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963 Farmington Rd (2) Davie County,NC I Tax Parcel Report Wednesday, February 15, 2017 r r 981 ------- --- 963 ---- - -963 RC1 --- --------------------�--- 955 z `G7 --------- - ------------------ ------------------ ------ -- =-- — --- - I I 951 ._.................................._.._................_....___............................................_.................................................._._....._.......................................................................�':`^_ ..4.J.J_.........................._................................_..........._....................................... _. WARNING: THIS IS NOT A SURVEY —777 Parcel Information Parcel Number: E50000001705 Township: Farmington NCPIN Number: 5841650802 Municipality: Account Number: 8301672 Census Tract: 37059-802 Listed Owner 1: WILSON DAVID Voting Precinct: FARMINGTON Mailing Address 1: 963 FARMINGTON ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27028 Voluntary Ag.District: No Legal Description: 3.00 AC FARMINGTON RD(1.23 AC) Fire Response District: FARMINGTON Assessed Acreage: 1.21 Elementary School Zone: PINEBROOK Deed Date: 12/2012 Middle School Zone: NORTH DAVIE Deed Book/Page: 009110192 Soil Types: EsC,EnB Plat Book: 12 Flood Zone: Plat Page: 196 Watershed Overlay: DAVIE COUNTY Building Value: 60030.00 Outbuilding&Extra 3600.00 Freatures Value: Land Value: 24580.00 Total Market Value: 88210.00 Total Assessed Value: 88210.00 All data Is provided as Is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmles]dusto County of Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action �O�N C NC or arising out of the use or Inability to use the GIS data provided by this website. OPERATION PERMIT or ice use Only Davie County Health Department *CDP File Number, 191285-1 210 Hospital Street 5841-65-0802 P.O. Box 848 County ID Number. Mocksville NC 27028 Evaluated For NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Alanna L. and David T. Wilson Property Owner. Alanna L.and David T.Wilson Address: 963 Farmington Road Address: 963 Farmington Road . City: Mocksville City: Mocksville StatefLip: NC 27028 State0p: NC 27028 Phone#: (336)941-3261 Phone#: (336)941-3261 Propegy Location & Site Information r dress/Road#: Subdivision: Phase: Lot: 963 Farmington Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY 1-40 exit 174, turn left 1.6 miles on left #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert *System Classification/Description: TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS *CA issued by: 2140-Nations,Robert SaproliteSystem? QYes ONo .Design Flow: 3 6 0 * GRAVITY-PARALLEL d-box Pump Required? 'Distribution tom' ()Yes (E)No Soil Application Rate: 0 a 'Pro-Treatment: Drain field ("'Nitrification Field 1 8 0 0 Sq. ft. *System Type: INFILTRATORQUICK4 STANDARD No. Drain Lines 3 Installer: Dennis Gallaher Total Trench Length: 4 5 0 ft. Certification#: 1071 Trench Spacing: — 9 Oinches O.C. (E)Feet O.C. 'EHS: 2140-Nations,Robert Trench Width: 3 inches Feet Date: 0 a / 0 a / a 0 1 7 Aggregate Depth: inches _ Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Status Maximum Trench Depth: 3 6 Inches ® Apprayed 0 Dlsapprovetl Maximum Soil Cov er. 2 4 Inches CDP File Number 191285 - 1 County ID Number: 5$41.95.0802 ` Septic Tank Manufacturer Shoat Lat. STB: 760 Long: Gallons: 1000 Installer. Dennis galGher Certification#: 1071 Date: 1 1 / 0 8 / a B 1 6 ` 'EH S: 2140-Nations,Robert *Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker. ❑ Yes [i] No Date: 6 a / 0 a / a 0 1 � Reinforced Tank: 11Yes R) NO ; Approval Status 1 Piece Tank: [I Yes ® NO ® Approved❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EH S: Date: / / Date: RiserSealed ❑ Yes [3 No RiserHeght: ❑ Yes ❑ No (Min.6 in.) yApprovalSttus j , einforced Tank: ❑ Yes ❑ No p Approved❑ iJtsapproved . 