120 South High Field Road Lot 32DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 rad
Account #: 989900573 Tax PIN/EH #: 5870-69-0403.3291
Billed To: Glenn Johnson Builders Subdivision Info: Windemere Fams Lot # 32
Reference Name:
Proposed Facility: Residence
ATC Number: 2826
Location/Address: Beauchamp Road -27006
Property Size: see map
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 reatm t and Disposal Systems). THIS
AUTHORIZATION FOR WASTE A -TER C S I D F PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur : ate: O
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.
-Ta J K bNT6 s - z1
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
I—,�axjk
� � a
I
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
P. O. Bos 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900573
Billed To: Glenn Johnson Builders
Reference Name:
Proposed Facility: Residence
Tax PIN/EH #: 5870-69-0403.32gj
Subdivision Info: Windemere Fams Lot # 32
Location/Address: Beauchamp Road -27006
Property Size: see map
q�l
TC gbyr: 2826
**NOTE** s mprovement/Operation Permit DOES NOT authorize the construction of 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 IAW!�>- #People #Bedrooms #Baths 2.5
Dishwasher: 2(1, Garbage Disposal: Washing Machine: Er Basement w/Plumbing: ❑ Basement/No Plumbing: 1211 -
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ,� AueK > Type Water Supply Design Wastewater Flow (GPD) 7ZYZO Site: New 171 Repair ❑
System Specifications: Tank Size1000 GAL. Pump Tank GAL. Trench Width _ R-eek-Bepth Linear Ft. 7-S7
Other: '25Z &1Q1dCT1QtJ —SV5-71/I? 1STRl �T1C `3�1CGS
Required Site Modifications/Conditions: 1ASMLL .J
ON) C4J^ICoK!`-Fp _10'o
IMPROVEMENT/OPERATION PERMI AYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Ccrntact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.r or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
l _L 1<L rA
/ l�c►'� —Its t►`1 �TAu.._
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Environmental Health Specialist's Signa ate:
DCHD 05/99 (Revised) v
352
LARGE PINE
STUMP
3,2
31
110
876.79 N 87.03' 09
i
i
I
LAWRENC_E L. MOCK
BY WILL
p��.n o Cn 0- ��
•IWR 2 0 a
ENVIRON
ON FOR SITE EVALUATION/IMPROVEAIENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(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
61em., J. X,5,, 94 �j ae.PS _.JC'
Contact Person GIee6l
Mailing Address
13 y6 �Hd��95� itr/
Home Phone /gC14
City/State/ZIP
�l/Q'ar'r/621 , �V
Business Phone / �C� ✓W
2.
Name on Permit/ATC if Different than Above
Mailing Address
City/state/Zip
3.
Application For:
❑ Site Evaluation
mprovement Permit/ATC ❑ Both
4.
System to Service:HFA
-Hou—se ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
s.
If Residence:
# People #
Bedrooms 3 # Bathrooms a ��
LYDishwasher -M Garbage Disposal C Washing Machine ❑ Basement/Plumbing Wtiasement/No Plumbing
6. If Business/Industry/Other: Specify type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community,
�-
e . Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ N
If yes, what type?
***IAtPORTANT*** 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: 5�:= � WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # S� 70 —& S, I)'/a 3 . 2 ;---" A",.> e - X- C � 6.y\_
Property Address: Road Name
City/Zip
If in a Subdivision provide information, as follows:
Name:L
Section: �" Block: Lot:
��--� )LOA.
Date Property Flagged:
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 cuter upon above described property located in Davie County and owned by _
to conduct all testing procedures as necessary to determine the site suitabiliy.
DATE (— -o— 0, / SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN
property lines and dimensions, structures, setbacks, and septic loc:
Revised DCHD (07/99) n J
;-310�
of the following: Existing and proposed
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. /
Invoice No.
APPLICATION FOR SITE EVAWATION/IMPROVEMFM PERMIT & ATC
Davie County Health Department
Envilronmenbd Nee/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
.r
AUG 2 5 1999
,.,,..,-,,,,,....rte_ ....,,... ._...
***nVORTANT*** THIS "PleleATION CANNOT = PR=SMW mmzs8 Alm THa R$QUIMM
IMMRMATION IS PROVIDED. Refer to the INFORMATION BULL$TIN for instructions.
1. Ilan* to be Billed WESiV1EW 1�FJCWF.-MJi-n C01-10AW1 Contact Person �) G CY
sailing nddreas 243% 9-EVI')6VnA RQ- soca shone _ 336. 0-1.008
City/stat*/sIP ul:NirM-SALtv�'NC, '11106 Business noon.
2. Naas on n*raiit/ASC it Different than Above
Nailing address
City/state/sip
s. Application For: teits =valuation 0 Improvement Permit/ATC O Both
Sw0woo
e. system to services Houses O Mobile Homs O Business 11 Industry O Other
S. If Residence: i People ! Bedrooms 0 Bathrooms
a Dishwasher 0 Garbage Disposal a washing Naohine 0 Basement/Plumbing 0 Baaesent/No plumbing
6. If Business/Zndustry/others specify type
i Commodes # showers
# Urinals
# People t siaks
# Water Coolers
IF TOMBRI VICs: # Seats Estimated Water Usage tgallons per day) {.
7. Type of Maur supply: 0 County/City 0 Well O Communitty
s. Do you anticipate additions or expansions of the facility this system b Intended to serve? 0 Yes ETNo
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM IM by the client with TIM APP1dCATION.
Property Dimensions: Se-,
Tax 081ce PIN:
Property Address: Road Name
City/Zip f%O'yd'icc/1/c-'2%C
WRITE DIRECTIONS (from Mocknille) to PROPERTY:
}�AEnry o>J LEFf.
If in a Subdivision 7 provide Information, as follows:
Name: A)l WocMN� �tt.MS
Section: 'I/ Block: Lot: 3;7,- Date Property Flagged:
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 we change, or if the information
submitted in this application is falsified or changed 1, also, understand that I ant responsible for all charges Incurred from
this appUcadon. 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.
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the Mlowtng: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
I Date(s):
Client Notification Date:
EAS:
Account No. /A6
Invoice No. z2Lfq: )
LAWRENCE L. MOCK
' BY WILL
REF:D.B. 49 P9. 8
ON PACE
Q63 37
T FENCE CDRNER 14
2C
V
APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Env1tvnmenta/ Hgwith Sectfon
P.O. Bos 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
AUG 2 5 1999
***IMPORTANT*** THIS APPLICATION CANNOT Bic VX=SMW UNLESS ALL THE REQUIRED
IMFOR14AT1OM IS PROVIDED. Refer to the IMH'ORWION BULLHTIN for instructions.
1. Maas to be Billed WESiV1r'J -DFJCW?J N7 cam' wy Contact Amon ) GogaCY
Mailing Address 2031 REVNOI.nA TRO. moms phone 3300-1008
City/stat./asp WINiT&J-SA►-Cv%'NG 2110(• Business phone 336.11"1- 6011
Z. Haas on permit/71TC it Different than Above
Failing Address
City/state/sip
3. Application For: 1948ite =valuation 0 Improvement Permit/ATC O Both
„1510si
4. system to service: L3/Houses O Mobile Rome 0 Business O Industry O Other
S. If Residence: f People s Bedrooms i Bathrooms
O Dishwasher O Garbage Disposal O Mashing Machine O Basamant/Plumbing 0 Sasement/No plumbing
6. Zt Business/2ndustry/Other: "City type i people f Sinks
f Commodes I showers i 'Urinals • Mater Coolers
Ii TIOODSERVICE: # Seats Estimated hater Usage (gallons per day)
1. Type of Mater supply: O County/City 0 Well 0 Community
9. Do you anticipate additions or expansions of the facility this system is intended to nerve? 0 Yes t3 No
If yes, what type?
***IMPORTANT*** CLIENTS MAST COMPLEIETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MAST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tai Office PIN: # d ,70 —� in� �C�.J
Property Address: Road Name �'C uc L'
IF
City/Zip AOy11-'7c e - /!/c- 2%C>
If In a Subdivision provide information, as follows:
WRITE DIRECTIONS (from MockrAlle) to PROPERTY:
Mocks Curt To Piaui' cw 9106"P„ d
�AEnry o� LFFf .
Name: (Ali A/DEMt-8f I A%916
Section: �� Block: Lot: �31 . Date Property Flagged:
TMis 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 we change, or If the information
submitted In this application Is falsified or changed I, also, understand that 1 ant responsible for all ciarges incurred from
this applicadom 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. �^ / L
DATE 8'
M%9.7 _ SIGNATURE A0V ! 1�G Z/"'
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the lilillowfug: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
ZEAS:
Account No.
Invoice No. 60 6
ON PUCE 63 37
T FENCE C�6NER
LAWRENCE L. MOCK
BY WILL
REF:D.B. 49 P9. 8
34
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION
Account #: 989900136
Billed To: Westview Development Co.
Reference Name: Brant Godfrey
Proposed Facility: Residence Property Size:
Water Supply:
Evaluation By:
PROPERTY INFORMATION
Tax PIN/EH #: 5870-69-0403.32
Subdivision Info: Windemere Farms Sec.2 Lot # 32
Location/Address: Beauchamp Road -27006
See Map Date Evaluated:IC>/Iqhq
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
C
L -
Slope %
14Z-
%HORIZON
HORIZONI DEPTH
Texture group
CL_
Consistence
7s F
Structure
c e
Mineralogyl
HORIZON II DEPTH
Texture groupC
Consistence
`
Structure
SS
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: rS
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
Landseane 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
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)