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1087 Wagner Rd OPERATION PERMIT or fice U§U Ufflv Davie County Health Department *CDP File Number 138507- 1 210 Hospital Street ti P.O.Box 848 County ID Number. ���"'� Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Gene Dickey Property owner. ,lames Anderson Address: 4815 Southwin Drive Address: 177 Hickory Drive City: Winston-Salem COY Mocksville State2ip: NC 27104 State2ip: NC 27028 Phone#: (336)608-2643 Phone#: (336)608-2643 ProperW Location & Site Information Address/Road#: _ . Subdivision: Phase: Lot: Wagner Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY" US Hwy 601 N. To left on Liberty Ch Rd. Left on #of Bedrooms: 3 Wagner Rd and property on right. #of People: *Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert 'System Classification/Description: TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations,Robert Seprolite System? OYes eNo Design Flow: 3 6 0 GRAVITY-PARALLEL d-box Pump Required? Distribution Type: (�' ) 0Yes A&No Soil Application Rate: 0 3 *Pre Treatment: Drain field Nrification Field 1 a 0 0 Sp *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 4 Installer: Tim Beeson Total Trench Length: 3 0 0 ft. Certification#: 3018 Trench Spacing: _ 9 Inches O.C. Feet O.C. 'EH S: 2140-Nations.Robert Trench Width: _ 3 Olnches &Feet Date: 0 7 / 0 7 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 . Inches Minimum Soil Cover. a 4 Approval Status'. Inches Maximum Trench Depth: 3 6 ® Approved D °Disapproved Inches Maximum Soil Cover. 2 4 Inches CDP File Number 138507 - 1 County ID.Number. Septic Tank ' Manufacturer. Shoaf Let. STB: 760 Long: Gallons: 1000 Installer. Tim Beeson Certification#: 3018 Date: 0 1 / 0 8 / a 0 1 5 ` *EHS: 2140-Nations,Robert *Filter Brand: POLYLOKPLA 22 With Pipe Adapter ST Marker. ❑ Yes No Date: 0 7 / 0 7 / 2 0 1 5 Reinforced Tank: ❑ Yes ® NO Approval Status 1 PieceTank: ❑ Yes ® No i®Approved❑=;Disapproved Pump Tank Manufacturer. Installer PT: Certification#: Gallons: *EHS: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeigttt: ❑ Yes ❑ No (Min.6 in.) Approval Status , Reinforced Tank: _❑ Yes ❑ No =❑ Approved❑ Disapproved 1 Piece Tank;_ ❑ Yes _ a- No ee _ . , Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings Yes ❑ NO Approval Status t❑ Approved© ,Disapprovetl Pump Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS' *Chau: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ NO App ravalStatus', PVC Unions ❑ Yes ❑ No V­ed D Dlsapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 No CDP Fite Number 138507 - 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer. Box 12 inches Above Grade E3 Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: ' -Approval Status Alarm Audible ❑ _Yes ❑ NWo Alarm visible ❑ Yes ❑ ❑ Approved❑ Disapptoved 2140•Nations,Robert *Operation Permit completed by: Authorized State Agent. Date of Issue: 0 7 0 7 / 2 0 1 5 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal .15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a WPE a A, sewage septic system. Rule.1961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System,Review ByThe Local Health Department: N/A _. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator. N/A Reporting Frequency By Certified Operator. NIA Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. C)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** {. . OPERATION PERMIT 138507 - 1 1 Davie County Health Department CDP File Number: , 210 Hospital Street County File Number: P.O.Box 848 Mocksville NC 27028 Date: w Olnch Drawing Drawing Type: Operation Permit - Scale: OON A k ft. I C I � CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 138507- 1 Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: NEW 00— P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax: 336-753-1680 0 8 / a 9 2 0 1 9 Applicant: Gene DickeyProperty Owner: James Anderson Address: 4815 Southwin Drive Address: 177 Hickory Drive City: Winston-Salem City: Mocksville State/Zip: NC 27104 State/Zip: NC 27028 Phone#: (336)608-2643 Phone#: (336)608-2643 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Wagner Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY US Hwy 601 N. To left on Liberty Ch Rd. Left on Wagner Rd and property on right. #of Bedrooms: 3 #of People: 'Water Supply: PUBLIC System Specifications CFlowMinimum Trench Depth: a 4 : Provisionally Suitable Inches Minimum Soil Cover: O Yes No 1 a Inches 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches *System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: QYes ®No O May Be Required Nitrification Field 1 2 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: QYes ONo Total Trench Length: 3 0 0 ft GPM--vs— ft. TDH Trench Spacing: OInches O.C. _ g ®Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 O 111 01V 1 ) Page 1 of 3 a CDP File Number 138507 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:®Yes O No O No, but has Available Space CDesign System Inches O. . Trench Spacing: 9 O fication: Provisionally suitable — ®Feet 0.C. Trench Width: Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 3 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 LESS) a Inches Maximum Trench Depth: 3 6 *Proposed System: 25%REDUCTION Inches Nitrification Field ], a 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 *Distribution Type: Total Trench Length: 3 0 0 ft. Pump Required: OYes ®No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R mer'mg 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Characters 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the Information submitted in the application for a permit or Construction Authorization Is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(A 937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes O No Applicant/Legal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 9 / 0 a l a 0 1 4 Authorized State Agent: Malfunction Log OYes (9)Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 138507 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 09 / 0 .2 / a 0 1 4 0 Inch Drawing Drawing Type: Construction Authorization Scale: 0 Block 0 N/A i A, t L............................... ... ........ ...................... ............ ............... 'Ole ............. C 777t�R I .............................................. Page 3 of 3 Pi P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 138507 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: A9J 0.2 /.a.0.1.4. Click below to import an image from an external location: Drawing Type:Construction Authorization � 3 � 0-- 40 --4 <z �ttP S Page 3 of 3 P1 P2 IMPROVEMENT PERMIT For Office Use Only *CDPFIIe Number 13$507.- 1 •., o Davie County Health Department w 210 Hospital Street County ID Number .4 �. P.O. Box 848 Evaluated For NEW Mocksville NC 27028 Township Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 6/18/2019 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Gene Dickey Property Owner: James Anderson Address: 4815 Southwin Drive Address: 177 Hickory Drive City: Winston-Salem City: Mocksville State/Zip: NC 27104 State/Zip: NC 27028 ���Pne#: �(336) "-"_._._____-._-"__ -Phone#: (336)608-2643 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Wagner Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY US Hwy 601 N. To left on Liberty Ch Rd. Left on #of Bedrooms: 3 Wagner Rd and property on right. #of People: *Water Supply: PUBLIC System Specifications Initial -System *Site aSSI Ica ion: Provisionally Suitable Minimum Trench Depth: a 4 Inches SaproliteSystem? OYes (gNo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 3 1-Piece: O Yes ®No . Pump Required: OYes (9 No O May Be Required *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes O No Repair System Required:®Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes (9 No O May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 138507 - 1 County ID Number: *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rte" 750 _ - - ------ - - --------- - *Permit Conditions _ ------------ - - ---- - -------- The issuance of this permit by the Health Department in noway guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. R xn ng 750 Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equals no more than 60 feet,that Includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or Intended use changes(NCGS 130A-335(f)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring, reporting,and repair(.1938(b)). Applicant/Legal Reps.Signature Required? O Yes O No Applicant/Legal Reps.Signatures Date: / / *Issued By: 2140-Nations,Robert Date of Issue. 0 6 / 1 8 / 2 0 1 4 Ov OValid without Expiration? Authorized State Agent: O Create CA? ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 138507 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Improvement Permit Scaler , O Block Q N/A ft. 51 A- OL Lq Q 4 Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 138507 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: A 6./.1.8. .a.0.1.4. Click below to import an image from an external location:Drawing Type: Improvement Permit Page 3 of 3 P1 P2 D . APPLICATI FOR SITE EVALUATION/IMPROVEMEN IT & ATC 4 1� Davie County Environmental Health CEIVED 2� P.O.Box 848/210 Hospital Street moa: Mocksville,NC 27028 IZ4 V (336)753-6780/Fax(3 gxpansion/Modification 680 Application For: ❑ Site Evaluation/Improvement Permit To ons /t(��C) Both Type of;Application: ❑New System ❑Repair to Existing System of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name 147en'e 1G Se Contact Person S kyL Address b '• Home Phone City/State/ZIP yt S 4 Business Phone Email c e .' . C Name on muV C i ren han Ab ve Mailing Address,` 1 , � City/State/Zip PROPERTY INFORMATION *Date HouseXacility Corners Flagged MG- 1 �1 NOTE: A survey plat or site plan must accompany this application. Included: Site Plan lat(to scale) (Permit is valid or 60 month ith sit lan,po expiration with complete plat.) ; Owner's Name Phone mb Owner's Address C 6 N V or, /-Citv/StaW/`Zip Property Address �Y iG Lot Size a. 10 TaKPIN# Subdivision Name(if applicable) Section/Lot# 6� Directions To Site: Specify Problem Occurring: //f ,0 N� J� IF RESIDENCE FILL OUT THE BOX BELOW Aldo #People 6K #Bedrooms #Bathrooms d. Garden Tub/Whirlpool ❑Yes No Basement: ❑Yes o Basement Plumbing: ❑Yes 9lo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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:"Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other - Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'I-No If yes,what type? 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 permit(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 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flaggin r st in the house/facility location,proposed well location and the location of any other amenities. Pro owner's or owner's legal representative signature Site Revisit Charge Date(s):' -Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account Revised 11/06 Invoice# -7 Nom ! i -� r I 1zCs e� -736. ' r V ^ � r N _sem--- . � Q1 (11 s I' r �a7s- , 1 10 r+ f , I ! ------ ,j1065 c� r s PrintedWay 12, 2014 All data is provided as Is without warranty or guarantee of any kind either expressed or implied including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina, its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT i Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: Tax PIN/EH#: - Billed To: Subdivision Info: Reference Name: Location/Address: /_ ' Proposed Facility: Property Size: Date Evaluated: (� ! ? ;.i Water Supply: On-Site Well Community Public + Evaluation By: Auger Boring Pit Cut , . �. FACTORS 1 2 3 4 5 6 7 Landscape position L. Slope% HORIZON I DEPTH — Texture group C Consistence Structure Mineralogyl� HORIZON lI DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence i Structure i Mineralogyj HORIZON IV DEPTH i Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE A ^ SITE CLASSIFICATION: EVALUATION BY: 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-Ten-ace 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 ! NS-Non sticky SS-Slightly sticky S-Sticky VS Very Sticky NP-.Non plastic SP-Slightly plastic .P-Plastic VP-Very,plastic i 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 i Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface j 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-Lone-term accentance rate-aal/davM2 ru-un nvnc mo..—AN 160 Mier r.wri M M C•'•A'r w 6.!J Mnrp.i•p k v r•wl.Mlw Mr low•UwN,' - .. I I e ,, +qw.+►r.wwi.wrrwM..w.t"ww'~^r•: __-- - - I a.�r �7"1R0�•: . •r•i•.•w w r�'rw..yww.r -I. PQ 1l! oa soy.Pa sat VICINITY MAP I N •aaiar a ay7/s o�6ft 6.rr...•f►A 'Ci' : DJR 1pl. • ..r i rworr+w+ t nw for�gtrarn r. p�1•rr�,x y QQDaEL 7 MAN Lo 6706 wt net.e•t M wr 0 f - vht.f�r� rtswa►.ne�ur+.r�r IRIAw l.OIJ IC. -__-___- .1�1 •��rIOIIIY NII[drt 00U1H' '. .. —••—__�,__„� �y�.,�p� ..i. Al ae ------ a nr..o WACM GL A h � ;,AdPIR �I a. Psr� a PCL Is* i I er.y L «..,trr w.tae w t fwl o aX a , .rrl.s•r.M.r•h•.I w..rr.fop•.r. RARget i --•r 1% -11ti (rl '•"w M' II•S !,PC. IO2 �+ �,C',Z:- .. 