122 James Rd AU'FHOR1Z'ATION NO;,, 1508 DAME C UNTY HEALTH DEPARTMEN
I W �TArw•- rte,,, nmental Health Section PROPERTY INFORMATION
PermitteeP.O. Box 848 , 1
Name: K!)w (, Iocksville,NC 27028 Subdivision Name:-2
Phone# 336-751-8760
Directions to property: lV � (-ut: Section: Lot:
j� AUTHORIZATION FOR
tiQN it, WASTEWATER % 0& - lD�
Tax Office PIN:#
SYSTEM CONSTRUCTION l`
tJ � Road Name: . A,tN1 t=. , Zip: -7UC /
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliant with Article l l of G:S..Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMNTAL HEALTH SP CI DATE ISSUb
„� ,� �ri� kr� y:: rgtir W+ ,.f1�i'''` c ` ” -,.1 -. v •., ... ,' r
1,508DAVIE C UNTY HEALTH DEPARTMEN -
WTo�n•.or IN �t� AWkNT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee.s ," i w," w ►-�
Name. t- . . zs'�i9 Subdivision Name: pL.1t
Directions to property.` 4'.{ 't_G �) Section: Lot:
} t IMPROVEMENT ,,.. ,
bX�f^v}�[i'����L'�l� 4+Lf" � PERMIT � �/�J 6`41 q&4Tax Office PINI
Road Name: tY1 L. I Zip•f
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of aseptic 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE
-4TENDED USE CHANGE.YOUR WASTEWATER
HEALTHSPE ST. DA ED
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTALINSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE'_1AQLZ #BEDROOMS_ #BATHS #OCCUPANTS t GARBAGE DISPOSAL:Yes oloo
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE I k& TYPE WATER SUPPLY rv� DESIGN WASTEWATER FLOW(GPDNEW SITE �,REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE
AL. PUMP TANK GAL. TRENCH WIDTH CO ROCK DEPTH LINEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS%CONDITIONS: 1 ASU 1-L- Vel ��, re!)re
se
-IMPROVEMENT PERMIT LAYOUT 1
' n,c1Z
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W
' I
f fao�"P"
**CONTACT A REPRESENTATIVE OF,THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
t.
F
6 o ! •!�/
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NOWAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 051%(Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
` ( Davie County Health Department
a Environmental Health Section
D P.O. Box 848 NEW PHONE NUMBER:
Mocksville,NC 27028 EFFECTIVE MARCH 22, 1998
JUN 2 9 1998 (704) 634-8760 $36 761-8760
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ;Ti • 6&,eII1&— Contact Person S AYE^-q'
Mailing Address J 9 oo zRIfl W ood 1., yQl(e Home Phone 76o - 98g0
City/State/Zip `P)461-an C54-1e , /►/C-, a 7/D q Business Phone -777- 436, 2
2. Name on Permit/ATC if Different than Above J`itl irl e S SD i(&
Mailing Address City/State/Zip
3. Application For: [ ]Site Evaluation [improvement Permit&ATC [ ]Both
4. System to Serve: [House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other
5. If Residence: #People--Z— #Bedrooms `3 #Bathrooms 7- knishwasher[ ]Garbage Disposal
[1^ashing 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: [v4<ounty/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [V]No
If yes,what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT**0ky4W OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 133.8 R/, 6-� X33• Y WRITE DIRECTIONS(from Mocksville)nTO PROPERTY:
Tax Office PIN: # ��7 - DCv - 68 3 ��' &A - ICC
oval
Property Address: Road lame y)03/n e,5
nn ,r I
City/Zip AdUd A,,,-'�; IU 1 d'1DDeo ;
If in Subdivision provide information,as follows:
Name: SCS W. u I PAI
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 above described property located in Davie County and owned
by to conduct all sting cedures as necessary to determine the site suitability.
DATE &-d 9-9� SIGNATURE n
Revised DCHD(06-96) V q66 9171463
THIS AREA MAY BE USEb FOR bRAWINC YOUR SITE PLAN:
i
' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERNIIT&A - 2
Davie County Health Department Q l5
Environmental Health Section
P.O. Box 848
S�
Mocksville,NC 27028
r.
(704) 634-8760 C,
****IM: 'ORTANT**** THIS APPLICATION CANNOT BE PROCESSED S ALL
THE REQUIRED INFORMATION IS PROVIDED.
t 1. Name to be Billed 164 w jLXy pL_ Contact Person (l k• J6:
4 Mailing Address Home Phone c-f_7 *--:5�2R 2170
City/State/Zip AgIZ4 Ate— Z-7006, Business Phone
2. Name on Permit/ATC if Different than Above
rt,
} Mailing Address City/State/Zip
3. Application For: Vite Evaluation [ ]Improvement Permit&ATC [ ]Both
t:
4. System to Serve: [Wuse [ ]Mobile Home [ ]Business [ ]Industry [ ] Other
5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal
[ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Busnaess/Other:Specify type #People #Sinks #Commodes
M` - #Sho•t ers #Urinals #Water Coolers a
If Foe.service:#Seats Estimated Water Usage(gallonsper day)
7. Typa of water supply: Count /City Well Community
' 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes 5.Ao 3 L-U TS L
If yes vhat type? >:
E I TILER A PLAT OR SITE PLAN
; r Y.{r '^n--"nwT•nrq`,y rr r;:,..M t:,,...: a ..,n... ,.,NUI,..:RED:
PRO ERTYCINFORMATIOMREQ ***IMPORTANT**' AST OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: fLLLC.L/:��� !',�A�VVR/IT/EDIRE (frooSk�ville)TO PROPERTY:
Tax Office PIN: #_f1 ��----y -- '-'y- v - y�q AVrJ,Q`'�/ .,/ /7f9%
1
Property Address: Road Dame :-:724 m ; 5- 1-0,0 7J fj,. j ,X,� g?
City/Zip .jj:a XM.c,<--C
If in Subdivision provide information,as follows:
Name: P/I/r rQ fqr:� ----
s Section: ` Lot#: _
1
1
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,vi suspension or revocation,if the site plans or intended use,change,or if the information submitted in this application is falsified or.
changed. f, also, understand that I am responsible for all charges incurred from this application. I, hereby,give consent to the Authorized
,t
Representative of the Davie County Health Department to enter.'upon above described property located in Davie County and owned
y n by to conduct all,testing pr ced as necessary to determine the site suitability.'
''• DATE��09-:4262-1��0 SIGNATURE i
z:J ,
FY. Revised,DCHD(06-96)
THIS AREA MAY 8E USED FOR DRAWING YOUR SITE PLAN:
t
F
Y
e a.,
,t
ti
d
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITYPROPERTY SIZE 11 l�-CO
SUBDIVISION ROAD NAME d 4wtgs� 42,=>
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring c/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% 20
HORIZON I DEPTH f'
Texture group (�
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH Zy-
Texture group
Consistence SY
Structure -<Zk
Mineralogy `
HORIZON III DEPTH 2Z-
Texture group
Consistence `
Structure 5
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE Q.
SITE CLASSIFICATION: 1 s EVALUATION BY: � H
LONG-TERM ACCEPTAANNCCE RATE: OTHER(S)PRESENT:
REMARKS: (244-1"
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 I 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(01-90)
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fiP
See P/ tot tot
ak
t eC 2
1p "� J p\ra Doe w S/17 k Pv9e //
�j I8j burn 9
9 074
0",E-
70,
-
�'� uti/i 111 �
v win e 47. \
E oge
y ent H/P
a *Y'
0
c
0
a
Parcel O
M. Webb
D.Bb
D.B. 83 — 043
w -
4 N O O
T o n z
C6 W v e u m
Z m m m m
u N N u 1
0 60 120 180 b)
1 . 00
t0 0
' IF. JO _ , c ���� '
C S
ICALE — FEET u
-
R/w as Claimed by o I \
U
the N.C. Hi
7hWM Commis,ion I-
t ne ._ ___ I NIP
NIP _ I T y-y� p
N -97 / NIP UO -- O� I ) 111 li S
• ' Point - 27.44' n42.91' f ou J t
78.62' �7 .R • 1 1 c�
r. N 86°-4d' W point �N 89° 24' W Point J 991 3' Int °-' 55.25' patrA
N 68° 13' S0" W 155.18' Point S 81°50'25"W
Total 70,
" LEGEND
f Davie County Health Department
and Come Health Ag, 'y
Environmenta(Healtk Section
P.O.BOX 848/ 210 HosPITAL STREET
' COURIER#09-4-06 +
;i •
MomsvILLE,N.C.27028
r
i PHONE:(704)634-8760
I '
September 19, 1997;:-1:;-
James
997 -�;James W. Wilson
114 James Road
Advance, KC 27006
Re: 3 Site Evaluations/James.Road ,
r r,
James W. Wilson Property
> v Dear Client(s) :
As requested, a representative from this office visited the "aforement> +ned
! sites on September 17, 1997. Based upon the information provided on the
application(s) for site evaluation(s) and after the evaluations were completed,
the sites were found to be provisionally suitable for the installation of an
on-site sewage disposal system on each site. y
Before any permit(s) can be issued the appropriate application(s) must be.
filled out and the house/mobile home location(s) staked off.
If you have any questions, please feel free to contact this office.
a
{ Sin ,
+
i -
Jeff Beauc p, R.S.
Environmental Health Specialist
JB/wd
i Enclosure(s)
cc: Zoning Office
1
4