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386 Buck Seaford Rd (2) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751.8786 OPERATION PERMIT Account #: 990004253 Tax PIN/EH#: 5727-90-2929 Billed To: Donald' Lakey Subdivision Info: Reference Name: Location/Address: 386 Buck Seaford Rd-27028 Proposed Facility: Pool House Property Size: 55.26 ATC Number: 4604 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. Q-1 I System Type: � S.T.Manufacturer 4� Tank Date 3 ✓r Tank Size 1%d®0 Pump Tank Size System Installed By: 000 A i k H. Specialist: c) `Pioµ ate: + 0 7 I - a `Nd L _j Q w 4i to L �� c j",I �h"Puy L !� r DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 Mz-qf67 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990004253 Tax PIN/EH M 5727-90-2929 Billed To: Donald' Lakey Subdivision Info: Reference Name: Location/Address: 386 Buck Seaford Rd-27028 Proposed Facility: Pool House Property Size: 55.26 ATC Number: 4604 Site Type: ❑New ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type Poolc�.�5—#People .1� #Seats Square Footage(or Dimensions of Facility) arR O o Lot Size ('0{ Type of Water Supply: QL`ounty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow(GPD)_JN[O Tank Size o co GAL.Pump Tank /J�-GAL. Trench Width 3 4 Max.Trench Depth ?0' Rock Depth LinearFt. C o Ko. s,, ti . 4§A NCAC 18,A.a9a9(s1 6 Site Modifications/Conditions/Other. Vi„„is2"NJI G1,1Taiiag- Tse-1 t75t; Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on th da of installati n. Tele hone#(336)751-8760. �WIDp U CO 'VG QVQ GSfC tf '(6 S�0Jg� 3 P 0- (60y �.t�p�1r /Il tcp 1 -- a Environmental Health Specialist Date: -7 DCHD 11/06(Revised) .E E U U E : -A� SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health FEB 2 6 2007 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 ��(p �wv E1ifi2LiL01 (336)751-8760/Fax(336)751--8786 DME CdUW1Y pp icahon For: Q Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed 40v L J 6/ Z--145 Contact Person Aolawe l ��I� Billing Address <(/G 5 =' 1 Home Phone?S•/ J V.7� — - City/State/ZIP �G / , �% 4 2 S1 Business Phone .G yJ 7C s' 7 Name on Permit/ATC if Different than Above Mailing Address ' City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) c Owner's Name V A G G��j/Y �5 4- F Phone Number Owner's Address x �(/�/� ,,'/� City/State/Zip j!-�'/ < 6 /o -'- Property Address 2 A AZ/C/ City Lot Size -55,10 Tax PIN# 5727-q —1�Zg Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes YNo Does the site contain jurisdictional wetlands? ❑Yes ErNo Are there any easements or right-of-ways on the site? ❑Yes&o Is the site subject to approval by another public agency? ❑Yes E�qo Will wastewater other than domestic sewage be generated? ❑Yes ffNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business ,A,/, Total Square Footage of Building &-Z �f Gd #People #Sinks_ ::2- m #Commodes_� #Showers�_ #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats AIIa .!�� - iZ;lcx• F- '1 u,, Type system requested; ❑Conventional .Accepted 01nnovative ❑Alternative ❑Otherr/l�/�/l�/ff��. Water Supply Type: EA'County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1440 If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permits)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners_ and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. 4, -�& Site Revisit Charge Property owner's or owner' egal representative signature Date(s): 0 , Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# '" Zoa P•� 1 ZL)OO t C p U f/ Z�� V RA 7 7777T7 7e;� 77 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS}�PERMIT'AND='CERTIFICATE �O.F COMPLETION r ` OT.E.,%Issued in Compliance with G S. of North Carolina Chapter 5i30 •Article 13c r r n Se age age Treatment and Disposal Rules ('10 NCAC 10A 9347 :1968) Perit Number NameDates �L .�a - 4252 Location - > Lot,-No. t °• ;Sec or-'Block No.".," - . . ;•:.".i(`. �i P - �.. ", F ___. *. -�'•_ ': i ". .. 'i:r T -. w tis°__ Lot Size ` i�/� House Mobile Home Business Speculation No. -Bedrooms No Baths No: in Family _ Garbage_Disposal ,,,,, i yYES;p NO:r�!: Specifications for System: Auto Dish Washer;- YES.• NO,,Q t� / .Auto Wash Machine YES .{NO ifl, TYPe Water:Supply ,, � �✓This permit.Void if sewage system described-below is not installed within 36 months from date of issue. aoa ! Improvements permit by ,. t .-: .. _• - -ter., *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 R.M. on"day-,of.completion. Telephone Number.:.704-.634=5985 - Final Installation Diagram: _t. . �` ` r " ` f "'F System Installed-by _ - '• .. art. _ .. Certificate of Completion Date 1 "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO Way be as a guarantee that the system will function `satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 . 3 4 5 6 7 Landscape position L5 L-1D- Slope% $7. $ W. HORIZON I DEPTH O— IT Texturegroup $(, S Consistence GR f Structure ' Q Mineralogy :I ; HORIZON 11 DEPTH 110—4 Texture group Consistence Structure CAZZ Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION .77 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PIrdEVALUATION BY- 0.1 L LONG-TERM ACCEPTANCE RATE: G• ' OTHER(S)PRESENT- VQSSIC C N14 REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terr4ce 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 1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3y t 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 Nato 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 05105(Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■e■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■e■■■■■■eee■■■■�, r■■e■■■ee■e■■■e■■■■■■■■■■■■■■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■sate■eve■■■■■■■■■ease■■se■■■■■e■■e■■■■■■■e■e■■■■vee■■ae■■■■■■■■■ ■■■■see■e■e■eeese■■■s:ae■e■■e■�a■■�le■e■e■e■e■■e■■■e■■■■e■■■■■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■!A■■■■■■■■■L'ii]I■■■■■■G;�AC1■■fir■■■■■■■■■ ■■■e■■ ■■■■■■low moo■■■i■■■■■T.I-4116!e ■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Ili■v■L'l■■■Y■■■■■I.■■■%\e■■■■■■■■■■■■■ ■■■■■■■■■■■■■11■�u��iiii:CC��===C:::iiia:iG�i�C�:J/.i■■\■■■■■■■■■■■■■ ■■e■■■e■MONO MONO■■■■■■■■■■■■■■■■ ■■11■W7i■■■■■■■■■■■\e■■■e■■■■■►e■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■IIIIJL.a■■■■■SEEMS MON ONi■■e■pAWi■11■■ ■■■■a■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■Illi■■■■■■■■■e■■■e.■■■u■■■■■��r.�■■ ■■■■■■■■■■■■■■■■■��'�:ir,.�1■■■■■�i■■I�e■■■e■■■a■e�;7■■■e■■ell■■■■■flfll%■■■■ ■■■■■■■■■■��ii■■■■■■■[i lie■■■��■■■Il■■■■■■■■■■■%11■■■■■■■■I■■■■■■It■■■te ■■■■■■■■err■■■■■■■■■■■■�■■■■■I■■■■'�■■■■■■■■■■II■rl■■■■■■■■I■■■ee■■/_ice■■ ■■■■Ott■■■■■■■■/i■■■■■�1/■/.■■■■e■I■■■■■■%■I�■[/■ry�l■■e■■■■■■■e'■■■■■■■■■ ■■■■■■■■■■■■■■■■I■■■■■■R'■■>■■■■rI■lViii/e■■■I,■■i■■e■ee■■■e■■e■■e■■■■■ ■■■■■■■■■■■■■■■■eeee■■■a■■■■r�■■■i�ee■■euee■a■■e■■■■■■■■■■■■■■■■s■■ ■■■■ee■■e■■■e■■■■■■■■■■■■e■■eeee,�ie■■■r�r.■■■■■e■■e■■■■■■■■e■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■eee■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■e■■■■eeee■■■■■■■■■■■■■■■■e■■■■■■■ee■■■■ee■■■■■■e■ ■■■■■■■■■■■■■■■■■■ee■e■■■■■e■■■■I�■■■ee■■eeee■e■■■■e■■■■■■■■■■■■e■ ■■■■e■■e■■eee■■■se■■■■■■■■■■■■■■■■■■■ea■ase■■■■■e■e■■e■■■■■e■■■■■■ y _ 55 A) L rJJOO £ s app��jj + WV 70 E" (17 04A)/ ao F _ 7�, � z ., 1 1 gas Y y � 4r ISMf YA WAY " g,a HOW" L e+ $ 386low .. n P: �` 5525 A an No lie Sho to rn s A fPEC2 = V ChA 70coney M RAN ??. ICU bnono! 1, 01s P, s s N 1 low - v1J a'�� !, :2 w`Fg a ,�i�� " K Ate. � ,,• Yq SW WIAM at k,5d last TWA ' -� ....„ter ,•�? �� .h m - j l l 71 f. A IS vI 638 6, A�psi n a ep t Apil yti AW -IRS”11=0 WN :� +J r Via WN M, T", N 00 10 NovIsm, - Won or v t 1 • fork� f �+ ` VOR -- r 2(H) ; 1321 ; p - p 4r as a $4 4 ` •L a • r_ Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004253 Tax PIN/EH#: 5727-90-2929 Billed To: Donald' Lakey Subdivision Info: Address: 386 Buck Seaford Road Location/Address: 386 Buck Seaford Rd-27028 City: Mocksivlle Property Size: 55.26 Reference Name: Proposed Facility: Pool House **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: [R.-Kew ❑Repair ❑Expansion Permit Valid for: years ❑No Expiration Residential Specifications: #Bedrooms 0 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People 7.' #Seats' Square Footage(or Dimensions of Facility) ay Oo Design Flow(GPD): LI 0 Type of Water Supply: ZCounty/City ❑Well.❑Community Well Site Modifications/Permit Conditions: As Stat areepte�d in 15a NCAC 4Br,.Inf,( System Type LTAR Initial y Repair Site Plan ` t Q 6p` 41V o AN y0 p y t, Ar 1 T CZ, Environmental Health Specialist Date o� _ 2 G i.p.l1-06