406 Rabbit Farm Trail Lot 6' DAVIE COUNTY HEALTH DEPARTMENT
4
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003291 Tax PIN/EH #: 5870-41-6476.06 GW
Billed To: George Warwick Subdivision Info: Rabbit Farm Phase 2 Lot # 6
Reference Name: Location/Address: Rabbit Farm Trail -27006
Pro osed Facility Residence Property Size: 5 acres
ATC Number: 3814
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 a Tr tment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CO ST f O S ALID FOR A PERIOD
OF FIVE YEARS.
Environmental Health Specialist's Signature:
As stated in 15A NCAC 18A.11
accepted S stems may aisu uc uavu
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.
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Septi System Inst By:
Environmental Health Specialist's Signature : Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003291 Tax PIN/EH #: 5870-41-6476.06 GW
Billed To: George Warwick Subdivision Info: Rabbit Farm Phase 2 Lot # 6
Reference Name: Location/Address: Rabbit Farm Trail -27006
Proposed Facility: Residence Property Size: 5 acres
ATC Number: 3814
**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 � #People 2-- #Bedrooms _ #Baths
Dishwasher: Jn`�— Garbage Disposal: ❑ Washing Machine: 0"- Basement w/Plumbing: lr Basement/No Plumbing: ❑
Commercial Specification: Facility Type
#People #People/Shift
#Seats
Industrial Waste: ❑
Lot Size Type Water Supply
��U-- Design Wastewater Flow (GPD)
�
Site: New Repair ❑
System Specifications: Tank Size 1000GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft. Lk#
STI � 2�As stated in 15A NCAC 18Aalso
1969(5)
be used
Other: `�Xl✓� accepted Systems may also be used
Required Site Modifications/Conditions: � r� Ate-- r �i�, K� wi 1A �, ' ';�'' 9- � -
VOMV • •.�v
lU
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTIC Contact a representative oft}H unty 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 t}Jte day of i stallat%on. Telephone # is (336)751-8760.****
3PO � I
*d1�, I NDOSC:5�
L{a
Environmental Health Specialist's
DCHD 05/99 (Revised)
C��l
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section 7_ 2d' _X3
P. O. Boz 848/210 Hospital Street
• Mocksville, NC 27028 r
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003291 Tax PIN/EH #: 5870-41-6476.06 GW
Billed To: George Warwick Subdivision Info: Rabbit Farm Phase 2 Lot # 6
Reference Name: Location/Address: Rabbit Farm Trail -27006
Proposed Facility Residence Property Size: 5 acres
**NOTE * per: 81 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 1 -100L -C #People Z #Bedrooms 3 #Baths 3
Dishwasher: u Garbage Disposal: ❑ Washing Machine: 0Basement w/Plumbing: E Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size /� ;S Type Water Supply � J ELI - Design Wastewater Flow (GPD) �CD Site: New � Repair ❑
System Specifications: Tank Size 10CCUAL. Pump Tank GAL. Trench Widt, 2-1 " Rock Depth 122 Linear Ft. qoo
Other: ," SrAeA ,04 S
Required Site Modifications/Conditions: / Al Sr4 — 6,j C . ' �I �'�� �-' L-)kLp kzol`� (�
• LIJS
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.****
3LZ
NOOSE_
leo"
10s;
0S.
M�r.�•
Environmental Health Specialist's Signature:
^PMVIV-1 IM � I *5w) Lo4 w
09 ?*
a
05/99 (Revised)
May 27 04 12:50p ountu envhealth 336 751 8786 p.l
*^ ...3 n
U.. O/\((PUI. 'F It SITE EVALUATION/IMPROVEMENT PERMIT & ATC
2 UJ``tt avie County Health Department
nvironmenta/Hea/t/f Section
P.O. Box 848/210 Hospital Streot
�iV1RON�^E�TALH�L Mocksville, NC 27028
pV1ECdU��� (336) 751-8760
** ANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
t •` n,
1. Name to be Billed (�.JtLf LlitiL1_. contact Parson %qS,4)- fr ...
Mailing Address Home Phone
City/State/ZIP 'Zj,V:`�S �� �l�.i� Businoss Phone y03 -Moo
2. Name on Permit/ATC if Diffe::ent than Above
Nailing Address _ City/State/Zip
3. Application For: ❑ Site. Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to service: )( House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: X Conventional ❑ conventional modified ❑ innovative
6. if Residences N People 2. I Bedrooms -3_ t Bathrooms_
XDiahwasher ❑Garbage Dic;posal 1WWashing machine .gfBasement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes 1: Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Eatimated Water Usage (gallons per day)
B. Type of water supply: ❑ County/City g Well ❑ Community
9. Do you anticipate additions or expansions of the facility (his system is intended to serve? ❑ Yes X No
If yes, what type?
***IhfPORTANT*** CLIEPITS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. _Either a PLAT or SITE PLAN MUST SCSUBMITTED by the dicot with TMS APPLICATION.
Properly Dimensions: WRITE DIRECTIONS (from Mocksville) to PROVERT1':
1'2x Office PIN: ll 5,F7 c, — 7///
Property Address: Road Namc"Ab TX-
City/Zip
�
City/Zip
If in a Subdivision provide inform::tion,,ass follows:
Pamc: c 6 l >L F7iT /�%—
Scct��Iocic ___ Lot:
Date home corners Ragged: a�Q
This is to certify (hat the Information provided is correct to the best of nny knowledge. I understand (bat any pernnit(s)
issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or If the information
submitted in this application is falsirrd or changed. 1, also, understand that fain responsible for all charges iucared from
this applicatloa. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located (u Davie County and owned by
to conduct all testing rocedur s a$ necessary to determine the site so' bility.
DATE SIGNATURE al C+
TII1S AREA MAY BE USED TOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
� J ` LA—' -7 Datc(s):
Client Notification Date:
EHS: q
Sign given Account No. /
.d
ilcciscd DCN (OS/03 /���� � Invoice No. 1-
1. Name to be Billed
Mailing Address
City/State/Zip
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 848 i
Mocksville, NC 27028
F.i�
(336)751-8760rTBE
****IMPORTANT**** THIS APPL PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED
l�eii V I�� Contact Person
CN Home PhoU yo✓
A 6IJ , l 27 a 6l :2 Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. If Residence:
Q Dishwasher
6. If Business/Other:
W" Site Evaluation
[�✓ House
# People
r❑ Mobile Home
J
ff Garbage Disposal
Specify type
City/State/Zip
❑ Improvement Permit & ATC
❑ Business ❑ Industry
#' Bedrooms
❑ Both
❑ Other
# Bathrooms
Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
# People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats , Estimated Water Usage (gallons
per day)
7. Type of water supply: . ❑ County/City ❑" Weil ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLA W. THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: 504 07/ �4 1 WRITE DIRECTIONS (from
�j l / / /,, 1 Mocl�sville) TO PROPERTY -
Tax Office;PIN: # / 0 - r - lL • ID�D,EJ
Property Address: Road Name R4 i
_.
City/Zip /-f /y✓_g
If in Subdivision provide information, as follows: 0012,K
Name:rC1✓,�Ji� �" �j�l�/2'L �•
1'
Section:f ��if S Q Lot #:
1
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 Representative of the Davie CWounty Health Department to enter upon above described property located in Davie County
11
and owned by —fie 1 U r, to conduct all testing procedures
as necessary to determine the site suitability.
DATE _3Z 21qZ6q SIGNATURE
Revised DCHD (06-96)
YOU MAY USE THE BACK FF THIS FORM FOR DRAWIM5 YOUR SITE PLAN.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME `-1' "" "AWL
PROPOSED FACILITY
SUBDIVISION"—'
Water Supply: On -Site Well Community
Evaluation By: Auger Boring Pit
SECTION I LOT G
DATE EVALUATED
PROPERTY SIZE �ose)i
se
ROAD NAME %
Public
Cut
SITE CLASSIFICATION: �" J
LONG-TERM ACCEPTANCE RATE:
REMARKS: AV m4 6 FLSR 1avoq
LEGEND
DCHD (01-90)
EVALUATION BY: Aaz
OTHER(S) PRESENT:
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
position
groupLandscape
Texture
ConsistenceHORIZON
II DEPTH
groupMineralogy
Texture
■r�rr�wo�®�
Consistence
W14 -Al
Mineralogy
Texture group
EN ' MIM
�'M MAMMON
��
0 1 REM 0 5.���a
MineralogyHORIZON
IV DEPTH
Texture group
Mineralogy
RIM,
�'�r�Z�=E���r•�����
SITE CLASSIFICATION: �" J
LONG-TERM ACCEPTANCE RATE:
REMARKS: AV m4 6 FLSR 1avoq
LEGEND
DCHD (01-90)
EVALUATION BY: Aaz
OTHER(S) PRESENT:
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
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Davie Gounty,,Health Department
Environmental ,Health Section
PO Box 848 / 210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
April 13, 1999
Mr. Vance Walser
201 Country Club Drive
Lexington, NC 27292
Re: Site Evaluation -5 Acre Tract
Rabbit Farm -Phase 2, Lot 6
Tax PIN #: 5870-41-6476
Dear Mr. Walser:
As requested, a representative from this office visited the aforementioned site on
April 9, 1999. Based on the information provided on the Application for 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.
"SPECIAL NOTE: Due to some complex topography on this tract, the area available
for installation of the system is limited. Additionally, placement of the house may require
setting a pump station.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct, the appropriate application must be completed in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
If you have any questions, you may contact our office at (336)751-8760.
Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
enc(s)