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829 Point Rd '-Davie County Health Department V t Environmental Health Section , 4 y. - .. P.O. Box 848 ~ , .S, 210 Hospital Street O U TA Courier# 09-40-06 1911 Mocksville, NC 27028 Phone:(336) 753-6780. ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 !, (Check One) Replacement Remodeling ReconnectionJ36— Name: pp � Phone Number 33�o -".211115 Mailing Address: (Work) 2 Email Address: (�, /Q/?Js Detailed IXrections Toit : ) DoNIP-thIllill oa(i( m /A 7 yd") l" qw a J� ISP �S id('I M a Property Address: l l Please Fill In The Following Infformationl ,About The EXISTING Facility: Name System Installed Under: �(,1 /N W /I ( �yr]S Type Of Facility: U Date System Installed(Month/Date/Year): Number Of Bedrooms:__� _Number Of People: 2, Is The Facility Currently Vacant? Yes If Yes,For How Long? Any Known Problems? Yes o If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: -1b!�4a C A(9 G iw qif Number Of Bedrooms: Number of People Pool Size: Garage Size:_Z x Other: )(Requested By: //' - ate Requested: . /211 (Signatur For Environmental Health Office Use Only Appro Disapproved Comments: Environmental Health Specialist Date: *The'signing of this form by the Environmental Health Staff is i' 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(fheck Money Order # Amount:$ /h Date: Paid By: / Received By: GGf/U/�GZ Account#: W} 10 IV Z Invoice#: DAVIE COUNTY ENVIRONMENTAL HEALTH -4 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 989900142 Tax PIN/EH#: 5764-02-6143 Billed To: Edwin Williams Subdivision Info: Reference Name: Location/Address: Point Road-27028 Proposed Facility: Residence Property Size: 6.868 Acre ATC Number: 4714 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system '�func ' sati factorily for any given period of time. f ��/l C do System Type:S.T.Manufacturer Tank Date - Tank Size Pump Tank Size J� Specialist: System Installed By: E.H. 'GDate: // r v �U G6 Ito (oma i q �41 ,Fv 3 G�u5 a ----�7 1 r 1~ I I DCHD 11/06(Revised) Ck V • DAVIE COUNTY ENVIRONMENTAL HEALTH P� P.O.Box 848/210 Hospital Street lo� Mocksville,NC 27028 (2� (336)751-8760 Fax#(336)751-8786 n AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION l!( Account #: 989900142 Tax PIN/EH#: 5764-02-6143 Billed To: Edwin Williams Subdivision Info: Reference Name: Location/Address: Point Road-27028 Proposed Facility: Residence Property Size: 6.868 Acre ATC Number: 4714 / Site Type: 9 ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms 4. #Bathrooms #People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size U.'`67 Type of Water Supply: ❑County/City @'Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)510 Tank Sized GAL.Pump Tank�AL. 2/(r �• r. Trench Width Max.Trench Depth Rock Depth 12 Linear Ft. 3,3r Site Modifications/Conditions/Other: As staled in 15A NCAC 18A.1.969 accepted-Systerns may also or use Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. cn r � 133 -?- N M ` , -. � o At o �7�•n . /leg 9 Environmental Health Specialist Date: DCHD 11/06(Revised) U I TION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocicsville,NC 27028 (336)751-8760/Fax(336)751-8786 Site E aluation/Improvement Permit Authorization To Construct(ATC) Both V1RQ�M plication, System Repair to Existing System Expansion/Modification of Existing System or Facility ORS ORTANT***THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed &Ji ZL/J!!t f Contact Person /!?� Billing Address 3 (o tf-U,S )V4j/66/ S Home Phone 3310 o7£t'f aS� City/State/ZIP /y1 GC S!/i LL�� NC �2 70A i' Business Phone / Name on Permit/ATC iDifferent than Above eLi( 7oy Z39-7,3ZZ f Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged 5-111-07 NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Plat(to scale) (Permit is valid for 60 months ith site plan no iration with complete plat.) Owner's Name -dC./a ¢�i�M � �d/LC i�321 f Phone Number Owner's AY,2,-rJ Owner's Address 6-0/S City/State/Zip/NO Ce -Z e,lUl 7709,f Property Address /n City Lot Size 6.Zy we — Tax PIN# 7b t/0Z&Z0 Subdivision Name(if applicable) Section/Lot# Directions To Site: / UAT C C dN LPFT Ti'qT 4��� a 6f 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, Does the site contain jurisdictional wetlands? Yea �o Are there any easements or right-of-ways on the site? No-5f�'Tt•PoA� �0� Is the site subject to approval by another public agency? Yes �jo Will wastewater other than domestic sewage be generated? Yes <20 IF RESIDENCE FILL OUT THE BO"BELOW #People _— #Bedrooms #Bathrooms A. Garden Tub/Whirlpool QeJs No Basement- Yes Basement Plumbing: Yes t 7 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 ONL��Y #Seats Type system requested: 1/Conv��entional Accepted Innovative Altemative Other Wats Supply Type: County/City Waterew Well Existing Well Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Yes 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 sulm k.W in this application is falsified or changed. I hereby giant right of entry to the Authorized Representative 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 Imes and comers and locating and flagging or staling the lame✓faci`ty location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): .S--Z/ -2M Client Notification Date: Date EHS: Sign given Yes No Account# /q7 Revised I V06 Invoice# L.H. :Izz, vc,. j o o . PARCEL #3 exi3t(nq Iron f �� (TIE) \ new iron on at 3tbne �. N 88'58'03' E- � property.line' N 88'58'03' E (1028.76 total) 193.34 998.76 R dpike _ existing in L road 30.00 2.5' iron new nail �' ZG� '� ooS -cin _—.. .. In C/L rood o N R ET ALTt> �. R'a R EA ARV. INCLUDES S.R. 1822 R/W existi 00.00 new nail \ In C/L road CD )TE* co AAj2KEG-POIK-IN-C/L-ROAd o i �. LSE S7'1 RIt G DISTANCE Z W-. -74.48 t61• W 131.19 I •14 W' - -116.86 Z63 W 83.84 ex(isting S 23'38'21' E Z8'1.W 84.28 iron / 7°7:31 w��j W 68.14 4 L (` 361 W 49.88 L2 L ! is''• w 7592 -THOMASENE D. HAUSER, E:r AL ,� w ail Pn road' )5" W 94.45 pl ced R R spike 30 W 214.85 D.B. 150 1'G. 405 new nail 39' W 113.29 In C/L road _-- 38' W 415.36 52' W 85.47 07'. W 28.57 WADE i D.B. 15 i i •� a �'' � {_Y � }- A T q !' Y WIN Y. a �..SY*u . * � may,- Z,•r__,, i S t t i i Davie County Health Department 9 P61Environmental Health Section 4 P.O. Box 848 1 210 Hospital Street I (jti41 Courier# : 09.40.06 Mocksville,NC 27028 Phone,(336)•751-8760 Fm;(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: Fd[d„t/ �i' Y126'4791 5- Phone Number 33� a8 f�dSSY (Home) Mailing Address:3/6q ll S42.)/601 S 74/I -636.5517/3 (Work) /b�CilSv,ILP �I/c d7oa8 Detailed Directions To Site: e'S 601 .,5- 7a' e_s. TLL #i C'.lre,4,Y#.(L �.aA Ch o/eFx 3�o rk,Lw. T/r° Yninl% �oA_h l.7 Yh,�Lec nti CEF7- TET T Property Address: Please Fill In The Following Information About The EXMSTING Facility: Name System Installed Under: Type Of Facility: Date System Installed(Mcnth/Data(Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: ' /' Type Of Facility: �FS%(�F cE Number Of Bedrooms: 7 Number of People a— Requested By: "TK_f"A Date Requested (Signature) 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 property for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#: Invoice#: 3) (961) 2 � � �, PcB2 0 vo J / / (8.30A) / \ 3965 u I \ (716) I ./ (242) � DAVIE COUNTY HEALTH DEPARTMENT �'' '• Environmental Health Section Soil/Site Evaluation APP.LICAN;!N& MELON Tax PIN/EH#: 5764- DARTY INFORMATION Billed To: Edwin Williams Subdivision Info: Reference Name: Location/Address: Point Road-27028 Proposed Facility: Residence Property Size: 6.868 Acre Date Evaluated: —d Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position t_ I,- - — Slope ,- Slope% '2 HORIZON I DEPTH A _ I r3- %3 Texture group 15'4 Consistence r` Structure S Mineralogy HORIZON II DEPTH (1 - (r)-- Texture groupGL- Consistence Structure C,13,11 Mineralogyf 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 d SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: O ' 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 loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE 141St VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm, 3ygt 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:I,Mixed Notes ,_ Horizon depth-In inches I Depth of fill-In inches I 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) Davie County Environmental Health - P.O.Box,848/210 Hospital Street Mocksville,NC 27028 (336)7514760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 989900142 Tax PIN/EH #: 5764-02-6143 Billed To: Edwin Williams Subdivision Info: Address: 3164 Highway 601 South Location/Address: Point Road-27028 City: Mocksville Property Size: . 6.868 Acre Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: Aew ❑Repair ❑Expansion Permit Valid for: 56"Years ❑No Expiration lo– Residential Specifications: #Bedrooms _#Bathrooms'3ti #Peopled_Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 1-1130 Type of Water Supply: ❑County/City Gell ❑CommunityWell Site Modifications/PermitAs stated in 15A NCAC 18A.1969(5) Conditions: ,,� —�re2 .,,,�ed Sys-,,, 111ayUW uzvu ,System Type LTAR Initial CC +— Repair ©. Site Plan 9A 5z�6�5�� J� CL L ev /O Environmental Health Specialist _. Date ''o�Q 7 , i.p.11-06 ��4•�-I G-ci' Davie County Environmental Health P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87601 Fax(336)751-8786 WELL PERMIT Account #: 989900142 Tax PIN/EH#: 5764-02-6143-Well Billed To: Edwin Williams Subdivision Info: Reference Name: Location/Address: 829 Point Road-27028 Proposed Facility: Well Property Size: 6.868 Acres ATC Number: 0003 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New Repair F-1Abandonment ❑ o'°` d Proposed Well Location Diagram Certificate of Completion Nagram ` 3 v err f K� 30 . - J C, a 5��i�� l � / �-erComments: `17/-UI/lleg Certification#: Grout Inspected: Well Head Inspected: 7'.,o GPS Coordinates:3 N 6.6W & � ,7#�1�/ EHS: Date: 7— d EHS: y �� Date: 7-a f4AI P Kl4rW-Peira W& q3lx W.P.7-08 SilTk Calfa 1U' 1 D AF ATION FOR PRIVATE WELL PERMIT i� 3ut 6 �Q(y8 avie County Environmental Health P.O.Box 848/210 Hospital Street vE%1N 4A�N Mocksville,NC 27028 EN�1RpP jEC0�1' (336)751-8760/Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Wo m Name to be Billed Contact Person Billing Address Home Phone — City/State/ZIP C -"l/i &4i O' ` Business Phone gp _ � Name on Permit if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 11//(o/O' NOTE: A survey plat or s'te plan must accQmp py this application. Include : " ite Plan ❑Plat(to scale) Owner's Name �� / �Z ,7 S' one Number —0 `� Owner's Address City/ tate/Zip _ /J/��.Lp Property Address Z City �l�Gc��iJ1/l Lot Size r7, z?C j� Tax PIN# Subdivision Name(if applicable) Section/LoG Zections To Site: N QNtO 1 DEVELOPMENT INFORM ION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES N Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine st location for a well. •gned Date 7/1/08 Account# 0qtV106Z Invoice# \ •N J,��•J 