115 Kerr LnOPERATION PERMIT
.,, Davie County Health Department
�- 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
StatehZip: NC 27028
Phone #: (910) 409-0579
Address/Road #:
Kerr Lane
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: NEW WELL
*IP Issued by. 2140- Nations, Robert
*CA issued by: 2140. Nations, Robert
Property Owner. Andrew Zalewski
Address: 434 Comatzer Road
City: Mocksville
Statefzip: NC 27028
Phone #: (910) 409-0579
ierW Location & Site Information
Subdivision: Phase: Lot: 1
Design Flow: 3 6 0
Soil Application Rate: 0 - 3 a 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Directions
Hwy 801 North, turn on Woodlee, right on Kerr Lane
*System Class ification/0escription:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? 0Yes (3) N o
*Distribution Type: GRAVITY- SERIAL Pump Required?
()Yes WNo
*Pre Treatment:
Drain field
1 1 0 7 Sq. It.
3
a 7 3 ft.
— 9 Inches O.C.
Feet O.C.
Inches
- 3 . Feet
inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Shannon Henderson
Certification #: 1091
*EH S: 2140 -Nations. Robert
Date: 0 a/ 1 1/ a 0 1 6
Minimum Trench Depth: 3
6
Inches
Minimum Soil Cover. a
4
Inches
Maximum Trench Depth: 3
6
Inches : ,
Maximum Soil Cover. 2
4
Inches
CDP File Number 198481 - 1
Manufacturer. Shoat
STB: 760
2Gallons: 1000
Date:
0
9/
0 7
/ .2 0 1 5
*Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker,
1:1
Yes
2
No
nforcedTank:
C]
Yes
2
No
I Piece Tank:
[I
Yes
ff)
No
❑ Yes
El
No
❑ ApprovedO Disapproved=
S�
Manufacturer.
PT:
Gallons:
Date:
RiserSealed [:]
Yes
0
No
RiserHeight: 0
Yes
C3
No (Min.61n.:
Reinforced Tank: C3
Yes
0
No
�l Piece Tank: C]
Yes
0
No.
Pipe Size: inch diameter
Pipe Length: feet
*Schedule.
Pressure Rated 0 Yes ❑ No
approved fittings [3 Yes 1:1 No
County ID Number: C70000013406
Let.
Long:
Installer: Shannon Henderson
Certification 9: 1091
*EH S: 2140- Nations, Robert
Date: 0 2 / 1 1/ 2 0 1 6
Approval
Approvedtoved ❑;-Disapproved
Pump Tank
Installer.
Certification #:
*EH S:
Date:
Date:
pprovaStatus
3M
Aprove d,Disapproved
Pump Type: Installer.
Dosing Volume: Gal Certification 9:
Draw Down: Inches *EHS:
'Chain:
Date:
Valves Accessible
El Yes
13
No
Flow Adjustment Vatve
El Yes
13
No
Check -valve
0 Yes
El
N o
Approval Status
PVC Unions
❑ Yes
El
No
❑ ApprovedO Disapproved=
S�
Vent Hole
El Yes
El
No
Anti -siphon Hole
El Yes
0
No
CDP File Number 198481 -1
r=rGaurc eaurarnenz
County ID Number: C70000013406
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:
ApprovalStatus;
Alarm Audible ❑Yes ❑ No
Approved El Disapproved
Alarm Visible ❑ Yes ❑ No
2140 • Nations, Robert
*Operation Permit completed by;
Authorized State Melt
Owner/Applicant Signature:
Date of Issue: O a/ 1 1/ 2 0 1 6
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 as conditions of the Improvement Permit and
Construction Authorization. This property Is served by a TYPE 11.k sewage septic system.
Rule .1961 requires that a Type TYPE II 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.
WA
Reporting Frequency By Certified Operator NA
Rule .1961 requires that a Type 1V 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 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 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
Fe Y
**Site Plan/Drawing attached.** ``i
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
CDP File Number: 198481 -1
County File Number: 070000013406
Date: ! /
O Inch
Scale:._ OBlock
ON/A
- 7C,.
16
pa Q} ��-1
1-I I
i
I
i
I
i
-
-7
1
T-
7
XIL
-J
I
CONSTRUCTION
AUTHORIZATION
som Davie County Health Department
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
State/Zip: NC 27028
Phone #: (910) 409-0579
For Office Use Only
*CDP File Number 198481 -1
County ID Number: 070000013406
Evaluated For: NEW
Township:
PERMIT VALID UNTIL:
0aiO3/20a1
Property Owner: Andrew Zalewski
Address: 434 Cornatzer Road
City: Mocksville
State/Zip: NC
Phone #: (910) 409-0579
Property Location & Site Information
Address/Road M Subdivision:
Kerr Lane
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: NEW WELL
27028
Phase: Lot: 1
Directions
Hwy 801 North, turn on Woodlee, right on Kerr Lane
Page 1 of 3
Minimum Trench Depth:
a 4 Inches
\Site
Classification:
Provisionally suitable
Minimum Soil Cover:
1 a
Saprolite System?
O Yes ® No
Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 3.2
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) Septic Tank:
1 0 0 0
Gallons
*Proposed System: 25% REDUCTION
1 -Piece:
O Yes ® No
Pump Required: QYes
®No O May Be Required
Nitrification Field
1 1
0
Sq. ft. Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece:
QYes ONO
Total Trench Length:
a 7 3
GPM--vs— ft. TDH
ft
Trench Spacing:9
—
Olnches O.C.
® Feet O.C. Dosing Volume:
— Gallons
Trench Width:
3
j Inches
Feet
—
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01011
O 111 01V /
Page 1 of 3
CDP File Number 198481 - 1 County ID Number: 070000013406 j
❑ Open Pump SysbBm'Sheit
ReoairSvstem Reauired:®Yes O No ONO, but has Available
/Repair System
*Site Classification: Provisionally Suitable
Design Flow: 3 6 0
Soil Application Rate: 0 3
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field
1 a 0 0 Sq. ft.
No. Drain Lines 3
Total Trench Length: 3 0 0 ft,
Trench Spacing:
9 O Inches O.
— ® Feet O.C.
Trench Width:—
3 j Inches
Feet
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type:
GRAVITY - SERIAL
Pump Required: OYes ®No O May Be Required
Pre -Treatment: O NSF OTS -1 OTS -11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Characters
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. CharaRea��9
2000
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and may be Issued at the same time the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been
completed during the period of validity of the Construction Permit, the Information submitted in the application for a permit or Construction
Authorization Is found to have been incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become
Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature- Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 a / 0 3 / a 0 1 6
Authorized State Agent: alfunction Log O Yes zJ.
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
� � CONSTRUCTION AUTHORIZATION
. ,� • , Davie County Health Department CDP File Number: 198481 - 1
210 Hospital Street C70000013406
P.O.Box 848 County File Number:
Mocksville rvc 2�o2s Date: 0 a / 0 3 / a 0 1 6
�Inch
Drawin� Drawing Type: Construction Authorization Scale: , ' OO N%A k ,ft.
_ ��,.
..... _......----- I �
- --- --— = I — � �� —
. _� — �
_-- -_ �_�n �
__ -- ----- _ _-�_ -- _ _ __ _ __ ___ __ -- -- ___ ^� �._
_ __ ___ _-- --- _- -_ __.
-----
I �
_ - - - -
� `-�
_
_ -- _ __ --- -. _ _ _ _._ _ __ �' _ -- _ _ _ __ _ h I ��'�
f -�___ _--- _
;
; �� _ _ �' i i
_ �- -!- -���-:_ ! _
�_
�. �_
_ �,s —. --- � � ;-�, r,,, — — .-�.--
_ _ -- _ _--- - _ _.__ ___ } ___ ___ __ _ __ _. _.�.. __.
�- � __ _ I�,�- _ �--
; � �
� � --�-!_ __
_-: -� - - � - �
�� - ;
__��'�"-�- _. _ _ .
- - - - - - �-!�
�
----- -- - .� ��
� _
--� Qo
_._ .._. _........ .
.__. �ry7 _..._...._ �.......
I�-
. — � _ .
�
;
i l-I ...__ �
.. _.--- __ _ ___------_. __------- . ---- _ _
--------- ----._ _ P 1 P2
Page 3 of 3
CONSTRUCTION AUTHORIZATION _
Davie County Health Department
n (_?10 Hospital Street CDP File Number: 198481 - 1
1 C� II U. P.O. Box 848 C70000013406
"��/^ County File Number:
`e Mocksville NC 27028
'/ Date- .O. a. l 03 / a 0 1 6
Iii- -7 - �� G !il /1 G r! i3`L �'L L.�,�p,.s.- Z'e IFI
Click below to import an image from an external location: Drawing Type: Construction Authorization
��-- Pd
,,_I ( - t (e
Page 3 of 3
/<.,r_-7 1�0
L --q--
Pi P2
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 8413
Mocksville NC 27028
Phone: 336-753.6780 Fax: 336.753.1680 0 a/ 0 3/ a 0 a 1
Applicant: Andrew Zalewski Property Owner. Andrew Zalewski
Address: 434 Comatzer Road Address: 434 Comatzer Road
CRY: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone #:
Address/Road M
Kerr Lane
Advance
Structure:
# of Bedrooms:
# of People:
(P1 0) 409-0579
NC 27006
SINGLE FAMILY
3
*WaterSupply: NEwwELL
Phone #: (910) 409-0579
Subdivision: Phase: Lot: 1
Directions
Hwy 801 North, turn on Woodlee, right on Kerr Lane
System Specifications
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 1 0 7
Sq. ft. Pump Tank: Gallons
No. Drain Lines
3 1-Piece:OYes ONo
r
Total Trench length: a 7 3 GPM vs— ft. TDH
Trench Spacing: 9 Feet O.C. Inches O.C. Dosing Volume: _ Gallons
— � _
Trench Width:()Inches3 - QFeet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade -Level Required 01011 0111 O1V
Minimum Trench Depth:
a
,q,
Site Classification: Provisionally Suitable
Inches
Minimum Soil Cover.
1
a
Saprolite System? OYes *No
_._
Inches
Design f=low: 3 6 0
Maximum Trench Depth:
3
6
inches
Soil Application Rate: 0 3 2 5
Maximum Soil Cover:
a
4
Inches
"System Classification/Description:
"Distribution Type:
GRAVITY -SERIAL
TYPE R A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Septic Tank:
1
0 0 0
Gallons
"Proposed System: 2511/o REDUCTION
1 -Piece:
OYes
@) No
Pump Required: OYes ONo OMay Be Required
Nitrification Field 1 1 0 7
Sq. ft. Pump Tank: Gallons
No. Drain Lines
3 1-Piece:OYes ONo
r
Total Trench length: a 7 3 GPM vs— ft. TDH
Trench Spacing: 9 Feet O.C. Inches O.C. Dosing Volume: _ Gallons
— � _
Trench Width:()Inches3 - QFeet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade -Level Required 01011 0111 O1V
CDP File Number 198481 -1
County ID Number. C70000013406
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ()No, but has Available Space
,`Repair System
Q
*Site Classification: Provisionally Trench Spacing: 9 Inches 0.
ysuitabla s Feet O.C.
Trench Width: QInches
Design Flow: 3 6 0 _, 3 V Feet
Soil Application Rate: 0 3 Aggregate Depth: inches
.�
*System Classification/Description: Minimum Trench Depth: 2 4
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover 1 a
`Proposed System: 250A REDUCTION
Nitrification Field 1 a 0
Sq. ft.
No. Drain tines 3
Total Trench Length: 3 0 0 ft
Maximum Trench Depth: 3 6
Maximum Soil Cover: 2 4
*Distribution Type: GRAVITY -SERIAL
Inches
Inches
Inches
Inches
Pump Required: QYes @No (May Be Required
Pre Treatment: ONSF OTS -1 OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies In meeting their requirements.
chis Authorization for wastewater System Construction shall bevaiid fora person equal to the period 0f validity ofthe Improvement Permit, not
to exceed five years. and may be issued at the same time the Improvement Permit issued (NCGS 130A-336(b)� if theinstallation has not been
completed during the period of vaildity 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 orConstruction Authorization shall become
invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible forassuring compliance
withthe laws, rules, and permit conditions regarding system location, installation, operation, maintenance;, monitoring, repotting and repair
Applicant/Legal Reps. Signature Required? QYes ONO
Applicant/Legal Reps. Signature Date; 1
*Issued By: 2140 - Nations, Robert Date of Issue: 0 2 / 0 3 / a 0 1 6
Authorized State Agent: '�'�'_ � fialfunction Log QYes .t
*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
Drawing Drawing Type: Construction Authorization
CDP File Number: 198481-1
County File Number C70000013406
Date: 02/ 03 /.1 0 1 6
Q inch
Scale: 08lock
QN/A
NONE
MEMEMEN
M
OMMI
NONE
M
M
MEM
ME
MIM
IN
MIN
M
M
IN
MI
IN
MEN
N
M
IN
M1
M
MEM 1M
IN1
■
IN
■
M
M
M1
A
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
1 4
CDP File Number: 198481 -1
County File Number. C70000013406
Date: 02/ 03 /2016
Click below to Import an image from an external location: Drawing Type: Construction Authorization
-IMPROVEMENT PERMIT
Davie County Health Department J, p
210 Hospital Street
� X30.1
P.O. Box 848
•,`��•� 100
Mocksville NC 271
ForOffice Use Oniv
*CDP File Number 198481 -1
County ID Number. 070000013406
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
City: Mocksville
State/Zip: NC 27028
Phone #: (910) 409-0579,
Address/Road #:
Subdivision:
Kerr Lane
Inches
Advance
NC 27006
Structure:
SINGLE FAMILY
# of Bedrooms:
3
# of People:
0 Gallons
*Water Supply:
NEW WELL
Provisionally Suitable
SaproliteSystem? OYes @No
Design Flow: 3 6 0
Soil Application Rate: 0 3 a 5
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS) _
*Proposed System: 25% REDUCTION
J
Property Owner. Andrew Zalewski
Address: 434 Cornatzer Road
City: Mocksville
State/Zip: NC 27028
Phone # (910) 409-0579
Phase: Lot: 1
Directions
Hwy 801 North, turn on Woodlee, right on Kerr Lane
Minimum Trench Depth:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Septic Tank:
1 0
0
0 Gallons
1 -Piece: OYes @ No
Pump Required: OYes @No.OMay Be Required
Pump Tank: Gallons
1 -Piece: OYes O No
Repair System Required:@Yes ONo ONO, but has Available Space
Repair System
'Site Classification: Provisionally Suitable
Soil Application Rate: 0, 3
*System Classification/Description:
TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Minimum Trench Depth a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: OYes @ No O May be Required
Page 1 of 3
CDP File Number 198481 -1 County ID Number: c70000013406
*Site Modifications ❑ open Fill Sfieet
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 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 shag be valid for S years from dateof 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
sits forthe proposed Wastewater system, and the location of water supplies and surface waters).
Plat The improvement Permit shag 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 site for the proposed Wastewater system, and the location of water supplies and surface waders. Plat
also means, for subdivision lots approved by the localplanning authority and recorded with the county register of deeds, a copy
of recorded subdivisions plat that Is accompanied by a site pian 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 pian, plat, or Intended
use changes (NCGS 130A -335(o). The person owning or controliing the system shall be responsible for assuring compliance
with the taws, 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 / 0 ? / a 0 1 5
AuthorizedState Agen00, OValid without Expiration?
r 0Create CA?
(91 -land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
C
IMPROVEMENT PERMIT 198481-1
k Davie County Health Department CDP File Number:
210 Hospital Street 070000013406
P.O. Box 848 County File Number:
Mocksville IVC 27028 Date:
Q Inch
Drawing Drawing Type: Improvement Permit Scale: OBlock
j QNIA ft.
�i
�ly
W,
t
I
I
_
r r
f-%--- A -91f
IMPROVEMENT PERMIT
Davie County Health Department r
210 Hospital street CDP File Number: 158481 =1
P.Q. Box 848 C70000013406
Mocksvilie NC 27028 County File Number:
Date: 1/07 /2015
Click below to Import an Image from an external location: Drawing Type: Improvement Permit
APPLICATION FOR SITE EVALUATIONJNTROVEMENT PERNHT & ATC
ED Davie County Environmental Health
V,P.O. Box 848/210 Hospital Street
=Evaluationffinprovement
Mocksville, NC 27028
Dam: (336)753-6780/ Fax (336)753-1680
ApplicationFor: Site 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,"d=�v Z/� L lr5,el Contact Person 21Z,5z.5,,,'1
Address 99 t? g y L M Home Phone 9 i D- Y D 9- o s 7q
City/State/ZIP NQ 2700 G Business Phone
Email /Y 7 L G co S,y 1 10 F Email: A �- A L F4iSi-li � ti`c • /l p. eo s
Name on Permit/ATC if Different than Above
Mailing Address P D 6 o n 3 S/ City/State/Zip IA e oA nye r k e g 7oo6
PROPERTY INFORMATION *Date House/Facility Corners Flagged //—
NOTE: A survey plat or site plan must accompany this application. Included: 2'3ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name A/Y& 1 L G c..S.,�'/ Phone Number i /e2 ^yam_ oft
Owner's Address t/.2 4/ o A i2 J' ✓3 D City/State/Zip lel e, e- /_1 d,
Property Address /z GA 4, �' City /9 Q vAe-
�=
Lot Size�/ . S q Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: Qv I- w H T -'If R y
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 a1Qo
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 /fTo
IF RESIDENCE FILL OUT THE BOX BELOW
# People 9 # Bedrooms 3 # Bathrooms 2, Garden Tub/Whirlpool ❑Yes 2No
Basement: ❑Yes 2f%To Basement Plumbing: ❑Yes Eio
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: 96onventional ❑Accepted ❑Innovative ❑Alternative ❑Other.
