171 Primrose Rd Lot 6 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 n�
/ / l
Account #: 990002285 Tax PIN/EH#: 5789-97-0344.06
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#06
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Pro a Size: see ma
ATC Number: 4474
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUJCTTIION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /"y Date: �.
.e rooms
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
has m lled in co with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
D' osal Sy terns,"LAr NO WAY be taken as a guarantee that the system will function satisfactorily for any
iven peri c t( I
. 1 5� to
lai
Fi5FA 1
Septic System Installed By:
Environmental Health Specialist's Signature. Date:
DCHD 05/99(Revised) �'�` Ll
22�' To•I-�.1 �n•e�
i S�F7 2�O b r •-I l00�
DAVIE COUNTY HEALTH DEPARTMENT
' . ' • ' Environmental Health Section
• P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 ` a1
IMPROVEMENT/OPERATION PERMIT
Account #: 990002285 Tax PIN/EH#: 5789-97-0344.06
Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#06
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Property Size: see map
**NOTE *This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms � #Baths _
Dishwasher:A!r Garbage Disposal: C30' Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow(GPD) Site: New❑ Repair❑
J(
System Specifications: Tank Size&MEAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft
Other:
As stated in 15A NCAC 18A.I.969(-
Required Site Modifications/Conditions: aceepled Systems may also be used
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
"'7
Environmental Health Specialist's Signature: Date: !/
DCHD 05/99(Revised)
t"CtJ GJ vJV V 1 ; -T.](•' u 1..nrot tuet'�vtl --- •-- -. -- Q119 .7,70 t G t J
• '' ':' : �• . ' DoT- .�
APPLIC.t1111V EOR SITE EVAtl1AT10N/IMPROVENE1(f PERMIT&ATC a `
V;*-Coynty Health Departrnent ��J �7NI
'Envilanmental Haaltlr Section
P.O. Box aae/zia Hospital Street
119ghog133e, PC 27M
' (336)751-8760
a�•ZUPO$TAdT•••.T%= APPLZCXTION C:AJOWr BE PROCSSSED tlttt,HSS &LL mm V==RiM
DIP0tOt1lT20A Zs 7R0V=XZ. Refer to the
XMXMM=QN BOLLETIlr for instructioyn�D.
./1. Nae. to be 8111.4 / w"L4ty14t5,r -uo„t.ot P.a.w,/D/C(e d A)
r/1ra111ny Aedr.ss �L(>>N(r-LSA✓/rlf ZAI v.tfa.e 1Lon� �7E�"�5��
✓t:sty/at.to/za_ MA(xs t/id—e- .C. at7024 t�aataea.Phan. _ rK -7.179
Y r. tt.ea oa I,*,mLe/ArC 1f o •.rent thm Above
Natllag eddreaa r1.tp/scaca/z1p 410 NO V?e
r.3. application Por: Site EvAluation t7 Zaprmrs�ent parmi.t/ATC' ❑ Both
,tet. eye%;—to Baavla.. rd IIouae M Mobile 31ozee 13 Business CI Snduatry 13 Other
.`L. type ey.t—sequ.etod111, ❑ Co *#%tlooal d eon•wtlo.al s"tried Q Seawative
.—s. Xf Neesidences 1 Poople 1 Badrocum _ P Bathroom
-� idDl,Iwa.Mr lZwrbege Dloyaxal ukiey 7raeWe ❑D4eret/Pluebrsg ❑a�e...t/�te Pirbi.q
t. It ausin.ae/Industry/other: "city typo s People f Stako
1 Conmod.e s ranuere s Drinale s Nater Ceelers
IF FOOD-SERVICII; M�Boatt• Zitimgt.4 Wat-Or r7raga (yiliona Pyr dry)
—~s. type of otor supply, 4rCoun-y./City ❑ Well C Cczaauaity .
P. m you aotialpats adalttons or expansions of the fatality this system is intended to scrn?(3 Ya . u ria
r .
Ifyes,whatt " _
Ltf?0A7AN7—C'Lil?bN rl MUST CO)ri'.L'PE THE REQUIRED PROPERTY INFORMATION REQUESTED
DE EtthcraPLAT orSITE PL TBES1ZBMI7TEDb the eltent with THIS APPLICATION.
tf9ropertyDimensions: 1?9' PF..1. ItITEDIRESTIONS(froinmocuvm)t*rROPERTY:
nirax Office PIN: it ?8 7 6 3 SE 0 l58 f V Flvf g n,
- ProperlyAdit-- IiaadNama !xY>�GES C2 +e��
CityrGprATV-VA,e)CE A16z270.ze_
finsSuhdivuton rovidelaformatim asfollows:
Name. /M}2C-P(Il0/]c RIAOSE 4
Section: Block: Lor.=_ &.Efate home corners Ragged:, 15-46e,2$9_Ica,<6
This is to certify that the infortaatlon provided is correct to the best of my knowledge.I understand that any pernlit(s)
issued hereafter are subject to suspension or revocation,If the site pion or intended use change,or if the inrornution
submitted In this application is faisifird or ehran¢nL 1,alio.rmders!and cher/au r eslwnsr711Sjoraff eGprra incurred from
Osis applicarlat I,hereby,give constal to the Authorized Reprtstnta(Ive of the Davie County Heath Dcpartintnl
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as aeccuary la determine the site sub
t--DATE ..! -a.1 -0!5 -SIG-NATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SrM PLAN(Include all of the following: Existin sad proposed
property lines and dimeosfons,struetuits.setbacks, and septic locations).
Site Itcvfsit Crarge
Datc(s):
Client Notirication Date:
F.HS:
�S
Sign given 6 Amunt No. 72._ 2
it"ised DCHD(MM3 Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INfNRMATION PROPERTY INFORMATION
'TJIIQt7ZZ85 Tax PIN/EH#: 5789-97-0344.06
t ' Billed To: Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot#06
Reference Name: Location/Address: Peoples Creek Rd.-27006
Proposed Facility: Residence Property Size: see map Date Evaluated:
Water Supply: On-Site Well Community Public /
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slo e%
HORIZON I DEPTH '� b'rb
Texture group se-L-
Consistence g `
Structure
Mineralogy
HORIZON II DEPTH 6-19 Z
Texture groupC
Consistence V�SIV
Structure ,
Mineralogy
HORIZON III DEPTH ^3
Texture group ck5;
Consistence $
Structure
Mineralogy
HORIZON IV DEPTH 2X '-C)9 3A
Texture group () LS
Consistence jrr435
Structure 2
Mineralogy OCYF
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE S
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 0S EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: d' OTHER(S)PRESENT:
REMARKS: � .�I T' 1.�7- �o `1'
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
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
w
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-Prisipatic
Mineraloev
1:1,2:1,Mixed
Notes
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) r
LTAR-Long-term acceptance rate"-gal/day/ft2
ir
`* OPERATION PERMIT FCDP
ice use 051V
Davie County Health Department Number 198631 -1
210 Hospital Street
P.O. Box 848 umber.
Mocksville NC 27028 Evaluated For. EXPANSION
Phone:336-753.6780 Fax:336-753-1680 Township:
Ad
plicant: Alexander Birch Property owner: Alexander Birch
dress: 171 Primrose Road Address: 171 Primrose Road
CRY: Advance CRY: Advance
StatefLip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-6107 Phone#: (336)998-6107
Property Location & Site Information
r
dress/Road#: Subdivision: Marchwoods Phase: Lot: 6
171 Primrose Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 right on Hwy 801 cross RIR tracks left on
Peoples Creek Rd
#of Bedrooms: 4
#of People:
*Water Supply: PUBLIC
*IP Issued by. 2140-Nations,Robert *System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? ( Yes QNo
Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes @No
Soil Application Rate: 0 - a 7 5 *Pre Treatment:
Drain field
rNo.
cation Field 4 3 6 Sq-ft. *System Type: INFILTRATOR OUICK4STAND
ARD
rain Lines :2 Installer: Randy Miner
oaTrench Length: 1 0 6 ft. Certification#: 1128
Trench Spacing: — 9 Inches O.C.
