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942 Angell Rd (2) OPERATION PERMIT or ice se nv Davie County Health Department *CDP File Number 81497-3 210 Hospital Street F40000004701 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone: 336-753-6780 Fax:336-753-1680 Township: Applicant: Steve Peterson r perty Owner. Hal and Phyllis McCulloh Address: 131 Eastridge Court dress: 942 Angell Road City: Advance y: Mocksville State2ip: NC 27006 Statefzip: NC 27028 Phone#: (336)940-7319 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 942 Angell Road Mocksville NC 27028 Directions Address/Road Structure: OTHER 601 North, Angell Road on right. #of Bedrooms: #of People: WIP ater Supply: EXISTING WELL * I *System Classification/Description: ssued by. TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? QYes ®No Design Flow: 1 0 0Pump Required? *Distribution Type: QYes QNo Soil Application Rate: 0 - 2 7 5 *Pre Treatment: Drain field Nitrification Field 3 .6 4 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No.Drain Lines a Installer Jamie Biomes Total Trench Length: 1 .0 0 ft. Certification#: Trench Spacing: — 9 Inches O.C. Feet O.C. *EH S: 2140-Nations,Robert Trench Width: .a Inches gFeet Date: . 0 6 0 2 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Approval Status Inches Maximum Trench Depth: 31 6 ®,,Approvetl E Disappravetl F Inches Maximum Soil Cover. a 4 Inches CDP File Number 81497 - 3 County ID Number: F40000004701 Septic Tank Manufacturer: Shoaf Let. STB: 760 Long: - Gallons: 1000 Installer: ,Jamie Bames Date: 02 / a 1 / a 0 1 5 Certification#: 'EH S: 2140-Nations,Robert 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. El Yes 0 No Date: 06 / 0a / 2015 Reinforced Tank: El Yes R No Apgraval Status i Piece Tank: -® Approved❑ visa ,proved ❑ Yes R N o i;.'F Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) `Approval Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line FPiope ize: inch diameter Installer: gth: feet Certification#: Schedule: 'EHS: Pressure Rated ❑ Yes ❑ NO Date: / Approved fittings .❑ Yes ❑ No Y Approval Status - mr LLDApproved❑ Disapproved Pump Requirement CDosing Type: Installer. lume: - Gal Certification#: Draw Down: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check valve ❑ Yes ❑ NO �gpprovatStatus "' PVC unions ❑ Yes ❑ N o ❑ Approved D Disapproved Vent Hole ❑ Yes ❑ No .. . ,. . .rb , ..i � ww.. ,,,.Anti-siphon Hole ❑ Yes 0 No CDP File Number.81497 - 3 County ID Number: F40000004701 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ NO Certification#: Box Adj.To Pump Tank ❑ Yes ❑ N0 Conduit Sealed ❑ Yes ❑ NO *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible 11 Yes ❑ No ❑"Appro- ved Dtsapprovetl' Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: Authorized Stafe_kNPt• Date of Issue: 0 6 / 0 a / a 0 1 5 Owner/Applicant Signature: 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 et. Seq., and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE it& sewage septic system. Rule.1961 requires that a Type TYPE t1 A• septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System InspectioNMaintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator:NIA 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 entitywith 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 entitywith 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 by public or private management ently, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand 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. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** • OPERATION PERMIT 81497 - 3 Davie County Health Department CDP File Number. 210 Hospital Street F40000004701 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Operation Permit Scale: , 00 N/ABlock ft. .......... ...... . l 1- _ - --- ----- -- - -- --- r- -----1---- _ -- _-_- _-_ -- -{--- _ _-_-- - -_- - -- - -------- ------ -f-- _ _ _-- • Y 1 - - ---- - - --- ---� - - --- - - -----t--- - - - --------- --- ------ ----- ------------ - ----- I � I _ �____ ---- __________________ ------_____ _____'._-____..__-__I_-_________ _____..______ -__-__._._.._____..____-....._______ ........................... ........... __........... --- -1 -------...... – ----- - ------ ----- —- 1 ----- __ _...... --------- Page 4 of 4 P1 P2 P3 ' CONSTRUCTION For office use only AUTHORIZATION *CDP File Number 81497- 1 °'' Davie County Health Department County ID Number: F40000004701 .. J 210 Hospital Street Evaluated For: HDR/WWC P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 5 / 1 8 / a 0 a 0 Applicant: Decked Out Property Owner: Thomas and Phyllis McCulloh Address: 131 Eastridge courtAddress: 926 Angell Road City: Advance 7 City: Mocksville State/Zip: NC 27006 State/Zip: NC 27028 Phone#: (336)740-5957 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 942 Angell Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY 601 North, Angell Road on right. #of Bedrooms: 3 #of People: *Water Supply: N/A System Specifications Minimum Trench Depth: � 4 CSaproliteSystem? Provisionally suitable Inches Minimum Soil Cover: OYes l8 No Inches 1 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 3 6 4 Sq.ft. Pump Tank: Gallons No. Drain Lines 1 1-Piece: OYes ONo Total Trench Length: 9 1 ft GPM--vs— ft. TDH Trench Spacing: Inches O.C. g 2Feet O.C. Dosing Volume: Gallons Trench Width: — 3 jinches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 CDP File Number 81497 - 1 County ID Number: F40000004701 , ❑ Open Pump System Sheet Repair System Required:®Yes ONO ONO, but has Available Space CDesign System Trench Spacing: Q Inches O. . fication: Provisionally Suitable — Q9 Feet O.C. Trench Width: Inches w: 1 0 0 — 3 Feet Soil Application Rate: 0 Aggregate Depth:a 7 5 inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a LESS) Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Maximum Soil Cover: a 4 Nitrification Field 3 6 4 Sq.ft. Inches No. Drain Lines 1 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 9 1 ft Pump Required: OYes (&No O May Be Required Pre-Treatment: O NSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R men g 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. Rema``�9 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? O Yes ONO Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 5 / 1 8 / a 0 1 5 Authorized State AgentL Malfunction Log OYes ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 •._•_ A CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street F40000004701 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 05 / 18 / .1015 Olnch Drawing Drawing Type: Construction Authorization Scale: , O Block O N/A 4........ ___....- ----- ------ ----1------ ----------------------------------------------------------..------------------ -------- . ----- ----- ---- _ --- - .__�------------I _ -- ---- Y 1 0------ -�--�- -, M,. -�- --- - ---- - -- ------ - - - - ------- - --- --------------- --------- --------- -------- --- i---------- _--- I a d El ---_----- --- - ------------ Page 3 of 3 Pi P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 F40000004701 Mocksville NC 27028 County File Number: Date: A 5./ 18 / 2 0 15 Click below to import an image from an external location: Drawing Type:Construction Authorization I i Page 3 of 3 P1 P2 CONSTRUCTION For office Use Only AUTHORIZATION "CDP FIle.Number 81497'e-1Davie County Health Department County ID Number.F40000004701 210 Hospital Street Evaluated For. HDR/WWC P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 1 a 0 Applicant: Decked Out Pmpe yOwner. Thomas and Phyllis McCuiloh Address: 131 Eastridge court Address. City: Advance City: Mocksville StaterLip: NC 27006 State/Zip: NC 27028 Phone#: (336)740-5957 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 942 Angell Road NC 7028 Directions Structure: SINGLE FAMILY 601 North, Angell Road on right. #of Bedrooms: 3 #of People: "Water Supply: N/A System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable 7nchesMinimum Soil Cover.Saprolite System? OYes QNo 1aDesign Fiow: 1 0 0 Maximum Trench Depth: 36nces Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: QYes @No Pump Required: OYes @No OMay Be Required Nitrification Field 3 6 4 Sq.ft. Pump Tank: Gallons No.Drain Lines 1 1-Piece:OYes ONo Total Trench Length: 9 1 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. 9 - @Feet O.C. Dosing Volume: _ Gallons Trench Width: Inches 3 . 2Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-ll Septic Tank Installer Grade Level Required: 01011 0111 OIV Dann i nf'A CDP File Number 81497 - 1 County ID Number: F40000004701 ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Trench Spacing: Q Inches 0. . ification: Provisionally Suitable — 9 � Feet O.C. 0 Inches. Trench Width: w: 1 0 0 — 3 Feet Soil Application Rate: 0 a 7 5 Aggregate Depth: inches Minimum Trench Depth: a 4 "System Classification/Description: Inches TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches "Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a � Nitrification Field 3 6 4 Sq. Inches R. No. Drain Lines *Distribution Type: .GRAVITY-PARALLEL(eq.d-box) 1 TotalTrench Length: 9 1 ft. Pump Required: Oyes. ®No OMay Be Required Pre-Treatment: ONSF OTS-1 OTS-11 'Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *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. This Authorization for Wastewater system Construction shall bevalld fora person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe 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,theinformation submitted in the application fora permit or Construction Authorization Is found to have been incorrect,falsified or changed,or the site Is altered,the permit or constructlon Authorization shall become Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system locatiom Installation,operationj maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps.Signature Required? OYeS ONo Applicant/Legal Reps.Signature: Date: „ 2140-Nations,Robert 0 5 1 8 2 0 1 5 Issued By: - Date of Issue:.._._, Authorized State Agents Malfunction Log Oyes { @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street F40000004701 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 5 / 1 8 / 2 0 1 5 O inch Drawing Drawing Type: Construction Authorization Scale: , . aN/A k ft, +� 1 00Nrl �----------- L_ z � (A FFIH 1 .111111 ----j b �: CONSTRUCTION AUTHORIZATION ` Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 F40000004701 Mocksville NC 2702$ County File Number. Date: .0 5 / 1 8 / 2015 Click below to Import an Image Brom an external location: Drawing Type:Construction Authorization -IMPROVEMENT PERMIT For off;ceUse only *CDP File Number 81497- 1 Davie County Health Department 210 Hospital Street County ID Number F40000ooa7ot ., P.O. Box 848 Evaluated For. HDR/WWC Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-763-1680 PERMIT VALID UNTIL. 5/18/2020 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. .,. Applicant: Decked Out Property Owner: Thomas and Phyllis McCulloh Address: 131 Eastridge court Address: 926 Angell Road CRY Advance City: Mocksville StatefLip;. NC 27006 State/Zip: NC 27028 Phone#: (336)740-5957 Phone#: Property Location & Site Information FddressMoad;9: Subd'aisan: Phase: Lot: ell Road le NC 27028 Directions Structure: SINGLE FAMILY 601 North, Angell Road on right. #of Bedrooms: 3 #of People: *Water Supply: N/A System Specifications nitiSystem *SiteClassification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? OYes (&No Maximum Trench Depth: 3 6 Inches Design Flow: 1 0 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 a 7 5 1-Piece: OYes QNo Pump Required: ()Yes ®No OMay Be Required *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:@Yes ONo ONO, but has Available Space Repair System *S ite Classification: Provisionally Suitable Minimum Trench Depth:: -1 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches SystemClassification/Description: Pump Required: OYes @No OMaybeRequired TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 81497- 1 County ID Number: F400000047011 *Site Modifications ❑.Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. r *Permit Conditions The issuance of this permit bythe.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. Site Plan The improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions,the location of thefacillty and appurtenances,the 0 site forthe proposed Wastewater,system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a scale of one Inch equals no morethan 60 feet.that includes:the specific location of the proposed facility O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the coumty register of deeds,a copy of the recorded subdivisions plat that is accompanied by a site pian that is drawn to scale). The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article:This permit is subject to revocation If the site pian,plat,or Intended use changes(NCOS 13OA-435(f)).The person owning or controlling the system shalt be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring, reporting,and repair(A 938(b)} Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 5 1 8 / a 0 1 5 T OValid without Expiration? Authorized State Agent: O Create CA? ®Hand Drawing Olmport Drawing , **Site Plan/Drawing attached.** Page 2 of 3 . IMPROVEMENT PERMIT 81497- 1 Davie County Health Department CDP File Number: 210 Hospital Street F40000004701 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Improvement Permit Scale: . Oslock ON/A S. s _. d —410111* I F III 1-4w IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 81497 - 1 P.O.Box 848 F40000004701 Mocksville NC 27028 County File Number: Date: LOs / is / 2015 Click below to import an Image from an external location:Drawing Type: Improvement Permit APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC �',i CEDED Davie County Environmental Health l P.O.Box 848/210 Hospital Street Mocksville,NC 27028 �' (336)753-6780/Fax(336)753-1680 Application For: ❑ Site aluation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both Type of Application: PfrNew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name TC' �S� Contact Person c g:�rr 7- 11 Address 131 g-fgl 7 , L t G Home Phone City/State/ZIP 4-0 a.o Co Business Phone Email Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat oreite la t accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is f oaths with site 1an,no expiration with complete plat.) Owner's Name i C / f Phone Number, Owner's Address /J City/State/Zip_ Property Address AI City Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: j.,�e e, alt— Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑N [ People ement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No 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) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my lmowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspense rTevocation if the site is altered,the intended use changes,or if the information submitted in this application is falsif angel I hereby grant right of entry to the Authorized Representative . of the Davie ounty He th Department t ct necessary inspections to determine compliance with applicable laws and rules. I undersl at I sponse a proper identification and labeling of property lines and comers and locating and flagging or staldn us / n,proposed well location and the location of any other amenities. Prop � qwne s or owner's legal representative signature Site Revisit Charge Date(s): 41 -7 5 Client Notification Date: -_ Date EHS: I Sign given ❑Yes ❑No Account Revised 11/06 Invoice# ! DAVIE COUNTY HEALTH DEPAR NT Environmental Health Section Soil/Site Evalu4iion APPLICANT INFORMATION I PROPERTY INFORMATION Aeoe, Nelso I r qqD- 73M 0 iI Water Supply: On- ite Well Community Public I Evaluation By: Augr Boring -Pit Cut i FACTORS { 1 2 3 i 5 6 7 Landscape position Slope% ( j HORIZON I DEPTH I ! Texture group (. Consistence j Structure i Mineralogy HORIZON II DEPTH ► ! Texture groupj ! Consistence I Structure f Mineralogy { I I HORIZON III DEPTH Texture groupI ! Consistence Structure Mineralogy ! HORIZON IV DEPTH ( I Texture group Consistence ► •Structure (. Mineralogy SOIL WETNESS j ► ► RESTRICTIVE HORIZON I ( I i SAPROLITE ( i ► CLASSIFICATION I LONG-TERM ACCEPTANCE RATE J SITE CLASSIFICATION: I EVALUATI()N BY: LONG-TERM ACCEPTAN "RATE: I OTHER(S)PRESENT:: ► i. REMARKS: i i f , Landscape Position LEGEND R-Ridge S-Shoulder' ' L-Linear slope FS-Foot slope N-Nose slope CC Concave slope CV- onvex 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-dandy clay loam SC-Sandy clay SIC-Sil clay C-Clay ; Co SISTENC� Moist I ► VVR-Very friable FR-F 'able FI-Firm VFI-Very firm IEFI-Extre jely firm NS-Non sticky SS-.Slightly sticky S-Sticky VS-Very Stich NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic, i Structure SC-Single grain M-Massive CR-Crumb GR-Granular ;ABK-Angular blocky. SBK-Subangular blocky L-Platy PR-Prismatic I Mineralogy 1:1,2:1,Mixed No � i Horizon depth-In inches Depth of fill-In inches i Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsu;'table). I 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 rovisionally suitable),U(unsuitable) i TTA" T /v `c" - '`v1 �r� --------------- fly DZIN le County Health Department 10 Envirorimental Hcalth Section Y P.O.Box 848 210 Hospital Street Courier H 09-40-06 1 MoclLsviller SVG 27028 rhone:(336)-7.53- , tj`t ett Fax:(336) 75,I J 680 ON-STIP WASTEWATER CERTIFICATION (Check Cane) Replacement remodeling Reconnection qqo-gslq, Name:Na Phone Number "V% ' 1 -Z- omc (H ) Mailing Address: ?z e'7-5 Email Address - Detailed-Directions To Site.----4-4( vt 5 C Property Address: Please Till Fn The Following Information About The EXISTING Facility: Name System Installed Under: Tyke Of Facility: Date System Installed(.uMonth-Datell'ear): '� f f� ` Number Of Bedrooms: ` Number Of People: Is The Facility Currently Vacant? Yes if Yes,For How Long? v Any Ktiown Problems? Yes6) If Yes,Explain: na Please Fill Itt The FolloiNing Information About The AT-WF'acility: Type Of Facility: !"� � ° � �� ����.c� Number Of Bedrooms: Number of Peoples Pool Sul s ge Size: Other:��'r Requested Date Rechiested: lnaturc _ -.. 'For Environmental Hc€dth Office use Only Approved Disapproved 3,mw Comments: Environmental I-Iealth Specialist Date: *'ole signing of this form by the Environmental Health Staff is in no way intended; nor should be taken as a guarantee (extended or litiiited)that the on-site wastewater system will function properly for any given period of time. Payment: Cast -lCheck Money Order # 0 Qq1 7 y^1 Atnottnt:$ Date; - Paid By; _ _, Received By: Account : Invoice#: