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283 McKnight Rd ,. .. . . , ' , DAVIE COUNTY HEALTH DEPARTMENT � � - : Environmental Health Section • ' • ' P.O.Boa 848/210 Hospital Street ��� � — V Z Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990001517 Tax PIN/EH#: 5853-81-8802 Biiled To: Richard Montgomery Subdivision Info: Reference Name: LocatioNAddress: McKnight Road-27006 Proposed Facility: Residence Property Size: 53.18 ACRES ATC Number. 3112 **NOTE** This ImprovementlOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 STTE PLANS OR TI�INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type hi Q� #People �.P #Bedrooms `7" #Baths �'� Dishwasher: � Garbage Disposal: � Washing Machine: � Basement wlPlumbing: d� BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size � =� Type Water Supply�E�"�" Design Wastewater Flow(GPD) ��o Site: New� Repair❑ �� System Specifications: Tank Size�(�GAL. Pump Tank GAL. Trench Width� Rock Depth 12. Linear Ft. 5��, other: "y �I S T�.�6 J Tl o.J �ax�-S, 1�s��u u�J�,s q�o.Cr, ►.,.�,,�. Required Site Modifications/Conditions: 1+J S'`�L�- p� C.n+J'�bJQ., �–� � of� 1���� 1�'G.(� 100� �� —�ELL 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(336)751-8760.**** �, ''�.�Z � X� \`a� � G�'n.C• nna�, ��o' �� �, � -Z • rn��• �t;'`• Z J' s �7 3S J � l��L�(�NT ��T1 � l �a �p�� 1=2o�.►r Enviro ental Health Specialist's Signature: ✓ � DCHD OS/99(Revised) �x' 1 b �-ro ( � F� l—'l►J� �t� ���. PQoP,Cee�J�Z � . • ' ' ' DAVIE COUNTY HEALTH DEPARTMENT �� Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990001517 Tax PIN/EH#: 5853-81-8802 Billed To: Richard Montgomery Subdivision Infa Reference Name: Location/Address: McKnight Road-27006 Pro osed Facilit : Residence Pro ert Size: 53.18 ACRES ATC Number: 3112 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEWATER CON T UC N IS ALI FOR A PERIOD OF FI YEARS. Environmental Health Specialist's Signatur ate: `I "f �2- CERTIITCATE OF COMPLETION **NOTE** T'he issuance ofthis Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance ' Article 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in W be tak as a guarantee that the system will function satisfactorily for any given period of time. � �Ifl �O �.^ �3� ��� �i v� �� �t,tNvS � �� Q r .70 /p io io ��� �� � � � � � � � �yK� Septic System Installed� : I �� �� � � Environmental Health Specialist's Signature: _ te: � 7i (7 DC�ID OS/99(Revised) ,�.: . ° . � � . . � � � � o�� ' ' � APPLICATION FOR SITE EVALUATION IMPROVEk9FM P�RMIT&ATC D � � �,^ . � Davie County Health Department DEC 2 I 7��;;,t� Environmenta/Hea/lfi Section � � v� � � P.O. Box 848/210 Hospital Street l , �' MocksPille, Nc 2�028 �� (336)751-8760 �) ***Zl�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORt�►TION IS PROVIDED. Refer to the INFORt�TION BULLETIN for instructions. i. xa� to � siuea ��f,�'YA�A � ��1�U�OY�IGf7me%'/ Contact Peraon � ��F o�er� � �_I �- Mailing Add=eae � G �' CJ�� 8ome Phone �D��S City/State/2IP {')C L Q 8usiaesa Phone GI 9 �- G � 9 �'— ,�5� 2. Name on Permit/ATC if Different than Above Mailinq Addresa CiLy/State/Zip 3. Appiication For: [9'Site Evaluation � Improvement Permit/ATC ❑ Both a. syHtem to service: I�' House ❑ Mobile Home ❑ Business 0 Indus� ❑ Other 5. If Residence: � People �_ # Bedrooms ,���- ,' �/3�athrooms .�J �Z , 9�Diahwaaher � O Garbage Diapoaal �/Washing Machine 4�Sasemeat/Plumbing ❑ Basement/No Plumbing 6. Zf Buaine�s/Induatry/Other: Specify type $ People 1k Sinks # Commodes # Shorers 0 Urinals # Water Coolars IF E'OODSERVICE: . # Seats Estimated Water Usage �gaiiona par a$y) - �. �ype of water suppiy: �ounty/City � Well ❑ Community s. Do you anticipate additions or eapansions of the facility this system is intended to serve? 0 Yes C9� If yes,what tyPe' _ ***IMPORTANT***CLIENTS MUSTCOMPLETETHE RBQUIRED PROPERTY INFORMATION REQUESTED BELOW. .Either a PLAT or SITE PLAN U B SUBMITTED by the client with THIS APPLICATION. Property Dimensions: ��•� . 1 � WRITE DIRECTIONS(froro Mocksville)to PROPERTY: Tax Office PIN: # �� J� p( �g b a �m i �1�v5�'C�i�'"1 �,-�� / �wv �� ( � Property Address: Road Name � '� � �� U.-°'�-4- �-�o��� �trrn�n��, Qf,�O�Ok. �t�1� , � c;ty�z�p t��l�ance_ Nt,a��olo � � vn � �- �d lZ -fwur ns � �r+ - �ro��� y If in a Subdivision provide iuformation,as follows: i S 1u 5-4� b e u�„d 3 f� }�olis� , � Name: p h �-t+ _ , Section: Block: Lot: Date Property Flagged: �/ �f O � � This is to certify that the information provided is correct to the best of my knowledge. .I understand that pny permit(s) issued hereafter are subject to suspension or revocatioa,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 jor all charges incurred from this application:�I,Lereby,give consent to the Authorized RepresentAtive of the D/�avie County Health partment to enter upon above described property located in Davie County and owned by t 11�'�1�r�nC'' � . �G�15hn�� to conduct all testing procedures as necessary to determine the site suitability. DATE��IO O SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines and dimensions, structures, setbacks, and septic locations). .�� / Sitc Revisit Chargc �— ;._ Date(s): Q�`y� � Client Notification Date: ._ �'��S� � �- EHS: �:.---� a--� �`� � � - . , � (�� �, • Account No. /� � Revised DCHD(07/99) � . Invoice No. t � � 4� �7 ��f'� - �-" �-+�" `-�.-- ; rC.�/ o z. ,��- �''� `�g . . �/Y/ � � � � a McKNIGNT ROAD � � nm. n.n �. . . �� .'� �� � . . . ��. c , � �. �� : __-___-- �-� �s �-sM� ; Q� ' �`�S ° �°J� �_. , t . ��; G�I � l t;� �r-''�" ` � � �,, c,r `S,`�' � � � ��� � � � �. - ��`"` � �� ",' � ''�` � �'� �°' '' �'�+f,r�'. 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O �� b K� �, a,ttt��� Q£� ' . � �,; �f� �, ,�����r� ��}�, �M �d,�•�L��, -. . � - � _ ''�� :��''`�.,, < • � �- � DAVIE COUNTY HEALTH DEPARTMENT . � .. � • Environmental Health Section �-�• ' ' Soi]/Site Evaluation � : APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001517 Tax PIN/EH#: 5853-81-8802 Billed To: Richard Montgomery Subdivision Info: Reference Name: Location/Address: McKnight Road-270 Proposed Facility: Residence Property Size: 53.18 ACRES Date Evaluated: � ` Dl Water Supply: On-Site Well Community � Public Evaluation�By:' Auger Boring ✓ Pit Cut � . FACTORS 1 2 3 4 5 6 7 ' Landsca osition Slo % � s HORIZON I DEPTH ,. (p ._ �O � .. • _ Texture rou C� L. (`,tr Consistence � Structure �: ` � ; C, Mineralo � l� HORIZON II DEPTH LP- — 2 - , i - � Texture rou G `Consistence ; . � Structure Mineralo '� I HORIZON III DEPTH - Texture rou , � Consistence ( � Structure Mineralo � HORIZON N DEPTH Texture rou Consistence Structure � Mineralo SOIL WETNESS. RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE . SITE CLASSIFICATION: -� EVALUATION BY: L� Z�Lv�n _ C�•.� , ��rL.�►� �r��"�'►L LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: „ 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 J�� Texture S-Sand LS-Loamy sand SL-Sandy loam I,-Loam SI-Silt �7 SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam 3 i 1 I � SC-Sandy clay SIC-Silty clay C-Clay � CONSISTENCE , �{� Moist �l/v 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 2�� NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �� tru t e ��Q SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky � `� O SBK-,Subangular blocky PL-Platy PR-Prismatic }.� � Mineraloav / 1:1,2:1,Mixed � 'L'�� 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-gaUday/ft2 DC�ID OS/99(Revised) ■��■���■■■��■■■������■■�������■■■�■��■�■�����■■��■�■■■■�0■■ ���0■ ■��■��■■����■■��■����■��■�■�������■�■�����■��������■���■■■����■ ■■ ■�����■��■�������■���■��■�����■■�■����■�■■�����■�����■�■�����■s�■ ■�■����■■■■���s�■��■�■■�■�■��■�■ ■����■��■�������■���■■�a■���■��■ 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representative from this office visited the above site on January 3, ' 2001. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Based on the evaluation, a five-bedroom residence would require approximately 6701ineax feet of septic drain line. This is subject to change as actual dimensions of the septic dxain field will be detemwied at the time an improvement permit is issued. Before a representative of this office will ievisit the site to issue an Improvement Permit/Authorization to Construct the appxopriate application must be completed in full and submitted to this office. Please have preliminary grading and clearing completed prior to making this request. The location of the facility the system is to serve must be staked off. If you have any questions, feel&ee to contact this office at(336)751-8760. Sincerely, ' Jeff . Be e�af�p,R.S. , � '�'' � � Environmental Health Section enc(s) � + � � ; / _ ,, - . .;_ � . ; V � � � . , _ CATHERINE B. HIGHS:VIITH PROPERTY � DEED BOOK 77, PAGE 123 PART OF TAX PARCEL 91 ON TAX MAP C-6 N 01 °47'54"E 295.00' .NIP SE? NEW PROPEI7TY LlNE) NIP SE7 (NEW CORNER) � (NEW CORNER) � � i ^ O _ p O .. . . . . p � � ttj �`' � NEW AREA � N 3 � 2.00 ACRES , � W : 0 W (w000Eo to� o O a 0 � a O O a � O � � O O z v � �M � �M W�y a/Ny� W Vy ' . . . . . � . . v' � . �-- NIP SET N!P SET- ('ilE UNE) (NEW CORNER) (NEW CORNER) °°47'54"E 150.00' --� e- ' - S 01°47'S4"W 295.00' �----- (SOILROPD) ---- •-------- ------- ---"(16�vn�sa�Rao) ----- ---------------- - -- _- - McKNIGHT ROAD (s.R. ,45s� ;