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235 Deer Haven Trail � DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003607 Tax PIN/EH#: 5746-29-0629 Billed To: Jeff&Anita Lagle Subdivision Info: Reference Name: Location/Address: 235 Deer Haven Trail-27028 Proposed Facility Residence Property Size: 7 1/2 acres ATC Number: 4074 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 CONSTR CTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: 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 witIVArticle 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in 10 Y be taken as a guarantee that the system will function satisfactorily for any given period of time. lib Septic System Installed B : �1i ep Ys Y Environmental Health Specialist's Signature: /,4�/ / Date: 22 DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ` Environmental Health Section l • P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003607 Tax PIN/EH#: 5746-29-0629 Billed To: Jeff&Anita Lagle Subdivision Info: Reference Name: Location/Address: 235 Deer Haven Trail-27028 Proposed Facility Residence Property Size: 7 1/2 acres ATC Number: 4074 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWYITER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installat'orn 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 #BedroomsS #Baths Dishwasher: Garbage Disposal: ❑ Washing Machine:011, Basement w/Plumbing>. - Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD)c;�&"' Site: Newx Repair❑ System Specifications: Tank Size I y p �GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear Ft.s� 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.**** 1� Environmental Health Specialist's Signature: Date:�_j��� DCHD 05/99(Revised) CATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC lvJ Davie County Health Department E17Vft menta/Heath Section a�� g P.O. Box 848/210 Hospital Street Mocksville, NC 27028 o�c� l'�'Ktt (336)751-8760 ***I PO ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. T 1. Name to be Billed J e��E Yl( GL �e. Contact Person Mailing Address 3 S Oee r- holyC.h -1�1�'1 vI Home Phone "�� S t �3 7 City/State/ZIP d GkS V I�N C a I dOC 0 Business Phone �4 63 Y- 5 L� ( l/ 2. Name on Permit/ATC if Different than Above (? � -7 / 0 1 7 Mailing Address C ty/State/Zip 3. Application For: ❑ Site valuation Improvement Permit/ATC .loth 4. System to Service: House ❑ Mobile Home Business ❑ Industry ❑ Other S. Type system requested: Convention 1 ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms 3 # Bathrooms DL4 ishwasher ❑Garbage Disposal Mashing Machinea sement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes+ # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated W�a er Usage (gallons per day) 8. Type of water supply: ❑ County/City Ly Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes 0 No If yes,what type? ***I4fP0RT11NT***CLIENTS AlUST COAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE.PLAN AfUST BE SUAM17"fED by the client with THIS APPLICATION. Property Dimensions: / .� acres' WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: # 5-1 Ito 2-°tt7(02q S I t-crh L' 0h+6 ly -C;r,SS Property Address: Road Name IJ. _ Ever (A' I TLky-y\ ri '. City/Zip Dt,I�_SvI lit, w-Wfi 5� wb v� Cr' 11e �r r� G« t,4�RKfdf�h If in a Subdivision provide information,as follows: �W n" %JP leiS e W f` 11 u� t Name: Section: Block: Lot: Date home corners 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 am responsible for all charges incurred froili this application. I,hereby,give consent to the Authorized Representative of the Davie County I1calth Department' lLtoto enter upon above described property located in Davie County and owned by �F� Ah, t-nn k all- to conduct all testing procedures as necessary to determine the site suitability. DATE `1—ag-as 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 Notiflcation Date: EHS' Sign given Account No. � 7 Revised DCII (05/03 Invoice No. S c/ V �p Lco / 12 co / 135 _ = 143 v 15 J 157 ' EVE L O 1895 185 I I 4tiz I I I I 234 I 289 i ---------------- i i i i � � N DAYIE .COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME DATE EVALUATED O , ADDRESS PROPERTY SIZE PROPOSED FACIILTY S�7/ LOCATION OF SITE Water Supply: On-Site Well �/'� _ Community Public Evaluation By: Auger Boring L� Pit Cut FACTORS 1 2 3 4 Landscape position ,L .C- SlopeZ :=? HORIZON I DEPTH 77 Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group G` Consistence Structure / ie 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 SITE CLASSIFICATION: EVALUATED 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 :lay loam- SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vury 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 .iC--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' br 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 ■.■.■.■.■■■■_■.■■��...■■■■.■.■...■.......■■/■..■■■ MEMMM■■■MM.mo■■■ ■r�■■�n■.�■■■1►s■■■■■■.■■■■■.■w■....■.■■ ■■■■■CC■■■■.■■. ■.■■■■.■■■■■■ ■■�■■J\'Illi.■ilii■E.m.■■.■....■■©■■�L'/,■,C■■.■,■■.. ■■.. 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(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) *NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SCPECtALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS-�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW'(GPD) NEW SITE REPAIR SITE, 1` SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH�R FT OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT U IKI IV *'"CONTACT A REPRESENTATIVE OF THE DAVIE COUNT HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: 16 �✓ 'O /' j� "'� vol AUTHORIZATION NO. OPERATION PERMIT BY: DATE." **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT.THE SYSTEM DESCRIBED ABOVE 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. DCHD 07!02(Revised 97 ° `�� � DAVIE COUNTY HEALTH DEPARTMENT Name �r5� Environmental Health Section PROPERTY INFORMATION . j P.O.Box 848 } .-,-Directions to property: ` '�'� '' -:� � 1ocksville,NC 27028 Subdivision Name: / "-`Phone#:336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# a SYSTEM CONSTRUCTION - - AUTHORIZATION NO: 566 A Road Name: Zip: f k **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article l l of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION:BUILDING TYPE 1 #BEDROOMSP—#BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No r COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY ( DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH LINEAR FTA OTHER _IS �v REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 17 "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: Ile 1516n� AUTHORIZATION NO.w�OPERATION PERMIT BY. DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02(Revised) r; �� � � • DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME PHONE NUMBER ADDRESS ��a G �' G' SUBDIVISION NAME LOT# DIRECTIONS TO SITE _ A' oza/--4149 1.�2 DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY NUMBER BEDROOMS 2 NUMBER PEOPLE SERVED TYPE WATER SUPPLY �D SPECIFY PROBLEM OCCURRING DATE REQUESTED111 INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my know edg ,and that I understand I am res ible f r all ch r s incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1193