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1147 Godbey RdOPERATION PERMIT ,, ems• Davie County Health Department 210 Hospital Street `r. P.O. Box 848 ,. Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Mariam Wright Address: 1234 Godbey Road City: Mocksville State/Zip: NC Phone #: Address/Road #: 1147 Godbey Road Mocksville NC 27028 Structure: BUSINESS # of Bedrooms: # of People: 1 *Water Supply: EXISTING WELL *IP Issued by: 2140 - Nations, Robert *CA issued by: 2140 - Nations, Robert Design Flow: a a 0 Soil Application Rate: 0 a 5 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 27028 Subdivision: *CDP File Number 120172 -1 120000001201 County ID Number: Evaluated For. NEW 111�ownship: / Property Owner. Mariam Wright Address: 1234 Godbey Road City: Mocksville State/Zip: NC hone #: 27028 Phase: Lot: Directions Godbey Road west from Hwy 64, 3miles on left. *System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? O Yes CK No *Distribution Type: GRAVITY -SERIAL Pump Required? O Yes X No *Pre -Treatment: Drain field Sq. ft. a04ft. g _ 0Inches O.C. Feet O.C. 3 _ Olnches (9 Feet inches Minimum Trench Depth: 3 a Minimum Soil Cover: Maximum Trench Depth: 3 4 Maximum Soil Cover: Inches Inches Inches Inches Page 1 of 4 *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Rusty Miller Certification #: 1129 *EHS: 2325 - Mitchell, Brittany Date: 0 3/ a 4/ a 0 1 4 Approval Status ® Approved ❑ Disapproved CDP File Number 120172 - 1 '/ Manufacturer: shoaf STB: 760 Gallons: 1000 Date: 0 a/ a 5/ a 0 1 4 *Filter Brand: POLYLOK PL -525 No ST Marker: ❑ Yes ❑ No inforced Tank: ❑ Yes ❑ NO 1 Piece Tank: ❑ Yes ❑ NO Manufacturer: PT: Gallons: Date: / / Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ NO (Min. 6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No / Pipe Size: Pipe Length: *Schedule: 40 Pressure Rated ❑ Yes Approved fittings ❑ Yes 4 inch diameter a feet County ID Number: 120000001201 Tank Lat. Long: Installer: Rusty Miller Certification #: 1129 *EHS: 2325 - Mitchell, Brittany Date: 0 7/ a 4/ a 0 1 4 Approval Status ® Approved ❑ Disapproved mp Tank Installer: Rusty Miller Certification #: 1129 *EHS: Date: Approval Status ❑ Approved ❑ Disapproved pply Line Installer: Rusty Miller Certification #: 1129 *EHS: 2325 - Mitchell, Brittany ❑ No Date: 0 7/ a 4/ a 0 1 4 ❑ No Approval Status ® Approved ❑ Disapproved / Pump Type: Dosing Volume: - Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No Installer. Rusty Miller Gal Certification #: 1129 *EHS: Page 2 of 4 Date: Approval Status ❑ Approved ❑ Disapproved _J CDP File Number 120172 - 1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes `Activation Method: ❑ No Alarm Audible ❑ Yes Alarm Visible ❑ Yes *Operation Permit Authorized State Agent: County ID Number: 120000001201 ❑ No Installer: Rusty Miller ❑ No Certification #: 1129 ❑ No ❑ No *EHS: ❑ No Date: Approval Status El No ElApproved ❑ Disapproved El No 2325 - Mitchell, Brittany Date of Issue: 0 7/ a 4/ a 0 1 4 This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE 11 A. sewage septic system. Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed for a home/business 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 home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 ' OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC DrawinDrawing Type: Operation Permit I.1rb CDP File Number: 120172 - 1 County File Number: 120000001201 27028 Date: 07 / 24/2014 O Inch Scale: O Block O N/A 15, u�� ��ta IO 6&q � Page 4 of 4 P1 P2 P3 ��-1 U6 O9uIZA Tax Map: Address: Installer: Rarrdil Ni/le-Y' EHS: iheft Date: 7 2 /y Operation Permit Inspection Checklist Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement feet 2. Distance from system to well if applicable feet 3. Any other setback (.1950) requirements Supply line 1. Material supply line is constructed of�JFly G diameter. 2. Length of supply line (2' min.) 4 v') 3. Amount of fall in supply line (1/8" per foot min) 4. Distance from ST/PT to the nitrification field/dist. device) inches Septic Tank/Pump Tank 1. Visually inspect top of tanks(s), interior & exterior walls, baffle w"d bottom 2. Any honeycombing or exposed rebar present? Circle : YES or NO 3. Visually inspect sanitary tee air v nt for proper installation -and sealant 4. Tank Serial Numbers: ST 9GD PT q C(-.t,I� I 5. ST Win 6" finished grade? Circ e: YES or NO r r 6. Date of manufacture: ST o� 40, PT 7. Liquid capacity of tan(7 n Q PT 8. Effluent filter type 9. Pipe penetration seal present? CircjK AS or O 10. Riser(s) present? Circle: YES or Riser Type 11. Pump Tank riser 6" above finished grade? Circle: YES or NO 12. Riser approved? Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation I 2. Trench Depth Readings (inches) /1 3. Number of Trenches Distance between trenches 4. Trench Width 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth (inches) 7. Nitrification lines installed on contour? Circle: E or NO 8. Innovative system type Insta er certified for installation? Circle: YES or NO 9. 2' earthen dam between ST (or d -box) and beginning of nitrification line? Circle: YES or NO 10. Stepdowns a. b. C. d. 2' undisturbed earthen dam(s) Circle: YES or NO Proper rise over stepdowns? Circle: YES or NO Solid pipe used? Solid, Corrugated or other? Elevation of each stepdown Are all stepdowns lower than the ST outlet elevations? Distribution Devices 1. Type Is the device watertight? Circle: YES or NO Is it level? 2. Distance from Dist. device to trenches feet 3. Record elevations: Inlets Outlets CONSTRUCTION For office Use Only .:. AUTHORIZATION `CDP File Number 120172-1 ° Davie County Health Department County ID Number: :s 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 1 1/ 1 4/ 0 0 1 8 Applicant: Mariam Wright Property Owner: Mariam Wright Address: 1234 Godbey Road Address: 1234 Godbey Road City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone #: Phone #: Property Location & Site Inforr i Address/Road #: 1147 Godbey Road Mocksville NC 27028 Structure: BUSINESS # of Bedrooms: # of People: 1 *Water Supply: EXISTING WELL Subdivision: ,*Site Classification: Ps Saprolite System? (9 Yes O No Design Flow: 1 1 0 Soil Application Rate: 0 a 5 *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: 25916 REDUCTION Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: 1 a 0 ft Phase: Lot: Directions Godbey Road west from Hwy 64, 3miles on left. ons Minimum Trench Depth: 3 6\ Inches Minimum Soil Cover: Inches Maximum Trench Depth: 4 8 Inches Maximum Soil Cover: Inches *Distribution Type: Septic Tank: 1 0 0 0 Gallons 1 -Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Pump Tank: Gallons 1-Piece:OYes ONo GPM --vs-- ft. TDH Trench Spacing:_ O Inches O.C. Dosing Volume: _ Gallons _8Feet O.C. Trench Width:OInches _ o 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 0 CDP File Number 120172 - 1 County ID Number. 120000001201 ❑ Open Pump System Sheet m Requlred:VYYes v Iry vICU, uul. llds rwduduic o /Repair System *Site Classification: Ps Design Flow: 1 1 0 Soil Application Rate: 0 .2 5 *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: 25% REDUCTION Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: 1 3 6 ft. Trench Spacing:_ Inches O. 8Feet O.C. Trench Width:_ Inches 8Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches *Distribution Type: Pump Required: OYes O No O May Be Required Pre -Treatment: O NSF OTS -1 OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *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 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 (& NO Applicant/Legal Reps. Signature Date: *Issued By: 2244 - Daywalt, Andrew ' L Date of Issue: 1 1 / 1 4 / a 0 1-3 Authorized State Agent: tA( (� 9�/1�f Malfunction Log OYes VY ndl JU Irl dwn iy v 111 IPUI t vi awn iy Total Time:(HH:MM) **Site Plan/Drawing attached.