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165 Buckingham Ln 'J � DAVIE COUNTY HEALTH DEPARTMENT �� • ., � • Environmental Health Section �� 3 • , , P.O.Boz 848/210 Hospital Street ` �---' Mocksville,NC 27028 /►�, (33G)751-87C►0 C��S� `l, (�� IMPROVEMENT/OPERATION PERMIT 2 y Co q Account #: 990003011 Tax PIN/EH #: 5801-85-3D3��" Billed To: Ronald Gobble Subdivision Info: Reference Name: Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 5.61 acres ATC Number: 3638 **NOTE**'This Improvement/Operation Petmit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR 'WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residentia]Sp�ification: Building Type �` #People � #Bedrooms ' #Baths�� Dishwasher:� Garbage Disposal: ❑ Washing Machine� Basement w/Plumbing: � Basement/No Plumbing: 0 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply l/"(�)J Design Wastewater Flow(GPD)—s��-� Site: Nevyi�Repair❑ System Specifications: Tank Siz��AL. Pump Tank GAL. Trench Width� R k Depth�,�Linear Ft.�� Other: Required Site Modifirations/Conditions: IMPROVEI�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW FINISHED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m,to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-87G0.**** `✓ I Environmental Health S ecialisYs Si ature: �' � Date: ` �%�� P 8n K� � DCHD OS/99(Revised) . � • � • - DAVIE COUNTY HEALTH DEPARTMENT ` ' Environmental Health Section r.o.Bog sasnio x�pst��sr��r Mceksville,NC 27028 (336)751-87G0 Z�f c� 9 Account #: 990003011 Tax PIN/EH#: 5801-85 363�:RC3�— Bilied To: Ronald Gobble Subdivision Info: Reference Name: Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 5.61 acres ATC Number: 3638 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). T'his 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 YEAR . Environmental Health Specialist's Signature: //� // Date: el.�1 �� 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. ��G y�'C � -'�� r� , � Septic System Installed By: �� / � �/1•�r' Environmental Health Specialist's Signature:��,��(Q Date: _��f�D�� `� DCHD OS/99(Revised) • i t � � , utino�3in�a � aPPL1CAT10N FOR SITE EVALUATION/IhfPROV[�tENT P[RA11T& TC H1N3H1V1613NNO�IM13 Davie County Health Department Environmenta/Hea/th Section , P.O. Box 848/210 Hospital Street £�� 3� Mocksville, NC 27028 .� (336)751-8760 a ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS AL • I2dFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �011��/J (/�� 0�� Contacl Person �rv �"��L�� Mailing Address ��J �/T��`1c��—iC/ /},O Home Phone �3 36) y yr-S 5s3 !.__ City/State/ZIP �G�SUl`L� �i�� 7�a� Business Phone 2. Namo on Permit/ATC if Different than Above Mailing Addreas City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: ❑ House lld Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: L�J Conventional ❑ conventional modified ❑ innovative 5. If Residence: # People _� # Bedrooms _�. # Bathrooms � L7Dishwasher ❑Garbage Disposal UWashing Machine ❑Basement/Plumbing ❑IIasement/PIo Plumbing 7. If Busineas/Industry /Other: verify type t� People tk Sinks __ # Coamwdes # Showers # Urinals 4t Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (qallons per day) 8. Type of water supply: ❑ County/City Cf Well ❑ Communii:y 9. Do you anticipate additions or expansions of tl�e facility this systeui is intcuded to serve? ❑Ycs ❑No If ycs,�vhat type? ***IMPORTANT***CLIGNTS�11UST COAIPLETE TH� REQUIRED PI20P�RT'Y INrORMATION RLQUGS'CLD BELOVV. Either a PLAT or SITE PLAN MUST BESUBMITTLD by thc clicnt �ti�ith'I7IIS APPLICATION. Property Dimcnsions: 5 j u� ��`�'"fs Wlii'CG DIRGCTIONS(fron�l�iodcs��illc)to PROPI'sti'1'1': Taa orr��riN: � S�o/- �S-34�� W��9 � ��S� �� 5�•�,F�-,t�l� ,�i�, Property Address: Road Namc�U��..�ly�-�/a�1 L�� u/►/v �j..�G�r G/�.S��f�'��.� �� cityiz;��1 oc�Sv,��L.E �1V�G �7o�,s- GO TG ��s�(.�'�.�1-'�7'T�1��1'� �� Tu�� If in a Subdivision providc information,as follows: y"�+-�� O �G !'UL��/�G�� L�`�"!u� Namc: �� G EN.� Section: Block: Lot: Datc I�omc cor�icrs tlaggcd: �d�/ ��/�/�� Tliis is to certify that the information provided is correct to tlie Uest of my knowledge. I undei•stand Uint any pe►•mit(s) issucd l�creafter are subject to suspension or revocation,if the site plaus or intended use change,or if the iuformation submitted in this application is falsi�ed or changed. I,also, tuiderstantl diat I ant responsible jo��nll clra�b�es incru�rerl.fi•onr this applicatiar. I,l�creby,givc conscnt to tl�c Authorized Rcprescntativc of tlie llavic Couuty lIealtl� Departnicul to eutcr upon above described property located in Davic County and owucd by to conduct all testing procedw•es as necessary to determine the site suitability. DATE 1�` �l��/� SIGNATURE i��l 3-�C ��-(/� THIS AREA MAY B�USED FOR DRAWING YOUR SITE PLAN(Includc all of thc following: Lxistiug and proposcd property lines and dimensions, structures, setbacks, and septic locations). Sitc Rcvisit Cl�;u•bc llatc(s): Clicnt Notil'ication Datc: EIIS: Sign given Account No. � l Revised DCHD(OS/03 Livoicc No. �� `� '.,`� .. y �i.~ ` 'EXIS7ING �aON !�[y,r �pp.� ,' (REF3�R) O.ti ��r,c'_ TOTALa 749,68 ^rE'•v ;�.o�� 249.68 S 86'S7'21' E---�- ;^� �`- :x; 250.OQ !�°� 250.00 o ��0 g � w � � hE,,, �RoN , ;�o A�EA = 2.934 A °" �"E AREA = 5.610 A C. � � � , � � — z � � � - �� 22 C�j o �� , . � .. � �g - . . �_ � 3/4. Ex�s� N 89'1 B'04' E—� . IRON � . 221.04 3%'a Ex!S' . • IRO�� NEW IRON . :.� -.ON LINE • , - _ � . d . :- � � . oa�sY.CLINE ., . ��- D.B. 1�63, PG. 692 =� ,K r r" o, o �o - z ,. q ti+' � . . ,. ,.. S . �. m _ __ ". �3�n ., . ; . • � PLAGED `. N ��a ' ' lRON. y ' " 'NEIN A � GNWLINE N 4�.12 �--T--+--—375.00 -- - . IRON• h �— N 89•24'S4' 11 , � � � �----------- -- TOTAL= 422,12 - ---. � ___—� �. I99•J� k. � �, �,4g�9 4•,�, '" c NE1hf IRON � \ 5� (`�F1M � �` `��, j� \o �' oN Urre PROPOSED . . . •_ 14 ^�� `�n . EQ.SEMENT �� _4�,� �'��Qr ,. �� 9 , • .\ . . a°.��" � . � . `. �y jo �,, . � S9'rr, � F—=�. , ��{�• •` g.;, �' r,Ew � ., i�or� � , � - , r � _ �, ' � . -'�; tiEW �R� '• _:�� `��. _ .. . _. -�. __ � .� -,,_ _..._... _ , _. - ON UNE � - a r, �' i . ,ci fj � . � . . . � a i (� • � �" AREA= 10 OOQ�A�• ' �`'h� � ;�X' �Q —� ':`.-� . �j h�Y+ '4CN pp`', . •7 . ON IrNE. �� y': � ��n ¢v ; .�� _ . .._ '.3� F- o .r � � � r. � �Z } ��.�. �o ; .��, vEw ��,�., '` ";;' o�v ��vt: ;�� r.�.; t , � �� t:�� - �,�. -''� . � . . , -�: � �S �-� . . .�� i� ��- � �� .*. . �L��N�D Green Hill XLE Series Model 4663B � � � • 3 Bedrooms • 2 Baths • 1 ,737 Square Feet - �.u�.m.m.c _..+.�v...._�s...�..v....mm..w.„+�-R+ aa......m�. .,we..»....��.�.�....1..>.«aw.. ...,,e...». ...«.........«v...o..� mm.,,,...... ...�....<.��..w.o.......v.��Y�..u��..u....� � .�ro N,.��.+..�.m+w.�- 4� .,�.a � ru... �.,a � � �' a 66'-O" a-�$': . � ' � +.,� �.a. O --- - --'- i --1 ��_ OFf. �� _ - 1---' F�REPLACE oc � �� i �F ... �._i� / �Zw j � � � �ocu WALK-IN � �i UTILITY_'; ��4� 6EDROOM M. MASTEK ��oser i : � _�' SUNKEN DEN ��i BATH BEDROOM i � ' ; -t-; t?-6"xt2'-8" oo i � it'-10"X 12'-8" 14'-O"X 12'-10" I �' -t--i-' I I � � r�� O � O _ •• �-- � _i_:_ _ s�, � �A O� �� LINEN 26'-4" --------r— . . . . WALK-IN � � LL05ET ` - ' ' c- ' � � � ------------- -r ..1'� .............. �_:_.� i -1-t-c-'f- � �� — ..� �BREAfCFAST . , ; � _ _.. � � ; : � ,I._;:..._,._ ,_ -: - -- - NOOK-� � ,.'.__:::�_. O '.i_`- '_ -' - -- � '� -- ' :�_;_ 'r- - -i- -t-:�_. `__. .. .... .� . � �:_. � � ' �- - ' -- - -�'t-��.��:_._ � � '�-_..�.... I : �t- --- �'•- :»_ ' ' :.- ; -..,...� DINING _._: i ,.._;... � � - --- ;_ ;_T__;_:__�;�i-_;_. . i z� ¢ LfVING ROOM AREA . - � i _ � ' _ ._._ . � I �o m ; : 16'-6"X12'-8" 1 I ?- _ � BEDROOM , ;...... ��i s'-e•x t2'-e• - -:-- •- � , I 3 u 12'-4"X 9'-10„ :.._�....;......: I�I� _i._......:._ ;_: , �# ►arcHEni....:...:....:, i�ii � : , , ::: i _� i i i ; . ii ii � �- �---;---+ - - ...;_.__;.._;......... � � �;.�: i...:................... � ..+ i ii ii i , ; . i i�i� � o,r. ' �-�-_ � i � � �I�I I_��I � ❑❑ � I SHELF �PANTRY • �• EN7RANCE � � . � .�6, ;;�; � �� r Note ihat square footage is measured from exteriorwall to exterior wall,and is an approximate figure.Length indicated in floorplans is floor length only.Renderings and diagrams are meant to be representative and,in keeping with Fleehvood's policy of constant updating and improvement,may vary from ihe actual home.All dimensions are nominal.Ask your retailer for specifics.(Add four feet to arrive at transportable length.) PRICES AND SPECIFICATIONS SUB.IECT TO CHANGE WITHOUT NOTICE OR OBLIGATION.�i996 , GH/19/OCT02 , �, • y _ � (�(1'.�� • ' t� � � � �.S D � JUf� 17 L��3 A 1 ATION FDavie County Health' Department I�Lfih117&Ai�C Environmenta/Hea/th Section � �� +��,�p{ P.O. Box 848/210 Hospital Street EliV'��b';f��;(;y Mocksville, NC 27028 DA�.� (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS ALL THE R�QUIR�D INFORMATION IS PROVIDED. Refer to the INFORMATION IIULL�TIN Eor instruction�. l t /� � � 1. Name to be Billed ` ntact Person n�n,� �,__ _ �� i-�'�=-- ��_�-- � Mailing Address Flome Phone 3 �- ____�a _ City/State/ZIP �� V Business Phone 2. Nama on Permit/ATC if. Different than Above _______ Mailing Address City/State/Zip __ 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: �1`House ❑ Mobile Home ❑ Busine�s ❑ Industry `�l Other _ � }� 5. Type system requested: Conventional ❑ conventional modified ❑ innovative �I\ r1 L� 6. If Residence: # People ik Bedrooms 4k Eiathrooms y . �Diahwasher ❑Garbage Disposal �1Washing Machine ❑Basement/Plumbing ❑Basement/No Plunil�ing 7. If Bu3iness/Industry /Other: verify type # People ik Sinks # Commodea # Showera #� Urinals 4k WaL'er Coolera IF FOODSERVICE: # Sea Estimated Water Usage (gailons per day) a. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansious of tl�c facility this sySlCtli 1S IlllClldCd l0 SCl'VC? ❑ �'CS �No ir yos,,��r ty�� ***IAIPORTANT'`**CLILNTS�LIUSTCOAIPLGTCTHG RliQU11tED PROPLK'1'Y 1NFORMA'CION RLQULS'1'I:D I3GLO�V. Either a PLAT or SITE PLAN AIUST BE SUI3�111TTED by thc clicnt �vilh 7'II1S APPLICA7'ION. Property Dimcnsions: �/ 1� �}/ � t tiVRITIs llIILLC"1'IONS(from 119u I:s��illc)to PIZOPIsit'1'1': �� l—�S— 3 03 �j � Tax Officc PIN: # /1 i� � � � Property Address: Road Name � �,� �� City/Zip�, �� f ��, L � If in a Subdivision providc information,as follows: Namc: ' (.�,�'��'�` L Section: Block: Lot: Date home corners Ilagged: � . iZ� °,� Tliis is to certify that ttie information p►•ovided is correct to tlie best of►ny lcnoti��lcdbe. I uiiderstaiid ll�at.uiy permit(s) issued I�ereafter are subject to suspension or revocation,if tlie site plans or intendcd use clian�;c,or if tlic inforinAf10f1 submitted in tl�is application is falsified or clianged. I,also, understand that I uur res��aisiGle fur nll ch��b�es iircru•rer/fi•om lliis application. I,ltcreby,give couscnt to thc Authorizcd Represcutative of tl�c Davic Couuty IIcallll llcparlmcnl to c�►tec•upon above described p►•opcc•ty located in Davie County and o�viiccl by .____ _. ,___ to conduct all testing pi•ocedures as►iecessary to determine tl�c site suitab�lit��. / / l DATE iQi'"I ��, SIGNATU1tE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc Collo`ving: �xisling au proposcd property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Char�;c llatc(s): � Clicnt Notification llatc: �HS: Sign given Accouut No. � _ Revised DCHD(OS/03 � Invoicc No. ��—��- • � \. �•• i ,� • ' - • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002808 Tax PIN/EH#: 5801-85-3039.B Billed To: William Barneycastle Subdivision Info: Reference Name: Location/Address: Buckingham Lane-27028 Proposed Facility: Residence Property Size: 5.6 acres Date Evaluated: � �S � Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH �� / Texture rou � C G Consistence Structure Mineralo HORIZON II DEPTH y t�° y'� Texture rou Consistence Swcture /1 ' ! Mineralo ,�/ HORIZON III DEPTH Texture rou Consistence SUucture Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: �1��/ LONG-TERM ACCEPTANCE RATE: � 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-Tenace 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 Mineraloev 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) ; �K�o� DEED hC.�RTH HAZEL D. SMOOT -- - ----- ----- ---------- _____ _---- D.B. f 16. PG. 693 --- _ _ _- - D.B. 76. PC. 33 ------ - - . _..__. .. D.B. 71, PG. 613 -� __ _ , :� ' = , z '7 • F � -.:; .. - �:� . . .�,J n C. . Z � 7 - 195.00 60.36 s, 139.64 200.00 200.00 = " T�TAL= 539,64 • �`= N N 00'46'38' U "°� � . -. I ' - � N , r � a i i � _ � � � � � �� _ �� • �`� I I�Z ` � � o -- , (�W t � % z ID�O 11 N � I � Z� ,o ' a J C ' N I ��. IN� o � Z NA � � NC I _ ;� � � I� � J ---1 '� ' � - - �� ; ; , � , . . � . . _ t,�� , ; '' � � N� ;' . �;�� , ; � �� , � �_. � ' o • n � -. ^,.�� - _. � � 1 . �v ' � -'�` I ^', �� " �,Z I � ` � , ` . o m �. � � - z f !t �'l OD � • �- � / I N 02'a6'16' v �, �u j �----��.8z T- - :� � �� . _ , , -. �` ;_.� � ► c• •� � • ~ �� -.,.P..,�� ev�� ,; .--�..� —..� r :�:�.� ,,,..r..�. �w�...,,.a,.... �...�3��l��'�i�4�� gl��a��r_:_�>>..��__ _n __._M� � ��,wAk.wENViRONMENTAL HEALTH SECTION "w �M P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 .. � , � , - . P�one #: (336)757-8760 ° ' ° June 25,2003 William S. Barneycastle 1421 Main Church Road Mocksville,NC 27028 Re: Site Evaluations/3 sites on Buckingham Lane Tax Office Pin : #5801-85-3039 Dear Client(s): As requested, a representative from this office visited the aforementioned site on June 25, 2003. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site,the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, �o��t��/�1�,• Robert B. Hall, Jr.,R.S. Environmental Health Specialist RH/df