155 Legion Cemetary St i . "�.._.._,
. . - - DAVIE COUNTY HEALTH DEPARTMENT ' - �
_.._Y.
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760
Account #: 990003793 Tax PIN/EH#: 5745-15-2439
Billed To: William Froelich Subdivision Info:
Reference Name: Location/Address: Legion Cemetery St.-27014
Pro osed Facilit : Residence
ATC Number: 4363
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 O STRUCTION IS VAL FOR PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: � � Date: ���D���
As stated in 15A NCAC 18A.1989(S
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 t�sys�will function satisfactorily for any
given period oftime. a��, V�j
i��
�
�_
�tt
� C`--'-�
T
G ��•
9 SD'
�� +aat< �,
�L�K bA1=' S'Z3 9 �O'
�p� qp ' _ 1 f r ' t �
� (V
Septic System Installed By� -
Environmental Health SpecialisYs Signature: Date: �
DCI-ID OS/99(Revised)
.
DAVIE COUNTY HEALTH DEPARTMENT
' ' ' Environmental Health Section
. _:, -
�''= P.O.Boa 848/210 Hospital Street �
f Mocksville,NC 27028 �, Q
, '�� (336)751-87(►0 (V
� `
\�
IMPROVEMENT/OPERATION PERMIT �
Account #: 990003793 Tax PIN/EH#: 5745-15-2439
Billed To: William Froelich Subdivision Infa
Reference Name: Location/Address: Legion Cemetery St.-27014
Proposed Facility: Residence Property Size: 3.14 acres
**NOAI E�*�This�Improveme3iit/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
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. .
Residential Specification: Building Type � #People � #Bedrooms c� #Baths •2
Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: New� Repair�
System Specifications: Tank Siz��� GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft��
" Other:
�
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTiCE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
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(33G)751-87G0.****
As stated in 15A NCAC 18A.1969(5)
accepted Systems may a�so be used
1�
4 ' �Q'
fw
�
(
Environmental Health Specialist's Signature: Date:—� �
DCHD OS/99(Revised)
/
� � j � 4�O
- � �d. � /
. . . p
' 'O 05 A 7lUN FOR SI7E CVALUATION/Ihtl'1i0VL•biCM I'CR�111T Sc ATC
� � 24 Davie County Health Department
NOV • EnYfronmenta/Hea/th Section ��
P.O. Box 848/210 Hospital Street l
E�a����'tN Mocksvilla, NC 27028 ' ,y��
E�R�a�E���N� (336)751—n760 )� «��--
/
ItIPORT�INT*** TIi25 APPLICATION CllNNOT I?E PROC.CSSED UNL�SS ALL TFi� I2LQUIR�D ,
INFOR2•I1ITION IS PROVID�D. Refer to the INFOItTiATION BULLETI2d for inr�tructionD.
i � / �
4 1. Name L•o be IIilled �� / /� ,�` � , � (..� r��� �(' N /�
" � G 1 r�C, �/ L � Contact Pcrnon � Gr� o i r�
Mailing Addraso /" � �X ��7 IIomQ Phono (3.�'�� �b 7' yy�y
—�
City/Stato/zIP GOO��G�r>»� , ✓VG, r,��p��'� Du�inoaa Phono C.���/ ��� � �y�
2. Namo on Permit/]�TC if Aifferant than 1►bova 7`�/'� P ,�y[� ���7—����
Maili»c� Addroas+ City/Stata/,Zip
3.Zq•ov
3. Application For: fd Sitc �vuluation �mprovement Permit/ATC ❑ Doth
�. SysCem to Sorvice: [7 Ilouua ❑ tsobile Homo ❑ Duuine3ss � Induntry I�O�her �='��S-�
5. Typo n�•atem requa�tod: Conventional ❑ convnntional modified 0 innova�ivo tJa�Cepted
6. Ii Ra�idenca: ►! People � � Dedrooms � 1t Dalhrooma �~�
_XJDinliwauher ❑Carba�o Disspo3al washing t4achina ❑Dasement/Plun�ing ❑Danement/27o Plumbing
• 7. If Dunineua/Induatry /Otlior: verify type $ Peop1Q ik Sinkss
q Commodoa 11 Showozn 1{ Urinala It Ylal•or Coolora
IP I'QODSERVIC�: �� Seatu Estimated Water Uaage (�ailons par clay)
0. Typc of vrator aupply: � County/City P�ell ❑ CommuniCy
3. Do fou anticipato addiCions or cxp:lflSl0I35 OP��1C r:1Clllly tliis syslcm is iutcndcd to scrvc? CI�'cs �
If��cs,titi�tiat typc?
***I111POItTi1NT"°**CLILNTS AlUST C0�1lPLET�TIIC I►'LQUIXED PROPCR'TY INI�ORA4AT70N 12LQUI'sS'T[sD
R1;i.O1Y. Iiitlicr a PI,AT orSlTG PLAN MU.ST 13ESU/lAfI7'7'EA by tlic clicnt �vItl�TITIS APPI,ICATION. �
�•� � 5 !� � � g' , .
