149 East Knoll Brook Drive Lot 8DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028 (
(336)751-8760 1-L11,1
IMPROVEMENT/OPERATION PERMIT
Account #: 990001693 Tax PIN/EH #: 5749-53-3963
Billed To: Chris Johnson Subdivision Info: Meadowridge Lot # 8
Reference Name: Location/Address: Knollbrook Drive -27028
Proposed Facility: Residence Property Size: 150 x 536
**NOT C * Ihisblmprov7e nent/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.
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INS T LTS�r M.
Residential Specification: Building Type #People _ #Bedrooms #Baths,.A
Dishwasher-A00,4
Garbage Disposal � Washing Machined Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 1,,qType Water Supply_ Design Wastewater Flow (GPD) (?60
Site: Nevy�� Repair ❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width �� Rock Depth—, Linear Ft. D
Other:
Required Site Modifications/Conditions:
6�-22-z�y
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.****
Environmental Health �
Specialist's Signature: 1, Date:
DCHD 05/99 (Revised)
Account #: 990001693
Billed To: Chris Johnson
Reference Name:
Proposed Facility: Residence
ATC Number: 2797
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5749-53-3963
Subdivision Info: Meadowridge Lot # 8
Location/Address: Knollbrook Drive -27028
Property Size: 150 x 536
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, S ion .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTE WATE O S UCTION IS ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature:Date: —,�' -ev
CERTIFICATE OF
**NOTE** The issuance of this Certificate of Completionsha i
has been installed in compliance with Article I 1 G
Disposal Systems," but shall in NO WAY be t as
given period of time. '
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
MPLETION
Pte the system described on provement/Operation Permit
Chapter 130A, Secti n .19 `Sewage Treatment and
guarantee that the ction satisfactorily for any
Q
Date: 16
" -I2 (� 2 n nn ION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
��" } t l� L5 i t V
1, APR 1 7 2001
***1hp HIS PLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION Refer to the INFORMATION BULLETIN for instructions.
Davie County Health Department
En vironmenta/ Hea/ifi Section
P.O. Box 848/210 Hospital Street
i Mocksville, NC 27028
(336) 751-8760
1. Name to be Billed e"/3
I 15 7D HN/S,D N Contact Person �%Vjjj�, / 5^� `
Mailing Address /3t J/tAt LJ 620V A. Home Phone 944) `G7,81,
City/State/ZIP .ADIJe4lU'-E -'N e Z7Ct7(n Business Phone 336' `72 7- 209 z
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
4. System to Service: WYHouse ❑ Mobile Home
City/state/Zip
Improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
5. I£ Residence: # People _ 4 # Bedrooms _�_ # Bathrooms Z �Z
&4"hwasher �arbage Disposal P<ashing Machine ❑ 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: �unty/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �o
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 with THIS APPLICATION.
Property Dimensions: /,5-0 G)( )(:5-3 two 2 f+'�)
Tax Office PIN: {# 5 / `% ) - 5 3 - "7 � t1a
Property Address: Road Name NUL . ick Q)2.
City/Zip 4200 E4 w L 1- r
If in a Subdivision provide information, as follows:
Name: NZ-54Pow Ra?&E
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPER'T'Y:
L/UOL L RRO49 k , l 45 77 l_ a7 el /tJ LEfT
EEFo,�F -IWA P 2l G A4 T rxJA- v >= ,
S/GN ON LoT
Date Property Flagged: i>��ZV 1
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 frost
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 efZCMI S J- �'V Et/ S!5a4 jD/-//V. 0?L'
to conduct all testing procedures as necessary to determine the site suitability.
DATE �Q//ll %/o� SIGNATURE <
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the followi : Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
mkt
Revised DCHD (07/99)
Site Revisit Charge
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Client Notification Date:
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GRAPHIC
rrS
APPUCAiION F Davie County Depardltent PERMIT 8 n/7
�. D V IE
Envhnmentat Health Seg flon
B.O. Box 848/210 Hospital street JUL 11999
Moaksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL, QUZR=
INFORMATION IS PROVIDED. Ref fer to the INFORI ATION BULLETIN for/ instructions.
1. Nam to be Billed f�E N r4 T N L . ro S -re R . Contact Parson }CE N ae T m L • FoSTE 2
Wailing Address l hh1 G ('n a PL E Tgr. Lnyc no.e Phone 704 - 54(o--7 -7 9 8
City/state/zip -27028 Business Phone 33Co--1 Z3-8850
a. Name on Pewit/A= if Different than Above
Wailing Address City/state/zip
S. Application sor: it Site Evaluation 0 Improvement Permit/ATC 0 Both
t. system to service: td House ❑ Mobile Home 0 Business 0 Industry 0 Other
s. :Zmsh"asher
Reidence: 8 People L # Bedrooms ��� 4 / Bathrooms
0 Garbage Disposal 0ashinq Waddze 0 Basement/Plumbing a Basement/No Plumbing
6. If Business/Industry/Other: specify type
# Commodes / shavers • Urinals
# People f sinks
• Nater Coolers
I>< IWDSERVICE: Ii Seats Estimated Nater usage (gallons per day)
-/
7. T"m of water supply: 9"County/City 0 Nell 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'
***1MP0RTAN7'*** CLIENTS MUST CVAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either s PLAT or SITE PLAN MUST BESUB1111TTED by the client with THIS APPLICATION.
