1631 Peoples Creek RdPenni' tee's AVIECOUNTY HEALTH DEPARTMENT
Name: t ' -} Environmental Health Section
�. P.O. Box 848
PROPERTY INFORMATION
Directions to property: Mocksville, NC 27028 Subdivision Name:
i.i-r r GL`�..} (:F L'a',.;` ,A�` -� Phone#:336-751-8760
Section:
AUTHORIZATION FOR
Lot:
,, k � WASTEWATFR
t_.� ,.,.:.> 1 t. 1�. kj; l Tax Office PIN:# - -
' SYSTEM CONSTRUCTION
AUTHORIZATION NO: A Road Nam Im . i 1-Uf t -r r'- "�
Zip. .. ,I r i ;:
**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 Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
'ENVIRONMENTAL HEALTH SPECIALIST DATEi1SSUE1)
RESIDENTIAL SPECIFICATION: BUILDING TYPE - . # BEDROOMS 44 # BATHS'S' �' # OCCUPANTS :S GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT l # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE_ _ ��— �". TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ' ROCK DEPTH LINEAR FT. 'U
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i Gtr( x==5^''h'
AT(1`0 75'
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►��t'~�t_ t�Zt j
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
V)Nr,�2- (JG`' t
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AUTHORIZATION NO. �A 1 —2APERATION PJHT BY:
'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE
WITH ARTICLE I 1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAC
GUARANTEE THAT THE SYSTEM WILD 1NCTION SATISFA 64
DCHD 02/02 (Revised)
SYSTEM INSTALLED BY: I
IQ9 r — r'
Y FOR ANY GIVEN PERIOD OF TIME.
Pi IN COMPLIANCE
WAY BE TAKEN AS A
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION F DWELLING
(Check One) REPLACEMENT ❑ REMODELINq RECONNECTION ❑
ai � � -�
Name:
0,01cf -t— O �I �"� Phone Number: (Home)
Mailing Address: 1'75-7 V5 U iN 0 03q-S"20Qbj (Work)
n
Detailed Directions To Site: �S� �r L�%� (���� j27
Property
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: W N Q i�5 Type Of D I ellingg VSv
Y ( / Y/ ) i�' ��7 fj �N!aa r p —�
Date System Installed Month Da Year : // T Number Of Bedrooms: umber Of People:
Is The Dwelling Currently Vacant? Yves ❑ No 2f If Yes, For How Long?
Any Known Problems? Yes ❑ No 2f If Yes, Explain:
Please Fill In The Following Information About The New Dwelling.
3.>
Type Of Dwelling: JA� Number Of Bedrooms: Number Of People:
Requested By:
(Signature)
For Environmental Health Office Use Only
Approved [I Disapproved El 15W
�� 3
Requested: -142
Environmental Health Specs list Date_
'"The signing of this form by the Environmental Health Staff is in no wa%nded, nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date:
Paid By: r� Received By:
Account #: 1� (� Invoice #: — ��
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**NOTE** This improvement permit DOES NOT authorize the construction or installation 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 13OA, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
11 1•
PROPERTY ADDRESS
DATE
LOCATION fSY - !�"P` �'O/ J ✓ U�isv i/��liY,c R"'� e7v? .+civ /n�� /w'
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE abs l # BEDROOMS,?_ # BATHS L2Z # OCCUPANTS sI— GARBAGE DISPOSAL: Yes/Do
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) �e,, d NEW SITE !/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZVL22) GAL. PUMP TANK GAL. TRENCH WIDTH . / ROCK DEPTH 1r,, LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
Y
IMPROVEMENT PERMIT BY4-� 1
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT bD ICU SYSTEM INSTALLED BY Atz
.0
1�10
J�
A"TNnPT7ATTnW Mot�7N-1 nncWTTnu'ncouvr nV
**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 13OA, SECTION .1900 "SEWS 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.
DOHD 10/95 w
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Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction oust 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.*** j
NAME �dll (. AMO- /`t�`//�t" e -Z DATE /(%�5��; �AUTHORIZRTION NUMBER
�il
NAME ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATION
Y
COMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM
o�
;f1r, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. 0.. Box 665
Mocksville, NC 27028
i v �4�� 5
U I'll
JUN 3 0 1995
ENVIROIAlEWAL HEI1lTII
DAVIE COUNTY
1. Appiicatiowrermlt Requested By � n
Mailing Address ��Irl' ,14 Fg, `�`I/ .)r, Q, s I�� (� ,42 7/t 51
Home Phone �' �� Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve:
❑ Business
_�eneral Evaluation G,
El/ House ❑ Mobile Home ::ZJ) c
❑ Industry ❑ Other
5. If house, mobile home: Subdivision
[Tam
No. of People
No. of Bedrooms -"
No. of Bathrooms 4 .
I
Dwelling Dimensions
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes
No. of Lavatories
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures.
7. Type of water supply: Public ❑ Private
8. Property Dimensions ��,� r� Sewage Disposal Contracto(
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, whin type?
❑ Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot
❑ Basement/Plumbing
C315asement/No Plumbing
C-,Kwashing Machine
Dishwasher
0'*'G arbage Disposal
❑ Yes 0 No
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the Intended use change. Effective October 1, 1989.
Directions to Property: g, [ f E-� ��J %i V n -S
Oil �.iW eP!/ 010'� --Ilk 7 )-e-1, 1 114-11-1 i-�'5 A194 el
-A r ,f A,,::� p m/
V,,1 �o cel
l (�
This is to certify that the Information provided is correct to the best of my k
Incurred from this application.
DATE
r`
and I understand I am responsible for all charges
SIGNATURE
Q=01 M %N EVALUATION IQ @E QQNE QN ABOVE DESCRIBE D PROPERTY
MUST CHECK ONE: ❑ 1. 1 QM the property. 22. 1 DO NOT OWN the property.
If you checked Box N2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County He th Department to enter upon above described
property located In Davie County and owned by 44,1-,/1� /'/[�{_h,1�,! y
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation / r�
NAME �OJO'6 DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY ,.c I�SC LOCATION OF SITE A4 z cfei(
Water Supply:
On -Site Well _
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1
1 2
3 4
Landscape position
Slope Z
%Z
HORIZON I DEPTH
,'h
`•
`�"
Texture group
S '
fir✓
Consistence
Structure
Mineralogy
HORIZON II DEPTH
4
Texture group
Consistence
--1
Y.11
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
A77S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: & EVALUATED BY: /"k4l
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 :lay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- Vl---y friable FR -Friable FI -Finn 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
3C -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 (01-901
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Davie County Nealtfr De artment
v
and Nome Nealtli yency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
July 11, 1995
Dwayne A. Hartless
115 Flint Field Dr.
Winston-Salem, KC 27103
Re: Site Evaluation
Peoples Creek Road/4 Acres
Dear Mr. Hartless:
As requested, a representative from this office visited the aforementioned
site on July 10, 1995. Based upon 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.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure(s)