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580 Martin Luther King Junior Rd� DAVIE COUNTY HEALTH DEPARTMENT " Environmental Health Section .+. �'r P. O. Boz 848/210 Hospital Street . Mocksville, NC 27028 (33G)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002519 Billed To: Nettye fjames- Barber Reference Name: Proposed Facility: Residence � o �3 �-�� Tax PIN/EH #: 5739-72-0079 Subdivision Info: Location/Address: Campbell Road-27028 Property Size: 1 acre ATC Number: 3355 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHOWZATION 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 '�Ca-r- Type Water Supply �^1T� Design Wastewater Flow (GPD) �$e Site: New d Repair ❑ n ,� ,1,� 1 System Specifications: Tank Size �� GAL. Pump Tank GAL. Trench Width 3� Rock Depth �2 Linear Ft. "t�� Other: � �S�Q-1 �J�to.� ��x�5 1 �SSb�U.- u �;.�5. � � Z� .C. p-c.t r.� . q � rJ�T�� p-� Ge�T�2 1� J�f-F }i��._ 1L� 1Q c.�r Re uired Site Modifications/Conditions: , -- , Lrn7 � I1�IPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF C" BELOW FINISHED GRADE. ****NOTICE: Contact a r serrtative 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. 0 1:30 p.m. on the day of installat' n. Telephone # is (33C►)751-87G0.**** �J c:oR.��. .'� 57s1cf- �� J �. Q Q � � � / � �� l� Environmental Health Specialist's Signature: DCHD OS/99 (Revised) / / , ,�. �+ ��r� ✓ /Y" . /�� C � �a�� P n ❑ • , � ' DAVIE COUNTY HEALTH DEPARTMENT , Environmental Health Section P. O. Boa 848/210 Hospital Street Mceksville, NC 27028 (336)751-8760 Account #: 990002519 Billed To: Nettye fjames- Barber Reference Name: Proposed Facility: Residence ATC Number: 3355 1'� o� �� Tax PIN/EH #: 5739-72-0079 Subdivision Info: Location/Address: Campbell Road-27028 Property Size: 1 acre 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 WASTEWAT S N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatu : .�,: Date: �� b3 / CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit ; l�� S 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 bc. F�� given period of time. .�� L �- ��L � Z�Z� Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) 23� �� e��'l •E.��V o / 1°I�' / � �i �� 6 1 � Date: � � � ** �r '�\ `? , _. , APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � b Davie County Health Department - ` � _` Environmenta/Hea/th Section � P.O. Box 848/210 Hospital Street ,a;�tjN Mocksville, NC 27028 ,�� (336) 751-8760 *** THIS APPLICATION C1�NNOT BE PROGESSED UNLESS ALL THE REQUIRED IS PROVIDED. Refer to the INFORNg,TION BULLETIN for instructions. 1. Name to be Billed v � JContact Person ��[ �" �P �� 2— Mailing Address Home Phone �l '��p f City/State/ZIP C/ Business Phone ��f ��s'� Q��17/ !��%c 2. Name on Permit/ATC if Different than Above � ! Mailing Address _ e ip �" 1— �G-G3 3, Application For:�Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service: O House ❑ Mobile Home ❑ Business ❑ Industry F1' Other ��1��lZ/ . 5. If Residence: People � # Bedrooms _� q Bathrooms i� --Y-- ,. �►aasher Garbage Disposal 1J.l�Washing Machine lJ Sase�ent/Plumbing I1 Basement/No Plumbinq 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # ShoKers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage �gallons per aay) 7. R�pe of water supply: County/City ❑ Well p Community e. Do you anticipate additions or expansions of the facility this system is intended to servc? If yes, what type? ❑ Ycs � ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROP�RTY INFORMATION REQUGS'I'ED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMI77'ED by the client witt� THIS APPI:ICATION. Property Dimensions: 1 �2�� Tax Office PIN: #�� j �%v� �� Z.�_ Properly Address: Road lYame . c�ryiz�P ��,�ry��111 If in a Subdivision providc information, as follows: Name: Section: Block: Lot: WRITE DIRECI'IONS (from Mocksvilie) to PROPLRTI': �Q�,�i �d�`, t� �it�� • .��?/.�J �'��. l �� b�/ f , ��_, b�'>� G�'��-a��ir ��;�-� rr.Lc� C�.�v , �.��r� � ,��r/ �. —�— Datc Property Flaggcd: � / — � � "� � This is to certify that the information provided is correct to the best of my lcnowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended usc change, or if thc information submitted in this application is falsified or changed I, a1so, undersiand t/iat 1 a►n responsible for a!! c/rarg�es i�lcurre�/fro»i ihis application. I, hereby, give consent to the Authorized Representative of the ie unty alth Dep�rt cat� / to enter upon above described property located in Davie County and owned by �� --+� t4.� to conduct all testing p ocedures as necessary to determine the site suitability. . DATE / SICNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Includc all of thc following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locutions). � (��C../" "' . �� U,J� '��, �i4`i , �,�q,�a�� ' S � ; r�'' u� �-�- -//-� � Revised DCHD (07/99) ��'�� GP � ` '� 7 �L� � /r�S Site Revisit Charge Datc(s): Client Notification Dat�e: EHS: Account No. � ` � Invoicc No. � � � / 9 -'ifr'"� �� l,�� . �. 178 149 54 - .-,- ; �45{� T�}T�L �8 95 151 ' '�, _: ; � 06 t�Z' 99 � , �� S � 'a% , � �� ., � � , �� rn � Cfl N � �� C3� � � f � ;:_ ,� � � �1 0 �1 �� 8 , �� ; � � J ; � � � ;� �„ , � �� .:�. 1 ��\ 44. �'".r ^ � e, . I / 1�/� - +� �r 1 µ " � I I /\ I I �( j � �i h1 / 1+�' / �V ' �5 1 / '�*' � � , , , �. , , � , , V , . , , , , � , �. s . / .� . , o � , � �� ;.. � �: � � � � ' ' V ' ,, �� , , �:�,,� -p — , ,.., u� �14 _� � � � o . �, . ,, , � �6 � �..4Q I __{.3'1 1 � O � -J � � _, , . 9 ` , - c� y � � - � � ` � r V �� ..` � � .V ._ __�. � ��/ �"��—�...� __ ..._ ►-t.) � � �.._ .._.,.,__ '° 7 � ,a i 095 �, �� a� � DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation APPLTCANT 1NFORMATION Account #: 990002519 Billed To: Nettye Ijames- Barber Referenc� Name: Proposed Facility: Residence Water Supgly: Evaluation By: Slope % HORIZON Texture gro� Consistence Structure FACTORS I DEPTH II DEPTH PROPERTY INFORMATION Tax PIN/EH #: 5739-72-0079 Subdivision Info: Location/Address: Campbell Road-27028 Property Size: �" 1 acre Date Evaluated: i0 "v On-Site Well Community Auger Boring � Pit Texture group ' Consistence Structure . . ; Mineralogy HORIZON III DEPTH • Texture group Consistence Structure • Mineralogy t ; HORIZON IV DEPTH ' ;; � , Texture group , a a- �.. � � . Gonsistence, • Structure ' Mineralo SOIL WETNESS y RESTRICTIVE HORIZON� ' ' �. SAPROLITE CLASSIFICATION � ; LONG-TERM ACCEPTANCE RATE J . �.�SITE CLASSIFICATION: � u EVALUATION BY: � ''�t}-+��'� �f� LONG-TERM ACCEPTANCE RATE: �' OTHER(S) PRESENT: REMARKS: ��PD �Ul;� �6�i �tM�TI�� `I �.Tt�.�.�aG14Li�Y "rD�.d4=�D �`i=l� iJ� �-dP � . � , 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 �p 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 � ` '� 4� 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 Clas�ification - S(suitable), PS(provisionally suitable), U(unsuitable) ' LTAR - Long-term acceptance rate - gal/day/ft2 , � . 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336) 751-8760 / Fax: (336) 751-8786 December 11, 2002 Nettye Ijames-Barber PO Box 334 Mocksville, NC 27028 Re: Site Evaluation- 1 Acre Tract/Campbell Road Tax PIN#: 5739-72-0079 Dear Ms. Barber: As requested, a representative from this office visited the above site on December 10, 2002 to perform a site evaluation. 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 on-site sewage disposal system, Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally, the application indicates that 1 acre will be cut off of the parent parcel. This must be surveyed and the property corners located prior to making the request for a pernut. Enc(s) If you have any questions, feel free to contact this office at 751-8760. Sincerely,,�, - --- � � Jeff G. Beauchamp, . . Environmental Health Section � r� ` a �________..__ _..._.__.. __....-._ .. _._.__. � •-- _ _ _ .� � !� � �_�---� _.__ __ . ... �� \