118 Vogler Rd • � DAVIE COUNTY HEALTH DEPARTMENT
y . . + . Environmental Health Section �� '�-�. G -- oc�
��� P.O.Boz 848/210 Hospital Street
, � Mocksville,NC 27028 C l�—�/ 1 � 1' 7
� ' (33G)751-87C0
IMPRO�EMENT/OPERATION PERMIT
Account #: 990003278 Tax PIN/EH#: 5880-56-8306
Billed To: Moore Construction Co. Subdivision Info:
Reference Name: �����,r� Location/Address: Vogler Road-27006
Proposed Facility Residenc� Property Size: see map
ATC f�mber: 3808
**NOTE** �s Improvement/Operation 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 THIS PERMIT 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: New�Repair❑
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System Specifications: Tank Siz��GAL. Pump Tank GAL. Trench Width� Rock Depth� Linear FK,�U
Other: '
Required Site Modifications/Conditions:
I]FIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISI�ED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
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)751-87G0.****
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Environmental Health Specialist's Signature: Date: �
`\ ��-DCHD OS/99(Revised)
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. • • DAVIE COUNTY HEALTH DEPARTMENT �
Environmental Health Section
� P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990003278 Tax PIN/EH#: 5880-56-8306
Billed To: Moore Construction Co. Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006
Proposed Facility Residence Property Size: see map
ATC Number: 3808
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 11 of
G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CO STRUCTION IS VALID FOR A PERIOD OF FIVE YE S.
Environmental Health Specialist's Signature: Date: C9��� �/
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
has been installed in compliance with Article 11`�'i�ka ter , Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be t a guarante at the system will function satisfactorily for any
given period of time.
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Septic System Installed By: —''%\f 'i���(
Environmental Health Specialist's Signature:���/ Date: � �
DCHD OS/99(Revised)
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� . ' -� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT& � � 1:? � O f�
Davie County Health Department � `�
Environmenta/Hea/th Section ��1,t
P.O. Box 848/210 Hospital Street ���1� �9 ��
Mocksville, NC 27028 1�"��
(336)751-8760 • r��� /�
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***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE ���1'
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
l. Name to be Billed I'1�0�/��� CdKf.4� G�. Contact Person �/�r/�l�C3'J� �IdO��
Mailing Address Si,f�i y /Y�a�!r/!�/Iq/'t� h'��15' l.I✓ Home Phone �fG� I /� ����{
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City/State/ZIP C4F��Ox1S /✓C, Z�ry o/2 Business Phone (a34) 3y9'O�{2 3
�—�
2. Name on Permit/ATC if Different than Above �.�/JJQ�L�///�' � D►✓L��
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation �provement Permit/ATC ❑ Both
4. System to service: I(d'House ❑ Mobile Home ❑ Business ❑ Industry � Other
5. Type system requested: rJ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People � # Bedrooms � # Bathrooms �_
❑Diahwasher ❑Oarbage Diaposal ❑washing Machine �Basement/Plumbing ❑Basement/No Plumbing
7. If Husiness/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinala # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
8. Type of water supply: Wcounty/City ❑ Well ❑ Community
/� �/
9. Do You anticipate aaaiti ns or expansions of the facility this system is intended to serve? ❑Yes LJ No
If yes,wl�at type? �� � i�-U'c�-� t ti � ..-�C �2�
***IMPORTANT'°**CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INrORMATION REQUESI'ED
BELO�V. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dintensions:I7� �C��3 x/� 7 X 3 � � �VR1TE DIRGCTIONS(from Mocksvillc)to PROPERTY:
Tax Office PIN: # ��S g� � S� v �30 � f s� �_ �� J
Property Address: Road Namc V � � ��--� �— (�C„�� SS �-— C�
�
City/Zip ��-✓
If in a Subdivision providc information,as follows: c s � `�" r � �S f �°�"�
L�- � a-� 7--�- � /� �� �-
Name: '
Section: Block: Lot: Date home corners flagged: � �� �
Tl�is is to certify that the information provided is correct to tlie best of my.knowledge. I uaderstaud tl�at auy perinit(s)
- issued hereafter are subject to suspension or revocation,if the site`plans or intended use changc,or if the information
submitted in tl�is application is falsified or cl�anged. I,a1so,cutderstand that I un:responsiGle for al!chargL'S l/1L'l[Y/'L'LI'I'0/11
t/iis application. I,hereby,give consent to the Authorized Representative of the Davic Couuty IIealth Deparhnent
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE 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 Cl�arge
Datc(s):
U � /1��-�"`� Client Notification Datc:
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EHS:
Sign given �� Account No. d��"
Revised D HD(OS/03 Invoice No. / �--�
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SCALE: 11 =4-aOl APPROVED BY DRAWN BY
DATE: !O-
DRAWING NUMBER
NA/bN11L P�f/KST NO.16SA-18x2 -- ---
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APPLlCATION FOIi S1TC CVi1LUAS10N/IhIPItUVE11IL-N7 PL' i - ���l�r�p� 2 0 2004
Davie County Heafth Department
Envi�o�menta/Hea/t/�Section
P.O. Dox 84a/210 Ho�pital Strect F1tY�RON"'�M1E��TALH�1
riock3ville, Nc 2702Q DAVIECOUNIY
(336)751-B7G0
• --�------•---._....I
� ***IMPORTANT*** TI325 11PPLICATION C1lNNOT �3� PROC�SSI:D UIdLLSS ALL TIIL 12�QUIRLll
INFORMATION IS PROVID�D. ReFar to �ho INFORMATION IIULL�TIN �or in:,L'1'llCL1011:i.
, _..._.............. ...
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1. Nsme to be II'illed , v O ConLact Peraon _� _ \�[S�` S
Mailing Addre3s �3�1 e� �� � �i X ltanc l�lionc ����_�G-•a. .. . .. .
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City/statc/zIP La.���
0`1-c�l�f� c�c� ►n,� 2�'1c�o(o lluuinc�o Pl�onc ��_--��-�o�...._..
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2. Namo on Pcrmit/I�TC if DiFierent than 7lbovc 1 ` \Q2��h ���n�C�u
.
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Mailing I�ddre3s t_��l � �j� (C��� C�1� City/Statc/Zip
3. Application For: �Site �valuation � ❑ ImprovemcnL Peiznit/ATC " ❑ IsoCli
4. System to service: f�House ❑ 2dol�ile Homa ❑ Bu�ine�3 O Industry ❑ OL-llcr _____ ___
�a.
5. Type �ystem requeated: �Conventional ❑ conventional modiEied ❑ innovaCive
6. If Residence: 1{ People �_ 1� nedrooms ��• II I3aLliroomu �,,, ._,.._
� �Diahwasher ❑Garbago Diaposal �ashing Machino i�asement/Yltiunbing ❑Da::cinenL•/P�o l�luuibing
_ �
7. If Duainc3s/Indu3try /Other: verify type �p Ycoplc IF Sinl:� ^______
� Commodea I! Showers 4F Urinaln IE Wal•cr Cooler�
IF FOODSERVICE: ## Seats �stimated Water U�age (�a11on� per aay) ___,____'
8. Typc of water 3upply: �County/City � Well ❑ Communil-y
9. Do you anticipato additionn or cxpansious of tlic f:1C1111J'fI11S S)'SlCltl ls Il1ICUc1C(1 lU�Cl'VC? ❑ YCS �I�u
If}'CS�1�'11�f f)'j)C? '
***I1IIPOR'lAlY"l'`**CL1LN'fSil1USTCOAII'LGTt'fH� ltLiQUl1iGU P1tOPislt'1'�'INI�OKIYIA'1'lON ltLQU1sS'1'I:ll �_�
L3GLOIV. LiWcr a PLA'1'or SIT�PLAN�11USTBCSUIi�1fITTGD by tl�c clicnt n�ifli 7'li1S t1I'PLICA'1'IOR.
1'ropct•t)'llitncttsions: / ! Q x � � � � f�„�X 3��VR1'I'l;ll1KGC'1'lUiyS(fruiu I1•luclavillc) fo I'!tOI'l;lt'1'1':
l:�a orr«rirr: � �� � �d S� �3 o C, —' —� �b �.� ��i '
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Property Address: Road Naiuc V O� e, � (-- - U nc�i 2.(�c�S� ,. L — V!�c��2
. �
City/Zip �-1� ct i1,r,c�
If i�i a Subdivisioii providc i�iformalio�i,as fullo�vs: � �.2t. p-y-� ��---�.
Namc: . . �C�
Scclioii: Blocl.: Lot: Datc liomc coi•ncc•s ll:ibbcd: 7 - � 9'� T
Tliis is to ccrlify tIiat tlic iuforn�ztioii providcd is corrcct to tlic bcst ol'my lciiotivlcdbc. i uiidci•s[aiid tli:il aiiy pc�•uiil(s)
issucd licrcaftcr are subjcct to suspension or rcvocatioii,if tlic sitc plalis or intciidcd usc cl►aiibc,ur if llic inl'uruu►tiu�i
subtuittcd iu tt�is applica(ion is falsificd or cLauged. I,also,«iideislniirl!/rat I uuc res��u�1siLlcfur rrl!clnub�es iirc�u•rc•�!J'ruu,
11ris c,pplicariu�r. I,licrcbp,gi�•c couscut to (lic AuUiorizcd Rcprescutalivc of tlic!):n�ic Cawi(��llcaltli llcp:u•(uun(
lo cntcr upo►i aUo�•c desci•ibcd propci•ty locatcd iii llavic Coutity atid o�i•iiccl b�� __ _
lo cuuduc(all lesling proce�lul•es as iiecessai•y to dcici•ti�ine tl�e sitc suitabilil��.
DA'i'L SIGNATUIt�
TIiIS AREA MAY 13E USLD TOR DRAWING YOUR SIT�PLAN(Iiicludc al!of llic fullotivii�b: Lxisti�ib:i,icl p�•uposcd
�
property lincs ancl dinicusiais, structures, sctbacics, and scptic locatiolis).
� e� � = Site Rcti�isit Cluii•�;c
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! Cliciit Notific.ilio�i D:itc.
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Sign given ' Accouiit No.
Rc��iscd DCFiD(OS/03 � ' L�voicc No. _����
, � ' � � OP���
� a • �i�3�IL� �ai� £ �i��'�E�" . - � .
� . �p��.� t�lortYi Carulina
click on the Map to: Map Layel'S
� Zoomin r,zoomouc r Recenter Map � iaer,tiry: Parcels - Draw Layers
Zoam Factor: 2X " �' Radius Search(feet)�- Draw selected layers:
Boundary
NYx� •�(. NE r CensusTracts
City Boundaries"
r County ZoNng
Multi Symbol �
r E971 Fire Dtstricts
F,.--
r Flood Panels
r Flood Zones
� � �� Parcels
� i
i �� � � School Districts�
' Multi Symbol_
r� (-solls
�� i� r Town Zoning
�880368306 r Townships
Multi Symbol_
r Voting Precincts
'Infrastructure
r Driveways
r Rail L(nes
.��
�Street Centerlines
' �I US/NC Highways
Muiti Symbol-
�+,�,t . � SE US Highwa
. � �--�� NC Highwa
�+���� ���. ' � Interstat
Find Adjoinin�Parcels r Aerial Photography
Physical
• Land Unit/Type:F900000032 :/AC r Creeks and Rivers
• County ID:F900000032
• Deed Book/Page:1993E/0204 r E911 Addresses
• Account Num6er.3467070
• Deed Date:7994/06/08 r Fire Departments
• P/N:5880568306
• Sales Price:$0.00 r Schools
• Legal 1:1.55 AC VOGLER RD • property Address:
• Owner Name:BAILEY TAYLOR F Draw Layers
• Owner/Address 1:BAILEY TAYLOR F � County Zoning:R-A
• Owner/Address 2: • Census Code: MAP Cui7eriCy
• Owner/Address 3:493 BAILEY ROAD � Ci�Code:
• City,State Zip:ADVANCE,NC 27006-0000 • Fire District: This map is prepared for th
inventory of real property fr
• Land Value:$22,860.00 • Flood Zone:ZONE X within this jurisdiction,and
• Building Va/ue:$0.00 • Flood Community:370308 compiled from recorded de
• Out Buildin Extra Features Value:$0.00 plats,and other public recc
9� • Flood Panel.•0045 C and data.Users of this ma�
• Assessed Value:$270.00 • Flood Map Date:12-17-1993 hereby notified that the
aforementioned public prirr
a Property Record Eard � ��r p�2 informa4ion sources should
consulted for verification of
• Township:SHADY GROVE information contained on tt
• : � , . DAVIE COUNTY HEALTH DEPARTMENT
� • " Environmentai Health Section
. � . Soil/Site Evaluation
APPLiCANT INFORMATION PROPERTY INFORMATION
Account #: 989900111 Tax PIN/EH#: 5880-56-8306
Billed To: Gray Potts Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006����� y
Proposed Facility: Residence Property Size: see map 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
Slo e%
HORIZON I DEPTH e, ��
Texture rou �.
Consistence
Structure
Mineralo
HORIZON II DEPTH �" $'l�
Texture rou
Consistence
Structure �
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 �
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-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
Mineralo�v
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-gaUday/ft2
DCHD OS/99(Revised)
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� Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
� ��336)751-$760 r�'�
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Apri128, 2004
Gray Potts
5342 Highway 158
Advance, NC 27006
Re: Site Evaluation/Vogler Road
Tax Office PIN: #5880-56-8306
Dear Client(s): �
. As requested, a representative from this office visited the aforementioned site on,
Apri123, 2004 Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
�o2'�,t��/�a�,•
Robert B. Hall, Jr.,R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)
hone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier #: 09-40-06n i 1
Mocksville, NC 2702$
Fax: (336) - 753-1680
ON-SITE WASTEWAT . CATION
(Check One) Replacement Remodeling__ Reconnection
Name: %� > / P_Gu �z+'� r Lam— Phone Number��l -3 ?,j
Mailing Address: 15 V3 1jf5-4rvok- p%4 -a Dr, (Work)
k.) - �-, NU 9-710-3 Email Address: knSLAi to" 2—pg&0� � £�-
Detailed Directions To Site: A4,j,, 3o l G{G, a aS) AZ- —A V2,44 !moi ",
Property Address: VaRcl,W, �:w 7
Please Fill In The Following Information About The EXISTING Facility: /
Name System Installed Under: Type Of Facility: 4
Date System Installed (Month/Date/Year):��0!/ Number Of Bedrooms: 3 Number Of People:
Is The Facility Currently Vacant? Yes
If Yes, For How Long?
Any Known Problems? Yes (9 If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
�pprovedisapproved
Comments:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order #.
Paid By:_
Account #:
Amount:$
Received By:
DAVIE COUNTY HEALTH DEPAi FA ENT
. Environmental Health Section at
P. O. Bog 8481210 Hospital Street
Mocksvilie, NC 27028 C
i a (336)751-8760
!) IMPROVEMENT/OPERATION PERMIT
Account #:
990003278
Billed To:
Moore Construction Co.
Reference Name:
ng
Proposed Facility
Residen
Tax PIN/EH #: 5880-56-8306
Subdivision Info:
1It7'7
Location/Address: Vogler Road -27006
Property Size: see map
ATC Ng
b r: 3808
**NOTE** s lm provement/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 f #People (1�' #Bedrooms --2 #Baths_
Dishwasher: M Garbage Disposal:
Commercial Specification: Facility Type
Washing Machine: ❑ Basement w/Plumbing:Z110", Basement/No Plumbing: 171
#People #People/Shift #Seats Industrial Waste: 13
Lot Size Type Water Supply Design Wastewater Flow (GPD) Sry Site: New Repan ]
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width<"�� Rock Depth Linear Ft dAU
Other:
Required Site Modifications/Conditions:
II'4'[PROVENIENVOPERATION 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.** * *
Environmental Health Specialist's Signature: Date:_6h&4-_
DCHD 05/99 (Revised)