The URL can be used to link to this page

211 Parsley 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: Tomasz Lewtak Address: 211 Parsley Lane Cay: Mocksville Statetzip: NC 27028 Phone #: (336) 940-2444 rt -or urrrce use umv *CDP File Number 122411-1 N60000607715 County ID Number Evaluated. For: NEW Township; Property Owner: Tomasz Lewtak Address: 211 Parsley Lane Cay: Mocksville State2ip: NC Phone #: (336) 940-2444 27028 Propeqy Location & Site Information dressfRoad #: Subdivision: Phase: Lot: 211 Parsley Lane r Mocksville NC 27028 Directions 601 S Left Becktown. Right Cherry Hill. Left Structure: OTHER Singleton. Right Parsley Lane # of Bedrooms: # of People: 'Water Supply: EXISTING WELL *System Classification/Description: *IP Issued by TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 4$0 GPD OR LESS) *CA issued by: 2940 --Nations, Robert SaproiiteSystem? QYes jSNo Design Flow: 1 a 0 *Distribution Type: GRAVITY- SERIAL Pump Required? ©Yes t&No Soil Application Rate: 0 3 *Pre Treatment: Drain field rNinification Field 3 3 3 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD Drain Lines 1 Installer: K L Construction oal Trench Length: 1 0 0 g• Certificabon #: 4640 Trench Spacing: — 9 Inches O.C. Feet O.C. *EHS: 2140 -Nations, Robert Trench Width: — 3 Offiches Feet 0 7% 2 4 % a 0 1 5 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 1 4 Inches Approval Status Maximum Trench Depth: '3 6 ® approved O Disapproved Inches Maximum Soil Cover: 3 5 Inches CDP File Number 122411 - 1 Manufacturer. Shoal STB: 760 Gallons: 1000 Date: 0 5 / 0 4/.2 0 1 5 *Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker: ❑ Yes 0 No nforced Tank: ❑ Yes E No 1 Piece Tank: ❑ Yes B No County ID Number: N60000007715 , Lat. Long: Installer: K L Construction Certification #: 4640 *EH S: 2140- Mations, Robert Date: 0 7/-1 4/-1 0 1 5 Approval Status ® Approved ❑ Disapproved Pump Tank Manufacturer. Installer: PT: Certification #: Gallons: THS: Date: / / Riser Sealed ❑ Yes ❑ No RiserHeight: ❑ 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 ►pproved fittings ❑ Yes Pump Type: Date: Approval Status ❑ Approved ❑- Disapproved upply Line Installer: Certification #: *EH S: ❑ No Date: ❑ No Approval Status ❑ Approved ❑ Disapproved Installer: Dosing Volume: — Gal Certification #: Draw Down: Inches *EHS: *Chau: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval Status PVC Unions ❑ Yes ❑ No ❑'Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ NO . CDP`File Number 122411 -1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: Alarm Audible ❑ Yes Alarm Visible ❑ Yes *Operation Permit completed by. Authorized State Agent: County ID umber: N600000077" Clet:trlc CUU119)"JC[lt ❑ No Installer: D No Certification #: D No D No *EHS: D No I I Date: D No Approval Status D Approved D' Disapproved D No 2140 - Nations. Robert Date of Issue: 0 7/ a 4 / a 0 1 5 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 By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the, septic system. Rule .1961 requires that Type VI septic systems designed for a 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 privatemanagement entity, unless the system owner and 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 almport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.D. Box 848 Macksville NC Drawing Drawing Type: Operation Permit CDP File Number: 122491 - 9 County File Number: N60000007715 27028 Date: Q Inch Scale: OBlock ON/A ..... . . .... I- ... ......... ... .. . . .. ... . ... .. . ....... ............. ... . . ....... .. ...................... .......... ......... .... . . .. .. ...... ........ ...... .. ......... . ..... . . .............. .... . . ............. I. III - -- - ------------- ............ . SII .. .................... I............ � i Mb.. LOU I� -it CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street ��. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Tomasz Lewtak Address: 211 Parsley Lane City: Mocksville State/Zip: NC Phone #: (336) 940-2444 27028 For Office Use Only 'CDP File Number 122411-1 County ID Number: N60000007715 Evaluated For: NEW Township: PERMIT VALID UNTIL: 0 s/ 0 a/ .) 0 1 s /"Property Owner: Tomasz Lewtak Address: 211 Parsley Lane City: Mocksville State/Zip: NC Phone #: (336) 940-2444 I— r Location & Site Information Address/Road #: Subdivision: 211 Parsley Lane Mocksville NC 27028 Structure: OTHER # of Bedrooms: # of People: *Water Supply: EXISTING WELL `Site Classification: Saprolite System? O Yes X No Design Flow: 1 a 0 Soil Application Rate: 0 3 'System Classification/Description: TYPE II B. CONV. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Sq. ft. 27028 Phase: Lot: Directions 601S Left Becktown. Right Cherry Hill. Left Singleton. Right Parsley Lane Minimum Trench Depth: a 4 Inches Minimum Soil Cover: Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches "Distribution Type: GRAVITY - SERIAL Septic Tank: 1 0 0 0 Gallons 1 -Piece: O Yes ® No Pump Required: O Yes ®No O May Be Required Pump Tank: Gallons 1-Piece:OYes ONo 1 0 0 ft, GPM --vs-- ft. TDH O Inches O.C. 9 ®Feet O.C. Dosing Volume: Gallons _ 3 6 8 Inches Feet Grease Trap: Gallons inches Pre -Treatment: O NSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01 OII 0111 01V Page 1 of 3 CDP File Number 122411 - 1 County ID Number: N60000007715 Kepalr System rtequlrea:10W T es v IVU v Iyu, uut I ids tivcandUM: J *Site Classification: Design Flow: 1 a 0 Soil Application Rate: 0 3 *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: Nitrification Field No. Drain Lines Total Trench Length 1 0 0 ft. Sq. ft. ❑ Open Pump System Sheet Trench Spacing: 9 O Inches O. ® Feet O.C. Trench Width:3 6 (& Inches O Feet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches *Distribution Type: GRAVITY - SERIAL Pump Required: OYes ®No OMay Be Required Pre -Treatment: O NSF OTS -I 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 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. 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 130A336(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: 2244 - Daywalt, Andrew Date of Issue: 0 8 / 0 a / 0 1 3 Authorized State Agent: "M4 Malfunction Log OYes Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** 0 1 Hours 0 0 Minutes Page 2 of 3 S-8 - CA'S issued - new CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 122411 - 1 County File Number: N60000007715 Date: 08 /0.2/,2013 Olnch Scale: O Block O N/A 1 01 —o 41 tf� 1 p Page 3 of 3 P1 P2 CONSTRUCTION For office use Only AUTHORIZATION *CDP Fite Number 122411-1 Davie County Health Department County ID Number: N60000007715 1 " 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753.1680 0 8/ 0 2/ 2 0 1 8 Applicant: Tomasz Lewtak Property Owner: Tomasz Lewtak Address: 211 Parsley Lane Address: 211 Parsley Lane city: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone #: (336) 940-2444 Phone #: (336) 940-2444 Address/Road #: 211 Parsley Lane Mocksville NC 27028 Structure: OTHER # of Bedrooms: # of People: 'Water Supply: EXISTING WELL Subdivision: ,*Site Classification: SaproliteSystem? OYes eNo Design Flow: y ., n Phase: Lot: Directions 601 S Left Becktown. Right Cherry Hill. Left Singleton. Right Parsley Lane System Specifications Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches Sod Application Rate. Maximum Soil Cover: 0 3 Inches 'System Classification/Description, "Distribution Type: GRAVITY - SERIAL TYPE 11 B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25% REDUCTION 1 -Piece: OYes (j)No Pump Required: ()Yes QNo ()May Be Required Nitrification Field Sq ftPump Tank: Gallons No. Drain Lines 1 -Piece: OYes ONo Total Trench Length: 1 0 0GPM—vs-- ft. TDH ft. Trench Spacing: _ 9 ches Fe t O C.0 Dosing Volume: _ Gallons Trench Width: 3 6 /- Inches 6Feet Grease Trap: Gallons Aggregate Depth:ONSF OTS -1 OTS -II inches Pre -Treatment: Septic Tank Installer Grade Level Required: 01 OII 0111 OIV CDP File Number 122411 -1 Kepair 5 County ID Number: N60000007715 ❑ Open Pump System She( Kequireo:\VTCJ %-)IVV VIVV, VUIIidblAvdltdUlc opol:C /Repair System Trench Spacing: Inches 0. *Site Classification: — 9 k Feet O.C. Trench Width: Inches Design Flow -1 2 0 _ 3 6 Feet Soil Application Rate: 0 Aggregate Depth: inches 3 Minimum Trench Depth: 2 4 Inches *System Classification/Description: TYPE 11 B. CONY, SYSTEM WITH 750 LINEAR FEET OF Minimum Soil Cover. NITRIFICATION LINE OR LESS Inches Maximum Trench Depth: 3 6 *Proposed System: Inches Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY - SERIAL Total Trench Length: 1 0 0 ft Pump Required: QYes GNo OMay Be Required Pre -Treatment: (NSF QTS -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 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 be valid fora 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 besuspended 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 (i)No Applicant/Legal Reps. Signature: Date: / *Issued By- 2244 - Daywalt. Andrew Date of Issue:. 0 8 0 2 2 0 1 3 Authorized State Agent: Malfunction Log OYeS QHand Drawing Olmport Drawing TotalTime:(HH:MI.t) **Site Plan/Drawing attached.* 0 1 Hn„rs 0 0 Minutes CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Di-awina Drawing Type: Construction Authorization CDP File Number: 122411 - 1 County File Number: N60000007715 Date: 08/02/2013 Q Inch Scale: QBlock d N /A t IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Use Onl *COP File Number 122411 -1 County ID Number: N60000007715 Evaluated For: NEW Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 8/2/201$ *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Tomasz Lewtak Address: 211 Parsley Lane City Mocksville State2ip: NC 27028 Phone »: (336) 940-2444 Address/Road #: Subdivision: 211 Parsley Lane Mocksville NC 27028 Structure: OTHER # of Bedrooms: u of People: *Water Supply: EXISTING WELL Saprolite System? QYes Q No Design Flow: 1 5 0 Soil Application Rate: 0 3 *System Classification/Description: TYPE II B. CONV. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Proposed System: 25% REDUCTION e�PropertyOwner". Tomasz Lewtak Address: 211 Parsley Lane City: Mocksville State/Zip: NC 27028 Phone #: (336) 940-2444 Phase: Lot: Directions 601 S Left Becktown. Right Cherry Hill. Left Singleton. Right Parsley Lane SpecIT1 Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: QYes QNo Pump Required: QYes QNo OMay Be Required Pump Tank:. Gallons 1 -Piece: QYes QNo Repair System Required: (D Yes ONO ONO, but has Available Space Repair System *Site Classification: PS Soil Application Rate: 0 3 *System Classification/Description: TYPE 11 B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS ` *Proposed System: 25% REDUCTION Minimum Trench Depth: 2 4 Inches Maximum Trench Depth: 3 6 Inches Pump Required: QYes QNo Q Maybe Required Page 1 of 3 4.CDP File Number 12241,1 - 1 County ID Number. N60000007715 *Site Modifications ❑ Open Fill Sheet 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 perm it by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to Site O Ian scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the 0 site for the proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shad be valid without expiration with plat (means a property surveyed prepared by a registered land surveyor, drawn to a scale of one inch equals no morethan 60 feet, that includes the specific location of the proposed facility O and appurtenances, the site for 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 article This permit is subject to revocation if the site plan, plat, or intended use changes (NCGS 130A -335(f)). 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 2244 - Daywalt. Andrew Authorized State Agent: Date of Issue: 0 8/ 0 2/ 2 0 1 3 OValid without Expiration? O Create CA? (DI -land Drawing Olmport Drawing **Site Plan/Drawing attached.** Total Time:(HH:Gtf,1) 0 Hours 3 0 u inutes Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department 290 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Improvement Permit 03� CDP File Number: 122411 -1 County File Number: N60000007715 Date: Q Inch Scale: OBiock QN/A = ft. kt,k�; \ I ) , .• HEALTH'DEPARTMENT RELEASE Davie'County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Tomasz Lewtak Address: 211 Parsley Lan City: Mocksville State2ip: NC 27028 Phone #: For Office Use Only *CDP File Number 122411 - 2 N60000007715 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 0 7/ 3 0/ 2 0 1 8 UNTIL: Property Owner: Tomasz Lewtak Address: 211 Parsley Lan City: Mocksville State2ip: NC 27028 Phone #: Property Location & Site Information Address211 Parsley Lane Subdivision: Phase: Lot Road # Mocksville NC 27028 *Structure: # of Bedrooms: # of People: `Water Supply: EXISTING WELL Basement: 11 Yes ❑ No *Proposed Improvement: Garage Township: Directions 601S Left Becktown. Right Chert' Hill. Left Singleton. Right Parsley Lane Type of Business: Total sq. Footage: No. Of Employees: It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature; *Date_ / *Issued By: 2244 - Daywalt, Andrew *Date of Issue:. 