Water Supply Type: ❑ County/City Water ,0'gTew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes .1E o
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) Ab] itt 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 Dav' County Heal artment to conduct necessary inspections to determine compliance with applicable laws and rules
I unders d re o ibl or the proper identification and labeling of property lines and corners and locating and flagging
or s e hou faci o ion, 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):
1/. /, _ /S Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # —4V I
Revised 11106 Invoice #
427
i
PB11_PG285P288
LOT 5
-------------------------------------- --
7.21A
5327
------------ (0
1 --------- PB10 Pf
Lot,
V
ZS
R
r" Sao (5.21.
CD
�
BIC
(5.21.
25E
i.
PB11_PG285/286 CV4
------------------
LOTS cv)
815
F!
CV
CD
- 4
3 70
1Z
V .
4.18A cq
6127
(796)
D-.C—tyh....piikdlh..Vk--roams
.d MA. w va..tk. ap—d or
i.'PU.4i.f.d.m1.% indudmg widmt Emhmtim U
impliedWlm ofmmhmtmblty md fitma f—
p.tdmpmpm U--c.—.VAt..otdylh.GLS
DT.t—t of m.meitlmda i. the m . U ematiwt
—b meds it fdm vdfins.
DM.C.WyCU
Mk�M%NC 27W
\1/—EAMEX
(1.16A)`
03019—
1.000A
6910
Cq
9940
0'
0'
LOT I
mvpd.41111"15
cv
PBI0PG298
9�_Em�sjo.
D�KAWSWPI—Fd
1.009A
5719LO
U.):
cv 9744
4;
•N-• :
V— ..'
�3 �41p�."--
?2Q..
i
-- -_ '-woomezon._
6527
7587
PBll PG138
cv�
9511
PSCELPG190
CV;
t.
(5.85A)
co
6370
673
--j<m
427
i
PB11_PG285P288
LOT 5
-------------------------------------- --
7.21A
5327
------------ (0
1 --------- PB10 Pf
Lot,
V
ZS
R
r" Sao (5.21.
CD
�
BIC
(5.21.
25E
i.
PB11_PG285/286 CV4
------------------
LOTS cv)
815
F!
CV
CD
- 4
3 70
1Z
V .
4.18A cq
6127
(796)
D-.C—tyh....piikdlh..Vk--roams
.d MA. w va..tk. ap—d or
i.'PU.4i.f.d.m1.% indudmg widmt Emhmtim U
impliedWlm ofmmhmtmblty md fitma f—
p.tdmpmpm U--c.—.VAt..otdylh.GLS
DT.t—t of m.meitlmda i. the m . U ematiwt
—b meds it fdm vdfins.
DM.C.WyCU
Mk�M%NC 27W
\1/—EAMEX
I.Awi
03019—
IQ Mv
s
mvpd.41111"15
9�_Em�sjo.
D�KAWSWPI—Fd
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Andrew Zalewski
910 409-0579
Water Supply:
Evaluation By:
On -Site Well f Community
Auger Boring
Pit
IAUijitic7i &wi;Lei a�7- IiT•)��
Kerr Lane
11.53 Acres Site #1
Public
Cut
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY.
OTHER(S)PRESENT:
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
CONSISTF�.NCF
Moist
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
lYotteS
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(suMIUM), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - eal/dav/ft2 noun nvnc PD-4—AN
Landscape position
ConsistenceILI
HORIZON Il DEPTH
Texture group
Consistence
�► 11L�iG�l��C-��-�
Texture �ou
Consistence
Mineralogy_
Consistence
Mineralogy
CLASSIFICATION
NIKON
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY.
OTHER(S)PRESENT:
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
CONSISTF�.NCF
Moist
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
lYotteS
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(suMIUM), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - eal/dav/ft2 noun nvnc PD-4—AN