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434 Bonkin Lake Rd . . � � � � J�_ • ,J..��,1 �_ • DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003474 Tax PIN/EH#: 5833-08-6518. MS Billed To: Michael Smith Subdivision Info: Reference Name: Location/Address: Bonkin Lake Rd.-27028 Proposed Facility Residence Property Size: 3 acres ATC Number: 3982 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: ✓�-���� Date: -� �S� CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation 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. �n � �� �r J i� s� ��C3�C�g �� Se� � � Jn r� Septic System Installed By: �i � Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) y . DAVIE COUNTY HEALTH DEPARTMENT �� • � Environmental Health Section �' � ' P.O.Boz 848/210 Hospital Street � Mceksville,NC 27028 (33G)7S1-87C>0 IMPROVEMENT/OPERATION PERMIT Account #: 990003474 Tax PIN/EH#: 5833-08-6518. MS Billed To: Michael Smith Subdivision Info: Reference Name: Location/Address: Bonkin Lake Rd.-27028 Proposed Facility Residence Property Size: 3 acres ATC Number: 3g82 **NOTE**This Improvement/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 INSTALLING SYSTEM. Residential Specification: Building Type � #People�_ #Bedrooms � #Baths� Dishwasher� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply Design Wastewater Flow(GPD)� Site: New�Repair� System Specifications: Tank Size�GAL. Pump Tank , c� GAL. Trench Width�� Rock Depth��Linear Ft:L�-� Other: � Required Site Modifications/Conditions: �,2C I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLU . I TER RISER(S) IF G "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County ` h Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m. on the day of installa ' . Telephone#is(336)751-87G0.**** D� � �°°�� �� 1 G�I y l�s� �,� � � << ,�Q� � ��1,%�,�s ���l�� � � C��� � � A, � .. _ �� /n,s�lt-/�r G,� /)o ���� � I �-�p� ���� �,�,N�� � ��� �e f� u��'�`f � � �� ��E� l� Environmental Health Specialist's Signature: � Date: p��� /�S` DCHD OS/99(Revised) j � • ' � {� � � q� � 11 . D �� AP TION FOR SITE EVALUATION/IhiPROVEh1FM PERMIT&A7C r F ��r�5 Davie County Health Department r ' ��N � �' � Environmenta/Hea/th Section �.. �� �1.: P.O. Box 848/210 Hospital Street , Ep�SN Mocksville, NC 27028 "��NIRpa����pLN (336)751-8760 MPORTANT*** THIS APPLICATION CANNOT BE PROCESSED [7riI,ESS ALL THE REQUIRED � INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Namo to be Hilled �=� ��� ,s'-y/'f�� Contact Person _i�%��.GliGIL�-C�J�tr / i G Mailing Addresa ��GCG'�� ' � i < Home Phone ��/) - ����-� City/State/ZIP �%l ,�J�,�-r�� r / iL, ,� ��� Businesa Phone��- # / ����- f" 2. Name on Permit/ATC 1E Different than Above -� /�,/� ��L��� � � Mailing Addresa City/State/Zip (_JL" �!� 3. Application For:��Site Evalua�ion ❑ Improvement Permit/ATC ,�Both 4. systam to service: Q House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requeated: l�7 C onventional ❑ conventional modified ❑ innovative 6. If Residence: # People # nedrooms � # Bathrooms -�'� �,..,� � L1dDiahwasher ❑Garbage Disposal Washing Machine ❑easement/Plumbing ❑Basement/No Plumbing 7. If Buuinesa/Industry /Other: verify type # Peoplo # Sinks # Commodes # Showera # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gailona per day) 8. a�pe of water suppiy: ❑ County/City '� Well ❑ Community 9. no you anticipate additions or etpatisions of tlie facility tliis system is intended to serve? �I'es ❑No If yes,ivl�at typc? ^ ***IMPORTANT'"**CLIENTS d1UST COAIPLETETIIC RL•QUIRED PROP�RTY INFORMATION RGQUGSTGD •-- BELO�V. Eithcr a PLAT or SITG PLAN MUSTl3L•SUB�VlITTED by thc clicnt tiviti�TIIIS APPLICATION. Property Dimcnsions: ,3 �%l/Z-L�— tiVI2ITE D1R�CTIONS(Crom 119ocksvillc)to PROPGRTY: Tax Officc PIN: �g 3 ?i— a U � � 5� � �D C / � � l��G/ ��..� �,���c. , C'vl/�i� i Pro crt Address: Road Namc �-n �i j ��f�� �t.L-r,t. �/l, ' p y .���/�� � �°' �- ��' � .��- , , , . city�zip �(�r�l�, ,�( lc�� ��i�, If in a Sabdivision providc information,as follows: Namc: ' Section: Block: Lot: Date liome corners llagged: � �s This is to ccrtify that tlic information providcd is correct to thc bcst of rny lu�oivledge. I undcrstaud tl�at any permit(s) issucd licreaftcr are subject to suspcnsion or revocation,if tlic sitc plans or intendcd use cliangc,or if tlic iiiformation submitted in t11is application is falsified or cl�anged. I,also,tutdersta�id tlrat I nm resporrsiGle for all charges i�icrured from tlris applicatiou. I,licreby,givc conscnt to tlie Autl�orized Represcntativc of tlic Davie County IIcaltli Depnrtmc►it to enter upon above described property located in Davie Couiity 1nd o�vned by � tu conduct all testing procedures as necessary to determine tlic site suitnbility. ,DATE �_�' � D �� SIGNATUIZ� ��G2u . TIiIS AIZEA MAY B�USED FOR DRAWING YOUR SITE PLAN(Includc all of tl�c follotivii�g: �xisting and proposcd property liues and dimensions, structures, setbacks, and scptic locations). /� Sitc Rcvisit Charge C�--�`J_�r Datc(s): p" U � Clicnt NotiCcation Date: -7 � � - -�- �.-� � � . EFIS: Sign givcn /V� � �� Account No. � ��� Revised DCI�D(OS/03 �„ $ S �,� ��� � ' 9 Invoicc No. (Jv nn.��c�a�- y� �'-3 S �����o.� r� ^'-^`Y _ _ _ _ __ _ _ � � � : � � �� �` � � � ���� 'A - - I', � �� s� � - �''� s � ���, _ � � "'`� �3, w n ' - _ � � �� �� , , - - � �,. �.. � �.� � , � � .. �., � �� - , , � �� ���c� e � , _ � �.�,- - f �-, � ; a..-� ��� _ �� .� -. � �- � _ _ �_ _ __ ���� _ __ �� _� ��a _ � > � s � � C2 � z ��, — �� ��r� . E . � a ' � � � . ; _. —z �._— � .,: _ � �, _ r= � ��.�.. �., � �� �� � �� - . �.� � � �� � '� _, 4 , c� , ; '. ' s . � ar. �: , �F .; . ��, . - '� � -�; � s t z S F � ', � �., � � �ww.� � ��w,� � � �� � �', �� '�� _ � ' � ` ��� �� I � �� �—,.3� � ���r �� � ��� ! 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' � . � ' �; -� �- � � % ��, _ � �� " � �.�, ..� �' � � � � �� , � . �a � �; � �� , i4m,.....„,yw� . ��� � � �� �`� � b v� �� � � . � ; 1 � o r . � �,�i L f ry�� ��s � � �� .� �� s'�f � E �`� . „`�.tal����.�m-�r�,��.-� �'� � ��s ���""� �� � � � �� � � �r�� '��,� I ,' �, � -� ��� � ° ������� '� �,. � - � �z � � ���� � - � �� � � fl � �i� � � `� :� :� ���;�r� . � � ������ � � � � � . � � ih�������� ' � Il�i � '�� �� � �f � _= I ;, � 'a .� , • � . = ` ��;` i =�;; �' �;:�;���� i �,� '�' � %�s ", . ` ;- � � - � . ,.�� �'� . ,, �`._.__,. �,.'�' - -i ......_, .�., F,.,s €�ti.:. :.- .. ... ....,,..; _... ,,, „ � � �� �� �, y � �_� � ��; � � � � r � .� _� � � ' ,� ' � ��?���`� � � � � ; �. ���� � �., ;, �.� . � .va' —�„�.,;;z,,, �'" �u<,.,� � � � � a-�. . ���� � � � " � ��' s � '„�t � I � �y '" . ,-�`„" 'u , � � ' "- ���,�, �`�, � . = � "�� #d _ :: ��� „'�.'��. � / .��,9� ' i� , „� ., -,v,`-� � ; � .: '.. �.. � � � �.;, �f..� . _ . _ , � w.��..� .�� . �.,,�mn. .......... �,:� o ., ._ 3 � � � ��' � DAVIE COUNTY HEALTH DEPARTMCNT � •� • Environmental Health Section ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003474 Tax PIN/EH#: 5833-08-6518. MS Billed To: Michael Smith Subdivision Info: Reference Name: Location/Address: Bonkin Lake Rd.-27028 Proposed Facility: Residence Property Size: 3 acres Date Evaluated: ��pS� Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring Pit Cut L� FACTORS 1 2 3 4 5 6 7 Landsca e osition L Slo e% ' — HORIZON I DEPTH �� /i Texture rou • .� C Consistence Structure Mineralo HORIZON II DEPTH �' �S'f�`' Texture rou ' Consistence ; Structure �� - /J Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE � CLASSIFICATION LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: L�� '" � EVALUATION BY: T7"!c-�// LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: �I/4�� 7('L����� 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�y 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-gaUday/ft2 , DCHD OS/99(Revised) i ■■��■ ■���■�■���������������■����■■���■■■■���������fi��■■■����■■��■ ■��■ ■�����������������������■ ■���■■■��■■���■�■��■���■�������■ ■��A�■ ■�����■������■��■����■����������������■■■����■■����������■ ■��■ ■�\���■�����■■�����������������■��■����■■�����■■������������■ ■�■■■ ■/������������������■��■����■������■���■■�■■�■■�����������■ ....■ .�.......................................��................. ■�����■ ■■�■■■■■■����■■■■■■■■�■■■■■■�■■■■■■■■■■!:���■■■■■■■■�■��■�■ ....■.�C......................................�.►.................. ...... .......................................................... ■����■ ■��l������������■���■��■■ ■���■■�■■����l�i.�■�����■■��������■ ■�■��■ ■�����������■�■■����■���������■�■��������l����■■����������■ .....■ ■�.......................................,.................. ■����� ■ ■�■�■■��■�����■��������■■���������■���u���■■���■��������■ ■�_��■ ■��������������■������������■��■■��������■�s■■■■����������■ .. ...�........................................�................... ...... .......................................��................... iiii���ii�iiiiiiiiiiiiiiiiiiiiiii�iieiiiiiiiiiiiiiiiiiiiiiiiiiCii�i ■��■ ..... .�......................................�................o.C. ■������■ ■�������■���■������■�■■��������������u���■■■■��■�■■■������ ■�■�■ ■����■������■���������������■■■■�■■������■��■■������������■ iii�ii���iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii'r�i�iiiiiiiiiiiiiiiiiii ii �i�iii�iiiiiiiiiiiiiiiiiiiiiii�iiiiiiiiii�iiiiiiiiiiiiiiiiiiiiii :: C ':::::C:::C:C:C:C:C::C::CC::C:CCC:::CC�CCC::::CCC:C:C':�CC:C: .. a� ....................................................�. ..... ■�■ ■��■���������������■�■■���■����������\II�������N��������G����■ ...�Ca....................................►�...............�..■.... ... ..................................►................ .....�.. .... 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