188 Forest View Drive Lot 30DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900164
Billed To: Gray Laymon
Reference Name: Carl & Melissa Robertson
Proposed Facility: Residence
ATC Number. 2523
Tax PIN/EH #:
5749-43-5798.30
Subdivision Info:
Meadowridge Lot # 30
Location/Address:
Sain Road -27028
Property Size:
2.72 Acres
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 WASTEWA C NST UCTION IS VALID FOR A PERIOD OF F/IVE YEARS.
Environmental Health Specialist's Signature: Date: CS
290
krm i 4 Fort 3 Bda om
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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
Ps uperry renes and dimensions, structures. sethaclrm. And aanlin i�n..�,snumue 211 of the foiiowings Existing and proposed
•, '�, . ,� S
:1.Jpp t
If�i� i fi AEF `
KENNETH L. FOSTER
08 211 PG 857
19.614 Acres (dmd)
DAVE CO
a
D!RE�.OR•
The 10 Year Floodplain.
�.vRT
Fl -,,T; Or APPROVA OF Don,sZti
10 rear FModoloin ( Anoroximgfe location
SEE SHEET 2 OF 3
MOCKSYtL
,+N--
IT:) S A F iSPOSAL M5
•, HEREBY CEI
I HEREErr CERTIFY -THAT THE DAME COLWY HFALTH DEPARTMENT HAS
HMON HAS 6F
r if �
EVALUATED TNF. SU301 MXN FNTFTLED • MEADOW RIDGE - WTH
SU8VA$ION•RE(
RESPECT TO CRITERIA AND CONDRIONS ESTABLISHED BY STATE LAW OR •
V y .IF A
PROMULGATED TNEREUNDEF{ AND THE SAME 1S FMD TO COMPLY WITH SUCH
P .�
CRRER+A AND CONOnTONS-EXCENT AS FOUND IN SUCH EVALUATION. FOR -
REC=24 IN T
.�
DETAILS OF THIS' EV►L'alkT" ANTj FOR UY9A70Nl-- SE;- TWE WR!Tr—R DEPORT CW
Nstcfiiif' NSUjQ
-
FRE AT THE SATO OEPARTTI W. .
INCLUDE APPRV
30
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DOES IT WCLUDI
N ._? . /C ' U 3.2/7 Acres (dmd)
CUM= A P£$MR OR APP t CF tMOMWN LOTS tN
SAID S.l OrYI&ON -TJR INST IAT! tl S£1Y��F6idIiTIFS-
OF BUILE NM C
DATE
wz;c
a,nrF• 1A10 guild%ngs A.re Permitted 1.^,
D!RE�.OR•
The 10 Year Floodplain.
q
10 rear FModoloin ( Anoroximgfe location
SEE SHEET 2 OF 3
S 25 3 T 3T w i/ Azle 1
------------�_ 20'
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DAVIE COUNTY HEALTH DEPARTMENT
-. Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900164
Billed To: Gray Laymon
Reference Name: Carl & Melissa Robertson
Proposed Facility: Residence
Tax PIN/EH #: 5749-43-5798.30
Subdivision Info: Meadowridge Lot # 30
Location/Address: Sain Road -27028
Property Size: 2.72 Acres
**NOTEC * Tfii blmprovement/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 14 #People #Bedrooms #Baths -S
Dishwasher: C21"' Garbage Disposal: ❑ Washing Machine: 121`000' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply_ Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size iFOO GAL. Pump Tank GAL. Trench Width 310 Rock Depth �-- Linear Ft 00
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.****
ELJ
Environmental Health Specialist's Signature: Date: d IAS od
(&4Z
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 #: 989900164
Billed To: Gray Laymon
Reference Name: Carl & Melissa Robertson
Proposed Facility: Residence
ATC Number: 2523
Tax PIN/EH #:
5749-43-5798.30
Subdivision Info:
Meadowridge Lot # 30
Location/Address:
Sain Road -27028
Property Size:
2.72 Acres
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 L2UCTION IS VALID FOR A PERIOD OF FIVE YEARS.
��
Environmental Health Specialist's Signature: 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.
Septic System Installed By:
Environmental Health Specialist's Signature :
DCHD 05/99 (Revised)
Date: T
r nn R
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT U u M R
• Davie County Health Department
Enviimmental Health Section A98 " 8 2000
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760 ENVIRONMENTAL HEALTH
DAVIE COIINTY
***IMPORTANT*** THIS APPLICATION CMWOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed L7eAV fl: keriy/rlU/V Contact Pe =son
Mailing Address %,. L44 %t1"�J id_/ Homo Phone �7
City/State/ZIP / ' 1 . /(/G� Business Phone (/
2 . Name on Permit/ATC if Different than Above l 45W Sd Ai
Mailing Address City/Stato/Zip
3. Application For: O Site Evaluation wimy//provement Permit/ATC
❑ Both
4. system to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
s. If Residence: # People # Bedrooms _ # Bathrooms,2
VDishwasher ❑ Garbage Disposal ®'stashing Machine O Basement/Plumbing ❑ Basement/No Plumbs. -g
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: 131"County/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes fd'INO
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: Z. 7 Z 1116"C. WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # ,S'7 �q - 7 15-e - 7/41 -r..4.oW /2./
Property Address: Road Name -5 R/
R/ �/Yr•i S. w.r-1
City/Zip %j 644--, � IZC.. 27cZoe-
If in a Subdivision provide rm tion, as follows:
Name:
Section: Block: Lot: : o
Date Property Flagged: —46
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 ant 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 suitapoy.
DATE X— 7— /000 SIGNATURE (/ L,09U
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include 511 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:
I EHS•
q8-9000 I c�
Account No.
Invoice No. g
A
,S1 �
VVSS
3 v
KENNETH FOSTER
171
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D B 211 PG 857
2
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34.4 ACRES AGRICULTURAL)
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SARAH HOLLAND -
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-
1100.90
S fl 1 00'0 W 3/4 IMCH PIPE FOUND
'SPE FOUND
`— 1 O BASE OF 47 OAK
4
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SAMUEL S..SHORi, JR
DB 63 PG 1,64.
\
DB 66 PG 5
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•� KENNETH L FOSTER �*
FRANCIS McCLAt�AROCK
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-
- -
_
THIS MAP WAS DRAWN UNDER
CERTIP
DB 86—PG 504
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VEY MADE �
Al FIELD DSUPERVISION
PERVISION FROM
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ER CERTIFY Tf
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APPU(AIION FOIL SITE EYAWAIION/IMPROVEMENT PERMIT & AIC
Davie County Health Department
' Enviranmental Health SLacdon
B.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
�01 W
Ito 1A
***ZMPORTANT*** THIS APPLICATION CANNOT BE PROC'ESSE'D UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed KE hl n1 C- T N L... t o S R Contact Person � -N aE T H L • FmT-e p-
!tailing Address _ I S (n YYl A PLL TRF LANG Boma Phone 704-54<o--7-70"8
C1ty/8tate/LID N�OCK5,[iL-LC ,4:27U�2 Business Phone 33Co-�I Z3-f38So
Z. Nacos on Pe=it/ATC if Different than Above
Mailing Address City/state/Lip
a. Application Tior: It Site Evaluation 0 Improvement Permit/ATC 0 Both
s. system to service: td House 0 Mobile Home 0 Business 0 Industry 0 Other
e. It Residence: # People # Bedrooms 3- # Bathrooms L
B'Dishxasher 0 Garbage Disposal R hashing Machina 0 Basaoent/Plumbing (] Basement/No Plumbing
5. if Business/industry/other: Specify type
# Commodes
# Shovers
# People # sines
# Urinals # hater Coolers
ITT FOODSERVICE: 11 Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: O'County/City ❑ Nell O Cc=umnity
e. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 0 No
If yes, what type!
"""IMPORTANTP" CLIENTS MUST CIUMPLEiE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESU1U11TTED by the client elth THIS APPLICATION.
Property Dimensions: 135 X 4 o.39 419 x 188
Tax Office PIN: # 574-9 - 4.3- S`I 9 8
WRITE DIRECTIONS (from MockrAlle) to PROPERTY:
1. AST O N V S NA w T_1 C; R
Property Address: Road Name 15 A r -J Po A o T o S,N & t.3 RaP. o ( S R 1 (o 43) TV R tJ
City/ZipTcc-KS0tI1s 91OZ6 R%G1%T 00 SA,a _ APPa-u O.e), MILC-
If in a Subdivision provide information, as follows:
Name: iYIEAoov�R� UGE �Prc�PoSEn�
Section: Block: Lot: 36
-TCS S (Te n t-1 K\ C.-. %A T
Date Property Flagged: 6 • AS - 94
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
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, understand that I axe responsiblefor all charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Departmerae
to enter upon above described property located in Davie County and owned by tT'f/ , 7W - L' FQftT E R,
to conduct all testing procedures as necessary to determine the site suitability.
DATE -(.-?-8 -191)-% 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.
Invoice No. �'Z�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
_r SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account ##: 989900654 Tax PIN/EH #: 5749-43-5798.30
Billed To: Kenneth Foster Subdivision Info: Meadowridge Lot # 30
Reference Name: Kenneth Foster Location/Address: Sain Road -27028
Proposed Facility: Residence Property Size: 2.72 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
L
L
Slope %
$
HORIZON I DEPTH
to - "L
Texture group
C
G t
Consistence
Structure
6k
Mineralogy
HORIZON II DEPTH
Texture group
G
Consistence
P
Structure
MineralogyI
: I
HORIZON III DEPTH
Texture group
SA0
C,+<—,
Consistence
SS
Fr
Structure
qg
S
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
Q.
(�
SITE CLASSIFICATION: 0S
LONG-TERM ACCEPTANCE RATE: d
REMARKS:
LEGEND
Landscaae Position
EVALUATION BY:
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
os
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 OR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineraloev
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
I)CM (Revised 05/99)
(,okra
Davie County Health Department
Environmental Health Section
.8V316`& -n-' RECEIVED P O Box 848
Cz
Phone: (336) - 7.53 - 6780
�13
210 Hospital Street,
Courier #: 09-40-06
Mocksville, NC 27028
RECEIVED
AUG 1 6 2013
DC HEA
1014.h�-tc L co . `Dao; c . nc.. uS
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement emodelin Reconnection
Fia: (336) - 753-1680
Name: �� 1 MQ�v� SGS r72�S Phone Number ?J 3 t4 - 7S 1 " YJ 2 (Home)
Mailing Address: Fo(e �r - \Jit'.A Q( (Work)
Detailed Directions To Site: r) JG ` /J
C—
%1
S 1'
Property Address: ( f:::SC`9� 4- J" (�'3 Nur _ k j Lj 1-(0 1—OJT-.- ai o .-.?
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: 0 Type Of Facility:'.3pQ C-Q—
r 2do 3
Date System Installed (Month/Date/Year): % Number Of Bedrooms:- Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long? / �• 73 �%
Any Known Problems? Yes No If Yes, Explain:�'6
Please Fill In The FollTige
ng Information About The NEW Facility: 11T 5ro
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
equested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments: %0 0 at /V&9
ev anm
Environmental Health Specialist �,�,(d d,((��,(,(l lJ�( - Date: /Q—el7
*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 on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$lU U Date: X 1 1 q13
Paid By: 1013 Received By:
Account #: W9 Invoice #: %6(
, L5/7
1,&tfs1 Vt,CL.) -PA.
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