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137 Ferns Way - OPERATION PERMIT or liceuseunly, * Davie County Health Department *CDP Fite Number 193510-1 210 Hospital Street P.O. Box 848 County ID Number. Mocksville NO 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Eddie I. Nuckols Property Owner. Eddie I. Nuckols Address: 163 Boone Farm Rd Address: 163 Boone Farm Rd City: Mocksville Cky: Mocksville StatelLip: NC 27028 State2ip: NC 27028 Phone#: (336)492-7619 Phone#: (336)492-7619 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Boone Farm Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville left on Boone Farm Road, property on the left down driveway at 163 #of Bedrooms: 3 Boone Farm Rd #of People: *1Nater Supply: PUBLIC *IP Issued by. 21ao-Naiions,Robert '`System Classification/Description: TYPE III B.SYSTEM WISINGLE EFFLUENT PUMP *CA issued by: 2140.Nations,Robert SaproliteSystem? QYes QNo Design Flow: 3 6 0 PUMP TO GRAVITY Pump Required? Distribution Type: QYes QNo Soil Application Rate: 0 . a *Pre Treatment: Drain field (N7krnjfimtionld 1 8 0 0 SG.ft• *System Type: INFILTRATOR QUICK4STANDARD 4 Installer: Randy Miller Total Trench Length: 4 5 0 ft. Certification#: 1128 Trench Spacing: _ 9 Inches O.C. • Feet O.C. *EH S: 2140-Nations.Robert Trench Width: _ 3 8lnches � Feet Date: 1 1 / a 5 / a 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approvat Status" Maximum Trench Depth: 3 6 ® approved O Disapproved Inches Maximum Soil Cover. a 4 Inches CDP Fite Number 193510 - 1 Septic Tank County ID Number: ' Manufacturer. Shoaf Lat. : , STB: 760 Long _ Gallons: 1000 Installer. Randy Miller Date: g7 / as / a01s Certification#: 1128 THS: 2140-Nations.Robert '"Fitter Brand: POLYLOK PL-122 With Pipe Adapter 1 1 J a 5 / a 0 1 5 ST Marker. ❑ Yes p No nate: , Reinforced Tank: 13Yes [B NO „ Approval Status 1 Piece Tank: ❑ Yes ® No ®.Approved❑ Dlsapproved Pump Tank Manufacturer. Shoaf Installer. Randy Miller PT: 90 Certification#: 1128 Gallons: 1000 *EH S: 2140-Nations,Robert Date: 0 8 / 1 4 / . 0 1 5 Date: 1 1 / a 5 / a 0 1 5 RiserSealed Q Yes ❑ No RiserHeght: O Yes ❑ No (Min.6 in.) Approval status y Reinforced Tank: ❑ Yes ® No ® Approved❑ Disapproved 1 Piece Tank: ® Yes ❑ No Supply line Pipe Size: a inch diameter , Installer. Randy Miller Pie Length: 3 4 8 feet Certification#: 1128 THS: *Schedule: 40 2140-Nations,Robert Pressure Rated [E Yes ❑ No Date: 1 1 / a 5 / a 0 1 5 Approved fittings Yes ❑ No Approval Status ® Approved❑ Dlsapproved Pump Requirement Pump Type: Zoeter Installer. Randy Miller Dosing Volume: — Gal Certification#: 1128 Draw Down: Inches THS: 2140-Nations,Robert Chain: STAINLESS Date: 1 1 / a 5 / . 0 1 5 Valves Accessible p Yes ❑ No Flow Adjustment Valve Q Yes ❑ No Check-valve 2 Yes ❑ No at Stops' PVC Unions p Yes ❑ NO = ® Approved❑ Dlsapproved Vent Hole ff] Yes ❑ No Anti-siphon Hole Q Yes 0 No CDP File Number, 193510 - 1 County ID Number: Electric Equipment NEMA0BoxorEquivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS' Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: Approval Stofus Alarm Audible ❑ Yes ❑ No ❑ Approved 0 Olsapproved Alarm visible ❑ Yes ❑ No 2140-Nations,Robert 'Operation Permit completed by* Authorized State Age< Date of Issue: 1 1 / a 5 / 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 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: NIA Reporting Frequency By Certified Operator. NIA Rule.1961 requires that a Type IV and V septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed for a homelbusiness 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 ently prior to the issuance of an Operation Permit for a system required to be maintained by public or private management entty, 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. 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 193510- 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: / / Olnch Drawing Drawing Type: Operation Permit Scale: OON A k (-4-0 fi Q 0a � - ' -- ( 0 . Qx 6 907 i u Q.. _b 11 � I i �%M I r 4 IMPROVEMENT PERMIT * For office use only CDP File Number 193510- 1 Davie County Health Department f 210 Hospital Street County ID Number: '� .•, , � P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 5/20/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Eddie I. NuckolsProperty Owner: Eddie I. Nuckols Address: 163 Boone Farm Rd Address: 163 Boone Farm Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)492-7619 Phone#. (336)492-7619 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Boone Farm Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville, left on Boone Farm #of Bedrooms: 3 Road, property on the left down driveway at 163 #of People: Boone Farm Rd *Water Supply: PUBLIC System Specifications Initial S stem *Site t✓aSSI ICa IOn: Provisionally suitable Minimum Trench Depth: a 4 Inches Saprolite System? O Yes ®No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 a 1-Piece: O Yes ®No Pump Required: ®Yes O No O May Be Required *System Classification/Description: TYPE 111 13.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Repair System Required:®Yes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: ®Yes O No O May be Required TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 193510 - 1 County ID Number: *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 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. R mag 750 The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to Site Plan scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the (9 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 permit 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 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: ;10-Nations,Robert Date of Issue: 0 5 / a 0 / a 0 1 5 Agent: OValid without Expiration? Authorized state A g O Create CA? ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 193510 - 1 r Davie County Health Department CDP File Number. 210 Hospital Street j. County File Number: P.O.Box 848 Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , O Block O N/A _I I �U � 3 1° G A. ....__ 112, Page 3of3 P1 P2 IMPROVEMENT PERMIT , Davie County Health Department , 210 Hospital Street CDP File Number: 193510 - 1 ,l P.O.Box 848 Mocksville IVC 27028 County File Number: Date: .0.5./ DO a 0 15 Click below to import an image from an external location: Drawing Type: Improvement Permit i a� A D � � c� -e d --7� b f 12! c6 '57 ��-� � p.lV v`y `oc-,�a �•e r/ Page 3 of 3 1 P1 P2 CONSTRUCTION For office Use Only • AUTHORIZATION CDP File Number 193510-1 " °"•- Davie County Health Department County ID Number . 210 Hospital Street Evaluated For NEW P.O.Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 9 / 0 4 / a 0 a 0 Applicant: Eddie I.Nuckols Property Owner. Eddie I.Nuckols Address: 163 Boone Farm Rd Address: 163 Boone Farm Rd City: Mocksville City: Mocksville State/Zip: NC 27028 StatefZip: NC 27028 Phone#: (336)492-7619 Phone#: (336)492.7619 Property Location & Site Information rAddress/Road #: Subdivision: Phase: Lot: rm Road e NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville, left on Boone Farm Road, property on the left down driveway at 163 Boone Farm #of Bedrooms: 3 Rd #of People: `Water Supply: PUBLIC System Specifications CFlowMinimum Trench Depth: a 4 : Provisionally Suitable Inches Minimum Soil Cover 1 a OYes (j)No Inches 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches *System Classification/Description: "Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons "Proposed System: 25%REDUCTION 1-Piece: O'Yes @No Pump Required: ®Yes ONo OMay Be Required' Nitrification Field 1 8 0 0 Sq.ft. Pump Tank: 1 0 0 0 Gallons No.Drain Lines 5 1-Piece:()Yes @No Total Trench Length: 4 5 0 ftGPM vs— ft. TDH Trench Spacing: _ 9 Offiches O.C. Dosing Volume: _ Gallons • Feet O.C. Trench Width: _ Olnches 3 �r Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 O.TS-11 Septic Tank InstallerGrade Level Required: 01011 0111 OIV Donn 4 of Z CDP File Number 193510 - 1 County ID Number. ❑ Open Pump System Sbeet Repair System Required:Wes ONO ONo, but has Available Space rDesign System Trench Spacing: 9 Inches 0. . ification: Provisionally Suitable — E003 Feet O.C. Trench Width: Inches w: 3 6 0 . — . 3 . 2 Feet Soil Application Rate: 0 _ a Aggregate Depth:. inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover 1 a Inches Maximum Trench Depth: 3 6 Inches "Proposed System: 25%REDUCTION Maximum Soil Cover: a 4 Nitrification Field 1 8 0 Inches Sq.ft. No. Drain Lines 5 *Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 5 0 ft. Pump Required: @Yes ONo OMayBe 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. i *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. ; This Authorization for Wastewater System Construction shall bevalid fora person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)).If the installation has not been completed during the period of wilidity 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 orConsVuctlon Authorization shall become Invalld,and maybe 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 systemf location,Installation,operation,maintenance,monitoring,repotting and repair (1938(b)). ApplicanVLegal Reps.Signature Required? OYeS ONo Applicant/Legal Reps. Signature Date: *Issued By: 2140-Nations,Robert Date of Issue: . 0 9 0 4 / a 0 1 5 Authorized State Ag�M-c� --�. Malfunction Log OYeS @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CDP File Number 193510 - 1 County ID Number. \\ ❑ Open Pump System Street Repair System Required:@Yes ONo ONo, but has Available Space rn System Trench Spacing: Q 7et 0. ification: Provisionally Suitable - 9 • . C. w: 3 6 0 Trench Width: - 3 Q �, ,„ (•,�Feet Soil Application Rafe: 0 a Aggregate Depth: inches .� *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 Inches Maximum Trench Depth: 3 6 Inches 'Proposed System: 25°J°REDUCTION Nitrification Field 1 $ 0 0 Maximum Soil Cover: a _ 4 Inches Sq.ft. No. Drain Lines *Distribution Type: PUMP TO GRAVITY 5 TotalTrench Length: 4 5 0ft. Pump Required: @Yes ONo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department. *Permit Conditions The issuance ofthis 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. ; f This Authorization forwastewater 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 atthe sametime the Improvement Permit issued(NCGS 130A-336(b)j If the instalialion has not been completed during the period or validity of the Construction Perms 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 ONo Applicant/Legal Reps.Signature: Date: *issued By: 2140-Nations,Robert Date of Issue: . 0 9 J 0 4 / a 0 1 5 Authorized State Agvt•=•- -���-�.r'— —� Malfunction Log QYeS OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION • Davie County Health Department CDP FileNumber' 193510 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksvilte NC 27028 Date: 09 / 0 4 / .10 15 16 Q inch t Scale: . QBlock - ft• Drawing Drawing Type: Construction Authorization - ON/A a 1-0 e 6^0, e ,�! i 4 t � l' � M , r l ► L _� • r � ' l CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 193510- 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: _0 .g / 04 / 2015 Click below to Import an Image from an external location: Drawing Type:Construction Authorization . IMPROVEMENT PERMIT Forofficeuseonly 'CDP File Number 193510-1 • �d..�,,� Davie County Health Department. 210 Hospital Street County ID Number P.O.Box 848 Evaluated For NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 5/20/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Eddie 1. Nuckols r roperty Owner: Eddie I. Nuckols Address: 163 Boone Farm Rd ddress: 163 Boone Farm Rd City: Mocksville ky: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)492-7619 Phone#: (336)492-7619 Property Location & Site Information rddresslRoad#: Subdivision: Phase: Lot: arm Road le NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West from Mocksville, left on Boone Farm #of Bedrooms: 3 Road, property on the left down driveway at 163 #of People: Boone Farm Rd *Water Supply: PUBLIC System Specifications nitial S stem *Site asst Ica Ion: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Saprolite System? OYes @ No Maximum Trench Depth: 3 6 , Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 1-Piece: OYes @No Pump Required: @Yes ONo 0May Be Required 'System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 .0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: Oyes ONo Repair System Required:@Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 - a Maximum Trench Depth: 3 6 Inches Pump Required: @Yes ONo O Maybe Required "System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 193510 - 1 County ID Number: r *Site Modifications ❑ Open Fiil 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 way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. provement Permit shall be valld for 5 years from dateof issue with a site plan(means a drawing not necessarily drawn to Site Plan 'e Im O scale that shows the existing pnd proposed property lines with dimensions,the location of thefacility and appurtenances,the e :Cale proposed Wastewater system,and the location of water supplies and surfacewaters). 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 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 penults for failure of tate 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 13OA-335M).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(.1838(b)� Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: 'Issued By:' ZKO-Nations,Robert Date of Issue: 0 5 / a 0 / a 0 1 5 Authorized State Agent: OValid without Expiration? O C reate CA? @Hand Drawing 0Import Drawing ra. **Site Plan/Drawing attached.** Page 2 of 3 • IMPROVEMENT PERMIT 193510 - 1 • Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , 08lock , QNIA pill I l- \V- w n� I IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 193510 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: .Date: LO 5 / x 0 / 2 0 1 5 Click below to import an image from an external location:Drawing Type: Improvement Permit •y APPLI 'I0 FOR SITE EVALUATIONIRAPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street !►, Mocksville,NC 27028 Q (336)753-6780/Fax(336)753-1680 (� h Application For: ®'Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑Both Type of Application: ❑New 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 E l i e L . Ny r K b (S Contact Person Address /63 6 of n e F m R J Home Phone -736-197--71P/9 City/State/ZIPA?a cksy;I e, N C ?-70?—? Business Phone &4 Email_edd-, e-n v c-Kol s Q Yakoo , c.om Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged d 0` NOTE: A survey plat or site plan must accompany this application. Included: Z-Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Edd;P- L. A)r-ko I S Phone Number 336-17Z-7&1 g Owner's Address/63 Quone Fa r wt 2 t City/State/Zip l)%oe-ksv)/!e,N c Z 7 O Z o0 Property Address/(o3 Boone Farm P-d Citygycks.;11e Lot Size / cacren Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: In 4 we 5i- PMyvt /Y(jtck s c„it e 7e-T' n vy 860 r.e Fo.r m P J proaQr'�y Oyi ` Vsk leRf dan dt,V ivn� Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People _ #Bedrooms 3 #Bathrooms Z Garden Tub/Whirlpool ❑Yes KTo Basement: ❑Yes FVo Basement Plumbing: ❑Yes EVo 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: 2County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate.additions or expansions of the facility this system is intended to serve? ❑Yes. 9<0 If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my Imowledge. 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 corners and locating and flagging ' or staldn^ ouse/facili locati p posed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): Z OIZOA5 Client Notification Date: ate EHS: • I q3�1� Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# I i otj UN ; r , , ! I t t I I I , t I j , i 1 1 i 1 i , t 11 , I , It-Tl �:, t � -- - '4.5, • , • DAV IE COUNTY HEALTH DEPAR NT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATI N PROPERTY INFORMATION Ii001VC fq/Zn4 �f eMe n uekols ahoo,0094 y /,40, 5 i I • i Water Supply: On- 'e Well Community ! Public Evaluation By: Aug r Boring -Pit Cut i FACTORS 1 23 4 5 6 7 i:,_andscape 2osition Slope% i l HORIZON I DEPTH Texture group Consistence ! S r 5 .,Structure G S Mi eralogy -17 ( HORIZON H DEPTH • 1, —{ ! Texture group r C L-tj iConsistence - { Structure Mi eralogy { HORIZON III DEPTH ► j' Texture group ( ! Consistence . Structure 1 Mineralogy ( i ! HORIZON IV DEPTH I Texture group Consistence ( j Structure Mineralogy SOIL WETNESS j RESTRICTIVE HORIZON t j i SAPROLIT'E CLASSIFICATION LONG-TERM ACCEPTANCE RATE p , i SITE CLASSIFICATION: I EVALUATI N.1 iLONG-TERM ACCEPTANC7 .V: OTHERS) RESENT:REMARKS: (Al1 _ , LEGEND Landscape Position 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 I Head slope Texture S -Sand LS-Loamy san SL-Sandy loam L-Loam SI ,Silt ; �( SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay 10am ,Q n SC-Sandy clay SIC-Sily clay C-Clay � ��OJ•e vvi S Moist VFR-Very friable FR-Fi able FI-Firm VFI-Very firm IEFI-Extremely firm -� -)Yd firm Q NS-Non sticky SS-.Slightly sticky S Sticky VS-Very Stich NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic R r J Structure ; ✓ " .. SC-Single grain M-M 'sive CR-Crumb GR-Granular ABK-Anglar blocky. SBK Subangular blocky L-Platy PR-Prismatic j Mineralogy 1:1,2:1,Mixed Notes j s Horizon depth-In inches all Depth of fill-In inches = i Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsu�table). 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NUCKOLS I PL.BK. 11, PG. 2 f 5 8-4I ' F- TOTAL143.01 — _ — Z�- - - - - - - - - ———— --- N 02'36'24' E 363.00 total A o 0 3 02.36'24' W — 333.00• I 30.00 90.01 UNPM RK 3.00 10• GRAVEL DRNE L — — __ - - -- PONT — _ — - - - - - - - -- ^— r — _ _ -----._. .----- 3 0 Tract 1 1 0 AREA= 1.000 AC. _ w 30• � �s of - o�a. ^ � m a PIN##' 5728181535 w EDDIE L. NUCKOLS 4 Z F o PL.BK. 11, PG. 215 / 363.00 S 02'36'24' W 41432 x Z s 02'36'24' W p3 (TIE) z o / J ° o s—of— parent �J by an / been ments / l reon.