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139 Tutterow RdAccount #: 990001928 Billed To: Franklin O'neal Reference Name: Proposed Facility: Residence ATC Number. 3094 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH M 5729-11-0079 Subdivision Info: Location/Address: Tutterow-27028 Property Size: see map **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 174 #People J #Bedrooms �� #Baths Dishwasher:/Zr— ishwasher: Garbage Disposal: ❑ Commercial Specification: Facility Type Washing MachinejEr- Basement w/Plumbing: ❑ Basement/No Plumbing: #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply eh Design Wastewater Flow (GPD) Site: New ❑ Repair ❑ et System Specifications: Tank Size.�� GAL. Pump Tank GAL. Trench Width Rock Depth �/Linear FD Other: Required Site Modifications/Conditions: 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.**** l� Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990001928 Billed To: Franklin O'neal Reference Name: ATC Number: 3094 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5729-11-0079 Subdivision Info: Location/Address: Tutterow-27028 Size: see 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 WASTEWATEONS,TRUCTION IS VALID FOR A PERIOD OF FI'V/E. YEARS. Environmental Health Specialist's Signature: rd Qa�a A<, Date:�-- 611 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate ofGxnp let..._�Ls has been installed in compliance with Article 11 Disposal Systems," but shall given period of time. I indicate the system described on Improvement/Operation Permit .a ter 130A, Section .1900 "Sewage Treatment and as a guars that the system will function satisfactorily for any � / AG X�� Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date:`'(/ L� ltd /0-)°-(3/ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department ! � e) Environmenta/Health Section P.O. Box 848/210 Hospital Street f� Mocksville, NC 27028 I (336)751-8760 SEP 4 Din �` ONMENTAL NE '�OUNIY ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed rZ7),)1e4',J L e� IContact Person E64NktW Q',,,JetgC Mailing Address ) IMAMS Home Phone 336- City/State/ZIP n�Svj`LCe /y? �i02c Business Phone y39y�S --S3y� 57SS 2. Name on Permit/ATC if Different than Above $Alne Mailing Address City/State/Zip 7m,y_nZ 3. Application For: Site Evaluation ❑Improvement ermit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. If Residence: # People 3 # Bedrooms' # Bathrooms Dishwasher XGarbage Disposal Washing Machine ❑ Basement/Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People Basement/No Plumbing # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: Jd County/City d Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is.intended to serve? ❑ Yes gNo If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBM17TED by the client with THIS APPLICATION. Property Dimensions: C<SL-e--�- Tax Office PIN: # FV1 aq k I DD Sq Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: -VW dko.ss T -yo W O J 7ULket : U 4e) �n L R7 t-4At'-o-0 L)%N) Vbu�kCl ; tJ l7l2i ve yo �� 601,1j��t- 71I iNq ►4 1POp� - aeA �'ri AT/ 14 IAP Loe47/O/l) � �W5e- !`S __5�. 4 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 w 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 testing procedures as necessary to determine the site suitability. DATE �- `"� " SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHe07 ) j5 0- Site Revisit Charge Datc(s Client Notification Date: EHS: Account No. Invoice No. vim- S 4— 3871 528 186 1.78 A 3516 N N N 0 (6.23A) (2.22A) 6316 DROJECT ROAD# 8.1732403 SHEET 25 (311) 15 h (2.89 A) n A n1 8297 H300000079 (8.76A) m 7120 0079 (ISg) * ^ a r Lw (10,) T �� 6631 'Yqq \ 7531 , 8497 (13.32A) 4090 66, 8752 0 N 37.54A 1656 N.C. D.O.T. PPOJE2T f SHEETS 14,1 f'. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001928 Billed To: Franklin O'neal Reference Name: Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5729-11-0079 Subdivision Info: Location/Address: Tutterow-27028 Property Size: see map Date Evaluated: �-,2_"— Community Evaluation By: Auger Boring Pit Public J.'_�-- Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH y Texture group Consistence / Structure tL Mineralogyi 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: '0 LONG-TERM ACCEPTANCE RATE: r Z REMARKS: EVALUATION 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 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 05/99 (Revised) WATER SAMPLE/SEWAGE SYSTEM CHECK REQUEST Date Requested: DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Received By I`git- WATER SAMPLE TYPE: Bacterial 7) Protected O Chemical O-Onprotected O Dug O Other: O Bored O Drilled O Outside Spigot: O Other: --��------------------------------------ SEWAGE SYSTEM CHECK: O Yes Vacant: O Yes O Approved O No O Disapproved Owner's Name: l—/an k-L,,J U 'JVC L Buyer's Name Property Address: -c te o -,L) Directions: C o• ,,--o Special Instructions:2C Letter To: Closing Date: Attn: #:::- ------------------- 1 A d a ,7, s- /X-(-, C -,,s Date Taken: 74 Charges: Telephone: - By: DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street Courier #09-40-06 Mocksville, NC 27028 Phone #: (336)751-8760 October 01 , 2001 Franklin L.O'Neal 111 Adams Road Mocksville, NC 27028 Re: Site Evaluation/ Tutterow Tax Office Pin : #5729-11-0079 Dear Client(s): As requested, a representative from this office visited the aforementioned site on September 27, 2001. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/di