360 Bridle Lane Lot 11.�:?l `Y'.1. SJ{ i I •1�w i .'I '.,°1 l f_.a`'� �_d.� _
S 7
AU;HORIZATION'NO DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's 1 P.O. Box 848 !`
Name`. 1 t�"E �' `✓'�`Mocksville, NC 27028 Subdivision Name:
LPhone # 336-751-8760 yy
Directions to property:T'-e' Section: 1 Lot:
---. (�.
AUTHORIZATION FOR
1'� �J CyP.j 1`t �. G' WASTEWATER Tax Office PIN:/? _ 20
r , SYSTEM CONSTRUCTION #
v--z> Road Name: ip: ZU()(,
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County. Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when app'-lyi5g for Building Permits.
(In compliance with Article 11 f G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage,Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
J, IS VALID FOR A PERIOD OF FIVE YEARS.
VIR N Nfi l EALTH PEC�A IST D E I SUED'
5 9A DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS
Name` !L'j-r eV`L�w. Subdivision Name: 1.
Directions to property: j-
r
(1:,... t,-) it i+
PIP :5 -11q -
PROPERTY
r
PROPERTY INFORMATION
Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# - -
Road Name: ,' r' (.z: Zip:
**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.
(In compliance with Article 1"I/of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THUS PERMIT IS SUBJECT TO REVOCATION IF SITE .
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
t INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPEI i01?`�i� # BEDROOMS --2,_ # BATHS —S- # OCCUPANTS"-'..-- GARBAGE DISPOSAL: Yes or 1
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
_ �
LOT SIZE' CZ � TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) —�NEW SITE REPAIR SITE
a) II It Ll
SYSTEM SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 1 / _ _ LINEAR FT. ��
OTHER —� 1
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 NC Vti,LL CA Ct�)TDy�, 1 /—c —' )4rx)��"-
AWA A
LA it
Vrr-r ru-rrT FILTEG* #FtISER1S1 IF 6" . E.UMi FICISHED GRhDEt
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS%jWfd4jR6q;
13:351751-87r,6
OPERATION PERMIT /pp
r j�
YSTEM INSTALLED BY:T.
.•1!
MJ
.3 goy
ZZ v j
:s
'�i,t,a V D A rC- 61-2
K" r
AUTHORIZATION NO. 115 ' ' 4 OPERATION PERMIT BY: DATE:
*"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THEM DESCRIBED ABO AS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATME 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.
DCHD 05/96 (Revised) �?
1.
s.
4IPPUCA110N FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department t�
Environmental Health Seg WO)7 Q l�
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028 MAY — 6 1999
(336)751-8760
***DW0RTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TAE REQUIBSRC
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
Name to be Billed 4�16010)1 0l— 11 r' ?1/ �7�' l�O Contact Person
Mailing Address �✓rG� �GSGGti/ Same Phone
City/state/ZIP -,r¢ Z7O4o Business Phone
Name on Permit/ASC if Different than Above !"l % Al[e
Mailing Address City/state/Lip
3. application For: U Site Evaluation poo4fimprovement Permit/ATC
4. system to service: douse O Mobile Home ❑ Business ❑ Industry
❑ Other
0 Both
a. If Residence: # People 4 # Bedrooms # Bathrooms _'�;
01Dishwasher 0 Garbage Disposal 0 Washing Machine 0 Basement/Pluabing 0 Basement/no Pluming
6. If Business/industry/Other: Specify type
# Commodes
# People # Sinks
# showers # urinals # Water Coolers
IP FOODSERVICE: # Seats Estimated Water Usage tgallons per day)
7. Type of water supply: 0 County/City hell ❑ Commwnity
6. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 9.14'0
If yes, what type?
***1HF0RTANT*** CLIENTS AIUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �� iC I O 7 ✓
Tax Office PIN: #
Property Address: Road Name //,100 /P Z if -
City/Zip � Ra e
If in a Subdivision provide information, as follows:
WRITE DIRECTIONS (from MockrAlle) to PROPERTY:
.00tj?
Name:
Section: LBlock: Lot: �.�_ Date Property Flagged:f6 41 -
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. 1, also, understand that I am responsible for all charges fi curred from
this appUcation. 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 SIGNATURE
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. S�
Invoice No. ��
• COM Reoin
Chard
• CMfevlris
• Creon Out
. Conoerod Acme
• Cmre= Mew Pipe
• Men Ibis
b.t e*0cz cSf -LAT"
—Log"
• PC • Pdnt of Curren
• T - Torpent
•PT.PointMTtga y
•TRANS •Tronersim
• PVC - Po"nv c"orldo Mpo
. UP - thrttr Petr
• PA.. Prop" LM
• VCP • Mello Ciry Ppe
• R • Raduo
• MIM • Wotw hM for
• RCP • FWmWaed Convote Pteo
. �'�
F�z
• RNY•RrOhtefWry
4o,
a:A 1 ,1' C"
ti�v
i
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l�
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6 W
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tp
C
Loc q—rloQ MAP -
N•
'n .to
.
10 I
40-r
�!grV
-11U.)
I tefly hat lhls map was dawn horn an acUei field survey made under
tGNlJEI. A EAYEfz
rr
my supertAsior : hal ft rasa of predslon k 1:10.000..
