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190 Deer Haven Trail,' DAVIE COUNTY HEALTH DEPARTMENT . Environmental Health Section �_� c� P. O. Boz 848/210 Hospital Street Mceksville, NC 27028 (336)751-87C►0 990002240 Mike Taylor Residence IMPROVEMENT/OPERATION PERMIT 5746-18-8286 � �� Deer Haven Traii-27028 12 acres **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AiTTHORIZATION 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 TFiIS PERMTT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type _� #People � #Bedrooms �� #Baths �.� Dishwasher: � Garbage Disposal: � Washing Machine:� 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) ��,�_ Site: Newl� Repair ❑ System Specifications: Tank Size/'�?� GAL. Pump Tank Required Site Modifications/Conditions: i� .� l GAL. Trench Width�lv Rock Depth L� Linear Ft�(�� I1VIPROVEMENT/OPERATION PERMIT LAYO - APPROVED EFFLUENT FILTER. RISER(S) IF G" BELOW FINISHED GRADE. ****NOTICE: ContaFt a r�es ative ofthe Davie County Health Department for final inspection of this ! system between 8:30 a.m. to 9:30 a.m. or 1:00 p.� to%30 m. on the day of installation. Telephone # is (33G)751-87G0.**** / U �1Z,p �i<l ��' � � /' '� � ��'� �`� ��%� � � � � �j�1.�z' ��% , , �� - Env�r�nmental Health S�ec�ahst s S�gnatur . / )ate: �/ li� DCHD OS/99 (Revised) Account #: 990002240 Billed To: Mike Taylor Reference Name: Pr000sed Facilftv: Residence ATC Number: 3124 p� �- �. y-o z DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5746-18-8286 Subdivision Info: Location/Address: Deer Haven Trail-27028 5ize: �� acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION li *�NOTE** This Authorization for Wastewater System Construction MiJST BE ISSLJED by the Davie County Environmental I 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 I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT$ CONSTRUCTION IS V��' R A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: _ � Date: `�"lg� � L CERTIITCATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation 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 oftime. �� s° x 3 x'� �� 1 Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) Date: %f �,/ � Z � a h j ' ..r � . � • ' v � � / �`�.1 � �v � ti�a2 0 Q� �� n �' ��,�� ( p�2'i�1„` 1 � "-- \. IN FOR SITE EVALUATION/iMP1it3YF1i9ENT PE5tM1T & ATC Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 I' / " / �� i � � ***`�,DR��.QN�* THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFO ON IS PROVIDED. Refer to the INFORL�TION BULLETIN for instructions. y�, ' �� 1. Name to be Billed � y� � �� I �✓ � Contact Ferson � ^ I(� �CC t.f f QY Mailing Address �'l' l� ('a 1 Home Phone /��- 7�� City/State/ZIP Q(�1�� PJ / v� G- 7�/Z Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: fQ Site Evaluation a. system to service: �t' House ❑ Mobile Home 5. If Residence: # People �_ � City/State/Zip � rovement Permi.t/ATC ❑ Both ❑ Business ❑ Industry ❑ Other # Bedrooms � # Bathrooms � 17 DishWasher ❑ Gazbage Disposal R''Washing Machine �sement/Plumbing fl Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Peaple # Sinks N Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City �Well ❑ Community s, Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Yes J�'%No /" ***IMPORTANT*** CLIENTS MUST COMPLETETHG REQUIKED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESU6M17TED by the client with THIS APPLiCAT10N. Property Dimensions: J �--a-�iu�/ Tax Office PIN: #�J' �% �(p� ��o� � W �� Property Address: Road Name� GLUBtv � CCt,�, c�tyiz�p �Yir�:.� i I � e fUZ o� If in a Subdivision provide information, as follows: WR(TG DIRGC'I'IOhS (from Mocksville) to PROPGRTY: (�Uls-to � lu Cross � r n ��e-%� m-, �� G"� SS ��.� � � ��- �, �e.�- ��..-- Name: Section: Biock: Lot: Datc Property Flag�ed: � 5 d�� This is to certify that the information provided is correct to thc b�st of my knowledgc. [ undcrstand that any permit(s) issucd 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 clianged I, ulsu, rurderstund t/rat 1 am respo�rsib[e for aU cJrarges incrrrred fro�i� t/iis application. I, hereby, givc consent to the Authorized Representative of the Davie Cou t� �ca�lt,h Dc artn cnt/,�/ to enter upon above described property Iceated in Davie County and owned by �t��.v/c�, �� /UY to conduct all testing procedures as necessary to determine thc site suilabili . DATE `T ��-5/U� SIGNATURE � THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines Aad dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit� Chargc Dat�(s): Clic��t Notification Date: EHS Account No. �"2' �` V Invoice No. � � � � � r C:�. , i . a Y _.-� ':.� ,.. APPLICANT iNFORMATION Account #: 990002240 Billed To: Mi�3 Taylor Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Slope % HORIZON I DEPTH Consistence HORIZON II DEPTH Texture group Consistence Structure Texture Structure HORIZON IV DEPTH Texture group Consistence DAVIE CUUNTY HEALTH DEPARTMENT Environmental Heaith Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH �r: 5746-18-8286 Subdivision Info: Location/Address: Deer Haven Trail-27028 Property Size: 12 acres Date Evaluated: �/� ��v On-Site Well L/ Community Auger Boring ,+� Pit SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 1 2 � r ,�� i LONG-TERM ACCEPTANCE RATE: � Public Cut 3 4 5 6 7 EVALUATION BY: 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 plai❑ 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 tructure SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic MineraloQv 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 - gallday/ft2 DCHD OS/99 (Revised) ■ ■■■�■ ■\��■ ■��■ ■��■ ■��■■ ■��■ ■■��■ ■�■�■ ■��■■ ■�■�■■ ■��■ ■��■■■ ■■�■■■ ■■��■■ ■��■ ■�■��■ ■�■■■■ ■��■ ■■�■■■ ■■��■ ■ ■■��■■ ■��■■■■■ ■��■■��■ ■�■��■■ ■��■■■■ ■■■�■��■ ■■��■ ■��■��■■ ■��■■��■ ■�■■■��■ ■�■■■�■■ ■■■��■�■ ■�■■�■�■ ■�■■�■�■ ■■■��■ ■■ ii i ■ ■ ■■ ■■ ■■ ■■ ■■ ■■�■ ■��■ ■��■ ■��■ ■�■■ ■■■■ ■■■■�■ ■■��■ ■��■■ ■■■�■ ■��■■ ■��■■ ■■■�■■ ■�■��■ ■�■��■ ■��■ ■■�■■ ■��■ ' ■��■�■ ■��■ ■��■■■ ■■■�■■ ■�■��■ ■■■■■■ ■■■�■■��■■ ■■��■�■�■■ ■�■��■��■■■ ■��■��■e ■�■��■��■■ ■■■■��■■ ■�■■■�■■�■■ ■■�■■��■��■ ■��■��■��■ ■��■��■�■ ■■■��■ ■�■■�■��■■ ■�■■��■■�■ ■■�■��■��■ ■��■■�■��■■ ■■�■��■�■ s��■■�■■��■ ��■�■■■�■ ■�■�■�■ ■�■��■ ■�■■��■ ■�■�.�■ ' ■�■�►�■ ■��■■��■ ■■��■ ■■�■■■,� ■■��■��■ ■�■��i■ ■�� ■�■��i� ��::i■ ■■■��■ ■■■��■ ■■■■�■ ■�■��■■■ ■�■■�■�■ ■�■■�■�■ ■Bsi�■�■ ■��■■�■ ■■�■■■�■ ■■��■■ ■��■��■ ■�■��■ ■��■�■■ ■�■�■�■■ ■�■■�■�■ ■■�■�■�■ ■�■■��■ ■■■■��■ ■�■�■■■ ■��■■ ■��■■ ■■��■ ■■��■ ■■��■ ■■�■■�■ ■��■■■■ ■��■ ■