0 7 / 3 0 / 2 0 1 3 /�W Authorized State Agent: QLA4PIS " C� 111404 *Site Plan/Drawing attached.* Total Time:(HH:MM) 0 1 Hours 0 0 Minutes O Hand Drawing O Import Drawing APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health 1v�� P.O. Bog 848/210 Hospital Street �`,- Mocksville, NC 27028VY 11 (336)753-6780/ Fax (336)753-1680; _-,,on For: j<Site Evaluation/Improvement Permit lAuthorization To Construct (ATC) 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. APPTJC'ANT INFORMATION a\J t�X �n� `�'!�''� T) "117°1"" Name TO m PrS 2- L E w TAK Contact Perso Address 211 ?&AS LG V Lty. Home Phone 3 City/State/ZIP d V L t, 1 h(L Z} O Business Phon Email I r( FOLEL/TA K. CM CQ c 1, Name on Permit/ATC if Different than Above Mailing Address City/State/Zip FRUPE IA 1NI{UKMAIIUN *Date House/Facility Comers 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' 10 1'1 A S Z L & W TA•K Phone Number 33 6 R �i 0 Owner's Address 211 P!4`121 L. E tf L t1. ...City/State/Zip M 0CU S (11 L L 1 HC Z 1762c! Property Address S� E City Lot Size Subdivision Name(if applicable) SectionlLot# 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 No V Does the site contain jurisdictional wetlands? ,Yes No Are there any easements or right-of-ways on the site? Yes ✓No Is the :site subj ect to approval by another public agency? ,Yes VNo Will wastewater other than domestic sewage be generated? Yes t/No TF RESIDENCE PITT, OT IT T'RF. BOX BFLOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No TF .NON-RFS1DFNCF, FIT I, OUT THF, BOX.13EI..OW Type of Facility/Business S" P Total Square Footage of Building 0 # People # Sinks I # Commodes �_ # Showers I # Urinals �0� Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Xonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well 4xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?TC' Yes XN 0 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 hereby grant right of entry to the Authorized Representative of the Davie County He th Department to conduct necessary inspections to determine compliance with applicable laws and rules. IR�R t I am a on ble for the proper identification and labeling of property lines and comers and locating and flagging oouse/ ity ca n, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): Z Z D (-1 Client Notification Date: Dae l Z [� l 1 EHS: &tj* IDUC) Sign given ❑Yes ❑No I'SOo7 Account # Revised 11/06 Invoice # North Proposed New Building 50'x 120'_ 1303 o 14F 1 lExisting Single -Family House N O a1^4 �. 4N18 t VA Davie County Health Department Environmental Health Semon Phone: (336) - 753 - 6780 P.O. Box 848 210 Hospital Street R�' C�+ Courier # : 09-40-06 Dai: ? D Mocksville, NC 27028 Fax: (336) - 751 - 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name:T0 0 MAS Z L & w 1 /T K Phone Number 3 6 1` 0 -2'i Home) Mailing Address: Z P/1 R S L P/ L N.( Work) IOCI� (MLLE . 14C Z10ZI Email IH o LGW16K. col I Detailed Directions To Site: Property Address: Please Fill In The Following Information. About The EXISTING Facility: ,�(,�N Name System Installed Under: Type Of Facility: S I' e4C Date System Installed (Month/Date/Year): 1 q Number Of Bedrooms:__�Number Of People: Is The Facility Currently Vacant? Yes Any.Known Problems? Yes L 0 ONO If Yes, For How Long? If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: t Number Of Bedrooms: _QNumber of People c/ Requested By: Date Requested: —4-12 2- / ZO ( 7 (S ature) For Environmental Health Office Use Only Approved Disapproved Comments Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order #, Paid By:_ Account #: Amount:$ Received By:_ Invoice #: Date: �(P ( Existing Single -Family Hoy Proposed New Garage 40'x 301 Davie County, NC - GoMaps Advanced Page 1 of 1 ,t ' r• •.r 1"+r��.�� l 1 may`' n fi •_ i y.. , a4 �r� � y•.,A � `1,�t ,r , baa • M�,t 4'��q � �� ..0 A .. \Y�,t y+} '41 r'�� C� �. Ji; 4r' '1�� 'f' ij... ,O r k '� '�` i �lT��•t y�,� Y . 'W - \ p iii ,� ,� �. \. + ,{r,., as t t }a f, + k• r a •'.1I Alt.Ef r•...r S s "k"�` '}I.r �y�.�.t C-ar ! ,raw i �c4. tt�.. �� t°#C. �, 'i _..moi ti ,� d n 50 iii l\.,.oi3llh .a 97'. v�a� tea^ h 1 R �kji 5r , Chick on any resuft to Zoom to feature Latitude; 350 47' 58,04' Longitude; -801 28 49,77" LLJ http://maps2.roktech.net/davie_gomaps/index.hbnl 7/22/2013 ' � ' , -�.. . •-'fP- �^•��n `ar <'^� .y,.y,� *..t -.r ., - .^ .n- ; ,M. -ter ... ..�,:�.Zr - ,q-^ r 7r�rn� - Diu DAVIE >COUNTY HEALTR bEPARTMENT: �! IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a anitary Sewage Systems Name L`��.�, :: 77.3.7 ZL,, Date /2 Location Perm't Number N® Subdivision Name Lot No. Sec. or Block No. Lot Size House -�� Mobile Home Business _— Industry. No. Bedrooms -, No. Baths — 2 -_ No. in Family ;�? — Public Assembly Other Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma thine YES NO ❑ Type Water Supply — ��'�— ----,' 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. -improvements permit bY— NL�;5- *Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by r .�etaauri• Certificate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function `- -'--:r.. s:.� ............... -;^A of fima 7kr6 ..W)+4 -1kw Duium • DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Name r' 1,4n� Date .4-,i;... Ile COMPLETION Permit Number N0 387 Location �w 7kr6 ..W)+4 -1kw Duium • DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Name r' 1,4n� Date .4-,i;... Ile COMPLETION Permit Number N0 387 Location Subdivision Name Lot No. Sec. or Block No. Lot Size 101L—House _4e—'— Mobile Home _— Business __ Industry No. Bedrooms �,—? —. No. Baths — -2 — No. in Family �2__ Public Assembly Other Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ /v Auto Wash Ma thine YES NO ❑ GAG'.//` /r �. Type Water Supply _ ---�l `This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. Improvements permit bY *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by r - I Certificate of Completion /"% Date /0 "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ..{ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT`S rw� , + Davie County Health Department ` Environmental Health Section DEC - 7 W3 P. O. Box 665 % cksv ille, NC 27628 1. Application/Permit Requested By & % E. 0Q6;, SR. a- ��a R4,- S . ( �n�Pk-'a Mailing Address -62-37 '-S2wQ n.Ppo L7�, �. S;*p-zn,� d, L.4 1J.Q Home Phone go Business Phone 9/D. 96S'- 4 2. Name on Permit if Different than Above ;: A M.p AI A✓ri uva 3. Application/Permit for: ❑ General Evaluation N Septic Tank Installation 4. System to Serve: JO House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section5'.. MA Lot # No. of People 2 No. of Bedrooms No. of Bathrooms Dwelling Dimensions 3 &x' (, z r �-U-s�� 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers 7. Type of water supply: ❑ Public No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures ❑ Private 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? K Basement/Plumbing f�wgh•d'- ❑ Basement/No Plumbing '®. Washing Machine Dishwasher Garbage Disposal ❑ No ❑ Community "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: 6o / -5. vLu6;" I2 Qiv 44-4 7-0 ->•i.%s+•� le � This is to certify that the information provided is correct to the best of my knowledge, incurred from this application. DATE I understand I am responsible for all charges SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: W1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized repres v of he Davie County ealth De artent to enter upon above described property located in Davie County and owned S ad i- d s . & to conduct all testing procedures as necessary to -determine said site's suitability for a ground absorption sewage treatment and disposal system. 93 DATE DCHD (12-90) pp p 20754 77.`Or'Jr YJr "�.0�, 7 °•,� ,� k. 7 06 7 7. ( Vo 10 A c 11, 5 Ac ? _ 11.5 AG ' 10070 !� � �i�t• � � `� � �'�`° 107 .�� ` �,,�� 62.8 4G0.84 92.28 ' :s Q�' l 7x. "�� ,wry ^ F� ,f�!}xt��,�k', � ,,'�, r •,��f .�y °,(r Yah °.� `S e • �� r .Y ��' ( .. 53.01 Ac to x°t�}w� 1303 '>!�."'7yf Y +, `/i�r�. `� •fin .,' co ��' `�" !"�.",\ ' i :� � -" 1481• '�` '� 1430 3080.22 r a+►r, R. y wt 4, Sf_ A� 78 92 Acs ��, iii 4 � �•' ; Y ��''✓- 5 a ` ,'.11 825c, \ ter' u 4 •' ., " °;. (122: n. � �i % ,.�i; � �N:. 990 • .fin ♦M DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site Evaluation NAME ( (f c' /� �DATE EVALUATED ADDRESS �) PROPERTY SIZE A�1.7 e PROPOSED FACIILTY,_1c(R i LOCATION OF SITE Z'` ," �d — Cj Water Supply: On -Site Well ✓ Community Public Evaluation By: Auger Boring I Pit Cut FACTORS 1 2 3 4 Landscape position L d, Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH r Texture group Consistence Structure /L Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE _ y SITE CLASSIFICATION: /'� LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD(01-90) EVALUATED BY: Ala, 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 CONSISTENCE Moist VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet 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 Mineraloity 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 wateil 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 ■��■�� ■e��wo■ ■■��■��■��■��■��w��■ ■��■��■■�� ■��■■��■��■��■ ■��■��■��■��■��■��■��■ ■��■�� ■��■��■��■��■�■ ...........................................�...................... .......................................... ...................... ..........................................■............■.....■.... ............................�... ................................ ................................i�................................ ...........................�...................■.................. ........................... ...................................... ..........■................................... .....■.. .....■.... ......................................... .... . . ....�...... .. ■��■��■��■�■■��■■��■�� _��n�ii�■ ■��■��■��■�■��■��■ ■��■��■ ■�� ■��■ ■��■�s��■��■��■�� iiiiiii�iiii��iiiii�iiiiiiiiiiiiiiiii�iiiiiii��iii=iiiiiiiii�iiii! ■��■��■��■��■ ��=��u�� ■��s��_��C��_� ■■��■��■■�� %��%��N�� ■��■��N��[1��\��N��r��A�� ■�� ..■....■..................,..................■..�....._...�......�� ■��//��h��'}�� M�� ■ ..........................��....................�,�C............... .................................................................. .........................................................�........ ................................ ....................... ........ ��H��■■�� ■��■��/��■��\��r�� ■��\�� ■�� :::::::::::::::::::::::::�:::::�:::�::3::::�::::..::::::::::::: .....................................o�................ .......... ��ii�� ■��\��r��1��_i��■i�� ■��■ ■��■��■��■�\�■��in�� ■ �� ■ ..........................��...........�.. ..�. .. .....C........ ..........................��........... .E::�_:' �::C::C�:::::: ..........................��........... ::::::::::::::::::::::�C::�C:::::":::: ..::�' ' .:�:C::DC::::::� ■��r��■� ■� ��u�� iiiiiiiiiiii'�iiiiu�iiiiiiiiiiiiiiiiii�i�ii�� iuua'■Ciii��i ��■��■��■t�� ■ ■n� �� ■��N��n a �� ■��■��■�� ■ �� N��■�� ::::::::::::::::::::::::::':::�"=:C:��' �: :�:C:�........ ........ ................. ..............�.....e.�.. . . ............. ■��u��_��_=��•-..�r��,��::�d�� _��u��■ ■�� r,�i��`�::rIV�L�� .� ��: ��Jso �� :�:::::'��:C�::::�::::::::�::::::�:_■�■■■ � .■ .::.■■■._■�■■ ■■■■ ■ ..■■■■..■■■ ■■ ��l��H�� ■��■��■��_��b��■��■ ■�■�v��■��■��■■ ■ �� ■��■ ■��N�� /��n�� ■��/��■��■�� Nn/ ��■ ■\��/N��u�� u�\ �■�� /��/��/��/�� N� �/��/��N�� ■..... ....■.....■......0......... ....■........■................ .......�... ........ ..............C.............................. .......■..._........C........... ....■■.........■................ ........■■......................i�.■..■..■.■..■..........■........ ............■.........................�■........■.............■.. ...................................... .......................... .................................................................. ......................................■...■■......■...■■■■■.■..■■■ .■.■■......■....................■....■..■......................... .■......................... ..........■............■....■...■■.■■■ ■,..■ ...........................�.....■.......................... ................................ ................................ ..................................... . ...■.....■......■.......■