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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' C T�1< ►��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 l-�oo-o o� 2r)A� � 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 . 1, Tk `N?.. 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 � Yom✓,,, .s` 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 ■�■����■■���������������������������������������� �������■ �e ■■ ■�■���������_��■������N���������■�n������������ ��������������■ ■�������■��� ■��■�����■����■���■ ■�������������������■�������■��■ ■��������������������������������i������������■��■��5����■������■ ■�������������■���■����������������������� ����.'�� ■����������� ■�������■��■��������������������������■���������■�������������■��■ ■■����■���■�■�����������������■����■�����������■���.������■������■ ■�■��N�������������������■��■■����■������.� ■���■�� ��������■��■�� ■��������������������������������������►�� ����a��� ►������������ ■���������■�����������������������������������:�r.���= ■����■�����■■ ■���������������■��������������� a�������■���c��� �������������■ ■���■�����■■�����������������������■����������_�_.����►����������■ iiiiiiiiiiiiiiiiiiiiiiiiiii�iiiiiiiiiii=iii�iii:i�iiiiiii=iiiiiiii ■�■�������■����■�■�■��������■�������������r����� ��i��■��H ����■�■��� ■■�■���������■�������■�����������������■�i�uii=�:iu=iui�?i�iiiin�iiii ■�������■��������■�������■������■�����■�� ■���������■���■��■��■���������►i■��������������������i�������_��■�■���■ ■����������������������������r,�i������■�������■���c���■�i �u�����■ ■���■���������■������■����■��■r� �������N��■�.��■��■���■������� ■������������■�■������■���a��ca������►��■���Ni���i=�=iii��iiiii,iii ■��■������■■���■�����■�������������������■����■ �■ ������������������������������������ �►��� ������ ����� �������� ■■�����������������■�����������■�■ �������■ ■ �u �����■_� ��■�■ ■� ■�■■�����������������u�����������_���������■����_ ■ �■�■��i�� ��_ :C:::::riCC:::�::�.:�:::'::�CC":C:::::::':_::.'_.:�::::::::__::� ........................�........�3........._._ ....■............. .....................�....�................... i�...._..■....... � ■����������������������i�����■��������N������ ��� ��� ������� ...................•�..�........................ . �:':�.:::::.0 ■�����■■����������►���r.����������������■����������i � �i :::::::::::::::::�:':':::::::::::::::::::�::::: . :C:::5::�.::: ■������������������i�������������N�����N��u�N������������ ■�H���■���■���■���I1■��■■������■■ ����N�/���� ��N�■��■������� ■������������UH�������������������r�����������N���� ������� ■�����������/���t���������������u ■ ���� ■ ■ �■����■���� :::C::::::::::::C::::='.�:::::::_�■ ■ :� �:: _:::� ����������� ���ri�������������������� �� n�� ��ii�����_ ������ �_����� ������ ������ ���� �iu�i ■ �i ������ �iiiiii�iiiiiii�iiiiiiu�i=iiiii:i=iiiii = �i�iiiiii� ��������������(���I������Hu��■��� N � �� �������� ...............r�.��._.......�'�' � ': ::C:D: ...............�■.��. ....... . :::::::C:::::::�::;�:::��::..::.' .cC=:.... .... ............�..��.....�..._... .. ...�..�u=.�.�. ............ ...��..... ... ... . .... . . .... ......... .. ...��..... ... ■����������������11�■�� �u■��Y� �� M H���� �����������������11����■■���:�u� � � ������ ...............�._�........s....y. .� �:�.... ■�■���v�N����IN ����������v��� ■ v�■u� �����u��������I�nn��������� � �N��q�N� ..._... �'.C�...�...�...�_::.....0 :� ......�. ... ... . .E..�... ... . . .... . ■���������C=/��ll�l������������������ ■ ����N�� ■�■�������� ���11�1�■��������■\� ����� �� ■ ■■■������������11�1����������■���� ��� ���� N� ■��■v����������l�lu��■���■■������� ■ ■ u�N�u�■�■�■ ■������■�������/I�I�■�����������■ ����� ��N����� ����������u��I�l1��������H���■■���� ■ �������� �� �������� � '::::. ..::�:►:�C�::::::C:C::���:� . ■ .� . ....... __.......... ..:::: ::�::.::��.:CC:::::C:::... :C '::.::.'_..::::::::.�:::::: ...............■��......■...■...i�..■._..■..... ............... :::::C::::=:CCC:�:::::C:CC:C:'::C::::�:::':::?::.::::::::::::::: ..................�................................................ ■�����������������I��������������������N�����������v������������� ■�����������������I������������■���■■����/�����������/����\�������■ �����������H�����1���������������:���■/�n�����%�����������v���� ���������������I��I�������������v�����������u������������������� i 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)