• Feet O.C. *EHS: 2140-Nations.Robert
Trench Width: 3 Inches
Feet Date: 0 4 0 4 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 4 0
Inches
Minimum Soil Cover. 2 8 Inches Approval Status
Maximum Trench Depth: 4 $ ® Approved O .Disapproved
Inches
Maximum Soil Cover. 3 6
Inches
CDP File Number 198631 - 1 Septic Tank County ID Number:
R {
Manufacturer. Lat.
STB: Long:
Gallons: Installer:
Date: Certification#;
'EHS:
'Filter Brand:
ST Marker. ❑ Yes ❑ No Date:
ApprovalStatus
Reinforced Tank: ❑ Yes ❑ No .;
111z,Piece Tank: El Yes ❑ Na ❑ Approved❑ ;Disapproved ,
Pump Tank
MManufacturer. Installer.
PT: Certification#:
Gallons: THS:
Date: / / Date: /
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.) 01,
Approval Status
Reinforced Tank: ❑ Yes ❑ No ❑ .Approved Disappt-ovecl. .
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe length: feet Certification#:
"Schedule:
'EHS:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings ❑ Yes ❑ NoApproval Status
❑ Approvetl❑ Disapproved
Pump e u e e
Pump Type: Installer:
Dosing Volume: — Gal Certification#:
Draw Down: Inches THS:
'Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approvalstatus
PVC unions ElYes ElNo ❑ Appt=ovetl Cl Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 198631 - 1 County ID Number:
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ NO Installer.
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ NO
Conduit Sealed ❑ Yes ❑ No 'ENS:
Pump Manually Operable ❑ Yes ❑ No
'Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No
❑ Appirove- ❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
'Operation Permit completed by:
Authorized State AgeW"— Date of Issue: 0 4 0 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 of. Seq..and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE a A. sewage septic system.
Rule.1961 requires that a Type TYPE 11 A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
N/A
Reporting Frequency By Certified Operator:NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora homelbusiness 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 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.
OHand Drawing Olmport Drawing
**Site Plan/drawing attached.**
OPERATION PERMIT 1986 `1 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: Operation Permit Scale: OOrN/A = ft.
l � ' ► f
� I
I C I
III I �
1
Randy Miller -=
/--�j .�wvmrrufle:aows
V G s�rrs.w.
Septic Tank Service
New Systems Repairs Pumping & Cleaning
".Nobody sfichw their nose in our business"
295 Miller Road Phone:336.284. 826
Mocksville, NC 27026 Cell:336-399.7261
Cell:336.399.6862
December 16, 2015
RE: 9650 Reynolda Road
Tobaccoville,NC 27050
To Whom it Concerns:
A septic inspection of the above mentioned property was conducted on December 16, 2015
The system was found to be in adequate, proper functioning order and free of any observable
evidence of system failure. This property is hooked up to City of Winston-Salem public
water.
Regards,
Randy Miller
Certification#1128 I
CONSTRUCTION For office use Onlv
` ,AUTHORIZATION 'tDP File Number 198631.•1
646,nl'�
Davie County Health Department County ID Number.210Hospital Street Evaluated For: EXPANSION
P.Q. Box 848Township: ,
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336.753-1680 1 a / 1 0 / a 0 a 0
Applicant: Alexander Birch Property Owner. Alexander Birch
Address: 171 Primrose Road Address: 171 Primrose Road
CRY: Advance City: Advance
StatefZip: NC 27006 State2ip: NC 27006
Phone#: (336)998-6107 Phone#: (336)998-6107
Property Location & Site Information
Address/Road M Subdivision: Marchwoods Phase: Lot: 6
171 Primrose Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 right on Hwy 801 cross R/R tracks left on
#of Bedrooms: 4 Peoples Creek Rd
#of People:
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
Seprolite System? OYes ®No Inches
Design Flow: 4 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:
TYPE 11 A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
Gallons
'Proposed System: 25%REDUCTION 1-Piece: OYes ONo .
Pump Required: OYes ONo OMav Be Required
N1lrification Field 4 3 6
Sq.ft. Pump Tank: Gallons
No.Drain Lines 1 1-Piece:OYes ONo
Total Trench Length: 1 0 .9 ftGPM vs— ft. TDH
Trench Spacing: _ 9 InchesC.0 Dosing Volume: _ Gallons Feet O
Trench Width: _ 3 f 2Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 O.TS-11
Septic Tank Installer Grade Level Required: 01011 0111 IV
Donn I of Z
CDP File Number 198631 - 1 County ID Number.
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Inches 0. .
ification: PS 10"LOP — 9 Feet O.C.
Trench Width: Inches
w: 4 8 0 _ 3 ar Feet
Soil Application Rate: 0 a 7 5 Aggregate Depth: inches
Minimum Trench Depth: a 4 Inches
*System Classification/Description:
TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches
*Proposed System: 10•LARGE DIAMETER PIPE SYSTEM Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover: a 4
Nitrification Field 1 7 4 5 - Inches
Sq.ft.
No. Drain Lines 5 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TotatTrench Length: 5 9 1 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.
r
*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. ;
This Authorization for Wastewater System Construction shall bevaiid for a person equal to the period of validity of the improvement Permit not
to exceed five years,and may be issued at the'sanre time the Impmve meet Permit issued(NCGS 130A-336(b)�If the installation has not been
completed during the period of validity of the Construction Perml%the information submitted In the application for a permit or Construction
Authorization Is found W 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(8)).The person owning or controlling the systern shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system',location,Installation,operatlor,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? OYeS ONO
ApplicanYtelel Reps.Signature: Date:.Date of Issue:.-
*Issued By: 2140-NaUons,Robert 1 a / 1 0 / a 0 1 5
.- - - - - - - - - -
Authorized State Agent: Malfunction Log Oyes
@Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP FileNumber. 198631 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 12 / 1 0 / .1015
Q Inch
OBloDrawing Drawing Type: Construction Authorization Scale: ` . ON/A = ft.
Q N!
I64
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a
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 198631 - 1
P.O.Box 848
Mocksville NC 27028 County File Number.
Date: .1 2 / 1 0 / 2015
Click below to Import an image from an external location: Drawing Type:Construction Authorization
4
APP O FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
DIX, f � P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: ❑ Site Evaluation/Improvement Permit ❑Authonzap�'on To Construct(ATC) ❑Both
Type of Application: ❑New System ❑Repair to Existing System �ansion/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 4CC'Xk11hFA l,/RC 9 Contact Person g/RcM
Address i?, PR/•N R o sE /2/) Home Phone 3-S 6 -- F5F8 —61,o 7
City/State/ZIP 4AV1WC-&-, it/. C , Z-7 6 Business Phone —
Email 4 L RiAc 1••t-42 S',4 n rC•L ,,yr-T Email:
Name on Permit/ATC if Different than Above D/c K
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 Phone Number
Owner's Address City/State/Zip
Property Address City
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? Yes t-&o
Does the site contain jurisdictional wetlands? Yes✓*
Are there any easements or right-of-ways on the site? Yes o
Is the site subject to approval by another public agency? _Yes V
Will wastewater other than domestic Sewage be generated? Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms _ #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑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:1conventional ❑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 >11io
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 Ru presentative
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 g the house/facility to tion,pro osed well location and the location of any other amenities.
s � �-"� Site Revisit Charg:
Property owners or owners legal representative signature
Date(s):
Client Notification Date:
Date EHS:
\ ! Account# r � 9631
given []Yes ❑No
%ed 11/06 Invoice 9