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257 Stoney Brook Trail Lot 38 • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 gq Account #: 990001780 Tax PIN/EH#: 5820-33-134T1r Billed To: Joe Roush Subdivision Info: North Brook sect.3 Lot#38 Reference Name: Location/Address: Proposed Facility: Residence Property Size: 5.64 acres ATC Number: 2873 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 O ST UCTION IS A ID R A PERIOD OF FIVE YEARS. A Environmental Health Specialist's Signature: I Date:_ 4` /Z 0 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. . � D f Septic System Installed By: Ve Environmental Health Specialist's Signature: Q�G�G� 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 M 990001780 Tax PIN/EH#: 5820-33-1347jr Billed To: Joe Roush Subdivision Info: North Brook sect.3 Lot#38 Reference Name: Location/Address: Proposed Facility: Residence Property Size: 5.64 acres **NO 11:* iIsgmpro$ement/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 T #Baths Dishwasher: 0 Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type :1 # eople #People/Shift #Seats Industrial Waste: 13Lot Size Type Water Supply Design Wastewater Flow(GPD)WZ) Site: NewZ' Repair❑ System Specifications: Tank Siz // �� Rock Depth y p �l/� GAL. Pump Tank GAL. Trench Width-76" � S Linear Ft._?06� 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) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&A EC� E0WE Davie County Health Department , Environmental Health Section rl P.O. Box 848/210 Hospital Street r M JUN 6 2001 Mocksville, NC 27028 j (336)751-8760 ENti'IRONMENTAL HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORIAATION .IS PROVID/E�D. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed / Oy.S Contact Person 'C Mailing Address 7909 / eg-r/� �/�j Home Phone City/state/ZIP //�� �) 6CAr>_ .. AIL d./3!0 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to Service: )< House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People �_ # Bedrooms �_ # Bathrooms _ 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: County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes XNo If yes,what type? ***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 0 /11AG2ES WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # S2.20-33- I3 97j�-• _K90 Wi o Exir loo Ri4Nr o&/ 61O/N, Property Address: Road Name kW1Lt nC7�n 3 46F7 d.V -Z 9MLES &UaCH RV, l�16H7— Oh/ kor 38 City/Zip V ICF NTfl k Fro T i.C� If in a Subdivision provide information,as follows: /or 3S7 is , ,43r C-UOae'O Anergy v / Name: Amaaf llko/s IS RUNS B C-r-yJA,1 /-Or l'wo u riL;r.V Pt;OmST,4S, pry t.4Fr or- Cu1.0L SAC.. Section: _ Block: Lot: Date Property Flagged: 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 ♦7276 E, R oU'SY4 a to conduct all testing procedures as necessary to determine the site suitability. DATE 06 OC-01 SIGNATURE rN 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: Account No. Revised DCHD(07/99) Invoice No. �� � � APPLICATION FOR SITE EVALI ATiON/IMPROVEMENT PERM&ATC @ WRN • ,,, Davie County Health Department D Environmental Henith Secdon J P.O. Boa 848/210 Hospital Street AUG 1 81999 Mocksville, HC 27028 w (336)751-8760 ***nWCRTANT*** THIS APPLICATION CANNOT BE PW=SSED UNLESS ALL TH3 REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Nage to be slued o eL �1rb &4dj'u� Contact Person .Nailing Addr.ssvfK�Fi �t ao" Phone City/state/sIP � SXLr.L(� i /�//.�� 7/J suaiaess Phone � J . Z. Naris on Permit/LTC i! DLtrersnt than Aboae 2 e jqece, Nailing Address TV-I W Vd '/1 e C/6J/J-('Ali�I�'J City/State/zip 3. Application For: "Site Evaluation ❑ Improvement Permit/ATC ❑ Both s. system to servioe: ®" House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other s. If Residence: # People # Bedrooms # Bathrooms [3"Dishrasher ❑ Garbage Disposal h/washing Naohine ;/za,=/V3LusbLnq ❑ Dasensnt/No Plumbing 6. Il suainess/Industry/other: specify two # People # Sinks # Commodes # showers # Vrinals # Water Coolers Ir FOODSERVICZ: O Seats Eatimated Nater Usage (gallons per day) 7. Type of nater supply: �/` W Coua:. _.. ........ ... .. . . ty/City EJ Well/city ❑ Community a.- Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes e'Pto If yes,what type? ***IMPORTAIVT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with-THIS APPLICATION. Property Dimensions: Sri WRITE DIRECITONS(from Mocksville)to PROPERTY: Tax 08ice PIN: # 6,O/zy- Lamely 4,awef'CfiaRcfr 1, Property Address: Road Name �, aff 80 RTF 91?00I-L2 R i Ve 0�/ City/Zip 0 tr 0 r6 If in Subdivisslo°rideWiftion, follows: b e f i&h,0eJ7miCfd 1`e 6�— � e11 Na O: C �eC P e e- -D, &e 1--ez ,/// Section: 3 Block: Lots Sly Date Property Flagged: 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 to conduct all testing procedures as necessary to determine the site suitability. DATE ' SS y I�-�/ 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• Account No... Revised DCHD(07/99) Invoice No. Yd19 j X,5 eA . • 0823 38 n _a Sa4A CJ9 S]98 1347 ■ STONY0RO0K TRA& 0224 Itsm 2205 041e - m e• y - 6 5.30A 1011 � 9A ➢ S.s7A 1070 1951 ➢ ➢ a" SA2A ���EEf oen t +°16 7630 5540 9w NDEXED ON 6531 5820.03 - Nu 1435 am • e 4201 n m a 2220 n P 8100 P 2116 /3 ' •'e 9110 m3e e.07A 41M P • a 4207 'gY•1y _ a OPV 8• s C 0 0907 + ,.,224 POEXED 2925 ON 7.08A 20435820.04 ppy - 8961 -6889 1819 4892 8804 0058 180! 