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279 Sandy Ln � ` v . 3 z �•--!, 1 DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section _ P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 � Account #: 990003777 Tax PIN/EH#: 5778-05-4352 Billed To: Gerald Morse Subdivision Info: Reference Name: Greg Parrish Location/Address: Sandy Lane-27006 ATC Number: 4435 • AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authoriza ion for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section rior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie Coun Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 1 A,Wastewater Systems,Section.1900 Sewage Trea t and Disposal Systems). THIS AUTHORIZAT ON ASTEWA CONSTRU V ID FOR PERIOD OF FIVE YEARS. '� Environmental Health Spec lisY ' a Date: � � l ?� � � �' C E OF�COMPLETION � **NOTE** The issuance fthis C 'fica f C io indicate the system described on Improvement/Operation Permit has been in led in co ian 'th .S.Chapter 130A,Section.1900"Sewage Treatment and � Disposal Syst s,"but sh in WA . guazantee that the system will function satisfactorily for any given period i time. � �� � � � . , � ��Ti�2� ��� �s . � ►a�-` - (;?�tie�� `� st� �-��,..�.��ug� N��� � � —�.,.r�7n'� �-Zz. �2oaT �►v� � Septic System Installed By: � � � �Z- Environmental Health Specialist's Signa Date: 1 20 �l0 DCHD OS/99(Revised) , DAVIE COUNTY HEALTH DEPARTMENT � . Environmental Health Section „ �.... �� . P.O.Boa 848/210 Hospital Street � Mocksville,NC 27028 '��� (336)751-87G0 . I I. IMPROVEMENT/OPERATION PERMIT Account #: 990003777 Tax PIN/EH#: 5778-05-4352 Billed To: Gerald Morse Subdivision Info: Reference Name: Greg Parrish Location/Address: Sandy Lane-27006 • Proposed Facility: Residence Property Size: 2. 1 acres **NOTE�*"This�Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHORIZATION FOR WASTEWAT'ER 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 � #Bedrooms � #Baths 3 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industtial Waste: ❑ Lot Size 2+�C�'� Type Water Supply ��►1,��Design Wastewater Flow(GPD)� Site: New�Repair❑ .' � System Specifications: Tank Size�'��AL. Pump Tank GAL. Trench Width 3� Rock Depth� Linear Ft.� ocn�: Q�C�d� 2��i�����'J�J ��Sl--u�ti, , `� 1�t�Sr��t� c.t►�,.J �:�5 Required Site Modifications/Conditions: ��%� �Q�L �,��'-lZ�, ��,' t3 ��� p� � U•�1�%S �-. INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW FINISH ADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis ' • .m.to 9:3 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C)751-87G0.**** �laf�� , . . - ���zr_�JRFn.c� ��.-r�yz- —,.. --� --� �� _ , � M�^� �D � � � ��fT ��, �� o � � -�` ���.� , _ --r�-,,� , � , �_ .-� t-�-rv�. . , � -�� � ��-- .�u��,c,`r���-t ��3 ' ��� � ��=� �.►��—� �,� �� Environmental Hea t Specialist's Signa e: Date: �� �t�� DCHD OS/99(Revised) ' - � . • ' ' ;. � APPLIC FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � D N] � Davie County Health Department � � Envaronmental Healtli Section p P.O. Box 848/210 Hospital Street 1 �UN 2 3 2�p6 = Mo�ksv�ne,Nc Z�o2s M�j��� (336)751-8760/Fax (336)751-8786 Ap ica��� valuation/Improvement Pemut ❑ Authorization To Construct(ATC) ❑ Both *IMPORTAN7***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 �%'-e .�! � Contact Person .�� Billing Address c��o Home Phone � '� City/State/ZIP lQ,��,�f /l/.L'.>� /v2- Business Phone �/.(,Z • /C/ � �/�,/ C 33 Name on PermitlATC if Different than Above ��,�•�G'�'/ /�O.✓b'� - �/�' 3 " �go�� ' Mailing Address City/State/Zip d G�(/i /✓�•� / PROPERTY INFORMATION NOTE: A survey�plat or site plan must accompany this application. �.p�V�� (Permit is valid for 60 onths with site plan,no expiration with comp ete plat.) Street Address .�z„�� L� City �. Tax PIN# Subdivision Name Section/Lot# Lot Size Directions To Site: �v�C : •" �.� O ' ��G��-' O•-, P -Y� ��. d�Lv/S � oF' ��f�- /.O�� Date House/Facility Corners Flagged If the answer to any of the following questions is"yes",supporting documentation�m st be attached. Are there any existing wastewater systems on the site? ❑Yes CC�P�o � Does the site contain jurisdictional wetlands? OYes ❑� . Are there any easements or right-of-ways on the site? ❑Yes Q�� Is the site subject to approval by another public agency? ❑Yes � Will wastewater other than domestic sewage be generated? ❑Yes C}3�o IF RESIDENCE FILL OUT THE BOX BELOW #People 5 #Bedrooms #Bathrooms ,3 Garden Tub/Whirlpool es ❑No _ _ Basement: OYes C� Basement Plumbing: ❑Yes �� 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 Type system requested: nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: i7�ounty/City Water ❑ New Wel( OExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? [�� B�10 If yes,what type? /6 / c� ,��J� .. This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pemut(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 understand that I am responsible for all charges incurrec� frons tlzis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspec ' s to dete 'ne compliance with applicable laws and rules on the above described property located in Davie County a 8 o d by � Site Revisit Charge ro r owner's r owner's legal representative signature Date(s): Da�`�!� � Client Notification Date: EHS: Sign given OYes ❑No Account# �� Revised 2/06 Invoice# ,,� • ; � ,� `-�. � _ ...._ .���.'fl� , . � ' • . � � . /�� � . � , . "�'f (-!, _ y-s . ' � e � � , Af'l'LlCATtUIV FOR SI7E CVALUA7tON/IhiP[tOVCM1iCNT PLR�f17 - � � � 0 (�j ' , , DaVie County Health Department � v � • � Environmenta!/Yealtl�Section • P.0. Mocksvi llo NC P 2 026 treet �Cr ��9.?O45 , � (336)751-II760 E�R�NMpyr Al ***IFSPORTIINT*** TIiIS APPLICATION CANNOT B� PROCESS�D UNL�SS AI,L THE RLQ INFOR2•l1�TIObI IS PROVID�D. Refer to tha TPTFOFiDiATTON BULLETIN for i.nuEructionn. l. ?7ame Lo bc Dilled �{'{�CL'I� IYIDP�2 Contact Peraon (�Q(Gt4c�l �OfS�.. ldailing Addrosn �(,a�(/ /C//'//��'/}��h ,►�� Iiomo Phone 3j(p��]�i�' �r� �� City/Stata/ZIP GL/�/ps'�l�y/� �✓'Ua'�1� �� ,�7 f0 �- IIu�ino�a Phono ���" �3� � `,��5 2, ttamo on Permit/I�TC iL Differnnt than 1►bova Mailiiig Addruas . City/State/Zip 3. Application For: G7�5i.tc �valuation ❑ Improvement I'ermiL-/ATC ��Both '� 4. S alem lo Snrvicc: • •�jy t� y ljYIIouuQ ❑ 23obile Homo ❑ IIuBine3a 0 Tnduutry ❑ OL-her 5. Typa n�•ntem requo�tod: LW Conventional ❑ conventional modified ❑ innovaL•ivo pacCepted 6. Ii •Itosidenco: It People �_ 8 I3edrooms _� il IIaLhrooma oc ��- UdDinlu,ra�hor ❑Carbac�o Dispo�al L�It9ashing 2dachino ❑Dasement/Plun�ing ❑Daaement/2to Plumbing 7. If Duaineaa/Induatry /othor: verify type # People 8 Sinkn fl Commodoa 11 Showora fl Urinala p T•JaLor Coolora " � ; IE' FOODSERVICE: �� Seatu �sEimated i4ater IIaagQ (gaiions per day) � a. �o oE wator aupply: jLYC�ounty/City ❑ Well ❑ Commun'ity 9. Do �ou anticipata addiCion� or cxp:insions of tlic facility t]iis systcn�is iiitc�ided to scrvc? Cl 1'cs C�f'No If pcs,ticliat typc? , . . h . ***IniPOItT'�IN7�**cLiLHTs hruST CO111PLCTIi TIIC ItL•QUIRED PROPCRTY 1N1�ORA�I�ITION RLQULS'TI:D ;R fS1;i.O1V, isithcr 1 PLAT or51Ti:PLAN dIU.STBESU11bfITTF.D by thc clicnt �vith'I'IIIS APPI,tCAT10N. � 1't'opert}'Diulcnsions: �a J I�Cr�'S � lYIi1TG DIRCCTIONS(frutn��lodcsvilic)to P1i01'LR't'1':' . . •r:�.ocr,z�i�ttv: �, f� �7 �7 g' �.5� - �/3 sZ (2c� -}-v -�'a�� I'���I,� -�Ur» 1���- I'ropert}'Address: Road Namc�,� u f•1t�2 /Cv �lv� ��P���m�nf (�Q � 3�0 '° • Ci(y/Zip�(/:tH2 02,�[�!��n ��Il/� SO.�y L/�hf Olt��� UD �If iri a Subditi�isio�t provicic iiifoi•►nafioli,as lollo}vs: �t0 ��//6 �� d� l�-�� L.oncf'�� 1va,nc: ��h-�✓ .�r�� o� �hr�-� �.� Scclioii: Blocic: Lot: Datc Itomc coriicrs Aaggcd: JD�ZG�OS � 'I'l�is is to ccrtily tl�at Uic iufortnatiou provicicd is corrcct to thc bcst of tuy l:no�vlcdgc. I uncIcrslaiid lhat ai�y permi((s) issucd I�crcaftcr are subjcct (o suspcnsion or rcvocatiai,if thc sitc plans or intcndcd usc cliangc,or if llic informalion submiltccl in tl�is applicaliou is f•�Isiticd or clia►�gcd. I,also,rurrlcrslrrlyd tlrr�t 1 nur respousiL(c fi�r n!!cicnrgcs incru•1•ed jrunr tlris npf�licalion. I,I�crcby,givc conscnt to tlic Autl�orizccl Rcprescntativc of tl�c Davic Com�ty I�Ic�lth llcpartment to cnlcr t�port abo��c dcscribcd pc•operty�locatcd in llavic Cowity ac�d o�ti�ncclby to ca�duct all tcsting proccdures as�icccssary to cletcr►ninc tlic sitc suitabilit��. ' D�l'I'L � ��`�Z!� �Q� SIGNtIT'UIZI: T' ��(' _ TIIIS AI2LA 111AY BI;USI;D rOIt DI2A�VING YOUR St'T�PLAN(IiicIudc all of tl�c follotiring: L�isting aiid proposcd property lincs and dimensions, structures, setbacks, and septic locations). � . / ,�� � ' ���,�� Sitc I2cvisit Cl�argc ' (� . � � Q � D:►tc(s): ' 0��`��' � � �� ` �T'?� . . C� Clicnt Notificatiou Datc: � � � �I-IS: p � � 3 c�'`� ��r �, � � Sign givcn � 'C, �� CW-�''�`�-r� �`� � �,�lccouiit No. � ��� � � Revisccl llCII (05/03 Iuti•oicc No. I 6.73A � F . � y 6819 �o`° � . h / 5.�3a. �$� �� / 07�9 � � i � N Q) V N 7606 w W m � 13 506 912 _����912 - - � 180 _ 421 306 � -� ,� 506 � i ��' i � �i � � 170000009101 ��c �,� .5 e r�l �c�q�7� 5778054352 � I e,�� 101 A N 3.02A ,; � ' � - - — � a 0393 �� �l, � s S- �� � 1��,�� " 342 � t c ���� k� � � i I S fR �(e� piReaay � � , I �CI�PAS �� - - - - - 30� fi — - —�3� — • a - � ' DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003777 Tax PIN/EH#: 5778-05-4352 Billed To: Gerald Morse Subdivision Info: Reference Name: Location/Address: Sandy Lane-27006 Proposed Facility: Residence Property Size: 2. 1 acres Date Evaluated: �1' ��'� Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring ►� Pit Cut FACTORS � 1 2 � 3 4 ' S 6 7 Landsca e sition L Slo % � �o • HORIZON I DEPTH -�Z Texture rou SU- SGL Consistence - S� Structure �� Mineralo � .. HORIZON II DEPTH - 2. Texture mu Consistence � � � Structure � S � Mineralo � S� . _ ' HORIZON III DEPTH . � Texture rou .} -� , - Consistence � -r-SS 'SSS� � Structure � . �3k Mineralo .: 5�= � HORIZON IV DEPTH Texture rou � Consistence Structure • Mineralo _ . _ SOIL WETNESS 3 RESTRICTIVE HORIZON .. ' SAPROLITE CLASSIFICATION � pS ' LONG-TERM ACCEPTANCE RATE E�• Q.3� - SITE CLASSIFICATION:_ P� � EVALUATION BY:� ��c���wv�i-' � _ � �t,� �,�.; LONG-TERM ACCEPTANCE RATE: d'3 ' OTHER(S)PRESENT: REMARKS: � . . � LEGEND L�ndsca,Fe 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 � Texturg . 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 N�u1St 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 _ �� ' SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic ' MineraloQv _ 1:1,2:1,Mixed _ : rioi�s . 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/OS(Revised) � � ■�■■�■��■��■■��Of��■�■��■■■�■�■■■■■■�■��■�����■��■�I��\�■�■■����0■�■ ■■■�o■���o■�■�����■��■■■■■�■e�■■ ■�e�■e■■��■���■�i�■■■■■�■■o■■�■�■ ■■■■�■e�■�■s■.��,������■�����v�■s�i��■��es■o��■��■�io�■v■■��■����■■■ ■��■e■��■�������i■�■o��■o���.���■■a��������e�����■n�����■����■���■■ ■.�■�■��■���■s■�i■�■�■■■�a��■�s■s��■�■��■��s�����■�����s����■�■■�o■■ ■a.e�■a■■�■�e�se��ae■�■.���s��■■���������■�■�����■■u■��■��■o■����■■■ ■��■�■■.�■■■■s■�,i■���■�■■��■��■��■■�o■��■�■o�■■■s■i�■�■■��■����ee�s■ ■���■�����■�o■�ni�r,r:�■■■�■■■■■■■e��o■���■■�■�■■■�■i�■�■������■��■o�a 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■■�■��■�����■�■����■�■����■■���■ ■��■�■���■�■■■�■�■■■�s������■��■ ■��■■■�O■■■�■����■�■����■■■���■��■�■��■���■��■�������■��■�■��■�■■ ■■�■������■�s�■�■�o■■�e��■��■���■■■���■�e■eo■a�■�t■���■���■■����■■ ■■■■■��e��■�������■�■■■■�■��■���■������a����■oa■�■■���■■■■■■�■�■�■ J � . • • � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 /Fax: (336)751-8786 • October 25, 2005 Gerald Morse 4641 Kinnamon Road Winston-Salem,NC 27103 Re: Site Evaluation- 2.1 Acre Tract/Sandy Ln. Tax PIN#: 5778054352 Dear Client(s): As requested, a representative from this office visited the above site October 24, 2005 to perform a site evaluation. Based on 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. House location, size and other design criteria may necessitate the use of an alternative or innovative system. System design will be determined at the time an Improvement Permit/Authorization to Construct is applied for and issued. Before a representative of this office will revisit the site to issue an Improvement PermitlAuthorization to Construct,the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at 751-8760. Sincerel � Jeff G. Beaucham ,R.S. 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