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899 Howardtown Rd
4 OPERATION PERMIT F-CDPFileNumber ice use Only . Davie County Health Department 161251 -1 210 Hospital Street 5860-066145 P.O. Box 848 Number. Mocksville NC 27028 Evluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Q;�nship: Applicant: John Wyckoff IV Property Owner John Wyckoff IV Address: 6135 Olde Fields Way Address: 6135 Olde Fields Way City Pfafftown Cky: Pfafftown State/Zip: NC 27040 State/Zip: NC 27040 Phone#: (336)945-4210 Phone#: (336)945-4210 Propeqy Location & Site Information rAddress/Road M Subdivision: Phase: Lot: ardtown Circle le NC 27028 Directions Structure: SINGLE FAMILY Hwy,158, right on Howardtown, #of Bedrooms: 3 #of People: 2 *Wvvater Supply: PUBLIC *IP Issued by. 2140-Nations,Robert *System Classificatan/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? OYes @No Design Flow: 3 6 0 GRAVITY-PARALLEL d-box Pump Required? Distribution Type: (�' ) OYes (DNo Soil Application Rate: 0 - 2 7 5 *Pre Treatment: Drain field ' N1rification Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 3 Installer: Brian McDaniel Total Trench Length: 3 0 7 Certification#: 11118 Trench Spacing: — 9 Inches O.C. Feet O.C. *EH S: 2140-Nations,Ro4ert Trench Width: 3 Inches Feet Date: 0 1 / 0 4 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 4ApprovalStatus' Inches Maximum Trench Depth: 3 6 Inches ® Approved .Disapproved Maximum Soil Cover: a 4 Inches CDP File Number 161251 - 1 Septic Tank County ID Number: 5860•06-6145 r r Manufacturer. Shoaf Let. STB: 760 Long: Gallons: 1000 InstallerBrian McDaniel Date: 0 8 / 1 6 / x 0 1 5 Certification#: 1118 *EHS: 2140-Nations,Robert *Fitter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes D No Date: 0 1 / 0 4 / 2 0 1 6 Reinforced Tank: ❑ Yes ® No A 11 pproval Status Piece Tank: El Yes No Approved❑ �Dlsappro�ted Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: / / Date: RiserSealed ❑ Yes ❑ No Rise Height: '❑ Yes ❑ NO (Min.6 in.) Approval Status At einforced Tank: ❑ Yes ❑ No Q Approved❑ Disapproved Piece Tank; ❑_Yes _ ❑ No Supply Line Pipe Sizer inch diameter Installer , Pipe Length: feet Certification#: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings C] Yes El NO Approval Status ❑ Approved❑ Disapproved Pump Requirgment (' Pump Type: Installer. Dosing Volume: — Gal Certification Or: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No = ❑ :Approved 0 Disapp roved . Vent Hale ❑ Yes ❑ No Anti-siphon Hole El Yes ❑ NO CDP File Number 161251 - 1 County ID Number: 5860-06-6145 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ yes ❑ NO Certification : Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No '"EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: ,Approval Status, Alarm Audible ❑ Yes ❑ No Approved❑ Disapproved . Alarm Visible ❑ Yes ❑ NO 2140•Nations.Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 1 / 0 4 / 2 0 1 6 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 11 a sewage septic system. Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A 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 home/business owner must maintain a valid contract with a public management entity with a certified operatoror a private certified operator forthe 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 entky 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 ownerand 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 161251 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5860-06-6145 P.O.Box 848 County File Number: Mocksville NC 27028 Date: {.�.J,....i 4 Olnch Scale: . OBlock Drawing Drawing Type: Operation Permit ON/A 1 1-7 f t I 1 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street 161251 - 1 CDP File Number: P.O.Box 848 County File Number: 5860-06-6145 f U C Mocksville NC 27028 V / - 6j L — !�`� Date: .0.9./.1.5. /.a.0.1.5. Click below to import an image from an external location: Drawing Type:Construction Authorization �c � t f F f I i I i I � I t0 1 Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION 161251�1 . Davie County Health Department CDP File Number: f 210 Hospital Street 5860-06-6145 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 09 / 15 / .2015 Q Inch Type: Construction Authorization Scale: , O Block Drawi Drawing = ft. T Yp Q N/A --..._............__ _ - - _ d t 7 -- t I .... � - o, k ...... I_-. I I F _ ......... ...... ....... _ .................... .......... 7 T oto►— —- ...................................................................................................................................................................................... .................................... ..................................................... .... ......... ........ .......... -- Page 3 of 3 P1 P2 CDP File Number 161251 - 1 County ID Number: 5860-06-6145 ❑ Open Pump System Sheet Repair System Required:®Yes ONO O No, but has Available Space CDesign System Trench Spacing: Q he O. . ification: Provisionally Suitable — 9 ®Feet O.C. Trench Width: Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 a Aggregate Depth:7 5 inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a LESS) Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: a q, Inches No. Drain Lines 3 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 a 7 ft Pump Required: OYes ®No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Ra ww 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. Ra ie g 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the Information submitted in the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 9 1 5 / a 0 1 5 Authorized State Agen . Malfunction Log OYeS ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION For Office use Onlv AUTHORIZATION *CDP File Number 161251 - 1 Davie County Health Department County ID Number: 5860-06-6145 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 / 1 5 / a 0 a 0 —7 Applicant: John Wyckoff IV Property Owner: John Wyckoff IV Address: 6135 Olde Fields Way Address: 6135 Olde Fields Way City: Pfafftown City: Pfafftown State/Zip: NC 27040 State/Zip: NC 27040 Phone#: (336)945-4210 Phone#: (336)945-4210 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 899 Howardtown Circle Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, right on Howardtown, #of Bedrooms: 3 #of People: 2 *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 resign sification: Provisionally suitable Inches System? Minimum Soil Cover: 1 a y QYes ($No Inches ow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 , a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes (9 No Pump Required: QYes (&No O May Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: QYes ONo Total Trench Length: 3 a 7 ft GPM--vs-- ft. TDH Trench Spacing: _ g Inches O.C. Feet O.C. Dosing Volume: Gallons Trench Width: _ O Inches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 .-CONSTRUCTION For office use Only AUTHORIZATION "GDP File Number 161251 -1 °= Davie County Health Department County ID Number.5860-06-6145 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 / 1 5 / a 0 a 0 Applicant: John Wyckoff IV Property Owner. John Wyckoff IV Address: 6135 Olde Fields Way Address: 6135 Olde Fields Way City: Pfafftown City: Pfafftown StatefZip: NC 27040 StatefZip: NC 27040 Phone#: (336)9454210 Phone# (336)945-4210 Property Location & Site Information rAddress/Road#: Subdivision: Phase: Lot: 9 Howardtown Circle ocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, right on Howardtown, #of Bedrooms: 3 #of People: 2 "Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesiggn ssification: Provisionally Suitable Inches Minimum Soil Cover. 1 a System? QYes QNo Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons "Proposed System: 25%u REDUCTION 1-Piece: QYes QNo Pump Required: QYes QNo QMay Be Required Nkrification Field 1 3 0 9 Sq.ft. Pump Tank: Gallons No.Drain Lines 3 1-Piece:()Yes QNo Total Trench Length: 3 a 7 ft GPM vs— ft. TDH Trench Spacing: _ 9 OnchesFeet O.C.O.C. Dosing Volume: Gallons Trench Width: _ 2inches Feet Grease Trap: Gallons Aggregate Depth: - inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01 011 0111 OIV Dan A% 4 of Z CDP File Number 161251 - 1 County ID Number.6864-06+6145 , ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rrDesign System Trench Spacing: 9 E613. inches O. ification: Provisionally Suitable Fest O.C. Trench Width: tnches. w: 3 6 0 ,�,�, — 3 @ Feet Soil Application Rate: Aggregate Depth: 0 - a � 5 inches Minimum Trench Depth: a 4 Inches "System Classification/Description: TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 3 "Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 3 a 7 ft. Pump Required: Oyes eNo (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 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 Wastawater System Construction shall be valid tar 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)).If the Installation has not been completed during the period of validity of the Construction Permit,the Information submitted In the appiicaition fora permit or Construction Authorization is found to have been Income;falsified or changed,or the site ls,altered,the pennit orConstruction AuthortzaUon shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning or ciarldrolling the system shall be responsible for assuring compliance with the law%,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 1 5 1 2 0 1 5 . Authorized State Agen Malfunction Log Oyes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 161251 - 1 • Davie County Health Department CDP File Number, 210 Hospital Street 5860-M6145F.Q.Box 848 County File Number: Moftvilte NC 27028 Date: 8 9 / 1 5 / 2 0 1 5 Q inch . Drawi DrawingScale: QB►octc,Type: Construction Authorization 08lo I _ �. �I CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 161251 - 1 P.O.Box W 5860.06.6145 Mocksville NC 27028 County File Number: Date: .0 9 / 1 5 / 2015 Click below to import an Image from an external location: Drawing Type:Construction Authorization IMPROVEMENT PERMIT 161251 - 1 Davie County Health Department CDP File Number: . 210 Hospital Street 5860-06-6145 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , QBlock ()N/A ft, v"\ i f , i 1 � t � I oL i I 0:1 a - Goo , w L:j, : C-. Page 3 of 3 • ' - IMPROVEMENT PERMIT For OfficeUseonly *CDP File Number 161251 - 1 Davie County Health Department r: 210 Hospital Street County ID Number.5860-06-6145 P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 10/24/2019 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: John Wyckoff IV Property Owner: John Wyckoff IV Address: 6135 Olde Fields Way Address: 6135 Olde Fields Way City: Pfafftown CRY: Pfafftown StatefZip: NC 27040 StatelLip: NC 27040 Phone#: (336)945-4210 Phone#: (336)945-4210 Property Location & Site information Address/Road#: Subdivision: Phase: Lot: 899 Howardtown Circle Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, right on Howardto n, #of Bedrooms: 3 - 3 two�� RWIi Altus �� #of People: 2 'Water Supply: PUBLIC System Specifications Initial S stem .Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? QYes ®No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 a 7 5 1-Piece: QYes QNo Pump Required: QYes Q No O May Be Required "System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) 'Proposed System: 25%REDUCTION 1-Piece: QYes QNo 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 7 5 Maximum Trench Depth: 3 6 Inches 'System Classification/Description: Pump Required: QYes QNo Q Maybe Required TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'PropOSed System: 25%REDUCTION Pagel of 3 CDP Fite Number 101251 - 1 County ID Number: 5860-06-6145 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. cJR: 7 *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. CA Re 7 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 the facility and appurtenances,the O 0 site forthe proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale atone 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 surracewaters. 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 platthat 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(NCG5130A-335(o).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: 2140-Nations,Robert Date of Issue: 1 0 / a 4 / 2 0 1 4 Authorized State Agent. G�i OValid without Expiration? O Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health o RECEIVED, 5 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 PAID . Dates (336)753-6780/Fax(336)753-1680 Date q 1 Application For: ❑ Site valuation/Improvement Permit ❑Authorization To Construct(ATC) ❑ '- -_— Type of Application: New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***1MPOR7ANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. J APPLICANT INFORMATION • Name -To h n W c eases Contact Person c ¢rrcv Address ! S j c Home Phone _ 4 _AIZ/ a City/State/ZIP Pf a 4rF7P6,,,, AlC P 0Yc) Business Phone_ �Q Z = - 3 65 q Email 11��/ C Cjilr; b hn A'a 1., Com Email: �1/✓cYoF�'To>:,�, � xI o L ir Go r✓f Name on Pe�rmit/ATC if Different than Above JI Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name 9 4--o,rn•& c, L'�� 4 X r, Phone Number Owner's Address /4-6 2 City/State/Zip A-esgje. A n o IM 9_S- Property Address Ycfla f C-,re-Irn M 0&kr✓,�! Lot Size J e,r, Tax PIN# SSZ6 0 0 66 Subdivision Name(if applicable) '--" Section/Lot# Directions To Site: If the answer to any of the following questions is"Yes",supporting doc ntation must be attached: Are there any existing wastewater systems on the site? Yes o Does the site contain jurisdictional wetlands? _Yes -/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 wastewaterother than domestic sewage be generated? _/Yes No . IF RESIDENCE FILL OUT THE BOX BELOW #People 7X #Bedrooms #Bathrooms J Garden Tub/Whirlpool es ONO Basement: ❑Yes &640 Basement Plumbing: []Yes Ao IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People # Sinks 7 #Commodes # Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Vonventional ❑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 6"to / 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 sponsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the hour a ili location p posed well location and the location of any other amenities. y�. Property owner's or wner's legal repylkiep&ve signature Site Revisit Charge Date(s): l0 !tl Client Notification Date: Date EHS: S ( T �O �Q('c� lvlwsn Crcic lqGre- , 17 ya 9i w a 0 (,a c/Y)<- a+, a n W 04 t 13171 o-� D � _ G ` ' ` ^ « ' . ----'---------------------_----------------- 6�cumentNummber 213-503 ----------------------------------- .......... --........ � , Document Type Warranty Deed --------------------------------------------. . , Property Map 177 310-1 100 yard 200 yards bi ng G 240114 Microsoft Corporation 0 220114 Hok713 Lv bing - -rosoft Corporafion Q 2014 Nokh 02014 IAL *Lot Dimensions are Estimated ' � ^ � � 1 I I DAVIE COUNTY HEALTH DEPAR NT I Environmental Health Section f . Soil/Site Evaluation APPLICANT INFORMATION ` PROPERTY INFORMATION ! i 5860-06-6145 i John Wyckoff 336 945-4210 ( -Howardtown Rd $02 355-3255' ,13 Acres v i Lk i I Water Supply: On- ite Well Community blic Evaluation By: Aug r Boring Pit Cut { FACTORS 1 2 31 5 6 7 Landscape position Slope% HORIZON I DEPTH j © — Texture group } G Consistence Structure Mineralogy - " � 1 HORIZON 11 DEPTH t I 1 Texture groupY ! Consistence I Structure Mineralogy4 HORIZON III DEPTH Texture group Consistence ' 3 Structure Mineralo i HORIZON IV DEPTH Texture rou I A', `Consistence ! Structure { l I Mineralogy SOIL WETNESS { ! I RESTRICTIVE HORIZON i k SAPROLITE I I t CLASSIFICATION i LONG-TERM ACCEPTANCE RATE -.27F 1 i a SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANC 'RATE: O �75 OTHER(S)PRESENT: ►l ll REMARKS LEGEND 1' ` Landscape Positi2nn ± ! i R-Ridge S-Shoulder L-Linear slope FS -Foot slope N-Nose slope' CC-Concave slope CV- onvex slope T-Terrace FP-Flood plain H;-Head slope Texture ' S -Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL; -Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay f CONSISTENCF, j Moist VFR-Very friable FR-F#table FI-Firm VFI-Very firm EFI-Extremely firm NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky i 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 L-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed f � ' Notes Horizon depth-In inches ! i Depth of fill-In inches f 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) \ T TA TI T - ----- L-a- --I/j Ir'•I