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125 Kerr Lnt Well Construction Permit Davie County Health Department 210 Hospital Street LV ..� P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Property Owner: Andrew Zalewski Address: 434 Cornatzer Road City: State/Zip: Phone #: Address/Road M Kerr Lane Advance Mocksville NC (910) 409-0579 27028 Vl=KMI I VALIU UN I IL: 12/30/2020 Applicant: Andrew Zalewski ::::�l Address: 434 Cornatzer Road City: Mocksville State/Zip: NC 27028 Phone M (910) 409-0579 Property Location & Site Information NC 27006 Latitude Longitude Site Address: Kerr Lane Subdivision: Phase: Lot: 2 *Proposed use of Well: If Other: Directions Directions: Hwy 801 North Tum on Woodlee, then right on Kerry Lane on the left Well Contractor Information Drilling Contractor Driller Registration Permit Conditions *Permit Conditions Well to be shared with Lot 1 Well location, construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of the Local Health Department. The permit may be revoked at any time for failure to comply with existing regulations. The siting of approved well construction area(s) by the Health Department is to provide protection from the known possible sources of contamination. The approved well area(s) may not be changed without written permission from an authorized representative of the Local Health Department. No volume of quality of water is guaranteed by the Health Department. *Issued By: 2140 - Nations, Robert *Date of Issue; 1 , a , 3 , 0 , /..1, 0 , 1, 5 Authorized State Ag ® Hand Drawing O ImportDrawing Owner/Applicant Signature: **Site Plan/Drawing attached.** Page 1 of 2 Chw.dws Renaming 3972 -" WELL CONSTRUCTION PERMIT 198484 Davie County Health Department CDP File Number: 71n Hncnital Straat Page 2 of 2 P1 P3 WELL CONSTRUCTION PERMIT ,d Davie County Health Department _ 210 Hospital Street P.O. Box 848 �`•�°�� Mocksville NC 27028 CDP File Number: 198484 County File Number: Date:. 1.2./ 3 0/ 2 0 15 Drawing Type: Well Permit Page 2 of 2 P1 P2 A f ,,2LICATIOOR SITE EVALUATION/IlV.d'ROVEMENT PERMIT & ATC ���IM Davie County Environmental'Health P.O. Box 848/210 Hospital Street Dau: Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: OG 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. APPLICANT INFORMATION Name ,yd/1r1L.) ContactPerson 2rlLwr�.S�� Address ,�/� i2 y C N Home Phone S /29 y© g- o S-7 q City/State/ZIP A d v,6 N cir-- Al e--- 2,7006 Business Phone Email_ � L�-9R.P. eo4 Name on Permit/ATC if Different than Above Mailing Address P V i3 0 3 S / City/State/Zip A 0 aA n -c /= At 42 2 loo PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application, Included: 2 -Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name 1 /YOr,f 1, y A L a c,SPhone Number Owner's Address �/, �/ �� o .� I2 f R IID City/State/Zip s y_ v. /Iy= N c ;x moa PropertyAddress City v c r_ Lot Size IZ IqTax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: 9'19 l- 14,19 o a L 1"P It R 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? Yes % o Are there any easements or right-of-ways on the site? Yes -No Is the site subject to approval by another public agency? Yes _iNo Will wastewater other than domestic sewage be generated? ^Yes /1Vo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _ # Bathrooms '-2- Garden Tub/Whirlpool ❑Yes 2No Basement: ❑Yes bio Basement Plumbing: ❑Yes {moo 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 ,0''kew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions, of the facility this system is intended to serve? ❑ Yes �o If yes, what type? ! This is to certify that the inform atio n ovided on this application is true and correct to the best of my knowledge. I understand that any permit(s) r ATC(s) issued er after are subject to suspension or revocation if the site is altered, the intended use charges, or if the informat' n submitted in s pplication is falsified or changed I hereby grant right of entry to the Authorized Representative of the Dav' Co5Hrealth/1)arknent to conduct necessary inspections to determine compliance with applicable laws and rules I underst d thes o • ibl for the proper identification andlabeling of property lines and corners and locating and flagging or s e haci ' o tion, proposed well location and the location of any other amenities. Site Revisit Charge Pr perty owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No _ Account # M? / Revised 11106 Invoice # l OPERATION PERMIT Davie County Health Department •r 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Andrew Zalewski Address: 434 Cornatzer Road City: Mocksville Statefzip: NC 27028 Phone #: (910) 409-0579 Property Owner: Andrew Zalewski Address: 434 Comatzer Road City: Mocksville State/Zip: NC 27028 Phone #: (910) 409.0579 Property Location & Site Information dress/Road #: Subdivision: Phase: Lot: 2 Kerr Lane r Advance NC 27006 Directions Hwy 801 North Tum on Woodlee, then tight on Keay Structure: SINGLE FAMILY Lane on the left # of Bedrooms: 3 # of People: 'Water Supply: NEW WELL 'System Classification[Description: *IP Issued by. 2140 -Nations, Robert TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140 -Nations, Robert Seprolite System? QYes QNo Design Flow: 3 6 0 *Distribution Type: GRAVITY- PARALLEL (eq.d-box) PQYeseQNo? Soil Application Rate: 0 - 3 'Pre Treatment: Drain field rNk(ification Field 1 2 0 0 Sq•ft. *System Type: INFILTRATOROUICK4STANDARDrain Lines 3 Installer: Shannon Henderson oTrench Length: 3 0 1091 0 ft. Certification #:Inches Trench Spacing: — O. 9 _ eFeet 0 CC *EHS: 2140 -Nations. Robert Trench Width: — 3 Inches @Feet 0 2/ 1 1/ 2 0 16 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 • Inches Minimum Soil Caner. a 4 Approval Status Inches ' Maximum Trench Depth: 3 6 Cl�Apptovetl Disapproved" Inches Maximum Soil Cover. a 4 Inches ' CDP File Number 198484-1 Manufacturer. Shoaf STB: 760 Gallons: 1000 Date: 09/ I 1 0 7/ I 2 0 1 5 M *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker. ❑ Yes M NO nforced Tank: ❑ Yes ' NO 1 Piece Tank: ❑ Yes ® No ❑ Yes El No ❑ Appiroved ❑ Disapprovetl , Manufacturer PT: Gallons: ra County ID Number: Lat. Long: Installer. Shannon Henderson Certification #: 1091 THS: 2140 -Nations. Robert Date: 0 a/ 1 1/ a 0 1 6 Approval, Status ®Approved El Disapproved Pump Tank Date: / / RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fdtings [I Yes ❑ No Installer. Certification #: 'EH S: upply Line Installer. Certification #: 'EH S: Date: Approval Status ❑ Approved ❑ Disapprovetl f Pump Type: Installer. / Dosing Volume: — Gal Certification #: Draw Down: *EHS: Inches *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N o Check -valve ❑ Yes ❑ N0Appr6valStatus PVC unions ❑ Yes El No ❑ Appiroved ❑ Disapprovetl , Vent Hole ❑ Yes ❑ No \ Anti -siphon Hole ❑ Yes ❑ No CDP File Number 198484 -1 County ID Number: 2140 • Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 2/ 1 1/ 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 It A sewage septic system. Rule .1961 requires that a Type TYPE II A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System InspectionlMaintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified 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 entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @ Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** MUGUIG CgUIPHICIR N EMA 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 M an ually 0 perable ❑ Yes ❑ NO *Activation Method: Date: "Approval Stafus Alarm Audible ❑ Yes ❑ No 0 Approved ❑ Disapproved: Alarm Visible ❑ Yes ❑ No 2140 • Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 2/ 1 1/ 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 It A sewage septic system. Rule .1961 requires that a Type TYPE II A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System InspectionlMaintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified 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 entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @ Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Operation Permit CDP File Number: 198484 -1 County File Number: Date: Olnch Scale: OBlock ON/A 1 - -CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street .�,,. P.O. Box 848 Mocksville NC 27028 For Office 'Use Only *CDP File Number 198484-1 County ID Number: Evaluated For: NEW Township: 1'11'-A\ IT VA11A n.T. Phone: 336-753-6780 Fax: 336.753-1680 1 a/ 3 0/ a 0 a 0 Applicant: Andrew Zalewski Property Owner: Andrew Zalewski Address: 434 Comatzer Road a Address: 434 Comatzer Road CRY: Mocksville City: Mocksville StatefZip: NC 27028 Saprolite System? OYes *No State2ip: NC 27028 Phone #: (910) 409-0579 Phone #: (910) 409-0579 Address/Road #: Kerr Lane Advance Structure: # of Bedrooms # of People: NC 27006 SINGLE FAMILY 3 *Water Supply: NEW WELL Subdivision: Phase: Lot: 2 Directions Hwy 801 North Turn on Woodlee, then right on Kerry Lane on the left soecificatio "Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: p 1 0 0 0 Gallons 1 -Piece: Oyes QNo Pump Required: OYes (J)No OMay Be Required 1 a 0 0 Sq. ft. Pump Tank: Gallons 3 1-Piece:OYes ONo 3 0 0, ft. GPM—vs— ft. TDH 9 . @Inches O.C. Feet O.C. Dosing Volume: _ Gallons Inches _ 3 . � Feet - - Grease Trap: Gallons inches PreTreatment: ONSF OTS -1 OTS -11 Septic Tank InstallerGrade Level Required: 01 Oil 0111 OIV Cann 4 of Q Minimum Trench Depth: a 4 Inches \Site Classification: Provisionally suitable Minimum Soil Cover: 1 a Saprolite System? OYes *No Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - 3 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) Se tic Tank' "Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: p 1 0 0 0 Gallons 1 -Piece: Oyes QNo Pump Required: OYes (J)No OMay Be Required 1 a 0 0 Sq. ft. Pump Tank: Gallons 3 1-Piece:OYes ONo 3 0 0, ft. GPM—vs— ft. TDH 9 . @Inches O.C. Feet O.C. Dosing Volume: _ Gallons Inches _ 3 . � Feet - - Grease Trap: Gallons inches PreTreatment: ONSF OTS -1 OTS -11 Septic Tank InstallerGrade Level Required: 01 Oil 0111 OIV Cann 4 of Q COP File Number 198484-1 County ID Number. ❑ Open Pump System Sheet R@DairSvstem Required: *Yes ONO ONO, but has Available Space 1 rceualr aystem r Trench Spacing: 9 O Inches 0.1 *Site Classification: Provisionally Suitable — • Feet O.C. Design Flow: Trench Width:QInches 3. Feet 3 6 0 — V Aggregate Depth: Soil Application Rate: 0 - 3 inches .� Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE IIA. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Covera 1 a Inches Maximum Trench Depth: 3 6 "Proposed System: 25%REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 a 0 - - Inches Sq. ft. No. Drain lines *Distribution Type: GRAVITY - PARALLEL (eq. d -box) 3 Total Trench Length: 3 0 0 Pump Required: Oyes @No OMay lie Required \\ ft: 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 wayguarentees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be issued atthe 'sam9time the Improvement Permit issued (NCGS 130A -336(11)t. 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 became 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: - / *Issued By'. 2140 - Nations, Robert Date of Issue:. 1 a / 3 0 / a 0 1 5 Authorized State g Malfunction Log Oyes *Hand 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 CDP File Number: 198484 -1 County File Number: Date: 12/30 /20 15 Q Inch Scale: QBlock — ft. urdwln$ uraw ng i ype: %,onstrucaon Humorizauon QNIA -40 U-J[:L V i F1 I I FT] CONSTRUCTION AUTHORIZATION . Davie County Health Department 210 Hospital Street CDP File Number: 198484 " 1 es ket P.O. Box 848 Mocksvilie NC 27028 County File Number: u B "1 �,G 121Date: 2 1 3 0/2015 Click l etow to Import an Image from an extemai location: Drawing Type: Construction Authorization A 61 .-IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street ' P.O. Box 848 Mocksville NC 27028 For Office Use Only 'CDP Fite Number 198484-1 County ID Number. Evaluated For. NEW Township: Phone: 336-753.6780 Fax: 336-753.1680 PERMIT VALID UNTIL: 12/7/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Andrew Zalewski Address: 434 Cornatzer Road CRY: Mocksville State2ip: NC 27028 Phone # (910)4109-0579, Address/Road #: Kerr Lane Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: NEW WELL Subdivision: : Provisionally Suitable Seprolite System? OYes allo Design Flow: 3 6 0 Soil Application Rate: 0 3 *System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Property owner. Andrew Zalewski Address: 434 Cornatzer Road CRY: Mocksville State/Zip: NC 27028 one #: (910) 409-0579 Phase: Lot: 2 Directions Hwy 801 North Turn on Woodlee, then light on Kerry Lane on the left Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes (j)No Pump Required: ()Yes. QNoOmay Be Required Pump Tank: Gallons 1 -Piece: Repair System Required:QYes ONo ONO, but has Available Space Repair System Site Classification: Provisionally Suitable Soil Application Rate: 0 3 *SystemClassification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION OYes O No Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Pump Required: oYes *No O Maybe Required Pagel of 3 CDP File Number 198484 ` 1 County ID Number: , *Site Modifications 0 Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. r *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 requ item ents. $i lien The Improvement Permit shag be valid for 6 years from date of issue with a site pian (means a drawing not necessarily drawn to scale that shows the existing and proposed property tines with dimensions, the location of the facility and appurtenances, the ' 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 of one inch equals no morethan 60 feet, that includes: the specific location of the proposed facility and appurtenances, the sitefor 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 articie This permit is subject to revocation If the site pian, plat, or intended use changes (NCGS 130A -335(t)). 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)j. Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps. Signature: Date: / "issued By: 2140 -Nations, RobertDate of Issue: a 0 ? / a 0 1 5 State A a OValid without Expiration? Authorized St y �, --� OCreate CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 F IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 198484 -1 County File Number: Date: Q Inch ^_-- % -c^ IMPROVEMENT PERMIT Davie County Health Department ' 290 Hospital street CDP File Number,: 198484-1 P.O. Box 848 Mocksvi0e NC 27028 County File Number: Date: 1/07 /2015 Click below to Import an Image from an external location: Drawing Type: Improvement Permit APPLICATIO �OR SITE EVALUATION/IMPROVEMENT PERMIT &ATC gECEIDavie County Environmental Health P.O. Box 848/210 Hospital Street 6� Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: `NrSite 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. APPLICANT INFORMATION Name /y/%/1 lc� �✓� ` ! 7 � Ste/ Contact Person Aex2_ w _ 2,QL � 5. Address ,41 /s e p. y [ M_ Home Phone 9 /t? ' Y ©9 — 9 5 -7 g City/State/ZIP J9 D vA n2 Ala. 2 7 DO 6 Business Phone Is the site subject to approval by another public agency? Email /V Z AL F c,> -9e Email: or,%<i .� .Ee. X,P. c?cw5 Name on Permit/ATC if Different than Above Mailing Address P y A e) n 3$/ City/State/Zip AP OA PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: 2 -Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name %1 /y/�X i;F 4-v z /4 L r e-. 51--1 Phone Number 9 /d -yo os Owner's Address C/, �/ c o n� i2 .� R R D City/State/Zip 2,log ,2;- PropertyAddress City 6 v A & d - Lot Size f / C Tax PIN# Subdivision Name(if applicable) Section/Lot# c� Directions To Site: 9^,9t- If 'ot- 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? 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 wastewater other than domestic sewage be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People ,9 # Bedrooms _ 3 # Bathrooms 2, Garden Tub/Whirlpool ❑Yes 2No Basement: ❑Yes 2fTo Basement Plumbing: ❑Yes Erf�o TF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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: 06nventional ❑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 Ko If yes, what type? This is to certify that the informatio{ovided on this application is true and correct to the best of my knowledge. I understand that any permits) r ATC(s) issued r fter are subject to suspension or revocation if the site is altered, the intended use charges, or if the informat' n submitted in is pplication is falsified or changed I hereby grant right of entry to the Authorized Representative of the DavX County Heal artment to conduct necessary inspections to determine compliance with applicable laws and rules I unders dre o ibl or the proper identification and labeling of property lines and corners and locating and flagging ors a hou faci ' o tion, proposed well location and the location of any other amenities. Site Revisit Charge Pr perty owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # 19 Revised 11/06 Invoice # i CD (1.16A) ( N 1 ,QQQA PB11 PG285/286 6910 9940 o LOT 5 LOT 1 N i PB10 PG298 _ ------------------------------------- 1.009A ----------------------------------- 1.009A 5719 °R 9744 �i hAr* � 6pat1 T 7.21A 35z MI. 5327 4-220 t 1-....__. 10) —� -_ woD _ i 1 ---- 8 `o f;- -------------- PB10 P Lot y_•J�l �VCD ry� 6527 0i P811 PG138 ?� •i�(��' �`r` (5.21 7587 �r -, �_' �o t N 1 I. 9511 25E 1 PB08_PG190 I PB11 PG285/266 "i 151_ • _ 1 ------------------ LOTB N1 33' z�� 4 } � � � ;•— •--..._ •.-�.__.._. _.__._. __ ._... _ . ..815 tj CD t 1 co v (5.85A) 6370 I• 1' 4.18A m: r 6127 I k 1 673_ - _...__: _ -.... __ ._�'r • -; '.� _ .966._ ._ �.. — - .... _ 4�8.. .. .__._.... 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T��+J.. t�^'" `F�' '`u'1. - -f • DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Y Soil/ Site Evaluation APPLICANT INFORMATION Andrew Zalewski 910 409-0579 Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit PROPERTY INFORMATION Kerr Lane 11.53 Acres Site #2 Public Cut ff • •Landscape position HORIZON I DEPTH Texture group Consistence HORIZON H DEPTH Consistence HORIZON III DEPTH HORIZON IV DEPTH Consistence Mineralogy CLASSIFICATION SITE CLASSIFICATION: P5 LONG-TERM ACCEPTANCE RATE: • 3 REMARKS: EVALUATION BY: r' ON5 OTHER(S) PRESENT: Z% z Q LEGEND Landscape Position R - Ridge S -Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL Silty clay loam. SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC -Silty clay C - Clay CONSISTENCE aZ41St 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 1 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 - eal/dav/ft2 t,r,uM Hunt tee..: ea.