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195 Sawgrass Drive Lot 716OPERATION PERMIT Davie County.Health Department ® 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Isenhour Homes LLC/Rhonda Address: 3411 Healy Drive CRY: Advance State/Zip: NC 27006 Phone #: (336) 659-8211 Address/Road #: 195 Sawgrass Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC *CDP File Number 138354-1 E"00-00-716 County ID Number. Evaluated For: NEW township: Property Owner: Isenhour Homes LLC/Rhonda Address: 3411 Healy Drive City: Advance StatefLip: NC 27006 one #: (336) 659-8211 Subdivision: Saddlebrook Phase: Lot: 716 Directions 1-40 East exit Hwy 801 going .South. right on Oak Valley Blvd.Left on Seay Dr. right on Silverod, Left on Sawgrass *IP Issued by. *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *CA issued by: 2140 -Nations, Robert SaproliteSystem7 QYes ®No Design Flow: 4 8 0 * PUMPTOGRAVITY Pump Required? Distribution Type: ®Yes QNo Soil Application Rate: 0 . a 7 5 *Pre Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 7 4 5 Sq. It. 4 4 3 6 e- 8*Inches O.C. 9 Feet O.C. Inches 4 3 Feet inches Minimum Trench Depth: a 4 Minimum Soil Cover. 1 a Maximum Trench Depth: 3 6 Maximum Soil Cover: ' a 4 Inches Inches Inches Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer. Frank Transou Certification #: *EH S: 2140 - Nations, Robert Date: 1 0/ a 3/ a 0 1 4 Approval Status . 91 Approved 0 Disapproved CDP File Number 138354 -1 ' Manufacturer. shoat STB: 760 Gallons: 1000 Manufacturer. sHOAF Date: 0 5/ 0 9/.2 0 1 4 *Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ST Marker: ❑ Yes ❑ No nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No County ID Number: Eg-000-00-716 Lat. 0 Long: Installer. Certification #: *EHS: 2140 -Nations, Robert Date: 1 0/ a 3/ a 0 1 4 Approval Status ® Approved ❑ Disapproved Pump Tank Manufacturer. sHOAF Installer: Frank Transou _ PT: 42 Certification #: Gallons: 1000 *EHS: 2140 - Nations, Robert Date: 0 6/ a 3/ a 0 1 4 Date: 1 0/ a 3/ a 0 1 4 RiserSeaied ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ NO (Min.6in.) Approval Status Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line Pipe Size: a inch diameter Installer. Frank Transou Pipe Length: 7 6 feet Certification #: *EHS: 2140 -Nations, Robert *Schedule: 40 Pressure Rated El Yes ❑ No Date: 1 0/ a 3/ a 0 1 4 Approved fittings R3 Yes ❑ NO Approval Status El Approved ❑ , Disapproved Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: 2140 -Nations, Robert *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve Yes ❑ No Approval Status PVC Unions. ❑ Yes ❑ No ❑Approved ❑;Disapproved Vent Hole [:3 Yes ❑ No Anti -siphon Hole ❑ Yes 0 No CDP File Number 138354 ; 1 N EM 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: ❑ No ❑ No ❑ No ❑ No ❑ No Alarm Audible ❑ Yes ❑ No AlarmVisible ❑ Yes ❑ No 2140 - Nation, Robert *Operation Permit completed by: County ID Number: E9-000-00-716 Installer: Certification #: *EH S: Date: / / Approval Status',: ❑ Approved ❑ Disapproved Authorized State Agent: I— Date of Issue: 1 0/ a 3/ a 0 1 4 This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 at Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served bya TYPE III B. sewage septic system. Rule .1961 requires that a Type TYPE III B. septic system meet the following criteria: Minimum System Review By The Local Health Department: SYRS. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule.1961 (2) (e) requires a contract shall be executed between the system owner and a management entity priorto the issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. ft shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing f **Site Plan/Drawing attached.** OPERATION PERMIT Dade County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 138354 -1 County File Number: E9-000--00-716 27028 Date: W W Olnch Scale:. . .OBlock ON/A OMNI No No 0 mom MENN MEMO ME OMEN ME 0 No 0 NONE NENEEN 0 NONE mom mom OMEN mom MENNIM MEMO 0 M 0 No OMEN mom mom OMEN ONE ON mom NONE ME MEN No ON CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street •o_,. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680. Applicant: Isenhour Homes LLC/Rhonda Address: 3411 Healy Drive City; - wiKsj%,4 SA I&A State/Zip: NC 1, Phone #: (336)659-8211 Prc Address/Road #: 195 Sawgrass Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC 06/10/a019 Property Owner: Isenhour Homes LLC/Rhonda Cheyne. Address: 3411 Healy Drive City: -- - - State/Zip: NC Phone #: Subdivision: Saddlebrook FSlte Classification: Provisionally Suitable Saprolite System? O Yes ® No Design Flow: 4 8 0 Soil Application Rate: a 7 5 *System Classification/Description: TYPE III E. PPBPS GRAVITY DOSED SYSTEM *Proposed .System: 50% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 3 4 5 Sq. ft. (336)659-8211 Phase: Lot: 716 Directions 140 East exit Hwy 801 going South. right on Oak Valley Blvd.Left on Seay Dr. right on Silverod, Left on Sawgrass Minimum Trench Depth: Inches Minimum Soil Cover: 1 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover. Inches *Distribution Type: PUMP TO GRAVITY Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes ONO Pump Required: ®Yes ONo O May Be Required Pump Tank: 1 0 0 0 Gallons 3 1-Piece:OYes ®No a 9- 0 ft. GPM—vs— ft. TDH Qlnches O.C. — ® Feet O.C. Dosing Volume: Gallons a Qlnches ®Feet Grease Trap: .Gallons inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI Oil 0111 ON Page 1 of 3 CDP File Number 138354 - 1 Yes O No O *Site Classification: Provisionally Suitable Design Flow: 4 8 H Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE III E. PPBPS GRAVITY DOSED SYSTEM *Proposed System: 50%REDUCTION Minimum Soil Cover: 1 a Inches Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 3 Total Trench Length: a 9 0 ft County ID Number: Eg-000-00-716 ❑ Open Pump System Sheet but has Available Trench Spacing: _ 8 O Inches O. ® Feet O.C. Trench Width:_ a O Inches ® Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches *Distribution Type: LOW PRESSURE PIPE Pump Required: ®Yes ONo OMay Be Required Pre -Treatment: O NSF OTS -1 OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. -"d %w 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate'governing bodies in meeting their requirements. a °;"�', 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be Issued at the same time the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been completed during the period of validity of the Construction Permit. the Information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ®No Applicant/Legal Reps. Signature, Date: *Issued BT 2140 -Nations, Robert Date of Issue: H 6 / .1 0 a 0 1 4 Authorized State Agent: Malfunction Log Oyes ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION. Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksvllle NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 138354 - 1 County File Number: E9-000-00-716 Date: 0 6/ 10 a 0 14 O Inch Scale:. OBlock ft.. n N/A Nage 6 of s P1 P2 ■■■■■■11`■l�si`.E■■��M■■■■■ ■■■■■rl■G■��■ Vol ��,�\I■■■■ ■■■■■■■ir ■IN,■■■■■■■■■■�■■■ ■■■■■■�■s■■■r•■■��r ■■s�■■■ ■■■■■ ■■■■■tl■■■■■���I ISI■■■��\\ ;11M11■■'I■■ll-OON L■1N■�40■OI7■■ ■■■■■le■■■■ i■r■E■111U■MI■■■ ■�L! ■■■■■11■i■e�■1w%ramm"Es ■■■■■1l■■ ■■■■■i■■1�■min Emil ■l1■�!■■o■■■ ry■l1■■is■■■■■ ■■■Is■■ ■■■■■It■1l.t�i"i■■■■ic■,■■■■is■■ ■■■■■I■■le■■1■■■■■ Mi■■■�I■■■ ■■■■■'■■It■ ■■fie■E■■■inr■■ MEMO MR ■!'!�■■■r'�!�■''r :■ fii�li�■ ®::5: 197AEMM 15■ ■■MIN- :■�::0 MEN Nage 6 of s P1 P2 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Sfreet RECEIVED 1 M0 tilte,NC 27028 (330753-6780/ Fax (336) 753-1680 r1 App" to EvaluationRmpm epai,nt Per mit Authorization To CO.. ct(ATC) Typrcation: ONew System ❑Repair to Existing System OExpansion/67odification ofExisling System of Facility **'IMPORTANT"' THIS APPLICATION CANNOT BE PROCESSEDUNLESS ALL OF THE REQ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed .L X11 x�oV� L.L Contact Person 2�v 6 n0. GL Vt `�4 Billing Address Home Phone City/State/ZIP W Business Phone 3 — to 0 Name on Permit/ATC if Different than Above Mailing Address City/State/Zi NOTE: A survey plat or site plan mustaccompany, this application. Included:^ (Permit is valid for 60 months with si a lan, me xftah n w t complete pl Owner's Name �S� Vkh 6_ _.pL, 0 V X? I Owner's Address !)'ILL C'1 `t -OU "l Ta Y— City/Sta PropertyAddress 10%5 D 1—'City-2: Lot Size . "1 'rax � tPIN#, E Cl n 00 00 -1 Subdivision Name(if applicable) SAQUi,4—brotaIL Section/Le Directions To Site: 5 540 W r o ti :-t Lk w.A B O l Ol I DPlat(to scale) ne Number T � Ak -bn0 If the answer to any of the following questions is `yes", suoporting documentation must be attacbed. Are there any existing wastewater systems on the site? Dyes )?NO Does the site containjurisdictional wetlands? Dyes *0 Are there any easements or right-of-ways on the site? DYes/1o�f.,t�o Is the site subject to approval by another public agency? DYesvo Will wastewater other than domesti so emge'begenerated? DYes pMgo IF RESIDENCE FILL OUT/THE BOX BELO #People #Bedrooms '/ #Bathrooms �_ Garden Tub/Wbirlpool es ONo Basement DYes �dNo Bisement PlumbingrtYes o y y" IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) Type system requested: yConventional DAcce pled ❑Innovative DAlternative ❑Other Water Supply Type:XCounty/City Water O New Well DExisting Well O Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes If yes, what type? XNo This is to certify that the information provided on this application is true and correct m the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. 1 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locatingand flagging or staking the tlouse/facilibL Iomtion, proposed well location and the location of any other amenities. Property owner's or owner's legal representat a sig re Site Revisit Charge Date(s): 5/01 Client Notification Date: Date EHS: V, v lki f,id rks s f3 g35�F. Sign given Dyes ONo Account # - - Revised 11/06 Invoice 4 - I - - , . . nt . V APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & A;PC Davie County'Environmental Health " - P.O. Box 848/210 Hospital Street Mocksville,NC :27028' - - - -!,(336)753-6780/Pax (336)753-1680 Application For: CJ Site Evaluation/improvement Permit 0 Authorization To Construct (ATC) C) Both Type of Application, ONew System ORepair to Existing System ❑Expansion(Modification of Existing System or Facility *..fMPORT4)Vr-* THIS APPLICATION CANNOT BB PROCESSb'D UNLESS ALL OF TIiE,REQUiRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION' Name OR - .fpflEeA . 'Contact Person Address 0 Home Phone IF---, 146 I) City/State?ZlP M,,e j�l.. t C.1r►360 - ;Business Phonj�.9q,6Q Name on Permit/ATC if Different than Above Mailing Address-, _ - .---City/State/Zip._ 1'1CU1JEXI-Y INFORMATION - *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: O Site Plan OPlat(to scale) Remit is valid for 60 months with site plan; no expiratiori with complete plat.) ' Owner's Name Q r � ' Phone Nttmbe q Owner's Address. )N�y p�Is1��..' Okgi ,S,:(+� tp A_City/St to Zip Me ie, Property Address - City Lot Size—Tax PIN# '5R71 -Z3- SubdivisionName(tf appl�Addlehraak I Section/Lot#�( Directions To Site: If the answer to any of the following questions i5 "Ycs",supporting documentation must ba attached: Am there any existing.wastewater systems on the site? Yes No Does the site containjurisdictional wetlands? Yes' No Are there any casements or right-of-ways on the site? - No - _Yes Is the site subject to approval by another public agency? No _Yes Will wastewater other than domestic sewage begencrated? Yes No RESIDENCE.FILL OUT THE BO DW i - .. People - #Bedroom, _ #Bathrooms Gorden Tub/Whirlpool 0`. asement: OYes ONo; - Basement g: OYes ONo ]No F NON -RESIDENCE FILL OUT. THE BOX BELOW - - - 'ype of FacAityBusiness Total Square Footage of Building_. # People. Sinks # Commodes - # Showers # Urinals - - istimated Water Usage (gallons per day)__ (Attachdocumentotion df similar facility water consumption) 'OODSERVICE ONLY: # Seats - " Type system requested:'i'Conventional OAccepted OInnovative OAltemalive- Ii6ther KA'�tin In ril Water Supply Type: O County/City Water- 0 New Well 0Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes O No If yes, what type? This is to certify that the information provided on,this application is We and correct to the best of lily knowledge.. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension oncvocotion iY'the site is altered, the intended use changes, or if the information submitted in this. application is falsified or changed' I hereby, grant right of e6try'to the Authorized,, Representative of the Davie County Health Department to conduct necessary,inspections to determine ebmplance with applicable laws and roles. I understand that I am responsible for the proper-identifica[ion and labeling of property lines and comers and local fl �giny x 'ng the houselfeoilay, location, proposed well lineation and the location of anyoihe� amenities. Property c""', or owner's legal representative signature Site Revisit Charge Datc(s):_ D le Client Notification Date: - EIS:. Sign given Oyes Me Account Revised 11106 it ,' P.iSPLICATION FOR :;ITE EVALUATION/IMP ROVEMENT PERMIT & ATC E C t Davie County Health Department LSr_ Environmental Health Section P.O. Box 848/210 Hospital Street APR MOcksville, NC 27028 j (336)751-8760/Fax (336)751-8786 Application For. 0 Site Evsluatiomintpvvement Permit 0 Authorizat on To COnsbuct(ATC) n Both APPLICANT INFOR hhMATION N e t Name to be Billed VgIC a��c S vas �CortactPerson Billing Address ¢a Htrcne Phone City/State/ZIP - - 0 Business Phone �, UO Name On Permit/ATC if Different ikon Above ,, n. or site plan must accompany mss appucauun. d for 60 nu m n •vfh site plan, no expiration with complete plat.) Directions To Site: if the answer to any of the following quOstiam is'yes", supportmg noromenT An there any existing wastewater systems on the sire? M; Dorn the site comamjmEMSisdiclional wetlands? Ds o An there any eamcncots or ri&t�f-ways on the site? OYes ENO Is the site subject to appmv:d'ay motber public agency? OYrs ONO Will wastewater other than domestic sewage be generated? Ma ONO T nrrr�.nnv APrnw U/U �6C-G� .Sa_� IVlslOh #People _-._---- - #Bedmoms - # a ores Girder Tub/Whirlpool Oyes ONo Basement OYes ONO Basement Plum mg• oYes ONO IF NON -RESIDENCE FILL OL'T THE BOX BELOW Type of Facility/Business Total Square Footage of Building_ #People # Sinks # Commodes # Showers __ # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #SealL Type system requested: QConventim.-d OAceepted 01movative OAlternetive oOther - Water Suooiv Twe: C/County/City Vinter O New Well OFmI.sting Well 0 Community Well Do you anticipate additions or expaw,Om of the facility this systmn is intended to serve? O Yes a<, .. n,,,, • yr-. This is to certify that fire information lirovided on this application is true and correct to the best of my knowledge. I understand that any permits) or ATC(s) issued hcnula7 ere subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this applimtion is falsified or changed. I un& rttand that lam mspanrihle foroll charger incurred from this application. 1 hereby grant tight of entry to the Authorized Rcith [tentative of the Davie County Health Department to conduct necessary ons�°/q� mtine core Bance with applicable lana and odes on the above described property located in Davin Cot end owned by> x-a(A Dgip ��t,�,t ��,���h� Uaw�lu�l�f� I�ss U44, V 6 2006 D HEALTH Date - • I / Sign given uYes ONO Acmunt # invoice # f/ [� oOOV Revised 2106 BB' ss -v U- ' I l 12 yeo 33,278 Sq. Ft.l 30,894 Sq. Ft. I < es_ ode �—�eurse Drive \Pe I Pe PDQ �QQ 33,426 Sq. Ft. 9' epo• 9s\ _ ry" O 35,081 Sq. Ft. St. Andrews Golf Vill Section 98, Phase 11, Section 2 Plot Book B. Page 21 91� \ 6Q Qe ^ • ® j O 34.956 Sq. Ft. 35,486 Sq. Ft. 145' _ 142• ti Ctf,— `! I 243' ,� �— 227' 00 CO 14 1. Ii �m(� 1151 YI g X11 Z 100, 33,897 Sq. Ft. 1 N I O h d 30.(1 Sq. Ft. I 1 30.080 Sq. Ft. � 1 A• . p F 71, /A 270 Ott ��C I 16 � . er I, /1 33+9 Sq. Ft. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003765 Tax PIN/EH #: 5871-25-2458.11 Billed To: Oak Valley Associates Limited Partne Subdivision Info: Sawgrass Lot # 11 Reference Name: Bo Davis Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: d Water Supply: On -Site WellCommunity Public Evaluation By: Auger Boring L Pit Cut , FACTORS 1 2 3 4. 5, 6 7 Landscape position Slope %.__... HORIZON I DEPTH Texture group G , Consistence Structure Mineralogy -, HORIZON 11 DEPTH Texture grcifip Consistence.: -.. — Structure Mineralogy. HORIZON IH DEPTH Texture group Structure Mineralogy HORIZON IV `. DEPTH - .. Texture group Consistence , Structure t ; . Mineralogy- . SOIL WETNESS RESTRICTIVE HORIZON - SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 5 EVALUATION BY: G CO �4u _LONG-TERM ACCEPTANCRATE d T OOTTHE, RR S)/PRESENT: Q In tP 0 to IY tw� REMARKSiLA_ln� 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 -Floodplain H - Head slope T xt i - - _ - S` -.Sand ': LS * Loamy sand SL - Sandy loam ' ' L Loam SI'- Silt', -BICC - Silty clay loam iSIL - Silty loam � CL - Clay loam SCL -Sandy clay loam SC- Sandy clay SIC -,Silty nclay C -Clay CONSISTF.NCF. � ' 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 SYC�Smug e gram M -Massive CR -Crumb GR Granular ABK - Angular blocky ' : SBK -'Subangular blocky PL - Platy PR - Prismatic - Min raloev - - .. .. ....:..i '. .. -.... .. � .. t.... - .� ..,� 1:1; 2:1, Mixed "lYutes . , Horizon depth In inches ., Depth of fill - In inches Restrictive horizon -Thickness and inches from land- Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chrorna 2 or less Classification - S(suitAle), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) Oak Valley Associates, Ltd. Partnership Attn: Bo Davis 3401 Healy Drive Winston-Salem, NC 27103 Re: SAWGRASS Proposed Subdivision/ Lot # Caudle Tract / Beauchamp Road Tax PIN# 5871252458 Dear Client(s): As requested, a representative from this office visited the above site April 11, 12, 18, 2006 to perform site evaluations. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems)., This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Server 3 g12 v �� 1 �Zi.�'J= Wastewater Design Flow: 3(co System Type: ❑Conventional ;Kc�cepted DInnovative DAltemative ❑Other System Location: Site Modifications/Permit Conditions: ps-i.pletter 2/06 Valid: Z?51Years DNo Expiration (sll ID(V ate TRANSPORTATION YS iTRUCTlON N . 20 UNTY are the owners of the id within the subdivision ereby adopt this I establish minimum gets, alleys, walks, parks, rivate use as oted PLANNING DEPARTMENT/REVIEW OFFICER SURVEYORS CERTIF] FINAL SUBDIVISION PLAT APPROVAL f, .Toho F Rr>Paan certify that ti my supervision from an actual su math This is to certify that this pial meets the »cording requsrinunts ( PH ptson corded in Deed Book of the subdivtrim RerAatio fbr Davie County. .Page B that the sntio of is 1 • 10,000+, and that this plat sua-s prep I Iinrt.W 47-30 as amended. Witness my original sig aff4 er of Davie County. oerttfy toot the map or pial to uihtch this and seal this_day of A. D., certification is affts d mets all statjdory t.q%"mvwnts fbr recording. Approved Dt+.ator of fsa,uaGp/Jervin. OfJlwr Surveyor This the day of 20 NORTH CAROLINA—FORSYTH COUNTY NORTH CAROLINA —DAVIE COUNTY Certificate Qf APRroval of Private (on-site) Sewage DiSg2S41_50tem I hereby certify that the Davie County Health Department has evaluated the Subdivision formerly entitled SAWGRASS at Oak VOIIBv with respect to criteria and conditions established by state law or promulgated thereunder and the same is found to comply with such criteria and conditions EXCEPT as found in such evaluation. For details of this evaluation and for limitations see the written report on file at the said Department. P IMPORTANT NOTICE: THIS CERTIFICATE DOES NOT CONSTITUTE A PERMIT OR APPROVAL OF INDIVIDUAL LOTS IN SAID SUBDIVISION Now or Former) I FOR INSTALLATION OF SEWAGE FACILITIES. SUe 0, Whitehead, Partnership Deed Book 195, Page Date County Health Official PIN:5871-33-357 eQG S00°52'33'W 1121,16' 250.00'50.00' 133.63' 132.51 132.50' cu I ,i Date -- r Y LD (U 0 71 3 • L' L6 WLd CU I 35,486Sq.Ft. � 711 }}0i 0 710 CU 0 709 _ �06" CD 30,080Sq.Ft. to r cu 30,08OSq.Ft. io cc 6" u 30,078Sq.Ft. N00°17'53'E I 0c)Cd co z 00 d 244.13' CU Has I .LLo-L2hd z N 713 0 ,�gti - 10' Public Utili C6 m ng 106,64' - —132.50' - s� 34,956Sq.Ft. �576.94' — N00°52'33'E Cauc E - 10' x 70' (` Sight Et S00°52'33'W — 576.45' N88°39'03'E N00°18'39'E I Easement 99.75' —101.50' -114.65'- 79.62 - w s, �. 3 5' �� I Ago 3 _ cu c0 - SS g- m � cv r` I v S 3 �g (U w m OD r- 00 r 71 asp c 721 3 722 3 M. o, 35,081 Sq.Ft. ,720 cru ° N co c� to d tom _ e In CD I N00°00'15'E 30,088Sq.Ft. CU °` CU OC) Do w 229.18' „ q &,33,069Sq.Ft.z 30,05OSq.Ft. Z 3( (� 0 0 M m �� �' CU F� 0 715 / 3 A ACC) �� S1,3 °g6 , - j z 33,426Sq.Ft. / q U 4. 04'W 124.20' 114.74' R• V 244,43' cb g ` .)S 571.23' c e F 4! h ^o46c qo ,,ape nj 716 � p y _-• 33,897Sq.Ft_ t mss\ (., ��. Np oN 30,894Sq.Ft. o* +� ��° cu 78S Fto� N� 1°0 00 0 o e Z Robert Johi q t^ o S� o and Tracy Ai C,�` V-"' l I�Iq. W � � Deed Book 548, J- �P j ✓ PIN:5871-23 r— � nJ 10' x 20' Z Signage 46,306Sq.Ft. Easement S89°48'54'E 60.57 0 0 0 0 -gep Uv UZ; vela APDL: O)TION roll SITE EVA1W1nON/IAn7l0YGIFNC Ffllaftl S ATO Davie County Health r Iparhnent apimmmWHWA.i50c6Dn P.O. Boz ado/2lo UOSFital Stro.t Mociavillor NC 27020 (336)751-87to e �'Ii1PORTANT'a� 9IIIi APPLICATION CN7Nor BE PROLISSSD ONLLSS ALL T= REQUnEO r IrIPOAFNTION IS PPXO1V1lNlV. Rotor to Elio INrOWW::ON MIMLLTIN for igoatrua C£0aa. 1. N. W bo t13e01i1A`tT,� 1� Cl�'dN GSS ali��1 41. PG/jo eO cart Daroan dJ0 L]GV:S Ilalll.o Addraaa .1l 1 JW11-1 DI . Ibro phone Clcp/stata/ssr�tHfitn--ScLzn, �fJ(. •.�lyli(5 /Ia--!lu��clon.. PAon.7 n -714 316) f. Name on Par.it/ASC 1C al[tatent Elan above 1d'!.i TV am de wLlptvi R.111nP Mdra.e S�a.< dty/:: G[a/Llp '� s. Application Foca �1411to L^raluatiaa O I.r¢evaaaont romi.t/ATC O,Dotla d. s..... to aeevlca. ¢ atoune 0 15.6119 =.a a Duc )seas ❑ 1bUuatry; O out s_ asp. war. a a..ar.da Id ra.e..Uonal O ...v..Uaant :mdul.d ❑ roaovacbo Maceepted d. I�[� jlraidanc.a 1 Paopl-1 JJ t nedraacJcas L p maitur omo Fd 7 e.a .-Aat ,Karbala ala9aaal 'QNaahlay Y cillos lay aarmnt/rlu.olry Daase.en[/Ira plumbina 7. It aualaaa./[nduatry /0L4er: rarify type a PeeWa 1 alnko / Cdovlao _ 0 So... / arl..S. a Hata. realer. IF rOODWJMCE: 8 giants EetimaCCd m!tnr Dnagn-la9aldoa par dart 1. Trod Of vats eurp3r, a County/City ❑ Hol l 13 Cmmunity �� s. ao fav a..elelpata a.dltlma or =11wesiwn' oflllefau7ity lLissystwnisilucudrd losenro?Oyer . GI))N., lrycq'0111 type^ (flea n pvvtA }"e/ js^y/CQI ViJ IU4. 'i iaCJ ft�dl'v:.. Prolmmy DimuOiorm SCL lhJ'.��'L— l-- IYIOTC 31RECTIONS(r.,,, M.cluville) to l't101'EIIlTv Tax 0(6re PIN: 1� .Z ` J 5 16r',2 7 SS ) properly Address: Road Mame A�1. t! ?W, 1l' yi:l Nt, 1✓Ll'r Glymp &ccflalfic JI'M a Subdivision provide yafNance•Section: Block:awle comas Osgged: This it la certify Oral Ilia i ilernulu onledge I understand Ihat nuy permil(s) Issued hercanar aresub)cef la suspension or ravoeafion,if llivilla pleas ort. bided use ctuaCe, orlfilm iuformaliun . sultained in fills oPlinolian irralcired of changed /,'air., erndemeuds/mr: nm rapanriblofornlluugeslueurrrdfnrm shlrepplicnsie..I,hereby,Cly. mescal to Elie Autherrrced Repraeilfative oL9eDalie Comrq•}Iealll Deparbtutu n to cuter noun abosa daeribed properly lorafcd ill Davie County cold airnell 2ij/ to condutlan lcs11aCproceduresasncnvary todatern'hre (btsite:uilpMl'lie)1 rr J DA•I'C- R-Z3''(0S _ s1cNATORE; Ca�Pi.:c rti -"�r^7 Tlllsm A ALIYBE USED Folm'I)4ING YOUR S17L MAN(Indadeall afthe fellowhir; YseGngmWpraposed property Buts and dlntensionss structures, sclbadq and septic loalious). MatRalyllealiml Dalt: ENS. Sign fire. - Aaounl No. a Itdrised DCliD (0503 .. InvoiceNo. r APDL: O)TION roll SITE EVA1W1nON/IAn7l0YGIFNC Ffllaftl S ATO Davie County Health r Iparhnent apimmmWHWA.i50c6Dn P.O. Boz ado/2lo UOSFital Stro.t Mociavillor NC 27020 (336)751-87to e �'Ii1PORTANT'a� 9IIIi APPLICATION CN7Nor BE PROLISSSD ONLLSS ALL T= REQUnEO r IrIPOAFNTION IS PPXO1V1lNlV. Rotor to Elio INrOWW::ON MIMLLTIN for igoatrua C£0aa. 1. N. W bo t13e01i1A`tT,� 1� Cl�'dN GSS ali��1 41. PG/jo eO cart Daroan dJ0 L]GV:S Ilalll.o Addraaa .1l 1 JW11-1 DI . Ibro phone Clcp/stata/ssr�tHfitn--ScLzn, �fJ(. •.�lyli(5 /Ia--!lu��clon.. PAon.7 n -714 316) f. Name on Par.it/ASC 1C al[tatent Elan above 1d'!.i TV am de wLlptvi R.111nP Mdra.e S�a.