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123 Potters Ridge Dr Lot 8 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section 1� P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT(OPERATION PERMIT Account #: 990001716 Tax PIN/EH#: 5843-63-5666 Billed To: Robert Woody Subdivision Info: Potters Ridge Lot#8 Reference Name: Location/Address: Potters Ridge-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2829 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 tic)t S :� #People 2 #Bedrooms —S #Baths Z Dishwasher: 0" Garbage Disposal: ❑ Washing Machine: U Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size FS'1 Q0,0C'> Type Water Supply Design Wastewater Flow(GPDJ�� Site: New 121"' Repair❑ �► n System Specifications: Tank Size I()CO GAL. Pump Tank GAL. Trench WidtO Rock Depth `2 Linear Ft. "1�0 1 Other: le7— N�STA,Q, UN)C,J 91 -0-- 1%,k- Required Site Modifications/Conditions: 0 3TAL1L C), 'tpk)TDoQ, v G(--r g©ura:E 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.**** 'Tl �v O �� , ApP2bx,. Ips r Apl�(LQv-. lir Environmental Health Specialist's Signa Date: J DC 05/99(Revised) ��mF-WP, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990001716 Tax PIN/EH#: 5843-63-5666 Billed To: Robert Woody Subdivision Info: Potters Ridge Lot#8 Reference Name: Location/Address: Potters Ridge-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2829 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 WASTEWATER CON UC VAL A PERIOD OF FI YEARS. Environmental Health Specialist's SignatuC-7D Date:v �` CERTIFICATE OF COMPLETION **NOTE** The issuance of 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. � ZQ� Q 2 , V- d4TC 4-9 Septic System Installed By: �� Environmental Health Specialist's Signature: DCHD 05/99(Revised) Q ON FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Eavironmenta/Health 5;eWon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 a11�EC0l1:dTY (336)751-8760 ***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 Robert Woody Contact Person Mailing address 1137 Edenwood drive Some Phone 760-6246 city/state/ZIP winstan Ga 1 em Ne 27103 Business Phone 718-1829 2. Name on Permit/ATC if Different than Above Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both 4. system to service: RHouse 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: / People tjja # Bedrooms three # Bathrooms two [5t Dishwasher n Garbage Disposal Washing Machine ❑ Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/Other: specify type # People # sinks i Commodes ; showers # Urinals / Hater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Nater supply: ❑ County/City ❑ Well 0 Community S. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 0 No 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: 475 ' -540' -460' -417' WRITE DIRECTIONS(from Mocksville)to PROPERTY: f1SP3-(.3- S664 Tax Office PIN: # pg^^^^nnF'7Q Take I-40 East Exit'-.farmington road Property Address: Road Name Lot 8 Potters Ridge turn left-go though the light City/Zip Farmington 27028 at farminaton go one mile. turn left If In a Subdivision provide information,as follows: on p i n e v i l l e rd go 300, turn left Name: potters Ridae on potters ridge rd. the first lot on Section: Block: Lot: 8 Date Property Flagged: 4-20-2001 the r].eftit 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 1 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 Rohart woody to conduct all testing procedures as necessary to determine the site suitability. DATE 4-20-2001 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). Site Revisit Charge C p/< Date(s): �a► Client Notification Date: EHS: Account No. ` Revised DCHD(07/99) Invoice No. 49 ''b, Air AM db o' v� �� _ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. Soil/Site Evaluation NAME DATE EVALUATED ADDRESS S #� t�v PR9PERTY SIZE �' l PROPOSED FACIILTY 1A �, � LOCATION OF SITE 7'071-6 es R 1 a �, r %0-/?•g%/. Water Supply: On-Site Well 2 Community Public ✓,✓�J® Evaluation By:C�,,LAugerBoring L/ Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z 15i-1,5- HORIZON HORIZON I DEPTH el I' Texture grouR Q1 L L Consistence -7 _ Structure Mineralogy ) HORIZON II DEPTH Texture group Consistence �- Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION . (p, S LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: EVALUATED BY: LONG-TERM ACCEPTANCE RATE: 1 OTHER(S) PRESENT: ,va '0 Q REMARKS: � *� ` .� '''� A 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 :lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR--Vc.-y 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 3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralog 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 J APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT • Davie County Health Department Environmental Health Section it , i�+ U V( P. O. Box 665 AUG 2 _ .. Mocksville, NC 27028 ... 1994 1. Application/Permit Requested By W - -TZ• - ---- i__ Mailing Address / 2 3 %44"", )?d_ Home Phone 9S IV -3 �l/ 71(OC,CS Business Phone 2. Name on Permit if Different than Above 3. Application for: AGeneral Evaluation ❑Septic Tank Installation Permit 4. System to Serve: House -3_3o_q e El Mobile Home ❑ Place of Public Assembly p � ❑ Business ❑ Industry_F0��K -s b Other ❑ Unknown :7�fisr 5 5. If house, mobile home: Subdivision Section keC# 9-q-10-)J ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public ❑ Private ❑ Community 8. Property Dimensions :a-y aCl• ��`�' Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: �I/1ou9 4 1116- Rd AJ 0-p/1 FluA ! This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: �1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD(1193) •L D AVIE COUNTY HEALTH DEPARTMENTg Environmental Health Section Soil/Site Evaluation �KR� NAME �J , �% �R DATE EVALUATED �' 2 ADDRESS PR ` PERTY SIZE Gll' PROPOSED FACIILTY 1AC3 Q j < -5-�-IOCATION OF SITE Water Supply: On-Site Well c Community Public Evaluation By:CV____�AugerBoring V Pit Cut FACTORS 1 2 3 4 Landscape position Slope Z -3-1-570 HORIZON I DEPTH Texture group L_ Q L Consistence -' )' S Structure Mineralogy HORIZON II DEPTH LAD Texture group Consistence y•- Structure k 1 k Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: e' EVALUATED BY: (�� LONG-TERM ACCEPTANCE RATE: —L R OTHES) PRESENT: 'Q a N REMARKS: 3�� ��}^'� 1 �� 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 flay 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 3C-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(01-901 ■■■■■■■■■■■■■■.■■■■■.■.■.■■■■■■■■■■■■■..■■.■■■.■■.■■....■■ i .N■ .................................................................. ................................ ................................ ........................... ................... .................. 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Mocksville, HC 27028 lz /0 Re: 4 Site Evaluations) .5 Pineville Roadk6et-w 8, 9, 10 & 11 Dear Mr. Spillman: As requested, a representative from this office visited the aforementioned sites on August 29, 1994. Based upon the information provided on the application for a site evaluation and after the evaluations were completed, four sites were found to be provisionally suitable for the installation of an on-site sewage disposal system on each site. If you have any questions, please feel free to contact this office. Sincerely, Charles E. Little, R.S. Environmental Health Section CL/wd Enclosure