520 Greenhill RdAccount #: 990001559
Billed To: William Foust
Reference Name:
Proposed Facility: Residence
ATC Number: 2693
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 —14 52O
Tax PIN/EH #: 5728-23-8208
Subdivision Info:
Location/Address: 520 Greenhill Road -27012
Property Size: 19.254 acres
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 WASTE WA NSTRUCTION IS V F . R A PERIOD OF FFIVE YEARS.
Environmental Health Specialist's Signature: Date: 4:�;4`0z&
CERTIFI
**NOTE** The issuance of this Certificate of Completion sha dicate the sys m' a i on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter ectio .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be taken as a g that the s em will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Zia/ Date:If C
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 #: 990001559
Tax PIN/EH M 5728-23-8208
Billed To: William Foust
Subdivision Info:
Reference Name:
Location/Address: 520 Greenhill Road -27012
Proposed Facility: Residence
Property Size: 19.254 acres
**NOTEC* Thisfmprovement/Operation Permit DOES NOT authorize the construction of 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 ##Peeoople _ Q #Bedrooms � �
#Baths _
Dishwasher-/0-11"
Garbage Disposal Washing Machine:" Basement w/Plumbing: ❑ Basement/No Plumbin
Commercial Specification: Facility Type n #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 1,VI-,AL Type Water Supply Design Wastewater Flow (GPD) Site: NewP--�Repair ❑
System Specifications: Tank Size GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width Rock Depth Linear FtSOCb
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFL ENT FILTER. RISERS) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie o��ealth 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 * lation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: I Z ul Date: O� �� `(� f ✓
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/151PROMIENf PERINNY & ATC
Davie County Health Department
yw Environmental Healtfi Section
j P.O. Box 848/210 Hospital Street
���/// Mocksville, NC 27028
(336) 751-8760
FEB 2001
ENVIRONMENTAL HEALTH
DAVIE COUNTY
***IMPORTANT***
INFORMATION IS
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
PROVIDED. Refer to the INFORMATION BULLETIN for
Name 1. Nae to be Billed
JA/1L.1. JA M /- .
FO U S Contact Person
10 11- FD a 61'
Mailing Address
SOS WN t 7' eY
CT• Home Phone
11011-L
71?
1Z -,6 9 I+
City/State/ZIP
/6
CL-F-Mmems , iu
C • Z#7 Business Phone
2. Name on Permit/ATC
if Different than Above
SAmE.
Mailing Address
SAME,.
City/State/Zip .SQI^F-
3. Application For::Site Evaluation YImprovement Permit/ATC ❑ Both
4. syatem to service: NJHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
2 Newt L NoW
5. _If Residence: # People 2 # Bedrooms 2 VbL t ujUrtE # Bathrooms ig Tune,
�I Dishwasher W/ Garbage Disposal iY Washing Machine RI Basement/Plumbing VBasoment/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: B'County/City ❑ Well ❑ Community
s. Do you anticipate additions or expansions of the facility this system is intended to serve? Ef Yes ❑ No
Ifyes,whattype? Z 15EdRooMS _ I f3AiI4 to Feurts . 14AVC- Ne TtmE fRAmE„
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: If. ZS¢ A-C.&C.3
Tax Office PIN: # 522.19- Z3- 82-08
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
IlNe df FROM /(&CAsw" E 7 -
Property Address: Road Name SZo 44je0Ety NILE A GREEKHlL�•• R0•0 /IIRNt 4aoFi—
City/Zip McG/is�y��E u C Z?DZ8 6so /fl�pR-o�G • / /VIIG E T
If in a Subdivision provide information, as follows: .s2o 41i2E rAl "I'LL I?a. itlEk! Noose
Name:
Section: Block: Lot:
$E 8141&1 #00 # $FY6A1V &AYE .
Date Property Flagged:
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 Ilealth Department
to enter upon above described property located in Davie County and owned by AIM. Z. �90,eCCC.4 B. FopS-r—
to conduct all testing procedures as necessary to determine the site suitability.
DATE A// ZDo/ SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the foiling: I xisting and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. 5767 /
Invoice. No. 0 �✓
711
Davie County .wealth Department
and dome Health Agency
EnvironmentafHealth Section
P.O. BOX 848 / 210 HOSPITAL STREET
COURIER #09-40-06
MOCKSVILLE, N.C. 27028
Davie Farm & Lend Sales
1307 N. Main St.
Mocksville, NC 27028
3
Dear Client:
PHONE: (704) 634-8760
September 23, 199E
Re: 3 Site Evaluations on 18 Acre Tract
Green Hill Road/Tax Map J-3: Parcel 34
As requested, a representative from this office visited the aforementioned
sites on September 23, 1996. Based upon the information provided on the
application(s) for site evaluation(s) and after an evaluation was completed on
each site, the sites were found to be provisionally suitable for the
installation of a modified, oversized on—site sewage disposal system on each
site.
Before any permits can be issued the house/mobile home location on each
tract must be established and that immediate area evaluated.
If you have any questions, please feel free to contact this office.
Sincerely,
WeeW..�
Robert B. Hal 1, Jr. , R. S.
Environmental Health Section
RH/wd
Enclosure(s)
gg� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
/? Davie County Health Department V�
Environmental Health Section D lh g
Jt tid ��' P.O. Box 848
`iS' Mocksville, NC 27028 l SEP -3 1996
7 pJ ��� (704) 634-8760 � �
ENVIRONMENTAL
r****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed�� U � Q. I /� I `� t�•�- �� J Contact Person Aed aCe'l S 7—
Mailing Address r/ Home Phone /
City/State/Zip tlq z%� Z d' Business Phone &o 3 `Q ZS_ 7
W d
2. Name on Permit/ATC if Different than Above l �-1 pltA r f el2W" F(J U S % '7 4- 0 -- 73 9'
Mailing Address _" c ��'- A,
3. Application For: [Site Evaluation
4. System to Serve:
5. If Residence: L' -
Ci
[ ] Improvement Permit & ATC [ ] Both
[] IYlobile Home [ ] Business [ ] Industry [ ] Other
J# Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal
[ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: M-County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: '+C`zeS, WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #_�
Property Address: Road Name kZl_ Q -Q Y1 ' 1 �c� �� I L
City/Zip nDN OC. SV 1 `� C'— /21 U 1�
If in Subdivision provide information, as follows:
Name:
Section: Lot #:
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 abov scribed property located in Davie County and owned
by O'S l —_to conduct aJsti s as necessary�tp determine the site suitability.
DATE 5 ` 3 —9 (-- SIGNATURE
Revised DCHD (06-96)
/&0—Ci L
- 11 T
c
i'e CIL
s C7c 1 �'.c
� V
t
J/
DAVIE COUNTY HEALTH DEPARTMENTT !
Environmental Health Section
Soil/Site Evaluation
NAME f
ADDRESS
PROPOSED FACIILTY
Water Supply:
Evaluation By:
DATE EVALUATED % X/' �?/4 v
PROPERTY SIZE
LOCATION OF SITE
On -Site Well _ Community
Auger Boring Pit
FACTORS 1 2 3 4
Landscape position L
Slope Z
HORIZON I DEPTH
all
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 i
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (0 1 -901
EVALUATED BY: X&//
OTHERS) PRESENT:
LEG
Public ✓
Cut
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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V,:! -y 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
3C--S-ingle grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineraloity
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
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?. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028 ' , I „ /� SEE331996
(704) 634-8760 l `t-�-
Y
****IMPORTANT****
1. Name to be Billed':P�+ V I Q
Mailing Address
City/State/Zip
THIS APPLICATION CANNOT BE PROCESSED
THE REQUIRED INFORMATION IS PROVIDED.
�ItA lL�— Syl Contact Person
N x't'4;kt Home Phone
tit -x,Lit//
2. Name on Permit/ATC if Different than Abov W l CJL-/ /910--8
Mailing Address �rS �-�-
3. Application For: [ Site Evaluation [ ] Improvement Permit & ATC
4. System to Serve: use [ ] Mobile Home [ ] Business [ ] Industry [ ] Other
Business Phone_ ( f Q 7 S'� 7
c 4o -73 Cf S""
[ ] Both
5. If Residence: L I Pe'p
o- 'O # Bedrooms # Bathrooms [ ]Dishwasher [ ]Garbage Disposal
[ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [LJ-C"Ounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type?
r 1 0
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A FLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:(( [ ' j�C i2�S : WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #-�/- 1��eI972
�-
Property Address: Road Name �'cl`-�r`t�- ``�c�- e ej ' 1 L
City/Zip �MN 0(L --s 1 `\ ; /;2 1e
If in Subdivision provide information, as follows:
Name:
Section: Lot #: '
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 abov scribed property located in Davie County and owned
by / �� 7-S Z oto conduct a sti s as neces" determine the site suitability.
DATE` � `'� � SIGNATURE
n
Revised DCHD (06-96)
;his
? Il M e d7A '
r
�, c 1 �=l•C
s�
,� 11
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation 7
NAME i///A��� DATE EVALUATED�1���
ADDRESS
PROPERTY SIZE
PROPOSED FACIILTYLOCATION OF SITE 7,407
r
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring L/ Pit Cut
FACTORS 1 2 3 4
Landscape position L L
Slope Z
HORIZON I DEPTH 100.rF e'
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH t W
Texture group
Consistence '
Structure /( /
Mineralogy
HORIZON III DEPTH
Texture grou2
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION v
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCEATE
REMARKS:1�_�l-fir 1
DC11D (O1-901
EVALUATED 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 ;lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V+; -y 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
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineraloicy
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
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1
' - AIDPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028 �SEP - 3 1996
pv � (704) 634-8760 � 1
ENVIRONMENTAL
ii''* **IMPORTANT'*** THIS APPLICATION CANNOT BE PROCESSED
THE REQUIRED INFORMATION IS PROVIDED.
�Les 1. Name to be Billed �U 1 I `''1NContact Person Ad �l?z S %—
Mailing Address N
City/State/Zip
2. Name on Permit/ATC if Different than
Mailing Address
3. Application For: [
4. System to Serve:
5. If Residence: U
[ ] lyIobile Home
Business Phone LO�`7'' ,Q 75- 7d
�73 0/ (-"
[ ] Improvement Permit & ATC
[ ] Business [ ] Industry [
# Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal
[ ] Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
—
# Showers & # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [bounty/City [ ] Well (] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A FLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
IK
Property Dimensions:( ! K 4C12eS; WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: #-�- iKo-e- C � �
(�
�
Property Address: Road Name_ LSC- N -�Y� - �'` c� - �' eAJ
gl
City/Zip0�
If in Subdivision provide information, as follows:
Name: '
Section: Lot #:
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 abov scribed property located in Davie County and owned
by (f1 �� 7—S . to conduct a -sti s as necessa determine the site suitability.
DATE 5 ` `'C% SIGNATURES
Revised DCHD (06-96)
4 4:�
S 17
Al, le
71- 1"J/
.2
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
NAME ffs DATE EVALUATED 1�
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On -Site Well _ Community Public__
Evaluation By: Auger Boring �f� Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope 7. v
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH JD
Texture group
Consistence
Structure _ 441 -
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 5
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �S
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (ot-9n1
EVALUATED BY:1116,./,Z
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 ;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V ----y 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
.3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralolzy
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
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