Loading...
140 Irish Ln Davin County,NC Tax Parcel Report Wednesday, February 15, 2017 ti I L-220 157'--- , �5 I 5 140 i _ 1 f I 153 - i I ........................................................................_...._:.....%.................._ .._............._..................._............................................................................................_.................... ................... ..........._.. . .._.......:....... ....................................... . WARNING: THIS IS NOT A SURVEY Parcel-Information Parcel Number: E70000000104 Township: Farmington NCPIN Number: 5861320430 Municipality: Account Number: 8306251 Census Tract: 37059-803 Listed Owner 1: POPLAWSKI DONALD Voting Precinct: SMITH GROVE Mailing Address 1: 375 CASTLE LANE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,1-2-S State: NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27028 Voluntary Ag.District: No Legal Description: 4.00 AC OFF HOWARDTOWN CI Fire Response District: SMITH GROVE Assessed Acreage: 3.95 Elementary School Zone: PINEBROOK Deed Date: 4/2016 Middle School Zone: NORTH DAVIE Deed Book/Page: 010160498 Soil Types: MrC2,MrB2,EnB,IrB Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: 210670.00 Outbuilding 8r Extra 0.00 Freatures Value: Land Value: 35460.00 Total Market Value: 246130.00 Total Assessed Value: 246130.00 161 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 harmless the County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NC or arising out of the use or Inability to use the GIS data provided by this website. ` OPERATION PERMIT" or ice se n v Davie County Health Department *CDP File Number 197475-2 210 Hospital Street P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township. Applicant: Jennifer Poplawski Property Owner: Jennifer Poplawski Address: 290 Ridgeview Drive Address: 290 Ridgeview Drive City: Mocksville ,City: Mocksville StatefLip: NC 27028 State/Zip: NC 27028 Phone#: (336)553-7679 Phone#: (336)553-7679 Property Location & Site Information Address/Road #: - Subdivision: Phase: Lot: Suzanne's Way Advance NC 27006 Directions Hwy 158 East turn on Howardtown Circle turn Left on Structure: SINGLE FAMILY Suzanne's Way 3/4 mile down on right past building #of Bedrooms: #of People: 3 *Water Supply: PUBLIC "IP Issued by. ` 2140-Nations,Robert *System Classificatan/Description: *CA issued by: 2140.Nations,Robert SaproliteSystem? ( Yes QNo Design Flow: 3 GRAVITY-SERIAL Pump Required? Distribution Type: QYes QNo Soil Application Rate: 0 - 3 5 *Pre Treatment: - Drain field r ationField 102 9Sq.ft. `System Type: INFILTRATOROUICK4STANDARD rain Lines 3 Installer: Sherman Dunn Total Trench Length: 2 7 5 ft. Certification#: 2702 Trench Spacing: 9 OFeet nches O.C. O.C. *EHS: 21x0-Nations.Robert Trench Width: 3 Inches Feet Date: 1 0 1 2 4 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches :,,Approval Status � Maximum Trench Depth: 3 6 ® Approved CD Disapproved Inches r Maximum Soil Cover: 2 4 Inches CDP File Number 197475 -2 County ID Number: Septic Tank Manufacturer Shoat Lat. STB: 760 Long: Sherman Dunn Gallons: 1000 Installer Date: 0 7 1 a 9 l a 0 1 6 Certification#: 2702 *EHS: 2140-Nations,Robert *Filter Brand: POLYLOKPLA 22WiithPipe Adapter ST Marker E] Yes E No Date: - l a 4 1 a 1 6 s Reinforced Tank: El ®Yes NO Approval Status - ® Approved❑ :Dlsapproved 1 Piece Tank: ❑ Yes D No - .,. Pump Tank Manufacturer. Installer. PT: Certification 4: Gallons: *EHS: Date: 1 Date: RiserSealed ❑ Yes ❑ No RiserNeght: ❑ Yes :1No {Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑ No p Approved❑ , sapproved 1 Piece Tank: ❑ .Yes. --E1 No Supply Line Poe Size: inch diameter Installer. Pipe Length: feet Certification#: *ENS: *Schedule: Pressure Rated ❑ Yes ❑ NO Date: 1 1 Approved fittings ❑ .Yes ❑ No approval Status Approved© =Dlsapproved Pump e u e Pump Type: Installer. Dosing Volume: - Gal Certification;*: Draw Down: Inches *EHS: *Cham: f Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Ye5 El No Approval Status?-" PVC Unions ❑ Yes ❑ No ❑ Approved❑ Dlsapproved;, Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes ❑ NO ' CPP FileNumber 197475.2 County ID Number: - Electric Equipment NEMA 4X Box or Equivalent El Yes ❑ No Installer: Box 12 inches Above Grade El Yes El No _ Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No THS: Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: 'APprovStatus Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Dlsapproved=q ` AlarmVisible ❑ Yes ❑ No 2140•Nation,Robert _*Operation Permit completed by: Authorized State Agent: Date of Issue: 1 0 / 2 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 sewage septic system. Rule.1961 requires that a Type septic system meet the following criteria: Minimum System Review By The Local Health Department: Management Entity: Minimum System Inspection/Maintenance Frequency ByCertified Operator: _ Reporting Frequency By Certified Operator: 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 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 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 tong 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 19y475='2 . Davie County Health Department CDP.File Number: 210 Hospital Street ` P.O.Box 848 County he Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type:Operation Permit Scale: . O�A k i I � 42�' 3' � - i 1 �a. I k i i _tet_ i • CONSTRUCTION For Office'Use only AUTHORIZA110N *CDP File Number 197475-2Davie County Health Department County ID Number. 210 Hospital Street Evaluated For NEW P.O.Box 848 -IT—ownship: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753.6780 Fax:336-753-1680 0 a / 0 3 / a 0 a 1 Applicant: Jennifer Poplawski Property Owner: Jennifer Popiawski Address: 290 Ridgeview Drive Address: 290 Ridgeview Drive City: Mocksville Cay: Mocksville StatelLip: NC 27028 StatefZip: NC 27028 (336)553-7679 553-7679 (336): Phone#: Phone# Property Location & Site Information r dress/Road M Subdivision: Phase: Lot: uzanne's Way dvance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East turn on Howardtown Circle tum Left on #of Bedrooms: Suzanne's Way 3/4 mile down on right past building #of People: 3 *Vllater Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Saprolite System? + Yes Minimum Soil Cover. 1 a ys O ONo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 5 Inches Soil Application Rate: 0 . 3 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: "Distribution Type: GRAVITY-SERIAL TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons =Proposed System: 25%REDUCTION 1-Piece: OYes @ No Pump Required OYes @No 0May Be Required' Nitrification Field 1 0 a 9 Sq.{f Pump Tank: Gallons No.Drain Lines a 1-Piece:OYes ONo Total Trench Length: a 5 ft. GPM—vs— ft. TDH Trench Spacing: _ Feet O.C. 9 Onches O.C. Dosing Volume: _ Gallons Trench Width: _ 3 21nches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank InstalierGrade Level Required: 01 011 0111 01V Donn 4 of Z CDP File Number 197475-2 County ID Number. ` ❑ Open Pump System Sheet Repair System Required:OYes ONO ONO,but has Available Space rDesign System Trench Spacing: 9 Inches O. . ification: Provisionally Suitable — Feet O.C. Trench Width: Q Inches w: 3 6 — 3 r Feet Soil Application Rate: 0 - 3 a 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 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°!o REDUCTION Nitrification Field 1 1 0 8 ft. Maximum Soil Cover: a 4 Inches Sq, No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL Total Trench Length: a 7 6 ft. Pump Required: Oyes @No OMay Be Required Pre-Treatment: ONSF OTS-1 OTS-II "Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department. *Permit Conditions The issuance 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. ; This Authorization forwastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued 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 theapplication 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(bj). Applicant/Legal Reps.Signature Required? OYes ONo ApplicantlLegal Reps. Signature: Date: * 2140-Nations,Robert 0 a / 0 3 / a 0 1 6 Issued By: ,Date of Issue:.. Authorized State Age Malfunction Log OYes 't Gland Drawing Oimport Drawing **Site Plan/Drawing attached.** Page 2 of 3 .CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 197475 -2 ,210 Hospital Street P.O.Box 848 County File Number. Mocksville NC 27028 Date: 0 a / 0 3 / .1 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization, Scale: , pBlock QN/A is CC 1 1 f I 1 11 1 is c 4- b . G + �-� . CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 197475-2 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0 .,2 / 0 3 / 2 0 1 5 Click below to import an Image from an external location: Drawing Type:Construction Authorization WHON FOR SITE EVALUATIONJWROVEMENT PERMIT & ATC Davie County Environmental Health PAED nate: P.O.Box 848/210 Hospital Street ( ..� Date: Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Received b Application For: ❑ Site Evaluation/Improvement Permit 'Authorization To Construct(ATC) ❑ Both Type of Application:VNew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name _J � s- �OT�� 4C.� Contact Person y�2 D;�er Address Z°ip Home Phone 32U-653.'70-7 q City/State/ZIP_ -�dc j��&gT�Zc. z7oa5 Business Phone Email��r, 1T�S Cm Email: Name on Permit/ATC if Different than Above 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 ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name jky% ©fid, Sa,\v�EA2G�.r'� 4 Phone Number Lo—q9� Owner's Address-4\gis Lxs 6'Q City/State/Zip(,&_1 c!eTJ�( QDjC: � Property Address�tk-2 ar�,,�'S W c�,,� City C>duant Lot Size_LA_a.tX'A%S Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: 1AA SQ EGsk N : t JJ=,-: c,[ r L,- C:,c-C -�-1_�r n 1Q�4- �h Su.2�,ri�.�`s � .•,•= •, 31 Lt trY;��� c�c�r ��. c� c��4�c�k d�� b C,�1 i nQ If the answer to any of the following questionsons is�upporting documentation mustMe attached: Are there any existing wastewater systems on the site? _Yes /No Does the site contain jurisdictional wetlands? _Yes ;-No Are there any easements or right-of-ways on the site? Yes No W i It be,-f keN 0-0 Is the site subject to approval by another public agency? _Yes �o Will wastewater other than domestic sewage be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms "?)— #Bathrooms �. 5 Garden Tub/Whirlpool ❑Yes )<No Basement: ❑Yes VO Basement Plumbing: ❑Yes `i No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People # Sinks #Commodes # Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:yCounty/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑ Yes kNo 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 charges,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 staking the ouse/facility location,proposed well location and the location of any other amenities. Pro erty owners or owner's"legal representative signature Site Revisit Charge Date(s): — 1 -1 ce Client Notification Date: Date EHS: 1q � Sign given ❑Yes ❑No Account# 1 1 Revised 11106 Invoice# IMPROVEMENT PERMIT For office use only • " � Davie County Health Department (L *CDP File Number 197475- 1 210 Hospital Street �W ,�Q county lb Number. ,�.. P.O. Box 848 �\Z.V 1 Evaluated For. NEW Mocksville NC 27028 ` Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 10/25/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Dwight and Sallie Cleary Property owner Dwight and Sallie Cleary Address: 4193 US Hwy 158 Address: 4193 US Hwy 158 City: Advance City: Advance State/Zip: NC 27006 StatefZip: NC 27006 Phone#:, (336)998-3613 ,Phone#: (336�998-�3613 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Suzanne's Way Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 East turn on Howardtown Circle turn Left on #of Bedrooms:: 4 Suzanne's Way 3/4 mile down on right past building #of People: *Water Supply: PUBLIC System Specifications nitial S stem *Site Classification:asst Ica n_Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? ( Yes ONo Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 3 5 1-Piece: OYes @No Pump Required: OYes @ No OMay Be Required *System Classification/Description: TYPE If A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: Oyes ONo Repair System Required:@Yes ONO ONO, but has Available Space CRepair_System *Site Classification: Provisionallysuitable Minimum Trench Depth: 2 4 inches Soil Application Rate: 3 a Maximum Trench Depth: 6 3 Inches 7 .__. Required:Req 'System Classification/Description: Pump Oyes @ No O May be Required TYPE It A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: Page 1 of 3 CDP File Number 197475 - 1 County ID,Number. *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *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 tnprovement Permit shall be valid for 6 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 e site torthe 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 surveyor,drawn to a scale of one inch equals no morethan 60 feet,that Includes the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision tots 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(p).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(6)) Applicant/Legal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature: Date: "Issued By: 7140-Nations,Robert Date of Issue: 1 0 / a 5 / a 0 1 5 Authorized State Agen OValid without Expiration? OCreate CA? @Hand Drawing Olmport Drawing •r **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT . 197475 - 1 Davie CQunty Health Department CDP File Number. 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: I ! Q Inch Drawing Drawing Type: Improvement Permit Scale: OBlock ON/A 37" U ' IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street ' CDP file Number: 197475- 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 1 0 J -2 5 / 2 0 1 5 Click below to Import an image from an external location:Drawing Type: Improvement Permit P C1111- APPLIC RN FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC �A Davie County Environmental Health Do: gay P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: O'Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLIClANT INFORMATION Name Contact Person ! LVp Address §fl CA Home Phone City/State/ZIP Business Phone Email Email: Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/FacilityComers Flagge 10 f y NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to sca e (Permit is alid for 60 mon hs ith s' Ian,no expiration with complete plat.) Q ��ii Owner's Name t �� /L` Phone Number f�a'3 40/3 Owner's Address c- City/State/Zips oOI(,('G, Property Add ess Uf4AIA/E' City Lot Size Tax PIN# Subdivision Name(if a plicable) Sect'on/Lot# Dire c ions To Site: ! A,/ L, d 3 0 ! If the answer to any of the following quesiioins is"Y s",supporting docu , i ion must be attached: Are there any existing wastewater systems on the site? _Yes I Does the site contain jurisdictional wetlands? Yds Are there any easements or right-of-ways on the site? VYes No Is the site subject to approval by another public agency? _Yes Will wastewater other than domestic sewage be generated? Yes o IF RESIDENC FILL OUT THE BOX EJELOW #People #Bedrooms q #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑ s ❑No Basement Plumbing: B-Yes i7No 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: Veonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: C,,ounty/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? 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 charges,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 stak' g the house/facility location,proposed well location and the location of any other amenities. LPt 0" 00.,- Site Revisit Charge op owner l or owner's f8gal representative signature Date(s): Client Notification Date: Me EHS: Account# ISign given ❑Yes ❑No /Q Revised 11/06 Invoice# . 'N. - /,�,-o.o _ 3 ` i iAL_ 30 N 84'2 26 yVIPS-EIP) 10. THE PURPOSE OF 1 IPS FOR A WATERLINE 176.03' / N 84'236 W WIFE BARBARA ALLI • . M NEaSEMEi1"T. '? \ a 181.40' EIP 0 / IPS DWIGHT H. CLEARY AND WIFE I / SALLY RRY DB159PG 712 PIN NO. 5861320430 I ENT" co AD o� \ ~ QQ ., I / / Lo C.W. M odo c� BARE / / N DB 1 DB 1 PIN I o 7. 7' o EIP o � i •: . y0r /7/0 Q' 3p.. EASEMENT o 3� 13.68,1 �� S 4 8'3-E C ` gym SEAL r% , 14.3j' 2 E 90.72 ENTERLINE 0 :�- L- tz-, (TOT OTAL) F EASEMENT f�**V,, c 4*1 Off' �� �'°`°� .moo EASEMENT LESTER R. ALLEN N 82,01 SUE` DB 321 PG 301 18" WRV 'PIN 'N0. 5861229191 572.26' _- -- - _ DAVIE COUNTY HEALTH DEPARTMENT w Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION )/ wSA [[ ���a �uzANnVes Gil 9 Y ( �l 4 Acres Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 (1 5 6 7 Landscape position Slope% HORIZON I DEPTH UJ7 7 Texture group GL GL Consistence Structure Mineralogy HORIZON II 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 O— CLASSIFICATION LONG-TERM ACCEPTANCE RATE D SITE CLASSIFICATION: �i EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHERS)PRESENT: REMARKS: 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 CONSIST i.NC . MWA 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 LYfltgs . 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 acceotance rate-eal1dav/ft2 nt wn nvnc M-4—AN Application For:)itp Evalixtion/Improvement Permit ;D Authorization To Construct(ATC) ❑ Both f Type of Application: ❑New System '❑Repair to Existing System -❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED,UNLESS ALL OF THE R) INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. � '4 ►L' APPLICANT INFORMATION Name to be Billed JQA N �O 1�` Contact Person Jenn 1 i e,( PQ A t 1 Billing Address 40-�Q t\-k redi4-h r\ Home Phone 3-3 Ce - 53`7(p7C1 City/State/ZIP (-0- f--1—� x-7107 Business Phone Name on Permit/ATC if Different than Above _ 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 ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name 6,k\ '=C)� Tic'. sm - Phone Number " (� 31 --302/ Owner's Address 7 Gl A City/State/Zip_HOC.I(�j�IIQ UL a7 Property Address'O \QCknQ City''(hoC1�Sl \1p Lot Size Tax PIN_# Subdivision Name(if applicable),. Section/Lot# Directions To Site: 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?. ❑YesXNo Does the site contain jurisdictional wetlands? ❑Yes o Are there any easements or right-of-ways on the site? �❑Yes_ o Is the site subject to approval by another public agency? ❑YesNo �. Will wastewater other than domestic sewage be generated? ❑Yes o - IF RESIDENCE FILL OUT THE BOX BELOW- #People #.Bedrooms 3 #Bathrooms_ Garden Tub/Whirlpool ❑Yeslo Basement: ❑Yes o Basement Plumbing: ❑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: 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 Y 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 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 1 ing and flag ' or fMing t e house/f cili location,proposed well location and the location of any other amenities. Site Revisit Charge Prop rty owner's or owner's 1 gal representative signatur z Date(s): 7 Client Notification Date: