529 Richie Rd � -c .W k.rs./-s.,,1r�C,a..-i:.I •*N`+":fw,r,.�tr... •4+.;'. :.s.. rfT.F�,�-4�9;y.-.� . .,,�:x ..t w•-.�"� ....y.. _r�;:ter :rti.`.rs+c .F.
AU *AT10N NO: 1902 DAVIE OUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION '
Permittee's P.O.Box 848
Name: �`"a—'�� ��--1 ���'� ocksville,NC 27028 Subdivision Name:
`` Phone# 336-751-8760
Directions to property.,' (.�1 N 1C� �--tom l Section: Lot:
r r AUTHORIZATION FOR {C
F 1 t\f ft�:..y)C . ' i` Il. U'j WASTEWATER Ta Z�e PIN:#
—7 SYSTEM CONSTRUCTION r^�
Road Name: Zip:' - ! C?
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building.Permits:
(In compliance(with Article 1 I ofC, S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
hq—
ENV1Rd?-19E-N-T-A1 HEALTH S`PECI 'IST✓ DATE ISS ED
-;w,.„�— ..-.-. .a.wp.. ., -. ,if, p -r v;�,..+.,.. .,, '..:.+ k,, hJ "rk. •� _ ...., ...,..y �,. � ..�,,....-y
9.Q 2 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTs AND OPERATION PERMITS
PROPERTY INFORMATION
Fermltteess
t '.L:lM1Gt.;.. 1 Subdivision Name:
Dlrection�Ioproperty. Section: Lot:
IMPROVEMENT
TaxfceNPERMIT ` `1 _ 5. r
t Road Name �� r,L? Zip: "
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCITON 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-GS.Chapter 130A,Wastewater Systems,Section,1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRdItMENTAI ACTH SPECIALIST DATE SYSTEM CONTRACTOR MUST SEE TINS PERMIT BEFORE
INSTALLING THE SYSTEM.:
RESIDENTIAL SPECIFICATION:BUILDING ,
U LDING TYPE �#BEDROOMS � #BATHS 2 #OCCUPANTS GARBAGE DISPOSAL:Yes orc.—)
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE '2, A /
TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) NEW SITE � REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH JrZ7 LINEAR FT.3CJ:'
OTHERTK-1fJl�Tl�� �bGixl:�, AM-0061)
REQUIRED SITE MODIFICATIONS/CONDITIONS: SY�L-`^ o� C D j 1 Off, �^�� ' ��OJSt t ! I,�G� 7� �(�0M.
IMPROVEMENT PERMIT LAYOUT X 2I S eaS tAQc T
-�� � ,� �-r,,, ,�1� �S [�2�A►L�- err!
CP
►-� VS� 9G.
R4c+-II 2p
3
M1
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION,TELEPHONE#IS (336)751-8760.
OPERATION PERMIT �y/^,
SYSTEM INSTALLED BY: 1� 1�- 1
'X 12"
140
AUTHORIZATION NO. 902 OPERATION PERMIT BY DATE: �I
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT STEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
I CIO
CP
WITH ARTICLE I I 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.
DCHD 05/96(Revised)
APPLICATION FOR ENT PERMIT
Davie County Health Department
D U
Envim menia/Hea/tfi SftWon
� rr P.O. Box 848/210 Hospital Street JAN 1 21999
�9 Mockaville, NC 27028
(336)751-8760
ENVIRONMENTAL HEALTH
***ZHP0RrAIVT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS AL Q
INFORMATION IS .PROVIDED. / Refer /oto the INFO�R/�d/ATION BULLETIN for instructions.
1. Name to be Billed /�jnu,Qo�g,E/jAm� 1X�'i4(-11,/AmD -A f Contact Person --5CAm'e,
Mailing Address 3q0 s of it lc1 -�y o �c'i Boma Phone q S_g07o1
city/state/ZIP j I iD .- 1 V C" 09704 'J Business Phone
Z. Name on Permit/ATC if Different than Above O kn
Mailing Address M /�/[�i•Q /��Q� City/State/zip Aal)Sca&_ Nc- ':� 20 Dq
3. Application For: U Site `valuation rovement Permit/ATC 0 Both
4. system to service: House 0 Mobile Home 0 Business 0 Industry 0 Other
S. If Residence: # People �_ # Bedrooms # Bathrooms
8'Dishwasher 0 Garbage Disposal D-Washing Nachine 0 Basement/Plumbing 0 Basement/No Plumbing
S. If Business/Industry/Other: Specify type # People # sinks
# Commodes # Showers # Urinals # dater Coolers
IF FOODSERVICE: 11 Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 0 County/City Zel 0 community
S. Do you anticipate additions or expansions of the facility this system is intended to serve! 0 Yes 014-0
U, yes,what type'
""IMPORTANT•"CLIENTS AIUST COAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED.
i BELOW. Either a PLAT or SITE PIAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /Q,55 Oe- —ackez DIRECTIONS(from Mocksvilb)to PROPERTY:
Tax Office PIN: # / — �( 000 � 1 `I�'"� ��CZ-7
Property Address: Road Name ?r&" i-Nc& (9m ` l
City/Zip amlo 1Vc,,;)7W9 0
AA
If in a Subdivision provide information,as follows: 6,�
Name:
Section: Block: Lot: Date Property Flagged:
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
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 Ion responsible for all charges incurred from
this application. 1,hereby,give consent to the Authorized Representative of the Da a Coonealth epartment
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site ilit3
DATE—/ —// —q9 SIGNATURE
4
THIS AREA MAY BE USED FOR DitAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property fines and dimensions, structures, setbacks, and septic locations).
Account No. 33q
Revised DCHD(07/98) Invoice No. Z-20_
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department SSG Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By �V r 1`�1 I I /Vl LoWA 1
Mailing Address LIL;� M YY0 Q✓C- % C- ( q 1 Ci ? G 19n( ' �.S , A�C 7/U
Home Phone_ "/w - Z& b - 8 3 1 7 Business Phone _ -71Q- 7,1(e - Si.6
2. Name on Permit if Different than Above 64 61-P
3. Application/Permit for: ❑ General Evaluation 09-Zeptic Tank Installation
4. System to Serve: M40use ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No. of People L- ❑ Basement/No Plumbing
No. of Bedrooms 3 O -Washing Machine
No. of Bathrooms /Z 2Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
u1r Z CC, 1 G r a4��
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No.of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No.of Showers Water Usage Figures
7. Type of water supply: ❑ Public VPrivate We i L ❑ Community
8. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes BIN'o
If yes, what type?
`NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
This is to certify that the information provided is coV=SIG40URE
I understand I am responsible for all charges
incurred fr this application.
� 3v -9�
DATE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: b 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2,the rest of this form MUST be completed by the owner or a person authorized by the owner:
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 said site's suitability for a ground absorption sewage treatment
If
disposal system.
DATE SIGNATURE
DCHD(12-90)
' DAVIE COUNTY HEALTH DEPARTMENT
{ Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED ,7 �' y
ADDRESS PROPERTY SIZE 47
PROPOSED FACIILTY �%/r�° LOCATION OF SITE /C"'.X�,'r
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Sloe Z 2 IV
HORIZON I DEPTH £7 Q'
Texture group Sl
Consistence
Structure
MineralogX
HORIZON II DEPTH $'' J
Texture group
Consistence r
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: J"� EVALUATED BY: ,��Q�lj
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
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(01-901
■■■■■■■■■■.■■..�:,■■..■.■■■■■■■■■■■■■■.iiia!■■..........■■ ■■■...■
■■■■■..■....//■■■.■...■■■..■■■■■■..N..■..■■r.\/■......■■...ail■�i■
■■■■■■■■■win■■■■■■■■■■■■■■■■!.w■�i■■■■■■■■■■■■■■■■...■■■■■■■■■..■■
sommomom MENNEN i
■■■■■■■/■■■■■■■■/■■■■/./■■■//■■/■■//■■■■■�■■■■.■■■■■■■■■■■■■■■i�i■■
■../■..■■.■..................■/■/...■■/....//■/■//.■./■■/■■■/■■■■■
■■.■■..■■■!..■■.■■...■■■■■■...■■■■■■■■■...■.....■■■.......■...�■■■
■■......■■....■.....■..■■.■■■■O■�l�]rl/�s/Jam■ ■■/.//aa.aa......i.a.■
MEMO
■..■N..■■■■...■H/■■■aa.■m..m.■■■..mann■■■/■...■///m�11■/■■■mama.■
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii■'�iiiiiii�iiii=iii i.iiiiiNo
�iiME iiUiiiiiiUiiiiiiiiiiiii�iiiiii�iiiiiii�ii''■iii�iii'iii�
...................................... . ....... .O.■...■■■■/■..■
...................................... ........ . ..............
........................■■aaa..7�q■!G/�.■.a H m■ ■ .. ■■■a■■
.1 ..//�.■Q.�e�:::::1■m■■■!/�immY/� :�..a`I�■����iii� .....�.■..■ Oman
■��%///..1t■■■■■■n.a■■.■■■■■..■■■■■■■����m■ i.! ./ME:'J'E■J■ ■
■.■/aa■■■■■■■..■■■.■.■H■/■■..■■■■■ .mamma/■��■ ■■■■■..��■a■.■�■
■■a.../■■as..////■/a/aa■■■■■aa..■■■■■■■..■ .■ ■ ■..■■ H.■//■/
...................................:�.::�:�:::' =:5:R::�nommommm
:::::::::::::::::5::::::::::::::.::••�::•'S' mommmo::mm
■■■■■■■MEMEMON0
MOMMEMM /.■Man■■■■■■■■ ■■.■■■■■■■■■■■■�■H■�■ ■■MOMm ■m■mm■■■ ■MEMMEMEMORMMUMMEMOMMEm■/■
......................................=...s�� am
■■■■CC■■.■=■■■■■■m■■■
■.■■■a.■■mmm■.■.■■....■.■.■■■■.!■■■■N mom ■m■mOa■■aa. ■!.NIsom
NONE
■■a.m.■...■■/.■■■a.aa.aa.■■■■■.a ■■■aaa. ..■..■■.mmm./.■.aa■masa■
■■■■■aa.■.Na..mlaaaaa■■■■■!.■■mala.■■■■■ N.a.N..na...a.an■laa.■
■.../.■■a..m■■mm■■/■■aa■/.ilii lirf/.L/C%■mmm...■■■■■■.../■■.■m.Ha..■■a.
................................ ■O■mamma■■■■■MAN■■■■O■■■!■■■■aa■
..................................................................
..................................................................
■n.■ ........................... ■.■...■aa.■..a■.■aa.■.■■..N■■■■
Davie County .�lealtfr De artment
and .1�ome �ealtFi .. yency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE,N,C. 27028
PHONE:(704)634.5985
July 7, 1994
John Klimkowski
4825 Commercial Plaza 9—A
Winston—Salem, NC 27104
Re: Site Evaluation
Ritchie Road
Dear Mr. Klimkowski:
As requested, a representative from this office visited the aforementioned
site on July 1, 1994. Based upon the information provided on the application
for a site evaluation and after the evaluation was completed, the site was
found to be provisionally suitable for the installation of an on—site sewage
disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure