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953 Eaton's Church RdI 'i HEALTH DEPARTMENT RELEAS d4 Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Peter Pappas Address: 953 Eaton's Church Rd City: Mocksville State/Zip: NC 27028 Phone #: (336) 998-0411 For Office Use Only *CDP File Number 188128 -1 D3-000-00-+055-03 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 0 1/ a 9/ a 0 a 0 1 IAITII Property Owner: Peter Pappas Address: 953 Eaton's Church Rd City: Mocksville State/Zip: NC 27028 Phone #: (336) 998-0411 Property Location & Site Information Address953 Eaton's Church Rd Subdivision: Road # Mocksville NC 27028 Township: Directions Hwy 601 North Turn on Eaton's Church Rd. exactly 1 mile from Hwy 601 on left. House at end of driveway *Structure: SINGLE FAMILY # of Bedrooms: 2 *Water Supply: N/A Basement: ❑ Yes ❑ No # of People: *Proposed Improvement: Concrete pad for Future Garage Phase: Lot: Type of Business: Total sq. Footage: No. Of Employees: Characters Remaining 750 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 9 / 2 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** f& Hand Drawing O Import Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 188128 -1 County File Number: D3-000-00-+055-03 Date: 01 /29/.2015 O Inch Scale: O Block ":_ft. O N/A Drawing Type: HEALTHDEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release Page 2 of 2 CDP File Number: 188128 - 1 County File Number: D3-000-00-+055-03 Date:.0.1. / a 9/ .10 1 5 Davie County Health Department .[836` En ' onental Health Section t .i e "' RECEI.�mP.O. Box 848 r 210 Hospital Street toll prul Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 6rc—' YL {9�y��S Phone Number (Home) Mailing Address: (Work) �M D C 1 G S V c. 1 l 7y C. Email Address: S k;kA a ,,j b c L T o S C7 y i4A Detailed Directions To Site: VXwe- U - F X It -c t !y f U'l ! y- e /+/ L e F T D w 61-W 7 '-0v S e01" G—I f R ovt,. &of F f7j2rd�u� �3 Property Address: 9 .r 3 I2�j' Please Fill In The Following Information About The EXISTING Facility: 1/ O US Z Name System Installed Under: Type Of Facility: 7 C Date System Installed (Month/Date/Year): p�(,D,3 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How bong? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: p r v�Jt,`� Type Of Facility: e 0 �" G%l t- *C- PG( (� �4n Number Of Bedrooms:-A%Number of People Pool Size: 4 Garage Size: I Other: Requested By: Date Requested: For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *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: CashChec Money Order # ILI 0 Amount:$ Dater Paid By: C' Received By: Account #: Invoice #: f ?e-4r,rl- ,?MfJ9-s ?,53 t'97"vs C t, u" t. P At M 0C, (::�S vt l [ e.,. JV 2v (336)9V-6q;l J 5eoi a, Davie County Health Department �0�►8 I�` Environmental Health Section f P.O. Box 848 C� ,S, 210 Hospital Street Q U �'t Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: tG2 J agdei l Phone Number 33 yip' O(Home) Mailing Address: .9V3 G- f'ow S CLLyz e-4 %2&.1 (Work) j/V) D G I_/S (/I 1 h- , IV G 2-2w Email Address: Detailed Directions To Site: 0-rijJ2t S S k -�oj c Property Address; Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: �PDPrA (I R-0 Type Of Facility: RendCh,-X, Date System Installed (Month/Date/Year): 5�(��� Number Of Bedrooms: Number Of People:_ Is The Facility Currently Vacant? Yes Any Known Problems? Yes 6 If Yes, For How Long?, If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 19 J f) Aa, a ct44- fd CX 7 S % Number Of Bedrooms: a Number of People Pool Size: 611A Garage Size: Other: - Req?!n 'P-te-r �iit�; X„S (_'�P ! pkun _ CM11'1 SAe�equested: (Signature) For Environmental Health Office Use Only Approves Disapprovled ), (+ omments:l_Crl��fi,�e4iJh, M1,4 t no OD OL+ fll Zi(i n<, -L4ne mb 6e"4 Q_ 1 5 Q ' n S Ss44 rr r- a r- arc,-_ are_ nth 4'f-1 cc;�'. c( Environmental Health Speci lst A ' 4�) Date: 2/ Z�113 *The signing of this form by the Environmental Health Staff is irizb 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 tithe. Payment: Cash � Check Money Order # Amount:$ Date: Paid By: Received By: Account #: Invoice #: DAVIE COUNTY HEALTH DEPARTMENT OW N a : -PL-}K ?A. pes Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002781 Tax PIN/EH #: 5822-61-1503 Billed To: Barry Allen Subdivision Info: Reference Name: Location/Address: Eatons Church Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3553 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This 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 WASTEWA VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature Date: Z O CERTIFICATE OF COMPLETIONenr,cm1 T-zt Z brd rabm .Zj2g/I o? **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation P 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. —TA -41e. IDA-m SepticSystem Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) I sg6+Lm i:5 siu'd -to azm JL b4,mvr-s <S kx ln61 L,- • , S DAVIE COUNTY HEALTH DEPARTMENT A Environmental Health Section �?��- (�/a-$'/a 3 P. O. Boa 848/210 Hospital Street Y Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002781 Tax PIN/EH #: 5822-61-1503 Billed To: Barry Allen Subdivision Info: Reference Name: Location/Address: Eatons Church Road -27028 Proposed Facility Residence Property Size: see map ATC Number: 3553 **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 I 1 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 2 #Bedrooms #Baths ' Dishwasher: 13" Garbage Disposal: 0 Commercial Specification: Facility Type Washing Machine: E Basement w/Plumbing: ❑ Basement/No Plumbing: 0 #People #People/Shift #Seats Industrial Waste: ❑ Lot Sizey •nl Ae� Type Water Supply LskvDesign Wastewater Flow (GPD);I—qo,. Site: New V Repair 1 System Specifications: Tank Size ���2GAL. Pump Tank GAL. Trench Width LO Rock Depth Linear Ft. �?bd Other: �I,C Required Site Modifications/Conditions: Ir4-';T� LL -OA CA0010JR, FAd S' 0�� [Ws,<, IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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 (336)751-8760.**** f J 2� 41 Environmental Health Specialist's Signature: Date: (6� DCHD 05/99 (Revised) • ` . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �= P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002781 Tax PIN/EH #: 5822-61-1503 Billed To: Barry Allen Subdivision Info: Reference Name: Location/Address: Eatons Church Road -27028 Proposed Facility: Residence Property Size: see map ATC Number: 3553 **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 �2— #Bedrooms 1 #Baths l • 5 Dishwasher: 01`� Garbage Disposal: ❑ Washing Machine: 93"" Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type 11/� #People #People/Shift #Seats Industrial Waste: Lot Size `5- 01 kr-� ype Water Supply 0Wt' Design Wastewater Flow (GPD) 2L�D Site: New 17 Repair ❑ rr System Specifications: Tank Size I OCO GAL. Pump Tank GAL. Trench Width 3 Rock Depth Linear Ft.; -00 Other: �f > 70�%iO 6.' `11.17"'��-= j)omu- L4� -1 '0 -0— A",) - ji , Required Site Modifications/Conditions: C)") C—C) c-r7o tier Y4a "01 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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 (336)751-8760.**** 1�14'oN 'OV -IV Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: as 18 >R ) 5> T? t(]3STR1.)CT10N C0 a 336 '751 6786 ND. g36 UO3 0$/3012003 T: daviio county envhealth 336 757 6796 p.2 r_ APPUCA1 lON FOn srrE EY4LWTl0N/IMPftcwEMENi PEnVIT i ATC • DaYie County Health Department i FistgTiOirnranta//Yaa/eYi Sett/avr r` P.n- sox 048/210 HOepital Street MOckovilla, Nc 27026 .67tto i — we ZKJbVRTANT... THIS "I'L.ICATIO)t CANNOT 6S PROCE151W WR$SS LLL S m YERVZEED� IMYODIgTIOH IS pAOVZDED. senior to tor, INFORt MATZON BULLETIN !or inazmetione. s. we_ to be. ai4lsd ����% � • Contaa4 rar.en _ �wr��. sta4ni„y waar.er j —'�' �1V ' ,ry./� LA,� _•`-" Dow. rtes.<. — �+ , ca ty/a,..,�/zrr j" -'TT^^_ DY1iwaYa rtwnae•ly' r. wee. use, a.reut/as'C it paet.r.ttt: the. Meiling adaresa a- 7. applleatiOA Fort Waite 8'relut►ti oA + D Improvement a "t/ATC [] Both e. ayetew to a.sraCe, go Noun i ❑ Mobile Home © Luaineee G IAduotry Q Other 5. Type ayetoe reQueacad, Gl'�eoa.•mlionN D eaevekeioael agditlod C3 ioaavetive 4. X9Remittances a People ���—, — a 8edreoms Ls sathroee+e 2/ 4akwe",er I3q.tbey. D4apo,•el elNirhaae M..Aine (]a...weet/Ii,iaiay 1'lmyawest/lto pI,reiep 7. Zf e.s wave/i edueaey /ath... ...Isr type a r.opae a links a CeAsndoe s a!''ewYr �-, a otisala ,_ a water ce.l.ro _ SF t000seetvlcs, N Seats Ea Cimated Neter Vmaya (acl;oa. per aay) 4. types of ..at.r .apply, ar"Cowr::y/city ❑ well ❑ community { s. no 3— entisiPat..adicieee er t:arpmnsiuna of thr facility this sys(cot Is Amended to serve' D Yes t3'_Ror If yrs, what typer —.52--ORTd0— CLIU4Tt MuJr CUAFPLGTC THE REQUIa/_U pltOpepYY 1NFORMslr10N X4:Qilfu•'TEb Property Dimetutons: IS t 7� � ,r'�/ WHITV utitEC7'IONs ("in hletksviile) to PNOrERTYt Tax office PIN: a / ! Sy 3 e., _ ProptetyAddress: Crtyrz�p 1�\'d� !61e.01'\ E.4'� o►1SQA. 4. i$C 'SedN It In a Subdivlalon provide ItIrnadoa, as tallows: !\etnc: Oil �e's"T l..twid S�A3'3� 5cet)on: Block: —. , Lot: Dates hom coQ ers flagged. ole gk+,+w4e en oT K`�s si'C'�" 3�-03 This is to sanity that the Wisrtttation provided Is correct to lieu best mtmy xnowledge. I understand that any portnil(s) issued bcreaher are subject to snspensfon or revocation, it the site plans or Intended us* change, or it The inforsnat)on ,( - sebntitted )n this epplltaUmn is falslDed ar ebanCed I, rise, nn/rrrrai+t Moe Issue respansWef r aft rhmrrea tnturmd from, *., owls AW14ation, t, heresy, give consent to the Authorized Representative of tits Davie County HeallltDa rtn)Cttt to enter -upon above described properly tscaled in DavitCoun(y and Owned by p ) ,i so ,ao conduct all testing procedures as necessary to doto►nuone the site nth"bnity. S1GhATU 1 y THIS'KA MAYBE USED FOR DRAWING YOUR SITE PLAN (laciuy) aU of tho folio W) lixlst)ng.Und proposed , property tines and dlsnensteas, airtoetul m, setbacks, and septic location Site Revisit Clnargv Datd(gt�. -- Client Nutillcutton DAtco EH.%s I i Sign Oren Aecow)t Revised DCHD (011193Invoice No. j ' 1 j' ' - , ":' :•: �; 7; . I — �; ... .... �� ,:. �., - ". O', " - , , " , .. , , * * . ..... ... .3: ::': %: c , ;---�.,.�:,- . ;: �:� . . -� ..-- -:7- * . . ¢ j: :i:: •04;" . -, , "" , . , :•17 :j. b t:+, a• .;. U i 0 s•;• 1 :_ :i� , N `.0 r AA, �F. CS) :f: :` :'. - .i� �s :ie :.q :: �i :,: ►. i:' :t. :y 7 •: i :;:: r: x::: :::' :t: c is :; _. M 'r= .z: tD iyt :e: Y':% N L. :j: L= _ r _t: :_:_. t: %moi:(« ;:;: �` :`: i� i L`; :R ): :�: a�' �7'.`.' �. .a�••'•" 3. •.. _. h :7: :1: ti ;' 'i y' y:, �: .j 4M1 j::: _ i. .'-, ';' .;: :t U) 4 ' ... M )= :'1L• '.' :� i (: .} ' M _ I . . 1i: " ii :y_,• (� .� :'Y' �•' n '�:: •. 0 • �`' -e.J�jr - . ` _+y( tx}T Z ,-I °fi: —� -1.: ;t" c .; n Jj: :b < �' :x:; ::': -� :` �z `.'- f `: ;: f `} :i:- '� c.i'•:. ; E /�{Y( "I T 0 :r== luVwk=< :� f .D 'r.� :� ., . �; y c: ,!*, , . . . i:z:;. W ;_. �.'. s; - �] .,�. .: t UI :i::f. . T. ;_: :� �. }• ':. I• . '!• i:r .;: J' :! :s:-: y.;:; 1:5: Y f; .. :k :{' , �. :� :;: ;:. -- :y. ;j: i.: _. Z p n W Ln APPLICANT INFORMATION Account #: 990002781 Billed To: Barry Allen Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5822-61-1503 Subdivision Info: Location/Address: Eatons Church Road -27028 Property Size: see map Date Evaluated: Water Supply: On -Site Well / Community Public Evaluation By: Auger Boring ✓ Pit Cut SITE CLASSIFICATION: V LONG-TERM ACCEPTANCE RATE. D ` REMARKS: EVALUATION BY: OTHER(S) PRESENT:_ 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 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 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 05/99 (Revised) yrh✓ Landsca e: position HORIZON I DEPTH Consistence 02-�ARMI AKMVA�®-- HORIZON II . • 1 Mo�l Mflw+= y NIMMMMEME Texture group Consistence - 7�L'S�1001MMWIME Mineralogy HORIZON III DEPTH Texture group KWLa WOW,01t�'".03WA'i. MAINE�®INE ME Mine HORIZONConsistence . • Texture groupConsistence SOIL WETNESS SAPROLITE Mi SITE CLASSIFICATION: V LONG-TERM ACCEPTANCE RATE. D ` REMARKS: EVALUATION BY: OTHER(S) PRESENT:_ 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 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 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 05/99 (Revised) yrh✓ ecce■ecmem■■ E■■■■■■■■■■■ ■■■■■■mem■mm E■■N■■■■■■■■ ■■■■EON■■■N■ ■mmmmmmmm■m■ ■■E■E■■N■■Ee ■■■■E■■■E■E■ MEMO■■■N■■■■ ■■■E■■■■E■■■ ■■E■E■■E■■s■ ■■N■■■E■■■■■ ■MENU■■eee■ NONE ■■E■■■ ■■E■E■■■NEE■ ■E■■■■eeeee■ ■■E■EEE■E■E■ ■■■■N■■■E■E■ ■E■■e■E■■ee■ ■■■E■■■■■■■■ ■■■e■■■■■■E■ ■■■■■■■■■■■■ ■■■■■E■E■■■■ Nam mmm mmmm ■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■sea■ ■N■■ NOON■■■■■■■ecce■■■■■■■■■■■■ ■■■■e■■■■■■■■e■e■■■e■■■■■■■s■tee■ ■■■N■■e■E■■■■e■■■■ee■■■■■Nee■■e■■ ■ecce■ees■e■■■e■■■■■■■■■■■eeee■e■ ■\.s�i■■■■■■■aEOO■■■■■■■■■■■■■■■■ e■■■eee■■■E.�■■■■■■■■■■■■■■■tees■ ■ecce■ee■eee�•■eeee■ee■■■■■seee■■ ■■es■■■■■■■■■e��■■■■■■■■■■■■■■eee ■■■s�■eee■Nee■■■■e■eee■■■■■eese■ MEMO ■■se■■■■■■■■.�■■■■e■■■■ees■ ■■■■■■■eeeee■■■s■■■e■■■■■■■■■■Ee■ eee■■■■■■■■eEE■ee■■■ev�►■e■■■■■■■■ ■■■e■■■■■■■■■■■■■■■■Masa■■■■■■■■■ e■■■G�lI1■■■■eeeee■■■■eee\e■■ecce■■ ■OE■■lir■■■■■■■■■■■■■■■■■1\NOON■e■■ e=== -----!NNE ■N■E■■ ■■1■■■ ■■■ ■eE■■■■■■i�■■■■■■■■■■■■■■■,®NOON■■■ ■■a■Nee■ei�■e■eeee■■■■■e■■u■■e■■e■ Ery■■■■■■■■■■a■■■s■■s■■a■■ ■■■■■ee■■■eE■ees■■■ees■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ E z ��'z � g m� �� f.;:'e 9"' �g a� e w •,:.� `,t k � 64 '� t .. .a.� MM �Fm s"' �,�»s``� °�' s"' ¢• �`.' t�.: pax �t .� �z y�;_� r � tx wq, o R d JI glp 4� # � # a a ..� t s- xnt r*� r'x z�kz �z 3 4 •: �., r. � As° G,�d��y - ... A 77 , � z N W � �wy �' f x'y�!°n °' �x��� :+ �z-����t '� t 'ya;`,� z,•' H � t,x�'„ ,+�� ' zM - >' s �aqx y � way, �yt , Ev 1IIE'r 't"RY Y � i>Y:'�,k,� s' n { Y k al ntt q @ 4 2 f � hE � f � a LAW, OG 0" ;W.P ICA7ION FOR SITE EYAWAMON/IMPROVEMENT PERMIT & A 2 �S Davie County Health Department f5 R "J 1 , / Envfronmenta/Reafth SeWon ?G n t� L� Su .O. Box 848/210 Hospital Street QCT. U • i �'1 i Mockaville, NC 27028 IU C� (336) 751-8760 ' 11XVIRONMENTIIL If ***Il1P0RTANT*** THIS APPLICATION CANNOT eE PROCESSED UNLESS ALL THE REQUI - INFORMATION IS PROVIDED. /r Refer to the INFORMATION BULLETIN for instructions. 1. Ham to be Billed j (7 e✓1� !� ) _a S e,- Contact Person i Nailing Address Hama Phone city/state/zip -.9-76,o& 7o a & Business Phone 2. Name on Permit/ASC it Different than Abave c� 1} �t,� i e � P ) , � h �✓ �.0 Nailing Address M -q-, City/state/Lip 3. Application For: Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: ,House 0 Mobile Home 0 Business 0 industry 0 Other a. If Residence: # People # Bedrooms Dishwasher 0 Garbage Disposalm washing Machine 6. if Business/industry/Other: Specify type # Coa modes 0 Basement/Plumbing # shavers # Urinals # Bathrooms 9-- 0 0 Basement/No Plumbing # People # Sinks # Nater coolers IF i'OODSERVICE: # Seats Estimated Nater Usage (gallons per day) 7. Tppe of water supply: County/City 0 Well 0 community a. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes XNo H yes, what type? ***IMP0RTANT*** CIJENTS MUST COAfflLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PIAT or SITE PLAN AIUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: L Y e WRITE DIRECTIONS (from Moclnville) to PROPERTY: Tax Office PIN: #2 - o p / 1✓ o� �k ��o�%T o Property Address: Road Name 8� �Dw l�Cj- 1 �1; 1 •e b city/up 8op e,. If in a Subdivision provide information, as follows: Name: Section: Block: Date Property Flagged:' This is to certify that the information provided is correct to the beat of my knowledge. I understand that any permit($) Issued hereafter are subject to suspension or revocation, if the site plan or intended use change, or If the information submitted In this application is falsified or changed I, also, understand that I airs responsible for all chmges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suits m y. / DATE f U 2 ' SIGNATU�- THIS AREA MAY BE USED FOR DRAWITIG YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). �> IV I (-T Revised DCHD (07/98) 142" Mapv�� Account No.a Invoice NO. l DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation /,tANT'S NAME ek, / ,r1POSED FACILITY ,SUBDIVISION Water Supply: Evaluation By: On -Site Well Community_ Auger Boring ✓ Pit SECTION LOT DATE EVALUATED /12 PROPERTY SIZE �// ROAD NAME /� Ten 04 Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence r Structure TG Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE c SITE CLASSIFICATION: A LONG-TERM ACCEPTANCE RATE: EVALUATION BY: -42 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 oist 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 Mineralogy 1:1, 2:1, Mixed Notes ,H 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 (01.90) 3 N 64 yN y e� s 6p, A_ iv.. \� I I P coJAMES & CHARLES rn D.B. 152 Pg. 13 551.02 ,.t n 9sl o2yr�'1rra� _ - JAMES & CHARLES EATON TOTAL A D.B. 152 Pg. 13 ALL AREAS AF •. �� '� r = I llvrnAT4.EG POINT .CENTER � L . ; '7OQ • PLAT OF SURVEY FORE " $toll REVISIONS SCALE. 1 = 200' APPROVE T :8, DATE SEPT 23. 1998 4 1RACT, BEING 4 TRACTS TOTALING 56.67 ,= i f1 i ; + iI i i I I ua a f•u,f .i n.1 . f. . ci, 1998 LYING IN THE CLARKSVILLE TOWI, — --- _ - j _ COUNT -f OF DAVIE, NORTH CARO I Q 1-' L IV ae.A.. MJIVP ITG 1 Account Nav`� d DCHD (07/98) Invoice No. 1 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 June 3, 2003 Barry Allen 1717 Holt Road Yadkinville, NC 27055 Re: Site Evaluation - 8.32 Acre Tract/Eatons CH RD Tax PIN#: 5822-61-1503 Dear Mr. Allen: As requested, a representative from this office visited the above site June 3, 2003 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. It should be noted that, due to complex topography and house placement, a pump station may be required on the initial and/or repair installation. 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. If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp, R.S. Environmental Health Section Enc(s) ID �. .. � � � VV r J q �� LD 31 y �� ,�� �� 7� ,.