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318 Rollingwood Drive Lot 9. Section 3' DAME COUNTY HEALTH DEPARTMENT FW • Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001871 Tax PIN/EH M 5747-26-5463 Billed To: Scott Matthews Subdivision Info: Southwood Acres Sec 3 Lot # 9 Reference Name: Location/Address: Rollingwood Drive -27028 Proposed Facility: Residence Property Size: see map ATC Number: 2946 319 Rollmn wood bP,, **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 S #Bedrooms #Baths .Z1 Dishwasher Garbage Disposal -;2-*, Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow (GPD) <7�? Site: NewrO-- Repair ❑ System Specifications: Tank Size,/ GAL. Pump Tank GAL. Trench Width Rock Depth L� Linear Ft,&V' Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contac aZreprresentative 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. toed a of installation. Telephone # is (336)751-8760.**** 010) �A e Environmental Health Specialist's Signature: % VDate: �U -U DCHD 05/99 (Revised) a _ 7 4 5 ' © Account #: 990001871 Billed To: Scott Matthews Reference Name: Proposed Facility: Residence ATC Number: 2946 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5747-26-5463 Subdivision Info: Southwood Acres Sec 3 Lot # 9 Location/Address: Rollingwood Drive -27028 Property Size: see map 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 WASTEWAT ONSTRUCTION IS VALID FA A ERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: 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. e/-7 . �v L Septic System Installed By: 6 I= w Environmental Health Specialist's Signature :n/J/%�� Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �---'—'--'n"n- Davie County Health Department u Environmental Health Section P.O. Box 848/210 Hospital Street (� Mocksville, NC 27028 AUG 1 G 620 (336)751-8760 s **)k`ZMP(j2L' V-4HTHIS APPLICATION CANNOT BE PROCESSED UNLESS ALL •THE REQUIRED —INFO" ED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed SrGM Contact Person G � n Mailing Address ! f p 21mAII I ,� �(/ � n / Home Phone 75,1-3111 City/State/ZIP _AJ�nt• ,I l t- Iy l 22 Ot Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Q Site Evaluation rovement Permit/ATC ❑ Both 4. System to Service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People .J� # Bedrooms _ # Bathrooms r4 -Dishwasher WcY��bags Disposal Li Washing Machine L7 Basement/Plumbing 1"I Basement/No Plumbing 6. If Business/Industry/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 ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R-Nv If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESUBMITTED by the client with THIS APPLICATION. Property Dimensions:— --w—�— // Tax Office PIN: # Property Address: Road Name Poll, City/Zip aell! sol c If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 64 Sw-lq rue, kcmr �/C o►�1 C.+ 1A C If _ O d //'/ e 2w1 -/r Name: & nTl to -A ACA C� Section: 3 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 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 the Authorized Representative of the Davie County Health Department sated in Davie County and owned by try to determine the site suitability. SIGNATURE_ Ieee� LING YOUR SITE PLAN (Include all of the following: Existing and proposed setbacks, and septic locations). LSI Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. 10911 Invoice No. 7� ! �� \ ''�-_~ �� ~_''� I/+--^ '' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM Davie County Health Department Environmental Health Section P. O. Box 665 I Mocksville, NC 27028 1. Application/Permit Requested By TRL a Mailing Address to 5 M L50V15 JUL 3 p 1996 Home Phone � -3 4 - 3119 r -r -s k/ 1 ( ( e2 of 0'R Business Phone 2. Name on Permit if Different than Above 3. Application for: 14 General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: g House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry I ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision, �f] � tu) n n A N ? C e S Section �_ Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 4 B -Washing Machine No. of Bathrooms 3 0 -Dishwasher Dwelling Dimensions 2 -Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: '14 Public - ❑. Private ❑ Community 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ® No If yes, what type? 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERT.11 INFORMATION REQUIRED: ``rr Directions to Property: Tax Office PIN: 6PCMIO�D� O �,000a �r10D PROPERTY ADDRESS, as follows( i 1 Road Name: D woos[ ,, City:Mce 2-7629 SU$MZT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. This is to certify that the information provided is correct to the incurred from is application. - "S(2 - g� DATE my knowledge, and I understand jAm responsible for all charges SIG CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. )Z 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 representativ f the Davie County He Ith Depart n to enter upon above described property located in Davie County and owned by ct e.r- to conduct all testing procedures as necessary to determine aid site's suitability for a grou absorption sewage treatment and disposal system. LUI.f 21.t -Cc J 41 -aA-D p DATE SIGNAT E Oy�it> DCHD (1/93) I DAVIE COUNTY HEALTH DEPARTMENT y - Environmental Health Section Soil/Site Evaluation NAME U% DATE EVALUATED ADDRESS PROPERTY SIZE --�- PROPOSED FACIILTY ,,G1S>1 LOCATION OF SITE7iy%li✓tt7/✓ �y� Water Supply: On -Site Well _ Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 Landscape position .C. 2_ Sloe Z —� HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group, Consistence r- l Structure S >.f 574- 74-Mineralo 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: DCHD(01-901 EVALUATED 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 :lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V, ---y 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 3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralotty 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 ■■��■��■�■■��■��■ ■��i V��■■ ■�■��_��■■N��■�n\�� _�� ■■��■ ��■ ■�■�■■■■��■ ��A�� r�■ ■��■�■��■ ■��■��■��\��■��■��■�■ ■��■��■��■��■�� ■��\��■��■ ■■��■�■■��■��■��■��■��■��■�■ ■�■■��■■��■��■��■■��■ .....�.....................................�........ ............. .......................................... ........ ............. ..........................................■...■...._ .■........... ............................�...�................. .............. ................................ ..............._................ ...........................C.................■.'. .._...._........ ........................... ................... .... .... ........ ■��■\��■��■��7��H��■ ■��■�■��■��■�� ■ I �1 ■ �� ■■ ■■��■■�■��■��■��1��5 �1��■��■��n�� ■�■■\��■■��■■�■��■■�� ■��IA��l91�r�i�%� ■■��■��■ ■�■■��■��■■��[l1��■■I!►.'ll��ILrII�Lr:��ii1��f�t��u��■ ■��■■��■■■��C��%��■■ ■C'��IL7�IL�N��1■(��i►/II/7��■��■�■�■ ■��!��■��1%��/:/%)■��'��1��■��N'��i/��II1��H��u�■ —�.��.i..,oa.��ri�r% .'L/\i/�■��■��■ ■■�■ ■��■■■��.,..,�--,.;��--1------------ ■■■�■��■��■■■■■��1/�//I111�"�r�i�� ■ii/��\ �inC:::—==��I��■� ■�■■��■��■t��■�%r�■■�■ ■�� ■ �� ■■■■��■■��■��r��■��_�■��n��=��■■■��i�■�■�__ ■��■��■��■��■��■�■��u�� ■ _�� ■��■��■■��■■��\��h��■��H■��N�u�■�■�■�� ■�� ■�■��■��■��■ ■��N�■ ■ �� ■■■��■��■�N��N�■��\��■�� ■��■�■��■��\�n��■��■�■■��N�� ■�■ �� ............................................... . ....C...... ...............................................i�= �.._.........0 ::C::::::::C::C:::::::CC:C::�s::C::::::::�:::::.. .:C::.:=5::::::: ■��u��,�a��u��uuuu��■ ■��■�� ■■H��■��■��■■�■��■f�lr/.%� ��H��■� �N��■C�� ... ........................��...............:C�C..... ....�.......................�.........�........ . ..C:�......� ................................. . .... . . ... ...... ��Hh�� ■ �� ■��■��■��■��■�� n�■ ��ii��■�� ■■�■�� ■ �iu�i ��i� ��■�� . ■�iiiiiiiiiiiiiiiiiiiiiu�i�i=iiiii■�i=iii � � i�ii�iiiiii� ■��■�■�■��■■�■■�N��■■�� ■N�� ■■�■ ■�i��■��■�■�� ■�■■ ■�■■■■■��n��■ ��■��■�� ■ N � ■ ■■ �N�� ■� ■��■��v�■��■■�� u�� ' ■ �� :::::::C::::::::::::::��::_:::" _ 'C=C =:::::�� ................................ ......�:�C:: ............ ......... ... ... .... . ......... ... ......... ... ... .. .. ...... . ■��■■■��H��■U��y� ■ M� H■�� ■�■■■�■��■��u��■ ■�■� �■�■ N �� ■��■�� CC::CCC:::::::::::::CC:::::::::�: :: . �'u.'.u: ■■��v��H��■��■■�■�■ ■ ■ ��u��n�� ■��■�� N■��N■ ..._... 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N.C. 27028 PHONE: (704) 634-5985 August 06, 1996 Stacy and Scott Mathews 654 Salisbury Street Mocksville, NC. 27028 Re: Site Evaluation Southwood Acres Lot 9 Tax PIN: #5717-26-5463 Dear Mr. and Ms. Mathews: As requested, a representative from this office visited the aforementioned site on August 2, 1996. Based upon the information provided on the application for 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. Sin erely, Robert B. Hall, Jr., R.S. Environmental Health Section RBH/wd Enclosure(s)