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224 Ralph Rd .' �• •' . +• _.�_ DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section r.o.Bog sasnio x�p���sr��t Mceksville,NC 27028 (33G)751-8760 Account #: 990001384 Tax PIN/EH#: 5769-33-3123 Billed To: Vicky Bullard Subdivision Info: Z2� Reference Name: Location/Address: Ralph Road-27028 Proposed Facility: Residence Properry Size: 7.35 acres ATC Number: 3245 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 a e Treatm and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT VA FOR A PERIOD OF FI YEARS. Environmental Health SpecialisYs Signature: Date: � �� Z S� ��p CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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. ,�p�p-rl�-1,��,.J� LnS� i/ 1 y �� 2y� �� D -� !O� �S � � � �S-ror1� ?o � r� . �' � ,vo r 1���,� °� + s,,,� �r►T Septic System Installed By: Environmental Health Specialist's Signature: ate: �7 L� DCHD OS/99(Revised) 'A� '. DAVIE COUNTY HEALTH DEPARTMENT ._. � .i. ' � Environmental Health Section Q� � Z3� ' _ P.O.Boa 848/210 Hospital Street _ , Mocksville,NC 27028 � ., (336)751-87C0 IMPROVEMENT/OPERATION PERMIT Account #: 990001384 Tax PIN/EH#: 5769-33-3123 Billed To: Vicky Bullard Subdivision Info: Reference Name: Location/Address: Raiph Road-27028 Proposed Facility: Residence Property Size: 7.35 acres ATC Number: 3245 **NOTE** This ImprovemendOperation 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 STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type Ne�sc. #People `� #Bedrooms � #Baths Z Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: � '�>. Commercial Specification: Facility Type #People #People/Shift #Seats . Industrial Waste:❑ Lot;Size <' ��'��""�T'ype Water Supply ��-�-- Design Wastewater Flow(GPD) ��� Site: New�Repair❑ � I�� - ,/ � System Specifications: Tank Size ��AL. Pump Tank GAL. Trench Width �o Rock Depth l 2-�� Linear Ft.'`�3�� ; �� ocher: � �I sT�i�3T10� F�x��S, j,n�s'i"e.t-�- (��n1�:s � �2�• C. j+-��r�• � Required Site Modifications/Conditions: �r�LL d^� C�7J � �� � �'+�% �=-t�=� �t � � U � I]VIPROVEII1ENT/OPERATION PERMI LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW i FINISHED GRADE. ****NOTICE: Co act a representative ofthe Davie County Health Department for final inspection ofthis ; system between 8:30 a.m.to 9:30 a.m.or 1: 0 p.m.to 1:30 p.m.on the day of'nstallation. Telephone#is(33C)751-87G0.**** � Af�eUx(c�O`Tt� �4'-�1�'� I �; - ; Ut„ �r . ' � � � � � .�t� � � �o, :� . !� � �Q �'� � �' �� � n n� � ��, ��t ' Z I O,� , � �1�.� . � �Z nvironmental Health Specialist's Signature: a : � DCHD OS/99(Revised) •' � • • �r, � � , APPLICATION FUR SITE EVALUATION/Ih1PROVEItiiENT P[R611T&ATC ,.� . -„ " Davie County Health Department ^ � Environmental Hea/th Section P.O. Box 848/210 Hospital Street �^"''� Mocksville, NC 27028 � � � a � � (336)751-8760 � r'�� ***IMPORTANT*** THIS APPLICATION C1�NNOT BE PROCESSED UNLESS ALL TH� I INFORMATION IS PROVIDED. Refer to the INFOR2�ITION BULLETIN for inst c ions. � p�TFI 1. rrame to be silled `' ` �NV��ONNIEN�� _Y (C_k � ������ `('`C1 Contact Porson ����F;�t�_-_"^��.: /�-- / ._,,..-..-,^",.' - Mailing Address �qL��1�� �{Q�� (.—�i�/�'�, Home Phone �' Ci ty/State/ZIP ��^�S(�1 �1�C. � � . Business Phone � ��� �P�� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip l�.� 3. Application FoLy�ti�Site Evaluation �rovement Permit/ATC CI Both � a. system to service: [�House p Mobile Home CI Business (=1 Industry ❑ Other . 5. Zf Rasidence: # People �� # Bedrooms 3 # Bathrooms �� �bishrrasher II Garbage Disposal �Washing Machine CI Basement/Plumbing fl Sas�ent/No Plumbing 6. If Dusiness/Industty/Other: Specify typo �k People # Sinks # Commodes !► Showers #f Urinals �i Water Coolers IF FOODSERVICE: � Seats Estimated Water Usage (gallons per day) 7. 2�pe of water supply; ❑ County/City l�Well ❑ Community , /� e. Do you anticipate additions or cxpansions of tl�c facility tl�is system is intended tu scrve? Cl Ycs ��io It'ycs,wliat typc? ***IMYORTANT***CLIENTS MUSTCONIPLBTCTHE REQUIRCD PRQPGRTY INFORMA'CION RLQUGS'fI;D I (3GL01V. Cithcr a PLAT or SITG PLAN MUST BESUBMI7TED by thc clicnt with TIIIS APPLICATION. .� 2 /� � Property Din�cnsions: �� J S �v �VRIT�DIRGGTIONS(from Mocic�vilic)to PKOPI:(i"1'1': Tax Officc PIN: # S ��o / � 3 J l Z3 (�� �l1 ;� Le-�� a n W�l��'`�' Property Address: Road IYamc !�� I,P �1 �q � , � ( ��� City/Zip_ / 'I DC IG1' [/ � ��t \ �� If in a Subdivision providc information,as follows: Namc: Scclian: 131ock: Lot: Datc Property rlagged: CJ �Q �� 'tliis is tn ccrtify that thc information providcd is corrcct to thc bcst of my lcnowlcdgc. 1 undcrst�nd tl�at any permit(s) issucd hercaftcr are subjcct to suspension or revocation,if t1�c sitc plans or intended usc cl�angc,or if tl�e inform:itiun submitted in this application is falsified or cl�angecl. I,a1.so,u�rderslruld t/rn!!ant rc��n�rsiGlefi�r n!/c/rarges incrrrrc�d jron� , 1/tis upplicatiar. (,hcrcby,givc conscnt to thc AutLoriud Rcprescntativc of thc Davic County Ffcaltl� Dcpartmcnl lo cntcr upon abovc dcscribcd property locatcd in Davic County and owned by �_^. to conduct all tcsting proccdures as ncccssary to dctcrminc tl�c silc suitabilit ` DA7'[: Z SICNATUR� . THIS A[iCA MAY B� USCD FOR DRAWING YOUR SIT�PLAN(Includc all of tl�c following: Cxisting and proposed property lincs and dimcnsions, structures, setbacks, And scptic locutions). Sitc Itcvisit Cl�argc Datc(s): � � . 6_� S v�� Clicnt Noti(ication D.itc: � � � CHS: � � �� Account No. I a � [ Revised DCH (07/99) �`�"�— Invoice No. ��� � �� .. . / �;t,r-e.�� , �71. hl I � � IV � � �' i U � � ' 5p3 t ; A89 , , , U, � � N 0 h �\ 1� e ) v� OA) �O�� (5.511A) � �4 � 9442 1 � ��Ay 3� � ��a 209 6^ t �� A Ol v� ` w`. = 2 _ �� R � � . � szo V � ,,� � �6408 � (310) �!� ��0-F�������� >>S 2 � ; �ryo �'�. _ - .. 1.00A 6139 7.35A g 3123 8 �38 � 467 � o _"""""- M � """""'_"", '�, 4Ai 88�, I , I 294 �24� � 676 q (29.64A) 2525 �.i :,, ; . .._. .. ' • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ,-. �. ' Soil/Site Evaluation + APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001384 Tax PIN/EH#: 5769-33-3123 Billed To: Vicky Bullard Subdivision Info: Reference Name: Location/Address: Ralph Road-27028 Proposed Facility: Residence Property Size: 7.35 acres Date Evaluated: Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo % HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEP'TH Texture rou Consistence � Structure Mineralo HORIZON III DEPTH Texture rou Consistence - SWcture ' Mineralo - � HORIZON IV DEP'TH m 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: 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz 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) „ • �� �� � � ,�� ' ;j , , H700000009 • � ��� °) ' � 7 � L�' � r�,, �., (1.20A) ,� ' / ,'� � 5840 ' 9442 � �� y � - .�.� _ .. 1h��s� T _ _ � � t .- - r- _ • : _ _ — ���'� a ,�:: -- - (1.60A) , � '°� saos J ; �.,�,r � , ,� , 4 . : �. __. �y ' - `. �-'� ... • .'.... \"���'._.. ', -. _.''. :'. ”.�... �.. .. . . .� - • _ . r. �T.* _ "_ _. . ." - - -� r . . � (17.97A) >fi . . _ - - : 7346 � - � ;, .: .. .. _ - �6 :: ��J (6.95 A) _ � .-. .. ,; , pY .�.:::.. . ,. . �, - - � 9301 "" M1 'r"'�� � . . � �. � _ �{� ' , _- - � 6139 (1290A) :. � -� t��= . - �2 A�� - - l r - n� �p� _ . . " 1 � 1: � - -. � . . '- .. . . .,,r � _ � . 1�8 �8 . . � � �59. . ... ;�:.. H700000009 ;; .e, � . ��:.. � • � . ,;#• 4A 8871 � 1z•, r Oo c�� Qs �� �_ ,� � Ry. ' (29.64A) '; ��; NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slighdy plastic P-Plastic VP-Very plastic t ct re SC-Single grain M-Massive CR-Crumb GR-Granulaz 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 . . ��....�. _ . " �F k �• � ' ' 1 '_ir � . . � . . �� T�avfe Coun ealth Z7e artment :� nl,7� � Envlronmental,�fealth Sectlon Po Eox s4s/slo xaspiral screet Mocksville,NC 27028 Pho� (336)751-8760 September 14,2000 Vicki Bullard 294 Split Creek Lane Mocksville,NC 27028 . Re: 2 Site Evaluations- 12.9 Acre Tract/Ralph Road Tax PIN#: 5769-33-9442 . v � Dear Ms. Bullard: As requested, a representative from this office visited the above site(s) on September 13, 2000. Based on the information provided on the Application for Site Evaluation and after the evaluations were completed, both sites were found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement � PermidAuthorization to Construct,the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions,you may contact our o�ce at(336)751-8760. Sincerel � � �� � Jeff G. Beauchamp, R.S. Environmental Health Section enc(s) . Q�-��--�3^� a . . �- • . APPLICATI�I FOR SRE EVAWATION/IMPftOVEMENT PERMtT&ATC [S � [� p�/ � '' e:! �` Davle County Heaith Department D Envr►ronn�r�ts/He�a/�fi Se�on p.o. Box 848/210 Eospital Straet au� 2 s 20�0 . Mocksville, NC 27028 . . (336)751-8760 . ***I?lPQR?AIQZ'�'�* Tfl28 APPLICATION CANNOT HE PROCE3SED UNI.L33 ALL TFiE REQVZRED INFORMATION I3 PROVIDED. Refar to the IN8'ORMATION BULI,ETIN for inatiructiona. 1. x.�.. to b. 9ill.a �j C��'�� �J��`�..,� ccntaot r.r,on V ►e��� 1�u��..�V lsailia4 1►�ddr��a ��1�l �C,��� reY'�,� 8oma phon� ���'�(� W�'c Q A+v��L. . � cs�/st.r../s:r �,�c�S v�, �t� llV G nu.�.., rhon. 2. Nw oa ?�rait/1►TC ir air!•srnt thu� 11bow Nailinq Addr��� City/Stab/zip 3. l►�rpliaation �or: Sit� Rvaluation D =mprovement Permit/ATC O Both a. sy.t�.a to s.rvio.: �ous• � Mobile Homa ❑ Huainass O =nduatry 0 Other s. z= R.�sicl�na�: f p�opl� _,,,�_ � Bedrooma �_, i Bathrooma �_ Di�hMaa�r Q Garbaq� Dilpo�al rB'Ka�hinq ltaohi�o U Sa��nt/BltsbiaQ O Has�s�nt/No Plvab 6. Z= Hu�in�s�/Zndu�try/Ot2��rt 8p�aity typ� � p�opl� � eink� • C000d�• i 8Aox�rs i Urinal• / Mat�s Cool�r• I! S'a0D8ERVICB: � S�ats Eatimated Water Dsaqo t�ioa• p.r a.y) �. Z�p� o! xater suppiy: O couaty/City �1 0 Co�ity e. Do yon aaHcipate addiHona or ezpaa�iona of t6e facility t6is system!a inteaded to aerve? O Yes 0 No If yes,what type? *�"IMPORTAN7'�**CLIENTS M(lST'C�OMPLETETHE REQUJRED PROPERTY INFORMATION REQUFSTED BELOW. Eit6er a PLAT or SITE PI.AN M!!ST BESUBMI7TED by the client with THIS APPLiCAT10N. P�operty Dimensiods:�nQO SCS 1., �[?k �f( � a(X.��p WR1TE DIRECfiONS(from Mocktville)fo PROPERTY: jCa$7JC 3/ O TA:Oftice PIN: # S�1 Li-�3 3 'CI`1 `1 � ��a �,�w h ls Y�i4�s�f - � "D i✓ � Property Address: Raad Name o��� ��\'��,o.� ��,,,?,ti r4?`?QR IC m� ' � �� City/ZIp wlot�,CS�,►�,� �.`7a1X l, � � h'� � V In s Subdivisioo provide lnformsH�,aa tdlawa: Name: Sectioo: Block: Lot: Ihte Property Flagged: �—���Csf� _T6b is to certify that the information provlded is cornct to t6e best of my knowledge. I anderstand t6at any permit(a) L�aed 6eresRer are anbject to=n�penaioa or revocsHon,if the site.plaas or intended oae change,or it the intormation snbmitted iu this sppllcation is falsttied or c6auged. I,also,anderstand lhat I am tesponsJb/e jor e//cbarg�s lncurr�d from Ibls app/Icatlon. I,6ereby,give consent to the Anthorized Representative of the Davie onnty H It6 Departmeat to enter npon above described property locsted in Davfe Conaty and awned by c:w e Y to conduct ail testing procednrea as neceasary to determine t6e site suitability. DATE SS' ,��' 27 SIGNATURE 1 � THI3 AREA MAY BE USED FOR�DRAWING YOIIR STTE PLAN(Inclnde All of the lollawing: EzisNng and propaeed property lines and dimenslons, atractnres, setbacks, and septic locations). Site Revisit C6arge Dste{s): � Client NotiticsHon Date: EHS: Acconat Na � �� Reviud DCHD(07/99) Invoice No. �a .• ` k � H700000009 � ✓ / � � ��� � �'" ,a" (1.20A) �¢�' � �3 5840 9442 � 1 e �.� � � 1�1 �a1�5� �� � � (i.60A) �e,� 6408 m,r °^� �,o� qa' (11.97A) 7346 �s (6.95 A) � 9301 � � 1A : 6139 (12.90A) 3442 a. ^ �� ^ �_. ' 1 ' l �c ' � : �� �a �5y� H700000009 , .�> � - '� � 4A 8871 Q �:., � ap� C��� �. QS'j � ! � �. (29.WA) .( t- � , + • - • � DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation APPLICANT INFORMATION , ; ; `' � PROPERTY INFORMATION Account #: 990001384 � Tax PIN/EH#: 5769-33-9442.02 Billed To: Vcky Bullard Subdivision Info: Reference Name: , Location/Address: 208 Ralph Road-2702 Proposed Facility: Residence PropeRy Size: see map Date Evaluated: � Ov Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut � FACTORS 1 2 3 4 5 6 7 Landsca e osition d Slo % _' HORIZON I DEPTH �=' ?� .—�p �-- Texture rou Consistence � �. — , Structure C(L Mineralo _ � , HORIZON II DEPTH ' �/� Texture rou � Consistence '� Strucfure Mineralo : 1 ` HORIZON III DEP"TH y� Texture rou � Consistence . ;-5 Structure - � Mineralo �: : � � HORIZON IV DEPTH t } , Texture rou � Consistence ' Structure Mineralo SOII.WETNESS : RESTRICTIVE HORIZON . SAPROLITE CLASSIFICATION -C " LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY. - � . l , LONG-TERM ACCEPTANCE RATE: �•� OTHER(S)PRESENT: REMARKS: �Lt'QIaJ�' �l.�k�-'�{��W� _ 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-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic � Mineraloav 1:1,2:1,Mixed Notes Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface 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Mockaville,NC 27028 Phon� (336)751�6760 t September 14,2000 Vicki Bullard 294 Split Creek Lane Mocksville,NC 27028 Re: 2 Site Evaluations- 12.9 Acre Tract/Ralph Road Tax PIN#: 5769-33-9442 � o � Dear Ms. Bullard: As requested,a representative from this office visited the above site(s) on September 13, 2000. Based on the infom�ation provided on the Application for Site Evaluation and after the evaluations were completed, both sites were found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Constivct, the appropriate application must be completed in full and submitted to this office. The location of the facility the system is to serve must be staked off. Ifyou have any questions,you may contact our office at(336)751-8760. Sincerel ' �� � JeffG. Beauchamp,RS. Environmental Health Section enc(s)