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268 Jesse King Rd • DAVIE COUNTY HEALTH DEPARTMENT P Environmental Health Section ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003074 Tax PIN/EH#: 5863-48-3164 JW Billed To: Jeff Williams Subdivision Info: Laurel Brook Lot#2 Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3767 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 WASTEWATE CONSIS VfID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur . 2Date: O CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the sys ement/Operation Permit has been installed in compliance with Article 11 of G.S.Ch r 130A.Section-MO"Sewage tment and Disposal Systems,"but shall in NO WAY be taken as uaran at the system will func ' satisfactorily for any given period of time. % q 10D ac Septic System Installed By: Environmental Health Specialist's Signature: D e: 2- DCHD 05/99(Revised) r DAVIE COUNTY HEALTH DEPARTMENT i ,. Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003074 Tax PIN/EH#: 5863-48-3164 JW Billed To: Jeff Williams Subdivision Info: Laurel Brook Lot#2 Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3767 **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 l l 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 CSE: #People�_ #Bedrooms #Baths �a Dishwasher: I'J- Garbage Disposal: I?"' Washing Machine: Basement w/Plumbing: 01-" Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 5—.D14A �_'S ype Water Supply K)aU— Design Wastewater Flow(GPD) Site: New Repair❑ ��.�, i if 1 System Specifications: Tank Size AL. Pump Tank GAL. Trench Width Rock Depth Z Linear Ft.(AD 100 Other: �� Required Site ModificationslConditions: !� O t IMPROVEMENT/OPERATION PERMIT LAYOUT- APPRO E E UEN LTE "BELOW FINISHEDRADE. ****NOTICE: Contact a representative ofth vie Co Hea en. 1 inspection of this system betwefn 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on t day nstall 'on. lone#is(336)751-8760.**** 15 t r 12' YL �1 y� �T f� Y (' � Environmental Health Specialist's Signa e: Date: �1 Q' DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section } P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003074 Tax PIN/EH#: 5863-48-3164 JW Billed To: Jeff Williams Subdivision Info: Laurel Brook Lot#2 Reference Name: Location/Address: Jesse King Road-27006 Proposed Facility Residence Property Size: see map ATC Number: 3767 **NOTE**This Improvement/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 �-tO►Js� #People y #Bedrooms `4 #Baths Z •5-- Dishwasher: e Garbage Disposal: 91"' Washing Machine: Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 'f"�= 5 Type Water Supply Wou- Design Wastewater Flow(GPD) 90 Site: New 0"- Repair 11System Specifications: Tank Size1000GAL. Pump Tank GAL. Trench WidthRock Depth Z Linear Ft. Other: 1 Required Site Modifications/Conditions: (►J�rA u. t�� l 1 fr�C�N� F-1 y IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED E NT FILTER RI )IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a reproesentativeie Cou nt for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to installation. Telephone#is(336)751-8760.,�3 �TQ ur toz) (9-c- sSisT- N ot7st. F�c�-►T Environmental Health Specialist's Signature: 7 Oq DCHD 05/99(Revised) APPLICATION 17011 SITE-EVALUATION/IhIMOMIL•Nf 110Ih11T A1C' !!. Davie County Health Department FF8 Envir0ninenta/Hea/tJi Section 6' P.O. Dox 848/210 Hospital Street: fjyi� loon Mocksville, NC 27028 (336)751-8760 �l7FC �y • My�i/, ***IMPORTANT*** TIiIS APPLICATION CANNOT DN PROCESSED UNLESS ALL TIIE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be' Dilled Tp Contact Porson Mailing Address ✓�_cJ J /I.;, �Q Ilome Phone � � ' City/State/ZIP �l�/%t /YjI�/j?4j �t/G �?7�1�Dusineas Plwue y / 2. Name on Permit/ATC if Different than Above7¢' __...._. _ Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation # Improvement Pexmit/ATC• ❑ Doth 4. System to Service:xHouse ❑ 'aiobile Home ❑ Business ❑ Industry. ❑ Other S. Type system requested.Conventional ❑ conventional modified innovative 6. If Residence: it People - 0 Bedrooms Il Bathroonlw O� WDiahwasher AGarbago Disposal Washing Machina �asement/P umbing ❑DasomenL•/No Plumbing 7. If Duaineas/Industry /Other: verify type # People It'.Sinks # Commodes # Showers It Urinals 11 Water Cooler) IF FOODSERVICE: #l: Seats Estimated Water Usage (gallons per.day) 8. Typo of water supply: 11County/City Well 13Coimnunity . 