Property Dimensions: 30 2 X 38 5 k 14o x 4-15 WRITE DIRECTIONS (from Mocluville) to PROPERTY:
Tax Office PIN: # 5-74-9 — 43- Si 9 E$ L A.5T oN V S �w �1 S R
Property Address: Road Name 5 A l 0 Q0 A o To Rena o (s R 1(.473) Tu P-1
Ci1y/ZipTicc-K50 ,115 9107,8
if in a Subdivision provide information, as follows:
Name: McAnoW R(.DG6- (-?' a Pca&0)
9,16 tAT oP Sn.t.l _ APP",,- O.e3 W1iLE
To S tTr n►1 f\C-,j4T
Section: Block: Lot: 6 Date Property Flagged: 6.018 - 94
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 responsiblefor all charges Incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmem4
to enter upon above described property located in Davie County and owned by 1%vye7W .- L. ;r E R.
to conduct all testing procedures as necessary to determine the site suitabilih.
DATE to - ?-8 - 199'► SIGNATU
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. La
Invoice No. A2-6
DAVIE COUNTY HEALTH DEPARTMENT
r Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #:
989900654
Billed To:
Kenneth Foster
Reference Name:
Kenneth Foster
Proposed Facility:
Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5749-43-5798.08
Subdivision Info: Meadowridge Lot # 8
Location/Address: Sain Road -27028
Property Size: 2.22 Acres Date Evaluated:
Water Supply: On -Site Well Community
Evaluation By: Auger Boring
Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
-
0 -3 --
Texture
Texture group
Act-
CL,
Consistence
kWe
Y
Structure
Mineralogy
HORIZON II DEPTH
- l0
-1
Texture group
G
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
r_ 4
G _
Consistence
i `�
Structure
5
Mineralogyt
HORIZON IV DEPTH
Texture group
Consistence
Structurek
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
$
CLASSIFICATION
V -S
V5
LONG-TERM ACCEPTANCE RATE
p,
SITE CLASSIFICATION: P S
LONG-TERM ACCEPTANCE RATE: 6)'5
REMARKS: al'I`I #1 2- 49.7)
LEGEND
Landscaue Position
EVALUATION BY: 1-14rrl
OTHER(S) PRESENT:
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
Mineraloav
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 (Revised 05/99)
Davie County Health Department
'I'D 11836 I� Environmental Health Section
�^ P.O. Box 848
C�
210 Hospital Street
O U �'t Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One). Replacement Remodeling Reconnection
Name:&JAd Phone Number (Home)
Mailing Address:K-)Aloll
/5Y70M: f) - 53(61 Zl T-' 2-9 Z (Work)
Email Address:
Detailed Directions To Site:
Please Fill In The Following IIn�formcation About The EXISTING Facility:
Name System Installed Under: J T�] I l J ��) / l S Type Of Facility: SQJ
Date System Installed (Month/Date/Year): Zc Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes oNo If Yes, For How Long?
Any Known Problems? Yes 6 If Yes, Explain:
Please Fill In The Following Information About The EW Facility:
Type Of Facility: ret N N l 541 A] POR ' ' Number Of Bedrooms: Number of People_
Pool Size: Garage Size: Other:
quested
Approved Disapproved
Requested:
For Environmental Health Office Use Only
Environmental Health Specialist
*The signing of this form by the Environmental Health
Date: 6 /J-/ l "Z
iin no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By:
Us
Account #: Invoice #:
1, SHEET 1
;UBDIVISION
'AGE 129
PAGE 366
1994
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ON
-awn by: GMG Map of Survey For:
e name: 149 e knoll brook drive (champion )
rs of record prior to this date and not visible at the time of inspection.
survey: That the property lines and location of all structures are
lcross property lines, unless noted otherwise.
etermined by the Department of Housing and Urban Development.
ncy.
"- 60' This Survey was performed without the benefit
9 of a title search and is subject to any facts and
easements which may be disclosed by a
120 1 complete title search.
TINTS SURVEYORS
rell, Professional Land Surveyor
ox 986 Summerfield, NC 27358
Fax 336.342.7760, Cell 336.669.0209
PTSS.com, email: matt@4ptss.com
VIEW 1
VIEW 2
VIEW 3
VIEW 4
Champion • •
• East KnollBrook
. h•• l V 4 �'R M "ls .
DavieMeadow Ridge Subdivision �-,4;'-
Plat Book 7, Page 129
Mocksville Township
Deed Ref. 2006 252
� 9
■ • • • r? .'%!;.tee o;�n.�`�"�• r t•i aiut
rs, PLLC ( firm no. P-0376 ) is owned and operated by Gregory Matthew Gorrell, PLS -4417 I VIEW 6 1
Account #: 990001693
Billed To: Chris Johnson
Reference Name:
Proposed Facility: Residence
ATC Number: 2797
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5749-53-3963
Subdivision Info: Meadowridge Lot # 8
Location/Address: Knollbrook Drive -27028
Property Size: 150 x 536
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, S ion .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA% O S UCTION IS ID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: °1'� ��/
CERTIFICATE
**NOTE** The issuance of this Certificate of Completion s
has been installed in compliance with Article 11
Disposal Systems," but shall in NO WAY be t�
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
MPLETION
ate the system described on provement/Operation Permit
Chapter 130A; Sectin .0c,
` Sewage Treatment and
guarantee that the l Vunction satisfactorily for any
Q
Date: /o a