1 Piece Tank: ❑ Yes ❑ NO Supply Line Poe Size: inch diameter Installer. Poe Length: feet Certification#: 'EH S: *Schedule: Pressure Rated ❑ Yes ❑ No Date: / Approved fittings ❑ Yes ❑ No Approval Status ❑ Approved❑ Disapproved p Requirement FDosing 7Down: Installer. — Gal Certification#: Inches 'ENS: 'Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ No Approvatstatus` PVC unions E] Yes ❑ No = El'Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No CDP File Number 191285- 1 County ID Number: SUI-65a02 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification 9: 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 p Approved❑ Dlsapprovetl Alarm Visible ❑ Yes ❑ No 2a• 'ons, *Operation Permit completed by: 14Robert Authorized State A Date of Issue: 0 a / 0 a / a 0 1 7 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 ul G, sewage septic system. Rule.1961 requires that a Type TYPE III G. 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: N/A 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 entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business 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 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand 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. OHand Drawing 01mport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department CDP File Number: �9�285- 210 Hospital Street 5841.65-0802 P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! / Q Inch 0131oDrawing Drawing Type: Operation Permit Scale: . OQN/N/A = ft. ld61r � r I y G I V7 a � CONSTRUCTION For office use only AUTHORIZATION q *CDP File.Number 191285- 1 ` Davie County Health Department n I County ID Number: 5841-65-0802 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 5 / 0 6 / a 0 a 0 Applicant: Alanna L. and David T.Wilson Property Owner: Alanna L. and David T.Wilson Address: 963 Farmington Road Address: 963 Farmington Road City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336),041-326111 Phone# (336)941-3261 Property Location & Site Information FAddress/Road#: Subdivision: Phase: Lot: ington Rd e NC 27028 Directions Structure: SINGLE FAMILY 1-40 exit 174, turn left 1.6 miles on left #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 5 resign ssification: Provisionally Suitable Inches Minimum Soil Cover. System? QYes ONO 1 3 Inches ow: 3 6 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a Maximum Soil Cover: a 4 Inches , *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: QYes @No Pump Required: QYes @No ©May Be Required Nitrification Field 1 8 0 0 Sq.ft, Pump Tank: Gallons No.Drain Lines 5 1-Piece: QYes ONO Total Trench Length: 4 5 0 GPM vs— ft. TDH Trench Spacing: Inches O.C. 9 . @Feet O.C. Dosing Volume: Gallons Trench Width: Q Inches 3 a� Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: OI OII 0111 OIV Dana i nf'A COP File Number 191285 - 1 County iD Number. 5$41.65,-0802 • , . ❑ Open Pump System Sheet Repair System Required:Wes ONO ONO, but has Available Space rDesign System Trench Spacing: Inches 0. . ification: Provisionally Suitable — 9 Feet O.C. Trench Width: Inches w: 3 6 — 3 . Feet Soil Application Rate: Aggregate Depth: � - a inches Minimum Trench Depth: a 5 'System Classification/Description: Inches TYPE IIA.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 3 Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: .2 4 Nitrification Field 1 8 0 Inches Sq.ft. - No. Drain Lines 5 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 4 5 0 Pump Required: Oyes GNo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-11 "Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout 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 bevalld 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 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 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: 2140-Nations,Robert 0 5 / 0 6 / .1 0 1 5 issued By: Date of issue: - - -- Authorized State Ag Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 i MR APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(3}6)753-1680 Application For. a Site Evaluation/Improvement Permit [ Authorization To Construct(ATC) I J Both Type of Application: ` New System nRepair to Existing System L]Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED rNFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed � �� Contact Person Billing AddressQ(g,.- Mit--�61D)W_ ()FVb Home Phone --JA&:Q chi —32-J,1 City/StatelZlP (. �,T�.c BusCuaeI � s Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zi PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:;(Site Plan OPlat(to scale) (Permit is valid for 60 months with site. Ian,nn expirationcomplete plat.) Owner's Narn Wi 1SOn Phone Number Owner's Ad ssRI23 Eqrmllu City/State/Zip Property Address, City Lot Size--L.M, c PIN# _C'JZ 9, Subdivision Name(if applicable) Section/Lot# Directj�To Site- it 114 _ -lus-n �ai jzr, If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes)(No Does the site contain jurisdictional wetlands? LiYes,<,No Are there any easements or right-of-ways on the site? 1]YesXNo Is the site subject to approval by another public agency? ❑Yes XNo Will wastewater other than domestic sewage be generated? ❑Yes'gNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms _,) #BathroomsA 2 Garden Tub/Whirlpool❑Yes o Basement:i�Yes o Basement Plumbing: i]Yes o 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: konvention! []Accepted ❑Innovative []Alternative LOther 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?n Yes 5;No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. i understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized R sentative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable cos d I and d that I am responsible for the proper identification and labeling of property lines and comers and 1 Ja staking the house/facility location,proposed well location and the location of any other amenities. V Site Revisit Charge Property owner's or owner's legal representative signature Q �—I Date(s): Client Notification Date: Date EHS: Sign given ❑Yes 0 N Account# Revised 11/06 Invoice# 1 U f ► - � ply i \ y M r �o M �z 'IMPROVEMENT PERMIT Forofticeuse only "CDP File Number 191285-1 rR-41 Davie County Health Department 210 Hospital Street County ID Number:5841-65-0802 Evaluated For: NEW P.O.BOX 848 Mocksville NC 27028 Township: Phone:336.753-6780 Fax:336-753-1680 PERbtITYALIO UNTIL: 5/6/2020 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Alanna L. and David T. Wilson Property owner: Alanna L. and David T. Wilson Address: 963 Farmington Road Address: 963 Farmington Road City: Mocksville City. Mocksville State/Zip:: NC 27028 State/Zip: NC 27028 Phone#: (336)941-3261 Phone#: (336)941-3261 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 963 Farmington Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY 1-40 exit 174, turn left 1.6 miles on left #of Bedrooms: 3 #of People: jh e- Ll."'l1 15 711:0 f? I44"". "Water Supply: PUBLIC System Specifications nitial S sy tem site Classification: provisionally Suitable Minimum Trench Depth: a 5 Inches Saprolite System? @Yes QNo 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: QYes (QNo "System Classification/Description: Pump Required: QYes QNo QMay,Be Required 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 CS e Classification: Provisionally Suitable Minimum Trench Depth: a 5 Inches l Application.Rate: 0 a Maximum Trench Depth: 3 6. . Inches *System Classification/Description: Pump Required: QYes QNo QMaybeRequired TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 191285 - 1 County ID Number: 5841-6 -0$02 ' *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 no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; Site Plan The Improvement Permit shall be 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 wM dimensions,the location of the facility and appurtenances,the 0site 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 morethan so 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 13OA-335(f)).The person owning orcontrolling 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: 2140-Nations,Robert Date of Issue: 0 5 / 0 6 / a 0 1 5 Authorized State Agent: OValid without Expiration? 0Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 191285- 1 Davie County Health Department CDP File Number: 210 Hospital Street County File Number: 5841-65-0802 P.O.Box 848 Mocksville NC 27028 Date: Q Inch Drawing: Drawing Type Improvement Permit Scale: , Qslock , _ QN/A � 1I1 X 1 1 I 1 ! 