154 Princton Ct Lot 12 • / DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990001825 Tax PIN/EH#: 5860-81-5359
Billed To: Mike Hester Subdivision Info: Princeton Lot#12
Reference Name: Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: see map
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ATC Number: 2907 /0 /'ONMON
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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 WAS CO N IS V ID FOR A PERIOD OF22FIVE YEARS.
Environmental Health Specialist's Signatu e: Date: c J b/
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 AY taken as a guarantee that the system will function satisfactorily for any
given period of time.
Cos � LlrsG N oY
fie% 5 to•
U^1ioSD
WATIER- 1-1-1E
SST
Septic System Installed By: A �✓� ^' �'��
Environmental Health Specialist's SignaCe: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section `
P.O.Boz 848/210 Hospital Street
Mecksvlllc,N'— 27028 — -�
-- (336)751-8760 -
IMPROVEMENT/OPERATION PERMIT
Account #: 990001825 Tax PIN/EH#: 5860-81-5359
Billed To: Mike Hester Subdivision Info: Princeton Lot#12
Reference Name: Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: see map
ATC Number. 2907
**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 { Q OSC #People #Bedrooms #Baths 2
Dishwasher: Garbage Disposal: ❑ Washing Machine: 12"' Basement w/Plumbing: Ur" Basement/No Plumbing: ❑
Commercial Specification: Facility Type # EI
„People #People/Shift #Seats Industrial Waste:
Lot Size 3I 10�2 Type Water Supply CW� T Design Wastewater Flow(GPD) Site: New En/ Repair❑
System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width &n Rock Depth
cIT'
Linear Ft.2S-b'
Other: 3 'D1STP.Q�-r o•J`� t� SfAt� L.1��S l O•L' .
Required Site Modifications/Conditions: C-0”Awoo,, r�CFQ is C.-C i40iaca , 1c,,—p 16 ap
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISIIED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system betty :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.****
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Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001825 Tax PIN/EH#: 5860-81-5359
Billed To: Mike Hester Subdivision Info: Princeton Lot#12
Reference Name: Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: see map
ATC Ny��ppber: 2907
**NOTE** Thls 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 I 1 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 = #People #Bedrooms—/� #Baths
Dishwasher: 21/ Garbage Disposal: ❑ Washing Machine: 03PeBasement w/Plumbing: 21 Basement/No Plumbing: ❑
Commercial Specification:
: Facility Type ^ #People #People/Shift #Seats Industrial Waste:
Lot Size ,,l4q 47Type Water SupplyGOrW Design Wastewater Flow(GPD) 3(-00 Site: New E� Repair❑
System Specifications: Tank Size� GAL. Pump Tank GAL. Trench Widt Rock Depth Linear Ft.�
Other: 3 471ST�tPZO i 10.A �xcS , ` STqu L1n1ES
Required Site Modifications/Conditions: c.�S``All �l�Q 15 l7� 'pFF�
G
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6 G°BELO7ofthis FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection
s tem between 8:30 a.m.to9: a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**
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Environmental Health Specialist's Signature:
it-1
DCHD 05/99(Revised)
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• APPU FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
• JUN 2 7 2001 Davie County Health Department
Environmental Health Section
.O. Box 848/210 Hospital Street
ENVIRONMENTAL HEALTy Mocksville, NC 27028
DAVIE COUNTY (336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruction/s.. I
1. Name to be Billed 11/ 4 1�-eS J-ej Contact Person
Mailing Address a-t / 1 >6 s L /`f`' Home Phone
City/State/ZIP 'Tv VA ti C -7 C.GG Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation vement Permit/ATC ❑ Both
4. System to Service: Clouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms -- .7- # Bathrooms -�
1-1- ishwasher L] Garbage L°f
Garbage Disposal ing Machine 'Basement/Plumbing II Basement/No Plumbing
6. If Business/Industry/Other: Specify type # People # Sinks.
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 0--do--Unty/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes O NO---
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
4
Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: # S (a G�11 — S 3 S79 ( S 'jam c, i3 c7 I ��"i c—<
Property Address: Road Name LG% 5`I.L 117121 Act. C/' +C-4 v`^ cZ G •10
City/zip. k Lle--,-1 C. P y')co 6 C
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date Property Flagged: �c
This is to certify that the information provided is correct to the best of my knowledge. 1 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 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 1 CJ/ 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
Datc(s):
Client Notification Date:
EHS:
Account No. D-5-
Revised DCHD(07/99) Invoice No.
Doti 6Tr•etor, Davie County Planning •portm•ni
i
C,
Parcel 65
F ' James Mayhew
I o D.B. 071-392
CO
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4 - ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
SoiVSite Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900111 Tax PIN/EH M 5860-81-3295.12
Billed To: Gray Potts Subdivision Info: Princeton Lot#12
Reference Name: Gray or Betty Potts Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: 132x317x99x2 Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit ,------ Cut
FACTORS 12 3 4 5 6 7
Landscape position L
Slope% �o
HORIZON I DEPTH - b ,
Texture groupL'L
Consistence $$ SS
Structure k
Mineralogy
HORIZON II DEPTH 10
Texture group
Consistence C:
Structure 614
Mineralogy m i Y-iO
HORIZON III DEPTH Iq •ZCo 10-2-4 -
Texture group C-v
Consistence G;S P R
Structure dJ9 K
Mineralogy ri► 1Gafl
HORIZON IV DEPTH + f
Texture group
Consistence Cr 53 S F- SP
Structure t_ PL
Mineralogy ml
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
..11 \
SITE CLASSIFICATION: V'� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS: l ale
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 fine
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)
.l?h.IGATION-FO ;S TE EVALUATIONAMPROVEMENT PERMIT&ATC
(� [ n _r . �, avie County Health Department `
O Environmental Health Section
IM P.O. Bax 848
2 Mocksville,NC 27028
E V1011.Et1TAL hEALTil (704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed G."2 A.C 1-9u7--/' S Contact Person
Mailing Address /07n ss i?o� • Home Phone
City/State/Zip sl p�44 rJC_gT, C` . Z 7 U U G Business Phone :5f9 fL
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 Serve: P4 House [ ]Mobile Home [ ]Business [ ]Industry [ J Other
5. If Residence: #People #Bedrooms #Bathrooms [ J 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 [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [ ]No
If yes,what type?
EIllli.:lf t 1'L-11 OR SITE- PLAN
PROPERTY INFORMATION REQUIRED:***IMPORTANT**#,A-nNAT OF THE PROPERTY MUST$E'
SUBMITTED WITH THIS APPLICATION.
�
Property Dimensions: G �� 66h
I,'2a;WRITE DIRECTIONS(from Mocksville)TO PROPERTY.
Tax Office PIN: # !5--66 o - �-— !_ 5� 1 _-(J. S /�P L74 5 ol
Property Address: Road lame 43 A C 7WVyx�-�Tj?L� [ A L Zlz22oze ar le c.
Ci /Zi A .4.�/[c Al. C'� ; 70c; � /1/v,rll �'c1 /- ?C��,il.�
City/Zip P —2� � _
If in Subdivision provide information,as follows /�i��,c��d ; �c�4 v / G.i S ?' S/,c-0 4-;'—
Name:
,Name: 4 ;
Section: Lot#: 3(LOT I 1 iJ 040 M 4-P)
M W rµ oe 1 co aJ �r '
This is to certify that the information provided is correct to the best of my knowledge. L 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 gr
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 testing procedures as necessary to determine the site suitability.
DATE 7- / Z �y SIGNATURE
e
Revised DCHD(06-96) '
THIS AREA 11411 13E USED FOIA I)RAIVINC I101IR SITE PLAN:
� r
�� 'Ole
Filed for regis
iiy that the subdlvlslon plat shorn hereon has C&TWUate OJ Approval by the P(anniny �OaTd
.imply with the County SuEdlvlslon Regulations, DEPARTMENT OF TRANSPORTATION -- -
lion o1 such variances. It ony, as noted In the r ianning Board and that It has been o The Da"t•County Planning Board hereby hereby th•final Pkat far tr. DIVISION OF HIGHWAYS
no office of the Register of Deeds. 111 svhereby °d•rood Subdk6ion. In Plat Book
-h approval for recordation does not Include PROPOSED SUBDIVISIOIN ROAD
,stall and dflllce sanitary facilities nor does It CONSTRl1CnONSTANWDSCERnFICATION
vl for the construction or occupancy of Dvlldings -
Date Chd+mon,County PIamInBoard
9 Filing Fee Paid
APPROVED
DISTRICT ENGINEER ------ -- -- —
Director, Davie County Planning OeDaritttenf DATE by� ---__- _—
oF
Parcel 65
James Mayhew
D.B. 071--'92
---------------
S
_yS 83°51'35"E 1548,89'
150.08' 150.08'
1 50.Ofl' 150.08' control corn
150.08' 1
150.08' 112.18'
�9IV r' 5.04'
w W
�n W point
W i
5 16 -
17
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point
148.69' 150.0 int
0' 150.00' 150.00' 150.00'
Providence Court S 85644'15"E 1048.69'
,050.4,' �
S 8.5o44'1 5"E 1050.00' 6&0 ' public
ZS ( 150.00' 15.0.00' 150.00'
y 150.00'
LO O tet - `t tT d' i n i` - �) _ U'; —
7 �n 77
°
1 `'
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900111 Tax PIN/EH M 5860-81-3296.13
Billed To: Gray Potts Subdivision Info: Princeton Lot#13
Reference Name: Gray or Betty Potts Location/Address: Baltimore Road-27006
Proposed Facility: Residence Property Size: 150 x 282 Date Evaluated:
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 - �P
Texture groupGCS G
Consistence
Structure IL 1Z
Mineralogy M M
HORIZON II DEPTH &-10
Texture group
Consistence A.
Structure
Mineralogy 1 M �
HORIZON III DEPTH I L4 -Z<R 70--03
Texture group C4- a C'4Consistence G' S
S Y
Structure :50k--
Mineralogy M )G-00
HORIZON IV DEPTH - Zo -
Texture group
Consistence Fe
Structure S L
Mineralogy �.
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION t?$
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 5 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 05/99(Revised)