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468 Pineville Rdi DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002948 Tax PIN/EH #: 5843-46-1057 Billed To: Toni Wright Subdivision Info: Reference Name: Location/Address: Pineville Road -27028 Proposed Facility: Residence Property Size: 1.57 acres ATC Number: 3595 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 CON STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 16-1 7S 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. ST Septic System Installed By: - � -J�,o /Z Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT �� (o Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 7 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002948 Tax PIN/EH #: 5843-46-1057 Billed To: Toni Wright Subdivision Info: Reference Name: Location/Address: Pineville Road -27028 Proposed Facility: Residence Property Size: 1.57 acres ATC Number: 3595 **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 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 `7 #Bedrooms �� #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water SupplyDesign Wastewater Flow (GPD) Site: New 121" Repair ❑ System Specifications: Tank Size YaGAL. Pump TanV00 GAL. Trench Width<Z Rock Depth/ Linear Ft.� 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.**** .-5- Q Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) r TION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC • Q V Davie County Health Department Enlrironmental Health Section P.O. Box 848/210 Hospital Street OC� Mocksville, NC 27028 (336) 751-8760 ...atil.tlU'�1 APPLICATI OT BE SSED SS -ALL THE INFORMATT6NIS PROVIDED. ReferrNtoAthe INFORRMATION BULLETIN for instructions. 1. Name to be Billed -7 �1 LA) t - Mailing h� Mailing Address / O 5 O.Th Q_ r, City/State/ZIP �adk:,,J.?1C t c 7-7oS5 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: .'KSite Evaluation Contact Persoq ;3-e-, r,,, S ri "+k Home Phone Business Phone % O 4- g O Z- l T3 fO City/State/Zip 1R Improvement Permit/ATC X Both 4. System to Service: ❑ House Mobile Home ❑ Business �❑�IInndustry ❑ Other ,( 5. If Residence: # People # Bedrooms S- Akathrooms -4,_ U Dishwasher ❑ Garbage Disposal X Washing Machine U Basement/P-lumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City 9 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 REQUES'I'ED BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Properly Dimensions: /. WRITE DIRECTIONS (from Mocksville) to l'IZOI'I?R'1'1': Tax Office PIN: # S$4t-3 ''f 6- /OS7 E -`6 Ext 174 Property Address: Road Name p ., ev , He- 5. a r,, : t 2 t usr.., L City/zip N e - If in a Subdivision provide information, as follows: Name: Section: Block: Lot: t,,'Ile- Rd, o, t. s , te. o-% R. (/ � v►s1• Parsed 4 5 b P,'yeV Date Property Flagged:. This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. DATE __? Off' 03 SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EHS: f Account No. Revised DCIID (07/99) `r - �-d d . Jei�,, Q c. c. Invoice No. . SG r' —Oto —L U 0_J 1 1 : z. t. HI'1 I Y cL c, iSc r-aL L 1 1'1 1 1 I e!' Nvw xasaua evla oounay envhaal%h December 31,2002 JJb J.i'b 4jLL S98 761 *0818 NVIRONMEWAL HEALTH &F-enoN P. O. Box 948/210 Hospital Street -Courier #C&4Ge6 Mockwine, NC 27029 Phone M. '(330)751.8160 MichRcl Graae 301 N. Maim St, , Suite 100 Winston-Salem, NC 27101 Re: Site Evaluation/ Pineville Road Tax Qf$ee Piz : #5843-46-1057 Dear Client(s): m qrY ML L at.r in fitt%tt. As requested, a representative from this office visited the afor=emioned site an Dacemiber 34, 2002. Based upon the information provided on the Application for Site Evaluation and after a0 evaluation was completed on the site, tho sito was fb=d to be provieionslly suitable fox the instaUation of an on-site sewage system. Based on the location of the future home a pump may be required. 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, 1f you have any questionls, pleaso feel fm to coatact this office. 8iaceroly, Robert B. Fall, Jr., R8. Environmental Health Specialist Rw f P.2 Lli s IL4 � � a ix �� �► IK . LL ,�vb (2-a8A) 4 #Ay _ ,`" 5ll 93 :.1. •z , - FROST J __- - -- - � [.14♦ �Fd-..:.�..f :I H��kE�� _ :_s.� �tif�l�x=_r. - !' / }H'N W- w Im,lilr�.. - -,t: �r'��rG. y.�; �f' • Iirry :_ _ .L. �i� � . r: O 302; �"+�•�_ .,r_ •.`y'7.• a41:1'.: 79 act Hills _ �"I�{:ry:r•tCI:F-.v. 'sswr..yi,�. ' 239 (64$� iICiI�Ft3�� '. s3 HCS AND HOWE o �79 � (i .94A) LD CY CN 1972 co 5824 316 3878 LDLD i m 333 co210 CP M1 V- 1769► o ��3 7783 co mCGt-�RC� 33 rs CD 75 Qo IV 5883 u CD ca CD C) (1.25A) r- (256) 0 $5 1660 cv MCCARO v , e-�r, a APPLICANT INFORMATION Account #: 990002948 Billed To: Toni Wright Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5843-46-1057 Subdivision Info: Location/Address: Pineville Road -27028 1.57 acres Date Evaluated: Community Evaluation By: Auger Boring Pit Public 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 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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) I l ll � ��.� ��� � � e� ,,nc �,. � p ��.� �.����. � �� � � .. �� � � �f�t _ t\� .�'� � II ��'�.��. �, � ,�4�.�� � �, � ca 3_�-. 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"� '��.�. , . s,v� _ � ��^�_ � �� � �'_ . � . .. ���� �., .���. .. .. . . , ... . . . ,�, r� �:_�- . . . . . .�� . � < � m.� � t^ � � a`. �.. �� _ �4 � � g c m 4 �� � ��� ���� � ,i«� ��'�''� ���� � � �r a L � "5 � �i � �_" ; � �`� ��� � �� , � ��� ��� �� � �� ���� 3� x _ . � � 5044 � � , �. � , � ��, ` a � �C� � � ���§ � �� � � -� i a,'� � , �i �`.� »� � � �" � � s�'4 `�� _ '.�� �� _ � �a>x a �a rf Dec 02 02 04:56p davie county envhealth 336 751 8786 ' v APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department ��1 L` © C EnvfronmenW Health Section _ 3 �' P.O: Box 868/210 Hospital Street Mock (336) 751-87607028 k C() HE4CTH ***IMPORTANT*** THI3 APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED !Y INFORMATION IS PRROO'jVIDED./� Refer %too the INFORMATION BULLETIN for instructions. Name to be Billed )J/��/(,%���f'QI^� 1�(-04-0i 1 FJZ4tDContac Poreon Mailing Address �5N Al,/ U / /� ;. o 'V . �i,[.�.�a+ � O �n / _B�ome Phone City/State/ail W�/Os/s bone - n /i oU/� A,,Q /1. I Name on Permit/ATC if Different than Mailing Address _ -( amt - City/state/zip -'�3'. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both v4- system to service:-$q-kouse v Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: I People I Bedrooms # Bathrooms 2 utY"Dishwasher Il Garbage Disposal Lfl washing machine CJ Basement/Plumbing 0 Basement/No Plumbing S. if Business/Industry/Other: Specify type I People # sinks I Commodes # showers _ I urinals # water Coolers IF FOODSERVICE: ti Seats Estimated Water Usage (gallons per day) _-9Type of water supply: County/City ❑ Well ❑ Community .-e: Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes -❑ N - If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED LOW. Either a PLATvor/SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION. Property Dimensions: q� /`[yL�D 4Lt 1 to i, ,'7 J WRITE ,D/_WCfIONS (from Mocksville) to PROPERTY: TsrOfrice PIN: # 5 D '7 � ` 1pl 0-57 l -t � e ng rC2 rliltN �I Property Address: Road Name Bllyldt/'* X.11 tJCSol "� J city/zip a 262 If in a Subdivision provide information, as follows: Name: Section: Block: Lot: ► . ' .: fit, � :. � � � 1 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. 1, hereby, give consent to the Authorized Representative of the Da County County Health Department to enter upon above described property located in Davie County and owned byCto conduct all testing procedures as necessary to determine the site suitability. URATE j�'?,'U SIGNATURE L THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed lr, \ property lines and dimensions, structures, setbacks, and septic locations} l � Site Revisit Charge (,,, pp W l Datc(s): J'Client Notification Dale: u P�f EHS: Account No. Revised DCHD (07/99) Invoice No. � t f � � l q ?KI '5 179 CJF W 0 m a ' APPLICANT INFORMATION Account #: 990002525 Billed To: Michael Grace Reference Name: Doris Short Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5843-46-1057 Subdivision Info: Location/Address: Pineville Road -27028 Property Size: see map Date Evaluated: 621 -FF OZ Community Evaluation By: Auger Boring f Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 4Z. Slope % HORIZON I DEPTH Texture groupL Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure -s- 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 r SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: l REMARKS: EVALUATION BY: tez OTHER(S) PRESENT: 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) J DA A CQUN �IEAL'TH'DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone#: (336)751-8760 December 31,2002 Michael Grace 301 N. Main St. , Suite 100 Winston-Salem, NC 27101 Re: Site Evaluation/ Pineville Road Tax Office Pin : #5843-46-1057 3% Dear Client(s): As requested, a representative from this office visited the aforementioned site on December 30, 2002. 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. Based on the location of the future home a pump may be required. 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, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/df