1 I i I 1 1l 1 or A, w roc I IMPROVEMENT PERMIT ' Davie County Health Department . 210 Hospital street CDP File Number: 191285 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: 5841'65-0802 Date: 0 5 / 0 6 / 2 0 1 5 Click below to Import an Image from an external location:Drawing Type: Improvement Permit — IL c � o I I i- 1 _'_ —.r— L1—i s -,- -r- _ �_i 1_I j —r - --1- c I { — - ` � f j O CO z6M1 Z JS � I I—•—I ___..—i. I I � j I I j I � T— --�--+---��. a' _ Fo � -i -I s- —-- --a—: �__ 1—�— L I' -«.-...r y —II H U �� f •- .1. I 1 I I �' c �— T 1 V ,Bb'!BI A.2S.bS.bB N,7 1 m IV r 8v8a 9E1 ed 6 Id y eml9Nruave 156 ..... W ., 208cUo8ueeG3 pared pq � d19159168G I yd l^ N vNN88 NBSAiBNl " _ Fj x . eddi. q ,lt756 Fl,8o,C2.L8 S-) �^ IP .. i dd 'Id -P 621 •I'' E91 r•a.q.yu Y,w rm IL L,H W i 6Ai[STC[ O.. <so��o pf>i3 b.989•oCl 7 1.7 bb y n 261 Od 116 G9 m� c GoC18o887o53 R� j 90 ,+ _G. :, 668DG91685 A Md sNrroo NA78 H e' E! r++hY Icte 8v08 N81714N8tl!696 311383A3 A8 L d N e.Ni e2vtc ,. YNNY7V SMN71 v . d�. gr$ 1 i•7 A'I9 OIAYB N4971A a i r m ...9'601 _ , m- .•P.lana.,p .• y N c-,[cosis rot �, voC 3.2495.88 N -'oA N I '0 i <-.95'661 3.51,28.68 N c <91ro )N. .Oo.Op N '29r CE6855I BS b 4d 901100000053 IfTmd o .b EOIY N q z� CONSTRUCTION AUTHORIZATION ' Davie County Health Department 210 Hospital street CDP File Number: P.O.Box 848 5841-65-0802Mocksville NC 27028 County File Number: Date: .0.5 / 0 8 / .7 0 1 5 Click below to Import an Image from an external location: Drawing Type:Construction Authorization CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street 5841-65-0802 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 5 / 0 6 / 2 0 1 5 Q Inch Drawing Drawing Type: ,Construction Authorization Scale; , o°N/AkCVF ft. etp I �S r t � I_. 411 b` .............. ...................... 1 Feb 06�1511:12a Alanna Knaus 7045394411 p.1 � EIVEn Dom. A 1 f6APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT 6 c 7� _ Davie CountEnvironmental Healtb Dom' P.O.Box 848/210 Hospital Street Mocksville,NC 27025 (336)753-6780/Fax.(336)753-16SU Application For. .'t Site Evaheationamproveement Permit iJ Authorization To Construct(ATC) n Both Type of Application:*%Ne tv System 1":11epair to Existing System I lExpansion/Modification of Existing System or Facility ***AVPORTAh"1w*t THIS APPLICATION CANA'OTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Rcfcr to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION y A Name to be Billed N �' t Contact Person N v 1 D 1 ' Billing Address Home Phone_�� — l City!Statc/ZIP ryl0 G 1f3L.1 ".1V (ate?_$ C'e�s Phone Name on Permit/ATC if Different than Above Mailing Address Cit /Statc/Zip PROPERTY INFORMATION *Date ffouse/Facility Corners Flagged NOTE: A survey plat or site pian must accompany this application. Included.XSite Plan F.Plat(m scale) (Permit is valid for 6u months with site an,111Q piration with complete plat.) Owners Name in U I SO/i Phone Number 3 3(,s-� -3I Owner's Address City/StatelZip Property Address i .�/n City Lot Size - ax PIN4 L� �fr510YOo Subdivision NFame(if applicable) SectioWLot# Direc= � Site—. i l- 114 `'}'1 t ISS of 1 e 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? L1Yes ti(No Does the site contain jurisdictional wetlands? LIYes$.No Are there any easements or right-of-ways on the site? 17Yees xNo Is the site subject to approval by another public agency? !1yes?(No Will wastewater other than domestic sewage begenerated? I IYes'5( o IF RESIDENCE FILL OUT THE BOX BELOW #People 9, 1 #Bedrooms .3! #Bathrooms 2 Garden Tub/V4 hirlpool!;Yes No Basement::IYes Xo BasementPlutnbin : UYes o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square:Footage of Building k People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(galloatper day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested Conventional ,-IAccepted •JInnovative I"Altemative 1101her Water Supply Type:)(County/City Water t New Well -Existing Well :I Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?L I Yes `j<'No lfyes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. 