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1270 Godbey RdDAVIE COUNTY HEALTH DEPARTMENT /0=00 Environmental Health Section r P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900063 Tax PIN/EH #: 5708-88-1208Im Billed To: Larry McDaniel Subdivision Info: Reference Name: 3D W&LILF-Q Location/Address: Godbey Road -27028 Proposed Facility: Residence Property Size: 21 acres * *TEQ* Tlii bfinprove8me NOnt/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 1-x©0 St, #People 2 #Bedrooms 3 #Baths 2 • S Dishwasher: V Garbage Disposal: d Washing Machine: E Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 21 ", �Q Type Water Supply C U- Design Wastewater Flow (GPD) Site: New 121'*' Repair ❑ System Specifications: Tank Size I000GAL. Pump Tank GAL. Trench Width 3to Rock Depth 1'L Linear Ft. 3!50 Other: 3 01ST21 P-:>0Tl 0 r,) F ccS . rJ�TQ1 t_ U tJ l''S D.C. K-cJ . Required Site Modifications/Conditions: 1 AS\ALk_. O^l c jTW Q . V4P 5D' Qc:L L, 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 jzetweep 8:30 ajq.-to 9:30 a.m. or 1.:QQ.p-rp.,tqjo;p m-Qp the.dgyof inst�ilation —TKlpphone # is (336)751-8760.**** Environmental Health Specialist's DCHD 05/99 (Revised) (alp, D e. /3 O DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900063 Tax PIN/EH #: 5708-88-12081m Billed To: Lary McDaniel Subdivision Info: Reference Name: )b Location/Address: Godbey Road -27028 Proposed Facility: Residence Property Size: 21 acres ATC Number: 2875 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION n� **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 CO T75, ION I VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : Date: 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 I 1 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but sh&n NO WAY be taken as a guarantee that the system will function satisfactorily for any cm given period of time. d� s� PAD to/ CA&" �S 1 �► 1 l�,a�L Tjan Septic System Installed By: Environmental Health Specialist's Signator ate: C/ DCHD 05/99 (Revised) .0 ruua��un ruu brit tVALIA11un/IMMOVt1MIM PERM1I sit AIG ` Davie County Health Department EntrfronmenW Health Section VAN Q �P.O. Box 848/210 Hospital Street Moaksville, NC 27028 (336)751-8760 ] 2(}01 FBI •••IZD'ORT11H'le** THIS APPLICATICK Coil UM BE MWMSSiD V=88 ALL-nm-RRQVIn_?n —.,.� XMMF 9MON IS PtLMDED. Refer to the IN�'t7R�t WION BOLIATIN Tor iastW0 ;a� NJ,vy 1. None td be Billed 1-- rru_ 0A L- \OA ('e- ( l u r (�6aoutsot sere«, k R p Mailing Address 1' � � 5 1 9 Nous pilose city/state/zIs V , 0Ck c d_1 LC P( 'o?r'160'6- swan ss Phons 40- r� 2. None on Permit/ATC If Different Uum Above 3 �� . W wiling Address LP Zl' 40r1 city/state/zip T i1 ! � � ri 11 Lt ay 0 . 3. Application Vos: U Site !valuation I] Inprovaaeat Permit/ATC Both 4. system to Sendoe: Hme 0 ouse 11 Mobile HoBusiness 0 Industry 13 other s. If sclerae: f People r _ i Bedrooms � • Satbroom . Bich+rasher Vl"afage Disposal I�IashiaQ Nadine 0 Basement/Plumbing 13 Basement/No Plmbitq Hosiaess/1ndn:try/other: speclly type People t# siNu III Cawood" / showers # 1l2.4na18 / hater Coolers I! 1=8ZINICE: 11 Seats Zstimated Water Osage (galioas per day) 7. Type of water supply: 0 Conaty/City Woll 0 Community S. Do you anticipate additions or expI; of the facility this system b Intended to serve! 0 Yes, 0-9-0� U yes, what tyF+e' "'IMPI7RMNT"' CLIENTS AIUST COAMEW THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. EHher a PLAT or SITE PLAN MUST BESUMOTTED by the client with THIS APPLICATION. al al PCz-S Proppeerty Dimenslo n: )Ci � -74 X � 12 ,t 12 S x ya�i , S X WRIT& DIRECTIONS (from Modlsville) to PROPERTY: Tu Office PIN: d?16 ()Ob0 occ q 0 Aw6k( to ,-, Property Address: Road Name o l b Id o a o e air 11 City/Zip 1'Yl0 cl-Cgy► I wt!b rc c l FeeIU U In a SNbdivbia i provide informatkw, as follows:1 �o��n1� Q� Name: u �v� �Lsn l -7h %c7 PCC— RR(1 Section: _ Block: Lot: Date Property Flagged: 10 -(o -D I v This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any perwit(s) Issued hereafter ne subject to suspension or revocation, if the site plus or Intended nse change, or U the information submitted in thi ► appikation Is falsified or changed 1, also, nnAw3z=d that Ion rro wmOkefor ell charges Incurredfi m shk gpUcadm,. ' I, hereby, give consent to the Authorized Representative of the D County Health Department to eater upon al ove described property located in Davie County sad owned by � 1OmlluA . to conduct all b sdug procedures as necessary to determine the site suitability. DATE - q -0 SIGNATURE THIS AREA Al BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property Han, and d st"res, setbacks, and septic locations). Revised DCHD (07/98) ", ojck�.� tj ar A Account No. Invoke No. .y., it,) ic.UVwvu i INDEXED ON 5709 2847 1200000006 21.62A 1200000025 2467 �J sA 0589 8 a i � J (8.23A) 6404 5.000A 0298 8361 .oa 2. 20 f5 by �h (5.3W 3711 *a (8 3 . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900063 Tax PIN/EH #: 5708-88-1208 Billed To: Lary McDaniel Subdivision Info: Reference Name: Location/Address: Godbey Road -27028 Proposed Facility: Residence Property Size: 21 acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group 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 SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: 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 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) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & '. • Davie County Health Department Environmenta/Hea/tfiSecton $ 20Q�. �k� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for"in'structions. 1. Name to be Billed—1a.4ai ��l�[!\(�/� / Contact Person Mailing Address I'?S ) c1/ [il N�� �.J✓ Home Phone City/state/ZIP C.pi/4/t/��c/i.l 110 �+E'"�j� S Busineas Phone 2. Name on Permit/ATC if Different than Above / 6 o Mailing Address City/State/Zip 3. Application For: pQ/Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: rr*Ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms --� q.pishwasher C bags Disposal ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City IWWel1 ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [ 0 If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITI'ED by the client with THIS APPLICATION. Property Dimensions: -21 n{,eF S Tax Office PIN: #-5-70A0 Property Address: Road Name ° or A, City/Zip _ �r,� S`i� �iIl k %C' If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: fi-tt c�t�t an/� hod , Qai. 1b ASrOri..t L-11 H''� t�R�eo-�, FRI-9,0 CAt2 i lck: Ir, fx "e'xce-r6,30 TiT-eQL�n•e .. C'ommin..4 o,,tof (7t ees a,,f4L FLA (--�d Date Property Flagged: 8/FE5 f 0 I This is to certify that the information provided `is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, 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 b to conduct all testing procedures as necessary to determine the site suitabili DATE 444 I o/ SIG RE THIS AREA MAY BE USED FOR DRAWING YOUR ITE P n tl� following: Existing and proposed property lines and imensioW structures, setbacks, a tijs tic 1 �tio sJ.� t 4 Site Revisit Charge 1 Date(s): Z Client Notificati Date: Z- --7D EHS• 5O 1570 Account No. � � � ✓, Revised DCHD (07/99) (� Invoice No. 6 .r---�-�- k P. S ;YIC D.L S yylC EcOO.D D. B 19 1- EGCGD �• 329, L,G 385 pL A� Joy AIcCALLI �lcCALRR .b B. L` PC- <�4 4 BRENDA WELLS D. B. 322, PG. 62 I - TWIN HICKORYL T. RpY S 61'55'13' E i 125.46 IIUNTIM; Air 112 — — [.1 P S 03.06'17' .W � 50 35.00 0Cr � Y '` Ub RANDY D. Mc CLAMR 0 CK l �`"" 3°: 4q % ' GENEVA A. McCLAMROCK I s 6 0 E.I. D.B. 315, PG:`- 467 9 o N.I. Ob X= -Feb -08-01 12:04P Fleming, Miller & White 336-998-3416 P-02 ' �.I' �C/ . Gam`// �-✓�r�� A`� 1(?f.X6Rv • T•� l r rY a5 It r ti t,001) S 5314610, c' i ) "91 jV11 1-61001) ' F 216 {)7 S f1'S°5"1:?' f. t .. ...... ... t n0. !cn ..... . r!r r 4,21 ' l (�, 444 'S:Nf'tl � M tMPIVA4 )Yx'.1,LS' �> 1.x. D. 3212, .1�'C;, Z lith --. T �`. '`' v, it q In a. m 1J 1 N 14'a5't9' ! � � ~ ,3•' N8 9J \, RANDY M+, I'�111'1, }' l). 1i'It (.LAMROC.Ir �r✓! 3}��n s C; AN EVA A, Mc;CIA11111OCK ter.• y" F� t"� r. APPLICANT INFORMATION Account #: 990001570 Billed To: John Walker Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5708-88-1208.jw Subdivision Info:` Location/Address: Godbey Road -27028q Property Size: 21 acres Date Evaluated: 21 O Water Supply: " ` On -Site Well Community Public Evaluation By: Auger Boring Pit Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: q • q REMARKS: EVALUATION BY: �G f 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) HORIZONConsistence Texture group Consistence Mineralogy HORIZO KNEW . . � rdAW101 Consistence orm"o WAS "'WMWINMineralogyTexture groupConsistenceMineralogySOIL WETNESS CLASSIFICATION ��r���■���r� SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: q • q REMARKS: EVALUATION BY: �G f 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) ■■■■■\1.X11■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■\��■■■■■■■L!!: Gl[IA/li■■■■■■ ■!•■■■■Ill!■■■■■■■■■■!•■■■■!•■■■■■■■►s!!�!■��■■I��■■■■■w!]I■■■■■!•■■■A■r!■ ■■■■■■V■■■e■■■■■■■■■■■■■■■■■■■■■®7■It■[!�/C`�I ■■■■■Rid■■■■■!1■■i�'J■ L�►7 ■■■■■Ci►�■!■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■lei■■F.77111y■■■��I.TI.i]i��■■■■■■■■■■■ ■■■■■■■I■■■■■■■■■■■■■■■■■��■■■■■■■■■■■■■■epi■■■■■■■■■a■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■Cir■■■■■■■■I>f■■■■■■■■■■■■■11■■■■t•!■■■■■■■■■■■■ ■■■■1\■�■■■■■■�■■■1:�■�ifl'►J■■■ �lslarir■■■i■■■■�■�■■■■■■I■e■■■ ■■■■■■■1■■■■■■■■■■■■■■�►►�======����I.�===yea■■■■►i■■■■■■■a■■■a.,■'■■■■■ ■■■■■■■I■■■rlur.�wrGrtsu■■■■■■Ir■■■■■■I■ ��■■■■■■■■■■■■■■■■■■■�■■■■■c■■■■e ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■1■■■■■mil■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Weir%�^■:�■■■■■■■■■■■■■■■■■■■ ■ ■ ■