165 Meadowlark Lane Lot 16DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002222 Tax PIN/EH #: 5822-97-3654.16 RA
Billed To: Tycor, Inc. Subdivision Info: Whip O Will Lot # 16
Reference Name: Location/Address:
Proposed Facility: Residence Property Size: 5 + acres
ATC Number: 3110
**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 #People_ #Bedrooms _ #Baths o�
Dishwasher: 2'*" Garbage Disposal; Washing Machine: Basement w/Plumbing:Rr Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seatats Industrial Waste: ❑
Lot Size Type Water Supply _ Design Wastewater Flow (GPD) �6 Site: NewRRepair ❑
System Specifications: Tank Size AOao GAL. Pump Tank/PP 0 GAL. Trench Width sW Rock Depth �E Linear Ft.�
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). 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.
/y�/�,.
1 '
Environmental Health Specialist's Signature: Date: 4/-.2 `? 2-
DCHD 05/99 (Revised)
Account #: 990002222
Billed To: Tycor, Inc.
Reference Name:
ATC Number: 3110
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5822-97-3654.16 RA
Subdivision Info: Whip O Will Lot # 16
Location/Address:
Size: o +
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 WASTEWATE O STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �• AK
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.
Septic System Inst
Environmental Health Specialist's Si
DCHD 05/99 (Revised)
2 V L..^.�
ENVIRMWNTAI HEALTH
IN FOR SITE EVALUATION/IMPRGVEMENT PERMIT & ATC
Davie County Health Department
EnvifonmentaiHeaith Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(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 ", Q, k Nc. Contact Person
Mailing Address ,.`,��2 Home Phone
City/State/ZIP ,Q,..J�c7�S 1w� 7710 'L Business Phone
2. Name on Permiat/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: ❑ Site Evaluation M Improvement Permit/ATC ❑ Both
4. System to Service: ZHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _L_ # Bathrooms ZYZ
I/Dishwasher Garbage Disposal F,(Washing Machine Id Basement/Plumbing LI Basement/No Plumbing
6. If Business/Industry/Other: Specify type
# Commodes # Showers # Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U -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.
Property Dimensions: _ s- NLR%
Tax OfficPIN: # ��ZZ�1 �„S�1 I � PA
Property Address: Road Name
City/Zip
If in a Subdivision provide information, as follows:
Name: V��►�-�t`�- \'u\
Section: Block: Lot: \U
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
`ub\ 7 L fid. -�
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 ani 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 sitesnitabilit
DATE SIGNATURE NT
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).
/-L,k- a" O
Revised DCHD (07/99)
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No.
Invoice No. ZS /
APPLICA750N FOR SITE EVALUATION/IMPROVEMENT PERMIT &
Davie County Health Department
�✓ Environmental Health Section
P.O. Box 848/210 Hospital Street ' 7 2000
Mocksville, NC 27028
(336)751-8760
***1WORTANT*** THIS APPLICATION CANROT BE PROCESSED UNLESS ^aIY
INFORMATION IS PROVID]E�D. Refer to the INFORMATION BULLETIN for instructions. �)
1. Name to be Billed `I It, `, ✓inr� �o �^Sdi✓ 1- � . Contact Person �kk,,,,, V�
Mailing Address -el 7727 0 7^ Home Phonal -1 o ` 2 (9 LI
City/state/ZIP �sL� / W Rosiness Phone
2. Name on Permit/ATC if Different than Above_
Mailing Address / City/state/Zip
3. Application For: E3 Site Evaluation ❑ Improvement Permit/ATC
❑ Both
4. system to service: O/House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 61 ,
5. If Residence: # People # Bedroommss � # Bathrooms _/�
U/Dishwasher ❑ Garbage Disposal t3 hashing Machine t0 Basement/Plumbing O Basement/No Plumbing I-AaSJ_
""'tel►
6. If Business/Industry/Other: specify type
# People # sinks
# Commodes # Showers # Urinals # hater Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: w/ounty/City ❑ Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes /No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: #
Property Address: Road Name
City/Zip M c J,25 L- 27 Q:9
If in a Subdivision provide information, as follows:
Name: W) ,!.- - (9 — �t� raW/ ✓v—S
Section: Block: Let:.1�
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
:{
nw,, 'x%117 7,-,12' J
Date Property Flagged: 7r Z ^- o -
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 1, 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
to conduct
�all
ltesting procedures as necessary to determine the site sVitFbility.
DATE 1 / l '7 /�i�7 SIGNATURE / _Z
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN'Unclude all o1Jh ffojeMng: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS•
Revised DCHD (07/99)
Account No. 3-6
Invoice No. 7-
00 ,r
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AREA FROM FENCE_ TO
/ EDGE OF ROAD IS
COMMON AREA
-70 tee- Iv
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55 W
5NEET
e
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1..'Application/Permit Requested
Mailing Address
Home Phone i0li- aa -S -(401 `1 I
5� Sas 1-�-!
63 Business Phone"'t )0-
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2. Name on Permit if Different tpan Above
3. Application for: ❑ General Evaluation peptic Tank Installation Permit
4. System to Serve: U, 140 -u -Se
❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision l-°� O O- O- W ` 11 Section Lot # 4�!
No.,of People
No. of Bedrooms `T
No. of Bathrooms J '/-z-
Dwelling
Dwelling Dimensions � 100 5 44-::
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
asement/Plumbing
❑ Basement/No Plumbing
C7'GVashing Machine
C -Dishwasher
arbage Disposal
No. of Showers Water Usage Figures
7. Type of water supply: LWI°ublic ❑ Private ❑ Community
i. Property Dimensions Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2'No
If yes, what type?
'NOTE: mprovements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989. ; 1
Directions to Property:
�o � s 6 r Ca r\ C. 12-A
4 W .
�-
`a r e; Oo 4 ( o� V
b r\ c L42+ b ee Lo r -Y
S�-v�co 0"e k0QSC---
This is to certify that the information provided is correct to the
incurred from this application.
Q - ) �,-�S
DATE
PROPERTY INFORMATION REQUIRED:
Tax Office PIN # TfQ OCA TL P/0 3
Road Name 'a Tim G-L�
Box # (if available)
City
apLL, �►
mlo) �lo�gaa-�
of my knowledge, and I understand I am responsible for all charges
SIGNA'
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
1 ull�
MUST CHECK ONE: ❑ 1. 1 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 todeter ine said site's suitability for a ground absorption sewage treatment
and disposal system.
— ) -) , V�- - / S- C.,�
DATE SIGNATOR
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME 42c .✓ >
ADDRESS
PROPOSED FACIILTY 4V.S`Y
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well _ Community Public_
Evaluation By: Auger Boring_ Pit Cut
FACTORS 1 2 3 4
Landscape position ,I—
Slope
Slo e % 1 0
HORIZON I DEPTH
Texture group
Consistence
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
LONG-TERM ACCEPTANCE RATE
E_�'_ 1-2 1
SITE CLASSIFICATION: /l_�
LONG-TERM ACCEPTANCE yATE:
REMARKS:
DCHD(01-901
EVALUATED BY:
PTHER(,$) PRESENT:
Z.iffiAiAN
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- V ---.-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
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
Davie Caunfv Nealtvi Department
and dome Xealtlr Ayency
210 HOSPITAL STREET / P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5096- 7160
January 26, 1996
Tony & Judi Tonti
c/o Shannon Conrad
3411 Healy Dr.
Winston-Salem, NC 27103
Re: Site Evaluation
Whip-O-Will/Lot 16
Dear Mr. & Mrs. Tonti :
As requested, a representative from this office visited the aforementioned
site on January 25, 1996. Based upon the information provided on the
application for a site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of a modified,
oversized on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R. S.
Environmental Health Section
RH/wd
i Enclosure
DAVIE COUNTY HEALTH DEPARTMENT %�� 02 C-)
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001309 Tax PIN/EH #: 5822-97-3654.16
Billed To: San Filippo Companies Subdivision Info: Whip -o will Lot # 16
Reference Name: Anthony San Filippo Location/Address:
Proposed Facility: Residence Property Size: see map
ATC Number: 2511
**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.
i
Residential Specification: Building Type # #People #Bedrooms #Baths !Z S
Dishwasher: RT"'
Garbage Disposal: ❑ Washing Machine: ET Basement w/Plumbing:;2" Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size IV— Type Water Supply Design Wastewater Flow (GPD) —11fd Site: New Repair//❑
System Specifications: Tank Size Z25'� GAL. Pump Tank'? -5Q GAL. Trench Width C � Rock Depth / ? Linear Ft.
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.****
Environmental Health Specialist's Signature: zzooa Date: Y/-? ),61
DCHD 05/99 (Revised)
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001309
Billed To: San Filippo Companies
Reference Name: Anthony San Filippo
r1upubvu rdullny. rCeSluefll:e
ATC Number: 2511
Tax PIN/EH #: 5822-97-3654.16
Subdivision Info: Whip -o will Lot # 16
Location/Address:
rrupeny We
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: 0"� ' Q�
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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date: