303 Charleston Ridge Rd HEALTH DEPARTMENT RELEASEr For office use only
*CDP file Number 187846-1
wed Davie County Health Department
J5-000-00-037-04
210 Hospital Street
County,ID
F P.O. Box 848
Evaluated For: HDR/WWC
•�V.w�'d'p*
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 1 i a a i a 0 a 0
UNTIL:
Applicant: Jeff Herbert Property Owner. Jeff Herbert
Address: 303 Charleston Ridge Rd Address: 303 Charleston Ridge Rd
City: Mocksville City: Mocksville
State/Zip:. INC 27028 State/Zip: NC 27028
Phone#: Phone#:
Property Location&Site Information
Address 303 Charleston Ridge Road Subdivision: Phase: Lot:
Road# Mocksville NC 27028
SINGLE FAMILY Township:
*Structure: Directions
#of Bedrooms: #of People: Hwy 64 east Charleston Ridge Rd to end
*Water Supply: N/A
Basement: ❑Yes❑No Type of Business:
Total sq.Footage: No.Of Employees:
*Proposed Improvement:
Building 40x40
'Release Conditions Rh,e ws
Maintain 5 foot setback to any portion of the septic system 691
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? O Yes O No
Applicant/Legal Reps. Signature: *Date:
*Issued By: 2140-Nations,Robert *Date of Issue: 0 1 a a / 22 0 1 5
Authorized State Agent:
**Site Plan/Drawing attached.**
®Hand Drawing 0 Import Drawing
HEALTH DEPARTMENT RELEASE • '
sw£4 Davie County Health Department CDP File Number: 187846 - 1
y 210 Hospital Street J5-000-00-037-04
` P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 01 / 2a / ,2015,
QUW O Inch
Scale: O Block = .ft.
Drawing Type: Health Department Release O N/A
i
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Page 7 of 2
Davie County Health Department
4-� 36 Environmental Health Section
P.O. Box 848
p §10 Hospital Street11 Vk �1
p Cos Courier#: 09-40-06 4,;
Mocksville, NC 27028
Phone:(336)-753-67ww' Fax:(336)-753-1680
ON-SITE WAS CERTIFICATION
(Check One) Replacement Remodeling Reconnection �lZlCOGU� /rP
Name: V � Phone Number 31R J`l J' ` M (Home) P
Mailing Address: (Work)
Email Address:
Detailed Directions To Site:
Property Address:
Please Fill In The Following Information About Th EXISTING Facility:
Name System Installed Under: `� Pir�� Type Of Facility: d
Date System Installed(Month/Date/Year): Oto/n Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes _e If Yes,For How Long?
Any Known Problems? Yes U If Yes,Explain: a 3. ZU
Please Fill In The Allowing Information bout The NEW Facility:
Type Of Facility: 11(x O Q Number Of Bedrooms: O Number of People
Pool Size: Garage Size: Other:
equested By:. \4 Date Requested:
(Signature)—
For
Signata e) For Environmental Health Office Use Only
"rjoDisapproved
Comments:
Environmental Health Specialist ate:__z- a /45,_
*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 properly for.any given period,of time.
Payment: Cash Check Money Order # 414 VAmount:$ Ido.00 Date:
Ll 1731115-
Paid By: Received By:
Account#: Invoice#: 677q
L-L 11
V-_4
-el
LI_l-
DAVIE COUNTY ENVIRONMENTAL HEALTH O
` P.O.Box 848/210 Hospital Street
Mocksville,NC 27028-
(336)753-6780/Fax
7028-(336)753-6780/Fax#(336)753-1680
J
OPERATION PERMIT
Account : 990002794 Tax PINIEH#: 5747-09-8890 3 ��
Billed To: Kristy&Jeff Herbert, Subdivision Info:
Reference Name: Jeff Herbert LocalioniAddress: d-27028
Proposed Facility: Residence Property Size: 23.50 Acres
ATC plumber: 5098
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. , �p
System Type: S.T.Manufacturer'CJ '"'o!Tank Date 1 —.)/Tank Size !D GU
Pump Tank Size: I d aG
System Installed By: i ?can, E.H.Specialist: / Date: (9 U
97-741
r�6
Sao
r�t v ch
465
5�k
DCHD 11/06(Revised)
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O:Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
f
• Account #: 990002794 Tax P€NlEH#: 5747-09-8890 /1
Billed To: Kr€sty&Jeff Herbert Subdivision Info: 303 CIkOf('Qs'(c#''t`K-+i�- '*'
Reference Nance: Jeff Herbert LocationiAddress: X27028
Proposed Facility: Residence Property Size: 23.50 Acres
ATC Number: 5098 Site Type: 211ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms 3 #Bathrooms 3 #People BasementO<t ement plumbing? --
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size ��• Type of Water Supply: ❑County/City We110Community Well
1 000
System Specifications: Design Wastewater Flow(GPD)3/ Tank Size=GAL.Pump Tank I/ AL.
Trench Width 3 G ,Max.Trench Depth-3o� Rock Depth , Linear Ft-5 W
Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.
may also be use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30-9:30a.m.on the day of installation. Telephone#(336)751-8760.
�°
/ 1
kv�
t
'5
Environmental Health Specialist Dater
DCHD 11/06(Revised)
- Davie County Environmental Health
P.O.Bog 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
r
IMPROVEMENT PERMIT
Account #: 990002794 Tax PIN/EH#: 5747-09-8890
Billed To: Kristy&Jeff Herbert Subdivision Info: 363 eksv-r��s �
Address: 121 Cloister Drive Location/Address: EahwFRevd-27028
. City: Mocksville Property Size: 23.50 Acres
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.
Permit Type: ew ❑Repair ❑Expansion Permit Valid for: C�Years ❑No Expiration
Residential Specifications: #Bedrooms #Bathrooms l� #People 9 Basement�sement plumbing �r
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): Type of Water Supply: G4E�`6unty/City ❑Well ❑Community Well `fid
Site Modifications/Permit Conditions: As stated in 15A N
vu s ems may also be use \
System Type LTAR V�
Initial I Aei,C e -{4�- Cj , 5-
Repair
Re air 00-re -! .1
t00 r
Site Plan \ 9 ,„e. 'TO
E"M fl
Vin;�5Y?I 1 C-
ceco
ko
l -�0
Environmental Health SpecialistDate
i.p.11-06
LZ N FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
`\ Applic ite Ev provement Permit Authorization To Construct(ATC) Both
` o w y m Repair to Existing System Expansion/Modification of Existing System or Facility
` • ORTANT•••THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION `,
Name to be Billed R � d SEFF 1�FRA1=KT ContactPetson
Billing Address 1a\ Home Phone 23 G- 75'1 -030%
City/State/ZIP M c\C K SytLLr, We- a-104,7 Business Phone 153- 0 T3 Q
Name on Permit/ATC if Different than Above SpfM�
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facili Comers Flagged 6'13-6W
NOTE: A survey plat or site plan must accompany this application. Included: Site Pian Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat
Owner's Name AA I`o U -' P—O SS F.a Tt Lt.:e Y Phone Number
Owner's Address Ili 1"jat NOR-7t_ City/State/Zip Ogg—�Zpc,E�NC ;.731 O
Property Address 30.4-1 ncP-ies oto 6rrToty 0 Ci nCxsysLLJ9
Lot Size g3`Ja Aces-s Tax PIN# 574'70 S 1
Subdivision Name(if a pliable) 'V Section/Lot#
D ctio To 'e
V-LW1W--i:4Z
If the answ r to any of the following questions is es",supporting documentationmust be attached.
Are there any existing wastewater systems on the site? Yes o
Does the site contain jurisdictional wetlands? Yes o VLOOO P t-Mw ZMS 6XyS T
Are there any easements or right-of-ways on the site? es o
Is the site subject to approval by another public agency? Yes o
Will wastewater other than domestic sewage be generated? Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People 4 #Bedrooms LA #BathroomsGarden Tub/Whirlpool Yes No
Basement: es No Basement Plumbing: ('es No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: onventiorral Accepted Innovative Alternative Other
Water Supply Type County/City Water New Well Existing Well Community Well
y
Do you anticipate additions or expansions of the facility this system is intended to serve? Yes
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that arry permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
locating and flagging orstakingthe house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Property c er's owfi�'s legal representative signature
Date(s):
Client Notification Date:
t ;!�'
Date C, EHS:
Sign given Yes No Account#
y Revised 11/06 Invoice# LL_
arw
.,� .,� ,. `=✓115
2Y 4 {F 2770 125a
mak'
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28-33o-
2453
Emma
q i' _2914
265,1 294
�24�3 252 WINDING CREEK RD'
2r� 265�2743 252 2555 299 ,
cJx `•C i
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tiouslE , t
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A-91 1�tt.• �P.oP �.TY
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• DAVIE COUNTY'HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPIralFd&N•il'jNWQWZM42N Tax PIN/EH#: 5747MORTY INFORMATION
Billed To: Kristy&Jeff Herbert Subdivision Info:
Reference Name: Location/Address: Eaton Road-27028 d
Proposed Facility: Residence Property Size: 23.50 Acres Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% Ll
HORIZON I DEPTH 4Q
Texture group G
Consistence
Structure A K,
Mineralogy
HORIZON II DEP'T'H
Texture group
Consistence oC
Structure J 10,
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS '
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION U
LONG-TERM ACCEPTANCERATE
10-16-
Q
SITE CLASSIFICATION: ��b�-StiG n 5 , All ll EVALUATION BY: 1,a�Q 1V C� 1�y t4 �7
l"
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: t CT4 N C4 ,1J G
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
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
LYstcs.._
Horizon depth-In inches
Depth of fill="In inches
Restrictive horizon-Thickness and inches from land surface j
Saprolite-S(Suitable),U(unsuitable) -
Soilwetness-Inches from land surface to free water or inches;from land surface to soil colors with chroma 2 or less
Classification-S(st itable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05/05 (Reviced)
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