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268 Pinebrook Dr � DAVIE COUNTY HEALTH DEPARTMENT • � Environmental Health Section �Z f Z ,�v3 • P.O.Boz 848/210 Hospital Street �� Mocksville,NC 27028 (33G)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990002212 Tax PIN/EH#: 5841-87-5946 Billed To: Brad Rogers Subdivision Info: Reference Name: Greg& Beth Little Location/Address: Pinebrook Drive-27028 Proposed Facility: House Property Size: 35 Acres ATC Number: 3624 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AITTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE T�iIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type �� #People g #Bedrooms �� #Baths ��� Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 3��tC� Type Water Supply l.�V/�7�Design Wastewater Flow(GPD) (y� Site: New❑ Repair❑ System Specifications: Tank Size (��GAL. Pump Tank GAL. Trench Width ���1 Rock Depth ��� Linear Ft. ���� Other: � �l���t�Tio-� 1�D�C�.Si ��-1�i�V�T�� �wl..) 1/�1.�� � Required Site Modifications/Conditions: �I�rAI.L Dn1 G°^5T��7� I4�-'� �O� (>(-F i rk-�,U�,7�%, � 5�pFF /�.� Ih1PROVEI�1ENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 830 a.m.to 930 a.m. r 1:00 p.m.to :30 p.m.on the day of installation. Telephone#is(33()751-87G0.**** . ��1 J� f� 1�,LT�lLr.�-r�.�- � � �.sp' � ��,►�� 2s?o �� IZ�Jc.Ti�1 S�ST�:�,� � � S 3(L• ,�T�-7L�-�r1 b �L.�t,J�1 AL-�Jc� ��f`- � ���3�yc4=.,S .. �,� tJ,� ' �o�� �'�; ' A��``� •�`�i�-ti7 U,�I tiS t.� �� �AL-�G � 1ov'x��wz,� P��K , ic�' . �Q i�. � , Environmental Health Specialist's Signature: i Date: ' DCHD OS/99(Revised) ��G�? L t�c �_ CoerJ:� ----_ �, DAVIE COUNTY HEALTH DEPARTMENf /e r Environmental Health Section P.O.Boz 848/Z10 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990002212 Tax PIN/EH#: 5841-87-5946 Billed To: Brad Rogers Subdivision Info: Reference Name: Greg & Beth Little Location/Address: Pinebrook Drive-27028 Proposed Facility: House Property Size: 35 Acres ATC Number: 3624 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 Treatmen and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE RUC VALI FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: te: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section .1900"Sewage Treatment and Disposal Systems,"but shall in Y be taken��uarantee that the system will��pn satisfactorily for any given period of time. d ` �!J gG • �, 7 �2��, �, � �z�. ---�o� ,� � ��t,. w2'' '�u !2S. n�5 �.2�ti S �-----� � ��. ��� i ���� �A`f�: ��-I o � 12.�j C�'�� ��.,��- Septic System Installed By: l�c�. Z . Environmental Health Specialist's Signature: � Date: % ' ✓ .L DC�-ID OS/99(Revised) . ,(1� ''+' • • . )�L�- U�� �' �%: U' � , APPLICATION FOR SITE EVALUATION/IhiPKUVC•tifENT P[Rh11T&AT � Davie County Health Department �� � , Envi�onmenta/Hea/th Section , Nb�r � 18 2003 P.O. Box 848/210 Hospital Street �_.—..�-.-�•, ,-a • Mocksville, NC 27028 ,,,""'"�"r; '� ;� , `, (3 3 6)7 51-8 7 6 0 ENVIROP,��ENTRE�H E/1�jH.___�-- •, � NlY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNL�S5 ALL THE R�QUIR�D • INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. l. Name to be Dilled �,J '"`^'^'�'� Contact Person J�*� � Mailing Address �j r��1 i ►T� +"� Home Phone City/State/ZIP /,�,^�li- NG ���� Business Phone �I� "11{ � 2. Name on Permit/ATC if Different than Above �� �"�`�� �� ��-L/ Mailing Addreas City/State/Zip 3. Application For: ❑ Site Evaluation LtfImprovement Permit/ATC ❑ Both 4. System to service: LtiJ House ❑ Mobile xome ❑ Business ❑ Industry ❑ Otlier 5. Type system requested: IJ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People _� # Bedrooms � # Bathrooms 3• � YJDiahwa3her ❑Garbage Disposal lr]Washing Machine ❑Basement/Plumbing ❑IIasement/No Pliunbing 7. If Buainess/Induatry /Other: verify type # People $ Sinks # Coumiodes # Showers # Urinals $ Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay) 8. Type of water aupply: �County/City ❑ Well ❑ CommuniL-y 9. no you anticipate additions or expausions of the facility this system is intencled to serve? ❑Yes ❑No If ycs,what typc? ***IDIPORTANT*** CLILNTS A1UST COb1PLETE THE REQUIRED PROPCRI'Y INFORMATION RGQUGS7'LD 6ELOW. Eithcr a PLAT or SITE PLAN A1UST BE SUB�177'7'BD by tlie clic�it witl�TIllS APPWCATION. Pr'opCCty Din]ensiolls: �� ��� WRI'fG D1RGC'TIONS(from 1llodcsvilic)to PIiOPI:R'fl': Tax Officc YIN: # �����?�'��� �«�.��,_„_ � �����t�L Property Address: Road Name �"[►J��- `�� c U City/Zip �'�A��l�-L� If in a Subdivision provide information,as follo�vs: Namc: Section: Block: Lot: Datc home coruers ilagged: ��-fi �"� S�h.s Tl�is is to certity tl�at the information provided is correct to tlte best of my knowled�e. I understand ll�at aiiy pa•niit(s) issucd hcrcaftcr are subject to suspensioii or revocation,if thc site plaus or inte��dcd usc changc,or if thc information submitted in this application is faisified or chauged. I,also,tuiderstand tltat I am res��onsiGle jor nll clrarges iuc�u•rcrl.fi•nu� t/tis app/icutiar. I,l�ereby,give consent to tl�e Authorized Represeutative of the llavic Cou��ty Iie• lth lleparUucul to cuter upon abo��e described property located in Davie County and owned by - �1- to conduct all testing procedures as necessac•y to determine tl�e site suitabili DATE �� I �� I fl3 SIGNATURE `7�Sh,'i� � - THIS AREA ATAY B�USED FOR DRAWING YOUR SITE PLAN(Inclu f tl�c followiug: L. ' ' b and proposed property lines and dimensions, structures, setbacks, and septic locations). Sitc Revisit Cliac�e llatc(s): � Clicnt Notification llatc: �HS: Sign given Account No. ZZ�� Revised DCHll(OS/03 Iuvoice No. �� � / ✓ . • T � / /u/ ,� �C,�� � \LJ � . `• > APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER IT &ATC . ��� Davie County Health Department ` � � Environmental Health Section I� � � P.O. Box 848 � �'7� �� � Mocksville, NC 27028 ��'/� � ��� (704) 634-8760 �� �� ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed C18,�,�v/'�hG-S Contact Person �L�v/Yii.� �il��/S�.Y� Mailing Address l:��X/l� Home Phone City/State/Zip �i l�/h an�vvS � �t 2'74l 7 Business Phone �!�O'7��3 � 2. Name on PermiUATC if Different than Above�l �/�i���c�r� L li"l� Mailing Address ����.-�1 2R��1/1�'_ City/State/Zip �(,�,r����!U� �, Z 7aD 6 M 3. Application For: [ ] Site Evaluation [ ]Improvement Permit&ATC [ ] Both 4. System to Serve: [ )House [ ]Mobile Home [ ]Business [ J Industry [ ] Other 5. If Residence: #People #Bedrooms� #Bathrooms [ ]Dishwasher[ ]Gazbage Disposal [ ]Washing Machine [ ]BasementlPlumbing [ ]Basement/No Plumbing 6. If Business/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 [ J Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,what type? � PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ��L�r4 � �WRITE DIRECTIONS(from Mocksville)TO PROPERTI': . Tax Office PIN: #��- �J7 -'E'9� ; ,�r��� �� , �� � l � ; � r / Property Address: Road Name��ri�l��"l>OGI �/� � /�"'OY��✓i'ov� �/ City/Zip /��oliG�,s/�i�/v ; � If in Subdivision provide information,as follows: � � Name: � � � Section: Lot#: ; This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter aze 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 o conduct all testing procedures as necessary to determine the site suitability. 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L�. .-�'� �•, { �`Y� -�:r.v�M�,��i�v ,'v�x. t �'3� f� ��F tr r� �� }� � •� �'�"'�' `�,, j�n �G .;,+ ha;�es�(�e:'h . /. , t..►:� .,�.� **, �.. �`..�-,r.n . �.Y y J.. ' ���:t i .�3., �.j' . , t '� �`1'•f. . + � . � �Lrt1s+.q f�y '.1.} � � � �;�.• , � � . r � ,•�,�, ' " i �� . . ..• r� � ' � .-� 1 � � � r i r` �� � t yr s �. , � y : } 4 j9�i,���'�:l�ir 'l :A°�x�k`4'" ��'�' ��' .. �� � 4j� . •�... .. :vs. u4M �;�- . �'a v.�.YfK-tt�. . .�ri....,, C. �... .... , , ,, �.- � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001449 Tax PIN/EH#: 5841-77-7913 Billed To: Bob Furches Subdivision Info: Reference Name: Location/Address: Pinebrook Drive-27028 Proposed Facility: Property Size: 30 acres Date Evaluated: /� 6��� 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 � `' � " `' l " Texture rou /` Consistence Structure Mineralo HORIZON II DEPTH " " ` J�/ Texture rou C' Consistence , .' Structure L/ �� 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: OTHER(S)PRESENT: REMARKS: �(�,� '��=L� LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 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) . • .--. . , ..._ ,_.. ._�, . ...___ ,._. . . , Di��I� �f)U�I'I'Y�I�I.T�i g���tTh��N'T ^ : , : _ __ ENVIRONMENTAL HEALTH SECTION P. O. Box 848/210 Hospitai Street Courier #09-40-06 Mocksvllle, NC 27028 Phone #: {336)751-8760 October 24,2000 Bob Furches P.O. Box 115 Clemmons,N.C. 27012 Re: Site Evaluation/Pinebrook Drive Tax Office PIN: #5841-77-7913 Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 20, 2000. Based upon the information provided on the Application for Site Evaluation and a$er an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of a modified, oversized 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, �i�!�,t����. Robert B. Hall, Jr., R.S. 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