487 Rabbit Farm Trail Lot 15DAVIE COUNTY ENVIRONMENTAL HEALTH
' P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990005887 Tax PIN: EH #: G800000215
Billed To: Robert and Kerri Creel Subdivision Info: Rabbit Farm Lot # 15
Reference Name: RELOCATE LINE FOR POOL LocationiAddress::'4'87-Rabbit Farm Trail -27006
Proposed Facility: Residential - Relocate Property Size: : 8:30 Acres
ATC Number: 5941
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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.
System Type:_ S.T. Manufacturer L04j Tank Date Tank Size /
Pump Tank Size ✓ ,j Bedrooms
System Installed By ,�G_ YLI y�,�,�`�l!"w Installer#: Date: 119 1201Z
GPS Coordinate:
Environmental Health Specialist: 0 A A jL Date: /�
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005887 Tax PIN/EH #: G800000215
Billed To: Robert and Kerri Creel Subdivision Into: Rabbit Farm Lot # 15
Reference Name: RELOCATE LINE FOR POOL :: LocationiAddress: 487 Rabbit* Farm Trail -27006
Proposed Facility: Residential - Relocate PropASW: 01 b $air ❑E
*�^*� TE** Thi% horization to Construct (ATC) MUST BE ISSUED, by the Davie County Environmen'
ATI�3Y eeCl on p i to.issuance of any building permit(s);' (incompliace with Article 11 of G.S. Chapter 130A'
Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms 3 # Bathrooms Z S # People 3 Basement❑ Basement plumbingF!r
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size .9 Type of Water Supply: OCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) :3(CO Tank Size QX /� AL. Pump Tank _.-- GAL.
Trench Width`Max. Trench Depth Rock Rock Depth Linear Ft.,'�Sd�
Site Modifications/Conditions/Other: Rdu(.fzvh
Contact the Davie County Environmental HeAlth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
1GL
Environmental Health Specialist ffj "IT141101"010111f M1.1 #13
DCHD 1. 1
Davie County Health Department
o P18 l� --Environmental Health Section ,
P.O. Box 848
C�
210 Hospital Street
O U T; Courier # : 09-407-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (330 - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: � � / S" ���� ��v� � s Phone Number (Home)
Mailing Address: ��y /fib f/�//V ///�%/, (Work)
/YIt�C%C SU�I/ /t/C
7)'7&,2? Email Address:
Detailed Directions To Site
,4)
C CIS / M "bE
�4
Property Address: au n/a l�G�`'f = s4 j� Vii/ ,� lm A,, ce:-�
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: / ��/� Wiz. Type Of Facility: tf /1l/S c
Date System Installed (Month/Date/Year):Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes CND If Yes, For How Long?
Any Known Problems? Yes No if Vis, Explain:....-..-
Please Fill In The Following Information About The NEW Facility: -'
Type Of Facility: Number Of Bedrooms, '\, Number of People
Pool Size: � � !l' 3"17 Garage Size: Other: `
Requested By: Date Requested: 6�'V—%2
(Signature
} For Environmental Health Office Use Only (�[�
Approved Dispproved % 7
?
� -
Comments: !' ,' o CiG� ( C �_ (l � L�(w
3
t
t
Environmental Health Specialist .. (_� % ` , C� -� ;, Date: �i —Ca
*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 CasAmount:$ f Check Money Order # �� .0d Date:` --lZ
Paid By: +Y N Received By: A
Account #: �- r) � Invoice #: ITI
3Zs�
Th Sa._r.�6 ',:Aie
21 f
j I 3 Tg
IBX 3q n
rlberigm5s P601
3l — Fo f)6prj9
CRC -6t, R6-S;j),6AJCC- *
,4 a VAA.ICE N '
F."'RON 7000
0
b 9�
AUTHORIZATION No: 18 9 5 DAVIE COUNTY HEALTH DEPARTMENT f
- Environmental Health Section
PROPERTY INFORMAT6N �J
Permittees P.O. Box 848
Name: =oft f'� =c ��i�— Mocksville, NC 27028 Subdivision Name:
�
Phone # 336-751-8760
Directions to roperty: "��"`
111C2,`
AUTHORIZATION FOR
tC i! r J 1Z r 61 T r l) C2 ,` 1 Al 54CLL WASTEWATER
STEM CONSTRUCTION
Section: -., Lot:
Tax Office PIN:#
RoadK"7
me: `�`'I J rit-I2!ip. J
**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 applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
`E9VIRON9ffN—TAL HEALTH 9PM&Ljs'r
141"
-895 DAVIE COUNTY HEALTH DEPARTMENT
T N
IMPROVEMENT ANn PROPERTY INFORI�I OPERATION PERMITS At, O
PeMlittee'sr"" j Name: � �-,-,, Subdivision Name:
r� E,i=ice
w. ,
Directions to property: i , .: l�� ] ., ,. 1 I Ii:
_ Section. Lot•
ROVEMENT
r.1 . ►,�., t i� -- l., t L ' PERMIT T`az,CO�ffice PIN:#
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a sepdticc 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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONmENTAt' HEALTH SPECIALIST DATE ISSUED
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE kjf)QSct # BEDROOMS ', # BATHS # OCCUPANTS _ GARBAGE DISPOS : Ye ,N.
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/ SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �) • TYPE WATER SUPPLY �%�
DESIGN WASTEWATER FLOW (GPD) � 7 NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE I CCOGAL. PUMP TANK ILMGAL. TRENCH WIDTH � ROCK DEPTH , LINEAR FT. [F
OTHER `J� PsT(2,5 rTl o-3 T, Ce -1 ! / �i't �.�1J�1.� (%�� ( l%C^IT F) LTi.�-
REQUIRED SITE MODIFICATIONS/CONDITIONS: I Ivy at.l O'� U'31000- <tG{: p 1 p Ur
PERMIT LAYOUT `. A (V C* n ` 1-'
ltC: x�co 'x12
.j
l'iGr=N� Int e
-74
�-Isb
r'S�GS Q� tS�I�
**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 (336)751-8760.
O
)PERATIOTT
���J— SYSTEM INSTALLED BY:
o
H
0
""-0
1> .
AUTHORIZATION NO. OPERATION PERMIT�4A
DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICSTEM DESCRIB OVE HAS BEEN INSTALLED INC MPLIANCE
WITH ARTICLE I 1 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
i
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
• Davie County Health Department .
Environmental Health Section
P. O. Box 848 FEB
Mocksville, NC 27028 121999
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS E UN I " (`�" i
ALL THE REQUIRED INFORMATION IS PROVIDED. II /
1. Name to be Billed - ► i/ Contact Person L. I nd y 20 �/ngL'�
D Co w� an• Tri ea
Mailing AddressAd, ^ s Home Phone
City/State/Zip , �a,VLG� --;L C-- ou o Cc Business Phone `'7 /gy/ p� 79/6
t
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Reside ce:
D❑ ishwasher
il--'S to aluation
House ❑Mobile Home
:G-arbapge
PeoDisposal
le 3
6. If Business/Other: Specify type
_ City/State/Zip
❑ Improvement Permit & ATC _Qb� ❑ Both
❑ Business ❑ Industry. ❑ Other
qp
s.$^6 n,t A2¢�
# Bedrooms # Bathrooms
�4e
U— aching Machine C3Basement/Plumbing ❑ Basement/No Plumbing 'S
# People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ElCounty/City a -Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes a -W-0
If yes, what type?
INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: o0X I a �6,� I7 /l ice- 1 WRITE DIRECTIONS (from
�
Qcksville) TO PROPERTY:
Tax Office PIN: # 5'�O - -� - 37 �QP�' /
) 1 t fCoI Cor
Property Address: Road Name�.hi � h1 �►'Yt i ; _ _ r 77
City/Zip oa 0_ C- a 2 00 Q, 1
1
1
If in Subdivision provide information, as follows: 1
Name:
1
JS 1
Section: Lot #: 1
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 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 : r' 9 "6T SI SIGNATURE
Revised DCHD (06-96)
n
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DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section SECTION_ LOT j
Soil/Site Evaluation
APPLICANT'S NAME E-n�u� 2
PROPOSED FACILITY Roos
SUBDIVISION
DATE EVALUATED lzq-lq 1314
PROPERTY SIZE�,j O W� �-
ROAD NAME 42417 Ti's I l
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit
Public
Cut
FACTORS
1
2
3
4
5
6
7
Landscape position
L
L
Slope %
3
270
HORIZON I DEPTH
O -
0-0
0 - 61
0 -
d -
0-(,
b - !o
p.g
Texture group
r 1
GL
S CL
, CC_-
C L_
GI;
5 GL
SC.1,
Consistence
X55
S S
1-r SS
- 5 P
I;r S5
G
5S
Fio
Structure
ll -x(01
e2
CoQ-
C_ L7
G2
-P-
48
Mineralogy
/17iA
M
/Y)l -.
M I A5?0
(A 1
M I
M 1)0--D
14,XP
HORIZON II DEPTH
- /2-
ZjLk
6 -f
-/q_
If
Texture group
G
C
C
G
5 G
S L
Consistence
V r17_S7F`
1-- � 5
1'; 5r
Structure
M
M
!c Mk -
Mineralogy
2-; 1
2,1
2: 1
Z
1
Z.'t
PZ Ali
it,
HORIZON III DEPTH
1 7�.
124-
! D f
1-12-t
Texture group�'
S
S�
n
S
�%
Consistence
Structure
�}
MineralogyJh
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
SAPROLITE
CLASSIFICATION S U5 1 U-15 S PS
LONG-TERM ACCEPTANCE RATE I I I I I 0 Z � B•Z
SITE CLASSIFICATION: w - �� �v5N EVALUATIONBY:
LONG-TERM ACCEPTANCE RATE: d Z OTHER(S) PRESENT: 1')i)r,YL "aLU 51q of
REMARKS: /V�-� ` �� /r- > c9Y
n U �jZ�r MjpoD(�tCGLEGEND W1Lb tDwj -TD pon -To SASCsta-n
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope Fp-o^yT P4(,117- e-C12)6fZ-
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture CP
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 (OI -90)
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Davie County Neal th Department
Environmental Nealth Section
Po sox 848 / 210 Hospital street
Mocksville, NC 27028
Phone: (704)634-8760
March 4, 1998
Mr. Edward Haberberger c/o
Coldwell Banker Triad Realtors
5342 Hwy 158, Suite 1
Advance, NC 27006
Attn: Cindy Johnson
Re: Site Evaluation
Rabbit Farm H Lot # 15
Tax PIN #: 5870-50-5372
Dear Mr. Haberberger:
As requested, a representative from this office visited the aforementioned site on
February 24, 1998. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed, the site was found to be provisionally
suitable for the installation of an oversized, modified on-site sewage disposal system. Due
to the location of the residence, it will also be required that the sewage eluent be VO-Mped
to the septic drainfield.
If you have any questions, feel free to contact this office.
Sincerely, /
Jeff'G. Beauchamp, R. S:
Environmental Health Section
enc.(s)