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1048 Wagner Rd ' , ' DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section , � P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33G)751-8760 Account #: 990003686 Tax PIN/EH#: 5811-91-1900 Billed To: Douglas Baileau � Subdivision Info: Reference Name: ���1 LA D���.�.., Location/Address: Wagner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4156 A� �t�ted in 15A NCAC 18A.1969(5) ��cepted Systems may also be used �UTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLIED 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 Ofl'ice 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 CONST. GTI IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: ` 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 of time. �������� ��j� c� �� � � .Qr t� �� �b t �� � �� � ( ��L- �, (o`2-(o �i1�,..��,�s�8��t� �c Septic System Installed By: J � nL T�� �� Environmental Health Specialist's Signature: Date: �� c DCHD OS/99(Revised) , DAVIE COUNTY HEALTH DEPARTMENT ��� �/Z�Jb s- /`� Environmental Health Section � . � ' P.O.Boz 848/210 Hospital Street �y��j '�( � . Mocksville,NC 27028 C/�-`� I/ S �/ • (336)751-87G0 ���`c�:,,�-.w{,�•�v �L.�rr•-�- IMPROVEMENT/OPERATION PERMIT Account #: 990003686 Tax PIN/EH#: 5811-91-1900 Billed To: Douglas Baileau Subdivision Info: Reference Name: A.,a,tL• D���,,�,� Location/Address: Wagner Road-27028 Proposed Facility Residence Property Size: see map ATC Number: 4156 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AIJTHORIZATION 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 �1 #Bedrooms � #Baths 2- Dishwasher: � Garbage Disposal: � Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �•��3�.�5 Type Water Supply�^��T`� Design Wastewater Flow(GPD) �� Site: New�Repair❑ System Specifications: Tank Size �E�O GAL. Pump Tank �'�7 GAL. Trench Width �'M Rock Depth 1Zj1 Linear Ft.��f Other: (D�iST���UTi.o� �Dx�� As stated in 15A NCAC 18A.1���15) accepted Systems may also be u�etl Required Site Modifications/Conditions: ���A�-'- � �-�-`�� �5 0� �:= ����F�p ua� I]VIPROVEIV1ENT/OPERATI ERMI YOUT- APPROVED EFFLUENT FILTER. ISER(S) IF G "BELOW FINISII E. ****N ICE: Contact a representative ofthe Davie County Health Depa nt for final inspection ofthis system bet een 8:30 a.m.to 9:3 a.m. or 1:00 p.m.to 1:30 p.m. on the day of installation. Telephone#is(336)751-87G0.**** � � � �� 57 �� � q � ` �� ��� �� � �1���,� � '� ,�Q��,� � �� 1 rJ . . Q � � fw � � � �� a� X � , ��1 � � � s ; x Q ,� (Q ` � ���� �-o.� �,� dw�,� '�� �`� °` r0 J �.��,r�,+cax.. y-�-�nk.���a �9 �2'' ��"�'"�,o ' YM��•�Q' Environmental Health Specialist's Signature: i Date: � �7 29 DCHD OS/99(Revised) .� . : . D � ��' � M � .� � � APPUCATION FOR SITE EVALUATION/IMPROVCM1iENT PCRI411 ' . . Davie County Health Department � '• Environmenta/Hea/t/�Section JUC 2 � ���� P.O. Box 848/210 Hospital Strea� Mocksville, NC 27028 EAMRONMENTALHEqU}r (336)751-8760 DAVIECOUNTY ***TMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORtdATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Namo lo be IIilled (,C('al(�S �� VI Contact Peraon `�� Mailing Addrasu �� S�VP� �� �� Iiome Phone �� �3$�ao� 5 City/State/ZIP LihGJOU� /V�— �7� / / eusinesa Phona 2. Namo on Permit/I�TC if Different than Abovo J�,n�p�C�i �u��1 1 n� _� Mailing Addresa ��La�D(l e� \�d City/State/Zip Ma��csv�l�e fi.