171 Baity Rd • HEALTH DEPARTMENT RELEASE For office use onN
*CDP File Number 201913- 1
Davie County Health Department
C3-000-000-7213
°yds ro 210 Hospital Street County ID Number.
P.O.Box 848 Evaluated For.
HDR/WWC
'�•�•r-,_ ..�
-•-'
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMITY.ALID 0 3 / .2 3 / a 0 a 1
UNTIL.
Applicant: Harris Pool Property owner: David Whitaker
Address: 277 Pleasant Acre Drive Address: 171 Baity Rd
City: Mocksville City: Mocksville
State2ip: NflotrisP061,51MAWC27028 State2ip: NC 27028
Phone#: kdi'Ylfhf(t MPhone#:
Property Location&Site Information
Address 171 Baity Rd Subdivision: Phase: Lot:
Road# Mocksville NC 27028
SINGLE FAMILY Township:
'Structure: Directions
#of Bedrooms: 3 - #of People: Hwy 601 North right on Baity Rd.on the left
'Water Supply: N/A
Type of Business:
Basement: F]Yes n No
Total sq. Footage: No.Of Employees:
'Proposed Improvement:
Pool
'Release Conditions
Maintain 15 foot setback from pool to any portion of the septic lines or tank I
-Idtri 'if
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps.Signature Required? OYes ONo
Applicant/Legal Reps.Signature-, *Date: _
*Issued By: 2140-Nations,Robert *Date of Issue: 0 3 / a 3 / a 0 1 6
Authorized State Agent:
**Site Plan/Drawing attached.**
0 Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE 20'1913 - 1
Davie County Health Department CDP File Number:
210 Hospital Street C3-000-000-7213
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 3 / 2 3 / `a 0 1 6
OWnt
0Inch
Scale: OBlock = ft.
Drawing Type: Health Department Release ON/A
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Page 2 of 2
New 16x24 Pole Shed
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Proposed
16x24 Pole €
*Rough in for Shed * 3
future bathroom if
possible Pool
septic00
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House
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107'
171 Baity Rd
Davie County Health Department
-V;8 onmental Health Section ;
P.O.Box 848
I
in• 210 Hospital Street ' fj
0 � 3 Courier#:09-40-06 1 n1 1
Mocksville,NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: IS O D Phone Number y;V2-7 (Home)
Mailing Address: (Work)
PC Email Address:
f� � Pll ,C
Detailed Directions To Site: G� D�C�f '¢� O
V,ev ,Z, �UU6 - oar -7zf3
Property Address: 7/ �/ QC
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: I/AVi J A da ke( Type Of Facility:
Date System Installed(Month/Date/Year): "0 /
`� + 13 Number Of Bedrooms: .�' Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes � If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility://� /000 / Number Of Bedrooms: Number of People
'Pool Size:�%P 1v 3 2- Garage ize: Other:
Requested By: Date Requested: �e
(Sign tune)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*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 proi ly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Al I Date:
Paid By: Received By:
Account# Invoice M
J"�u
S
., - DAVIE COUNTY HEALTH DEPARTMENT
y�� IMPROVEMENTS -PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary,Sewage Systems Permit Number
Name ' ' ` ' R' �`` �' r ' `'- Date l f N� .
LocationV. , �► ,\;
Subdivision Name. Lot No. Sec. or Block No. v
Lot Size House Mobile Home _T Business __ Speculation
r
No. Bedrooms .No. BathsNo. in Family
Garbage Disposal YES ,❑ NO .p S ecifications for System:
fes,_
Auto Dish Washer YES :gip NO E] " .,r
Auto Wash Ma thine YES ❑' NO ❑ t
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
�: ..sties � :��.=�• .. �
Ali
Improvements permit by
*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 day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: ;. y tem Installed by
\b� >9 <`
3�
Certificate of CompletionG 1/1'la-1 Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of.time.
.� - .: DAVIE COUNTY HEALTH DEPARTMENT 3 p U . t�
IMPROVEMENTS--PERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
sant ry Sei�rage systems Permit Number
Name `� ;9,>�1,-C C�� �, Date - -� 7--'
rt N_ 6513
Location
2�-c `t. V.) �.a�/7 0 1 U n t,
T) C.� 4�`�• V '-- �a'-�''J��J
Subdivision Name Lot No. Sec. or Block No
Lot Size House �� Mobile Home Business Speculation
No. Bedrooms No.'Baths r)A- No. in Family
Garbage Disposal YES E) NO S ecifications for System:
Auto Dish Washer. YES �[( NO ❑ (1 o u: c--, ��, , 0 - �
Auto Wash Ma:hive i YES (2, NO
�,t
Type Water Supply _
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
1 3
y
P Y
Improvements ermit'b
P
'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 day of completion. Telephone Number 704-634-5985.
Final Installation Diagram: C4 "�s }j tem Installed by
ks
3 s
)17G <`
,F
--------------
c
X"a
Certificate of Completion Date Z,��3
*The signing of this certificate shall indicate that the system descr bed above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
: Ob I ' Fi
" APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERL.�DAVIECO
Davie County Health Department UN 8 i
Environmental Health Section ems..
P. O. Box 665
Mocksville, NC 27028 UNTYHEALTH DEPT.
1. Application/Permit Requested By. ayd M. UU( t I+A'h cr AA(
Mailing Address� D Sox Ne, dZ
Home Phone __���2-- 7�2 oZ, Business Phone
919-769- 1261 16 )
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluation 5G- GJ e-r-M12L ❑ Septic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision Section Lot#
Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms )(washing Machine
No. of Bathrooms 2 Y2 X Dishwasher
Dwelling Dimensions_ 2& ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No.of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public X Private ❑ Community
8. Property Dimensions S- 4 c res Sewage Disposal Contractor i�8
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes No
If yes, what type?
'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: �� N. --� �LAKrc �Z�JT.�/ f�D, 01� RIC��-4T (1-JUST PAST
1�uTcNM� N UEW 921 ' C ► - d�;
cam fy, V l�
R H - 760 - �/� �i►n (� I+ fir
This is to certify that the information provided is corre to the best of my knowledge,and I understand I am responsible for all charges
incurred from this application.
2 2 2 '
DAtrE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
Fanddisposal
ECK ONE: ❑ 1. 1 OWN the property. 2. 1 DO NOT OWN the property.
ked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
ve consent to the authorized representative�ppf the Davi County Health Department to enter upon above described
cated in Davie County and owned by fkf j A. \IKK
all testing procedures as necessary to deterfnine said site's suitability for a ground absorption sewage treatment
s stem.
DATE SIGNATURE
DCHD(12-90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
pp Soil/Site Evaluation C
NAME C�s � ��� DATE EVALUATED
ADDRESS S -Qm� PROPERTY SIZE Qc7 � o
PROPOSED FACIILTY r3 V S.Q LOCATION OF SITE -)a:;&' R�
Water Supply: On-Site Well Community Public
Evaluation By.!`,� Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position S
Sloe 7.
HORIZON I DEPTH / 2 " '•�
Texture group L
Consistence T
Structure C C
MineralogX
HORIZON II DEPTH t��t' �'' 31 a4 '
Texture group
Consistence h
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS S s s S s s
RESTRICTIVE HORIZON i
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
�� t
SITE CLASSIFICATION: EVALUATED BY•
LONG-TERM ACCEPTANCE RATE: 3 OTHER(S) PRESENT:
REMARKS:
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(01-901
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