< dty/:: G[a/Llp '� s. Application Foca �1411to L^raluatiaa O I.r¢evaaaont romi.t/ATC O,Dotla d. s..... to aeevlca. ¢ atoune 0 15.6119 =.a a Duc )seas ❑ 1bUuatry; O out s_ asp. war. a a..ar.da Id ra.e..Uonal O ...v..Uaant :mdul.d ❑ roaovacbo Maceepted d. I�[� jlraidanc.a 1 Paopl-1 JJ t nedraacJcas L p maitur omo Fd 7 e.a .-Aat ,Karbala ala9aaal 'QNaahlay Y cillos lay aarmnt/rlu.olry Daase.en[/Ira plumbina 7. It aualaaa./[nduatry /0L4er: rarify type a PeeWa 1 alnko / Cdovlao _ 0 So... / arl..S. a Hata. realer. IF rOODWJMCE: 8 giants EetimaCCd m!tnr Dnagn-la9aldoa par dart 1. Trod Of vats eurp3r, a County/City ❑ Hol l 13 Cmmunity �� s. ao fav a..elelpata a.dltlma or =11wesiwn' oflllefau7ity lLissystwnisilucudrd losenro?Oyer . GI))N., lrycq'0111 type^ (flea n pvvtA }"e/ js^y/CQI ViJ IU4. 'i iaCJ ft�dl'v:.. Prolmmy DimuOiorm SCL lhJ'.��'L— l-- IYIOTC 31RECTIONS(r.,,, M.cluville) to l't101'EIIlTv Tax 0(6re PIN: 1� .Z ` J 5 16r',2 7 SS ) properly Address: Road Mame A�1. t! ?W, 1l' yi:l Nt, 1✓Ll'r Glymp &ccflalfic JI'M a Subdivision provide yafNance•Section: Block:awle comas Osgged: This it la certify Oral Ilia i ilernulu onledge I understand Ihat nuy permil(s) Issued hercanar aresub)cef la suspension or ravoeafion,if llivilla pleas ort. bided use ctuaCe, orlfilm iuformaliun . sultained in fills oPlinolian irralcired of changed /,'air., erndemeuds/mr: nm rapanriblofornlluugeslueurrrdfnrm shlrepplicnsie..I,hereby,Cly. mescal to Elie Autherrrced Repraeilfative oL9eDalie Comrq•}Iealll Deparbtutu n to cuter noun abosa daeribed properly lorafcd ill Davie County cold airnell 2ij/ to condutlan lcs11aCproceduresasncnvary todatern'hre (btsite:uilpMl'lie)1 rr J DA•I'C- R-Z3''(0S _ s1cNATORE; Ca�Pi.:c rti -"�r^7 Tlllsm A ALIYBE USED Folm'I)4ING YOUR S17L MAN(Indadeall afthe fellowhir; YseGngmWpraposed property Buts and dlntensionss structures, sclbadq and septic loalious). MatRalyllealiml Dalt: ENS. Sign fire. - Aaounl No. a Itdrised DCliD (0503 .. InvoiceNo. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003765 Billed To: Oak Valley Associates Limited Partne Reference Name: Proposed Facility: Residence Property Size:. Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5871-25-2458.28 Subdivision Info: Oak Valley Lot # 28 Location/Address: Oak Valley Boulevard -27028 see map Date Evaluated: A122, r On -Site Well Community Auger Boring Pit Public Cut SITE CLASSIFICATION: 15 ($b 2 LONG-TERM ACCEPTANCE RATE: D • nS 4 1 ;Z EVALUATION BY: OT-IER(S) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loamL - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTF.NCF. Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3f'et ' NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure. SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mi_ neralogy. 1:1, 2:1, Mixed lyutes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LT AR -Long-term acceptance rate - gaUday/ft2 noun n;/ns rua ;�aai HORIZON I DEPTH ft Consistence NEW r©������s■�I Consistence r-a��®■�®�® HORIZON III DEPTH Or+IIlt,..���������■ Consistence SOILWETNESS SITE CLASSIFICATION: 15 ($b 2 LONG-TERM ACCEPTANCE RATE: D • nS 4 1 ;Z EVALUATION BY: OT-IER(S) PRESENT: 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 loamL - 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 CONSISTF.NCF. Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3f'et ' 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 Mi_ neralogy. 1:1, 2:1, Mixed lyutes 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) LT AR -Long-term acceptance rate - gaUday/ft2 noun n;/ns rua ;�aai DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION" PROPERTY INFORMATION Account #: 990003765 Tax PIN/EH #: 5871-25-2458.28 Billed To: Oak Valley Associates Limited Partne Subdivision Info: Oak Valley Lot # 28 Reference Name: Location/Address: Oak Valley Boulevard -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 10107&r Water Supply: On -Site Well Community Public Evaluation By: 'Auger Boring Pit Cut FACTORS, 1 2 ,3 4. 5: 6 7 Landscape position V Sloe % HORIZON I DEPTH Texture group GL ..Consistence SX; 5P FrSS I/ Structure Mineralogy HORIZON H DEPTH - $ Texture group Consistence Fr Structure, Mineralogy HORIZON IH DEPTH Texture group Consistence 55 _. Structure 3`c Mineralogy- HORIZON IV DEPTH; Texture group._ Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S. LONG-TERM ACCEPTANCE RATE SITECLASSIITCATION--'Q�.EVALUATIONBY:V/X ;LONG-TERM ACCEPTANCE RATE. O' 27� OTHER(S) PRESENT. REMARKS: Landscape Position .. .. . _ LEGEND 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 fora 3Yet NS - Non sticky SS - Slightly sticky S - Sticky VS -Very Sticky T NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic' . ;Str i �r _ SCK Single mbloc arPLe Plat CR - Crumb GR -' Granular ABK - Angular blocky -' 8 � ' . Subangularblocky M' y PR - Prismatic '.. Mineralogy ; 1:1, 2:1; Mixed i Horizon depth, In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) i .. . Soil wetness Inches from land surface to free water or inches from land surface to soil colors with chroma 2'6r less Classification -, S(suitable), PS(provisionally suitable), U(unsuitable) ! !. LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) �5ep_-cj_Uzi ua:-tnp'. - APPI.;Oyf1ON FOR SITE EYALVA7[ON/p,(1710V0ILVT YERANY I ATC Davie County HeaM)I C rpartment - FDPiianmenblNWIL.MCCAbn - .. - P.O. Boz 8401210 Roapltal SLroaot - - - - Matknvillo, NC 27020 - - - - (3361781-87::0 •llnl'ORIANT••• MMS APPLICA=Mf CAMOI' nE PROL.TSSED UNLESS ALL ISG REQUIRED II1POlUL1II0N IS Ra1/C.T t0 the SNE ww.:ON BDLLr= for Snnaernet onfl. ' /VROPIDRD.' J/ Sl1(ry ySS oaaj:.l ���. P4rbw• be ocV..s . a. Nam to h. Willed I:A.. Comae[ Paraon _ fV� Hailingit"".. 3-IGt llje) (y b/. - Dow Prone . �/ 1 CLLy/.tato/:ZP 4�l nf;rr'��SGltts. IIJL - ll,f Pana. ?7G / r)q ?W - IIm�on�,iaean 1. Naw oa P*Colt/ATO It vletarmt a'. la.vo �d'f.5 70. Clr. d ,t,:J,,n<:,1 1' - n.11lap m Mda. .S �».{ ata•/::Gta/Lir `� . ]. A"linatioo sore (Sita GYaluatlaa 0 ya,;.ravoaaat P.Cnit/ASC O Doth n .11. ,.yf x122 v( nJ �IOV�� s.. sY.taa to LarYle.• ta/noue.- O Mobilo Roan 0 nue lila. 0 reduatri ❑ OGlar C�j4�[Ql Vid rJl+ (Q[J fr�'l^1'a�' s_ Typ..r.t.. w0uesa.d: or ConvanClmu: 0 eo.v..elan.i :mdttlM (3 l.ewatlr. gjCCCpCad - 6. I�t)pmldeAce: /P.Cpl•+ 1IIadr�Ja/:aa / 1L // kdolahwa.mr l/Carhop. maossai Tdlmahing st chla. 12(wa o.t/ri"obi y - Dn..maaw nv planhln0 7. - It Coosa .../I.duotry /oaL.e: arlr, type 0 Paopla 1 sink. - 1 Cowlea 1 eh... 0 Urloa. P W.U. Co.s.. IP POOOSP.RVICE- 0 Seta Eatimted linage, tgau. par oayl - 0:. Tm. of Yatec .vpP]Y• County/City 0 Ne.11 I] femininity �/ I. neY.N...uelv.e. admtlaw or eslrauimn or(hcfam7iq lLissysL muiufc.it loserre70 Yes. tl'Nu - Ifycs, 101A type.. - - •••IAIPORYANI'•••CL[r PROP UHSI'cu IPIFImitAi PLAN 11ELO\Y: Ettlmra PldTarSITIt rma byEn StTR hi by ILrtRont xA4TrnSA1`PLICATION. whIMITSAITUTATION. {PUNAfrdTTnL'SURFln7ED Proptrg• Dimemonm '�lZ j,Q+D,V IVIIfTE OIRECr1�Ci(frva hlatluville)lo 1'llD 1'kll'1'1': - TasOrfreIT* 59 -71 Properly Address: Road ttame_ A1. 1/%tYlew,irajA 14, JJL)�v Cityryp__ Iris a Snbdie6ion prorida iufomlz(icu, as folloln: Nan¢: . Section: - Bloch:__ Lot: 2 d Dale ho de corn» nap,ed: - This is to Ctrliry Unit [be infurnLlUon pro rided is correct to the but ofmylt'omledg¢ r understand that any pen:dl(s) - - limed hereafter are subject to suspension or revocation, if the site plans or 1. (aided use change, or KIM iufarmatimi - - - subndlleUislUl4applialiun it faisif¢d of Chanted. /,'e4o, undervaudtlmr.'nn, reoponsiblef.raffdiullTaGo:um•dfrvm - _ rhirapplicoapn. Lbaraby, giro Cowen[to fin: AuthorirN RepresWtatireoLheDasia Coung4lea111 Deparfuwd _ ' n to enter upon abQrCd0cliba0praperiyl0arad in DaYte Countyand pmt 1✓ - - - (a conduct all(filing procedures as mammary to de(ernlhm thesite suiWdl//it/�y] - DMT R"Z.%-0S L ,J- , COvr7/•:G L(, R - _ 51CNATURE �" fi CL/ THISAnL% MAY BE USED FORDRARWG YOUR ME PLAN(fadaddccall of Ute foUoninF EsetingaWpmPosed property Una and dimensloa; Strad a, se(le clq sad septic blaUems). - Site Revisit Charge - - Sign pisco AanwANa. 1+ 71 Rerlmd DCIII) (05/03 Imvim Na