9 ,�c.i 7 rf� �;
1'roperly 1)itnctisionsi 1 �— � � G1VR1T�DIfiCC'TIOnS(fi•um IYlodcsvillr)lu 1'1tOPLK'I'1':'
�c•� 1
Tax Officc PIN: f� ����)�7 �+�- 3 � �a�� � �� �'OW..J'.�5 C�n�r�r n�r'P `�'
/f7 / `�J
�
I'ropcl•tyrlddi•ess: RoadNacnc e 'On �P%r�eyy,-����n ��G,�r/- o� �6'D l ~�
cityiz;j�_c�dl�e.��e a�Di y� Aprnx. 1 , S �,'. i rn
If i�i a Siibdi��isio�i providc inforciiatioii,as follotivs: L P�+--�- Or� ���i U� CE'���4!'��
Namc: �T�,�-�'�"}'�' on ���}- �� wc�c�r
�'�i L�i hoJSE' Gn c� I�DC�d$
Scclioii: Bloclt: Lot: Datc Iiomc corncrs Aaggcd: 11�//6 /�'7 s
'1'liis is to ccrtil'y tliat tlic ilifortttatio►i pi•ovidcd is coi•rcct to tl�c bcst of li�y I.notivledgc. I w�cici•slaiid lI�at any pci•itiil(s)
issucd ficrc:lf�C1'1I'C SUU�CCI�O SllSPCI1SIOI1 OI'J'CYOC��l011�1C tI1C SI�C pI811S OC lI1�CIl(JC(I I15C CI1111�C�OI'IC�IIC 1I1P01'l111�1011
suUmittcd in this applic�fioii is falsificd or cJiac�gcd. I,also,tr�rrlcrslcurd[Irut I aur resf�orlsiLlc fi�r all clrrrrgcs i�rcurrc�l jrnnr
11ris npplicrrliu�r. I,hcrcby,{�ivc conscnt to tl�c Autl�orizcd Rcprescntati��c of thc Davic County I�Icallli 1)cpartuunt
to ctitcr upmi abovc Jcscribcd property locatcd ii�llavic Coutit}'and o}ti�ticcl.by
to conduct 7!1 tcsling proccclures as ucccssary�lo dctcru�iuc thc silc suit. 'lil}�
•� r � .
D�\I C y�[1�0� SICNtt7 URL �
�T
TIIIS AItI;A A7AY BL USI;D rOR DI2A�VING YOUR SITL PLA1V(Inctudc all of tt�c follo�ving: L�isling and proposcd
praperty lincs anc!dimeusions, structures, setbzcics, and septic locations). � ,
Sitc Rcvisit Cliargc '
. D:►tc(s): � �
�� � Clicnt Nolification Datc: �
��t��� �.e-r� �i�is: � :
... :�� 2:� ��. .
Sign biven '. ��lccount No. � � �
�
Reviscd llCIIll(O5/03 � Im•oicc No. ��` g
, From:CLAYTON HOMES 072 704 872 1166 11/08/2005 16:19 #055 P.002/003
W' � , � bav,ie County, North Carolina Spatial Data Ex�lorer Page ] of2
�
,u
'' � S�a�al Data�7C��1r�t' ���
��U N� rJorth�r�lirr
Click on!he Map to: �ap L:
C�;�zoomio �.�ZoomOut ��Recenter Map �tdentity: PBfC@IS '� Draw L
2X �;�"� �_� Dra w selec+
Zoom Factor: ��;z �.,Radius Search(feet) �
Boundary
n�w . 1�' �v�
�`'��';Census Tro
� P "�'"`""��,���"�.;,�.� � "0i�;�r ` City Bound
#
�� `'a �' �.�: -
�' �*_� � �. �County Zor
i ��`'"-��,, ��``E;.�� � Multi Syi
q{ � ''� 1���E911 Fire C
r
R� • �t �r' �` ��Flood Pane
�, �f � �j Flood 2one
�•�4Q� � t + `�vs Parcels
8523 � � �
Q39 :� �Y !" i School Dist
�`'J�s � j � Multi Syi
cJ p �j `
� ��� 3359 ".F �r� � 1,-''so��s
�`=,,,�M gN�'�8�� w f � �=_;Town Zonh
���4� � ;�' S3� 4� � ;'J;Townships
�`5'^�-YC��jy�S„R �/`„�iC �j �. .3�Q� ��,.� MUltl.S�/1
��-��� `� � � 6234 �' �young Prec
�`�x �°�R��''p�.�„Y � �� � Infrastructu
� �`�"'`�, f� � �,� �'�iDriveways
�180 � �,y'` ��� '�' '� f �,_I Rail tines
•:o� � 08T y` ��`' � � �'"3 Streei Cent
,`
� '� � lt � � i�'US/�IC Higf
h�'s t
� � � ,� ; �� �
� �
y� 8900 f $` �'°'�•� `'`� �` � Multi Syi
'� : r`� ''xT �... �� f .�'
E,4++t; � „�, � Sf t
n
Parcel Data
Find Adjoining Parcels ;`�`;ae.+a�Pno�
Physical
• Land Unif/Type:M5150A0009 J AC ��� �Creeks artd
i.._l
• Deed Book/Page:00076/0209 ���E9��Add�E
• Deed Dafe:1966/07lt 1 f"?FAe D art
• Gbunty JD:M5150A0009 • Sa/es Price:50.00 `-�' �
�Schoots
� Account Number.•79852000 � property Address: "—r
• plN:5745152439 ��W L
• Lega1 13.14 AC�EGION CEMETERY • CounlyZoning:R-20
• Owner Name:WILLIAMS WILLIAM B � Census Code: MAP Cl
• Owrter/Addreu f:WILLIAMS WILLIAM B • CifyCode:
• Owner/Address 2:WILLIAMS JOEY • Fire District•COOLEEMEE FIRE jhis map is prepi
• OwnerlAddress 3:158 KAREN COURT • Flood Zone:ZONE X fnventory o�rea►�
wfthin this jurisdic
• Cily,Stafe Zip;OZARK,Al 36360-0000 • Flood Community:370309 compiled irom re•
• Lertd VaJue:$24,980.00 • Flo�Panel:0075 C plats,and other y
and data.Users c
• Building Va�ue:$0.00 � Ro�Map DBte'12-17-1993 hereby nolificd th
http://71.16.185.125/servledcom.esri.esrimap.Esrimap?Name=Davie&Cmd=Clk&Left=15... 1 l/8/2005
.
.� - � - • � DAVIE COUNTY HEALTH DEPARTMENT
� � ' Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003793 Tax PIN/EH#: 5745-15-2439
Billed To: William Froelich Subdivision Info:
Reference Name: Location/Address: Legion Cemetery St.-27014
Proposed Facility: Residence Property Size: 3.14 acres Date Evaluated: �f d��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring_� Pit Cut
FACTORS 2 3 4 5 6 7
Landsca e sition
Slo e% _
HORIZON I DEPTH <<~ �/
Texture rou C
Consistence /
Structure
Mineralo � - j� `
HORIZON II DEPTH �
Texture rou � .
Consistence ` �
Structure - /
Mineralo •� a'
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo . . .
HORIZON IV DEPT'H ` : �
Texture rou - �
Consistence '
Structure
Mineralo .
SOIL WETNESS - -
RESTRICTIVE HORIZON •
SAPROLITE _ .
CLASSIFICATION r`
LONG-TERM ACCEPTANCE RATE .�
SITE�CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND- �
i.andscane Position - _ . .
. R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace -FP-Flood plain H-Head slope
T�r�
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
�'�415� ,
VFR-Very friable FR-Friable : FI-Firm VFI-Very firm EFI-Extremely firm '
. .�' , .
• NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �
S�u�tur� _ ; :
SC-Single grain M-Massive CR-Crumb GR-Granular ' ABK-Angular blocky -
SBK-Subangular blocky PL-Platy PR-Prismatic `
� , '
Mineraloev ' . .
1:1,2:1,Mixed _ ' .
lYQtes .
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-gaUday/ft2 . DCHD OS/OS(Revised)
> � .
��� ��-�,,.��.� ����- � w, ,, . '
R �
���,:,.���. ' �.;?,p . �.��,��a�.1�I�C�i11V°i'Y����.������TI��C; >���r��. t�,v�x -..:
���
Environmental Health Section
P. O. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
f � ` � k `� ' (336)761-8760 � z ' � �
d x � � , . F �. �
7y�^y��j�8/�y.: � f � ������g��+ , � �' t3 a r, - ��ad "^�,d � �. ""� ��1�5'� ' ,�
� ,r�,� e ,y k r7 6 �r r� 4� ,/s`d S f a�
s d5�r ,;^t��*��� ��i �t+ � ,4� �n: ���4 t�s����'t x .� . �' s�s��„�z�+c;.�s � e .✓ y
"� ����^�maai�'�z�."ytt �� , �u.,,�� � ���..��. `"�,� ria.ss7r.�'.� _ €# t s=tamv ,/?g .r �, t )
November 18, 2005
William Froelich
P.O.Box 587
Cooleemee,NC 27014 -
Re: Site Evaluation/ Legion Cemetary
Tax Office PIN: #5745-15-2439
Dear Client(s):
As requested, a representative from our office visited the aforementioned site on
November 17,2005. Based on the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, it was found to be
provisionally suitable for the installation of an on-site sewage system.
Before and Improvement/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
�d2'.�,t�B C�,/��'
Robert B. Hall,Jr., R.S.
Environmental Health Specialist
RBH/dlf