** 0 1 Hours 0 0 Minutes Page 2 of 3 S-8 - CA's issued - new CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 . Mocksville NC 27028 CDP File Number: 120172 - 1 County File Number: 120000001201 Date: 11/ 14/a013 O Inch Drawing Drawing Type: Construction Authorization Scale:. 00 NSA Block = ft. Plow, K P-VtKd S C) lb ( Fur l tmd , = 9•0 I eWi <a Q 9 2v c( 2 x �Pc( cJ Page 3 of 3 P1 P2 11 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 120172 - 1 County File Number: 120000001201 Date: IL / 14/ 2 0 13 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 No 'CONSTRUCTION AUTHORIZATION ti Davie County Health Department f�a 210 Hospital Street . P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Mariam Wright Address: 1234 Godbey Road City: Mocksville State/Zip: NC 27028 Phone #: Address/Road #: Subdivision: 1147 Godbey Road Mocksville NC 27028 Structure: BUSINESS # of Bedrooms: # of People: 1 'Water Supply: EXISTING WELL / For Office Use Only *CDP Fite Number 120172-1 County ID Number: 120000001201 Evaluated For: NEW Township: PERMIT VALID UNTIL: 0 1/ 0 1/ 0 0 0 6 Property Owner: Mariam Wright Address: 1234 Godbey Road City: Mocksville State/Zip: NC Phone #: Site Informatio 27028 Phase: Lot: Directions Godbey Road west from Hwy 64, 3miles on left. SDec Pagel of 3 Minimum Trench Depth: 3 6 \ l Site Classification: Inches Saprolite System? OYes ONo Minimum Soil Cover. Inches Design Flow: 1 5 0 Maximum Trench Depth: 4 8 Inches Soil Application Rate: 0 . a 5 Maximum Soil Cover: Inches 'System Classification/Description: 'Distribution Type: GRAVITY - SERIAL TYPE 11 B. CONY. SYSTEM WITH 750 LINEAR FEET OF Septic Tank: NITRIFICATION LINE OR LESS 1 0 0 0 Gallons 'Proposed System: 25% REDUCTION 1 -Piece: OYes (QNo Pump Required: OYes (QNo 01.1ay Be Required Nitrification Field Sq. ft. Pump Tank: Gallons No. Drain Lines 1 -Piece: OYes ONo Total Trench Length: a 0 0 ft GPf.4—vs-- ft. TDH Trench Spacing:8Inches 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: OI Oil 0111 OIV Pagel of 3 CDP File Number 120172-'l r rtepair a County ID Number: 120000001201 ❑ Open Pump System Sheet uireo:CJ c:D, vrvv �—INU, Uui 1ld5 rrvdndUie OPdrt! /repair System Trench Spacing:8Feet Inches 0. *Site Classification: PS — O.C. Trench Width: Inches Design Flow: 1 5 0 _ Feet Soil Application Rate: 0 Aggregate Depth: - a 5 inches Minimum Trench Depth: 3 6 Inches *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF Minimum Soil Cover. NITRIFICATION LINE OR LESS Inches *Proposed System: Maximum Trench Depth: 4 $ P Y 25,o REDUCTION Inches Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY -SERIAL Total Trench Length: a 0 0 ft Pump Required: Oyes 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 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. requirements for dog kennel is attached to permit. 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 sametime the Improvement Permit Issued (NCGS 130A -336(b)). If theinstallation 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)). ApplicanVLegal Reps. Signature Required? OYes ONO Applicant/Legal Reps. Signature Date: / / *Issued By: 2244 - Daywalt. And v ate of Issue: 0 3 / a 5 / a 0 1 3 Authorized State Agent: (b&"Malfunction Log Oyes OHand Dr%wing Olmport Drawing Total Time:(HH:t,tla) **Site Plan/Drawing attached.** 0 1 Page 2 of 3 Hours _ Lt mutes ` CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 120172 - 1 ' 210 Hospital Street 120000001201 P.O. Box 848 County File Number: to ground waters or surface waters. (f) The discharge of any hazardous chemical/substance into any floor drain, sink drain, shower or toilet is prohibited. (g) Products containing volatile organic compounds shall not be used. (4) Sizing Criteria Design daily flow shall be determined as follows: (Sum all ofthe followingflows for services and staf) Primary Enclosures' Cage 5 gpd/cage Inside run 10 gpd/run Outside run 20 gpd/run Services Grooming 10 gpd/animal Staff Surgery 50 gpd/surgery room Vet doctor 75 gpd/vet doctor Vet assistant 75 gpd/vet assistant Support staff 20 gpd/support staff 'If dealing with large animals (horses, cattle, game cats, etc.), contact the On -Site Water Protection Section for design flow rates. (5) ][Yesigcnts: (a) Two state -approved septic tanks, with access openings extended to finished grade shall be installed in series. The capacity of each tank shall be sufficient to handle the total flow and shall be determined in accordance with I SA NCAC .1952(b). The first septic tank shall receive only effluent generated at the kennels (IPWW). The second septic tank shall receive effluent from the first tank, in addition to any domestic sewage. The effluent ends of both septic tanks shall be fitted with an effluent filter capable of filtering animal hair. (b) Screens to catch hair and other solids shall be provided at the floor drains or at the inlets to the trench system collection pipes to exclude solids and bedding materials from entering the wastewater treatment system. (c) Operation and Maintenance: (i) For those facilities performing pesticidal shampooing and/or dipping: 1. Spent pesticidal dip solutions and medicated shampoo rinse waters shall not be discharged to septic tanks. Any existing animal dip and bathing equipment drain lines shall be disconnected and sealed off from discharge to the septic tank. Rinse water shall be collected in a holding tank for transport to a sewage treatment plant via an approved hauler. 2. Soaps, shampoos, and other cleaning agents shall be biodegradable. Wastewater containing synthetic pesticides and insecticides (e.g., products containing pyrethrin or limonene, organophosphates, carbamates, etc.) shall be transported via approved hauler to a wastewater treatment plant. Ir • '' ' IMPROVEMENT PERMIT ' �•'`"`• Davie County Health Department f. 210 Hospital Street �... P.O. Box 848 Mocksville NC 27028 For Office Use Only 'CDP File Number 120172-1 County ID Number: 120000001201 Evaluated For: NEW l Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 3/13/2018 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Mariam Wright Address: 1234 Godbey Road City: Mocksville StateJZip: NC 27028 Phone 9: Property owner: Mariam Wright Address: 1234 Godbey Road Cay: Mocksville State/Zip: NC Phone #: Information 27028 Address/Road #: Subdivision: Phase: Lot: 1147 Godbey Road Mocksville NC 27028 Directions Structure: BUSINESS Godbey Road west from Hwy 64, 3miles on left. # of Bedrooms: # of People: 1 *Water Supply: EXISTING WELL *Site asst Ica an: Saprolite System? OYes ONo Design Flow: 1 3 0 Soil Application Rate: 0 2 5 'System Classification/Description: TYPE 11 B. CONV. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS 'Proposed System: 25% REDUCTION Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 4 8 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: Pump Required: Pump Tank: 1 -Piece: Repair System Required:OYes ONo ONo, but has Available Space Repair System *Site Classification: PS r . Soil Application Rate: 0 2 5 *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: 2515 REDUCTION OYes ONo OYes ONo OMay Be Required Gallons OYes ONo Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 4 8 Inches Pump Required: OYes ONo Q Maybe Required Page 1 of 3 CUP Fite Number 120172--1 County ID Number: 120000001201 '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 by the Health Department in noway guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. See attachment for design requirements for system. 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 thefacility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shad 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 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(t)). 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: / / 2244 - Daytvalt, Andrew Date of Issue: 0Import Drawing 0 3/ 1 3/ 2 0 1 3 OValid without Expiration? O Create CA? **Site Plan/Drawing attached.** Total Time:(H1-1111,1) Page 2 of 3 Activiv Code: 0 1 Hours 0 0 minutes IMPROVEMENT PERMIT ~ Davie County Health Department CDP File Number: 120172 - 1 ' 210 Hospital Street 120000001201 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: QBlock ONia ft. lid CZE .. _ tao1 IgUL� ek Page 3 of 3 APPLICANT OR SITE EVALUATION/IMPROVEMENT PERMIT &ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 r (336)753-6780/ Fax (336)753-1680 ter. �,, ;: /A�u ��Svste!�or"acility Applica�ior: Site Evaluation/Improvement Permi o tion To Construct (A Type of Application: ❑New System ❑Repair to Existin ystem ❑Expansion/Modification o ***IMPORTAN7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name N�Ae\r.,— ( t,) (,, I,,+ Contact Person MCr \ Address V—oa) Home Phone 3 3%— t_/ 0,-, —211 Z City/State/ZIP hen Business Phone n ZSR JS Email S rv. J Name on Permit/ATC if Di rent than Above 5k n. Mailing Address Vo City/State/Zip AA C) C C s u\ l 1,- _ tic FKUYLK1 Y INPUKMA1IU1N 'Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Mn r cx� n _ \ J (A Phone Number Owner's Address l?3yC-',64to9tn K, Property Address Lot Size 90, re PIN# Subdivision Name(if applicable) Directions To Site: Go d 17 -1poi —City/State/Zip M o m KS (,%I k —City C ' N)c YZ 000 U 0 0 12--01 Section/Lot# 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? _�Xe s _No Does the site contain jurisdictional wetlands? Yes -�,X_o Are there any easements or right-of-ways on the site? _Yes -�eNo Is the site subject to approval by another public agency? —Yes _),Xo Will wastewater other than domestic sewage be generated? Yes _d'o P (-t 5CPAAc TF RESIDENCE FIT J, OI TT TNF. BOX BELOW # People #. Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ONo Basement Plumbing: ❑Yes ❑No .IF -NON-RESIDENCE Fff J, OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building y D X 5 D # People # Sinks a # Commodes �_ # Showers `I # 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? 1 O < 4-8 r �l 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 corners and locating and flagging or stng the house/facili location, proposed well location and the location of any other amenities. rr" S Site Revisit Charge Property owner's or owner's legal represen ive signature Date(s): 02 13 Client Notification Date: Date EHS: ab? / z 01Tz Sign given ❑Yes ❑No Revised 11/06 Account # l 31 Invoice # Appraisal Card Page 1 of 1 I . I nAVIF COUNTY. NC ODBEY CREEK FARM LLC Return/Appeal Notes: I2-000-00-012-01 UNIQ ID 14647 300531 ID NO: 5708953472 COUNTY TAX (100), FIRE TAX (100) CARD NO. 1 of 1 eval Year: 2013 Tax Year: 2013 8.763 AC OFF GODBEY RD 8.760 AC SRC= Appraised by 02 on 01/01/2005 01001 OAKLAND TW -01 C- EX- AT- LAST ACTION 20130103 CONSTRUCTION MARKET VALUE DETAIL DEPRECIATION CORRELATION OF VALUE TOTAL POINT VALUE Eff. BASE BUILDING USE MOD Area UAL RATE RCN EYB i AYB REDENCE TO ADJUSTMENTS 97 1 00 1 1 1 1 % GOOD )EPR. BUILDING VALUE - CARD TOTAL ADJUSTMENT TYPE: Vacant DEPR. OB/XF VALUE - CARD 121,01 ACTOR 14ARKET LAND VALUE - CARD 51,53 TOTAL QUALITY INDEX STORIES: rOTAL MARKET VALUE - CARD 172,54 TOTAL APPRAISED VALUE - CARD 172,54 TOTAL APPRAISED VALUE -PARCEL 17254 TOTAL PRESENT USE VALUE - PARCEL TOTAL VALUE DEFERRED - PARCEL TOTAL TAXABLE VALUE - PARCEL 172,54 PRIOR UILDING VALUE BXF VALUE ND VALUE 49,99 RESENT USE VALUE DEFERRED VALUE TOTAL VALUE 49,990 PERMIT CODE I DATE I NOTE I NUMBER AMOUNT OUT: WTRSHD: SALES DATA FF. RECORD DATE DEED INDICATE SALES BOOK IPAGE MOJYR TYPE PRICE 0912 944 12 01 WD E V _ 0912 936 12 01 WD A V 51500 0468 702 3 00 WD E V HEATED AREA NOTES SUBAREA UNIT ORIG % ANN DEP % OB/XF DEPR GS RPL CODE I DESCRIPTION LTH WTF UNIT PRICE GOND BLDG#L B AYB EYB RATE GOND VALUE SHED 60 W 4,080 6.00 0 _ _ 200720015 _OVR 70 1713 TYPE AREA CS 24 W FIREPLACE 4 HED 98 40 3,920 6.00 0 _ _ 00 00 S 70 16464 UBAREA 2 GARAGE 41 4 1,64 20.0 _ _ '007200 S 8 2689 OTA LS 2 GARAGE CANOPY 61 21 4t 2,92E 4E 1,OOE 20.0 12.0 _ _ _ _ 00 00 00 00 S S5 82 70 4801 846 39 9 CANOPY 12 4 48C 12.0C 2007200 55 70 403 OB/XF VALUE 121,01 OTAL UILDING DIMENSIONS NO INFORMATION IGHEST LAND TOTAL ND BEST USE LOCAL FRON DEPTH / LND GONDrTHENRAD3USTMENTS ND OTESROA UNIT LAND UNT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAGS EPT SIZE MOD FACTRF AC LC TO OT TYPE PRICE UNITS TYP ADM UNIT PRICE VALUE NOTES URAL AC 0120 0 0 1.1710 4 0.7500 10-15 +00 +00 +00 PD 1 6,700.0 8.760 AC 1 0.87 5,882.60 5153 OTAL MARKET LAND DATA 8.76 51 53 OTAL PRESENT USE DATA http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=I20000001201 2/6/2013 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: Tax PIN/EH #: Billed To: Subdivision Info: Reference Name: Location/Address: Proposed Facility: Property Size: Date Evaluated: 3W&13 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Y Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % p pa 00 HORIZON I DEPTH _ Texture group C C L, Consistence FT FR Structure p jL Mineralogy C' 1 T HORIZON II DEPTH �. p Texture group Consistence )r Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS ` RESTRICTIVE HORIZON SAPROLITEL CLASSIFICATION LAL Ut Lt S LONG-TERM ACCEPTANCE RATE I, SITE CLASSIFICATION: P'5 LONG-TERM ACCEPTANCE RATE: - `dS REMARKS: EVALUATION BY: lei C1 A) /)—jj41' OTHER(S) PRESENT: 1`Qi\& f .I &r 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 10 rim VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wd 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 Ll4tes 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 (Revisei. ■■■■■■■■■■■■■■■■■■■■■www■■■■■■■■��■■■■■r►��■■■■■■■■■■■■■■■■■■■■www■■ ■■■■■■■■■■■■■■■■wwww■■■■■■■■■■■■11■11■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■wwww■■■■■■■��■■■�■■■■■��•■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■www■■■■■■■■■■■■■■■■■■■■s■1■■al■■■■■■r■■■■■■ww■■■■■■w■■■■■■■■■ ■■www■■■■■■■■■w■■■■■■■■■■■■■■■■Ilf■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■wwwww■■■■■wwww■■■■■■�■■■u■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■www■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■\1■■www■■■■■■■■■■■■■■■■aJ■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■r.■■■■r■■■■■■■■■■■■wwww■■■■■��■www■■■ ■■■■■■■■■■wwwww■■■■■■■■■■■ww■■■1■■■■■\■■■■■■■■■■■■■■■■■■�:\■■rte'■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■R�1■■■■■■Il■ ■■■\■■■■■■■■■■■■■■■■■■■let?■■i'iL•■■■ ■■■■■■■■■■■■■■■■■■■■■■■al■■■■■II■■■■■■■■■■\':CCS■■■■■■■■■■■■■!�►7■■■■■■ MENNENEMISEMiiiiiii MENNENMENNENiiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■lt■■■■IiC'.11111■■■��■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■1\■■■■■■■■1:■�CO�C7■■A■=CCS■■■!�i\■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■al■■�■■■■11■C�■■■1■■■I■11■■■L'•i■■ice■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■11■■■L'ii■li■■mew■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ I ow-) .. ru _w _ - 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Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990001439 Tax PIN/EH #: 12-000-00-012-01 Billed To: Mariam Wright Subdivision Info: Address: 1234 Godbey Road Location/Address: 1147 Godbey Road -27028 City: Mocksville Property Size: 52 Ac Reference Name: Proposed Facd ty Ke nel/Residen aEm NOTE* This improvementVe/rmTDOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: ❑New ❑Repair xpansion Permit Valid for: RTYears ❑No Expiration Residential Specifications: # Bedrooms _a # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People _# Seats 2 / Square Footage(or Dimensions of Facility) Design Flow(GPD): U4 Type of Water Supply: ❑County/City IWWetl ❑CommunityWell Site Modifications/Permit Conditions: System Type LTAR Initial cc t r Repair IV Site Plan Environmental Health Specialist_ i.p. 11-06 j Date t ;A APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health PAW RECEIVED P.O. Bog 848/210 Hospital Street)-- ' 13 2" Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ tion To Construct (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing Sysansion/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. APPT.TC'ANT INFORMATION Name r s Contact Person c� G-) /A Address Home Phone City/State/ZlP l k 290M Business Phone Email 11 Name on Permit/ATC ifDffere t than Above Mailing Address City/State/Zip I1►11NN►yiI_IIIMQ 'r, -Date House/Facility Comers NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with sitelan, no expiration with complete plat.) Owner's Name' ' M WA a-___. (Z� . 1 e � r-lc� ';A- Phone Number Owner's Address Property Address j I c4:1 (off' Lot Size S" ops Tax Subdivision Name(if applicable) Directions To Site: ( L4 w P c t Pity/State/Zip City �/� Ise to o u�l 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? des No i Does the site contain jurisdictional wetlands? Yes . LNo Are there any easements or right-of-ways on the site? Yes -6-No Is the s6', ubject to approval by another public agency? _Yes V,,No Will wastewater other than domestic sewage be generated? Yes -. No IF RKSI 1)FN(;F, F11,1,0)1T1­FH F, BOX F3KLOW `4 0er� I # People N—_ # Bedrooms Q— # Bathrooms Garden Tub/Whirlpool ❑Yes 'VNO- Basement: ❑Yes 5CNo Basement Plumbing: ❑Yes qVo .IF .NON-RF,STDF,NCF. FIT: I:, OUT THF, BOX BFd..nW 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 ❑Altemative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well ting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? -[7 Yes -CLPd'o 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 staking the house/facility-location, ropose }ell location and the location of any other amenities. ��X 1L- ` I ` VV�� Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: Datel 1113 EHS: AM Sign given ❑ Yes ❑ No �N",/ unt # 20 n L Revised 11/06 W 1 V 1 Invoice ICOW3 APPLICANT INFORMATION Acct# 120172 Billed to: Mariam Wright GUEST HOUSE Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION I2-000-00-012-01 Godbey Road 1 52 Acres Property Size: Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON 11 DEPTH 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: LONG-TERM ACCEPTANCE RATE: 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 lYoSG� 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 accentance rate - ¢al/dav/ft2 nt'Wn nsinc rno.„—AN i AK • .. P �; � y� 3,. Al" e A i y r �' ' �. x�• . Sr '• X11 .. . Survey By: D.J.M. Dwg. By: D.J.M. Fite No.: 000?DAOl Dona Id J. Moore Land Surveyor Land Surveying, Mapping, Subdivisions, Planning P.O. Box 30130, 15311 1/2 Hawthorne Road, Hlnston-Salem, NG 21103 Phone: (336) 1198-0100 www .Caro I ina5urveyor.com Gopyright © 2006, Donald J. Moore, P.L.5., L-3482 N.G. D.B. 747 , PU. 3U�l PL.BI(.i 4, PC. 47 TRACT 4 A unmq