1 til�l.l:L �J ' exi9tinq Iron J (TIE) new Iron on at �tbne f N 88'58'03' EI property line N 88'58'03' E- (1028'76 total) 193.34 998.76 . existing in R �1- road 30.00 2.5' iron r � ' new nail �' Z. IMFoo� p -- in C/L road X r o Q^ - X41 c� ; A N ET Ai, t - x AREA. INCLUDES S.R. 1822 R/W existi �► �J5.00 new nail . \� In C/L road r� �� (ED-POIKr-4N-C/L_ROAD- DISTANCE OAR DISTANCE H .74.48 C� H 131.19 <j i N 116.88 N 83.84 N 84.28 existing S 23'38'21' E N 68.14 g iron 77:31 81 49.88 L Le L 75.92 THOMAS-ENE D. RAUSER, ET AL new nail N 94.45 In C/L road PIp�ods f R spike N 214.85 D.B. 150 , 1�G. 405 new nail tl N 113.29 in C/L rood H 415.38 - H 85.47m 78.54 ! H 26.57 WADE D.B. 15 DAVIE COUNTY • WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: CU , �_ ( '�« v� 5 File#: Site Address: °l pn ,1n IQ rO Subdivision: Lot: Permit Type: New Well ✓Well Repair Well Abandonment Other Facility Type: Residential ✓ Food Service Church Commercial Other Initial Inspection Were Setbacks Maintained? Yes No What is the Grout Depth? ft. If No, Explain: What is the Grout Thickness? in. What is the Type of Well? Was a Well Screen Installed? What is the Casing Type? Q C Type of Drilling Fluids Used: What is the Casing Depth? (4 g ft. Well Grout Inspection Date: What is the Well Diameter? in. GPS Coordinates: What is the Well Depth? lad- ft. EHS ID: 1 4 y Well Head Inspection Is There an Access Port? Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? What is the Casing Height? Is There any Grout Settlement? What is the Static Water Level? ft. What is the Yield? GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name: Pump Installer Name: Contractor Certification #: Date Installed: Depth of Well: Depth of Pump Intake: Casing Depth and Inside Diameter: Pump Horsepower Rating: Screened Intervals: Opening for Piping &Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: Date Well Completed: Well Head Inspection Date: EHS ID: Construction Completed Date: Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Date: Authorized Agent: DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST � • Applicant: . � « vt File #: ��� ��� Subdivision: Lot: Site Address: , Permit Type: New Well ✓ Well Repair Well Abandonment Other ✓j Facility Type: Residential Food Service Church Commercial Other Initial Inspection Were Setbacks Maintained? Yes I✓ No What is the Grout Depth? If No, Explain: What is the Grout Thickness?Q_ in. What is the Type of Well? Was a Well Screen Installed? What is the Casing Type? ev C Type of Drilling Fluids Used: What is the Casing Depth? _ft. Well Grout Inspection Date: What is the Well Diameter?._ in. GPS Coordinates: What is the Well Depth? fry- ft. EHS ID: 4 Well Head Inspection Is There an Access Port? Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? What is the Casing Height? Is There any Grout Settlement?- ZZ What is the Static Water Level? �l ft. What is the Yield? _ GPM Is the Well Contractor ID Plate Complete? ✓ Is the Pump Installer ID Plate Complete? Contractor Name: Pump Installer Name: kowa•.t Ul1cc�W. ���� •P Contractor Certification #: Le Date Installed: 1 Depth of Well: Depth of Pump Intake: 100 r Casing Depth and Inside Diameter: (: Pump Horsepower Rating: Screened Intervals: Opening for Piping & Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: . 10 Static Water Level and Date Measured: 7 - )--2. Date Well Completed: 7 -2�l Well Head Inspection Date: --7-2q— g EHS ID: Construction Completed Date: 7 ~ D---z -C��E_ Contractor Reports Received Date: Sample Date: C� _ �-� —'-jo _ -- � — pdo Results Mailed Date: 7' Certificate of Completion Da : Authorized Agent: /'