��- 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC �IIoth 4. syatem to service:� HouBe ❑ Mobile Homo ❑ Business ❑ Induatry ❑ Other 5. Type Dyntem requontad: l�.Convontional ❑ convantional modified ❑ innovativo pac�epted ( ^ 6. If itesidence: # People �_ # Bedrooms 3 �k Bathrooms '� �piahwasher �Garbaga Disposal �Washing Machino ❑Hasement/Plumbing ❑Basement/No Plumbing l ' 7. If Susinea8/Industry /Othor: verify type # PeoplQ S Sinka # Commoclos # Showers # Urinals # Wator Coolera IF FOODSERVICE: �� Seats Estimated Water Usage (gailons por day) 8. xypo o� water aupply�County/City ❑ Well 0 Community 9. no You anticipate aclditions or expansions of tl�e facility tliis systecn is inteiided to serve? ❑Yes � o If��cs,i��l�at typc? ***IAIPORT�iNT"�**CLILN7'S MUST COh1PLETL TII� REQUIKL•D PROPCRTY INrORMATION RLQULSTGD [3CL0��'. Cithcr a PLAT or SITG PLAN 1LfUST BE SUIIhfITTLD by thc clicnt `vith TIIIS APPLICATION. Property Ditnctlsiotls: � �x'`f����2 x�`� �VRIT�DIRGCTIONS(fron�Mocicsvilic)to PROP�RTY;` T:�.orr,��i'IN: �E 54v 11� I 19D� lU o n 601 -fi�1— c�� L`be��y PropertyAddress: RoadNamc �<Gr�21 '►�C l ��L�n R� T�L U''t �,.�C.�(�.Pl City/Zip 'f r rdG v�1� �r���1�-•,+ Gn �-e�t' -�-. If in a Subdi��ision providc inforn�atioii,as follotivs: Namc: � /� �41 M ���.r bo/ ,5;�,� C� �' C�O�G( Section: Blocic: Lot: llate home corners ilagged: '7��•51D5 1'his is to ccrtify tl�at tl�c information providcd is correct to tlic bcst of ii�y knowlcdgc. I undcrstaiid tli�t any permit(s) issucd licrcafter are subject to suspension or revocation,if the site plans or intended use cl�ange,or if tlie information submitted in tl�is applic�tion is falsi�ed or changed. I,also,understairrl tlrat I ain responsiGle jor a!!cltarges i�rcrrrrer!fronr t/�is npplicnlion. I,l�creby,givc conscnt to tlic Autliorized Rcpresentativc of tl�c Davic County Hcaltl�Dcparhncnt to entcr upon abovc dcscribcd property located in Davic County and owncd by to conduct all testii�g proccdures as ucccssary to dctcrminc thc sitc suitaU' DAT� ��2sla s SIGNATUIt� � THIS AR�A MAY B�US�D TOR DRAWING YOUR SIT�PLAN(Inclu 1 of tlic follo�ving: �aisting 1nd proposcd property lic�es and dimensions, structures, setbacks, and septic locations). Sitc Iicvisit Cii�rgc . � �` . .� Datc(s): �gp� C/C-{� Clicnt Notircation Datc: � ` b �'y l� S v o �IIS: 6`' �v --�'3°4 � A��o�nt nTo. ���� Sign givcn Reviscd DCI-ID 05/03 ����� Lrvoicc No. � N.T.S.) - �, J. TODD EVERHART CERTIFY THAT THIS MAP WAS DR,4WN FROM AN ACTUAi,, g MADE UNDER MY SUPERVISION, THE RATIO OF PRECISION AS CALCULATED IS 1/10, • - I HEREBY AFFlX MY HAND ANO SEAL THIS 8th DAY OF JULY � 2C � o . � � . RE r24TlON N0. L-3° � � ^ �`��N���A I REVISION FOR TNE DIVISION OF � :�� •'''ES s i� 4 ` �::•oF c J. FRED RATLEDGE ESTATE � ;'Q� PB 6 PG 135 / c _ SEAL DIVlSiDN OF L-35� J. FRED RATLEDGE ESTATE : .��9ti ;`'�''•.o � TRACT 7 ' .. u � PB 6 PG 134 �,� �.• .,S R, � �� \ � ���''���i Ei ANGLE IRON p / rRacr �3 FOUNO S 83'44'tg`E 162.63' (77C) �� S 83' SP E�FOUND 31•33' � 4.5�00"E�� �•280,1]'� � 248.84' �p� �'�Jn�, � o,• —�_ (;t • 603.42� (nE� � � ��- N 83'45'00`yy / _� �� �09 0� PHYLLIS J. ALLGOOD / - " ' �— DB 354 PG 793 � i �l �d�� NOTE' ' S A FAMILY DIVIS/ON. .N � ry`'�' � 1.213 AC. o ? A POnTlON OF o / DB 354 FG 793 � 'S� m PHYLLIS J. ALLGOOD s�iKE°S�r � 3��•` � � DB 354 PG 793 • �5� � N Q �� � ' ����� N �S'37'�9.w 32?.63• . . � �� �, Q� (3S3 �3� . �,\a `.�.��ry . . . ���� � LEGEN D ' PHYLLIS J. ALLGOOD o IRON PIN fOUNC • IRON PIN SET (� � DB 354 PG 793 O CONCREfE MONL G POINT CALCULA' � � DAVIE COUNTY HEALTH DEPARTMENT , . � � • ' Environmentai Health Section , Soil/Site Evaluation ' APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003686 Tax PIN/EH#: 5811-91-1900 Billed To: Douglas Baileau Subdivision Info: Reference Name: � Location/Address: Wagner Road-27� Proposed Facility: Residence Property�ize. -see map Date Evaluated: �7 / Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 5 6 7 Landsca e sition Slope% � HORIZON I DEPTH p . O�j Texture grou 'Gc. ' Consistence � �.r S Structure Mineralo S HORIZON II DEPTH 2� Texture rou 'G 'L Consistence 5 � 'Structure c < Mineralo HORIZON III DEPTH 2fl— . Texture rou 'L+ Consistence 1`; Structure ?vIL Mineralo � , .HORIZON IV DEPTH �l f- Texture rou ;L � Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � ' SAPROLITE CLASSIFICATION ' LONG-TERM ACCEPTANCE RATE F�. SITE CLASSIFICATION: -� �1i�:�) EVALUATION B'Y: �� `P LONG-TERM ACCEPTANCE RATE: �'� OTHER(S)PRESENT: REMARKS:__�/�t�'f(IJ)�V A�I 7iJl '�' ,Q t��LC��I r r��FZ , ��SZ(�. +� -{"I� 2���'. ' LEGEND i_.�nd��pe Position R-Ridge S -Shoulder L-Lineaz slope FS -Foot slope N-Nose slope �`�U�jj CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope �Ss ��G•� . T�tur� 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 r :�. .ONS ST�.N . . �415� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm '�' � 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 Mineralogv 1:1,2:1,Mixed LIQt�.� 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/OS(Revised) � � � . � � I REVfSION FOR THE OIVISION OF � � J. FRED RATLEDGE ESTATE m p��gION OF PB 6 PG 135 / a , J. FREDPB TPG�G34 ESTATE rRacr � TRACT 13 qAIGLE IRON � S 83'44'19"E / fOUND 162.63' (T�E) � S 83�45�00"E—�- �280.17�� Sp�xE�ouNo 31.33' F 248.84' � 603.4 � • ; N 8J' _ �o`o S� �`' - �� �0 �� � LUS J. ALLGOOD � NOTE — HtS S RVEY' IS A FAMIX D ION. , N . PH DB 354 PG 793 N � - - �.2�3 AG�'. r �� � o N - A PORTI N OF °D Y G 793 c�n 2 ' . ` m / -�. �'` + - . ! RAILROAD � 30.50' a � � SPIKE SET �� k/i N . � � � 22.E3' � OQ __N 75�37'19"�y 3 • � j �''53.13') . � \ ���� � • � �_^ 1�Q'��- PI-IY�B�354�PGL79�OD r ���;.,�,� � __ , wy t, � i ? � �.ar ^f,assk� � �'� � * ` '�a . oei�'j ��"f"e"z . � . �444� � ae9:... �,�-.tsaal ���,�r �� a � ��'� � ,,� •.�3�� y � � � , g 1T1� rv ' �'f '� , �P"� ��° r� ,�^ �u. . f� t "' ,��-`�+r x'�' ,� ).�� ��3'.. .. . 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