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184 Stony Brook Trail Lot 42 DAME COUNTY HEALTH DEPARTMENT r Environmental Health Section V P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001502 Tax PIN/EH#: 5820-22-9527.42 Billed To: Mousavi Gen. Contractors Subdivision Info: Northbrook Lot#42 Reference Name: Ali Mousavi Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map 64 **NO'I'U**'Obimproveement/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 #People #Bedrooms-f #Baths ol,,,S Dishwasher:0' Garbage Disposal: ❑ Washing Machine: 121"� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �'9C Type Water Supply Design Wastewater Flow(GPD) 6 Site: New Repair❑ System Specifications: Tank Size A&GAL. Pump Tank GAL. Trench Width Rock Depth/.7 Linear Ft.STA�2,1 i Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE.. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account M 990001502 Tax PIN/EH#: 5820-22-9527.42 Billed To: Mousavi Gen. Contractors Subdivision Info: Northbrook Lot#42 Reference Name: Ali Mousavi Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number. 2647 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 WASTEWA CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: c /Date: G� 'te)!D CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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 the system will function satisfactorily for any given period of time. o, 5'�It roJ )Pd /vd Septic System Installed By: Environmental Health Specialist's Signature: % ,�(�4 Date: -S DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT • • ' ' Environmental Health Section '—"-� P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990001502 Tax PIN/EH M 5820-22-9527.42 Billed To: Mousavi Gen. Contractors Subdivision Info: Northbrook Lot#42 Reference Name: Ali Mousavi Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map **NOTIu** Ttii bNprov ment/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 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 #People #Bedrooms #Baths Dishwasher:/2j1**' Garbage Disposal:❑ Washing Machine,; Basement w/Plumbing:❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type �1 #People #People/Shift #Seats Industrial Waste: ❑ Lot SizeType Water Supply C 'Q Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Size/ e?4 GAL. Pump Tank GAL. Trench Width��J`Rock DepthL?� Linear Ft. ' t Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6 11 BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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.**** cr rk Environmental Health Specialist's Signature: _ Date: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001502 Tax PIN/EH#: 5820-22-9527.42 Billed To: Mousavi Gen. Contractors Subdivision Info: Northbrook Lot#42 Reference Name: Ali Mousavi Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map **N Is gin oveement/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 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 74-1 #People #Bedrooms V$ #Baths -)-5- 5--- Dishwasher: Garbage Disposal: ❑ Washing Machine,j27`� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ZfA- Type Water Supply Design Wastewater Flow(GPD) Site: New Repair❑ System Specifications: Tank Size/ad GAL. Pump Tank GAL. Trench Width�� Rock DepthL� 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 of the Davie County Health Department for final inspection of this 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.**** Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001502 Tax PIN/EH#: 5820-22-9527.42 Billed To: Mousavi Gen. Contractors Subdivision Info: Northbrook Lot#42 Reference Name: Ali Mousavi Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2647 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 WASTEWATER NSTRUCTION IS VALID F PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Dater CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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 the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC D 0 U R Davie County Health Department Envdrnnmenf&Hea/dt Seddon P.O. Box 848/210 Hospital Street NOV 2 O 2000 Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH DAVIE COUNTY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the IN�F—ORMATION BULLETIN for instructions. 1. Name to be Billed M o U 5 ct%// CX9 Yf P.J Contact Person f}I► lUI D�S��/V% Mailing Address -� �b �Qu_� Home Phone _3 3 b/— City/State/ZIP (A)lp Sa��x�1 �^/ G 2�//3 Business Phone 33{, g�'L— 1 Cr 2. Name on Permit/ATC if Different than Above UJ Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation improvement Permit/ATC ❑ Both a. system to service:. A House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms 34 # Bathrooms 2- %2 Dishwasher ❑ Garbage Disposal Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks. # Commodes # Showers # urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: KCounty/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes No If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions. WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # -5-F a.o- 15-z 7 0 0 =-,I-AW,- Property Address: Road Name SIV N r S,-a o& pn_ C -A• RIC. _. ( /� J b ^� Iti B Q4h 6 co- (e City/Zip Q- -h )1l/ &-00X'- If in a Subdivision provide information,as follows: Q , Name: . (7 O ��. Section: Block: Lot: LA Date Property Flagged: i a.0 e m 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 1 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 to conduct all testing procedures as necessary to determine the site suitability. DATE IIS 2 ° 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: ro Account No. O Revised DCHD(07/99) Invoice No. I APPLICATION FOR SITE EVALUATIOP T� • Davie County,HealthVepartment, `EnvironmentalHeald`Sectiori d. P.O.Box 848 SEP "13 2000 Mocksville,NC 27028, - (336)751-"8760` ENVIRONMENTAL HEALTH ****IMPORTANT' *** THIS APPLICATION*CANNOT BE PROCESS DAVIE COUNTY ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed JFje e&e Ee#)y e.T*9 Contact Person Mailing Address /I)'l A&1/ 4aN e, Home Phone City/State p _t� �b.� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State p 3. Application For. III/Site Evaluation O Improvement Permit&ATC ❑ Both 4. System to Serve: U/House O Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People # Bedrooms # Bathrooms ® Dishwasher O Garbage Disposal IdWashing Machine O Basement/Plumbing ❑ Basement/No Plumbing 6.' U Busmess/Other.! Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water UsagcUallons per day) 7.' Type of water supply: �ounty/City ❑ Well O Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ❑ No If yea;what type? 7 T PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A Pks1THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Tax Office PIN: # S !LO2� L'I_'T 1 MocksvWe)TO PROPERTY: 1 1 IN - Property Address: Road NemoST DiV V f ClJok h ri UP/ 1 L Q �C' rc c( rr" If in Subdivision vide information,as follows. 16W S16701 V grt�ok -Name !o r'T�i Rl'Or�D 1 , Loi�� �r 3 Section: Lot #� • Ccrovld N,v This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter aro 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 die Auth6rked Representative of the Davic County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE ral Revised DCHD(06-96) YOU MAY USE THE SAC OF THIS FORM FOR DRAWING YOUR SITE PLAN. n , A. o°g. S35 `�." GILBERT TODD D.B. 82 Pg. 532 D.B. 148 13,3 p9: 784 9 319 D.B. 1 r---j D.B. 1 S 87.51'57' E — S 84.29'35' E j 467.88 299.93 i' W n o r o � 1 LOT #37 LOT (5.224 AC.) s jrr (5.64 s S9.S9,J3, �O� s 96 634 �r `STONY BR W OTA L4 • /C3 cu a �g oPp Q An z LOT #36, (5.302 AQp�� LOT #41 i, ,,�� ► (5.008 AC-) t Z 3 I I e �F W I O� co ( 4. S 86.1030' E--� i, I O �'' m W^ 502.64 TDTAL 47Or vi 2.49 30.13 IW • �r LOT #42 ass (5.425 AC.) YI I F�. O 01 1 co -` a W LOT #35 z cul C (6.304 AC.) i 60 UTILITY & , N ACCESS EASEMENT FOR THE PURPOSE OF INGRESS EGRES z N 87.42'24• E 656.92 TOTAL 39.490 617.43 rha � �1� h W v SS LOT �OhQy �5�,pp. 34 313.�c'• # . (6.076 AC.) �+r b F b, 1 J z LOT #33 h (7.087 AC.) I .o a I Qe,�c�. tiN y lb I ASF? �' 6C'3 lg6•?°�, S cl 83• 65.oo �' '1604• 4N38' E DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900214 Tax PIN/EH#: 5820-22-9527 Billed To: Eugene Bennett Subdivision Info: Northbrook sec. 3 Lot#42 Reference Name: Location/Address: Stony Brook Drive-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 1'fides Water Supply:1 On-Site Well ommunity Public r� Evaluation By: Auger Boring 1,Z Pit Cut FACTORS 1 2 3 4 5 6 7- Landscape position Slope% L L HORIZON I DEPTH 0000 Texture group Consistence Structure Mineralogy HORIZON II DEPTH Y N i Texture group Consistence Structure Fs' Mineralogy ' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �!� EVALUATION BY:_2ZZ LONG-TERM ACCEPTANCE RATE: G 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 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) DAI(IE COUNTY HE LTH >)AtAf.ThIgN'T w.' ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336:)753-8760 Eugene Bennett 107 Nail Lane Mocksville,NC 27028 Re: Site Evaluation/ Stony Brook Drive Tax Office PIN: #5820-22-9527 Dear Client(s): As requested, a representative from this office visited the aforementioned site on September 20, 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 an 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 off. If you have any questions,please feel free to contact this office. Sincerely, Robert B. Hall,Jr.,R.S. Environmental Health Specialist RH/di Enclosure(s)