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171 Childrens Home Rd Lot 12 c t DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section io:_-�,, P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900207 Tax PIN/EH M 5813-88-8704.12 Billed To: LGS, Inc. Subdivision Info: Oak Grove Sec.2 Lot#12 Reference Name: Ashton Sauls Location/Address: Children's Home Road-27028 Proposed Facility: Residence Property Size: 2.05 Acres **NON&JIffi bgr: 2340 is mprovement/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 m'14Om1: #People 2-- ,#Bedrooms Z #Baths Z- Dishwasher: 03/ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size O� A( 5 Type Water Supply W CUA Design Wastewater Flow(GPD) Site: New 93"'Repair❑ is op z System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width v Rock Depth 2 Linear Ft. �� Other: 61 DQ&P ' Dga5 , WS -A LL 0-IC-5 TO.G, M 1,.J , Required Site Modifications/Conditions: vNSYAu, Un) Kel P 56' Few t.�LLI 41tc: ,FF M."or-V o' 2oP. IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6°'BELOW - t� FINISHED GRADE. ""NOTICE: Contact a representative of the Davie County Health Department for n�spection 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 inst tion. hone#is(336)751-87600 PSP, t_t�S,L ��'�s`•� 12' �P-ccal(� SIR��' moo' coy- . P�oPaSd� �e67eoP t Jr �d>'^�' a 120 p: (L I Environ ental Health Specialist's Signature: Date: PD DCHD OS 9(Revised) . I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 989900207 Tax PIN/EH#: 5813-88-8704.12 Billed To: LGS, Inc. Subdivision Info: Oak Grove Sec.2 Lot#12 Reference Name: Ashton Sauls Location/Address: Children's Home Road-27028 Proposed Facility: Residence Property Size: 2.05 Acres ATC Number: 2340 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.190 a Tr ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEW CO CTI IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date:VU V c3 21 0� 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. F G� Septic System Installed By: Environmental Health Specialist's Signature:— QG Date: DCHD 05/99(Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENIF PERMIT&A Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street F8 2 8 2000 Mocksville, NC 27028 (336)751-8760 ENVIRONMENTAL HEALTH COUNTY - -- ` ***IIVORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed un - Contact Person R.-A--a,a Mailing Address Home Phone 5 16(i 4 City/State/ZIP I 'l- ' A1C 2z 1O I!;- Business Phone 2. Name on Permit/ATC if Different than Above t-''� Mailing Address City/state/Zip 3. Application For: ❑ Site Evaluation C4ymprovement Permit/ATC ❑ Both 4. System to Service: ❑ House Wi bile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People 2 # Bedrooms 3 _ # Bathrooms Z U Dishwasher ❑ Garbage Disposal [7 Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: specify type . # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City . g4ell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes L-14O If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �`G` -//C/L WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax Office PIN: #_ ' `'l3 8 `: $�6`��/2J ��c u`/�61 -'�i(�4cT� Property Address: Road Name (���/�''<G/�S Ael, City/Zip�Z 44411e 27ozV If in a Subdivision provide information,as follows: Name: e- Section: -2- Block: Lot: Date Property Flagged: i 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 County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitabi ' DATE �-j�-� I SIGNATURE w 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 Date(s): Client Notification Date: EHS• Account No. -2 C7 Revised DCHD(07/99) Invoice No. -2 W �-•ZY-act APPU(1t11ON FOR SITE EVALUAIIUM/IMPROVEMENT PERM17 do ATC Davie County County Health Department D r� �Glti Environments/ ealth 56CH0nAUG P.O. Box 848/210 pospital Street 2 5 1 Mockaville, NC 27028 (336)751-8760 ORT ** THIS APPLICATION CANNOT BE ALL THE REQUIRED StIFORMATYON IS PROVIDED. Refer to the INFO ULLETIN for instructions. Name to be Billed I Ck,n e_L i Ct taat person SaM P Nailing Address ? r�l�io\� L�n► e_ Some phone city/state/zip 1 o►JS IJ C—. 7-701 Z Business phone 7 eo �P - 107 T. Name on pezmit/A1C if Different than Above Nailing Address City/state/Sip old G sri� 3. Application For: U Site Evaluation 0 Improvement Permit/ATC At Both / 4. system to service: 0 House Mobile Home 0 Business 0 Industry 0 Other a. If Residence: i# People 3_ T Bedrooms 3 # Bathrooms Z— XDishwasher 0 Garbage Disposal YWashinq Machine 0 Basement/plumbing 0 Basement/No Plumbing S. If Business/industry/other: Specify type * people • Sinks f Coamodes f Shovers t# urinals # pater Coolers IF FOODSERVICE: 11 Seats Estimated slater Usage (gallons per day) 7. 