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318 N Pino RdDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 a644 P64ar Account #: 990003882 Billed To: Amy Bolmer Reference Name: Amy or Jonathan Bolmer ATC Number: 4338 Tax PIN/EH #: 5833-33-3895 Subdivision Info: &/ 9 Location/Address: N.Pino Road -27028 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Dated D 4 3 Fa&bm pl::_�/L M4 I CERTIFICATE **NOTE** The issuance of this Certificate of Completion has been installed in compliance with Article l Disposal Systems," but shall in NO WAY V., given period of time. Septic System Installed By: Environmental Health Specialist's Signature : DCHD 05/99 (Revised) rK ETION ids a the system described on Improvement/Operation Permit ,VChap!pel30A, Section .1900 "Sewage Treatment and a guqAteqAat the system will function satisfactorily for any /C t -7A4 , rl /� DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P. O. Boz 848/210 Hospital Street • ~ Mocksville, NC 27028 1 (336)751-8760 11� IMPROVEMENT/OPERATION PERMIT 111 Account M 990003882 Tax PIN/EH #: 5833-33-3895 Billed To: Amy Bolmer Subdivision Info: Reference Name: Amy or Jonathan Bolmer Location/Address: N.Pino Road -27028 Proposed Facility: Residence Property Size: 10 acres **NO" 19*%Th s7mproveme8i t/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 \—f #Baths, Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #S13Seeats Industrial Waste: Lot Size Type Water Supplj? Design Wastewater Flow (GPD) (o D Site: New0—Repair ❑ System Specifications: Tank Size GAL. Pump Tank J GAL. Trench Widt� Rock Depth Linear Ft.4 I�Jkl� J Other: r\ a `r IL, Required Site IMPROVEMENT/OPERATION PERMIT LAYO FINISHED GRADE. ****NOTICE: Contact a repre system between 8:30 a.m. to :30 a.m. or 1:00 p.m. to 1:30 'I ku,. 1, Ute, WED EFFLUENT FILTER RISER(S) IF 6 " BELOW the Davie County Health Department for final inspection of this on the day of installation. Telephone # is (336)751-8760.**** X /V;? P(�n -t Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) They ' 11 6l d�tllleEt r� :-�� APPLICATION FOR SITE EVALUATION/IMPROVEI Davie County Health Departmen Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/'Fax (336)751-8786 FEB 1 3 2006 ENVIRONMEr4TAL HEALTH DAVIE COUIJTY Application For: Site Evaluation/Improvement Permit VAuthorization To Construct(ATC) ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed �� (Y1 e � Contact Person M t Billing Address A , Home Phone - -599 31 City/State/ZIP Business Phone Name on Permit/ATC if Differel4t than Above 1 2 Mailing Address City/State/Zipe / - OZg PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete p t,) Street Address_ 3-) City �, [ACL SUj � � Tax PIN#,Sti' 3 -33 3�73 Subdivision Name Section/Lot# Lot Size lb QC• Directions To Site: --G, V e 1r)H (1 4t _i?n Q -.� - FA -1 164 - cw,-),4n t"l'k Date House/Facility Corners Flagged 7 I - (-)I„ 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 9No Does the site contain jurisdictional wetlands? Dyes �Ivo Are there any easements or right-of-ways on the site? Dyes Wo Is the site subject to approval by another public agency? ❑Yeso Will wastewater other than domestic sewage be generated? 0 e 90 IF RESIDENCE FILL OUT THE BOX BELOW # People 5 # Bedrooms _3 # Bathrooms Garden Tub/Whirlpool5'Yes ❑No Basement: ❑Yes SNo Basement Plumbing: ❑Yes DVo 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: U<-'onventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑ County/City Water ❑ New Well ;<xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Vo If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance wi applicab laws and rules on the above described property located in Davie County and owned by Property owne 's r owner's legal representative signature t, OL a Date Sign given V es ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # CM12 Invoice # N n 306 541 906 (28.72 A) 3895 8� a cK say ` VII " LLJi N n 306 541 906 (28.72 A) 3895 a cK say ` " F 1 k. e � w s q;J 6 ¢ V141 - w e s � CC r ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990003882 Billed To: Amy Bolmer Reference Name: Amy or Jonathan Bolmer Proposed Facility: Residence Property Size: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5833-33-3895 Subdivision Info: Location/Address: N.Pino Road -27028 10 acres Date Evaluated: On -Site Well Community Public Auger Boring Pit Cut / SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S Sand., LS - Loamy sand SL - Sandy loam L Loam SI'- Silt SICL - Silty clay loamSIL - 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 3yet NS - Non sticky SS - Slightly sticky S -Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) Landscape position 1•. G L����--®I 9-7KV Texture group WAU Consistence r.A�W WA HORIZON groupTexture 1:WIMMWf i171/IConsistence -® �/ M1111111111111 ®HORIZON III DEPTH Texture group Consistence '�IWA� W14. ® IV DEPM Texture group ConsistenceHORIZON Mineralogy SOIL WETNESS CLASSIFICATION / SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S Sand., LS - Loamy sand SL - Sandy loam L Loam SI'- Silt SICL - Silty clay loamSIL - 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 3yet NS - Non sticky SS - Slightly sticky S -Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■se■■■s■e■■ees■■■■■■■■■■■■■■■■eeeee■■■■■■ ■■■■■■■■/e■ee■■e■ee■■es■■■■■e■e■■■/e■■■■eee■■e■e■■ee■e■■e■■ee■e■ ■■■■■■eee■■■■■■■e■■■e■■■■■■■■■■■i�i■■■■■■ee■■■■e■e■e■■■■e■■■e■e■■■■ ■■■e■e■■■■■■■■e■■■■e■ee■■e■■■■■■■■■■e■■■■■■■eeeeee■■■e■ee■■ee■■e■■ ■■■■■eeee■e■■■■■e■■■e■eee■ee■■■■■■■■■■■■■■■e■■■■■e■■■ee■■e■■■eee■■ ■■■■■■e■■■■eeeee■■■■■■■■■■■e■■■e■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■/■see■■e■■■eeeeee■■■eeeee■eeee■wee■ee■■eee//■eee■e■ee■/■eee■eee■■ ■■■■■/■■■■■■■e■e■e■e■e■■■eeee■e■■■■■■■■■e■■■■■■■■■■■■■■e■ee■■e■■e■ ■■e■■■■■■■eee■■■■e■■■■■■e■■e■■■■■■■■■■■■■/■e■e■e■e■■■/■■■e■e■ee■ ■■■■■eeee■■■ee■■■■■■■e/■■■■e■■e■�i■■e■■■ee■e■e■e■ee/ee■e■ee■e■■■e■ ■■■■■/■■/e■■■■■e■e/■■e/e■■■s■■■■■■■■■ee■eee■e■e■■■e■■■ee■■e■■■■■■■ ■■e■e■■e■■■e■eee■■ee■ee■■■ee■■■■r■■■■■■e■■■■■e■■■■e■■■■e■e■■ee■■■■ ■■■e■■■■■■■e■a■■■■e■■■e■■■■■e�■■�rrie■■■■■■■■■eee■■■■■■■■■■■__■■■■e■■■ ■■■■■■■eeee■■■ee■■■■■■/■■■■■.■e.w■■/■■■■■/e■■ewe_■■■■�-w■■■■■:=tee■ ■■■e■■ee■e■■ee■■e■e■■■e■■■e■ee■■ ■■■■■eeeee■e■■■■eeeee/e■■■■■■■■■ ■■eeeeeeee■e■e■■■■■■■■e/■■__w__ew�■■■.■■_�eea■eeee■■ee■ee■■eeee■e■ ■■//■■■■■■ee■e/■eeee■■ee■e■e■ee■■■■eeeeeee�e■■►�■eee■■■eeeeee■e■■ ■■■■e■se■■■e■eee■■■■■e■■■■■■■■ee■■■■■■e■■ee■■■e■■e■e■■■e■■eeee■■■■ ■■/■■■■■■■■■■■■■■■■■■■■■■■■■■/l!li� ■■■■■■■/■/■■1/■■'ire■■■■ ■■■■■■■■■■■ ■■■ee■■■■e■■■■■e■■■■■■■■■�I■/■■e■■e■I■■eee■eeee■■■■■■■■ee■ee■e■ee■e■ ■■e■■e■■e■■e■■■■■■■ee■■■■glee■■■■ee■�■■■■■■e■■■■■i■e■e■■■■■■■■■■■■■■■ ■■■se■■■■e■■■e■■e■e■■■e■■�I■■■■■■■■■�■■ee■■■■■■e■I■e■■■ee■■■■■■■■■■e■ ■■■■■■■■■e■e■■e■■ee■e■■■e■I■■■■e■■e■■■ee■■■■■■■■ee■■■■■■■eeeeee■ee■ ■■■■■■■■■■■■■■■■■/■■■■■■■ale■e■e■ee■■■■■■■■■■e■■/■■■■■■e■■■■■■se■■■ ME NN::::::::::NNEN I:::::: MEMNON�CMEMNON�C::::::::::::�! 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Skvarla; III Secretary The Comprehensive Site Assessment Report received by the UST Section, Division of Waste Management, Winston-Salem Regional Office on May 7, 2014 has been reviewed. A review of the report indicates that soil contamination does not exceed the soil -to -groundwater maximum soil contaminant concentrations (MSCCs) and that groundwater contamination does not exceed the level of the standards or interim standards established in Title 15A NCAC 2L.0202. Based on information provided to date, the UST Section determines that no further action is warranted for this incident. This determination shall apply unless the UST Section later finds that the discharge or release poses an unacceptable risk or a potentially unacceptable risk to human health or the environment. This No Further Action determination applies only to the subject incident; for any other incidents at the subject site, the responsible party must continue to address contamination as required. If you have any questions regarding this notice, please contact me at the address or telephone number listed below. -- Sincerely, , q Linda Estkowski Hydrogeologist Winston-Salem Regional Office UST Section, Division of Waste Management, NCDENR An Equal opportunity/ Affirmative Action Employer - 50 % Recycled 110 % Post Consumer Paper