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683 Mr Henry Rd , . . , � . DAVIE COUNTY HEALTH DEPARTMENT �d 9✓�D� � Environmental Health Section . P.O.Boa 848/210 Hospital Street � . ///��� Mocksville,NC 27028 } ��I (336)751-8760 I V�� V `UrV�� '� u IMPROVE T�OPERATION PERMIT Account #: 989900023 Tax PIN/EH#: 5716-77-5966 Billed To: Kyle Swicegood Subdivision Info: ��3 Reference Name: Todd Swicegood Location/Address: Mr. Henry Road-27028 Proposed Facility: Residence Property Size: 12 Acres ATC Number: 2531 **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 PERNIIT 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 #People� #Bedrooms � #Baths� Dishwasher: � Garbage Disposal: 0 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: New3� Repair❑ ,r ,� System Specifications: Tank Size���GAL. Pump Tank�GAL. Trench Width� Rock Depth� Linear Ft� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PE MIT LAYOUT- APPROVED L T FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: ontact a representative ofthe Da e Co Health Department for final inspection ofthis system between 8:30 a.m. 0 9:30 .m. 1:00 p.m.to 1:30 p.m.on the da o in a lation. Telephone#is(336)751-8760.**** �� � ��� �!--�� �-�� � .� ���s-0,� �'-��-�/ e� � r IN�� nG� � c`v�Oy -fo ��c 6��/�� S'�o � � � Environmental Health Specialist's Signature: /� Date: c3 DCHD OS/99(Revised) � . ' - , � � a���-� .. � DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900023 Tax PIN/EH#: 5716-77-5966 Billed To: Kyle Swicegood Subdivision info: Reference Name: Todd Swicegood Location/Address: Mr. Henry Road-27028 Proposed Facility: Residence Property Size: 12 Acres ATC Number: 2531 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �//.��1 Date: ��,�`C�� C RTIFICATE F M L TION **NOTE** The issuance ofthis ertificate fCompletion shall in icat the em described on Improvement/Operation Permit has been installed in ompliance 'th Article 11 of G.S Ch pter 3 A,Section.1900"Sewage Treatment and Disposal Systems,"b t shall in O WAY be taken as gu ntee t at the system will function satisfactorily for any given period oftime. D�� S� �i JP D�11 � �,.(' �1i,� � f i�� �% ,Y� ,Y�.� "P�`�,C. � L..i�.2 � � Se tic S stem Installed B : ��L��Ll C�� P Y Y ' Environmental Health SpecialisYs Signature": t ' " Date: `�� � DCHD OS/99(Revised) • ' •{ , ,• � V l�] � 1__! � ;' �� APPLICA710N FOR S[fE EVALUAT70N/IMPROVEMEI�IT PERMIT&A � � Davie County Heaitt� Department ^^ ,, Environme�rta/Hea/tfi Se�clion f�1AY 2 3 �-��� P.O. Bos 848/210 Hospital Stroet Mocksville, NC 27028 (336)751-8760 ' '` . � ***II�ORTANT*** THIS APPLICATION CANNOT EE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORt�,TION BULLETIN for instructions. 1. Name to be Billed (,,,//,�� o�� Contact Peraon /�-��F' sw/G�qc'��ri( Mailinq ]►ddresa / C Home Phone City/State/ZIP (J/ � ���ZIJ Suainess Phone ���' 7r�' �ZZ� 2. Namw on Permit/ATC iP Ditferent than Above /j� rJGf' �Lc)l�CCc��� MailinQ ]address �� [ V��� c�-f�Y City/State/Zip �'�C[`-,f U�/�� /N� ?i! O�i¢ 3. Appiication For: �/Site Evaluation �mprovement Permit/ATC ❑ Both ,a. sy8t� to se�ioe: C�Ffouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. if Residence: � People �_ t Bedrooms � _ � Bathrooms � 'Id'Diahnasher ❑ Garbaqe Diaposal ashinq Machine Hasement/Plumbinq ❑ Baeement/No Plumbinq 6. If Huaineas/Induatzy/Other: Specify type Y People # 3inka # Co�odea � Shoxera # Urinals # Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallona �r a8y) �. Type of water supply: ❑ County/City ell � Community e. Do you anticipate additions or ezpansions of the facility this system is intended to serve? ❑Yes ❑No If yes,what type7 ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PI.AN MUST BE SUBMITTED by the clieat with THIS APPLICATION. Property Dimensions: / .� ���/lJ� WRITE DIRECTIONS(from Mocksville)to PROPERTY: �/ 7�� �. � � � /ft Taz OfTice PIN: # �' �' ' t' '� P r /O ��,�/y���r � ��� vt Property Address: Road Name !'�� �2� � /<�C�` 'r �..' f'�,' � �,ty�Z,p .�-o�Ksv,'11:� /�,�,��� ��� �-P� �,�_ If in a Subdivision provide information,as follows: �� �. � c�' T�� r�/�IJi r Name: �t`�' 5�,�� �C,v� � Section: Block: Lot: Date Property Flagged: ��`�"��Q This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued Lereafter are subject to suspension or revocation,if the site plans or intended use change,or if t6e information submitted in this application is falsified or changed. I,also,understand that I am responsib/e jor a/1 charges incurred jrom thls app[icatlon. I,hereby,give consent to the Aut6orized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testiag procedures as necessary to determine the site suitability. DATE � �L- SIGNATURE TfiIS.�REA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include ollowisg: Ezisting and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge � Date(s): � � Clieut NoNfication Date: EHS: � � /D 6 Account No. ��� . °� ,/ � � l� Revise�l DCHD(07/99) _ �^J� /F G�S, Invoice No. � �—/ � i z/�d � ._'� �v ♦ i`�, . 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C ��� ` � 3 .�,� € ''C.i� �� ,�'i� . z � _a�� h�. y.' � �,i _ ,_ . _ �.._.... ._,. _...�.,.. .,.....� :._.�...._ _, .. _.. ., _ , D��II�COUNTY�I�I.T�I D��'�ThI�NT ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 June 13,2000 Mr. Todd Swicegood 854 Valley Road Mocksville, NC 27028 Re: Site Evaluation/Mr. Henry Road Tax Office PIN: #5716-77-5966 Dear Client(s): As requested, a representative from this office visited the aforementioned site on June 12, 2000. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked o� If you have any questions, please feel free to contact this office. Sincerely, I��f�c��i��i• Robert B. Hall, Jr., RS. Environmental Health Specialist RH/mp Enclosure(s) ,, ;.� ' , , DAVIE COUNTY HEALTH DEPARTMENT � , , Environmental Heaith Section � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900023 Tax PIN/EH#: 5716-77-5966 Billed To: Kyle Swicegood Subdivision Info: Reference Name: Todd Swicegood Location/Address: Mr. Henry Road-27028 Proposed Facility: Residence Property Size: 12 Acres Date Evaluated: � '/1�� Water Supply: On-Site Well �,� Community Public Evaluation By: Auger Boring_� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH '' '' Texture rou Consistence �i i Structure l /j Mineralo � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Stntcture Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE ' , SITE CLASSIFICATION: � EVALUATION BY: ( LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: �[/el Si �,�(�' /�j��/; ➢'� e � LEGEND Landscape 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 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 Mineraloev 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 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Davie County Health Department • � ,, . �:�� "� `�`���� E vironrnental Health Section � � , � ti�:, �: -,, �,�'0►0� P.O. Box �3�18 � "r=� �f.. � ` �' �� y'� +�' .h �S [\� , < <1�. , � f1 (� �/1 21.0 Hospital St�-eet � � � � . `�+` �`\1 .r �D / / L,��1 . . ��� i .- . , � j� : [� V �- . Coui�ier # : 09-�0-06 . ��'., ; M r� � �., r F'1 4 a � ' �'..:�`Y�`°f Mocl:sville, NC 27028 °� k�,;,,. � ��1�-- ` ��a�• ��}�u- _�.__ Phoue: (33G)-753-6780 Pa�: (33fi) -?i3-1 G80 ON-SITE WASTEWATER CERTIFICATIONFOR DWELLING (Check One) Replacement Remodeling Reconnection �1ame: ����n 1��� PhoneNumber (Home) , Mailing Address:�p�3 ,' �'� � �Q(1�(I•� ��� ' ''�r' 1���y S�'���3 (Work) 3 ;,� . , n �,rn 1�' ,� �,,.- . Detailed Directions To Site: �1 Q.�,f1�''�� 1�-�{ � ��� � �����'"� ` -I-� N��' � -�t�.rn �. o� ; � a�. 1� -� d�wn Le-Ff . Property Address: Please Fill In The Following_Information About The EXISTIlVG Facility: . / � Name System Installed Under: - Type Of Faciliry: f.�� Date System Installed (Month/Date/Year): ��� . Number Of Bedroorns:�_Number Of People: � • Is ThB Facility Currently Vacant? Yes� No If Yes, For How Long? Any Known Problerns? jNo J If Yes,Explain: '� u Please Fill In The Following Information About The NEW Facility: Tyre Of Faciliry: ( �r�Q/yf /�DO Sfi�i', Number Of Bedrooms: / Number of Peorle�_ Poo1 Size: ' Garage Size: Other: �/Requeste�i By: f�. � � �(Date Requested: �` ZZ ' I � �� y � (S ure) �� � - •. For Environmental Health Off ce Use Only Approved Disapproved Goinments: �.�/l� /`,lC�(/1Q ,� � �Ul('111f,_,(,� i��a(� , ��I" ��b°�C9$ 1 S s��Z��— C�7l�Q��i�Gt.�.c�j��SPP �Gt�.S'� � Environmental Health Specialist ' Date' Z6 ( *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will fiinction properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: '`?�`�� Invoice#: ���