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827 Fairfield Rd9'A s . CONSTRUCTION For Office Use Onty--� AUTHORIZATION Qfj 13 `CDP File Number 120601-1 Davie County Health Department �1 COU ID Number: L60000000501 210 Hospital Street ®11 1 EV at For: NEW P.O. Box 848 ownship: Mocksville NC 028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 8/ 2 8/ 2 0 1 8 Applicant: Tony Capote Builders Property Owner: Yvonne Fink and Jackson Glover Address: 5426 Capote Road Address: 172 Canterbury Place Coy: Mocksville City: Mooresville State/Zip: NC 27028 State/Zip: NC 28115 Phone #: (704) 483-7313 Phone #: &S Phase: Lot: Directions 601 s. left on Fairfield Road, Go to end, property on corner on left. System Specifications #: gZ�Address/Road Subdivision: filIpZ-r(E1d ' Mocksville NC 27028 Structure: SINGLE FAMILY 4 of Bedrooms: 4 # of People: 3 'Water Supply: PUBLIC Phone #: &S Phase: Lot: Directions 601 s. left on Fairfield Road, Go to end, property on corner on left. System Specifications n--- 4 -r '11 __2� AN;dly) Minimum Trench Depth: 2 4 \ Inches /Site Classification: PS \ Minimum Soil Cover. SaproliteSystem? OYes QNo Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - 2 5 Maximum Soil Cover: Inches *System Class ificationlDescription: "Distribution Type: GRAVITY - SERIAL 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: OYes G No Pump Required: OYes (j)No 010ay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No, Drain Lines 1 -Piece: OYes ONo Total Trench Length: 4 8 0ft. GPM—vs-- ft. TDH Trench Spacing:— Q Inches O.C. Feet O.C. Dosing Volume: Gallons — Trench Width:— OInches Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 0111 011/ /� n--- 4 -r '11 __2� AN;dly) CDP File Number 120601 - 1 County ID Number: L60000000501 ❑ Open Pump System She( Kepalrz)ystem Kequireo:v 1 Ca \./1VV v1vv, Uut 11dJ r1Vd11dU1C aNdGC /Repair System Trench Spacing: Inches 0. *Site Classification: P5 — Feet O.C. Trench Width:8Feet Inches Design Flow: 4 8 0 — Soil Application Rate: 0 2 5 Aggregate Depth: inches Minimum Trench Depth: *System Class ifx;ation/Description: Inches TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches Maximum Trench Depth: *Proposed System: 25%REDUCTION Inches Maximum Soil Cover: Nitrification Field Inches Sq. n.. No. Drain Lines 'Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 8 0 ftPump Required: QYes ONo ()May Be Required Pre -Treatment: ONSF 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. *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 be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe 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 theapplicaUon 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 maybe 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 location, installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature Date: / / 'Issued By 2244 - Daywalt. Andrew Date of Issue: 0 8 / 2 8 / 2 0 1 3 Authorized State Agent:_ %M624& Malfunction Log Oyes OHand Drawing Olmport Drawing TotalTime:(H1-111M) **Site Plan/Drawing attached.** Page 2 of 3 0 1 Hours 0 0 I.t inutes CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawin<, CDP File Number: 120601 -1 County File Number: L60000000501 Date: 08/28/2013 Q Inch ack - A W9 J IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Use On1y 'CDP File Number 120601 -1 County ID Number: L60000000501 Evaluated For: NEW Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL; 8/28/2018 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Tony Capote Builders Address: 5426 Capote Road City Mocksville State2ip: NC 27028 Phone #: (704) 483-7313 Address/Road #: Subdivision: Will Boone Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 x of People: 3 'Water Supply: PUBLIC ,/Initial System 'Site Classification: PS Saprolite System? ()Yes @No Design Flow: 4 8 0 Soil Application Rate: 0 3 'System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25% REDUCTION A roperty Owner: Yvonne Fink and Jackson Glover Address: 172 Canterbury Place City: Mooresville State/Zip: NC 28115 Phone #: Phase: Lot: Directions 601 s. left on Fairfield Road, Go to end, property on corner on left. Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: ()Yes (QNo Pump Required: ()Yes QNo QMay Be Required Pump Tank: 1 0 0 0 Gallons 1 -Piece: ()Yes QNo Repair System Required: 0 Yes ()No QNo, but has Available Space Repair System 'Site Classification: PS Soil Application Rate: 0 3 'System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25% REDUCTION Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Pump Required: ()Yes QNo Q May be Required Pagel of 3 CDP File Number 120601 - 1 County ID Number. L60000000501 *Site Modifications ❑ Open Fill Sheet 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 bythe Health Department in no wayguarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. The Improvement Permit shall be valid for 5 years from date of Issue with a site plan (means a drawing not necessarily drawn to SitO Ian scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the 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 O surveyor, drawn to a scale of one Inch equals no more than 60 feet that includes: the specific location of the proposed facility 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 county register of deeds, a copy of the recorded subdivisions plat that is accompanied by a site plan 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 plan, plat or intended use changes (NCGS 130A335(f)). The person owning or controlling the system shall be responsible forassuring 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 (S)No Applicant/Legal Reps. Signature: Date: *Issued By: 2244 - Daywalt. Andrew Date of Issue: 0 8 / 2 8 / 2 0 1 3 Authorized State Agent: OValid withot Expiration? O Create CA? (S)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time_(FIH:611,9) 0 1 Hours 0 0 Minutes Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Improvement Permit CDP File Number: 120601 - 1 County File Number: L60004000501 Date: I I Q Inch Scale: 0 0. 06lock 1 0 0 QN/A IMPROVEMENT PERMIT For Office Use Only 'CDP File Number 120601 -1 :u ;• Davie County Health Department 210 Hospital Street County ID Number: L60000000501 � c f• , � P.O. Box 848 Evaluated For: NEW w Mocksville NC 27028 Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL. 3/25/2018 'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Tony Capote Builders Property Owner. Yvonne Fink and Jackson Glover Address: 5426 Capote Road city: Mocksville State2ip: NC q28 Phone #: (704) 483-7313 Address/Road #: Subdivision: Will Boone Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 3 'Water Supply: PUBLIC a SaproliteSystem? OYes ONo Design Flow: 3 6 0 Soil Application Rate: 0 2 5 'System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25% REDUCTION Address: CID State/Zip: Phone #: 172 Canterbury Place Mooresville NC Phase 28115 Lot: Directions 601 s. left on Fairfield Road, Go to end, property on corner on left. Minimum Trench Depth: a 4 Inches Maximum Trench Depth: 2 4 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Pump Tank: Gallons 1 -Piece: OYes ONo Repair System Required: 0 Yes ONo ONO, but has Available Space Repair system 'Site Classification: PS Shallow Placement Soil Application Rate: 0 - 2 5 'System Classification/Description: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25% REDUCTION Minimum Trench Depth: a 4 Inches Maximum Trench Depth: a 4 Inches Pump Required: OYes ONo O Maybe Required Page 1 of 3 CDP File Numbdr 120601 -1 County ID Number: L60000000501 *Site Modifications ❑ Open Fill Sheet No grafting or construction activity is allowed in areas designated for system and repair without approval of Health Department. *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 wild for 5 years from date of Issue with a site plan (means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions, the location of thefacility and appurtenances, the site for the 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 O surveyor, drawn to a scale of one Inch equals no more than 60 feet that Includes: the specific location of the proposed facility 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 county register of deeds, a copy of the recorded subdivisions plat that Is accompanied by a site plan 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 perm it Is subject to revocation If the site plan, plat, or Intended use changes (NCGS 130A -335(f)). The person owning or controlling the system shall be responsible forassuring 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 ONO Applicant/Legal Reps. Signature: Date: / Issued By: 2244 - Daywall, Andrew Date of Issue: 0 3 / a 5 / a 0 1 3 Authorized State Agent: OValid without Expiration? O Create CA? 01 -land Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(H1-1111,t) 0 1 Hours C3 v 1.11nutes Page 2 of 3 Activdv Code: Page 3 of 3 it - APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE ATC Davie County Environmental Health ; <, q,�� P.O. Box 848/210 Hospital Street . . ��(3 a Mocksville, NC 27028 ll� lZ (336)753-6780/ Fax (336)753-1680 l ca ion For luation/Improvement Permit ❑ Authorization To Co t ❑ Both pIIf A is ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***Ah-6RTAN7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMcATIION BULLETIN for instructions. APPLICANT INFORMATION ��`�" �LW- -PLIt C ' 0 A-0 Name Contact Person dZy Address Z G,5112, -t.- Home Phone City/Stat�ZIP /YI rc'eG d-0 Business Phone 2Oyt7co qyt— Email l017 <2 cJ�cbc,��l C�-f• Name on P rmit/ATC if Different than Above Mailina Address Citv/State/ZiD PROPERTY INFORMATION *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan 1?Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name�ti8�� �r rllC l ,/��,lcSv� C� (v vev-- Phone Number X 36 - ` Of - 3 0 S,6 Owner's Addres City/State/Zip a Z o Z Property Address 2C. City V 0dCjc,, & ,t --C, Lot Size Tax PIN# 1Jffo 6 ISD Subdivision Name(if applicable) Section/Lot# Directions To Site: a--, Cc, -,7 e-- r�c/,4 I ((a /Ld If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes XNo n Does the site contain jurisdictional wetlands? _Yes .x No Are there any easements or right-of-ways on the site? Yes No ��� Is the site subject to approval by another public agency? _Yes �No � Will wastewater other than domestic sewage be generated? YesNo _ _ I IF RESIDENCE FTTJ, OUT THF, BOX BELOW # People S # Bedrooms -E L/ Bathrooms 3 Garden Tub/Whirlpool ❑Yes ANo Basement: ❑Yes into Basement Plumbing: 0Yes Gkio 1F NON -RESIDENCE FIT I, OUT THF, 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: PConventional ❑Accepted ❑Innovative ❑Alternative ❑Other_ Water Supply Type: Wounty/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 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 I 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 locating and flagging or st th house/facility location, proposed well location and the location of any other amenities. Proowner's or owner's legal representative signature Site Revisit Charge pe PAW Date(s): Client Notification Date: Date Dates b Z`� 0 EHS: �Recelved E�: Sign given ❑Yes ❑No Revised 11/06 Account # 33 Invoice # C -'/', moa will boone lot a Printed:Jan 31, 2013 All data is provided as is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. E j x Aeact � snow— nok 117 " kis, "xt,}�: �'"� , . �' '�� �r» � �. 'ua�`',. { • . .tom M o. I - � �s p G�14(lil�r $T4� I Anraisal'Card e rmw4v u Page 1 of 1 FINK YVONNE BROGDON GLOVER JACKSON H Return/Appeal Notes: 11.6-000-00-005-01 UNIQ ID 22100 2531260 ID NO: 5756066550 COUNTY TAX (100), FIRE TAX (100) CARD NO. 1 of 1 eval Year: 2013 Tax Year: 2013 5.156 AC WILL BOONE RD 5.410 AC SRC= Inspection Appraised by 19 on 05/20/2008 05004 FAIRFIELD TW -05 C- EX- AT- LAST ACTION 20110712 CONSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE OTAL POINT VALUE Eff. BASE BUILDING USE MOD Area UAL RATE RCN EYB AYB CREDENCE TO 1 1 1 1 1 1. % GOOD I DEPR. BUILDING VALUE - CARD ADJUSTMENTS 971 00 1 TOTAL ADJUSTMENT TYPE: Vacant ACTOR TOTAL QUALITY INDEX STORIES: DEPR. OB/XF VALUE - CARD MARKET LAND VALUE - CARD 35,46 TOTAL MARKET VALUE - CARD 35 46 TOTAL APPRAISED VALUE - CARD 35,46 TOTAL APPRAISED VALUE - PARCEL 35,46C TOTAL PRESENT USE VALUE - PARCEL TOTAL VALUE DEFERRED - PARCEL TOTAL TAXABLE VALUE - PARCEL 35,46( PRIOR UILDING VALUE BXF VALUE ND VALUE 35,46 RESENT USE VALUE DEFERRED VALUE OTAL VALUE 35,46 PERMIT CODE I DATE I NOTE I NUMBER AMOUNT ROUT: WTRSHD: SALES DATA ATE DEED INDICATE SALES R TYPE / PRICE 1 00 r�A/TO WL E V 1 199 WO X V HEATED AREA NOTES OYD MCBRIDE SUBAREA UNIT ORI G % SIZE ANN DEP % OB/XF DEPR GS RPL OD UA DESCRIPTIO T NIT PRICE CONO LDGXL/ FACT Y RATE V C0N.1VALUE TYPE AREA CS OTAL OB XF VALUE FIREPLACE SUBAREA TOTALS UILDING DIMENSIONS ND INFORMATION IGHEST ADJUSTMENTS LAND TOTALND BEST USE LOCAL FRON DEPTH / LND COND�THER ND NOTES ROA UNIT LAND LINT TOTAL ADJUSTED LANDSE CODE ZONING TAGE DEPT SIZE MOD FACTRF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE E NOTESURAL AC 0120 3: 0 1.2780 4 0.87001 +1R +00-20-10 PW 5,900.0() 5.40 AC 1.11 6,560.80 61 HAPE j34 OTAL MARKET LAND DATA 5.40 6 OTAL PRESENT USE DATA QkM ry i 'e http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=L60000000501 3/12/2013 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section • Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990006033 Tax PIN/EH #: 1-6-000-00-005-01 Billed To: Tony Capote Subdivision Info: Reference Name: Y.Fink J. Glover Location/Address: Will Boone Road -27028 Proposed Facility: Residence Property Size: 5.410 Ac Date Evaluated: 31201DOR Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public ;P` Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L L Slope % G'/o G% °o HORIZON I DEPTH C Texture group S(_L CL Consistence OeR L7 Structure Mineralogy HORIZON II DEPTH t 6-q3 Texture group Consistence Structure 1L ww-sm w—s W 5w - wMineralo Mineralogy ; ( V k k; t HORIZON III DEPTH Texture grou2 Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P5 LONG-TERM ACCEPTANCE RATE .2 SITE CLASSIFICATION 93 LONG-TERM ACCEPTANCE RATE: •26 REMARKS: • psl' L MW /..� OTHER(S) PRESENT: U U 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 i► _rim VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Mkt 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 Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ee■e■■■eee/■ee■■■e■■e■■ee■eee■■■ee■■■■■■■■/■■■■■■■■■■■■■■■■■■■■■/■ '■■■■■■■■■■■■■■■■■■■■ecce■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■e■ I■■■■e■■■■■■■ee■■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■ ■ee■■■■eee■■■■■e■■ecce■■■■■■■■■■ ■■■/■■■■■■■■■eee■■■■■/■■■e■/eee■ ■■■■■■eeee■■eee■■■ecce■eee■ecce■ ■■■■■■■■e■■■e■■■■■eeee■■■■■■■■■■■■■■■■■■■e■■■■■■eeee■■■■■■■■■■■//■ ■■■■■■■■e■■■e■■ee■ee■e■■e■e/e■ee■eea■■■■eee■■■eeeeee■■■■■■■■eee■e■ ■■■■■■e■e■■ee■■■ee■eee■■■■■■■■■■■e■■e■■■e■eetr..�e�l■e■ee■ee■■e■eeee■■ ■ee■e■■■■■e■e■■■■ee■■■■eeeee■■■■■■■■■tr.�■ee■�le�l■■■e■e■■■■■ee■■■■■ ■■ee■eeee■■e■■ee■e■■■■■eee■■■■■■■ee■t•�■eee■■e�l■11■■■eeee■e■■■■eee■■ ■s■■■■■/■■■■■■■■■■■■■■■■■■■/■■■■■■��■e■■■■■e■�I■11■■■■eeeee■■eeeee■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ee■■.�e■■■■■e■■e�l■11■/■■■■eee■/■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■e■■■■■■��e//■■eeeeeee■■■lelleee■e■eeee■eee■e■■ ■■ee■e■■■■■eee■■■■■■■ee■■e■■.■e■ ■■■eee■■■■■�I■Ile■e■■■ee■■■■■■■■■■ ■■■■ee■■e■e■■■■■■e■■■ee■■■t•.�e■■■■■■■ee■■■■e■i■11■■e■■■■■e■■ee■■■■■ ■eeee■■■■■e■■■■■eee■■■■��■■■■■■e■■■■■ee■■■■ee■t■11■eee■■■e■■■■■e■■e■ ■■■e■■■■■■//■■■■■■■eel•e■■■■■■■■■■■■■�I,■■■■eeee■telle■■e■■e■■■■■eee■e■ ■■■e■■/■■■■■eee■eeee■I�e■■e■eeeee■eeY■■■eee■e■■t■Ileeeeeeeeeee■■eeee■ ■eeeee■■■■/■■■■■■■■■■Ike■■e■■■■■■■■■■■■■■■■■■■■I\�/e■■■■■■■■■e■■■■■e■ ■■■■■■■■■■e■■■■■■■■■■Ike■■■■■■e■■�■■■■■■■■■e■■IE�1■■■■■■■■■■■■■■■■■■ ■■■■■■■■/■■■■■■■■■■e■II■■■■■■■■tree■■■■■■�■■eee■I,��1■ee■■eee■■■■■■■■■■ ■■■■■■■■■■e■■■■■■■■■els■■■■■e■■■■■�t■�iw�e■t■■■■■■Ilr/l■■■■■/e■ee■/e■■e■■ NOMINEE MEMNON --to---W 111iiii ill MEMNONiEMMONS ■■■■■■■■■■■■■■■■■■■ecu■■■■■■■■■■■■■■■■eeee■ee■i■11■ee■e■■e■e■■■■■■■■ ■e■ee■■■■/■■■eee■■■■■I�■■/■■■■■■■■e■■■■■■■■■■/■■ue/■e■■■//e■■e■■ee■ ■■■■■■■■■■/■■■■■■■■■■■■■■■■rye■ren�lu;,1■■■■■■■■■■■■■/■■■■■■■■■■■■■■■■ ■■eee■■■■■■■■■■■■e■■■C..�■■��'::::�'.�.��_��_�_�_�_�_�_��_�eel7■■■■■■■■■e■■■■■■■■ ■■■■e■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eller■e■■eeee■■■eee■■■■ ■■■■■■■■■■/■■■■■■■■■■/■■■■■/■■■■■■■■eee■■e■■ell■I■e■■■■■■/■■■■■■■■■■ ■■■■■■■eeee■■■■■e■■e■■■■■e■e■■■■ee■eee■■■eeeellel�■■■■■eee■■■■■■■■■■ ■■■■■■■■■■/■■■■■■■■■■■■■■■■/■■■■■■/■■■/■■■■■ell■It■■■■■■■/■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■eee■■■■■■I�ee■■■■■■■■■11■I■■■■■■■■■■■■■■■■■e■ ■■■■■■■■■eeee■■■■■■■■■■/■■■■■■eee■■■■■■eee■eellel■e■■eeee■■■■eee■■■■ ■■■■■■■■■■eee■■■■e■/■e■■■■■/■■■■■■■■■■■■■■■■■11■I■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■eee■■■■■eee■■■eee■■■■■■■■■e■■eellel■■■■■■■■■■■■■■■■■e■ ■■■■■■e■eee■eee■■■■■■■■■■■■■■■■e■■■■■■■■■■■■■�■■■■■e■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■eee■/■e■eeeee//eeee■■■■■■■■■■■■■e■■e■■eeeee■eeeeeee■■■■■■■■eee■e■ ■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■eeeee/■■■■■■■■e■■■■■■■■■■■■■■■■■ ■■■■■■■■■■/■■e■■■■■■■/■■■■■/■■■■■■■■■■■■■■■■/■/■■■eee■■■■■■■■■■■■■ ■■■■■■■■■■/■■■■■■■■■■e■■■■■■■■■■■■■■■■/■■■■■/eee■■■/■■■■■■■eee■■■■ ■■■■■i■■/■/■■■■■■■■■■■e■■■■■■■/■■■■■■■/■■■■■/■■■e■■■■■■■eee■/■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■eee■■■e■■■■■■■■e■■/■■■■■ s V Show Application Record North Carolina Iit1S _UnSite Sewage & Well S Property Return Address 1 , 1120601 Nill Boone Road Show Application Appl Number 1 Case Number Status NEW Type NEW Date 3/12/2013 Assigned To Bonnie Lanier on Fee Amount, Payment Date & Receipt # 150 3/6/2013 IP CA Applicant Information Name Tony Capote Builders Address 1 5426 Capote Road Address 2 City/ state/ ZIP Mocksville North Carolina 27028 Home / Cell Numbers (704) 483-7313 (704) 400-5481 Work Number / Ext ext. Email Tony@capotebuilders.com Owner Information Name Yvonne Fink and Jackson Glover Address 1 172 Canterbury Place Address 2 City / State / ZIP Mooresville North Carolrna 28115 Home / Cell Numbers (335) 909-3036 Work Number/ Ext ext. Email tony(Cfcapotebuilders.com Myl-abel Facility Type SINGLE FAMILY Other Facility Type Residential Specifications -' Sasement Basement Fixtures Bedrooms 4 Occupants 3 Dimensions "Whi,rlpool Spa -i' Multi Family Units Total Bedrooms Non -Residential Specifications Church Food Service CHURCH School School Students Day Care Daycare Students Page 1 of 2 https://portal.cdpehs.com/NCENVOSW/OSW. APPLICATION/ShowOSW APPLICATI... 8/26/2013 Show Application Record A Sanctuary Seats CHURCH Seats Hall Seats CHURCH Hall Seats Restaurant Dine In Restaurant Seats Square Footage i Office Employees Hours Per Day SHIFTS Day Number of Restrooms Public Restrooms 0 Private Restrooms Type of Systems Requested 1 N/A 2 N/A 3 N/A 4 N/A System Other Water Supply PUBLIC or Repair Application Only Utility Reference Number & Visit Date Year Built Utility Visit Date or Health Department Release Only Proposed Improvement Does the site contain any jurisdictional wetlands? NO i Does the site contain any existing wastewater systems? NO i Is any wastewater going to be generated on the site other NO than domestic sewage? I Is the site subject to approval by any other agency? NO I Are there any easements or right of ways on this property? YES Has any grading, removal or addition of soil been done NO to this property? � i Description Well Monitoring i Monitoring Well Request? NO i # of Wells Name Of Site Comments i Setup / Last Updated 3/12/2013 8/26/2013 OK Copyright © 2012 Custom Data Processing, Inc. All rights reserved. (ncenvosw version 2.1.15 6/17/2013 isd8.0.2 db=kyprod1) Page 2 of 2 https://portal.cdpehs.com/NCENVOSW/OSW APPLICATION/ShowOSW APPLICATI... 8/26/2013