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202 Seawall Trail � _.. DAVIE COUNTY HEALTH DEPARTMENT � '� Environmental Health Section • ' P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 Account #: 990003695 Tax PIN/EH#: 5778-79-3915 Billed To: John Waller Subdivision Info: �-t,,,r�y��-� Reference Name: Location/Address: Baileys Chapel-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4165� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MLJST 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 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUC ION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: � � � � CERTIFICATE OF COMPLETION **NOTE** T'he issuanc..�e��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. � .� `q�awt°�-S �„�rz-S=72' a a 1�� ?Co' �� 1� G'�a�� �� � I � �--��t�� � C� . � � _ .4 , ��� � ��� �� �� ��� ���� � . � �� �� Septic System Installed By: � Environmental Health Specialist's Signature: � � / e: 7 `�� DCHD OS/99(Revised) , DAVIE COUNTY HEALTH DEPARTMENT ��,� Environmental Health Section � � � P.O.Boz 848/210 Hospital Street �� . � -� � , Mocksville,NC 27028 �� s � (336)7S1-87G0 �i� 'J�� O ! IMPROVEMENT/OPERATION PERMIT Account #: 990003695 Tax PIN/EH#: 5778-79-3915 Billed To: John Waller Subdivision Info: ��y��,`-�(� Reference Name: Location/Address: Baileys Chapel-27028 Proposed Facility Residence Property Size: 1 acre ATC Number: 4165 **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). THLS 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� Dishwasher:� Garbage Disposal:� Washing Machine:f� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size Type Water Supply�jL Design Wastewater Flow(GPD) [P� Site: New❑ Repair❑ i� System Specifications: Tank Size,1�0� GAL. Pump Tank GAL. Trench Width��Rock Depth �� Linear Ft.C�� Other: Required Site Modifications/Conditions: I1�IPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW ` FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.**** ' � � Environmental Health Specialist's Signature: Date: �� `f��✓ DCHD OS/99(Revised) • � � - ' ' . APPUCATION FOR SITE EVALUATION/lh1PROVEM1tENT PERM1tI T� � � � � � . �. Davie County Heaith Department • Environmenta/Hea/t/�Section ,��� .. 2 �j P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-6760 �IRONMENTALNTMEAUti ***IttPORTANT*** THIS APPLICATION CAIVNOT BE PROCESSED UNLESS A ED INFORMATION IS PROVIDED. Refe� to the INFORMATION BtTLLETIN for instructions. Namo to be IIilled ���I� �.t�a�,C{Z, Contact Pornon '�c �-. r-,P_ �a�p..,J�t� �n�a���, . �Mai ng Addresa �1 02[.Q f�R.c,n o�-Ly� C[ft,�rv� K�l, _ Iiome Phone �Lo(t ��l 3� �/State/ZIP ��dNonS, /UC 1'Z� !1 BffBtnaae Phone J d�n ��"��f�1�'l( ,/l. Namo on Permit/ATC if Differeat than Above �..�1��. �I'1�-- 39 5`� �iailing Address City/State/2ip t� Applica�ion For: Site Evaluation �provement Permit/ATC ❑ noth c.9,/s atem to services L�iouse � Mobi1Q Home ❑ Iiusiness ❑ Induatry ❑ Other �5/. Typo aystem reguestod: ❑ Conventional ❑ conventional modified ❑ innovative p ac Cep ted 6 If itesidence: , N People �_ # Badrooms _� � Bathrooms _� '/ODi�hwasher �arbage Diaposal Qfsashing Machino ❑Dasement/Pluu�ing ❑Dasemant/2do Plumbing 7. If Duainesa/Induatsy /Otherz verify type # People S Sinks # Commoclea # Showere # Urinala I� Wal•or Coolera IF FOODSERVICE: #� Seats Estinlated Water Usage (qaiions par day) �Type of water supply: C�County/City ❑ Well 0 Community 9 no You anticipatc additions or cxpansions of tlic facility tliis systc►n is intci�dcd to scrvc?�Ycs �'l�io If y�cs,�rl�at typc? ***lA1PORT�INT't**CLILNTS MUST COhlPLETL•TII� REQUIKLD PROPCRTY INrORMATION RGQUGSTCD I3GLO�V. Eithcr a PLAT or S1TG PLAN J�fUST BE SU6htITTED by thc dicnt �vitli T[(IS APPLICATION. ro cr(y Dimcnsions: / �— RIT� fron�Modcsvillc)to PROI'CRTY:` C, � Tax OfGcc 1'IN: # ���O '�/"J /�� lD� ,�g4� �+ �e�C�i 4 . �, Ra. � �w�N1 P perty Address: Road Name�,t �1t1 S �/�� �cD� . (M �`o�.�- o-r 6A:��..`s ��ty�Z,P � o� ��. ��.�� a��,� �a�+ � �in a Subdivision providc inforniation,as follows: (��,,,����r, 1 a,,.. 2�a� :r �'��-�-n o� Namc: ' Scction: Blocic: Lot: atc liomc corncrs llaggcd: `��a �05 Tl�is is to ccrtify tl�at tlie iuformation provided is correct to tl�c best of r»y knotivlcdgc. I undcrstand tliat any permil(s) issucd I�crcaftcr are subject to suspensioii or revocation,if thc sitc plans or intendcd usc cl�angc,or if tlic inform�tion submitted in this application is falsircd or ct�anged. I,also,tu�derstand tliat I anr responsiGlc for al!cliargcs i�tcrrrrcd froui tlris applicatiou. I,hcrcby,�givc consent to tl�c Autl�oriacd Rcprescutativc of tl�c Davic County Iicalll�Dcpartmcnt to cntcr upon abovc dcscribcd property locatcd in Davic County an� otivncd by to conduct all tesling procedures as necessary to deter►nine tl�e site suitab'ity. �T� S�I��QS GNATURC TFIIS AR�A MAY B�US�D TOR DRAWING YOUR SI'fE PLAN(Includc all of thc follo�ving: �listing:tnd proposetl property lines ana dimensions, structures, setbacks, and septic locations). � Sitc Rcvisit Chargc �� . Datc(s): ' � Clicnt NotiCcatiou Date: �HS: � � Sign givcn� . Account No. J�� �s � ; Reviscd DCIiD(05/03 Invoicc No. »�- � ��� , "� _ � ���PPLICATION FOR SITE EVALUATION/IMPR�VEMENT P �C . . •°• �� Davie County Health Department `' ' '� � � � � ;$ � ,N :�•���� CQ Environmental Health Section �`�` ` ��� "�� ;;�� : �c. 1 �� �Q ` (p� P.O.Box 848 � �t "�_ � 1 � � � Mocksville,NC 27028 � � � �4� a v c�ee. �'�f �"h r� a� ��e �- (704) 634-8760 � ... -' be��pt� %►^ t�'t or�'� nS ****IMPORTANT**** TI�IS APPLICATION CANNOT BE PROCESSED UNL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �o1�n In�h��.e.R Contact Person 7oH�n (�J���e,C MailingAddress i`1��+ ��a�c��r 1^c..,,�-rr� �c�l HomePhone �,°110, `7Co(...-'1�135 City/State/Zip C,\-�,Mm�nS; NC, �70��- Business Phone �°�ia��7C,(.-')�13� 2. Name on PermidATC if Different than Above Mailing Address City/State/Zin " c•�,(,�Q �._.� _,_ . r._, 3. Application For: [./jSite Evaluation [ ]I�p oveme� ntFermit�ATC [ ]Both 4. System to Serve: [�]House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #People a #Bedrooms�_ #Bathrooms a• [vj Dishwasher[ ]Garbage Disposal [�]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing 6. If Business/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 [,/J Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [./jNo If yes,what type? PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: ��� a�►�� �WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: #�j'7?5f -�_- 3`� I�J ; �v�{,,� `�-c.� �d�� �n u�c1� f:c�� Property Address: Road Name � 11- ��" �'�`�au�s � '�u�►�t �e��. �u v�✓t le;�,�+ r>v� �3�`�1�'n n.,s City/Zip (�.��e.c., a'taol� ; �c�. � c��.� e✓io�. � If in Subdivision provide information,as follows: � � Name: � , . � � Section: Lot#: � � This is to certify that the information provided is conect to the best of my knowledge.I understand that any permit(s)issued hereafter aze 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 this application. 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 t�g�res as necessary to determine the site suitability. DATE I-5��r1 SIGNATURE Revised DCHD(06-96) T. �ls-eoQ '�o b e '�-� u� �� � � , t�;Q�S . i �# � "y S � � �, � y� � t . � � � I ' Y y �`'{,� y, • _' y O '/ i �, ' O � �F ,3� 4 t ' � O tv O - �� �; !; �� G :Q _ ; ����, � x� ' � �� �! Q � � �� �i � � e ` 1' `+ I� - .. . ;F .. e � �f i � 3 I 9 �' '{ � S � � �t � �9 � �. �a s i ("A ¢ ; v� � !i ' v E� � �� � 8° _� d � � A �v Y ' Y W �o - � - cj J . . DAVIE COUNTY HEALTH DEPARTMENT :� � ' - ' Environmental Health Section SECTION LOT ., , ' SoiUSite Evaluation APPLICANT'S NAME �T//9/ls�r DATE EVALUATED � �� PROPOSED FACILITY ,� PROPERTY SIZE_ V , O � � SUBDIVISION ROAD NAME G�h��1.r L�i�G�dd j� Water Supply: On-Site Well v- Community Public Evaluation By: Auger Boring i/ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slo e% '- HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � � � ./ � Texture rou C�- G Consistence T Structure iG Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE - � SITE CLASSIFICATION: � EVALUATION BY:_�f� 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-Tenace 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-Granular 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 DCFID(01-90) ■�■�■�■■��■���■■■�■■■■■��■■��■■■■■��■■■■■�■■■��■■��■■��■�■■�■■o■�n 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I � � � MOCKSVILLE,N.C.27028 � � � � PNONE:(704)634-8760 � , � � February 14, 1997 , j , , t . � � ; John Waller � ' 1726 Brandon Farm Rd. .- ` ; ; Clemmons, NC 27012 , I. Re: Site Evaluation/Williams Road Tax Office PIHc �5778-79-3915 Dear Mr. Waller: As requested, a representative.from this office visited' the aforementioned.site on February 7. 1997. 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. � Sincerely, y � �` . ��.�������� Robert B. Hall, Jr., R.S. , Environmental Health Section RH/wd � - � Enclosurets)