0045 0 179• n •m s ➢ pnN e• + V • ° 2578 , 114 a1f4 ➢ ➢ ➢ ➢ R ➢ ➢ '^ '• _ m Bus 0 1597 3587 4597 .5587 0595 7585 ➢ a - e595 9595 osa esu f+• SR OCT 8 8 SR 1307 ►.... ++. • nw fW fr " w 14732472 3451 2051 SMO2090 UANEO CHURCH ROAD ° pyy nAN 83M rL 9396 ` '• °. oA 9322 6. 1226 3]12 i➢ R,Sv II n am TM �. 7258 17 9225 am •v �114 1217 11.7209 E . H 2212 3211 1220 ➢ � 0212 sm 51e9 elect 7169 viae 3 1- 7 . ➢ 0-4 - E 120 WOO a7W 'RT- TODD H. SHERRILL 34, D.B. 165 P 19 g' 695 GREGORY D.B. 154 Pg, 185 �` p 8 BBY� 0. MOTT , GLEN FOSTER "I BUS B• 176 Pg. 522 ', D.B. 89 Pg. 117 '� D.S. Sy8428'1'6•"E==„`,-- - _ � B. 449.86 D. z S 84.88'16' E--t 0 786.26 o CD LOT #38 ti (5.649 AC.) 0 r M J I � Q - t ' C F- O► W STONY BROOK TRAIL _— c C.)L3 `_- __�_ —''3 LOT #39 rt L2 (11.650 AC.) L! PRIVATE ROAD fi _OT #41 W :5.008 AC.) p LOT #40 N r A (5.519 AC.) Ln vi Oa ;r u; t 0 Z Z L33 L to `35 L28 f �S �.%AC:v iaG� `/`Z/ \ LOT #19 �- ,RPOSE dc EGRESS LO/ 61,11, P - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ` Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900214 Tax PIN/EH#: 5820-33-1347 Billed To: Eugene Bennett Subdivision Info: Northbrook Sec. 3 Lot#38 Reference Name: Derrick&Becky Petree Location/Address: Stonybrook Trail-27028 /� Proposed Facility: Residence Property Size: 5.649 Acres Date Evaluated: A �_4 _ Water Supply:• On-Site Well �� Community Public-- Evaluation By: Auger Boring Pit Cut FACTORS - 1 2 3 4 5 6 7 Landscape position Slope% . HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group (� Consistence i Structure 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 G .% SITE CLASSIFICATION: EVALUATION BY: 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 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) ■■■■■■■■c■■■■e■■■■■■■■■ecce■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■co■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■e■■■c■■eee■ess■■c■■■c■■■■ecce■■�■■■■■■■■ec■■■■■■■s■c■■■■e■�n■c■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■c■■■■■■■s■■■■ee■■a■e■■eee■■■■c■■■■■■■■■■ase■c■eae■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■cc■■■■■■■■■■■■■■■■ecce■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■c■■■■■■■■■■■cess■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■■■cc■■■■■c■■■ MEMNONMENNENMENNEN EiiiiiMENNENiiiiii�iiiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ •. e DAYIE COUNTY'... DEPARTMENT Environmental Health Section P. O. Box 848/210 Hospital Street Courier 09-40-06 - Mocksville, NC 27028 .(336)751-8760 - August 30, 1999 Mr. Eugene Bennett 107 Nail Lane Mocksville,NC 27028 Re: Site Evaluation North Brook Section 3,Lot 38 Tax Office PIN: #5820-33-1347 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, August 27, 1999. 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, A,40trt.g;,WA. Robert B. Hall,Jr.,R.S. Environmental Health Specialist RBH/msp Enclosure(s) (� e County Health Department n ronmental Health Section ; , P.O.Box 848 �P�N�p�SH 210 Hospital Street Courier#: 09-40-06 Mocksville,NC 27028 Phone:(336)- 53-6780 Fax:(336)753-1680 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement modehn Reconnection Name: lle.l ( i l. Phone Number L/717_(Home) \ G � MailingAddress: 7 U o� P)}�) )'�Ya'G(. 3 _j� 4-?0 (work). Detailed Directions To Site:_ y0 Lje f r 7L E aril /70 /,hcz�u� .66/ ?'i,rw &!2h T 11'1 I l es L) Tv,, .j L e F,ro c•/ el�Yh e S %cifl�� /e.q�l r--� �THFfit,'rirl': r e -' LPfr a�1 .�T7�n iL .P G 1- 7 Property Address: r L Please Fill In The Following Information About The EXISTING Fa 'ty: 0/ZA Beoo k I©F 0,5s' r /' Name System Installed Under._Inek!" L¢v�s9r 6) l a~�tJ�'� Type Of Facility: eS� Date System Installed(MonthMate/Year): ADD 1 Number Of Bedrooms: Number Of People: 2 Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes If Yes,Explain: Please Fill In The Following Information About The NEW Facility: S,-z e /gxyo Type Of Facility: r 17 : �1a0 Number of People 3 Requested By: Date Requested: (Signature) LL For Environmental Health Office Use Only Approved Disapproved Comments: c' e 2 e, ' / nV1 e I °Z1, Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or imited)that the on-site wastewater system will function properly'for any given period of time. Payment: Cashl heck Money Order # Amount:$ / 0- ' Date: Paid By: J6V1V A1e4'-( Received By: t f Account#: Invoice#: +Q&