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149 Jim Frye RdOPERATION PERMIT Davie County Health Department + 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: dames Waters Address: PO Box 2241 City: Advance Statefzip: NC 27006 Phone#: (336) 971-9766 Address/Road #: Subdivision: Peoples Creek Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms:: 4 # of People: 'Water Supply: EXISTING WELL 'CDP File Number 137036-1 H8 -060-A0-033 County ID Number. Evaluated For. NEW � Township: /'Property owner. ,lames and Cindy Waters Address: 159 South Hemingway Ct City: Advance State/Zip: NC 27006 1\P_hone #: (336) 971-7587 y Phase: Lot: Directions Hwy 158 E, right on Hwy 801 turn left on Peoples Creek Rd. Pass Marchwood, Corner of Peoples Creek and Jim Frye Rd. 'IP Issued by. 2140 -Nations, Robert "System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) "CA issued by: 2140• Nations. Robert SaproliteSystem? OYes f)No Design Flow: 4 8 0 *Distribution Type: GRAVITY- SERIAL Pump Required? Soil Application Rate:OYes q)No 0 a 7 S *Pre Treatment: Drain field Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 7 4 5 Sq. ft. 4 4 3 6 ft. o Inches O.G. Feet O.C. 3 inches Feet inches Minimum Trench Depth: 3 a Minimum Soil Cover. a 0 Maximum Trench depth: 3 6 Maximum Soil Cover: a 4 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: Brian McDaniel Certification #: *ENS: 2140 -Nations. Robert Date: 0 3% 1 8/.2 0 1 5 Inches Inches Appro Inches® Approve Inches tus isapproved CDP File Number 137036 - 'I Manufacturer. shoat STD: 760 Gallons: 1000 County ID Number: H&a60•AO-033 c Tank ' Lat. Long: Installer: Brian lOcDaneil Date: 1 1 / 30 i a 0 1 4 Certification #: ❑ No Valves Accessible ❑ Yes ❑ No *EH S: 2140- Nations, Robert *Filter Brand: POLYLOKPL-122 With Pipe Adapter Check -valve ❑ Yes ST Marker: El Yes ® No Date: 0 3/ 1 8/ a� 1 5 nforced Tank: El Yes ® No ❑ No Approval Status ® Approved ❑ Disapproved 1 Piece Tank: ti ❑ Yes ® No Pump Tank Manufacturer. rag Gallons: Date: / RiserSealed ❑ Yes Riser Height: ❑ Yes nforced Tank: ❑ Yes 1 Piece Tank: ❑ Yes ❑ No ❑ No (Min, 6 in.) ❑ No ❑ No Su Pipe Size: inch diameter Pipe Length: 1 feet *Schedule: Installer, Certification #: *EHS: Date: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Approval Status ❑ Approved ❑ Disapproved Pump Type: Installer. Dosing Volume: - Gal Certification #: Draw Down: Inches *Chau: 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 *EH S: Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 13703£ -1 CieU[nc caururr MIL County ID Number: H8 -060 -AO -033 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 *EH S: Pump Manually Operable ❑ Yes ❑ No / *Activation Method: Date: Approval status Alarm Audible n Yes ElNo O Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ NO 2140 - Nations. Robert *Operation Permit completed by; Authorized State Owner/Applicant Signature: Date of Issue: 0 3/ 1 8/ 2 0 1 5 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 it 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: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator. N/A 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 for the 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 forthe 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 shalt 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 Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Dra*vviing Drawing Type: Operation Permit CDP File Number: 137036.- 1 County File Number: H8 -060 -AO -033 27028 Date: Olnch Scale: OBtock ON/A Applicant Address: City: State/Zip: Phone #: i CONSTRUCTION For Office use only AUTHORIZATION *CDP File Number 137036-1 Davie County Health Departme4t County ID Number: H8 -060 -AU -033 210 Hospital StreetE ' Evaluated For: NEW P.O. Box 848 ` �pacc� Township: MOCkSVIlle NC 27 Phone: 336-753-6780 Fax: 336-753-1680 James Waters PO Box 2241 Advance NC (336)971-9766 Address/Road #: Peoples Creek Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 'Water Supply: EXISTING WELL 27006 Subdivision: 028 PERMIT VALID UNTIL: 0 4/ 1 1/.2 0 1 9 Property Owner: James and Cindy Waters Address: 159 South Hemingway Ct City: Advance StatefZip: NC 27006 Phone #: (336) 971-7587 Phase: Lot: Directions Hwy 158 E, right on Hwy 801 tum left on Peoples Creek Rd. Pass Marchwood. Corner of Peoples Creek and Jim Frye Rd. 'Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 7 4 5 Sq. ft. 4 4 3 6 ft Septic I ank. 1 Trench Depth:suitable a 4 Inches Site Classification: ProvisionallyMinimum OMay Be Required Pump Tank: \ Saprolite System? OYesONo Minimum Soil Cover1 GPM—vs— a Inches Design Flow: 5 8 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 -SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 7 4 5 Sq. ft. 4 4 3 6 ft Septic I ank. 1 0 0 0 Gallons 1 -Piece: OYes QNo Pump Required: OYes ONo OMay Be Required Pump Tank: Gallons 1 -Piece: OYes ONo GPM—vs— ft. TDH — 9 8Inches Feet O C.0 Dosing Volume: Gallons 3 _ 8Inches 17eet Grease Trap: Gallons inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI OII OIII OIV Pagel of 3 CDP File Number )37036-1 County ID Number: H8 -060 -AO -033 ❑ Open Pump System Sheet Repair System Required:OYes ONO ONO, but has Available Space epair System Trench Spacing:8Feet Inches O.C. *Site Classification: Provisionally Suitable — 9 O.C. Trench Width: 0Inches Design Flow: 4 R 0 _ 3 0 Feet *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. cA« 7; '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. X., 2( 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 maybe Issued at the same time the Improvement Permit Issued (NCGS 13OA-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? Oyes ONO Applicant/Legal Reps. Signature: Date: / / *Issued By. 2140 - Nations. Robert Authorized State Agent: Date of Issue: 0 4/ 1 1/ a 0 1 4 Malfunction Log Oyes QHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 Aggregate Depth: Soil Application Rate:0 a 7 s inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 7 4 5 Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY -SERIAL 5 Total Trench Length: 4 3 6 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. cA« 7; '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. X., 2( 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 maybe Issued at the same time the Improvement Permit Issued (NCGS 13OA-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? Oyes ONO Applicant/Legal Reps. Signature: Date: / / *Issued By. 2140 - Nations. Robert Authorized State Agent: Date of Issue: 0 4/ 1 1/ a 0 1 4 Malfunction Log Oyes QHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 ra« -n Drawing Type: Construction Authorization CDP File Number: 137036 - 1 County File Number: H8 -060 -AO -033 Date: 04/ 1 1/ 2 0 14 Oinch Scale: QBlock QN/A Waters/ Mellow Mushroom 336-941-3199 p,1 i�+�CEI D APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health Date, �0ta: P.O, Box 8481210 hospital Street Mocksville, NC 27028 (336)753-67801 Fax (336) 753-1680 Application For:Lv to uationRmprovemcntPermit Cv�CuthorizationToConstruct(ATC) oth Type of Application: f" 'ew System -_Repair to Existing System 1"_ExpansionlModification of Existing System cr Facility `t •'1tl1PORTA h_P-- THIS APPLICATION CANNOT IM PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORIs1ATI0N BULLETIN for instructions. Name to be Billed act vYt `e -S �C�2 is Contact Person 0' A ✓ ifse)C/r7S Billing Address 0. Home Phone Ciry'State2lP �(-7 Business Phone 3% — O Name on Permit/ATC if Different than Above .-J a r7f 2 4 G . ��t -e-►rs [ . r.. C r Mailing Address CityiStatc!zip T PROPERTY INFORMATION 'r Dati NOTE: A survey plat or site plan must accompany this application. (Permit is v for 60 mon witjjtt site plan, expip�ttion i Owner's Name �m I tE Cil Com. Owner's Address J h Property Address a. t?.O ✓ oilk Lot Size 5jge y, eS Tax PN# S Subdivision Nam e(if applicable) Directions To Site: lousaNacility Corners Flagged lZ I Included: U Site Plan UPlat(to scale) complete plat.) 33 Q 7 G7�O��S Phone Number NG Z -7o n r� ,rte d answer to any of the following questions pporting documentat or ust be attached Are there any existing wasteaaater systems on the site? CYcs i y Doesthe site contain jurisdictional wetlands? (' )Yes A 1QV Are there any easements or right-of-ways on the site? r� Yes G1V-1, Ts the site subject to approval by another public agency? ,- Yes P'l�j� Will wastewater other than domestic settaae be Generated? rlYes:Vo t A /1 7 5.6? 7 OV9 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms athrooms Garden Tub•Ndhirlpool [':Yes : o Basement:: We�o BasementPlumbine: r-*Vcs 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 OILY: # Seats Type system requested: C., ornentional :lAccepted UInnovative CAlternative iOther ----.—_._�._.__...-----_.,.... _... .. ... . _AAAA...._ ____.____ ................_.._.........' _AAAA. _....._........... Nater Supply Type: 0 CounrylCity Water F. New Well CMExisttng Welt .j Community Well Do you anticipate additions or expansions of the facility this system is intended to serve" U Yes YNo Tfyes, what type? This is to certity that the information provided on this application is true and correct to the best of my knowledge. [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. l hereby grant right of entry to the Authorized Representative ofthe Davie County Health Department to conduct necessary inspections to determine compliance with applicable I rules I understand that] am res onsibie for t'rte proper identification and labeling ofproperty lines and comer and catmg ltd flaggin i t to houselfaci i n. proposed well location and the location ofany other amenities. Site Revisit Charge 11_ope oume s or owner's egal representative signature Date(s): Z1-2-7- 1 / t� Client NolificationDate: Date EHS: Sign given ❑Yes I]No Account# /�J(0 Revised 11106 Invoice # CV CL M . C0 f� 1 tLIOFCATE OF 004CRSHP AND DCXArM W 9799!66419 l l+.•r e.rin, tMl I N. Ow- el N. pq-t, iabd . .T1A'.I-W 1, a. tubtll3.r L9 752 PG KXX) .Ww.tkn al U.- C-ty MN MOI l ke, y mql PU9PGm It M.p6.Wm pm slh mr Ow eavrtt. eew h mwMwn Ou1Kly r1Ee[Y br ad d.e4ef. ..I we.i WK .aba PYU..d anw Mtr etA � I.L W. 71 R: flctTrv' u('It�bD• l� t -t Oel. 2- .a �h. n G.1. G.d, G 'Met., We arrow' M— HD /'fyDEPARRRM APPROVAL KOLMA II /U.aM7 C..EOTaR CT.taf. Wslm DAVIE CO'JNf REGISTER OF HEEDS PLAT REGISTRATION FILED FOR E157RATION l 3 O'CLOCK P—M. THE DAY Or h.1L.(y(1� 014. AND will" ECQRDEfl IN PUT BOOKIL PACE�!Y . -Y — M. BRENT SHOW. EGISIER OF ULLUS _ voau�* — — i I FILING FEE PAID..60 T- ---- 1 BY: Nodl Caa<sf..• L I I I I I 1 1 1 1 I I 1 I 1 1 I + I I I t 1 I + 1 1 T t I I 1 1 I 1 I + I t _ 5.OW AcreeI I I� IC GI 1 1 1 I I T 1 + I � t 1 1 I i I 1 I 1 1 t 1 1 I + � t 1 + W 9799!66419 L9 752 PG KXX) PU9PGm e Y l� �II rm i� ttooa +1-r..+ W. 71 R: flctTrv' u('It�bD• kl-z n NAa der �h. n G.1. M-1 arrow' M— M It 2. O..A I..n.+r.• A p.tr-.0 ted 7.Ta IF 1M10 40 1010 N(X,K MdlSAM9ATUU try �i9 A�, 9. � DAVIE CO'JNf REGISTER OF HEEDS PLAT REGISTRATION FILED FOR E157RATION l 3 O'CLOCK P—M. THE DAY Or h.1L.(y(1� 014. AND will" ECQRDEfl IN PUT BOOKIL PACE�!Y . -Y — M. BRENT SHOW. EGISIER OF ULLUS _ voau�* — — i I FILING FEE PAID..60 T- ---- 1 BY: Nodl Caa<sf..• L I I I I I 1 1 1 1 I I 1 I 1 1 I + I I I t 1 I + 1 1 T t I I 1 1 I 1 I + I t _ 5.OW AcreeI I I� IC GI 1 1 1 I I T 1 + I � t 1 1 I i I 1 I 1 1 t 1 1 I + � t 1 + Jam: I.. Water CM4 C. W7fss FIN, 5799166419 w 732 FG 1000 FD 9 FG 220 aAvcl, �1 C. iV.trA ro i10M 2211 AA.-, NC 27006 R.*. 0M.W. C-Ofk.. STATE OF NORIA UBOIINA GUI" Ir DAME I�ai Iy..w yy int. er 0.1 c.r al ,. MIG ab c.rG.nlle. b atn.w mM..R L --y C. A.r, rrtlty tool Pit O{OI aM er.-i vnd- m, .v-w.Iee 1mm a wel -se.T n.edt u.e-m, -�P-'A•I.n je-e -Nvip a r.e-d.e i, Ilium*102. P••• 1000): flet q. u.wa-:. not .n.y.e Wed AeOYN.e d bw irs b1.ra.41a !sd 4 Bo•k as Py.�Rjl; IFeI Me T.Ib f pwren .. ..4.w.w b 1 W.r.: " Gi. l..t ..a P..~ I. Qva— wtA a5 47-00 w orndM; Mol &9 S ♦7-ia(!)(M f 0 11 IN a TO.eA..l 01 10.10 Ntlln M -r O(0 .wnlT d mlAkptlil, fedi t,•• .n a.rin.na. a.e ..MAetr p-e.1..f Teal. red... .n, etP;.d .ipne(r....q•Ir•t�e...e..1x- e1e t..e Mb un m, a ra.wx xln._ L -MIG Subdivision Hat Branch River Ranch %"-�- Shody Grove Towohip. INI Ie County NORTH CAROLIPA 0' 25' O 50' TOO' U." am An # O01A1W 1•..50' 02/01/14 046a JWUtf Em ml ply em ICS IA MG SU.Y E,7 RE ro eoa eo. Ad110 z7 (336)75 - r �-s7Ga IYWr.1Y�.i:M.MtliCiOM! Jim rye Road rm tmx a NOIN F kl-z n NAa der 1. NN:1 l.ato. d 570916 M-1 PS � T of RrwC M It 2. O..A I..n.+r.• A p.tr-.0 ted 7.Ta IF 1M10 40 1010 N(X,K MdlSAM9ATUU 9. � VtIK: SV.NiT 4. l0si� EF PAVEMENT EW OPMYfN(NT trot - 10' rmK It RIC.1T1]I.YAY m" 15, PIN PIN IAAgL tOL'NIIRU.TION NUIRFR It" - sa .Y- FEW 0 oKM A0(IAITY p VTIVIY POtt Jam: I.. Water CM4 C. W7fss FIN, 5799166419 w 732 FG 1000 FD 9 FG 220 aAvcl, �1 C. iV.trA ro i10M 2211 AA.-, NC 27006 R.*. 0M.W. C-Ofk.. STATE OF NORIA UBOIINA GUI" Ir DAME I�ai Iy..w yy int. er 0.1 c.r al ,. MIG ab c.rG.nlle. b atn.w mM..R L --y C. A.r, rrtlty tool Pit O{OI aM er.-i vnd- m, .v-w.Iee 1mm a wel -se.T n.edt u.e-m, -�P-'A•I.n je-e -Nvip a r.e-d.e i, Ilium*102. P••• 1000): flet q. u.wa-:. not .n.y.e Wed AeOYN.e d bw irs b1.ra.41a !sd 4 Bo•k as Py.�Rjl; IFeI Me T.Ib f pwren .. ..4.w.w b 1 W.r.: " Gi. l..t ..a P..~ I. Qva— wtA a5 47-00 w orndM; Mol &9 S ♦7-ia(!)(M f 0 11 IN a TO.eA..l 01 10.10 Ntlln M -r O(0 .wnlT d mlAkptlil, fedi t,•• .n a.rin.na. a.e ..MAetr p-e.1..f Teal. red... .n, etP;.d .ipne(r....q•Ir•t�e...e..1x- e1e t..e Mb un m, a ra.wx xln._ L -MIG Subdivision Hat Branch River Ranch %"-�- Shody Grove Towohip. INI Ie County NORTH CAROLIPA 0' 25' O 50' TOO' U." am An # O01A1W 1•..50' 02/01/14 046a JWUtf Em ml ply em ICS IA MG SU.Y E,7 RE ro eoa eo. Ad110 z7 (336)75 - r �-s7Ga IYWr.1Y�.i:M.MtliCiOM! r------- 30' Rrar Setback g — I �R I I , , I 1 r James L. Wates Ck* G. Water PN: 5199166419 176132 pG 1000 FV 9 P6 220 NCGS Monument .FRYE. N: 796.056.33' E: 1.591.218.90' NAD 83 Combined Grid Factor. 0.99991196' Gnd O� and 3, tb) 1 j1RS EP —'—rieitr4 S 85'31'37"W 350.00" — er PI< — Jim Frye Road 50' public R/hr NOTES: 1. PIN: A portion of 5799166419 2. Deed Reference: Arowde Amir MW 3. Zoned: RA 50' 4. Zoning setbacks.M Front 40' Side 15' Rear 30' LEGEND M I IIWI NCG5 NORTH CAROUNA Glxxxmc SURVEY Ww NUMBER -x- FENCE 4 ,or 8 Y SITE u v Jim Frye Road VICINITY MAP NTS James L. Wates Grdy G. Waters MN: 5199166419 PIP 2 pG 1000 PP 9 pG 220 �K� E —ROWS Development Plan Jim & Cindy Waters Shady Grove Township, Davie County NORTH CAROLINA 25' 0 50' 100' 150' SCALE DATE JOB # DRAWN 1"=50' 02/28/14 0486 JCA/MCF ics L AND SURVEYING Allen Geomatics, P.C. (C-3191) PO Box 89, Advance, NC 27006 (336) 782-3796 www.AllenGeomatics.com .w Z J 0 Q �_ U) Q i2f J O <20- LL, Of i2f Z Q Z < O LLJ W 1- Z 0 0 Z 0 Jul 30 07 01:.44p APPIt AUG ] 6 2001 ENVIRONMENTA- t DAVIE Crnwrv_ day i e county envhea l th 336 751 8786 p.3 S"TE EVALUATION/IMPP.OVEMENT PERMIT & ATC Po( Davie County Environmental Health "I /6-7 P.O. P.O. Box 848/210 Hospital St reet "f / Mocksville, NC 27028 (336)751-8760/ Fax (336)751-11786 Application For: W'Site� a ua io mpro,.ement Permit U Authorization To Construct(ATC) ❑ Both Type of Applicaiion: FHVew System [JR pair to Existing System ❑Expansion/Modification of Existing System or Facility 'IMPORTANT " THIS APPLICATION CANNOTBE PROCESSED UNL:E-SS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer -o the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed :lr,&\Nw-rey,%_ Contac: Person 71rN \N,a;rzj2s Billing Address :!Jlm Ct��nt��,1�csn&n2-c Honte Phone City/Stake/ZIP _\&I-, %A% -ti - :SA — nA, _ N.C. Z1 \O(a 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 act ompany this application. Included: mite Plan ❑Plat((o scale) (Permit is valid for 60 months with site plan, no expiration with complete: plat.) Owner's Name e ,,.w %x LLC Phone Numb r qc(% -Z.33q Owner's Address P.p.- n Nrvr,�.eE N.C. 2-1doc. City/:')tate/Zip NC,4,P C N.C. 2'?rX� Property Address ��C R%)C R4M&-Q ~City-N_yact, N.C. ?-?ooto Lot Size_Za kc2cS T:tx PIN# b4EM- N�+e 1gq , O .x79,1-21-79ZJ Subdivision Name(if applicable) ' Section/Lot# Directions To Site: So% Scsoxh,,_LR_12!x If the answer to any of the following questions is "yes", supporting documentation must be attached. tvrr. �w►Zo ��,�,� Are there any existing wastewater s -,stems on the site? . , Dyes EKo Does the site contain jurisdictional wetlands? Dyes 93Ci) Are there any easements or right -of ways on the site? Is Dyes 91�7 the site subject to approval by another public agency? ❑Yes E 0 go Will wastewater other than domestic: sewage be generated? Dyes IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms �_ # Bathrooms 3.5 Garden Tub/Whirlpool es [�No Basement: 1�'Yes LINO Basement ['lumbing: @N"es ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage o:` 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:. B'Conventional 7A.ccepted ❑Innovative []Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well D'Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to :verve? nlYes 13 No If yes, what type? p !� This is to certify that the information provided on this application is true and correct to the best of my knowledge. I undcrstand that any permits) or ATC(s) issued hereafter are wbject 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 detenrine compliance with applicable laws and rules. I u,pdCrsta_iV that I am respo"ble for the prober identification and labeling of property lines and corners and locating and flagging r staking Jhe housei�,aci° well location and the location of anv other amenities. b% owner's legal representative signature V Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given Oyes ONo Account # Y7—r1- — Revised 11106 Invoice # 4':7 g 9 rn 9 0 3 O W WVRO :IILOOMIS-13OVd L 1300WOd8-.-. s WV ROW: 1l LOOZIM - t 3EJVd l 1300W OdH DAVIE COUNTY HEALTH DEPARTMENT • ' Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990004424 Billed To: Jim Waters Reference Name: Proposed Facility:. Residence PROPERTY INFORMATION Tax PIN/EH #: 5799-2-792 Subdivision Info: Location/Address: Peoples Creek Rd. -27006 Property Size: 20 acres Date Evaluated: o:% Water Supply: On -Site Well Community Evaluation By: Auger Boring I Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L_ `- Slope % HORIZON I DEPTH G - Texture groupG G Consistence Structure & Mineralogy ( 'YIII HORIZON II DEPTH .. G( "10 ` C( Texture group :611 C_G Consistence P -1' /' Structure k -- cMineralo Mineralogy 1 �. HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE f CLASSIFICATION u 1 LONG-TERM ACCEPTANCE RATE ,a7 7 O SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: 9n k )ja-k-6 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Hki 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 tCS Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/0.9 (Reviced) ` Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990004424 Billed To: Jim Waters Address: 4010 Chadwyck Court City: Winston-Salem Reference Name: Proposed Facility: Residence IMPROVEMENT PERMIT Tax PIN/EH #: 5799-26-7921 Subdivision Info: Location/Address: Peoples Creek Rd. -27006 Property Size: 20 acres **NOTE**This Improvement Permit DOES 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: YNew ❑Repair ❑Expansio((n Permit Valid for: R5Years ❑No Expiration Residential Specifications: # Bedrooms'111 # Bathrooms�J� # People (9 Basement❑ ga-sement plumbing ff' Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): y �� Type of Water Supply: /County/City ❑Well ❑Community Well Site Modifications/PermitAs stated in 15A NCA,C 18A.1969(5) Conditions: , eept6d Syst__ J ._ _ A Site System Type LTAR Initial QC � to n , 5 - Repair T -e D • 7 Environmental i.p.11-06 h a 17% - T6� G/ KNO " ` 1 Gl 'S .vJPr�C_ — t-e�U�I �tecL —*7!---- Date Il 67 e' S �j '� 71 Il moo_ t �— Environmental i.p.11-06 h a 17% - T6� G/ KNO " ` 1 Gl 'S .vJPr�C_ — t-e�U�I �tecL —*7!---- Date Il 67 e' S