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124 Georgia RdAccount #: 990003460 Billed To: Jonathan Allen DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Reference Name: Johathan Cell #: 689-9982 ATC Number: 4378 Tax PIN/EH #: 5800-88-4659 Subdivision Info: Location/Address: Georgia Road -27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: — Date: f �� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as ag arantee that the system will function satisfactorily for any given period of time. co ,K� 06 u 1c� 3 i Ca q, Septic System Installed Ey: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section r • P. O. Boz 848/210 Hospital Streetf&1 Mocksville, NC 27028 {� (336)751-87601 110 aC IMPROVEMENT/OPERATION PERMIT J Account #: 990003460 Billed To: Jonathan Allen Reference Name: Johathan Cell #: 689-9982 Proposed Facility: Residence Tax PIN/EH #: 5800-884659 Subdivision Info: Location/Address: Georgia Road -27028 Property Size: 15 acres ATC NuMber: 4378 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms � #Baths Dishwasher: Ef Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: 8' Commercial Specification: Facility Type #People #People/Shift #Seats Industtrriall Waste: ❑ Lot Size r"t� Type Water Supply Design Wastewater Flow (GPD)C?a, Site: New aRepair ❑ System Specifications: Tank Size -/®aGAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Widt1/Rock Depth /Linear FtlOW *t) As stated in 15A NCAC 18A.1969(5) accepted Systems may also be used IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHEDGRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** /� 4� Environmental Health Specialist's Signature: � Date: �4 Az, DCHD 05/99 (Revised) AP ON FOR SITE EVALUATION/161PROVEAIENT PERMIT & ATC C �Q05 Davie County Health Department t - D 3 Environmenta/Health Section P 0. Box 848/210 Hospital Street VLH Mocksville, NC 27028 (336) 751-8760 ** IMPO *** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INF TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed _j Li lAa�_ ��'� `` Contact Person Mailing Address L � � t X I'- �il Home Phone — City/State/ZIP _� �^, d l nl. 7_' Z&5 Business Phone '? 2. Name on Permit/ATC if Different than Above rL ('Og��(� Mailing Address City/State/ip� �1 A Q 3. Application For: Site Evaluation Lmprovement Permit/ATC ►1 ❑ Both 4. System to Service:/1 House 11 Mobile Homo E3 Business El Industry 11 Other 5. Type system requested: LTJ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People. # Bedrooms .3 #Baatthrooms I�shwasher ❑Garbage Disposal 92Washing Machine ❑Basement/Plumbing Masement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day) S. Type of water supply: ❑ County/City ®' Well ❑ Community 9. .Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [iii If yes, what type? ***IMPORT,INT*** CLIENTS1l1USTC0AIPLETETHE IW-QUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUSTBE SUBMITTED by tl:e client ivitli THIS APPLICATION. Property Dimensions: 15WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # (sk�- , x5 (a q —i -o .56e--PPz--�t IJ bul Property Address: Road Name. R, -A 3 w i To 4)Lk,-- LUl ►- z/x - City/Zip rAce.r,6v, t�� 270 4' yt v4. s Z t'3'i t `�-a L? O6�j If in a Subdivision provide information, as follows: Name: Section: Block: Lot: `moo � `l�c�.v'' � �o �yc�� �'o �`�.✓'vY� K • Date liome corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that.1 aur responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealtli Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE — O SIGNATURE y TIIIS AREA MAYBE USED FOR DRAWING YOUR SITE PL Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). O Sign given Revised DCIID (05/03 L L: 6 (a % Site Revisit Charge Datc(s): Client Notification Date: EIIS: . Account No. 0 Invoice No. r _ ryy pa 111 DYALL LN 4 k` M R� 119 r _ ryy pa 111 k` M R� 119 I r I Yr r t � >' , s 1057 APPLICANT INFORMATION Account #: 990003460 Billed To: Jonathan Allen Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5800-88-4659 Subdivision Info: Location/Address: Georgia Road -27028 Property Size: 15 acres Date Evaluated: 1-.24 12 s Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH d Texture group Consistence <' Structure Mineralogy/ HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 'A S LONG-TERM ACCEPTANCE RATE: 12 REMARKS: EVALUATION BY: OTHER(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 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 oiA VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet 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 05/99 (Revised) ■ ■ E ■ SEEN ■E■N■■ ■ ■ ......................................................... ....................................................... ONEC..................................................... ....................................................... ■■■.■■................................................. E ■ SEEN ■E■N■■ ■ ■ DAME COUNTYAELTH DEPARTMENT Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 January 21, 2005 Jonathan Allen 2101 Deep River Road High Point, NC 27265 Re: Site Evaluation/ Georgia Road Tax Office PIN: #5800-88-4659 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, January20,2005. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, &. glw-A• Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s) WATER SAMPLE/SEWAGE SYSTEM CHECK REQUEST DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION Date Requested: O Received By WATER SAMPLE TYPE: 6 Bacterial O Protected O Chemical O Unprotected O Dug O Other: aU) O Bored O Drilled O Outside Spigot: O Other: SEWAGE SYSTEM] CHECK: O Yes Vacant: O Yes O Approved Owner's 0 d%1Q O No O Disapproved ,led Name: ..Buyer' s Name Property Address: Directions: / / / Special Instructions: Letter To: Closing Date: Attn: — — — — — — — — — — — — — — — — — — — Date Taken: Charges: Telephone: 7nw4 By: Account #: 990005149 Billed To: Jonathan Allen Reference Name: Proposed Facility: house ATC Number: 0009 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 WELL PERMIT Tax PIN/EH #: 5800-88-4659 . Subdivision Info: Location/Address: 124 Georgia Road -27028 Property Size: 15 acres Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New J Repair ❑ Abandonment ❑ Proposed Well Location Diagram Certificate of Completion Diagram r Aje uop -e / r rC i Ji Comments: 5 Driller: Certification #: zJ6 3 i Grout Inspected: C 9 —OcE Well Head Inspected: 10 -7 (DG GPS Coor at CG�r l �; -1 c. ( t✓ 41, EHS: Date: 'U� EHS: Date: A W.P. 7-08 APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 gait- w 64��C. CA1Q,t�-� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed -1 %4 1 Contact Person Billing Address Z i cs i _ 147, t Home Phone City/State/ZIP o v, --h A) Z7' Business Phoni Name on Permit if Differ nt than Above i Mailing Address City/State/Zi a ,STC 1S4t-o 5-a- PKUPHKl'Y INFU1 AIN11UN 'Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat (to scale) Owner's Name = Phone Numbe C 7 1 Z /,/-) Owner's Address -4 i City/State/%� <<, ; ed -A C Z 7-24S,Property Address 1 2, ��'�" ��-- a City—A1117 14, , y Lot Size */-'5 -F- ✓�-Lv- c `� T PIN# .04(,,44-4- S j Subdivision Name(if applicable) Section/Lot# Directions To Site: L:.4 l,0I�> SSI..).—�:.'��,� �; v�-�•. i�-E- , ,,�.-,.�. Pte-}- 'c"^-- i�r_'l' P— 4 �i�� t� �N�t3�✓ _'3 i �� J a:—. J( DEVELOPMENT INFORMATION Permit Type: New Well Well Repair Well Abandonment Other (specify) Facility Type: Residential ✓ Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES'NO I'll, Do You Intend To Install A New Septic System On This SiteYES V1 NO ftp" ss TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. Si4 7/1/08 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 'Necc Invoice # ;1, W/ rr� � ;S DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003460 Billed To: Jonathan Allen Reference Name: Johathan Cell #: 689-9982 Proposed Facility: Residence Tax PIN/EH #: 5800-88-4659 Subdivision Info: Location/Address: Property Size: Georgia Road -27028 15 acres ATC Nurpber: 4378 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 14 #People_ #Bedrooms `�—? #Baths Dishwasher: Z!� Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: Er�' Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: El Lot Size Type Water Supply Design Wastewater Flow (GPD) ��� Site: New a Repair ❑ System Specifications: Tank Size ®6Vr--AL. Pump Tank GAL. Trench Widt � tock Depth/"L inear Ft vii P Other: As stated in 15A NCAC 18A.1969(5) Required Site Modifications/Conditions: accepted Systems may also be used IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on tlhe day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: File #: Site Address: Subdivision: Lot: Permit Type: New Well Well Repair Well Abandonment Other Facility Type: Residential Food Service Church Commercial Other Initial Inspection Were Setbacks Maintained? Yes No What is the Grout Depth? �33 ft. If No, Explain: What is the Grout Thickness? ? in. What is the Type of Well? P Ci Was a Well Screen Installed? What is the Casing Type? Type of Drilling Fluids Used: What is the Casing Depth? ft. Well Grout Inspection Date: What is the Well Diameter? in. _ GPS Coordinates: 3 50 15-06 UJ What is the Well Depth? ft. EHS ID: Well Head Inspection Is There an Access Port? `/ Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? _ What is the Casing Height? y r w / Is There any Grout Settlement? What is the Static Water Level? ft. What is the Yield? GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name:AA.D . �� � � t Pump Installer Name: r� Q Contractor Certification #: 20 Date Installed: `l �� -7 Depth of Well: ?? Depth of Pump Intake: Casing Depth and Inside Diameter: Pump Horsepower Rating: G 75 Screened Intervals: Opening for Piping & Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: o 0 Date Well Completed: Well Head Inspection Date: — -- EHS ID: l t 6 Construction Completed Date: — l,� - dd Contractor Reports Received Date: d� Sample Date: Results Mailed Date: Certificate of Completion Da : Authorized Agent: