The URL can be used to link to this page

194 West Knoll Brook Drive Lot 34• DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 8481210 hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003138 Tax PIN/EH #: 5749-33-5745 Billed To: Peter Falk Subdivision Info: Meadowridge Lot # 34 Reference Name: T.D. Hatcher Location/Address: Knollbrook Drive -27028 ATC Number: 3748 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 WASTEWATER CONSTRUCTJON IS VALID FOR A PERIOD OF/FIVE YEAR . Environmental Health Specialist's Signature: Date: **NOTE** The issuance of this G has been installed in cc Disposal Systems," but given period of time. / 12 CRTIF� EAY OF COMPLETION Kshall indicate the system described on Improvement/Operation Permit 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and taken as a guarantee that the system will function satisfactorily for any 111111015.0 &LAC.V-4'!:- Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section • '+ P. O. Boz 848/210 Hospital Street 1 ww f Mocksville, NC 27028 (336)751-8760 6/-3/ s IMPROVEMENT OPERATION PERMIT Account #: 990003138 Tax PIN/EH #: 5749-33-5745 Billed To: Peter Falk Subdivision Info: Meadowridge Lot # 34 Reference Name: T.D. Hatcher Location/Address: Knollbrook Drive -27028 Proposed Facility: Residence Property Size: see map **NOTE * This Improvemeent/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 INS/,TALL G SYSTEM. Lair 1�:%44 a WILC`{vr�2�b� Residential Specification: Building Type #People #Bedrooms #Baths_ Dishwasher: ;3111,- Garbage Disposal;' Washing Machinery Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supp, �o Design Wastewater Flow (GPD) Site: New ❑ Repair ❑ i� �� System Specifications: Tank Size AL. Pump Tank GAL. Trench Width & Rock Depth �lLinear Ft.�pCJ Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a repres fthe 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 a day of installation. Telephone # is (336)751-8760.**** c� r0 j r^ Environmental Health Specialist's Signature: Date: 6 DCHD 05/99 (Revised) 03/30MO4 09:59 FAX 336 714 4401 PRUDENTIAL CAROLINAS qR-30-2004 12:27 AMPETER J 0 002/003 FALK ARCHITECT 631 234 0005 P.02 Ali tl,ldl'npN FOR tint: awt lilTloWWP48Vr WVr POWT m ATC WYie cow* Hgdlk aspsitimt • Mer/No9 trl y.0. am 04tin10 amoL al l;a"at JltatshfwLUQ, W 27021 c�igass:.�t;o j ... ... �I¢tr iprJ:rjQ�lICEI' Cai�eaQr � ]io 11�7.>cEg ]1Z+L tC=,: ix�ltuv rx�+alt_wtrel� za PWY==. ll+smg to taa Joamo mr zvzjac= Al.r inaeruotla_a; 1~ raw n10 oultitt1L- _ � �� 1l� '1�'�--2O`? a.ry K,�,. aecNaca,ws;► ��t�S4��.,w 11 l� t►�o b�..l. _ 2 34.:'�� S�i � / ° y fs.s � >•mtWssa is airi9.ee ta.r Hb.�,,,��i` .��.+-...^� .. .. • "KAAlMr Od"6 mra-/aleia/:lr .... (c >' (- 2 3S 51' 7 "-'I. Ap UlLtsao nW, to, atbluiti® t t7 a0 wa Amr V&vuiblAW D out + ./ �. q+ecw v iPaeVLei 110 O Mobile ]ia�+e G 0, taeuatt7 ❑ cr.4ca' .i( � T� a'e*+o+eaiil �er�a►+1 t'.t ...vol+ssotnt eadttica Q ><�eeetl.�o r 'tea. it: =amidenoll� ; 't�libaLal rte, !! llndsv®1 �„ t uaa�troca+er t,_ �.. �et.raea.r Oaatalma si•twat �I.W1atr a�1.,. ��.,.:..rfaiui►ti>0 Oo..�+,onsJw n.r....0 7. i>li siratewa/ae�alr /oafor:.oa�l t�� 1 1eoplo �,,,l� • Ot�a► „r„„�, e aer�uaae �,�� v1 ia~aliw �� f 0i:aa11 �,^� - • 1 Yetee Ca.lerr .,...�,.� _ I! r6eWo oto I /gases Srtta`aad w•sar trasgo mall-w ser day$ a—+t 2vpw of eats owwav AlwyclAw O rail G em.ot►yus ty, . I* rm aewa o at+ rlatv4adau of is radr y MW x7acat 14 iomtltdod W surve G Yue •e'IAm A�gAldi PKGf9 l'rV ANVOli ANMON so WQ%J""kb ^• IiR.OW., �)ml�tQ aff4 Yta la utodtest wiaTHIS A FL1CNVl • `„�►ltltfij' liltopl�N'(i� � �C leg �MIR[Tr i�litli�l�DllY t1n'1r 4+�lYuj 1� NINI'1J:11': .i oma, rum: 1 ? ` 3 3 r viraltetyar3dta3c gad Naim ��OLj,si'<.'GaJ� 1—r't��1f��O�� (3 �,_,_ it sub Pala tym"llromilats, 0 SWlatitu MUM rase SaaUooa mock: .�., tit; 0atr1• AtAh* t Omwd. D `� Tbb is to cerary last tuaielarasssa a#kvuW Tt acme V tba fuss otilty kuvwlt Om 1 utldarotaad tlml jiuY loart1111(t) tape$ bo=Atr an Rwmrd w my-vtdeo. Y tho sib Piaui a r LOWWAW aw” Wm m w Jf qe ill(orwldeo sebsNual to m>yii rppltmtloa sic taislJiad er dlintab j �++. aafsa+ralf ewrtsr t�.i+#�lr.0 ar�.i rcarrt✓lya: t�Fi +JlJrimefOfile� !, 4arsbs� p A tweeol ti ct. tafNilarsd R�►t+mlaataQrs e[the 47e 4a Colw(r llarillJ► GepaHwen► ... ma toter �Avaibolz tJaaarllad lappa►(7 tr,caiCid b DaKa 4:w+r sad awed � _. . to wwWvrt atl t aC%& lu=W w 0 octt>Jary lu datC WAW tLeslia itl L021ty �3lgAttStt M1Y3S tl�G�03D�Tt910 YDDRi'1J1i'( all a1 mJ>o ltt�A1 iltlttlr aatl prop prupo'q'4aailwddiareidoar� sOreaQro4 satbadef, aod�titl°attlarf}. Vit6liaVtf11 • � l ©� Daie�+ 3-0 Cz~weNallCa�latia�ta: - ' At— elp Clive tt , i- O Acvtltd DMID (OSIm I �S tt ka ZQa. 41 11 I f Ammost Igf a UK b w �� t>Yf.9t �r�r � 9@L � 11116E 1 , • �' 4' =- awt2�.rsrsw��rww. PW OWK 1 PW M �• E No sm' t•oosae�,-� P{�hrfS i4it�1A1�CIt - � � o• s+i ri sre�'i�i ni�ir A ..M MW rare° a w 7N ro�r Zr Suva W la some 1a et I" wiww k a a co OR 7f Wft tyt a W4. ro r CO yn,R 1f ar ods . r ttrfe� vara m a dos. Fa` m_ m A a M t]71 Aou� ; w m D 3 ♦ :� m m m S7q 1k.ss td� • r 1 \ - 1 `it A WhI%"sftmas or10014 • S..lA /ILRa itsli 1 -I_ r �' 1'� tiles M Mw w i yam• i c� yd_liijdw.WpvprrW r 11�f I S{ Il goo am N y i1ftworM it �t ! � � � � � (� (t � • M M w M■1 r tAw wr D t,hh r \� M c c 3.m7, arae iaa9 i A m -4 n� Al a" MOM JIL C2 Y e1 Q R t~ \ O . 1 7 RM grim 7i no IQs � -1 0 VG ZT co IP 01 N dl � � I, \�• � (in war `n% •m'rr.� Ma 0 � tswwa► a•�1 � m �E ibelfi��1C /R AMK /a W AAWPAW vA i Vtom mm MWUA iM mac w o ..m (rA - - nor tl�Rlic I � y0 � W T 1 .. / �-� 0- APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC L �Davie County Health Department � ri p Environmental Health Section ( , o P.O. Box 848/210 Hospital Street �{ G 3b Mocksville, NC 27028 7j (336) 751 8760 ***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 1 + A NO e% 11 Glh �J Contact Person J-0,1-1/ Mailing Address/ g / `(� Home Phone 33'� -?e? Z✓/fv City/State/ZIP ]Yr'gl _q `V % C / O (3 Business Phone 3N — Y9? 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: Site Evaluation 4. System to servi e:AKHOuse ❑ Mobile Home City/State/Zip ❑ Improvement Permit/ATC ❑ Business ❑ Industry ❑ Other 5. Type system requested: Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People_ # Bedrooms —5—_ # Bathrooms PDishwasher 12narbage Disposal I�Washing Machine 7. If Business/Industry /other: verify type # Commodes # Showers ❑ Both ❑Basement/Plumbing ❑Basement/No Plumbing # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: k County/City 40 Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 19�No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: (� (y WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # S "7I (�- I . a J 3 y 7 I � +0 Property Address: Road N me �i�e5 K n e I l Br0(jkr& 8 dQ ir✓ I (1((,1 A'e–1 City/Zip MQ (IS V J I If in a Subdivision provide information, as follows: Name: /h ea latJ R it A 4-u Section: I Block: Lot: Date home corners flagged: U % 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 FoAi y' to conduct all testing procedures as necessary to determine the site suit ility. � DATE tr l f V — 4 SIGNATURE&411'� 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). Site Revisit Charge Client Notification Date: EHS: Sign given `� 0� S- Account No. Revised DCHD (05/03 !Invoice No. —75 l 8 t nom. APPLICANT INFORMATION Account #: 990003138 Billed To: Peter Falk Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5749-33-5745 Subdivision Info: Meadowridge Lot # 34 Location/Address: Knollbrook Drive -27028 see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION 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 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 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) APPLICATION FOR SITE EVAUJATION/IMPROVEINENT PERMIT & Davie County Health Department Environmental Health Se+Ww P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 MAY 9 2001 ENVIRONMENTAL HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL T zt INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Ketit,%ETH L• Fot.TEQ. Contact Person KEW F4S:X Nailing Address tZ(„ MAPIE TRE,= 1p,,3E Home Phone City/state/ZIP -_tA(-. , Business Phone 2. Name on Pertcit/ATC if Different than Above Mailing Address city/State/Zip 3. Application For: I(Site Evaluation ❑ Improvement Permit/ATC ❑ Bo '11'. 4. System to service: d House ❑ Mobile Home 0. Business ❑ Industry ❑ Other S. If Residence: # People 4 Bedrooms 4 i Bathroon.s 4- / V'Diahwaaher ri Garbage Disposal Washing Machine M Easement/Plumbing 13 Basemor.':;_Yo Plumbing 6. If Business/Industry/Other: Specify type t People It Si.ics 1 Commodes I Showers # Urinals # Water Coolora IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 12r County/City D Well it Gcmmunity e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ Ne If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED F BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: (-8)( 34o-7 7 q 19 'X 367X 250 5749 3-3 2338 Tax Office PIN: # Property Address: Road Name _ City/Zip If in a Subdivision provide information, as follows: Name: WADow RiooE ( pRoeoseb) Section: Two Block: Lot: 34 WRITE DIRECTIONS (from Mocicsville) to Plt! +PARTY: US 159 14bRrak. RkCtAT OAJ �_Atnt FORD RiGEL XT 9=A/7i94h/C-6- , O Mt:ADow Ri/oGE-� X'V Dep -D S,4.Sti _T()Ri1 POGL4t -Go Tri' Ego v1= Date Property Flagged: to `( 9 ,t Z O C / This is to certify that the information provided is correct to the best of my knowledge. I understand that any pi:d mit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the inforrvition submitted in this application is falsified or changed. ],also, understand that am responsible for all charges 1^74:rirred front this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Departmeat to enter upon above described property located in Davie County and owned by t a3eRT G• f1c.CLram1A,oc1L4. to conduct all testing procedures as necessary to determine the site suitability. DATE m n Y 71 ?,Wl SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing acid ;arc,pased property lines and dimensions, structures, setbacks, and septic locations). Site Revisit CluirfA ; I Datc(s): Client Notification Date.- EBS: ate:EBS: Account No. Revised DCHD (07/99) Invoice No. _� „„ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LOTr Soil/Site Evaluation APPLICANT'S NAME G'S�� DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ✓ ROAD NAME Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position .4— Slo e % HORIZON I DEPTH t 1 Texture groupS L Consistence Structure Mineralogy HORIZON II DEPTH rt r� Texture groupC, C 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 i SITE CLASSIFICATION: U=� LONG-TERM ACCEPTANCE RATE: REMARKS: "� e Landscane Position EVALUATION BY: �a�/ OTHER(S) PRESENT: 65�1'4/`/' 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 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 (01-90) 6L (� �l APPUCATION FOR SITE EVALUATION/IMPROVEMEIV.i;rERMIT & ATC ) L Davie County Health Department ' Environmental Health u ection ( P.O. Box 848/210 Hospital Street L 3 p Mocksville, NC 27028 3 (336) 751-8760 i f ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESSHE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN ory;znstructions. 1. Name to be Billed 1+ Mailing Address City/State/ZIP !Cher C+i)/ C5 Contact Person/," 1 ark Home Phone 2. Name on Permit/ATC if Different than Above L/ O� ' Business Phone ' Mailing Address City/State/zip 3. Application For:!HO1 \Site Evaluation ❑ Improvement Permit/A'.. ❑ Both 4. System to Servi e: se ❑ Mobile Home ❑ Business ❑ Industry 5. Type system requested: Conventional ❑ conventional modified ❑ innovatir-.. .. ii 6. If Residence: # People - J # Bedrooms 5— # Bathroo'n (Dishwasher C9 arbage Disposal fsWashing Machine ❑Basement/Plumbing ❑Basesicat `: iiia`,/," , 0 7. If Business/Industry /Other: verify type # People # S.t, # Commodes # Showers # Urinals # Water Co,,I, . IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply:.( County/City •� Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1�W <0 If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: (� a 2 WRITE DIRECTIONS (froom Mocksville) to PROPERTY: Tax Office PIN: # Jr '7 T I J J, 7 T 5 �5 E +0 I I 5 (b A�{� Property Address: Road Na'Ives+ A n d i t Brovkr&,t ft M -e Gi (,101 ✓ I I I' 01 -ei / iT/� T kli City/zip M Asy,' 1 If in a Subdivision provide information, as follows: jj�� Name: � eq Ja t -J 'I 1 4f/ Section: Block: Lot: =_ Date home corners fl 7-0 tti This is to certify that the information provided is correct to the best of my knowledge. I understand that y permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the in ration J-1 S submitted in this application is falsified or changed. I, also, understand that 1 am responsible for all charges incur roar 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 ility. DATE — a SIGNATURE �f✓ 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). Sign given )V Revised DCHD (05/03 J,. y /I,- ��d X Site Revisit Charge Dates Client Notification Date: EHS: Account No. Invoice No.