Reference Name: Kenneth Foster
Proposed Facility: Residence
Water Supply:
Evaluation By:
PROPERTY INFORMATION
Tax PIN/EH #: 5749-43-5798.14
Subdivision Info: Meadowridge Lot # 14
Location/Address: Sain Road -27028
Property Size: 2.30 Acres Date Evaluated:
On -Site Well Community
Public
Auger Boring Pit 1_1_� Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
1_
Sloe %
20
HORIZON I DEPTH
-!
Texture groupL
Consistence
S
Structure
Mineralo
: 1
HORIZON II DEPTH
-
10-3b
Texture rou
Texture
Consistence
;
Structure
5 t
Mineralogy
HORIZON III DEPTH
I
Texture group
G }
Consistence
r
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
$
LONG-TERM ACCEPTANCE RATE
O,3
SITE CLASSIFICATION: S
LONG-TERM ACCEPTANCE RATE: 0
REMARKS: '&�TfiL-a. N0oob I
EVALUATION BY: Qk F � d
OTHER(S) PRESENT:
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
Mois
VFR - Very friable FR - Friable Fl: - 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)