229 Meadow Glen Ln � r
.• DAVIE COUNTY HEALTH DEPARTMENT �� +(�
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Environmentai Heaith Section ��
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990000782 Tax PIN/EH#: 5812-03-4083
Billed To: Brian Lusk Subdivision Info: Bellhaven Lot#3
Reference Name: Location/Address: Meadow Glen Lane-27028
Proposed Facility Residence Property Size: 12.617 acres
ATC Number: 3865
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental
" Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of
G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONS R TIO S VA OR A PERIOD OF F VE YEARS.
Environmental Health Specialist's Signature: Date: f�
- CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
t Y 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
L� given period of time.
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Septic System Installed By: L=� V
Environmental Health Specialist's Signature: ate: �
DCHD OS/99(Revised)
- � - . � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)75]-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000782 Tax PIN/EH#: 5812-03-4083
Billed To: Brian Lusk Subdivision Info: Belihaven Lot#3
Reference Name: Location/Address: Mea�Glen Lane-27028
Proposed Facility Residence Property Size: 12.617 acres
ATC Number: 3865
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An ALTTHORIZATION 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 ' �5�. #People #Bedrooms � #Baths �
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ BasementJNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��.�i� Type Water Supply l,Ot,��a'Ttij Design Wastewater Flow(GPD) ��� Site: New u Repair❑
System Specifications: Tank Size Ia'�GAL. Pump Tank GAL. Trench Width�" Rock Depth �Z-�� Linear Ft. ���
o�h�: � ��5�����t�,� �cS
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Required Site Modifications/Conditions: I[JSTA Gc7��2 F+=U" � L171�}�.I �. , � ��
I1�1PROVEl1'IENT/OPERATION PERMIT LAYOUT- APPRO EFFLUENT FILTER. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe 'e County alth Department for final inspection ofthis
system between 8:30 a.m.to 930 a.m.or 1:00�,m.to 1:30 p.m. the da f in ati . Telephone#is(33C)751-8760.****
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Environmental Health Specialist's Signature: Date: "/ ' ���"�/-
DCHD OS/99(Revised)
� . � DAVIE COUNTY H�ALTH DEPARTMENT
` Environmental Health Section '
� � P.O.Boa 848/210 Hospital Street ��C/�-J 7 v�-�
. Mocksville,NC 27028
(336)7S]-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990000782 Tax PIN/EH#: 5812-03-4083
Billed To: Brian Lusk Subdivision Info: Bellhaven Lot#3
Reference Name: Location/Address: Meadow Glen Lane-27028
Proposed Facility Residence Property Size: 12.617 acres
ATC Number: 3865
**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 Y #Baths �
Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �Z��0 �' � Type Water Supply �`�u"�1 Design Wastewater Flow(GPD)�� Site: New� Repair❑
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System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width � Rock Depth /� Linear Ft.Je�
other: '��/�157�I�t�c�'��
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Required Site Modifications/Conditions: * �i� � ��6�� �� ,�1 � -' �r�M-'
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IMPROVE111ENT/OPERATION PERh'IIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 930 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. T lephone#is(33O751-87(0.****
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Environmental Health Specialist's Sign e. `"" '*� Date:
DCHD OS/99(Revised)
. • �, �....�...�+�+�""""...
�� ;,� � (� �, U � I ION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
'4, �,i�� Davie County Health Department
"` � `' r� Environmenta/Hea/th Section
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� A�� i�.l�� �~'`'� P.O. Box 848/210 Hospital Street
'.�a • Mocksville, NC 27028
; ������ � (336)751-8760
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*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL TFiE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to ba Billed � (1������/ �y16� Contact Person
Mailing Addresa T��i' c��_�- ����� Home Phone 13��� %�'! z '– 5 U�Z'1�
City/State/ZIP �7�'�,�/�.;<_i �c:�� � �j�G, zc`��usinass Phone �`]4y� — G�G r�i��
���s��
2. Name on Permit/ATC if Different than Above
Mailing Addreas City/State/Zip
3. Application For: ite valuation !XJ Improvement Permit/ATC ❑ Both
4. System to service: HL�i' ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. Type syatem requeated: Colf� nventional ❑ conventional modified ❑ inn vative �! ]
�, � '1��� � 1� �i/Z�
6. =f Residence: # People # Bedrooms _� # Bathrooms �
L�bishwasher L7Garbage Diaposal asL+-t9P�hing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. I£ IIuainess/Industry /Othar: verify type # People # Sinka
# Commodes �_ # Showers � # Urinala # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gailons per aay)
8. Type of water supply: �County/City ❑ Well ❑ Community
9. no you anticipate additiona or expansions of the facility this system is intended to serve? �Yes ❑No
If ycs,�vhat typc?
***IMPORTANT'�** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION R�QUEST�D
' BELO1i�. Eitl�cr a PLAT or SIT�PLAN MUST BE SUB�IITTL•D by the clicnt witl�THIS APPLICATION.
Property Dimensions: l 2- �l/ �� WRITE DIRECTIONS(from Mocksvillc)to PROPERTI':
Tax OfGce PIN: #��r�- 6�— `f CJ_'c � (.P O � /� � c� n L(,g �-� '
Property Address: Road Name �1e�a� C�-e^� L"`"� -� ,//" 1 e e�c9� � �--e"-� _
City/Zip 2�a ^�-b� L2�� o �� • v � �� �
If in a Subdivision providc information,as follows: � fi�
Namc:
Section: Blocic Lot: 3 Date liome corncrs llagged: ��� d 7
This is to certify that the information provided is correct to the best of my knowledga I understand that any permit(s)
issued liereafter are subject to suspension or revocation,if thc site plans or intended use cliange,or if the information
submitted in this application is falsiCed or clianged. I,also,u►rderstaad tlrat I anr respo�rsible jor a11 charges i�rcrrrred from
t/iis npplication. I,licreby,give consent to the Autliorized Represent:►tive of tlic Davie County Healtli Department
to enter upon above descriUed property located in Davie County and owned by
to conduct all tcstin proccdures as ncccssary to detcrminc tl�c sitc suitaUility.
, DATE � 3d U SIGNATURE `�- / `
THIS AREA MAY B�USED FOR DRAWING YOUR SITE PLAN(Include all of tl�c following: Exi ing and proposcd
property lines and dimensions, structures, setUacks, and septic locations).
Sitc Revisit Chargc
�c��/ ��. -�—� 5 t�-e-' vatc(s):
� � ��L� �� /u c �- Clicnt NotiCcation Datc: '
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Sign given �� E yH. � ,. Account No. �U �
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Revised DCI (OS/03 � Invoice No. L�3 � �
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, ' DAVIE COUNTY HEALTH DEPARTMENT
' Environmentai Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000782 Tax PIN/EH#: 5812-03-4083
Billed To: Carl Lusk ' Subdivision Info:
Reference Name: Location/Address: Meadow Glen Lane-27028
Proposed Facility: Residence Property Size: 12.617 acres Date Evaluated: � �'� �-�
Water Supply: On-Site Well Community Public ✓
Evaluation By: Auger Boring ✓ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L �
Slo e% Lfl
HORIZON I DEPTH �-(p �- l.i �-
Texture rou : t�- ; lr
Consistence ti rJ
Structure C-s.R
Mineralo �-�*b.
HORIZON II DEPTH Q- �'
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Texture rou Si�-- . C-- �C-
Consistence `S� - ; �
Structure '
Mineralo , ,,
HORIZON III DEPTH �
Texture rou 5�Cf 'Ur
Consistence, �
Structure �
Mineralo � -
HORIZON IV DEPTH � +
Texture rou S� 5�
Consistence r��
Structure
Mineralo
SOIL WETNESS �
RESTRTCTIVE HORIZON
SAPROY,ITE '`. S
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE L`�. � �j.
, SITE CLASSIFICATION: EVALUATION BY: � ������
LONG-TERM ACCEPTANCE RATE: ' �� OTHER(S)PRESENT:
REMARKS: � '^""Var ���� ,2 '
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
Mineraloev
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 OS/99(Revised)
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, ,, , APPIJCATION FOR SITE EVAUTA�IION/IMPROVEMEM P�iMIT&ATC �,a�r��M t2
� ' Davie County Health Department D � l� l5 � u 15
� •. � �• - Envjrtinmenta/Hea/[fi Se�ion
�� P.O. Box 84B/210 Hospital stseet SE� 2 � ��
U��C� �so�s��ie, Nc 2�oze
(336)751-8760
1U ENVIRO�R;tENTAIHEALTH
� ***Il�ORTANT*** THI3 APPLICATION CANNOT BE PROCESSED LTNLE33 ALL QUIRED �
��YFORMATi�N Is PROVIDED. Refer to the INFORMATION BOLLETIN for instructiotts.
,,
1. Name to be siiled �. �2G S Gontact Beraon
Mailinq Addre�a G,3 Nq ,c�,e �,b 8a�e IIhone 9�/G � S GG Z
Clty/StaYe/ZIP i�ruSvic�� lllC 7'7o ZS Buainesa phone�7o y) - G3( - �G� �rr yii,3
2. Hame on Bemrit/ATC if Different thasi Above
Mailing Addreas City/State/21p
3. �lpplication For: [Q�ite Evaluation 0 Improvement Peanit/ATC � Soth
�. Bystem to Service: �use ❑ Mobile Home 0 Business 0 Industry ❑ Other
a. If itesideace: # People �,� ; Bedrooms � f Bathzooms Z
8'�Diahwasher @��arbaqe Diapoaai �ashinq tlachine O Haae�ent/Piumbinq O Basement/No Plum6ing
6. If Buainess/Induatry/Other: Specify typa # Beapie � Sinl�a
♦ Coamodes / 8howers � vrinala • Nater Coolers
�s' FOOD3ERVICE: � 3ests EstimBted Watez Osage (gailona per day)
7. Tppe of vrater supplp: C'�ounty/City CI tdell ❑ Com�unity
e. Do you anticlpate addition�or e:pansions of the facility t6is ayatem Ia intended to aervei ❑Yes 0 No
It yea,�v6at type'
*"IMPORTANT't"'CLIENTS�llUST COlilPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PL.AT or S1TE PLAN AtUST BESUB�tITIED 6y the client wlt6 TH1S APPI,ICATION.
Property Dfinensiona: l����7 /���'�S WRiTE DIRECTIONS(from Mocl�ville)to PROPERTY:
Ta:Office PIN: # �g / Zd G/�//d� G� 1 1�1a2T►.� �o �//.�r�.zT; �v�c,y
Prnperty Addresa: Road Name///�rlooc� ��n,�r �r�„i� 12.o f,��T' v,d,P G�>6�.c�: �'s>virc.�/
City/Zip ii'"/oC�rsvit[tt3 Z7GZv �� �,����zs�s���v ��� ��n��
If in a Subdivi�ion provide fatormation,a�followa: L��i O�'% O� L� /L�
Name: �GT. �
Section: Block: Lot: 3 Date Property I�lagged: �� �G�.��
This is to certify ihat the ioformatioo provided is cornect to the best ot my knowledge. I underatand t6at any permit(s)
issued 6ereafter are subject to su�peosion or rcvocation,lf t6e aite plan�or intended usc cbange,or if the information
aubmitted in t6i�application ia falsitied or chaaged I,a[so,unders�tand tbat I am responsiblejor a/1 cha�ges incurred from
this applirasion. I,6ereby,give conaent to the Authorized Representative of the Davie County Health Department
to enter upon above descrfbed property located in Davle County and owned b�- f/-�v�en?.n �YI,_ _�S,-r�p�✓�cs
to cooduct all teating procedurea as neceasary to determine the s�te auitabili �.
�� .�
DATE �R� _ SIGNATURE .
TflIS AREA MA.Y BE USED FOR DRAWINC YOUR SITE PLAN(Include all of t6e following: EL�ting and proposed
property liues wud dimeasions, atructures, setbacks, and aeptic locatfons).
Account No. I ��
Revised DCHD(07/98) invoice No. �'�
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12.617 ACRES � 11 .032 ACRES �,
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D.B. 42 - 340 D.B. t00
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;=`S ( by d.m.d. ) • ;
- ' , • ^ DAVIE COUNTY HEALTH DEPARTMENT
v y Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000782 Tax PIN/EH#: 5812-04�909
Billed To: Carl Lusk Subdivision Info:
Reference Name: Carl Lusk Location/Address: Meadow Glen Lane-27028
Proposed Facility: Residence Property Size: 12.617 Acres Date Evaluated: �a–����
7—
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring v Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e% L
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH ,� " � G v
Texture rou G
Consistence i
Swcture /� i �/
Mineralo , -
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON .
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE � i
SITE CLASSIFICATION: 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-Tenace 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
MineraloEv
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
Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD OS/99(Revised)
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Btk�fI� E�UNTY��LT�I I���'ik�T��t`T
ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-OG
Mocksville, NC 27028
Phone #: (336)751-8760 �
October 7, 1999
Mr. Carl B. Lusk
1031 Cornatzer Road
Mocksville,NC 27028
Re: Site Evaluation/Meadow Glen Lane
Tax Office PIN: #5812-04-4109
Dear Mr. Lusk:
As requested, a representative from this office visited the aforementioned site on
October 6, 1999. 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 on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location stalced of�
If you have any questions, please feel free to contact this of�ice.
Sincerely,
�,��t����•
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/mp
Enclosure(s)
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� N 87°13'20"W 7364.26� NIP . �P
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