TFTs day 1094--
B21 TT Cex-EMand EANE9—
of
GROVE'DAy 1£TOWNSHIP, COUNTY, N.C.
f
. �'�
F�z
$taiheG Co -r 1 1 oa= 'szc�sa.Sr-r
4o,
Qg. PCr.-71
ALs,ckos-f,
tc -
-•r-1540 •
yo -+ •
S�
l',,e'•.,,•URv�e•"5i
,Ca so o too
SCALE V. 100
:
,1jtt.+
GIZINSKI SURVEYING CO.
,does not meet N.C.O.S.47.30
7312.11-�-L-a lsA IJE 727 GALES AVE. WINSTON-SALEM, NC 27103
ds and Is not For recording.
BASS 1'r 1=A2 M
P-ONI> 722-0554
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 4 O o 4 Home Phone
C
� 0 Business Pt1b e �f�^3 L%
ILA-) W i _
2. Name on Permit if Different than AboveV! 11 1 IS%t 7r Uel 1U_ W 'W'-] v r r
3. Application for: G(General Evaluation ❑ Septic Tank Installation Permit
4. System to Serve: (House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑\Ind try ❑ Other ❑ Unknown
L%f
5. If house, mobile home: Subdivision �C! ��Y 1'1� Section 1 Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms ❑ Washing Machine
No. of Bathrooms ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories _
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: El Public (Private
8. Property Dimensions A C—r 'e S Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If ves_ what tvne?
❑ No
❑ Community
'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: Co V'Ylk*- Z k),V- J r ► V, h x'e 0(4
154 V -N
k,- 5
c
5-e e yrlpo /Jo us t, �� �-e- !� �e �� c N -vd el/'
� 7
This is to certify that the information provided is correct tg the best of my k off
incurred from this application.
DATE
and I
SIMOTURE
I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative the Davie qoynty HZIth De ent to nter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determin said it 's suita it foN6 ground abso n sewage treatment
and disposal system.
DATE SIGNATORZ
DCHD (1/93)
0 6
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY d o !"o
DATE EVALUATED �� 2 9 T
PROPERTY SIZE
LOCATION OF SITE-�
Water Supply: On -Site Well �'� Community Public
Evaluation Bye`, -:\ Auger Boring ✓ Pit Cut
FACTORS
1
2
3
4
Landscape position
S15
Sloe R
y- IT v
(J— �
o- E C,
(7) 0
HORIZON I DEPTH
L''
Texture group
C L_
Consistence1
Structure
C
Mineralogy
%
HORIZON II DEPTH
Texture group(�
C
Consistence
FIT,
FS
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SS
c <
f S
SS
RESTRICTIVE HORIZON
-
SAPROLITE
CLASSIFICATION
�.S,
S
S
LONG-TERM ACCEPTANCE RATE
•3
3
SITE CLASSIFICATION: "'S - EVALUATED BY: c Y,���
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
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
SILL -Silty ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-V--ry 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
,3C -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
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f t1.e fol lo.Sn{ a• 1Mlcat•{ tut: ® or Q
�ra tn•That : this plat 1. >Yae Ye ueiciWitY ttNt k.eeirl atdlnanfee•n�tltln
r•{ul�s�aop•�c�:� et lub4
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t ounty a unlcisalltr t.t 1s unr•{ul•ue a to an or{Ll— t.t
•{rl.t•• pare•1• of 1.nel
hat ar'. pl.t 3. • ii..r..>•ala in{ pare, er p•rdl. si 1•ne4
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1(.2.4G1
P B.L, 2 149
CERTIFICATE OF OWNERSHIP AND DEDICATION
I (we) hereby certify that I (we are) as the owners) of the
pr'perty ,horn end deacrlbed hereon and that I (we) hereby
adopt this plan of eubdivisi on with Inn (our) free Consent,
se tahlish all lots. and dedicate all roads. calks, parka,
,,,,menta, rights of way, and other open apace, to public
or private .sea sa noted.
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of loop.
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ryV K a.ntci.•ilV Wt L ..rc•pt.W .. a• aw aNlrK+ wt
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ceRTIrICATE or OWNERSHIP AND DEDICATION
1 lwe) hereby certify that I (we are) so the owners) of the
property anown and described hereon and that I (wa) hereby
adept ticia plan o[ subdivision with eq (our) free consent.
setabl Lsh all lots• and dedicate all roads, walks, parks.
ease.Knts, rights of way saa other open spsees to public
or private uses as noted.
R A'psS i"T �A
SHA9V GQp�
�AVIE G:
$EIwLG A AOGLTIor.l OF
pwwltr..o a•. ,aa..,1 N .
Davie County NealtI D artment
and .dome .7fealt§ Ayency
210 HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE, N,C. 27028
PHONE: (704) 634-5985
Auqust 4, 1994
Mr. George Wilson
3447 Robinhood Rd.
Winston-Salem, N.C. 27106
Re: Site Evaluation
Rabbit Farm Lot 11/Mike & Britt Weaver
Dear Mr. Wilson:
As requested, a representative from this office visited the aforementioned
site on August 2, 1994. Based upon the information provided on the application
for a site evaluation and after an evaluation was completed, the site was found
to be provisionally suitable for the installation of an on-site sewage disposal
system.
If you have any questions, please feel free to contact this office.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
CL/wd
Enclosure(s)