06 ON tr.l s wt..r.Fw•.rrrw.ir w.rQ'ij ' .. _ .. t.totla lee.t. -f'rIM•r % rr�,- - '6.ltltf AM 4 4iit AdO �. W t1A1 dww o.�.. - ... ------ A.in lot - i Ifttfwll teelem • i�.. for i a 0rr •IrM•Irelrrlr �+�� LJIIL.t000IC. I �' . lam ua ett IVo a�ROI AIG, I>f•: I � • Plr.� R P6; 18 NcAft d a pa Y/rilt ' P S 48',s r� _ _A`v PLAT MAP JAMES S. ANDERSON i I owmot -J«.��w�OMLDKR JAI&A.MIOE'M ` I . , I"1/am am , Lvmn u.M C t7ori 4 i••� r..i••`Itwn 0 a. Zoo"JLd.r wAittte+r•rrcen.•rrr••twrw•ri.r..i..r.w fIyr+rr.r•r.w.•1/.'�..w.y+w twrirtrlr►r"w.r•rrJr~••'trwrerl.t.w r w g P 1. MEUNT,ETOW TOWNSHIP set . COYNORTH CROU. NA 184 CO DA`I OLT-6-2000 rrp • ' r�"r r•ww r w a^r..e•r Do 30. jos 61 ru� a �-t "a t TAX YAP ■ !-6.PARCEL 610hd rile "w'a'}' I , "A rte. `.daw ..e•w. ..�w.:~ P.D.7. X C1tANT .I / '~'altAev[14D 6M '1 ��• •.rwu.l HA1tidS7 0 /1"c�^: 't ---------------- Web4177Tnow f.µ,,•� �' SURVEYQV6 C011PANY r�IRI i• •••'��wi"i r... / .. .. 107 NORM SA1156URY matt � ��FOOD / 1 IISKtG MC 27086 1 AR 7'Rf / (576)751-5816 1 60 90 0 i 60 1 120 ts0 ii Arcooa i I. ' �4 PIR 0[0 1 I .'SCALE IN FEET l � 1 :. ras M•N6 ,: is ANO-006 �•wotenwov '. I n ` 2. ' 0 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC �F Davie County Health Department Environmental Health Section D L5 U 15 v Q P.O.Box 848 V Mocksville,NC 27028 JUN 1 0 1998 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES ED ENTAL HEALTH ALL THE REQUIRED INFORMATION IS PR 1 �l1NTY 1. Name to be Billed Contact Person n— Mailing Address Home Phone City/State/Lip Q 1 Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address � City/State/Zip 3. Application For: 9 --Site Evaluation ❑ Improvement Permit&ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. =ishwasher # People # Bedrooms �� # Bathrooms ❑ Garbage Disposal Washing Machine WtasementIPlumbing ❑ 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 ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �l ch /rlWRITE DIRECTIONS(from - _�L� - �j� M�- ksville)TO PROPERTY: Tax Office PIN: # • "1' Property Address: Road Name C0 Fr. City/Zip 0174,ge ' Ad. If in Subdivision provide information,as follows: ' �� /' bN Name: Section: Lot #• 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 this application.I,hereby,give consent to the Authorized Re resentative of the Davie County Health Department to enter upon above described property located in Davie County 9.and owned by to conduct all testing procedures t as necessary to determine the site suitability. DATE 7 • l SIGNATURE J/" Revised DCHD(06-96) c 'J J % .l V. _ At �;.. .- . . Nory... " %, c, of 00.4Ca .('�4��/ A • . •n .• . Wf (-�j1I/�Jr 1(0 J A,nk,0.�/ - Q& HEM 4y g- t k a t c, 9&1" Ge o! 6 t wit 1k. bkrrc.1c,Z,(/m , A I.R. PEOPLES L E .: S S 0 D. • _ _ 16 E•- r> fund 396.76--- - r r. spike tJ `$od drove / found PARCEL III. TA X MAP F-3 v' RUI USth BECK O D.g. 29- 485 o j= V M N Q�t ' � M � 1 � S 62o- 14' E., p � c° N 'fon "Ound Z A. o r.S Ake found 956. 74• /17 z .m t.•- o s z -a o _3 N r Spike p` t` O f,un , Q ^ ol ca M 1 O ri N / 6 mN 27. 586 ACRES , m • •,.c► 162.7-r r'r spike fu.ind G N830-44_,}D..W J: Q�1 `•/M ov .^ � �; / �0 T 3.� `� PaRCEL 53ALA J L L"; 0 •;01 LY 9 62 •C JI) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �/IGJG/G��Sa/►/ DATE EVALUATED �O PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME Y /J�i�' Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH P . Texture group Consistence � Structure /l T ✓L Mineralogyt ' 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: EVALUATION BY: 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-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(01-90) ■■■■■■■■■■■■e■■■■s■■■■■■■■■■r■r■■■■r■■■■■■■■■cert■■■■■■■■■■■■■■■■■ ■■■ecce■■■e■■■■e■■■ecce■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■e■■■■e■■■■ ■cern■■■■■■rs■■■r■��■■■■v■■■■■■■■■■■■r■■■r■■■■■■■■■■■r■■r■■■■■■■■ MENNENMENNENiiiiiiMENNENMENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■sr■■■■wee■■■■■■■■■■■■■■■r■■eer■■c■■■■■e■■ ■■■■■■■■■■■■■■■■■■■■■■sr■■■r■■■gee■■■e■■e■■■■■■■r■■■■■e■■■■■■■■■■■ ■■■ecce■■■■cc■■■■■■■■■■■■■■■eeeeee■■■■■e■■■■■■■e■eee■ec■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■se■■■■■■s■■■■■■■■■■■■■eee■■■■■■r■■■■■■■■■■■■■ ■■■■■■■e■■■■■c■■■■■■■■■■■■■■■ecce■■■■■■■■■■■e■eee■■■e■■■■■■■■eee■■ ■■■■tt■■t■■■tt■■■■■■t■■■■■■t■■■■■t■■■■■t■■■t■■■■t■■ttttt■■■■■rrrr■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ee■■eee■■■■r■■r■■■■e■■e■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■r■■e■■■■■■�■■■■■r■■■■e■■■■■■r■■■■■■■■eee■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■r■■■■■e■■eee■r■■■■■■e■■■■ecr■■■■■■eee■■■ ■■■■ee■■■■■■■■■■■■■ee■■■e■■■eee■ ■■■■■■■e■■■■■■■■■e■■ee■e■■■■e■■■ w DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P.O. BOX 848 MOCKSVILLE, N.C. 27028 336-751-8760 June 30, 1998 Mr.James Anderson 177 Hickory Drive Mocksville, N.C.27028 Re:Site Evaluation Site 1,Wagoner Rd. PIN#5811-72-7635 Dear Mr.Anderson: As requested,a representative from this office visited the aforementioned site(s)on June 29,1998 . Based upon the Information provided on the application for the 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, A44-e& �. Robert B. Hall,Jr., R.S. Environmental Health Section R$H/jm Enclosure(s) ' AFPLICATION FOR SITE EVALUATIONAMPROVEMENT PERM Q tYJ Davie County Health Department OV Environmental Health Section JW ' O 1998 Qf't P.O.Box 848 j/ Mocksville,NC 27028 (704)634-8760 Won't NEAITH RUt ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed 6124YIJ- 1,4-Ai�� Contact Person �y f-e4&n� Mailing Address < Home Phone l��Y�— ��y l il- &- L 1-4& City/State/Zipd d,zg' Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address /� City/State/Zip 3. Application For. 9" Site Evaluation ❑ Improvement Permit&ATC - ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ''❑ Other 5. :7ishwasher iden : # People # Bedrooms .1 # Bathrooms OZ ❑ Garbage Disposal Washing Machine asement/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 ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: 4S756- 1 WRITE DIRECTIONS(from M Ile)TO PROPERTY: Tax Office PIN: # - ��. - - ®IUO� 1 dZZe� on) Property Address: Road Name 1 - Citymp 1 tree Rd. If in Subdivision provide information,as follows: Name: Section: Lot #• 1 1 This is to certify that the information provided is correct to the best of my knowledge.I understand that any penmit(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 this application.I,hereby,give consent to the Authorized Re resentative of the Davie County Health Department to enter upon above described property located in Davie County and owned by F to conduct all testing procedures as necessary to determine t(h�e site suitability. DATE 7 • l SIGNATURE Revised DCHD(06-96) ,/5 I� � � RPP J"08 _ � 3S Jya}q�y pw`l�ci of Qa,��G cok%+y lab L ..., /i�_ • • :.Ir'•. L.irC�ITJ 'f/ :Ir JW ♦M/Ar 4�i "&Nay L =�►�It� �.�LS'�'S1/ O� ��t�i ,,���� .. •. .... ,.. �,� � stirs .1. I• ., I •r ` • \ llAf� t� *SMOL �� I.i ,.1'/ X11 • .... .w+ �• r;w ;! ..,.. I.R. PEOPLES D_S.58-592 t;. I _ _ S830- 16 IrdA E—s found 396.761-—— — r r. spoke W 35011 dnve -� found N M PARCELWCIO / 1111 TAX MAP F-3 P R U`US8 ECK - ' �� /t w O.B. 29-485 s r=: /t 1 M S 6 2°- 141 E--+- ev p /o N I/On ~ 956. 74' `ound Z o; o Cr sp�Ik�e found �iI w 111\fir �. 0 co - O 01 z o / -3 N Q 4 rr h . 1 Splk CI' Infoin ti . 0 IF `f o1 °i ti a /) In CV m N ry o V ,27. 586 ACRES 1s2.T-:� m ••..: / r Spikr found C �9n , .T 01 �, �`v o1, Q o ` - c co : PARC_` 53 2 e r�" - -' 62 •C k -- • • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME 'e fS' DATE EVAL ATE �- U ) C/ PROPOSED FACILITY :/ Y PROPERTY SIZE C //, SUBDIVISION ROAD NAME A Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Sloe% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON 11 DEPTH > F A Texture group " Consistence r- Structure 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: EVALUATION BY: �( LONG-TERM ACCEPTANCE RATE: L OTHER(S)PRESENT: i REMARKS: 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(01-90) J DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P.O. BOX 848 MOCKSVILLE, N.C. 27028 336-751-8760 June 30,1998 Mr.James Anderson 177 Hickory Drive Mocksville, N.C.27028 Re:Site Evaluation Site 2,Wagoner Rd. PIN#5811-72-7635 Dear Mr.Anderson: As requested,a representative from this office visited the aforementioned site(s)on June 29,1998 . Based upon the information provided on the application for the 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, Robe all, Environmental Health Section R$H/j m Enclosure(s)