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1493 County Line Rd0 ' DAVIE COUNTY HEALTH DEPARTMENT / � � ' , Environmental Health Section ��- �� .�, � P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)75]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002045 Tax PIN/EH #: 4890-942794 Billed To: Robert Edwards Subdivision Info: Reference Name: Proposed Facility: Residence ATC Number: 3009 Location/Address: County Line Road-28634 Property Size: 4.144 acres I/•':�j **NOTE** This ImprovemendOperation 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 I7 #People � #Bedrooms �#Baths 1,%,-� Dishwasher: � Garbage Disposal: ❑ Washing Machine:,� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size _ L Type Water Supply f/N /� Design Wastewater Flow (GPD)� Site: New� Repair ❑ System Specifications: Tank Size� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width `� J� Rock Depth � Linear Ft�1�� IlV1PROVEI�9ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF (" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent 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 installation. Telephone # is (33G)751-87G0.**** r- , (�� /� �% Environmental Health Specialist s Signature: �'1 Date: �� y a� DCHD OS/99 (Revised) ,' . . � � Account #: 990002045 Billed To: Robert Edwards Reference Name: ATC Number: 3009 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mceksville, NC 27028 (336)751-87G0 Tax PIN/EH #: 4890-94-2794 Subdivision Info: Location/Address: County Line Road-28634 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSLIED 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 WASTEWAT C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �� Date: ��"�y �� CERTIFICATE OF COMPLETION I**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. 1��1��►� o► ��3'0�-- Septic System : Environmental Health SpecialisYs Signature : DCHD OS/99 (Revised) c �,1� D'" �� 22' .c FsTI F---�� (;, e�`� �-jo�s�-s � �'-2oa T `.��w�.M,� �v�S i �Date: � V f ~ �� , � , .; AI'PLICATlON FOit SITC EVALUAiION/Ih9i'R(DVi:�4'1EN� PLlil�18� �c Davie County Heaitt� Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Streei: Mocksville, NC 2702E3 (336)751-8760 � NOV � 8 2��1 ***IMPORTAP7T*** THIS APPLICATION CANNOT BE PROCL''SSED IJNI�.P�.SS ALL `I.'H� 12�QUI12�D INFORMATION IS PROVIDED. Refer to the INFOR2�iT20N BULLL•'TIN for instruction�. 1. Name to be Biilea 'RDat �l �I.i`�!`I� . /��%►t/i}-i'�l/ 5 Contacl: Per�on (` � D'p� I h�- �'� � 2�s Mailing Address %%� RI�Gp}� r"i��-� 4rl�� I`JJ � ltome Phon� 7 3%'� !�2^ �L1 � �l __ City/StatQ/ZIP /►10GKSV�"l-c-i.�'-- �iL� ��D�� Dusinoss Phone 70�1'g��' � � � � � ��,� nI/� ,y '�'' N C ' 2. Name on Permi.t/ATC if Difforent than Above IC i. �(�, U! �i (L�. S C. () it1,�' I`c �� (� C� A) �lJ 3� oi 4% Mailing ]�lcirass �� U 3 l. �J U rli 1(� � I ii/ "� IC. +G„_ City/State/Z.iP (�CI Q i'h f) �✓ �/ I� �. d+ ��A % _ 3. Application For: � Site Evaluation � Improvement Permit/ATC I I Botii a. system to service: f�. House ❑ Mobile Home ❑ Business Il IndustL-y I I Other 5. If Residence I�d Dishxasher �, � # People LI Gazbaqe Disposal � # Bedrooms � �t Bai:hrooms �i. �( Hashing DSachine LI IIasement/Plumbiny II IIasement/No Pluml�ing 6. If IIusiness/Industry/Other: Specify typo �f People If sinks # Commodes fl Showors # Urinals �f Y7ater Coolers IF FOoDSERVICE: # Seats Estimated ti9ater Usage �gallons per da;r) 7. Type of water supply: (�i'County/City ❑ Well II Community s. Do you anticipatc additions or cxpausions of thc facility this systcm is intcn�cd to scrvc? i-1 1'cs 6Q No If ycs, what typc? ***Id1PORTANT*** CLIENTS AfUSTCOhlPLGTETHG REQUIRED PIiOPLR'I'Y INC�OItllr[A'170N RGQUI.S'fGD I3Gl,O�i'. �ittier a PLA'f or SITL PLAN AIUST 13CSUB�117TLD by thc clicnt ��ith'CIfIS APl'LICA'1'ION. I'roperly Uimcnsions: �7"• � y�� '� Tax Officc PIIV: # ��/ �� 5 y��"� 9� Property Address: Road Namc �o wn -�--y �-- I�l-Q-� RE • CitylZip � If in a Subdivision providc informatioc�, as follows: Na mc: Scction: Blocic: Ltit: WRI"f1s llIRLCfIONS (I'r�,❑� I19ucics�-illc) tu 1'K<>I'I�:IZ'1'1': � � � J -� � ��.� �� . O � � �4 L � ,-e - / /�• �t � �- R ✓ a_ L Gl �- � ✓ � � `' � Go�_� L � /C.� .� � � T % �� 3 '? � ^'' . Datc Property I�laggcd: �� v � This is to ccrtity ttiat tt�c information providcd is corrcct to tlic bcst of my Icnowlcd�;c. I undci-stand th:it any permil(s) issucd I►crcaftcr are subjcct to suspcnsion or revocation, if lhc sitc pla��s or intcndcd usc cl�a��gc, or if thc infor��iatiun submitled ia tl�is application is falsiGed or cl�angecl. I, also, rurrlerst�rnrl t/rut I ruu res��uirsiGle fur «/! c/tur�es rrrcr�n•cd,%ranr lhis applicalioir. 1, I�creby, givc conscnt to tl�c Autl�orizcd Rcprescutativc of thc llavic County 1(cnith Dcp:irt�ncul ' to cntcr upon abovc dcscribcd property locatcd in Davic County and o�vncd by . __._._. ____ __ _.. . lo conduct all tcsting proccdures as ncccssary to dctcrminc thc sitc suitability. DATE SIGNATUI2C ` THIS ARCA MAY BE US�D FOR DRAWING YOUR SI L (lncludc all of thc following: �xistiu�; :in�l proposcd property lincs and dimcnsions, structures, sctbacics, a scptic 1 ations). � Sitc Revisit Cliart;c Datc(s): C' �.-A�-� �, 5� aGe. � I"rP �� y _ � � � Reviscd DCHD (07/99) � r� G��" L U, �r r {�� Client Notificatioii llatc: �HS: �f9�-7��-1 Account No. O �C J� � ' � �/ Invoicc No. � a .. . ' • . , . , ,. Ai�PUCATtON FUR SITC EVALUATION/IMI'It(DVEA7ENT 1'Eli69i�i & A3Q� Davie County Health Department Environmenta/Hea/th Secf�ion P.O. Box 848/210 Hospital 5treei: Mocksville, NC 2702Q (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�SS AI�L TH� i2�QU212�D INFORMATION IS PROVIDED. Refer to the INFORMATION BULL�TIN for instruction�. 1. Name to be IIilled Mailinq Address City/State/ZIP 2. Name on Permit/AT �if Different than Above Contact Person IIomQ Phone Dusiness Phone Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC 4: syste� to service: O House ❑ Mobile Home ❑ Business I_l Industry I I Other 5. It Residence: # People' # Bedrooms ►E Bathrooms i l Both U Dishwasher ❑ Garbage Disposal �LI Washing Machine U IIasement/Plumbing II IIasement/No P1umUing 6. If Business/Industzy/Other: Specify type N People N Sinks k Commodes # Showers � Urinals 1! Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons �er aa;�) 7. Type of water supply: ❑ County/City ❑ Well II Community a. Do you anticipatc additions or expansions of thc facility tt�is systcm is inlcndcd to scrvc'? ❑ 1'cs 1-1 No Ifycs, wl�at typc? `**Id1PORTi1NT*** CLIENTS hiUST COhiPLETETHG REQUIRCD PKOPER'CY 1NI�OItMA7'ION RLQUIsS'I'l:D 3ELOW. �ilhcr a PLAT or SIT� PLAN AfUST BCSUB�11I7TED by tl�c clicnt witL 'TI�IS AYPLICA"170N. Nroperly Uimcnsions: Tax Ofticc PIN: # Property Address: Road Namc City/Zip If in a Subdivision providc ittformation, as follo�vs: IVamc: Sccliun: Blocic; Lot: WKITIs llIRLCI'IONS (from 111ocktivillc) lo P{tO1'1?K'1'1": Datc Property I�la�ggcd: This is to ccrtify that thc information providcd is corrcct to thc Ucst of my lcnowlcdgc. 1 undcrstand tLal any permil(s) issucd hcrcaftcr are subjcct to suspcnsion or rcvocation, if thc sitc plans or intcndcd usc clinnbc, or if thc infor�u:�lion submitted in ti�is application is falsificd or cl�angccJ. I, nlso, «nderslu�rJ t/ia1 I rrm res7�oitsiGle fi�r u// c/rur�;es irrcrrrred./'ru�u !/�is applicatiat. I, hcreby, givc conscnt to tl�c Authorized Rcprescutativc of thc Uavic County Ilcalth Dcp:irtnicul to cntcr upon abovc dcscribcd property locatcd in Davic County and owned by • -----_.. lo conduct ail tcsting proccdures as ncccssary to detcrroinc thc sitc suitubility. llATE SIGNATUR� � � tGi�c�!/�/L THIS ARCA MAY BE US�D FOR DI2AWING YOUR SIT� PLAN (Includc all of tlic follo�ving: Cxistinb :uul proposcd property lincs and dimcnsions, structures, sctbacks, and septic locations). Rcviscd DCHD (07/99) . � Sitc Rcvisit Char�c Datc(s): Clicnt Notil7cation llatc: �HS: Account No. I►ivoicc No. v- �- ��N�' �, N.I.P i e� i �o --+• .--� 8•48'04• E�.i.c N.i.v S 8'48'04' E �' 100.06 S 88' 48'04' E � 1�9. 94 i I P D ORIS K. FO WLER 30.00 , �5�� . -- ��- -� q� t ' n:- D. B. > 17, Pg. 394 as y��,� ^� m o j D.B. 141, Pg. �� 644 5� � � .� ,� , � y � � c �,� STONE S7CWE � c�� S 88'48'47' E aB,��,i ' 7 48,43 --�' . � � o • ��j � r E.i o AREA = 4.1 1, 4 A C. b� � � � � i� v ►� �=1 �� N � N �` M+ v' v 'tj r�� Ei.P �+1 � N h _1� __— 1-- 393,� 3, W � � _ K�L�ER S69 � f f�� __— JAc� �. D � 78, pg, 639 LI SA R. YORK D.B. 189, Pg. 577 1G0 5u 0 � 100 cC�C: �OG r---, i �T =CALE i�'� �tET PLAT ❑F SURVEY F�R: � 5 I, GRADY L. T MY DIRECTI�N VAS DRAWN FR' MADE TU T � bV� REGISTERED L TUTTERO�ti 127 LI. M�CKS� <� R 0�3.E'P T .� ;CALE, S'� = 1 ��, APPRLIVED BY� � LT �,�, OCT t 8. 199 BEING 2 TRACTS TOTALING' S.032 ACRES TAKEN �ROM THE b! LYINv IN THE CALr"+HALN TOWNSHIP, G�`.'!_ COUNTY, NORTH CAR.OUNA "MX M;;P REF: �: —1, o portion nf �-',^-R� Ei DAVIE COUNTY HEALTT� DEPARTMENT � � - Environmental Health Section ' � ` � Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002045 Billed To: Robert Edwards Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 4890-94-2794 Subdivision Info: Location/Address: County Line Road-28634 Property Size: 4.144 acres Date Evaluated: �% /� �f Water Supply: On-Site Well )/ Community Public Evaluation By: Auger Boring Pit Cut iax�uic �ivu� Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLTTE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 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- 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky SP - Slightly plastic P- Plastic VP - Very plastic Structure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangulaz blocky PL - Platy PR - Prismatic Mineralo�v 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 OS/99 (Revised) ■ ■��■ ■■�■■ ■��■ O��e■ ■�■�■ ■��■■ ■��■ ■�■�■ ■�■�■ ■�■�■ ■��■ ■��■■ ■��■ ■�■�■ ■��■ ■■�■■ ■■■■■ ■��■ ■■ ■■ ■ ■�■��■�■■ ■�■■��■ ��■��s ■��■ ■�■�■��■ ■��■■■■■ ■�■■��■ ■w��■ ■�■��■�■ ■■�■��■ ■��■��■ ■��■ ■�■��■■��■ ■��■��■��■ ■��■��■■ e��■■ ■��■■■�■ ■��■ ■■��■��■■ ■■�■�■■�■��■��■��■��■��■��■��■�■��■��■ ■■��■��■■��■��■■ ■�■�■��■��■■��■■ ■��■ ■��■��■ ■�■�■■��■■■■��■��■��■��■■��■��■��■ ■��■■��■��■■��■■��■��■��■��■�■■��■��■�■��■ ■■��■�■■��..■■..�:��■�■■��■■■�■�■ ■��n��iiiiii��■��■ ■�■�■■■�■�i��■�■��■��■�■��■�■��■��■��■ ■��■��■�i��■��■�■��■��■��■■�■■��■■��■ :�:C::::i�C:C::C:i�iC::C::i� CC::::�:C::::�:C: ..........�� ................►................... ..........�� ...............��................... ..........�. ...............��................... ■��f��CC.:�CCCC:.:i�:i��■��■ ■■��■��■��■��■��■■■■�■ ■�■��■��■��■��■��■■��■��■■��■�■ ■��■■�■��■��■ ■■��■��■��■■�■■■��■■ ■��■��■ ■��■ ■■��o■��■��■��■�■��■�■��■��■��■��■��■ ■�e�■��■��■��■��■��■�■■��■■��■ ■��■��■�■■��■��■��■��■■��■��■��■��■■�■ ■��■��■ ■■��■�■��■�■■��■��■�■��■��■■��■��■��■■��■ ■��■��■��■��■��■��■■��■�■■��■■■■■■ ■�■��■■��■�■�■��■��■■��■��■��■��■■�■ ■■��■■■■��■��■ ■��■ ■��■��■■��■■■■�■ ■■��■■■��■■■ ■■��■■■��■��■�■■ ■ ■■■��■��■��■■��■�■■��■�■ ■��■ ■��■ ■��■�■■��■■��■■��■■��■ ■ ■■�■�■ ■■■��■ ■�■■�■