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264 Jesse King Rd (2) DAME COUNTY HEALTH'DEPARTMENT Environmental Health Section /fir .+ P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001776 Tax PIN/EH M 5863-48-3164.03w&m Billed To: Waters&McGuire Building Co. Subdivision!Info: Laurel Brook Lot#3 Reference Mame: Location/Address: Jessie King Road-27006 Proposed Facility: Residence Property Size: 5.8 acres ATC Number: 3054 **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 �a T:-, #People 4 #Bedrooms 3 #Baths --2.5 Dishwasher: V/ Garbage Disposal: CJ Washing Machine: Iff"' Basement w/Plumbing: ❑ Basement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size S Type Water Supply� Design Wastewater Flow(GPD) Site: New Repair❑ ,s System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width —362 Rock Depth 1� Linear Ft.&CO� Other: -5 pigoi�T/J^1 5, /A/-e,7-.0 UWc`S A14,.1. Required Site Modifications/Conditions: O+✓ elG%jMAO, )(1,&V is OFF /OD IoM tcat, 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.**** ,c.�2' jos AlPQoY-2op' � � QJ P ung k I�p' i400n c �oLD 9L0mbj,Jb oOT�PA- 1i bre rto �Vd1� r►�� A POMP Environmental Health Specialist's Signature: Date: 31 OZ DCHD05/99(Revised) C +�✓ OQ'�('� `-"� /T 1S off P�oQ To fkowtjob C1 W5-TD-010r 1 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 990001776 5863-48-3164.03w&m - - Waters&McGuire Building Co. - Laurel Brook Lot#3 Jessie King Road-27006 Residence 5.8 acres 3054 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 ON UCTION IS VALID FOR A PERIOD OF FIVE YEARS. 01 Environmental Health Specialist's Signature: Date: c� Z 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 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) ,; -- APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT Davie County Health Department Environmental Health Section 2 3 ^ P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONPRENTAL HEALTH (336)751-8760 DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. a .1. Name to be Billed i (�( Contact Person Mailing Address 0 Home Phone L34i-a o)(0 City/state/ZIP �f�nA_�ri-fi� Business Phone` / L(`�� K. Name on Permit/ATC if Different than Above Lyosj \\` �`� m'\�wA 1nti / Mailing Address �p (;i, (� 21\)Q City//State/Zip GAw"Q 3. ication For: i Evaluation U-1 rovement Permit/ATC v R—Both Sy tem to service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other ' ��` s . If R�esidence: # People '�' �C��:�\��1� # Bedrooms �� # Bathrooms �. 5 ,/'U"ishwasher U^/arbage Disposal R4ashing Machine ❑ Basement/Plumbing asement/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 ell ❑ Community ✓8/Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes CJ NP If yes,what type? 'IMPORTANT'CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. ,-.Property Dimensions: QQ ,r�/ 2 �RITEIRECTIONS(from Mocksville)to PROPERTY: -IT/ax Office PIN: # �o�� '"l b JI�D -.03 6 xc) A L 1'- Vtkl(<"f operty Address: Road Name !—n -} �� 4c,V a,16 rcoy < <>_we, �iX-Yf �-- City/zip �V(�nce 7GL7�L' �T�O n2M� �cs -O ��taSsp if in a S division provide information,as follows: a F�r' ���r l�;L Z& e Name: Section: Block: Lot: �ateroperty Flagged: — / n 'S �P 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. 1,also,understand that 1 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 to conduct all testing procedures as necessary to determine the site suitabi ' TE JS Oc(7 i) SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PL (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: r EHS- �j �' Accout No. evised D( 9) J I!!r ce No. APPLICATION FOR SITE EVAWATION/IMPROVEMEM PERMIT&ATC D • Davie County Health Department Environment/Health SeCiiott P.O. Bos: 648/210 Hospital Street NOV 1 91999 Mockaville, NC 27028 (336)751-8760 ***ZNPORTANT'*** THIS APPLICATION CANNOT BS PP.=SSZD UNLESS ALL THS INSORMATION IS PROVIDED. Refer to the 11WOM&TION BULLETIN for instructions. 1. Name to be Billed hAyi O 1)1- 14A NGi C.c,J llC,4•'f%XU,TAK contact "coon tk A U l to "A N as Mailing Address �01 l i4oet- re,,% Some phone al9g- 5197 city/state/Lzp OV4.^Gir,/J. C.. .2-700(o m. 3 NS-ilio 2. Name on Perait/ATC if Different than Above %eeQzu- '7 70-q l 31 Mailing Address city/state/Lip 3. Application For: 041te Evaluation 0 Improvement Permit/ATC 0 Both 4. System to servioe: "Ouse ❑ Mobile Rome ❑ Business 0 Industry 0 Other 5. If Residence: t People * Bedroom* ?2 t Bathrooms O Dishwasher .D Garbage Disposal O Mashing Machine O Basement/Plumbing O asserant/No Plumbing 6. if Business/Zndustsy/other: specify type t People t sinks t Commodes t showers t Urinals t Mater Coolers. IF I=SERVICE: d Seats Estimated hater Usage (gallons per day) 7. . Type of Mater supply: ❑ County/City U4.11 ❑ Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No If yes,what type? ***IMPORTANT'**CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:. S-9 i;'A,-� WRITE DIRECTIONS(from Mocksville)to PROPERTY: e Y(P3-Y$ - 316'! 0.3 Tax Office PIN: # 4=4 r.2--94-449*ter;- / S @,c rk X A-� Property Address: Road Name au SS►F K"nK Roc. Cityrn rkwANGC,, 2wo Hin a Subdivision provide information,as follows: Name: LatillEl (1noaK ' Section: i Block- -7 Lot: _ Date Property Flagged: to I N k I c}G This is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(:) Issued hereafter are subject to suspension or revocation,if the site plans or intended on change,or if the information submitted is this application Is falsified or changed I,also,understand that I ant responsible for aU charges Incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Departmea to enter upon above described property located in Davie County and owned by 'b&,%., M• VvL% .. ivy �i.►E-. to conduct all testing procedures as necessary to determine the site suitabWty. DATE ��� SIGNATURE T� M• t -�' _ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations Site Revisit Charge Date(s). Client Notification Date: EHSi G �' ►'Mdn✓�c�r �on,R, fV�cp✓�ar ��'}vr�. 1'1�1�c�✓�Gr ���G a C 41vR�� N I dbA n N,'nQV Tax MOP B-7 \ trout Virginia G. Walker River Bend Hills ft?jo D.B. 075-153 ` P.B. 6• P. 162 ,Cpp 'S°David M. Hanes' N N 89.45715"Eo%vim $ it ee p�`76 1392.97' Q6 e > " 6N 6 °IL-10 �'1Z ��� .• 's..�P 7•tsJ• 37? 1.'9 —16 19P53�� � 'Py L-17PL-18P pp5 4` 6 0a' F 5 64� W p• H u � N vi ad►'90n6a�Ce l Na /' 14.700 Acres = 202.54' 'L°� ro w 97,50' S 88608.35"E SIZP 1°66 0 wp oea 0-4 bu 1 .54' o 'S527 W �ko 4 N o q ry 1 •ry a o . 5 Z P C, 10.498 Acres a/ 26 s � 'a rom.w � v3 269 3500 / 40.40'00"E ro s point p \51.56'401-E 75.63' ±'�• y ° S\7°3665 L4.70' 6028967289• �•.eN s 2 5.105 Acres o e I� ` W NiP 7'' J- v1 30 5j4 �`� JJ° J �� N )51'b'Acrq�J m a ;� /s 17056is"w 87.32' t��11 r a < u ti �� ° \�I� P �s 38•512s"E 70.95 �/a O /u rte+ ? o ,�\" a° a° P Op HIP^ HP �S 55.20'00'•611134. e' P /�S 43°40'20"W 1.03' / 4- 59 t \ �5 36.49'35"E 6!.031 / ko�ti ' H� s s3°73' "E 88.98' / 10.640 Acres o a s 25•22.35"W 124.63 i W a,� N 89 10'50"E 71.27 / ' l ad15467' C! ,.y . P N h u 'f O 7 BBn��i�7.5"W P ' •. S 79.46'15"W 39.07 / y ° / EDP _ Cb = n a H 3 w 5.014 Acres 6-36, I \N ass./ P s31Y I 68.0 6 ' • 6 ^! .an 150• access easement ?7i 30. 3?OyP 000•\N h P P. 30- P P v°� �/I / S `6 • 6000• V y t�17 L 1 L-2 J31.�4� dy w / 6364p1E •v» p e78.36• E 32.87' 369.25' g / 60 ^ Seee acc •' S 83.39'50"W 402.06' a / I; °0 p e I N 76°36 40'ryy arcel 7 a a. David M4 Hones S 3 23'20' • T. Owner : David M. Hanes Carl 301 Han Advance Tota] Area — r% i r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900641 Tax PIN/EH#: 5863-48-3164.03 Billed To: David M. Hanes Contracting Inc. Subdivision Info: Laurel Brook Sec. B Lot#3 Reference Name: David Hanes Location/Address: Jessie King Road-27006 Proposed Facility: Residence Property Size: 5.815 Acres Date Evaluated: I 7) Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring Pit I/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position 121 L Slope% 0 7O HORIZON I DEPTH Texture group t✓ Consistence 7 —r St.4 Structure b Mineralogy HORIZON II DEPTH 3Z-4b Texture group Consistence Structure PL Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S 5 LONG-TERM ACCEPTANCE RATE ©.-L 1 SITE CLASSIFICATION: Ps EVALUATION BY: LONG-TERM ACCEPTANCE RATE: •Z ? OTHER(S)PRESENT':�� �, NWID I"j REMARKS: Pill 5AdDY 0,LAV txA,, 60,J L P`r l 'SPQR C, c .:� 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)