11"m of wages supply: 0 County/City dell ❑ Comounity e. Do you anticipate additions or expansions of the facility this system is Intended to serve! 0 Yes XNo U yes,what type' ***IMPORTANP**CLIENTS 11IUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBESURM!_r_r "ti..fm.._��-.-• ;,;;;;„$ ri.iiW�.Yiuni. Property Dimensions: ��x q �}q X WRITE DIRECTIONS(from MockrAlle)to PROPERTY: Tax Office PIN: �0-0 ( 5 Property Address: Road Name(� h\L AN e;t'l S U o ht 6'a� CA\l 6-Y e ti S City/Zip kAOC_ CSy\1.1(I- N L ?-7oZg If in a Subdivision provide information,as follows: Name: C��co v e.1 Section: Block: A_ Lot: �? Date Property Flagged: O //W V-� 0 ZO This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permits) issued Lereafter 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,anAwmand that l ani resporuiblefor all charges incurred fmm this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by M\Ca-ae LC4-OeC&'00Ctr Du..W'L4 to conduct all testing procedures as necessary to determine the site suitability.., DATE Z SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(include all of the following: E g and proposed property lines and dimensions, structures, setbacks, and septic locations). Account No. y� Revised DCHD(07/98) Invoice No. �.�� / 7.¢.SL Ort mxn r\�p Afllpi J i �44: ! I � ! rLLY L:.ARIA-AL \ TAX T r._—. \\ TAX t.CT S.t7 /� 6 I76-008 TAX L"T 7_M \ h4 f. _ \ \ /• .II'.S ALFM CASA \ ♦ .�,� \y z---•v - IM-1-74 LCG;i:CV 471 � Arc, ! ^ 147.50- Zxl N Y••71^?V asA_rT' ZlJL R\ 11 \a; 1 = 1 .o', —•r-___� Lac �< C !� 10TCC /__CL" O��Y ) �(2 SGC _ ACL" SCC ka ,+ 4rxs � +�! C4!1 1�• al J z V ;. a � �f o �� Ycuf Sart ii'. �j if\�• `��a \ y 1 o X,; _ �•. 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S. 7.__ o..n•cr.•r y.0 c9 :.,t c.R.QEYT —c-c 7 va9Q 2 "- :,.•i=.1 = t.7:7 S'iv�)Y AQ..a._ ♦M-. _ ._ S�: 477C COL;N—•/;. =��• is 3 a..�- •,�___--�-.tet — _�t_n\;C C - _ - _.rv_ _:;i ..575 %•C=r:z J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990000747 Tax PIN/EH#: 9900-EH-0747 Billed To: Michael Duffield Subdivision Info: Oak Grove Sec.2/Blk AO Lot#12 Reference Name: Michael Duffield Location/Address: Children's Home Ro 27028 Proposed Facility: Residence Property Size: 2.05 Acres Date Evaluated: I c) Water Supply: On-Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 23 4 5 6 7 Landscape position Slope% Z v HORIZON I DEPTH 0 - C� Texture groupS t, 6G LL Consistence Cr WW Ce-fJ5 IJ 4)S+1 Structure G2 Gn— Mineralogy HORIZON II DEPTH 2 -Z (s - r Z. .Texture group C_ L Consistence S "5-h Structure 5(�y 401 k 1L Mineralogy N41 M I34:"fl HORIZON III DEPTH 4S-LIC4 laO 17- c Texture group c p< Consistence , 'S. ;5 P Structure KASIZI Mineralogy x':10 HORIZON IV DEPTH Wo Texture groupU Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION F5 LONG-TERM ACCEPTANCE RATE 1 0. 3 1 O•'L5 L_L-3 \ SITE CLASSIFICATION: P� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: CO.ZS OTHER(S)PRESENT: REMARKS: 45CVVA7, Q.,, 1C, 1'yXCrrf-i.1-J tv t oc Svw . ev Gcc A F, Z LEG ND 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 X kL Mineralogy 1:1,2:1,Mixed f I r5b /SO Notes I ► -70 Horizon depth-In inches SO I 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 05/99(Revised) ■■■■ttt■■■■■■■■■■■■■■■tt■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■tt■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■t■■a■■■■■■■s■■■■■■■t■■■■■■t■■■t■■■■■■■■■■■■s■■■■tet■t■■■■■■■ ■■t■■■■ttt■■■t■■tttt■tt■■■■ttt■■ ■■■■■■■■■■t■■■s■t■■■■s■■■■■■■■t■ ■■■tt■■■■■■tt■■■■ttt■■■■■■■■■e■■■■■tttt■■■■tttttet.t■set■e■■t■■■a■ ■■■■■■■■■t■■tttt■■■■■tt■■■■■■■■■■■■■■■■■■■■t■■■■t■■■tt■■t■tt■s■s■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■a■►gat►�■t■t■ray:.��:a■■■■t■■■■■■■■■■■t■■■■■■■■■■■■ ■■■■■■■t■■■■■■sist�■■t►�■t■ttt■■t■■t■■tt■i■s■■■■■■■■■■■■t■■■■■■■■■■■ ■■■■tt■■■tss■■■esi.r;��■■■ttts■■■■■i�■■■■tti■■■■■t■■t■■■■■■tst■sttttt■ ■■■■■■■■■■■■■■■■■■.��t■■■t■■■■■■■■�r�;■■eaten■■■■■■■■■■■t■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■tett■■■■■■■■■■■�i■■c=�■�iu■■■■■■■■■■t■■■■■t■■■■■■t■ ■■■■■■■■■■■■■■■■■■■■�F7■■■■■■■■■■■■■■Llel■■,�■■■■■■■■■■■■■■■■■■■■■■■■ ■■tt■■■tttt■■■■■■■■■■l��■lift■■■■■■■s■■RJ■tl■tttt■■■■tt■■■tt■■■■■ttt■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■t■tt■■■tttt■t■t■■ttt■■t■■s■■■■ ■■t■■■n■■n■■■s■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■tt■■■t■■■■■■t■■t��■■��t■■■■■■■ttttts■■■t■