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193 Boxwood Church Rd (2) ' ' � . � I' //'C/\,. • I' DAVIE COUNTY HEALTH DEPARTMENT ---'-'"` � Environmental Health Section � P.O.Boa 848/210 Hospital Street , Mocksville,NC 27028 (336)751-8760 Account #: 990001635 Tax PIN/EH#: 5755-31-6048 Billed To: Gary�taura Medford Subdivision Info: �ZC� sp��-f��// L� Reference Name: Location/Address: Road-27028 Proposed Facility: Residence Property Size: 11 acres ATC Number: 1663 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). T'his 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 CONS S VAL FOR A PERIOD OF FIVE YEARS. � Environmental Health SpecialisYs Signatur : ate: !J �3 8Q �do,� - CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis 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 Treattnent 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. � Pt{�� T�JL�T� � � �' I�e,st- 1,�p� sF TII�S �o d` �� 2 ��.�;_,S ,io c-a�c- �oo',c�`'���� � �.}a� o� �� 5►25 ., FS u���c� t� c9 -�,. sf -���,� ��� -_�a'�.-���� �� z 3o-ao Septic System Installed By: �� L �L��(..fjPM�`T Environmental Health SpecialisYs Signature: — ate:�2 � '`� DCHD OS/99(Revised) �'�'. DAVIE COUNTY HEALTH DEPARTMENT 'Z-� ' �, r--� ,, �. ` Environmental Health Section P.O.Boa 848/210 Hospital Street , Mocksville,NC 27028 (336)751-87G0 � ! `(�,L. �- �.., IMPROVEMENT/OPERATION PERMIT .�L/,��, S��/'e� / Account #: 990001635 Tax PIN/EH#: 5755-31-6048 Biiled To: Gary 8�Laura Medford Subdivision Info: _� � V Reference Name: Location/Address: �,91 Boxwood Church Road-27028 Proposed Facility: Residence Property Size: 11 acres � A-�� Numb r: 1663 I�"I ����� T/� �� **NOTE*'�Triis gmprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type M . 1{O M� #People � #Bedrooms � #Baths 2 Dishwasher: � Garbage Disposal:,0 Washing Machine: C� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size ��'� d�='S Type Water Supply CA�NT'l Design Wastewater Flow(GPD) c3(n0 Site: New� Repair❑ System Specifications: Tank Size�I��GAL. Pump Tank GAL. Trench Width �,�Rock Depth�Z�� Linear Ft. 3L�O� oth�: 2- '�S�-2��r�o...� �,,,� 1 asTAu�. �,a:�s 9' o.�. ,,,�,�. , Required Site Modifications/Conditions: �'J�a u— o� C.�^�'�c7�� 1C� �� oFF �nn. ND� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative 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.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 1 ' I�pp• � �Ch�x�'�c.t Z,. G! '��4' ��M �-� "'S;/ �- � , �o�w�� `��E, �.} p�Ga�c s►��� Environmental Health S ecialist's Si atur : Date:� � � J/ � P � .,. DCHD OS/99(Revised) � , , � � < r .. .*, a .:te ` {� �r' � �l �AP('L!(�"q. N FOR SITE EVALUl�T10N/ItifPROVEhiFM PESiM111T&ATC L� _ �_..�.. , � ; - � `: `' -; Davie County Health Department ��'�n�%%/"�•1�- �� � ' Q ._ . ,. � �� � , :�� Environmen�/Hea/tfi Section �Q .�� S" v � � � - � LUUI p,0. Box 848/210 Hospital Street P�r""`� � .�� Mocksville, NC 27028 �s��e`�p�'�" � (336)751-8760 ENViR�� �t�i�„L�i�r;�iH =------- � .. D�3VIECOl1PriY__ . ..,� ***I2�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFOR2�ITION IS PROVIDED. Refer to the INFORMATION BULLETIN £or instructions. 1. Name to be Billed (xt/'C[ I�C Contact Person -T r/ /�Q Mailinq Add.seae Some Phone ��7_G0�v � City/State/ZIP ��/1Gl�.slJ l��<� . �C.� �/�/�V Businesa Phone 2. Name on Pe=mit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation � Improvement Permit/ATC ❑ Both 4. Syatem to se���e: D House �Mobile Home ❑ Business ❑ Industry 0 Other 5. If ResidenCe: � People �_ � B@C�OOIDS _�_ � B8�'lI'OOm33 _�_ fj!DishMasher (7 Garbage Disposal �Washing Machine ❑ Basament/PluaSiing O Basement/No Plumbing 6. If Bueiness/Industry/Other: Specify type � People # Sinka � Commodes i Shoxera � Urinala � Water Coolera IF FOODSERVICE: # Seats Estimated Water Usage (gallons per aay) �. 2ype of water supply: C�County/City ❑ Well ❑ Community s. Do you anticipate additions or eapansions of the facility this system is intended to serve? 0 Yes Q'I�Io If ycs,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETlIE REQUIRED PROPERTY INFORMATION REQUCS7'ED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by t6e clicnt with THIS APPLICATION. Property llimensions: [� �ftG � WRITE DIRECTIONS(from Mocicsvillc)to PROI'I:KTI': Tax Once PIN: #,� .%a�ie �f� s�/UTh s'7s5'-.3 - jy� 8 / „ � 1 Property Address: Road Name�,�wDo��/�Urr�KlJ. 1�t70�C �h R c;ryiz;p`���l�s��ll� , .27D�f� �n`� olrrve or� �e� lf in a Subdivision provide information,as follows: Name: Section: Block: Lot: Date Property Flagged: This is to certify that t1�e information provided is correct to the best of my knowledge. I understand thAt any permit(s) issucd hereatter are subject to suspension or revocation,if the site plans or intended use cLauge,or if the information submitted iu this,upplicatioa is falsified ur changed. I,also,understand lhat l am responsible for al!charges incurred jrom th�s opplication. I,hereby,givc consent to the Authorized Representative of thc Davie County Healt6 Departmcnt to cntcr upon abovc described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitAbility. r DATE - - SIGNATURE �TI THIS AREA Y BE US � � YOUR SITE PLAN(Include all of the following: Eaisting and proposed property lines a dimensions, structures, setbacks, and septic locations). . �S Site Revisit Chargc w Date(s): �S � Client NotiGcation Datc: `� � EHS: � Account No. � v � ;. , Revised DCHD(07/99) Invoice Na •� ✓✓ , � -zz-� �n Sk�- p«�y� � ►'►�.,t d�n.��.. ��1�2 .�Ptl)�� '(`�.� C�-�4'�' � � ��/� � IG ' O e�� � � �� O 3��ase `' ti� � 2 �� c�0� � � ti � 1070 O ,�o�� �O `� 23� �. ��� � �`��l���� �, ,��iz� A�c,21 �o / ` '� � � J � . ;3.15A) � �' N600 , �4108 0,54A) � �,. 2074 ��� (33.50A) �� � 7780 -� � � ,.,�,,, � � 1 � �48 9 ������� �'�J' � � � � � 390 � W � c9� °,�� v cN,o Ci 4489 � � 69�� 2.29A � 2406 � � � �s , 2 6 4395 � (12.03A) � Zg1 QS 5 W N 2232 5252 0225 .� a � !� 6�D�1 6, 3�6 ��'� , � ,l � 3 � � r+.� .�n � ^ � .. . . � ' ' • . - � , s,�d-«.,k,, �i� ��°:,.t -.��.r�' �;:i�,�r :,..�.�,,.,,,���,..�3�af rt���tC r�,✓�e4`•n=hi�;�c�'r�Yi's���,w 'f..��."t,"+Nl�•.-,-r=-�w ..�.K�•.,ti.y«,,.�, �r., :'. ' i t�: , �: .' �:'� �� .. , ALjTWQRI7,,-.�TION No: `� ���, : DAVIE CQUNTY HEALTH DEPARTMENT �. � � �`� ,: ' � ' � � ' "' � '�Environmental Health Section PROPERTY.INFORMATION Perm�ttee'S , '' � � P.O.Box 848 . . . � Name �,�Q�.�� ������ ` Mocksville,NC 27028 " Subdivision Name:: ' ' . .. , < , , . `" ' ' Phone# 336-751-8760 " Directions to propeRy. �r^�1 S '��� "�G!C c�1�t)�7 • � SecUon. Lot: ` ^�.: • AUTHORIZATION FOR -�7 �v �.., �-�7p Q }r•�� .�� f_ �i� ``'.;"F ���� : WASTEWATER , , . �/�'I2 J _ !C!'��!�... , .-- 1 .t�.rt�1i: ,c, �-�- Tax Office,PlN:# � _ � SYSTEM CONSTRUCTION � Road Name: p�\. �p: �-��.Z *,*NOTE**This Authorization for,Wastewater System Conswction MUST BE ISSUED by the Davie County Environmental Health Section prior� io issuance of any Buildin�Rermits:'This Fom�/Authorization Number should be presented to the Davie County Building Inspections.'. ' ' .Offic when applying`for Building Perm�ts.: , , '. � ' � . , p � ��_ �� p 130A,Wastewafer Systems Section.1900 Sewage Treatment and Disposal Systems) . . ; (ln com;liance`�tti Arti le 11,o G.S.Cha ter , ' , J� �. , ,� r� ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION E`�f .,GL^^-' I ��V J � IS VALID FOR A PERIOD OF FIVE YEAR5. - ENVIRONIGIEI� � A TH SPECIAL�IS�T + DATE SU D t r ,M 4, +�:` �F F— .,+ ..r ,;+ y' w3 ,. �,�..+a-+o,...^-� a i •'�.W--. v�V. >.r>..�..' r-r^'�v +�Yr...� 1 A r�Z.��i4y,� �r.;t ...wtcr��at�Y.kr.�:. 9 � ,�,. '� �^+t i Y' =h ,..v,r t� ' 4 �-�"�-`;��M. ` ' • ` � .s.�.�``���k � ��� ^ ' DAVIE � OUNTY.HEALTH DEPARTMENT �� ', - - , _, ���,:.,� r . � � ��� , �; � ., � ' s , ' ; � IMPRO EMENT AND OPERATION PERMITS " �`PROPERTY INFORMATION , 'Pe�nittee'�s� � ; , ' �.'` �:Name ' ,,,,,,,�J��.�� ���1''Q�� .• , ' Subdivision�Name �'� �� � i . , :. , . � .. F ., .�. ' �. . ' . .'�..1�'� ' . _. � Directions to property: �-�t�� � ��-n' t'�c�'v'�c'�c.��'�` Section: ♦ •Lot: � � � : � � IINPROVEMENT '; , '-� � �� + 'Q � .t�� "w--"� r,;:i i ���:.: t....�t,.,- � PERMIT Tax Office PIN:#.., ���.� ��.'����1 � Road Name. . ,.. :�Ct�p��ip; � O�' . NOTE. Tlus Im rovement P,ernut DOES NOT auth , � . t� �- � . ..,. ..- , . . , . . , , . , . - ** ** ' p orize the construction or installa6on of a septic tank system or any wastewater system.An ' ' '� .AiTTHORIZATION FOR:WASTEWATER SYSTEM CONSTRUCTION must be obtained from this DepartmenG:prior fo the . .. �.constxuction/installation of a system or the issuance of a building pernut. ,,. ; " ` � ` , � (In comphance with Artjcle'11�qf G S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) {"' � ::� ,� �;�� �. ,r� , ,.. �° �', `� �. • `" ,.... ' ***NOTICE***TI-QS PERMIT LS SUBJECT TO REVOCATION IF SITE • ,,,' ;'1, .�f, ��"�„-„,::,,.^�--�.,, �� , �1 :> : �{�) PLANS OR Tf�INTENDED USE CHANGE.YOUR�WASTEWATER :' .- ' �NVIRONME�QI.��-IE LTH SPECIALIST�' DATE SS D • '' SYS .. TEM CONTRACTOR MUST SEE THL�PERMIT BEFORE " �t�.. INSTALLING THE SYSTEM.: _ .: � . . ; . „. -. • � � . , , ;.. RFSIDENTIAL SPECIFICATION.BUILDING TYPE�_ #BEDROOMS 3 #BATHS � #OCCUPANTS_�GARBAGE DISPOSAL:Yes o . . . � .. COMMERCIAL SPECIFICAT'ION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS � INDUSTRIAL WASTE:Yes or No . " � r��� �" , � ,` , , . '. LOT SIZE J D A"�yPE WATER SUPPL� �� DESIGN WASTEWATER FLOW(GPD)�� NEW SITE ' �'' REPAIR SITE ' > . ,, 't , . � SYSTEM SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL. .TRENCH WIDTH � ROCK DEPTH� LINEAR FI'. �O _ . , OTHER � N"1�T�I�7 1 ��7� �� . . ' '; � ": , i ,I � 1.:n��rn�� o,� co��o�� , % �� 5 oFr N��►-k�. ��P so � . REQUIRED S1TE MODIFICATIONS/CONDTTIONS: c ��. %�� IMPROVEMENT PERMIT LAYOUT ` _ , , • _ ��v�JT � � �I�t���l��� � � � M,�,�;� io � �Io `lc�� "'-�---�,.` G,C .� '`--�=�;�'`.J , K .� ` K/� +� " � � � : M��,s, ;�af Y'�'����-� ��� ��, .`i��`Tn �2�:��� cl��+�.t� , F. v - . _ : : . , , **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF TH1S SYSTEM , • BETWEEN 8:30-930 A.M.OR 1:00,-1:30 P.M.ON THEbAY 0F INSTALLATION.TELEPHONE#IS (336)751=8760. ,` ' OPERATION PERMIT- ` _ � SYSTEM INSTALLED BY: , - � - � „ , . . . - .. , , . , , _.. .. , .. , , , .. , .... , �.. ; � .:;: ,.. , . . ; ° _ ' .., . - , . , , AUTHORIZATION NO. ; OPERATIO�I PERMTf BY: � DATE: ` '•THE ISSUANCE OF THIS,OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE ' ' ' WTfH ARTICLE 1 L OF G.S.CHAP'TER 130A,SECTION:1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A ; , GUARANTEE THAT THE SYSTEM WII,L FUNC!'ION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. . " DCHD OS/96(Revised) , : : , �j _ .af.`�F\J6:Y� T k v - �..�r+t ry�",..X� _ b.�_`4Y_.' 1< . M:. � .�..y`��v �l. �.-:� �,. � . � "' �w .. ,v�'..._.�s.i I.st'kH`. ,.,. . . � zY' Y �a �it' ."�.• �� ` � 4"� � ,v''� -h � . . . . . � .. . . � . .j-iw1 � . . . �,ry . �,�..-_'%�}y."�.!�(\#` �. i'M--'...�; � ��-� . .' . . .• .• .. . ' . . . .. . �, � �� ' '� ��,� DAVIE � OUNTY HEALTH DEPARTMENT _ ; -'.�,',`"�., �" -�' � � IMPRO EMENT AND OPERATION PERMITS ` PROPERTY INFORMATION <��Permittee's�'.,\y , . . ' Name: _I _.���12�`�L ���1'p�.��' I Subdivision Name: + .�....;. Directions to property: �-'� � �f�' � �'�' � 'a.-� �`� Section: Lot: , ; Il�IPROVEMENT � ,. �,. , , �--� i ^t"`e�� . . . . " t�� y` �. .i, �'..�,� .F ,:�;4,.., PERMIT Tax Office PIN:# `"�.`- "'> - r '� ��r ��' . . : Road Name: �l� Q?p�i'� ►�ip:=� ,:, . , **NOTE**This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An AiTIT-IORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construcUon/'u�stallation of a system or the issuance of a building pernut (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � € �- ""�� ***NOTICE***TI-IIS PERNIIT IS SUBJECT TO REVOCATION IF SITE ; � � . �^ . ��) PLANS OR TI-�INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMEI�'�AL-HE�LTH SPECIALIST'' DATE�SSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING TI�SYSTEM. •-- .. , . _ . , ; : . ;;:. :. . _ . RESIDENfIAL SPECIFICATION:BUILDING TYPE�� #BEDROOMS � #BATHS � #OCCUPANTS_ �GARBAGE DISPOSAL:Yes qfF1o�, ; �..� � ;s COMMERCIAL SPECIFICAT'ION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No �. 7 ���� * LOT SIZE Cy� r, TYPE WATER SUPPLY�J�7� DESIGN WASTEWATER FLOW(GPD)�� NEW SITE � REPAIR SITE : �� � �� 1 SYSTEM SPECIFICATIONS: TANK SIZE �..C� GAL. PUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH �- LINEAR Ff. •�-%� , OTHER � �..,Cy-� k=�t�l! !f""� t�t1�C ; � REQUIREDSITEMODIFICATIONS/CONDITIONS: �:�T�LI.,- Ci� CC:/�i.��-;� � �L� �� C.:+�� 1",•.�P�.}f��. I,L.L(.� ,`'���' '' c���• •!',G�l:. �. IMPROVEMENT PERMIT LAYOUT � � ���,,+��,; , � I�, a, . � ,�,. �t�F,�.� � r �� M . . . � . ,��,', i ; f��r�. �d�����'_ � : �: � ��, ..�,���_, ��`� '�" ---_......�_ � . . ..� � �-- �' -.._f � .:.. . _ ,. .. . ;� , , i-._-. � �Mp� ., ��..�_ j , M. . -- .../ { . �, � .._(�x� .� �* , ' ,.,. -�.,„� , ._,,,,,_,s: , . _ .. ` .,,, . - , _ , /� ., , �;-„-.�...1 ,,, ., G r---' ..• , Nt!'�, � � �{�G.i. Y �c;V' i v .; � , �� G(����'.1� C I�<.I;c�c.t L + . z { .$ �, : : . _ . **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM ,BE1'WEEN 8:30-9:30 A.M.OR I:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT . � SYSTEM INSTALLED BY: �. , ,. _ �.. ., f , : ,'-: < 'F' . 'Y '�, .�._ � 1 ._ . . ,� r. i ; �,�,�,�,y._=,,,.,e�.».�":'""_.... � l� �_ . � � . � 4'{~✓J�.�„�.-._... �-.� . . . ` __..__...,,_.—.__.. . , . _. AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **TF�ISSUANCE OF THIS OPERATION PERMTf SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BE�N INSTAL�.ED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPUSAL SYSTEMS",BUT SHALL IN�VO WAY BE TAKEN AS A: GUARANTEE THAT THE SYSTEM WILL FUNC1'ION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. � ; �' _„ DCHD OS/96(Revised) � / . . , ,4 , ' � ��-�!` �-c �,11 � e j� `,+ - J � i; �. �.� ��, � , , . , . � ._ . .__. ._ _ .- __ _.,- _ _.. . ._. ,_ � :-_.. _ , _:,, �_ ._ .. _,. _ . �:. _ _ _ _ _ ��g ' C� _ l�:U� . �.� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC �� � � � a � � Davie County Health Department � � Environmental Health Section � /J 3 I� P.O. Box 848 ,��`� ��52��'�V � 2 Mocksville, NC 27028 '���'� � � � ' 704) 634-8760 ��- �p � �-�� ���!� ..., ..,� ���—" �-� �:��,o::�.:����+� ��,� � � A��,� ; a ���� HIS APPLICATION CANNOT BE PROCESSED UNLESS ALL � THE REQUIRED INFORMATION IS PROVIDED. � ���� � . Name to be Billed Contact Person �/I Mailing Address � � Home Phone � 9 � "� �d City/State/Zip � �Business Phone � 9�^ ���f 2. Name on PermidATC if Different than Above Mailing Address City/State/Zip 3. Application For: [�] Site Evaluation [�mpr vement Permit&ATC [ ]Both 4. System to Serve: [ ]House {�Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #People� #Bedrooms � _ #Bathrooms� Dishwasher[ ]Gazbage Disposal �Washing Machine [ ]BasementlPlumbing [ ]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:�ounty/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No If yes,what type? '. �'�+�� EZTHEIZ A PLt1T OR SZTE PL,�tN ' PROPERTY INFORMATION REQUIRED:***IMPORTANT**��OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. . Property Dimensions: 3• ��7���" �WRITE DIRECTIONS(from Mocksville)TO PROPERTY: . XTax Office PIN: #;�)�1'`7J -_���-�L��� ' Property Address: Road�ame�eX w aoc0 G�. (z-cQ ,'�v�R� I city/Zip Ylflo tK.sv,tla. rit. Z?o z8' ; �-- If in Subdivision provide information,as follows: � . �'U � Name: � �1_t"��1y�. �1.� �� , ' � Section: Lot#: � �...J�_�� This is to certify that the information provided is correct 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 conduct all testing procedures as nece ary to dete ine the site suitability. �( DATE ��'GY� "4 O �IGNATURE � � Revised DCHD(06-96) • /�Q � �.�.���J V v N � q—��_ / � THI S AREA MA J $E USEb �OR �l�tW I NC �OUR S I TE PL,�IN• N/I� , � . . � � 'p� .._� A� � � ���-� _ _ t � � c�.2l-�F- �..cl� r� �- � C� f��tn,r•''�- ��,.���.. �.r....P �, , �o f � � 7 �-��d�- � , . , ♦ V � ' '"� _��,;. ,' - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT'SNAME ��''�CYI.r t'I�.�,Xr[1'�/ DATEEVALUATED � i3 a /�/� - PROPOSED FACILITY '*1� ��m� PROPERTY SIZE__ �J�� SUBDIVISION ROAD NAME , �/�0� G�- FL—� Water Supply: On-Site Well ' Community Public . Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slo e% HORIZON I DEPTH - p- '7 Texture rou �L ,5 C L Consistence SS S �� S P Structure C e(L Mineralo ' ► �; ( HORIZON II DEPTH Z '7- Texture rou ' S C S C Consistence r SS SP �� � • SWcture tL Mineralo ;i HORIZON III DEPTH 3 Z - � Texture rou SC t C}Se Consistence �r �SS S Structure 5(3 tG Mineralo �� � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O. t�. SITE CLASSIFICATION: EVALUATION BY: � ���k.c14►�lI LONG-TERM ACCEPTANCE RATE: �' � OTHER(S)PRESENT:�'�L '�''t'���oP...� REMARKS: �� C��4Y I� ( _ C���J `.j,=�� ��� � . ���G 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granulaz 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 DCHD(01-90) � � . , � / ■�■■■���■■■�■■■■■■■■�`���■■�■���0■■■■■■�■ ■■■■■■■■■�■�����■�Ii■■■■■■���■■■■■����■■■■■ ■���■����■■�����■■o■�\\\����■■����■■�■■�■���■■�■■■■■■■����5�11■�■■�������■■■�������■■ ■���■■■■���■■■■������■\�►���■�����■��■■�■■■■������■■■■■�■■■��11��■■�o�����0■■���■����■ ■■■■��■■■■���■■■■������\\�\'\■��■��■■■�■■����■■■■�i1■■■����■■■■■11■�■�����■■■■■��■����■�■ ■■■��■��■�����■■■���■■��\■t\■���■�■■��■����■■■■[a:ilf■■�L:1:7■■■■■11■�■��■��■■■0■■■■�����■■ ■■■■�■■�■������■■■�■������■►��■■■�■■��������■■■��a■■�����■■■■�i■�■�■����■■■■■�■■■■■��■ ■���■���■■■����■�■■■■■■■���■�■��■��■��■■■���■■■■��a■■■�����■�■�i■�■■■■���o�■■■■■■����■■ ■���■��■�■��■■��■■■■■�■■■�►�■.■■■���■�■■■���■■■i�■■■■■■■■■�■�����■■�������■■■�������■■ ■■■���■■■����■■■�■�����■■■■��■►■■■■�■��■■ 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■��■■■■����■■�■����■�■�■■■��■■■�■■■�■■����■v■�■■�o�����■■■■�o���a■�■���■■�■��■■■���■■ ■■■��■■�������■■■����t�■■■■������■■■■�■�■ ■■■■�■������■■■■■■���t���t■���■■■����■■��■ ■■■���■■�■���■■■■��������■■■����t■■■■■■■���■■■■■■■■�������■■�■����■■■■���■■����■■��■ / . / S IRON PLACED -- ES W� PN��P � JAM 122 P�. 2�� Q1 � �.V' , 1306• ro ;�u . �^� 60 R/W 2� � \R�a pLP��9 p�M II .. Lpo p8 . . . 0. . . . 1� 5 �� II.00G ACRES � i ` ' ,.� a84p6 a Ay DAVID J. SMITH iRorv PLACED � � o � _' � T � D.B.175 PG.S � � Pc� _ \ W e / R.B.MILLER y O � I �.sP�vcE �`' 6 S�µEN'C,— '� 3.0675 ACRES,- �� ��/ a DB.41 PG. 387 X IR 25• �P� s S� R�_� �•m � ,1�203� M 6�9. 2j tq� � N 1 � ' �' II 9�• S �z � t' 3�~ . OOUBLE POP�AR TREE � �' �I F ��w .7.9325 ACRES+- � � � N ,?9 52' , � m N 56o qp �q„E�oN P�rseo n � ' I � � . _ � �p1All. FOUND : � . � . . 10�1.12 . � ; �i� DAV�D J. SMITH ' „ y Fn p . D.B.153 PG.241 - � � . �i R.R.SPIKE PLACED �L ' / � i � , - , � , , . i � - i � � REVISED I-15-98 i i I � � 200� 100� O� 200� 400� � pAit FO�ND ' � i � / i 1' i JONN iiICHAfiD MOWARD ��� ,h., ,...�����••..,, �JOE ALLEN MEDFGl4D� DA/SY A. � *.� srrE this map was drawn from an actuat ';���,GARO �''•, 8 ,0 11P�d SU�1'^y under Ty dff6CilOf1 �f.Q'�.v�.�S�E�q���9'�. "SCALE' TOWNSHIP CAUNTY STATE DATE � � �,,, and su:� :�+sion, tnat the retio of , F � ; I = 200 JERUSALEM OAVIE N.C. 4-28-86 V a • 4�*p.. precis�cr. 1� t: 10,000 . :� ; S.. A L o_ r� ' =`�� 1 2880 ��: PART OF D.B.122 PG. 625 JOHN LEE BRADFORD et ai. �J ./ / z� •;•o �t�;aQ'�: MARIE TUCKER D.B.188 PG.359 r��sEo iz-a-sa �� ��� � '• 9••�'�'�Ay Q�,` RICHARD HOWARD JOB N0. � w � ••�/r. ""' I : � \ , Rep�:�.roa�anasureror L�800 ••.;hAfi��;;rf SURVEYING L�CATION MAP �~�~~• RIDVANCE� N.C. 86050 . y �. � � � Y ' = �� � - . � �avie County.�CeaCth �epartment � „h- VMgER: and.�-Come �CeaCth.�genc� . NEYJ ?�E Mp�,R H�2� 1� �nvironmentaC�Cealth Section �FEC'C 336 75�_876 P.o.�c RIER os�o-0s s�E�r MOCKSVILLE,N.C.27028 , � ' PNONE:(704)634-8760 April 21, 1998 Darryl tiedford 167 Jeseica Trl. Mocksville, NC 27028 . Re: Site Evaluation Boxvood Church Bd. Tax PIN: �15745-83-7815 Dear Clientts) : As requested, a representative from this office visited the aforementioned site on April 13, 1998. Based upon the information provided on the application for site evaluation and after the evaluation �as completed, the site was found to be provisionally suitable for installation of an on-site sevage disposal system. If you have any questions, please feel free to contact this office. Sincerely� Jeff G. Besuchamp� . . Environmental Health Specialist JB/wd Enclosure(s> � : �vi�,1 ����- (9-a�-��) cc pa U