1 understand that any permit(s)or ATC(s)issued hercatter are subject to suspension or revocation if the site is altered, c intended use changes,or if the information subnvttcd in this application is falsified or changed I hereby bnant right of ntry to the Auexxizcd R :,.d ntative of the Davie County Health Department to conduct necessary inspections to determine co pliance with applicable ws 1 and nd that I urn responsible for the proper identification and labeling ofproperty G es and corners and ca alrcl slaking the house/facility location,proposed well location and the location of any other atnenitie& Property owner's or owner's legal representative signature Sitc Rovisit Churbe Client Notification Date: Date EHS: Sign given I IYes i Wo Account-9 Revisal 11/06 Invoice it s- cappeu tbar Parcel E50000001706 16 4103 Pln # 5841558933capped N 01.01'51 • N I D8 971 Pg 622 't ar 4 f� 30.( Q N 88456112'E 250,77'—> N 00'00'04'W (T10. -•1 N 89402'15'E 199.56'-) 30.01` 104 rf r 9 rf he ravel-dw ' . de h ft ecl :`Tl •:Q:Q 2L2' Lot ..ro 3: MLO WILS❑N DAVID 53,629 SgF4 0 4.--- KNAUS ALANNA p.231 Acres) o -0 3 CD 963 FARMINGTON ROAD * w c 0. RY EVERETTE Pin it 5841650802 y :n C. OLYN COLLINS Parcel E50000001705 M .•�:� DB 911 Pg 192 .+ 06 130,686 sq Ft (3,0 acres) Lot 2 �O► 77,057 SgFt o O ••30' Access t N v:p. (1.769 Acres) A Easement—• barn raven d�. .^� 9 silo on 9 �� cs cont. pad �. Z rebarptaceci 163 155 pp PL ctbardl cappped Mbar <-S 87'27'08'W 451.71' 1 0 y v THOMPSON DONNA M I o Pin # 5841651612 ca Ln Parcel E50000001802 Y 951 FARMINGTON ROAD ca co PB 9 Pg 136 ri ca o� N O LJI N v a) Ln <-N 84.54052'W 181,48' 126 o Q 1L cappeg tbar Parcel E50000001706 16 .1103 Pin # 5841558933 capped N 01-05N DB 971 Pg 622 t ar I,� 30:( CLN 88.56'12'E 250,77'-> N 00'00'04'W (Tie) I N 89.02'15'E 199.56'-> ' 104 rf30,01' f r rer O .- de m a eel :.:�1 .. 21,2 Lot 1 N < MWILSON DAVID 53,629 SgFt o ¢ = v KNAUS ALANNA o -o ti 963 FARMINGTON ROAD w RY EVERETTE Pin # 5841650802 'AC).COLLINS Parcel E50000001705 m DB 911 Pg 192 06 130,686 sq ft U0 acres) (1231 Acres) _ o / Lot P- 19, 1O► 77,057 SgFt a a 30' Access ; 1 N :`!,Q• (1.769 Acres) �. • � � Easement- -131� -� R! b �, a •. �i/, •a1 t'I :.; barn 9raLet. dw. .^� silo on cr cont, pad rebarplaced 163 pp C d PL cappvd' ..... p 123 tbar ` appe tbnr <-S 87'27'09'W 451,71' 0 CD THOMPSON DONNA N o Pin # 5841651612 Ca -4 Parcel E50000001802 Y 64 951 FARMINGTON ROAD Ca co PB 9 Pg 136 c ITl co o� N W CII I� ca ru v Lo <-N 84'54052•V 181.49' 126 m LL i DAVIE COUNTY HEALTH DEPARNT Environmental Health Section Soil/Site Evaluation S APPLICANT INFORMATION PROPERTY INFORMATION A I�A/NA- r! �A i� (��llSd� . q�3r �r►�i n �On ! I5 { — 3 / I & cre-s i Water Supply: On- ite Well Community Public (' Evaluation By: Aug Boring / -Pit Cut FACTORS # 1 y1t 5 6 7 Landscape Msition Slope% j HORIZON I DEPTH 7 _ - Texture group Consistence j C ti Ot N� 620 ( Structure ' Mineralogyt ! HORIZON 1I DEPTH f y /' ' Texture group 5e, 5 0, 54-' ConsistenceVe N ( 4\1 . 'r ! Structure ( Mineralogy HORIZON III DEPTH — - • v_�:LICI I It—,It 0 Texture group 01 L _t LS <rN, 5 5cl- Consistence 'W"V0 ky Structure ce 6E r,P I Mineralogy HORIZON IV DEPTH f Texture group Consistence k I Structure }. ! Mineralogy • SOIL WETNESS I f RESTRICTIVE HORIZON I i' SAPROLITE ( ( S { CLASSIFICATION 1 LONG-TERM ACCEPTANCE RATE Q 7 y SITE CLASSIFICATION: . I EVALUATI N BY: d O� LONG-TERM ACCEPTANCERATE: ' I OTHER(S)PRESENT:; l REMARKS LEGEND Landscape si ion 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 �/7 L1 Texture i V Sol., — S -Sand LS-Loamy san SL-Sandy loam L-Loam SI,Silt SICL-Silty clay loam SIIj -Silty.loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay i J CO SISTENC� Moist f { VF`R-Very friable FR-Friable FI-Firm VFI-Very firm iEFI-Extremely firm NS -Non sticky SS -.Slightly sticky S -Sticky VS -Very Sticl�y NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Stru t� ure SC-Single grain M-M 'sive CR Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy i ' 1:1,2:1,Mixed ! Notes i Horizon depth-In inches Depth of fill-In inches i Restrictive horizon-Thickness and inches from land surface s Saprolite-S(suitable),U(unsu;table)• 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 T1 T ..�.- .---..- ----- - .