400 Livingston Rd�r��"fix r ;� ,s•". `3
AUTHORIZATION NO:DAVIE C OUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
s
Permittee ti, k P.O. Box 848 ` (6 p r D
N
Name:, 'Mocksville, NC 27028 Subdivision Name:
-- Phone # 336-751-8760 �`
Directions to property: \ -�t- 1� Section:p�a
/ , TT�� ��.,, /�'' AUTHORIZATION FOR / (� l
L) V) rTc 4 12 1 I r OLLL O WASTEWATER Tax Office PIN:# =I 6 _ 3 ,�
SYSTEM CONSTRUCTIONTr�
d Road Name: ip: "
**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 compliance with ArticlI of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
X/
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRO E�lTAL HEALTI CIALIST DAT IS UED
11
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 -. 9:30 A.M. OR I:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS. (336)751-8760.
OPERATION PERMIT A L./ A 2 i,._....,- -- -�
*•THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 BETAKEN AS A
cr TMr-MnW c A-MrArr —orf V 17nR ANV (.TVFN PPRTnn nF TiMF
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` ;, APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE n a
is j Z Davie County Health Departmen��� U
Environmental Health Section C
�J0 P. O. Box 848 �R — 1998
Mocksville, NC 27028 �
ENVIRONMEl1TAl HEALTH
(336)751-8760
�j� pAVIE COUNTY
f'J ` ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES NLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed f�N///�Tiil/�D��,d'Contact Person
Mailing Address % 7d J e1 A(C ETNf S Home Phone tM j' 1'bcFG ✓�
City/State/Zip U` INS 0D 4 - 2,41.- FM . A( l • a � � �3 Business Pholleo - "l —5561
2. Name on Permit/ATC if Different than Above
Mailing Address.
3. Application For: Site Evaluation
4. System to Serve: ❑ House LV' Mobile Home
5. If Residence: # People_
❑ Dishwasher , ❑ Garbage Disposal
6. If Business/Other: - Specify type
# Commodes
# Showers
_ City/State/Zip
❑ Improvement Permit & ATC
❑ Business ❑ Industry
# Bedrooms
❑ Both
❑ Other
# Bathrooms _
Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# Urinals
# People # Sinks
# Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City 2f Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes ❑ No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PIS THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: y� WRITE DIRECTIONS (from
1 Mocksville) TO PROPERTY:
Tax Office PIN: # Ce)— 7�
Property Address: Road Name 0 . / 111V �zf0/✓ �� _ 1
-� 1 �X�T 1s ,�As7-1
City/Zip FAR M I N G Toll, 11, e. 1
//'//VC_S R /l om
If in Subdivision provide information, as follows: 1
Name: 1
1
14i GATE ]"c>
Section:
1
All
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 /1 �C �/�//j�D �/(.c5/1{ to conduct all testing procedures
as necessary to determine the site suitability.
DATE `1' I 0 SIGNATURE
Revised DCHD (06-96) �CC�
YOU MAY USE THE BACK OF THIS FORM FOR bRAWINQ YOUR SITE PLAN. ,/• O r
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME Ylle, 4,Z 22
PROPOSED FACILITY
SUBDIVISION
Water Supply:
On -Site Well Community
Evaluation By: Auger Boring L"-, Pit
SECTION LOT.
DATE EVALUATED
,L
PROPERTYSIZE�.�.4f 1J/
ROADNAME
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
e,
Texture groupL
Consistence
Structure
M—el
Mineralogy
HORIZON II DEPTH
Texture groupG
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
ESr
LONG-TERM ACCEPTANCE RATE I
c2
SITE CLASSIFICATION: e - o ',<C
EVALUATION BY: &//-
LONG-TERM ACCEPTANCE RATE: C2_ OTHER(S) PRESENT:
REMARKS: n/erX7 SK.//
DCHD (O1-90)
LEGEND
Landscaue 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
. Davie County Heaft( Department
and Home HeaftFc sLAency
ca�i�BER:
NEw P�GH 22� 1998 Environmental?�eaCth Section
P.O. Box 848 / 210 HosarTAL STREET
rs
Ea -<!\J 7 A1_87g0 COURIER #09-40-06
:7 MOCKswuE, N.C. 27028
PHONE: (704) 694-6760
April 30, 1998
Kenneth L. Brown
1701 Princeton St.
Winston—Salem, NC E7103
Re: 2 Site Evaluations
Livingston Road/6.274 Acres
Tax 'IPJ: #5851-64-3332
Dear Client(s):
As requested through your application(s), Robert B. Hall, Jr., R.S.,
Environmental Health Specialist(s) with this office, visited the aforementioned
site(s) on April 28, 1998. The purpose of said evaluation(s) was to determine
the soil/site.suitability for the installation of an on—site sewage system on
each site.
Based upon the information provided on the application(s) for site
evaluation(s) and after the evaluation(s) was/were completed, the first site
with the utility easement was found to be provisionally suitable for the
installation of a modified, oversized on—site sewage disposal system.
The result(s) of the evaluation(s) of the second site with the lake, a
copy of which is attached, indicate(s) that the site is unsuitable for the
installation of an on—site sewage system for the following reason(s):
Rule .1940 (e) — Topography
.1941 (3) (b) — Soil Characteristics
.1942 (a) — Soil Wetness Conditions
.1943 (b) — Soil Depth
.1944 (a) — Restrictive Horizons
Due to the limitation(s) on the second site, this office is not aware of
any modifications or alternative measures that can be implemented at the
present time to upgrade the classification from "unsuitable" to "provisionally
suitable." Your application for an improvement Permit for the second site
must, therefore, be denied.
'Pa g e
Kenneth L. Brown
April 30. 1998
You have the right to an informal review of this decision by the
Environmental Health Director of this office and also by the regional staff of
the Department of Environment, Health, and Natural Resources. You should
contact this office to arrange for this further review.
You may also wish to obtain the services of a private consultant to
collect site—specific data and submit such data and a system design to this
office for technical review. A site ►nay be reclassified to provisionally
suitable provides written documentation, including engineering, hydrogeologic,
geologic or soil studies indicates to this office that a proposed on—site
sewage system or a proposed alternative system can reasonably be expected to
function satisfactorily. The substantiating data from these studies must
indicate that:
A. The effluent (wastewater) will receive adequate treatment;
B. The effluent (wastewater) will not contaminate any ground water
or surface water; and
C. The effluent (wastewater) will not be exposed on the ground surface or
be discharged to surface waters where it could cone into contact with
people, animals or vectors.
Finally, you have the right to a formal appeal of this decision if you
file a petition for a contested case hearing with the Office of Administrative
Hearings, P. 0. Drawer 27447, Raleigh, N.C. 27611-7447. A copy of a petition
form can be provided to you upon request. The petition must be received by the
Office of Administrative hearings within thirty (32) days of the date of this
notice. The hearing may be held in Davie County.
If you file a petition for a hearing, you must send a copy of the petition
to Mr. Richard Whisnant, DEHNR, Office of General Council, P. 0. Box 27687,
Raleigh, N.C. 27611-7687.
Please call or write this office if you have any questions or need any
additional assistance. Telephone number: 336/751-3760
Address: Davie County Health Department
Environmental Health Section
P. 0. Box 848
Mocksville, N.C. 270213
Sin rely,
�ew LI
it . ?_�/
Robert B. Hall, Jr., R.S.
Environmental Health Section
RHIwd
Enclosure(s): Soil—Site Report
Billing Statement