9. Do you anticipate additiona or Cipa11a1011s or the racility this system is intended to serve?❑yes ,�IVo If yes,what type? ***1n1P0RTdJYtom**.CLIENTSMUST C0n11LEMTHE R QUIREDPROPEICIV1Nl�ORNIA71-10Nlzl:pul.srt:u BELOW. Either a PLAT or SITE PLAN AIUSTBESU/MInTED by the:lieu!' irItIt THIS APPLICATION. Property Diulcnsions: 11�R1TE ll1KLC1'IONS(fruul 1lluclsti ills)to PItUI'Iat7'1': Property Address: Road Namees' K�A-� Ze- .4 01-1O f City/Zip .cs Ido G a If in a Subdivision provide information,as follows: f ow Naulc: Section: Block: Lot: � Date !tonic cornet's flagged: /o This is to certify that the information provided is correct to the best oriny knowledge. I understand Mat u11y peralit(s) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or it the nforniatiou submitted in t11is applicatioll is falsified or changed. Jr,also,1111derstaild that 1 tun responsible for all Charges ncurredf•nal. this application. I,hereby,give consent to the Authorized Representative of the Davie County I.C.11 ll Del):.lrb ul to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site sultabI it DATE o? O �'// SIGNATURE MIS AREA MAY BE, USED FOR DRAWING YOUR SITE PLAN 1lclude all of the following: Exislillg slid proposed property lines and dimensions, structures, setbacks, and septic locations). r Site Revisit Charge Client Notification Date: L f� ;. lC,f 7 � dl�•� p2 �•C� fs� / •�, EIIS• . AccountSt II give A` No. Revised D00(05/03 Jan-qB-04 12:27P P. 03 DAVIE LE V VM .11 HEALL i A aJE A�,a 3RLlY 1 17 EWIRa[VbiMAL HEALTH SECTION rot�rs�a i zsoli�;m;saoros Mack AM,NGZMZ rt,a.,. (W)7514760 December 9, 1999 David M.Hants C;owracting, Inc. Attn: David Hanes 301 Hanes Trait Advance,NC 27006 Re: Site Evaluations-6'rracty Laurel Brock-Griffith led., Jesse Icing Rd.,Sandpit Rd. Tax PIN#: 5863-49-3164 Dear Mr. Hw-xs: As requested, a representative from this office visited the. ft-ove sites)on Noverr&:r 30 and December 7, 1999. Based on the information provided on the Applicadonesr)for Silt Evaluwtioa(v)and after the evaluations were oompleted,the lots w.-rc fow d to br prvvisionaby suitable for the installation of on-site sewage disposal systems. Due to stomp and/or complex topography, space is iirrvited c n lots#I and 03. Restrictiow regardhV houwe location or size array be imposed to maintain the pr;yvisiLnaQy suitable akwification for these lots. Before an Improvement PermitiAwhorization to Construct zan be issued, rhe appropriate appliwi,oa(s)mutt be filed out, the house lncationmust be staked out on ea&site wid a copy of the recorded plat must be on file in our office. if you have any questions,you may contact our office at(336)751-8760. �Sinceerrel ,rf moi-• - �� Jeff G. Besuc ,R.S. 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Mns - �'�'-e' Z.Yfiies A".•-9b �� 'S •-� {c, �': ,,�` R .T�3r�'l �`.cti,•�,'?4�� _ ;`X� ..�...i�-.,'.' r'i�''"ctaa.7t' .iys 7' za' w -'�:�v7 33...`,iri: c: � Ls ,{#3•�� .: .`x��' �' � �` - �w,�,J ,� 5�.»� "`�s'�;q`',iS'�: ,t ��.,sy�a'�v,''S�-��.F x;�, K" r.. �,�} - , ;r _ r+j '� mak:-<..s 'L,+�•'.� r''� � ''1 ��"•"rr>, ,�, .”- ;�.l�_. �,is �i4..:t"a x =r . ��°�',q. .,, rT e'•>h�._�T'. �Va•�y '.t a ay `�.� •'-'ea•t- � � f� a �,is �-�`.i•'c":R�iI r� 'moo �s - r' w�,S,t _ x APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department D Environmenfa/Han/tb Section P.O. Boz 848/210 Hospital street NOV 1 91999 i Mockoville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BR FPtOCCSSSD UNLESS ALL THE REQ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nam* to be Billed `�faVl A rn JANLS C. Jl f'd.t�+Oc,TNL Contact Person `]A V vn RA A)(r5 mailing Address C ��."►tiS rG w Goma Ph«ne city/state/ZI3? pV�rCtrJ!J• L. .27od BusinessPhone°l4g-S4g1 m. 3KS•Ilia 2. Nass on Permit/LTC if Different thea Above %eety- 7 70-q l 3 1 Wailing Address City/stats/sip 3. Application For: u ete Evaluation ❑ Improvement Permit/ATC a Both a. system to services Wfouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residences t People t Bedrooms _ # Bathrooms O Dishwasher O Gasbags Disposal ❑ Mashing machine 0 sasement/Plumbing D sasseent/No Plumbing 6. If sassiness/Industry/others specify type People I sinks # Commodes f showers i urinals i Mater Coolers. r IF FOODSERVICE: ## Seats Estimated Water Usage (gallons par day) 7.. Type of Mater supply: ❑ County/City ell ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No If yes,what type? *•"IMPORTANT""'CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either s PLAT or SITE PLAN MUST BESUBMI7M by the client with THIS APPLICATION. Property Dimensions:.S•0%N ICG' WRITE DIRECTIONS(from MoclssvWe)to PROPERTY: Sg63-4$- 31 Gy /o Tax 011ice PIN: # -y 'ter !mom - P 2. R k k AJ-nt C*%k- Property Address: Rosd Nsme iTc SSi E K =� Cityizip rAzyArjc-e •_ alm6. U in a Subdivision provide information,as follows: Name: LctUtZEj QRAo K Section: Q 1 Block: Lot: 'Date Property Flagged: 101 lL!a el Thi,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,U the site plans or intended we change,or if the information submitted in this application Is falsified or changed I,also,understand that l am responsible for all charges incamd front this applicadom I,hereby,give consent to the Authorized Representative of the Davie County Health De rtment to enter upon above described property located in Davie County and owned by DEI-jig rn Wt mes Co.{yc.'}i-ti to conduct all testing procedures as necessary to determine the site suitability. t , DATE SIGNATURE 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: EHS: e p,ce VC, M C�✓lar �'�v r.�,`. a w N!yldb/� o, M!rQV I'V�t.CI JL Tax Map B-7 \ o c >> Virginia G. Walker River Bend Hills i1 / D.B. 075-153 \ P.B. 6, P. 162Loo c�oDavid M. Hanes C) N N 89°4515"E ` 0 00�` 4 Ln 0b 1392.97' 00, *d7, _ I �1� 2p P �' C3` P ,�y L-17 P L-18P V11pro c^ w 6 �� - --Q 5 64°Z•% 6,P Ln2a m qj 14.700 Acres my '\ 111 z 202.54' �o4, o o P 97.50' S 88°08'35"E o� q,'\ OrO6 0qo e0a � // °1`5„w ox a ouIn°r P S��,fib , ^�Ao 02 / t .54' 6 5 W N 0 Z C.7 TIN 5 10.498 Acres 09 N 26 S �� o Con,", oxle at aton= ., �p 3 �5�.0IV Q . of mere 2g 0F a3s. CT\ / 01 o 40°40'00"E 91.88' - / d r� m ez s38 p 5 51°56'40"E 75.63' -'o• point 3O c, EtP 'a 89, aw 11n° 5.105 Acres o o °°h S 41136'65'E--Li 632 6j Z g9' J ° w� C 03 J NIP ^� A� 3p l S 14 Qa w e O vj N 5.815 Acres - ;` �S 17°56.15"W 87,32• ° F S 38°51'25"E 70.95' u o cr a 2 P ° S 43°40'20"W 33.7 1' NIP NIP �S 55°20'00"E 134. 8' P /� �S 36°49'35"E 61.03' F 10.640 Acres 3 o� Nip S 53°13'0 IT 88.98' / o 0 S 2-5-22-35"W 124.63' N 89 10'50"E 71.27 � X47 L- . 154.67' N CO NI P S 79°46'15"W 39.07' i l •— c�il e /� 88 �I "WP n°' o° y p EIP N16 3 �- (0 /� 03 w 5.014 Acres 6 es9. 6, (0 C. 1 50 _7 P 3 I 8 O3023 60 0 � p ron . access easem rl /30`W 20'1y IP86° P 4 p.,E P P ihof 1 o O /P L-1 L-2 Lf 3 L�4 C9 0)110 36 P 1 Q76°36' 401 E '� 32.81' 369.25' `* 6Q 00. See pacce 402.06' o`°I / B 0 S 83°39'S�"H1 J a ao P 76°36 40"W '� ' I Da d M49 anes g2.539,� S 13°23 20"w. r / I All Owner : David M. Hanes Coni 301 Han Advance Tnt,a DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil,/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900641 Tax PIN/EH#: 5863-48-3164.02 Billed To: David M. Hanes Contracting Inc. Subdivision Info: Laurel Brook Sec. B Lot#2 Reference Name: David Hanes Location/Address: Jessie iGng Road 27006 Proposed Facility: Residence Property Size: 5.014 Acres Date Evaluated: / '8 Z Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 . 3 4 5 6 7 Landscape position 1 L_ Slope% 210 HORIZON I DEPTH ' -cy ('%-7 )4S4, O - Texture group SCIL- 5C— Consistence S 5 Structure Mineralogy v-I -n HORIZON II DEPTH -! 2 Texture group C_ ConsistenceS 19 Structure k Mineralo 1 XYD 1,6,1 X µIQ HORIZON III DEPTH I0 _t4 i z-20 2 Texture group CA, -n liq Consistence Fr S40 Structure 45 s MineralogyW1- -rt—Mi !+^► HORIZON IV DEPTH Texture group 5 Consistence $ $ Structure S Mineralogy Moto M►p� SOIL WETNESS 32_ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .Z SITE CLASSIFICATION: r EVALUATION BY: LONG-TERM ACCEPTANCE RATE: O•�- OTHER(S)PRESENT:We ��i-�-, DOVlb 14446 J REMARKS: 0,0 � �►r,Suw�� "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)