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206 Rhynehardt Rd � DAVIE COUNTY ENVIRONMENTAL HEALTH :'^ ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � � (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004413 Tax PIN/EH#: 5852-38-3180 Billed To: Kenneth Hayes Subdivision Info: � Reference Name: Location/Addre'ss: Rhynehardt Road-27028 Proposed Facility: Residence Property Size: ;��acres � ��ti��h'� ATC Number: 4750 � **NOTE**The issuarice of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T.Manufacturer Dt� Tank Date /" � ize t�� Pump Tank Size ��I t�� � ,_ System Installed By:��"1'�LW� l�EJ""" E. p 1 ��I���� H.S ecialist: ate: /rt/�!'"'� Z��o�''Y � °� � � � �� , �z� , . � r- s�-� , . - '�"� � �'L � v�T � G� h � N 31 _ ��� . 3� ��,�.� j�'8' � z �� � � ; �4�, Q �� G1a��-�.Q,g j`� + ' Z� p � ' � � �� ��� � � 'Ft��.� v—� . 1 G '.' DCHD 11/06(Revised) . o DAVIE COUNTY ENVIRONMENTAL HEALTH ^ `• y y �-y P.O.Box 848/210 Hospital Street ��d \�� Mocksville,NC 27028 ' (336)751-8760 Fax#(336)751-8786 1�\� I AUTIiORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004413 Tax PIN/EH#: 5852-38-3180 Billed To: Kenneth Hayes Subdivision Info: Reference Name: _ Location/Address: Rhynehardt Road-27028 Proposed Facility: Residence Property Size: ,� 5�'`acres . i ` ATC Number: 4750 Site Type: I�Tew ❑Repair ❑Expansion **NOTE**This Authorization to Conshuct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S.Chapter 130A � Wastewater Systems,Section.1900�Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. � � Residential Specifications: #Bedrooms-3 #Bathrooms2•� #People�Basement� Basement plumbing� Non-Residential Specifications: Facility Type �#People #Seats Square Footage(or Dimensions of Facility) ;�,. Lot Size � �R`t'� Type of Water Supply��unty/City ❑Well ❑Community Well � � System Specifications: Design Wastewater Flow(GPD)� Tank Size ��G�OGAL.Ptunp Tank ��GAL. � M ,� t Trench Width� Max.Trench Depth'� Rock Depth '1Z Linear Ft. �'� Site Modifications/Conditions/Oth : ��r15"fa � Q � � � r �. l� - MArJ ` oL� ,ti1.,,}0 Contact the Davie County Environmental Health.Section for final inspection of this system between � 8c30=9:30a.m.on the da of installation. Tele hone# 33 751=8760. j � . ��.. , As stated in 15A NCAC 18�i:i�E�d6) ' � a�c9piad Systems m$y als� b�'usFirl �� . ^� `�j q � � �� � , J � � � � � . . ` . �- � ���. -�� � =rizi:-Sr�� M�N j. �b� � r�P z ��M,.1t�u.� �x '�� � '��►G � \�j��K �Q��� �o v�/��r� - , ��o` � �-1�►��T � Environmental Health Specialist . t�' . DCHD 11/06(Revised) �� 6� ( . . � •^- w '{ •_ . "t � . :�; O SITE EVALUATION/IMPROVEMENT PERMIT & A � .�0�� Davie County Environmental Health Q 1 '3 P.O.Box 848/210 Hospital Street . \ A�G Mocksville,�TC 27028 ���.�c�,��'�'�� (336)751-8760/Fax(33�751-8786 � `��GpvNT1' . Ap ication F� 'valuation/Improvement Permit C]Authorization To Construct(ATC) �Both Type of Ap ' �ion: 63New System ❑Repair to Existing System DExpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � Name to be Billed ��,�,��2� ���(�.C,S' Contact Person Billing Address�t�,�/ s v�7u,,z� jP Home Phone 1,���=�"I3—c� 71�'� City/State/ZIP �u�l P� r .,;�./�_ �X`�G,S`"' Business Phone � Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged � ��0 7 NOTE: A survey plat or site plan must accompany this application. Included: �Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) - Owner's Name /�c�i rJ�.Z� �� c� Phone Number�?,�'�-G�t"�j�,i}9� Owner's Address ,�(f/�L y,��,�,rZ �ci/ City/State/Zip ,���,�,�� ,��f�'�,,./�c.�' Property Address���,���� �� City�c�3,,,,�.� Lot Size,tj,o,�� / �q��...� Tax PIN#�'S'3',�,��'3/g0 Subdivision Name(if applicable) Section/Lot# Directions To Site: ,,,d�r' �a/ ��,-�,�y ,��„>, ,� ��.?,,,� / ,��f� ��,.•��it,�% ��'= •f�c+�— �,��P,:�►,�,�► r��- .�� ' Tv �f� vve —�.�..r�rZ�-r a�-, ,��, If the answer to any of the following questions is"yes",supporting doc mentatio must be attached. Are there any existing wastewater systems on the site? ❑Yes�No ' Does the site contain jurisdictional wetlands? ❑Yes �'No Are there any easements or right-of-ways on the site? ❑Yes �No Is the site subject to approval by another public agency? ❑Yes 6d'No Will wastewater other than domestic sewage be generated?_.;_. ❑Yes D�No ir RES�B�I`TCL FIL;OUT THF BOX BELOW #People � #Bedrooms �_ #Bathrooms� Garden Tub/Whirlpool ❑Yes �3No Basement: ❑ es �No Basement Plumbing: ❑Yes j�No _ IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Typesystemrequested; 6�onventional ❑Accepted ❑Innovative ❑Alternative �Other . Water Supply Type: [�County/City Water ❑ New Well ❑Existing Well ❑ Community Well � Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my lmowledge. I understand that any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County tiealth Department to conduct necessary inspections to determine compliance with appiicable laws and rules.� I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the Iocation of any other amenities. �� .� / ,��y-�/.-�,��'-r�i°',r�'� Site Revisit Charge Property owner's or owner's 1a.�a�l represeniative signature � <`" Date(s): ���� _ � r, f' , _ 7 Client Notification Date: _ Date �'" 3 EHS: � r.� ,. °�. ��� Sign given UYes ❑No + R ` Account# ��r�r/� Revised 11/06 `� . Invoice# _��� .4 ; ���I �� ��� ��i f + �I� �_. � � . 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Tax PIN/EH#: 5852-38-3180 -' Billed To: Kenneth Hayes Subdivision Info: , Reference Name: Location/Address: Rheinhart Road-270 8 � Proposed Facility: Residence Property Size: 1 acre Date Evaluated: � ���� 9 IL�I�� � �.....�., , ,\ : . , .` � ,� Wa er Supply: On-Site Well Community Public �� � 7 Evaluation By: Auger Boring Pit Cut '�_ ; FACTORS 1 2 3 4 5 6 7 ,� Landsca e osition (� � L. �. L Slope% � Z ;,� � HORIZQN I DEPTH f p � 6---' ��- p- 4,-_ 1 p-�`7 �j � Texture- cfu �. ;, ' �� GL � ; Consisience � .1 . ('.:� S < < � Structure : - . � Mineralo : : � �t,� HORIZON II DEPTH ' �. .►- _ � ., � f 7,. �' Texture rou : ' - C �- L/ �# �.� � , Consistence `` � _ J ��S �C, � Structure M 11^ ,r„� , Mineralo � ,, � HORIZON III DEPTH �. 3 � �f . 2$ 3 5• Texture iou 5„� Sce, ,�' Consistence = ,r- �, � � Structure - (� � Mineralo �� �`'� HORIZON IV DEPTH - � ;..Texture rou E+j �C Btc Consistence . Structure Mineralo SOIL WETNESS � - 2 ._ � � RESTRICTNE HORIZON - /'7 � " , `- SAPROLITE - .— L/ .t� ,�CLASSIFICATI(3N.:. US � LONG-TERM ACCEPTANCE RATE . - SITE CLASSIFICATION:_ � ) EVALUATION BY: � LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: � REMARKS: - . . LEGEND . i,andsca,pe 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 , T�xLurs . 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-Silry clay C-Clay CONSISTF.NCF, �15� �'�'. VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky � VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic � ,�.�I31G�i1Lg 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 lYQie� . Horizon depth-In inches ' �_.. 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■���■��■�������■��■����1/���■�■�■�■■�e�������0�������������������■ ■��������������■�������fi����■��■ ■�������������■�■����■■�����■��■ ■�����■■�■■�������■s���i������■■�����■■���■��■■�■���■�■���������■■ ■����■■��■■����o■�������■■������oe�����■�■��■■�■��s�■���■����■��■■ DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P.O. Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760/Fax: (336)751-8786 August 28,2007 Kenneth Hayes 4611 Summit Road Purlear,NC 28665 Re: Site Evaluation 1 Acre Tract/Rhynehardt Road Tax PIN: 5852383180 Deaz Client(s): As requested,Jeff Beauchamp,Environmental Health Specialist with this office on August 27,2007 evaluated the above-referenced property at the site(s)designated on the pladsite plan that accompanied your improvement permit application(s). The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General , � Statute 130A-333 and related statutes and Title 15A, Subchapter 18A,of the North Carolina . Administrative Code,Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A;of the North Carolina Administrative i Code,Rules .1940 through.1948,the evaluation indicated that the site is UNSLTITABLE for a ground absorption sewage system. Therefore,your request for an improvement permit is DENIED. The site is unsuitable based on the following: Rule.1941 Soil Characteristics,and Rule.1942 Soil Wetness Conditions. These severe soil or site limitations could cause premature system failure,leading to the discharge of untreated sewage on the ground surface,in surface waters,directly into ground water or inside your structure. The sife evaluation included consideration of possible site modifications,and modified, innovative or�alternative systems. However,this office has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system � , designed to dispose of sewage to another area of suitable soil or off-site to additional properiy. For the reasons set out above,the property is currently classified UNSUITABLE,and an � improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVISIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SIJTTABLE. � You have a right to an informal review of this decision. You may request an informal review : by the environmental health supervisor with this office. You may also request an informal review by the N.C.Department of Environmental and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, Environmental Health Section. ' You also have a right to a formal appeal of this decision. To pursue a formal appeal,you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center,Raleigh,N.C.27699-6714. To get a copy of a petition form,you may write the Office of Administrative Hearings or call the office at(919)733-0926 or from the OAH website at www.ncoah.com/forms.shtml. The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150-B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g)provides that your hearing would be held in the county where your property is located. . Please note: If you wish to pursue a formal appeal,you must file the petition form with the ' Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is August 28,2007. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law(N.C. General Statute 150B-23)to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel,N.C.Department of Environment and Natural Resources, 1601 Mail Service Center,Raleigh,N.C.27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel,NCDENR. Please call or write this office if you have any questions or need any additional assistance, as follows: Telephone number: (336)751-8760 Davie County Health Department � Environmental Health Section P.O.Box 848 Mocksville,NC 27028 Sincerely Jeff Beauchamp,R.S. Environmental Health Specialist Enclosure(s):Rule .1948 Invoice , ,- • . LAWS AND RULES FOR SEWAGE TREATMENT AND DISPOSAL SYSTEMS 15A NCAC 18A.1900 Rule .1948 .1948 SITE CLASSIFICATION (a) Sites classified as SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules. A suitable classification generally indicates soil and site conditions favorable for the operation of a ground absorption sewage treatment and disposal system or have slight limitations that are readily overcome by proper design and installation. (b) Sites classified as PROVISIONALLY SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules but have moderate limitations. Sites classified Provisionally Suitable require some modifications and careful ' planning,design,and installation in order for a ground absorption sewage treatrnent and disposal system to function satisfactorily. (c) Sites classified iJNSiJITABLE have severe limitations for the installation and use of a properly functioning ground absorption sewage treatment and disposal system. An improvement permit shall not be issued for a site which is classified as UNSUITABLE. However,where a site is UNSUTTABLE,it may be reclassified PROVISIONALLY SUITABLE if a special investigation indicates that a modified or alternative system can be installed in accordance with Rules .1956 or.1957 or this Section. (d) A site classified as iJNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956 or.1957 of this Section or a system approved under Rule .1969 if written documentation,including engineering, hydrogeologic,geologic or soil studies,indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SiJTTABLE if the local health deparhnent determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent will be non-pathogenic, non-infectious,non-toxic,and non-hazardous; , (2) the effluent will not contaminate groundwater or surface water; and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people,animals,or vectors. The State shall review the substantiating data if requested by the local health department. History Note: Authority G.S. 130A-335(e); Eff.July 1 1982 Amended Eff.April 1, 1993; January 1, 1990. r " DAVIE COUNTY HEALTH DEPARTMENT � - Environmentai Health Section ' Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION �� -��in`o� Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring Pit � Cut � FACTORS 1 2 3 4 5 6 7 ' Landsca e sition C ��. L Slo % /O 2� HORIZON I DEPTH O- (�-- D- o �� Texture rou � Consistence Structure � Mineralo � HORIZON II DEPTH 3 -�f� �(� '3 Texture rou S ►- G�- �-F_ Ca Consistence � Structure � Mineralo - � HORIZON III DEPTH � -S l -�S -7 Texture rou f�-� •�' SC_L Consistence� . ;�S ' Structure 1`�` Mineralo '7C HORIZON IV DEPTH -7 Texture rou S.. Sc.L Consistence -r' SD `Structure C� Mineralo �. SOIL WETNESS � �"-' — - '— RESTRICTIVE HORIZON '1 3 �•?�31 /-S . , ,: SAPROLITE . . � _ � „ � S � CLASSIFICATION J LONG-TERM ACCEPTANCE RATE D. o• o-Z2?" 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' y � i ( .iQ - _ �4i 3' �=. .;i� O / , ��.-J .' , ��5 �ri� ,. ?JS' l .- � . ...� :.,t � �'�� , o I .. n i:? I -._ ' -_— � I ,rc S.i . l� �5q� <, _ y 1 � � - - 314.01R II c, ��. .. ,cs '� � . http: �maps.c��.�Itn�ic.nc.us��Go�\1a�ismap print.clin?CFIU 11-41&CPI�OI�I_A 6�3;SUh: ') 1O'_'OQ7 Davie County Environmental Health � . , � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 . (336)751-8760/Faz(336)751-8786 IMPROVEMENT PERMIT Account #: 990004413 Tax PIN/EH#: 5852-38-3180 Billed To: Kenneth Hayes Subdivision Info: Address: 4611 Summit Road Location/Address: Rhynehardt Road-27028 City: Purlear Property Size: 50 acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Pernut DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Pemut Type: ew ORepair ❑Expansion Pernut Valid for: 5 Years ONo Expirarion ` � Residential Specifications: #Bedrooms c� #Bathrooms�'� #People � Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): c�� Type of Water Supply�ounty/City ❑Well ❑Community Well Site Modificarions/Permit Conditions: � S stem T e LTAR Inirial M e�Ti o• Re air . ' Z Site Plan 7y+� 4s st�ted In �5A NCAC 1SA.1963(5) �ccepted Systems may also bQ used �—� �� .... _, . ��`�� ��. � � � �� � .�� �J � �, ��.+�� � o' �'io' N Environmental Health Specialist - a i.p.l l-06 �� � 1 ... ii. Davie County Health Department Environmental Health Section Payment�ue Now. PO Box 848 (210 Hospital Street) P/ease Refurn a Copy of fhe BiU wifh Payment. MoCksville, NC 27028 Your Check is Your Receipt. (336)751-8760� Kenneth Hayes Account No: 990004413 4611 Summit Road Invoice No: 6227 Purlear, NC 28665 Billing Date: 9/14/2007 Srv Date Service Code ID/f1TC# Description Srv Cost Quan. Extended Cost 9/10/2007 SITE EVAL-PS Rhynehardt Road-27028 $150.00 1 . $150.00 9/11/2007 SEPTIC-NEW-R 4750 Rhynehardt Road-27028 . $150.00 1 $150.00 Balance Due Now: $300.00