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1056 Pine Ridge Rd , DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section � � P.O.Boz 848/210 Hospital Street �`�� l� d 3 . �. Mocksville,NC 27028 �� � (33()751-87C0 � � ��G� �ZL z-- IMPROVEMENT/OPERATION PERMIT Account #: 990002761 Tax PIN/EH#: 5745-13-2271 MP Billed To: Mary&Gary Peacock Subdivision Info: Reference Name: Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.04 acres ATC Number: 3525 **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 PERMIT IS SUBJECT TO REVOCATTON 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: ❑ Washing Machine� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) <. !� Site: New�rRepair❑ ���p�; �� i� System Specifications: Tank Size�=(�,�""AL. Pump Tank GAL. Trench Width�� Rock Depth�Linear Ft.� o�h�: ��.)1 ��,� U��v c Required Site Modifications/Conditions: IM11PROVEI�1ENT/OPERATION PER1111T LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF G "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe D �e County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 130 p.m.on the ay i t llation. Telephone#is(33C)751-87(0.**** � � Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) � DAVIE COUNTY HEALTH DEPARTMENT � � , . ` Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990002761 Tax PIN/EH#: 5745-13-2271 MP Billed To: Mary&Gary Peacock Subdivision Info: Reference Name: Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.04 acres ATC Number: 3525 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED 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 CONSTRUCTION IS VALID FOR A PERIOD OF FI YE S. Environmental Health Specialist's Signature:� �G/ Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system de ibed on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130 , ctio .1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the s em will function satisfactorily for any given period of time. `�` ,;^P � � ��� f-�r;shC � � la rr��.s� �DS �.vl,/��✓k �✓ ✓ Septic System Installed By: i' / Environmental Health Specialist's Signature:���� Date: (�' ✓ DCHD OS/99(Revised) • �i.—��,y,""''"�"��� ' , ;;+..,.� [4 � � � ��,. A. TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC `, � 9 2�0� Davie County Health Department ',+ ,� !,��j�( � Environmenta/Hea/th Section 5J �.: P.O. Box 848/210 Hospital Street ,L�1� Mocksville, NC 27028 �1Y1R�N��,pUxS'( (336)751-8760 *IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed `�' ..QC�[�C� Contact Person �Ql� �C Mailing Addreas � Home Phone �.d y— µ g�y --r- City/State/ZIP ��/P��,�� �1e � '/�/�. Business Phone ''"•a•. 2. Name on Permit/ATC if Different than Above Mailing Addresa City/State/Zi (�-(' � ��-., 3. Application For: Site Evaluation cJ Imp ovement Permit/1�T� Both ��Y-ig __�__. , -- -- � 4. system to service: House �Mobile Home Business Industry Other 5. If Residence: # People _� # Bedrooms � # Bathrooms .2 '�Z /�bishwasher Garbage Disposal Washing Machine Basement/Plumbing Basement/No Plumbing � � 6. If Busineas/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 a. Do you anticipate additions or expansions of the facility this system is intended to scrve? Yes No If yes,what type? ���dC� ***IMPORTANT'r**CLIENTS NIUST COMPLETB THE REQUlRED PROPERTY INI+ORMATION R�QU�STGD BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by tl�e client witli TI[IS APPLICATION. Property Dimensions: � � 7 �t.r-�� WRITC DIRGCTIONS(from Mocksvillc)to PROPGRTY: Tax Oftice PIN: #3�7 ys- / 3 — �� � � ��� 5 � �ru-S� �R..r� a�' Property Address: Road Name Pi n✓ R�d�,c.�R,,� . �° � S � a r. ' /�h���...�+� . �� • City/Zip I'h a c-KS�� 11�a. ,l ✓ L'T1.. �r.-► e� ' �-o��f�v �'. If in a Subdivision provide information,as follows: .� S ►ws� ��.i'}' 7'- � �3 d" �+'��' Namc: D r� L 3-,.. � Z� � 7- Section: Block: Lot: Date home corners flagged: —_� � e� �— �"2h�.� 4.��� �a/�' �.�.�•. ,�c,� This is to certify that the information provid��ect to the best of my knowledge. I understand tliat any permit(s) issued hereafter are subject to suspension or revocatio�i,if the site plans or intended use change,or if tlie information submitted in this application is falsified or cl�anged. I,also,w:derstand diat I au:respousiGle for al!chn��es ir�curred fr�om t/ris applicatio�:. I,hereby,give consent to the Authorized Representative of the Davie County I-Iealtli Departme�it 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 � t I ro � SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include a of thc following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 4.� ,/" � / /u `` O / ` Site Revisit Charge /,� ��_�. �,� ��/ C � v l Datc(s): ( 'r-3a r7t3o) — L��.J � �' � a -0 � � �// � ' �� �"� � Ciicnt NotiFcation Datc: �� � I y� �1 � I�',�IS: �i'�-�4-2 y �'�`�C d C' .� Sign given Account No. a 7 � � Revised DCHD 07/99 Invoice No. �� ! / v � ) r — I , ....:..... .. , I ,', i I � ,,, � ... , .. � II � � ,•s �, ,,,r"�.,, . s�" � d%i, ,,. � �;; i � � „„,�„ � ��� t � � %i „jii/%..,,.. �*"", � � f, � E � � ° ;i,t o y���� �;:'�^...:� � � /�f,,,�y!, ' ; u ` �, � � ry �� t a � „,,,, i �� � '' � /' 4 �i�,,,, � �i,,,,,. �. � i t �` � t i � f1 �� t ��► : 1 .�1A ��� � t� � � t � � . , s � � t 4247 '�; � . , 4 1 gp t � I $, 1 t 9 1 � /yf ... � S � I n , s £�� �Y�„%,, �,;, ( 1 04A) � ; �; ,� . � � , , � � ,y,r� , ; , � 2271 ' � , � , ; 1 .Q1A ' '� N � ' �- ; ... ("��r? � r , ,, ; � , , , -� , � '�`,� � , � , c3� ' , .� � , �ii;�: ; � , � , , 5 ` � � t 51 ` I I t t l ; ,��� �....�-� �� , , , , , � � � _ � a , ,.,,,. .. , ... :����u R � � ; � 4 i � i I z� �� } t 1 " n � : 1 �;-,. „�„�., L� � <. ..�� �; ��� , ��' �. . �Nr � �.J �. �� _ : ��� ��� � �� � _..:... �. � . �` i ..... � %;:;;: �� ,, , r �� � `' f � � , ,,.:. �� �.,, i .,; _ .._. � �.. �,�-;i ;.;... . ,-�,������r> ^ �„ �� �- � � �n� � �� t '�,.. � "" " . , �d � 30� � � � �. � ., D c � � a � � y � " ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT J�. �' • � ' , . . Z � Davie County Health Department � � �Z�pZ„ n � , � � Environmenia/Hea/th Section " ���`� r P.O. Box 848/210 Hospital Street � Mocksville, NC 27028 E N`J I RDA VIE COUNTHI'Et�L T H � (336)751-8760 ***IMPORTANT*** THIS APPLICATION C,ANNOT BE PROCESSED UNLESS AI,L THE REQUIRED ' INFOF2I�TION IS PROVIDED. Refer to the INFORN�iTZON BULLETIN for instructions. 1. Name to be Billed c�✓1 CY u Contact Person (��� (V�G`{� Mailinq Address r�6� P.�.-? Q`��j.Z. h� Home Phone `�T J �a`7!'/ � ) City/State/ZIP r'��C�� ��I � � Jti •�. Z7���j Business Phone '�'—"--- 2. Name on Perm:i.t/ATC if Different than Above Mailing Address City/State/Zip 3. Applica.tion For: J�Site Evaluation ❑ Improvement Permit/ATC ❑ Both a. system to service: � House [� Mobile Home ❑ Business ❑ Industry ❑ Other � 2 5. If Residence: # People '� # Bedrooms 3 # Bathrooms � �Z' IW Dishwasher ❑ Garbage Disposal C�F7ashing Machine ❑ Basement/Plumbing f.l Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers ZF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: C�''County/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 INrORMATION REQUGSTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMI7TED by the clieot with TNIS APPLICATION. 4 Property Dimensions: l•l�� /��� WRITE DIREC"I'IONS(from Mocksville)to PROPGR'1'Y: Tax Office PIN: # S 7 t(S� � Z2�� �D 1 S {-d �'rr"�c�-� Co�;r��Qn 0 Property Address: Road Name P��. Q��� ��� `ad� S L-s' � M :�w �,ty,Z,p �a�����Ir �rv.�, �-�..�f � -�; ,�� �� �— ,. n � p lf in a Subdivision provide information,as follows: �c�7" � -(US''� (d� -1'•�" Name: �.��5 � ` `� f Section: Biock: Lot: Date Property Flagged: l- o � a%Z- This is to certify that the information provided is correct to the 6est of my knowledge. I uaderstand that any permit(s) issued hercafter are subject to suspension or revocation,if thc site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,uitderstaitd tltat I ant respo�rsible for al1 clrrirges i�rcurred fro»r this app/ication. 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 owncd by to conduct all testing procedures as necessary to determine the site suitability. ► DATE_����'�d� SIGNATURE ��v YYti C,'�_ THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and pro�osed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Chargc Datc(s): Client Notitication Date: � EHS: ' Account No. ��� � Revised DCHD(07/99) � Invoice No. ��� � � tc�` �. �� " , DAVIE COUNTY HEALTH DEPARTMENT ' • •, '• Environmental Health Section , � ' Soil/Site Evaluation ' � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002102 Tax PIN/EH#: 5745-13-2271 Billed To: Ron McDaniel Subdivision Info: Reference Name: Location/Address: Pine Ridge Road-27028 Proposed Facility: Residence Property Size: 1.04 acres Date Evaluated: /- � 3�� Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring�/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L Slo e% HORIZON I DEPTH ` �i Texture rou L �� Consistence Structure Mineralo HORIZON II DEPTH �� ��`� Texture rou Consistence " i SWcture / � Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY: �' LONG-TERM ACCEPTANCE RATE: e OTHER(S)PRESENT: REMARKS: (�(/��-S� ��/"/ �i/Oj "'�"� � 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-Subangulaz 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 Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/99(Revised) ■��������■����■■���■�■�■�����■�■��■��■�������������■���������5 ■■ ■�■�������■���■���■���■■���■��■�����/����■���■�■�����■�■������lSw ■�\��������■�������■������■����■ ■��������������������■����■�■�■ ■����������������������������/�����/����������������������������■ ■���������■■�O�i�ii�\�������������■■�■�■\��������\��l��■���������■ ■�/�■�■��■��\■■■��■������■■�������\���■����■��■■��■��������������■ ■��������������������■��e■■��■����■■■���������o��es�a�■■���������■ ■������■��■�e�■����■����������■��■����■■��■��■���■�■■�■����■��■��■ ■�����■�o■■��■�.������■■��■■���■�■■��■��■��■�����������������■■��■ ■�������������■■����������es�s�������■����■������e�s���������■���■ ■■��������■��■�������■■■��■■�■���■����■�■�������■■����■�������■�■ ■������■�■�■���■���■�������■��■■ ■����■��■�����������■■������■■�■ 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"+ r � � ,. . ... .;. .. . . . .... . . . .. . . .. . ._ ...„. _ .. -....y . ._. ., . . .._.. , D�YI��OUNTY�I�4LT�I D����TbI�NT. _ ' , � ,:` _ . .. _ _. � ENVIROIVMENTAI HEALTH SECTION P. O. Box 848/210 Hospital Street - Cour�er #09-40-06 Mocksville, NC 27028 , -i Phone #: �.(336)751-8760 _ `, . _ _ _ . . . .._.._:.a January 24, 2002 , � _ � Ron McDaniel 1068 Pine Ridge Road Mocksville,NC 27028 Re: Site Evaluation/ 1.04 acres Pine Ridge Road Tax Offce PIN: #5745-13-2271 � Deaz Client(s): As requested, a representative from this office visited the aforementioned site on January 23, 2002. Based on information provided on the Applications for Site Evaluations and after the evaluation was completed this site was found to be provisionally suitable for the installation of a modified, oversized on-site sewage system. Before Improvement Permit(s)/Authorization(s) to Construct can be issued the appropriate application(s) must be filled out and the house/mobile home location staked on each site. If you have any questions, please feel free to contact this office. Sincerely, /��'�t���d�i• Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di Enclosure(s)