220 Timber Trails Lane Lot 11MV -111 XI M is esN 0 Iq Vol._ -1111111 10 U, I
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003767 Tax PIN/EH #: 5812-00-8824
Billed To: Michael Caplan Subdivision Info: Timber Trails Lot # 11
Reference Name: Location/Address: Timber Trails Lane -27028
Proposed Facility: Residence Property Size: 5 acres
ATC Number: 4527
**NOTE** This Improvement/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 #People -191 #Bedrooms --T #Baths -� �k
Dishwasher: F6 Garbage Disposal: ❑ Washing Machine: Q Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size _ Type Water Supply C6 Design Wastewater Flow (GPD) Site: New ❑ Repair ❑
System Specifications: Tank Size/06& GAL. Pump Tank GAL. Trench Width S6 Rock Depth Al Linear Ft.5e'0
Other:
Required Site Modifications/Conditions:
accepted Systems may also be
IMPROVEMENT/OPERATION 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.****
F
b
Environmental Health Specialist's Signature: G Date: (J&11.6
DCHD 05/99 (Revised)
Oct -18-06 16:58 user P.O2
� rt
APPLICATION FOR SITE EVALUA'FION/IMPROVEM.I: AI'l' PI�.ItMiT 8-- AT
Davie County Health Department
F.�
'm irimniental IleaIM .!ectirin
P.O. Box 84W210 Hospital Street vU [5
Mucksvitle, NC,: 27028
(336)751-8760/ Fax (336)751-8786 OCT 19
206
ttpplicatiou For:: Site l valwAh rOmpiowntettl Permit 'W"Nuolorixation l'o Constrtct(ATC) Both
•Inti'Oir7ilY1 *` T'E[15 API'LlC fi [ tOti i'A"d,ti(37'Kt:'YRC)(;I )1h;1tiNLI tiS A[.t (}I ZIiI:: R:; jl;Ili&I) TjVIR0pg,9ENTAL
INFORM AION' i:: c Kcl, D 3). Rcfer to the : IN3`ORMATION BUL I E,HN for ia�tru uu s. Lr1j/IE EQU(ft� LTN
APPLICANT INFORMATION
f..../��k'>r_t.+r.t¢.__.+�11V.(i_
I`atne: to be E3tlI{'d "" � .._ 'r
Billing Address _ 'iti f t lJi f v r _Lc°saF,_.. ..—..._.. lloma PlJonc .._,2._ ' 1 _�..... ........
City`Statc'lTit"ray".._..._littsintssPhnne. 'rrt'-
Name ort PermitiX.R' if Dyre-rent than Above SN! r,)
'Mailing Addretes {-'ityt5tate;7,ip......... __._.__..__._—_-•- -.—_..-----._....._._.._
1'ROPl:i[Cf Y RNFClltk'y AIION
-- -- ----- - — ---------------- __ ' -' - ------ _ _ f
NCl l 1:: A survey plat or site plan must sccorr4nury this implication.
(Perin it is v alidi:tJr 6Cl ryn�uLlt� tvidt site Allan tx, �xpiraiion �sitit tvJn le1.c plat_)
Street Address _.. __.._._..__....__!/11 kfFl.._1 . f [[L %'�1:---_--C43, 10 %%. Tax I'M#
SuhdtvtsJottNemer_.'7f�'1}'_..I7t1_k.._.._.._...—._Stwtiu/n/LoL;..._..._. i,otSire_.C.._....___._.._.__..._..._.
........... _... _.......
DitcetionsToSitr.;: /tlRIP _ 1._ Jr_._,CE<f_ ti_ t c, _ r .e+a�__.:..�. ,e:J`T_ .a�---..{ rJ C.e _Li�x
Q.,R !. G+iii %im i� 7�F'rG7� .•�i7—....�'**T.. x"...11.... oeS `...IE't lxT.:.. s�tl et1' C C!ry_. fPe#i~ •Lei r'r'"
...._._...
........ ....... r_ .._.. _._..._ .._..... . ....... ..._._..----- ._....._.... _..
Da Rou:zr['acil ty Com_rs:E`lagaed_
_..- ...__._.._._...._.__.._._.....-..._._.._.._....._....__........... ... _
lI 137e ttBylUl'r to 911/' Gt t.t?l-. Firih:+Furl; [htCv'tI0i15 rS '•yCS •, sl!1fX!t}IL:I �� t�rxalnl"iit,511Ontittl.)t f7C 2itt ac'.htCF, j
anY a tin t wastc`-'.aier systeuis (,'n the Rite?
Arc there is
-1Ya "o t
M X -S Illi sttc LC:liit7! )tu15C11 (:()1131 wdlandi?
Yes i^v
Arc dic:re. arty c2tsentenh of right-of=ways or the site'?
;Yes txNo
Is the site subjrd. lei upIn4m al by lntltlicr public, agency?Yc-S
R.4
1�'ill wastx:w.itcr ok1wr than doTjwstic sewage be generated'?
Yes (drlYn
It' RESIDENCE FILL GUT Tt: E ROX RFLOW
ESI...__..._......
-- -... -..._ :.............................. ...................... ....................................._.._... ........ _.............. ............. _...... ....... ............ -...... -
?�
s: Pf'ople -- .. P - Bedrooms ^. 74 Bathrooms !;I,_ Ciardev'f ul�-V+'birlpool ::Yes :✓Na
l)asc:mo.—t:f:;k'es o Rastmtnt.Plumlring: ' IYesia
i
ii' NON -RESIDENCE, I'IL,I.. o 1171F. BOX BELOW
................ _._..__.-...._._........._...._..._........_........_..__.._...._......._....._..—..._.._..._..._...---..._..-'-------.......__....__..._....---..._.......__.._......_....._..._....._.._.._..._.._....._.....-..._.._.._......._......
[,pe. tr0'FtCility'Iiusntes _..._ __. _ _ TIotal Sgtuirc Footage. of Building_.. �.w k People
!: Sinks #r f'ornntodes _ it Sltr wens ft tJrittals
EslivutlL l Water Mage.. (gallons per day) ..._.. _._�. _..l -attach dt�cantentatitJn tzf similar facililu %vaicr consumpliwl
1,00T)"ERVtCs
:
Oct -18-06 17r00 User
i7mL
P.03
�j
z
w
w
CJ 13
___7413'21" E 1559.1$' EIP
5.52 2ti0 il0 3.1.0 85,
78:2$' 4 63 65'
860 \ +
w
S°
cp VA
'S;AOt1 r s 1,(dmdj� �,. _ .4'' w5 j 1 \�`\\\ 1 � ��\ ` _-��"'�•_ �
to63
j i f
77
` .870
t
5 ,6 3 Acres j&r d) 1 / I /`` � ° �C N , \ vv
y _
CO
7 l s� �6 1't r 141545 T Cres (,
�-- � LSD ., ,,.a �-.� .; I l � �""� i•
\ _ k
_. -
��. Lo
{, k
!1 tt
8
-"6 5050 AcSres (dmdj
_v
V
S 13 27' 34 W 991,56' 50.55'
ARRY E. BOLES
_ D�sTANCE J'BOLES
v 2.3.18' FVf"LYN T
E 154.13' _ _ D -B, fol, PC-
F_
E 152.49'
E 151.65'
E 148.92'
E 128.48'
E 100.39'
CURVE- RADIUS LENGTH CHORD- GEARING
C-1 435.44` 148.82' 148.24' S 84 31'35 E
E 170.56'
C-2 300.00' - 224.07' 218.90' S 71'54'43' E
all
ALF
«cc Soo
THIS RAT WAS ORAWN FROM A SURVEY MADE . BY 'TUTTEROW SURVEYING CO. .
THE TOPOGRAPHIC INFQRMF\'TION WAS TAKEN FROM A USGS MAR. NO FIELD WORK HAS
BEEN DONE BY KENNETH L. FOSTER &, ASSOCIATES.
C-3
300.00' %
40.39'-
40.36'
S '54 22' 1 T
E
C-4
300.00'
218.29'
213.50'
S 79W04'22
E
C-5
690.13'
- 77,76',
77:72'
N 7551'1
f-
6633, 68'33'
E
C-7
551,89'
`604»04'
574.34'
S 8510'04'
E
ALF
«cc Soo
THIS RAT WAS ORAWN FROM A SURVEY MADE . BY 'TUTTEROW SURVEYING CO. .
THE TOPOGRAPHIC INFQRMF\'TION WAS TAKEN FROM A USGS MAR. NO FIELD WORK HAS
BEEN DONE BY KENNETH L. FOSTER &, ASSOCIATES.
(4.86A)
8121
TRACT 10
G rB
0)
coco
3�
Account #: 990003767
Billed To: Michael Caplan
Reference Name:
Proposed Facility: Residence
ATC Number: 4527
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5812-00-8824
Subdivision Info: Timber Trails Lot # 11
Location/Address: Timber Trails Lane -27028
Property Size: 5 acres
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 .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: A1.4,1/ Date:
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.
Do l� q�Ilb DtAM�Rk �V
-W K
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
-�- �4 L
i
ma
t DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street ,
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786 ?, t
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003767 Tax PIN/EH #: 5812-00-8824
Billed To: Michael Caplan Subdivision Info: Timber Trails Lot # 11
Reference Name: Location/Address: Timber Trails Lane -27028
Proposed Facility: Residence Property Size: 5 acres
ATC Number: 4527
**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 FIVE YEARS. This ATC is subject to revocation if site plans, plat or
the intended use change.
Residential Specification: Building Type ' "C #People 2 #Bedrooms 75 #Baths 2
Basement w/Plumbing: T Basement/No Plumbing
Commercial Ston: Facility Type #People #People/Shift #Seats
Lot Size 41. Water Supply 6ix'/'MCsign Wastewater Flow (GPD),:5 oD Site: New ^epair
System Specifications: Tank Size % GAL. Pump Tank GAL. Trench Width Trench Depth "MAK
.
Rock Depth I Z" Linear Ft. 692
Other: t b) SM60-PoW
Required Site Modifications/Conditions: /ti-3r.4u- D'J C,-, . r i;K
Contact the Davie County Environmental Health Section for final ' spection of this system between Z_JcS
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
ckz) x' i 6R _j
M1 t3. ��
o
�►,, 50
1.1GRTN Ar " ;�
227
Environmental Health Specialist ate: /Z
DCHD 11/06 (Revised) `°
Rf
E C E o
OR SITZ• EVALUAT10N/IAiPROVEMENT P11-R�,111T & ATC
Davie County Health Department
Environmental Heath Section
Box 840/210 Hospital Stroot
Mocksville, NC 2702E3 5..
EWIRU MtNIALtitALIH (336) 751-8760
DAVIE COUNTY
***IMPORTANT*** TI11S APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORUATION IS PROVIDED. Refer to the INFORMATION BULLETIN for
,fiJnot/ruction�s'. J () 1. Name Lo be Billed MUUAF � NPI AL) Contact Person / /%eryq/CL CIf�PL/�! v
Mailing Address 114- b4 U lIi l7 / 0A) [ Iiome Phone 33 (O TGG 7 3 3 J
Ci Ly/SLaLe/ZIP �l�MtloaS Businoas Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/Stato%Zip
3. Application For:` Si Le Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: 9 House ❑ Mobile Home ❑ Business ❑ Induatry ❑ Other
5. Typo system requested: L1T Conventional ❑ conventional modified ❑ innovative Maccepted
of ,
G. If ;Residence: II People t1 Bedrooms �! 11 Batllz:ootna
fi(Diahwaahor ❑Carbago Disposal lashing Machino ❑Basement/Plumbing ❑Basement/llo Plumbing
7. If Busineaa/Induatry /Othor: verify type !!'People 11 Sinks
I Commodes 0 Showors 11 Urinals 0 WaLor Coolers
Ii' FOODSERVICE: It Seats Estimated Plater Usage (gallons per day)
8. Typo of water supply: X County/City ❑ well ❑ Community
9. Do you anticipate additions or expansiolls of the facility this systelll is llltellded to serve? ❑ Yes XNo
If ycs, ]what type?
***1jIrP0117AN7*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORA•IATION IZEQULs,rLD
BELOW. Either n PLAT
�1orSITE PLAN MUST RESUBMITTF,D by the client with THIS APPLICATION.
Property Dimensions: ��Q� / WRITE DIRECTIONS (Groan A,loclw111c) to PROPE,10 1'
'rax office 1'IN: 11 ,� J� O —AVA Z-1,649 i elVol_eW
Property Address: Road Naine _//h�i� %QX? I/ Ok±r) Tp
City/Zip_ l`�acKsul11rt- -f,'mQitit t2AIL
If in a Subdivision provide iuforulatiozi, as follows:
Nalue: i/Yn
Section: I310clt: Lot:_
Date home corners Ragged: /0 o
This is to Certify that the inforulation provided is correct to the best of lny knowledge. I understand that any perwil(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if lie information
subulitted ill this application is falsified or changed. I, also, understand that I aur responsible for all chuzges incurred fi'vzn
this application. I, hereby, give consent to the Authorized Representative of the Davie County Ilcalih Department
to enter i1pon above described property located in Davie County and owned by
to conduct all testing procetlul•es as necessary to de(c!•111ine tie site suitablllt '
D�l'1'L /V " Q "Q� SIGNA'I'URL
THIS AREA ATAY BE USED F01Z DItAIVING YOUR sin? PLAN (Include all of tie following: Le xislillg slut proposed
property lines and dimensions, structures, setbacks, and septic locations).
376 9 / Site Revisit Charge
Client Notification Date:
Sign given
Revised ll IIll (05103
C)-*,—.
EMS:
,llccount No. �
Invoice No. �0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003767 Tax PIN/EH #: 5812-00-8824
Billed To: Michael Caplan Subdivision Info: Timber Trails Lot # 11
Reference Name: Location/Address: Timber Creek Drive -27028
Proposed Facility: Residence Property Size: 5 acres Date Evaluated: �� S
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring__ Pit t i
Public 1::'_�
Cut
FACTORS
1
2
3 1
4 5 6 7
Landscape position
-L
Sloe %
a
v 2,•1
HORIZON I DEPTH
T
5
Q- .2 -
Texture
Texture grou
.f" -
5 e - t-
Consistence
Structure
r
Mineralogy
HORIZON II DEPTH
1-17
1 �(- • ZO
Texture group
S L
Consistence
; Sy
F - .s
Structure
c
IC_
Mineralogy
- /
I /
-5'ryT
S. -
HORIZON III DEPTH
22_ - W4
Texture groupSC
rSocP
C--+ S
Consistence
r;_ S
F. S .
Structure
S3k
A31"
Mineralogy
HORIZON IV DEPTH
Texture group5..
sc•�
Consistence
Structure
Mineralogy
SOIL WETNESS
c-�
--
RESTRICTIVE HORIZON
L�
O
SAPROLITE
CLASSIFICATION
S
O
LONG-TERM ACCEPTANCE RATE
71
T-7 I
CLASSIFICATION: ! EVALUATION BY: /V4 j
LONG-TERM ACCEPTANCE RATE: `-J OTHER(S) PRESENT:
REMARKS: A.-14 Po CK' lSyF (1AAY
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
45 im
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
Mineralogy
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
,sification - S(suitable), PS(provisionally suitable), U(unsuitable)
Long-term acceptance rate - gal/day/ft2 DCHD. 05105 (Revised)
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■\■�iii�■.\■■■■■■i■■\'�!dial■■■■r�iiC�\t■\■■■■■■■■■■■■■■■■■■■
BREMNER MENNEN SOMMER MIMMEMir`�iMUMMER MENNENMEMBERiiiiiil�
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■iii■■■■■■■■e■■_�•Irr�■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
lbtl9Z
V Ug'£
sbv
ZBuW
9L££
V000'0 L
N
Vil
01-4
A
. ,`
ro
co
cyp,
Azr'�1' rid
�*.l Vo
DAVM COUNTY HEALTH DEPAST
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville. NC 27028
October 21, 2005
Michael Caplan
177 Waddington Road
Clemmons, NC 27012
Re: Site Evaluation/ Timber Trail
Tax Office PIN: #5812-00-8824
Dear Client(s):
As requested, a representative from our office visited the aforementioned site on October
18 ,2005. Based on the information provided on the Application for Site Evaluation and
after an evaluation was completed on the site, it was found to be provisionally suitable for
the installation of an on-site sewage system.
Before and Improvement/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,
Robert B. Hall, Jr., R.S.
Environmental Health Specialist