159 Foster Road Lot 3• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:.990003432
Billed To: Scott Westbrooks
Reference Name:
Tax PIN/EH #: 5707-81-2043
Subdivision Info: Smoot Acres Lot # 3
Location/Address: Foster Road -27028
-roposea t-acnny Kesiaence rroperry maize: i.uou acres
ATC Number: 3938
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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
/ .
Environmental Health Specialist's Signature: / Date:
**NOTE** The issuance of this Certificate of C
has been installed in compliance wit]
Disposal Systems," but shall in NO
given period of time. `
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Article 11
system described on Improvement/Operation Permit
130A, Section .1900 "Sewage Treatment and
e that the system will function satisfactorily for any
f'4,� Ss1l' 6114vs/
��i SYI
Date --I
DAVIE COUNTY HEALTI3 DEPARTMENT
Environmental Health Section I
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
i
IMPROVEMENT/OPERATION PERMIT
Account #: 990003432 Tax PIN/EH #: 5707-81-2043
Billed To: Scott Westbrooks Subdivision Info: Smoot Acres Lot # 3
Reference Name: Location/Address: Foster Road -27028
Proposed Facility Residence Property Size: 1.958 acres
ATC Number: 3938
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of aseptic 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 D TENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type I14 #People #Bedrooms #Baths
Dishwasher_�Garbage Disposal: ❑ Washing Machin Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People_ #People/Shift #Seats Industrial Waste:
d
Lot Size Type Water Supply L /Design Wastewater Flow (GPD) C7 6 ® Site: New Repair El
System Specifications: Tank Siz&& GAL. Pump Tank GAL. Trench Width M Rock Depth.4t Linear Ft.'20
Other: m
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the . County Health Department for final inspection ofthis
system between 8:30 a.m. to 9:30 a.m, or 1:00 p.m, to 1';30n th installation. Telephone # is (336)751-876q.****
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Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)/ �Y
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APPLICATION FOR SITE EVALUATION/IAIPROVEMENT PERA TC D
Davie County Health Department DEC 8 2004
EDVilonmenta/Health Section
P.O. B6Y 848/210 Hospital Street HFALiH
NTAL
Mocksville, NC 27028 QWIEENIIIRONMENTAL Y
(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 SContact Person
Mailing Address /G( ?(3 Home ,Phone -2-71S 6/-,)8
city/state/ZIP " 644.j, ,o NC -Z Business Phone 7e 14 z! 3 (6 7-5'
'Z. Name on Permit/ATC if Different than Above -
Mailing Address - - City/State/Zip
---3. Application For: ❑ SiterEvaluation- ,Improvement Permit/ATC E3 Both "
9. Systemto Service; 13 House Mobile Home ".❑ Business 13 Industry ❑ Other -
S. Type system requested: 1 Conventional ❑ conventional modified ❑ innovative -
S.- If Residence. # People S # Bedrooms Z # Bathrooms
[]Dishwasher ❑aarbage Disposal dashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type "-. - p People - # Sinks -
# Commodes # Showers - # Urinals #Water coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
e. Typa of water supply: ❑ County/City r. ,Well ❑ 'Community
9. Do you anticipate additions or expansions of the facility tins system is intended to serve?�'cs ❑ No -
If yes, what type? Z4 X 3 0 I'd //-7/ Cs EDQcD/`�
***IMPORTANT*** CLIENTS A1UST COMPLETE TREREQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BrSUBkfITTEDby(lie client lilthTIiISAPPLICATION. - -
Property Dimensions: /fegr,S WRITE DIRECTIONS (from Alocksville) to PROPERTY:
Tax Office PIN: # Toy$ OA✓iG it �rJOP�:y
Property Address: Road NamoS
City/Zip L �j� 7- m ✓ % a tTF�2
If In a Subdivision provide information, as follows:I—
Name: T fte Px S
Section: Block: Lot: 3 Date lions corners Ragged: / a /3 dy
This is to certify that file information provided is correct to the best of illy knowledge. I understand that ally permit(s)
issued hereafter are subject to suspension or revocation, if the site plans or Intended use cbange, or if (lie information
submitted in this application is falsified or changed. Jr, also, Understand that l oa responsible jar all choges incurred jroo
this apPHCa(iai:. I, hereby, give consent to file Authorized Representative of (lie 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_( 2- SIGNATURh�� -
TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of file following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Sign given
Revised DCIiD (05/03
1
E
sit Charge
ate:
UNMARKED PC+NTS IN
LOCATED IN CENTER
CAD TO 5 FEET WEST a)
ENTER LINE. u'%
PINS LOCATED ALONG
ARE 25 TO 30 FEET
OF CENTER LINE. (n
rr
/LLJ
v I
r
4
1 I
�+
u ,
o
AREA - 1.9i7 ACRES
S 840 40' 106 E
7,04.79 TOTAL �
NIP
1 3RM3 2
674.69
Q
J
o
LOT o
F
3 C
M
AREA s 1.958 ACRES
R 0
4 I Z
o
I O
NIP
S 840 98 06" E -
',9.42 TOTAL
r
MS. 32
30.10
1
'
-w
I
LD T
o
AREA = 1.998 ACRES
o IZ
NIP
5300 37' 40" E
73406 TOTAL
0
30.10
I
703.96
I
W I
LOT 5
o
0 /
�/
C
C
AREA = 1.991 ACRES
N 86° 24' 13" E
z 30.10
} I
f NIP N Be 24 13" W NIP
' N 840 07' 35" W
{ + -8737
631.17
o .
� o
s m 12g 32 TOTAL
Z
PP N 86° 24 13 W EiP
25. w�.41
!o
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o jr
IVCTES: (I ) ALL AREAS INCLUDE SR. 1159 RIGHT OF WAY
(2) THIS PROPERTY AND AJCINING PROPERTIES ZONED: RA
(3) MINIMUM BUILDING SETBACK LINES: • 40' FRONT
(from R W line)
• 15' SIDE
• 30' REAR
EDWIN S. SMWT, ET AL (4) TAY, MAP: K-2, A PORTION OF PARCEL 27
D8. 124 PG. 684
D' ATION 1`013 SITE t VALUATION/1hIPHOMIL•NT 111:11M1T & A'fC
MAR 2 iU�i Davie County Health Department
EnvirOninenta/Hes/t/1 Section
P.O. Box 840/210 Hospital Street
ENVIRONMEOUMocksville, NC 27020
DAVIECAUT1M1 (336) 751-0760
I ***IMPORTANT*** THIS APPLICATION CANNOT DL PROCESSED UNLLSS ALL THE REQUIIZED• - --I
INFORMATION IS PROVIDED.Refer to the INFORMATION
� BULLETIN for instructions.
1. Name to be Dilled 4 70 A %`! .S/+..7 / conl-acl• Person
Mailing Address (/O 7 �/ (�/� None' Phone
City/State/ZIP Business Phono
2. Namo on Permit/ATC ifDifferentthan Above
Mailing Address - - City/Stato/Zip
1. Application For: �u^ite Evaluation ❑ Improvement- Permit/ATC IJ110th
4. System to Service; (1House ❑ Mobile Home .❑ Business ❑ Indust:iy ❑ 'Other
ti
S. .Type system requested: pjeeaventional ❑ conventional modified ❑ innovative
6. If Res' ace: 11 People 0 Bedrooms 2:1 Bathroom:
inhwasher ❑Garbage Disposal aching Machine ❑basemen L-/Plumbing-❑Dasomen L/1lo Plumbing
7. If Dusinass/Industry /ether: verify type it People 6 Sinks
I Commodes It Showers D Urinals-
II Water coolers
IF FOODSERVICE: $ Seats Estimated Water Usage (gallons par day)
8. Typo of water supply. ❑ County/City ❑ Well - ❑ Couununi ty
9. Do you anticipate additions or expansions of the facility this System is !III Gild ell to Serve? ❑ Yes Ehm
if yes, What type? 5.
**1Af1'0RTXhYT*** CLIENTS MUST COAR'LM- IE REQUIRED PROPEIfl'Y INRORNINI'fON REQUESTED
IELOW. fullers PLAT or SITE PLAN AIUSTBESUTAIIITTED by the client Willi THIS APPLICATION.
Property Dimensions: 111RITL DIRCC11ONS (rrunl A•lucksville) to 11ROPIilCl'1':
Tax suet: nm 11
Properly Address: Road Name
City/Zip
If in a Subdivision provide infornlatioi, as follows:
Nalnc
Sections Bloclu Lot: 3 Date home comers Bagged: e d y
This is to certify that the Information provided is correct to the best of May knoWlcdge. I understand that ally perulit(s)
issued hereafter are subject to suspension or revocation, if the site plans or Mended use change, o• if the inrurulatiol
submitted in this application is falsified or changed. I, also, Imdcrstaild flint I am reshunsiblejorall chmyes• incurred jr1ne
flusupplicatiaa. I, hereby, give consent to (fie Aullwrized Representative of the Davie Cutill ty Ileal (h 1)eparlulull l
to cuter upon above described property Inched in Davie Co only and onsd by
to conduct all testing procedures as necessary to determine (lie site su' • -
lily.
DA•I'S ) ` �%—may. SIGNATURE >
TRIS AREA MAYBE USED TOR DRAWING YOUR SITE PL (Include all of the following: Existing :old pro )used
property lines and dimensions, structures, setbacks, and septic locations).
.— —
Site Revisit Charge
Datc(s):
Client Notification Date:
E>Is:
Sign given Account No.
Revised Mil) (05/03 Invoice No. '7 8
co
co
650
(1.80A)
2146
(663)
co
(1.80A)
gn4:i
a
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/SiteEvaluation
APPLICANT INFORMATION
PROPERTY INFORMATION
Account #:
990003132
Tax PIN/EH #:
5707-81-2043 .
Billed To:
John Smith
Subdivision Info:
Smoot Acres Lot # 3
Reference Name:
Location/Address:
• Foster Road -27028
Proposed Facility:
Residence
Property Size: 1.95 acres
Date Evaluated:
Water Supply:
On -Site WellCommuni
ty'Public*
Evaluation By:
Auger Boring:::: Pit
Cut
I
FACTORS
1 2 3' 4
5 6 7
Landscape position
Slope %_
HORIZON I DEPTH e7r v
Texture group
Consistence
Structure ,
Mineralogy
HORIZON H DEPTH �• 7!
Texture group
Consistence
Structure /l
Mineralogy
HORIZON III DEPTH .
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence I
Structure
Mineralogy
SOIL WETNESS .
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE.
I
SITE CLASSIFICAT
ION:
ACC
EVALUATION BY:
LONG-TERM ACCERATE:�o� 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
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 j
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
1` Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LIAR - Long-term acceptance rate - gal/day/ft2
DCHD 05/99 (Revised)
cnvirunmeniai neaun aeuuun
P. O. Box 848/210 Hospital Street
Courier 09-40.06
Mocksville, NC 27028 .
April 6, 2004
John T. Smith, Jr.
1679 Sheffield Road
Mocksville, NC 27028
Re: Site Evaluation/ Smoot Acres, Lot 3
Tax Office PIN: #5707-81-2043
Dear Client(s): .
As requested, a representative from this office visited the aforementioned site on,
April 6, 2004. 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 oversized modified sewage system.
Before an Improvement Permitl /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; plc I e feel free to contact this office.
I
Sincerely,
/107 cO•a'OfO �•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)
Ji
Davie County Health Department
Environmental Health Section
L.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC;, 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CER
(Check One) Replacement Remodel'
Name: L/��I t �i�/�� Phone
Mailing Address: '
e, C !i Q Email Address:Q1U/��iFiIYISA�d%
Detailed Directions To Site:
(�/1/ GIJr/l%l;iY6
-753-1680 .
Property Address: /;/9 &i/�%Z KZ100A0003 �� 1/9 Ad
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ✓90 i/�6r/bI00/CS Type Of Facility:
Date System Installed (MonthMate/Year)- Z(1 -%Z Number Of Bedrooms: Number Of People'
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In
Type Of Facilitl
Pool Size:_
,tequested By_7'
About The NEW Facility:
leA9Number Of Bedrooms:." Number of People
;e Size: Other:
Rnr Tnvirnnmcntal APaltl, 0 4'ice TTce Only
%/A//7-'
Environmental Health
Date:
*The signing of this form by the Environmental Health Staff 1§ in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Chl!eck Money Order # Amount:$ Date:
Paid By: Received By:(h1 CU
Account #: Invoice #: .'/ Z ,.