282 Ralph Rd (2) : •__ . �., ' _ DAVIE COUNTY HEALTH DEPARTMENT Pd ��/3�.I��
� Environmental Health Section •
� , P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT �
Account #: 990000693 Tax PIN/EH#: 5769-33-8442
Billed To: Philip Allen ivey Subdivision Info:
Reference Name: MaGu�e McDaniei Location/Address: Ralph Road-27028
Proposed Facility: Residence Property Size: 12 Acres
ATC Number. 2110
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AiTTHORIZATION 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
PERNII'i'IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ���� �• �Peopte i-�' #Bedrooms � #Baths � •
Dishwasher: � Garbage Disposal:�Washing Machine:� Basement w/Plumbing: � Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People✓Shift #Seats Industrial Waste: �
Lot Size �2 aC2,:��j Type Water Supply W�`�- Design Wastewater Flow(GPD)�� Site: New�" Repair�
System Specifications: Tank Size �CCfC(`�GAL. Pump Tank GAL. Trench Width�G�� Rock Depth IZ�� Linear Ft. �1
Other: � !�'STiZ!&�T/o.J �o}�S
Required Site Modifications/Conditions: ���9G�i CJi� GE��V2,�� �SY�NOt1s+% �F���►.�� �I�.'� ���F�'``�
c�3�
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G°�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe 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.****
� � t�1.�S �1�
�QvX,.�O .F� -F�Psi
� ,o �� M, No� �
� � CR+4�.P� Rr��� F��,�. -CN✓-� Pt� ►►-� oR-D-�.�-.
' � �� �1 �`�o' �
� �oo�
1� 2 �
� ' �00�
*�3
�y too' '�
, �s loo` L
,... ��� C,
��
�
R�o�.�� ��
��� !�o' �,3t��,�2„
,
Environmental Health Specialist's Signatur • Date: Z
DCHD OS/99(Revised)
' . . .
, _�
�. DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0
Account #: 990000693 Tax PIN/EH#: 5769-33-9442
Billed To: Philip Allen ivey Subdivision Info:
Reference Name: Mackie McDaniei Location/Address: Ralph Raad 27028
Proposed Facility: Residence Property Size: 12 Acres
ATC Number: 2110
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST 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 T eatment and Disposal Systems). THIS
AUTHORIZATION FOR WAS E CTION VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signa Date: / 7iJ�
CERTIFICATE OF COMPLETION
**NOTE**The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation Permit
� `� 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 will function satisfactorily for any
given period of time.
U,J� �� �.J
� � �] ��
` " to"�l'�C s„�a �Ps'`'�,(�
ia ,
�-�,r �s'
i�, ��
<oS, ,�.
<vs-. �o,
�o;�
���
JoJ��
�o'
It7j� ' (p'
S�'w3r''ic�i' /
Septic System Installed By: <\�c�
Environmental Health Specialist's Signature• Date: –/ T/ �1
� —
DCHD OS/99(Revised)
, .� , :• �,,,� ,��Q
, a . ��'1 L��L"�G,v�IZt�
+•� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE R M R ���
' Davie County Health Department � L5 � U l5 ��
Environmental Health Section
P o.soX sas ,�J - 2 1998
Mocksville,NC 27028
(704)634-8760
�.� �R
��_,µ . `,�, �.��1, ,'_T'
****IlVIPORTANT*#** THIS APPLICATION CANNOT BE PROCES �"°�
ALL THE REQUIRED INFORMATION IS PROVIDED.
�� �l�.C�-.� �'lc�R..J�t�.
1. Name to be Billed Contact Person
�- �� ��.,�0� q p
Mailing Address Home Phone I �0 3���
City/State/Zip ��C�Sv(t`�2 w�_ �-��d-� Business Phone �S�� ���- �kta0'�
2. Name on Permit/ATC if Different than Above �� � e e
Mailing Address City/StateJZip -� .•:''' -
\, fR: �
�. . ,
; �y
3. Application For: • �`�ite Evaluation ❑ Improyement Permit&'ATC .O Both
�, _
4. System to Serve: x,,,�House ❑ Mobile Home ❑ , Business ` � q.Industry.. . , ❑ Other
, ,, � ':l M? .. . '.. '::i�.
5. If Residence: � # People � � #, Bedrooms _� -- . � #� Bathrooms _,�_
/� ' � .' � • -�.� ,
Q Dishwasher "�Garbage Disposal �Washing Machine . 9'�asemendPlumbing.�,� ❑`Basement/No Plumbing
'i ' -
6. If Business/Other: Specify type " # People "~ # Sinks
. �,;;;� . �
� ,j,- �� � �-� .�r...,�:.. �
# Commodes ''y.;�' # Showers =: # Urinals # Water Coolers
.,�' ,r ,.
If Foodservice: 3 # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: ❑ County/City 0'�ell ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensionsl��CReS S7 S�`� 7�X�7�3 1 y� � WRITE DIRECTIONS(from
� � Mocksville)TO PROPERTY:
Tax Office PIN: # '��! � - 3 3 _ °I YY�-- �
� �— � � �� e�
Property Address: Road Name �
[�_ t 1 d D ri�/
�:�C_`�S� \`.e. �� 1 }�
City/Zip L � J- �� l��
1
If in Subdivision provide information,as follows: 1
1 c �
Name: �
1
Section• Lot #: �
1
1
This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter '
are subject to suspension or revocadon,if the site plans or intended use change,or if the information submitted in this application is
falsified or changed.I,also,understand that I am responsible for all charges incurred from this application.I,hereby,give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by � � �°" to c all testing procedures
as necessary to detemune the site suitability.
,
DATE �P" �` -1 6 SIGNATURE
Revised DCHD(06-96)
,��u-/ ���.3
�� v��'.26
. .
. �k . � _--�-- � ` �-.
^ 6 ; �'3'� ss:.
�,• ' �
� '' ��"/r . �
• e' �
t�G.• �e -� ! .
t �'
�_ r I � \ } _ �O: .
� �` d� �. �i K '�� ,
> s.
,ga, . j � X �
,
i eh � ;
�
,
rj, e-!I i
i�
d ,1 � �
� �
� 1 � =C'"25
i
. J �
� �.000 �cres �
i
� "
ryry i
�
\!38. � ,
O�` . ''
•� �. - ---- �-
_�
P i
P �
' ,,,` ' 459. . � / /t/
'�I t' i
� n � �
� . I �
�\ �\ \��' __ � N 3 000 �Cr�s ' S�� �- �/I
-- - � I 3 '�- �7"Y Z
� .. � N �
�5�,
� i
I
_��Zy3 I
�\ ,
I
/,
� t` . � .
� • DAVIE COUNTY HEALTH DEPARTMENT
• � • Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME �N�k�� `d4`'( DATE EVALUATED � I$�b
PROPOSED FACILITY �1�115� PROPERTY SIZE YL��
SUBDIVISION ROAD NAME ��� �
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L
Slo e% ?,
HORIZON I DEPTH _/2 C9 -)p
Texture rou C,L L
Consistence ; S
Swcture 5 �
Mineralo '
HORIZON II DEPTH 1 Z-Zb -�`b
Texture rou C,
Consistence • S `
Structure Q�k Q
- Mineralo �v1� �s� �
HORIZON III DEPTH -�}Z � -2 '
Texture rou + C}
Consistence � ;
Structure k k
Mineralo rv1��0�
HORIZON IV DEPTH +
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON '
SAPROLITE '
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE o. D.Z �
SITE CLASSIFICATION: PS EVALUATION BY:� ����.�P
LONG-TERM ACCEPTANCE RATE: D�Z OTHER(S)PRESENT: �-L.ac� 'r�/-✓KA�
REMARKS: �/1�� �M�LL1�.on�'. —''7t�1�'L�12x� M.eb��r�s'.�
LEG ND
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
tructure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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-gaUday/ft2
DCHD(01-90)
■■���■■■��■■■�■■��■■■■�■��s■�a���■■��■�o�■���■���■■�����■■■���■��■
■■�■�■■��■����■■��■��■����■��■���■������■�������■■■����■■■������■■
■■�■■■o�■■��■�■��■■■�■��■■�����■ ■�■��■■�����■�■■��■■�■■����■��■■
■��■�■�■■■�■�■■��■■■�����■�����■�i�■■�■■■�■■■��■■■�■■■�■■���■■�■■■
■��������■�■■■■��■■�■���■■��■������■■■■■■��■■�■■■■��■��■��■�■■■■■■
■�����■���■■■■��■■��■��■■��■■■■■�����■■��■■■■������■■�����■■■■■■�■
■�■�������■■■■��■■�����■■�■■■�■���■■�■■��s����■���■■��■��■■■■■�■�■
■���■�■■��■■�■�■■■�■■������■■■■��■a■��■��■��►������■■����■■■■■�■��■
■■■���■■��■■�■�■■■�■■������■■■■��■■���■��s�li�i������■■�������■����■■
■■■�■■■■�■■���������■■■■�■■��■■��■■��■����u�i�■�������■■�■■■������■
■■■��■■��■■���■���■��■■��■■■��������■�������■�������■■■�■����■��■
■■�������■��■■■■�■■■■���■■���■�■ ■����■■��■����■■�����■■����■�■■■
■�■■■■��■■�■■■■■����■���■■■�■��■■��■■■■■■��■■���■■��■��■��■■■■■■■■
■��■�■�■���■■■■�■■■�■��■����■■■■■��■■■■■��■■■���■■��■■��■��■■■■■■�■
■�■■���■■■■■■■��■■��■��■■���■�■■■��■■�■���■■���■■��■■�■����■■��■�■
■�■����■■�■■■■��■���■��■■���■�■��s■■■■■��■■■������o�■�����■�■■��■�■
■■■���■■��■■���■■■�■■�■■��■■■■■���■���■��■■■■■�a�■■a����■■■■■�■�■■
■■����■■��■■�■�■■��■■�����■■■■■��■■���■��■■�t���o�■■�■■�������■■■■
■■■���■■�■■■����������■■��■���■■ ■��■�������■■�►������■�■■■■■���■■
■■■�■��■��■■■���������■��■■■�����ii���■��■■���■����������■■■������■
■■■■■■��■■�����■��■■�����■■�����■����e�■■��■■■���►���■■�■s■���■���■
■■�■■■��■■■■e�■������■��■■�����■�■��■��■■���■��■■���■■■■■■���■■■■■
■■������■■�■■■���■■■■���■■■����■n���■■■■■��■■■■■■���■■■■■■��■■���■
■���■■��■■�■■■■■■■■■■■��■■��■��■�i����■�■■��■■■�■■����■■�■■�■■■■■■�■
■��■■e�■���.�■■■■■■�■��■����■■■■���■■��■���■■■a■■��■■■��v��■■■■■�■
■��■■■�������■■�■■■�■■�■■���■■■■���■■�■■���■■�■■����■��■�■■■■■■■�■
■�■■■■■■������■�■■��■�������■■■■ �■���■■�■■■■■■■��■�������■■■■■■��■
■�■■■■■■■■o■��■�■■■�■�■�����■■■■�■■���■�■■■■■■■�■■�����������■■■�■
■�■■■■�■■■■■■���■■��■��■■���■■■■���■■����s■■s■■��■■■►���������■■■■■
■�■���■■■��■■���■■��■��■����■■■��■u■■����■■��■■��■■■����������■■■■
■������■��■■■■�■■■����■■��■■�����■[���■��■■�������■■���■�■■■■a���■■
■■■�■�■■��s■�e�■■■�■��■■�■■■■■���■u��■�■■■���■�o�o���►�■■■■■■���o■■
■■■���■■■�■■�■�■■��■��■■��■■��■��■�i��■��■■���■�t■■■������■■■���e��■
■■■�■�■■��■■■������■�■■■�n■■�����■��■�■���■���■���■■�����■■����■■■■
■■■���■■��■�■�������■■�_�u■��������■����■�������■■■�■����■■���■�■■■
■■■���■■��■�■��������■■��a■����■ �■�■�■■�������■■��■■i��■■�e�■■■■■
■■■�■�■■��■���■■��■■�■■�.�■■����■■■�����■■����■��■■��■■i■■■����■�■■■
■■■�■■■��■■���■■��■■■■��■i■��■�■■���■a�■■���■■■■■���■�i�■■��■■����■
■■�����s�■■�■■■■�e■��■���■�����■■o��■��■■����■��■���■�i�■��■■■■�■■■
■■�������■■�■■■■�■■��■��■■�����■■��i■■�■■�e■�■��■■�■■■�i����■■■■■■�■
■�������■■�■■■■��������■■����■■■��■i�■�■■�����■�■■��■■��i��■■■■■■■■�■
■������■■■�■■■■��■��o�■■■��■�■■■�■■i�■�■��■n�a�■■�■■■��i��■■■■■■a■�■
�iiiiii�iiiiiii�iiiiiii�iiiiiii�i�iiiii�iiiiiii�iiiiiii�i�iiiii�
■��■���■■��■■■�■■■����■■��■■■■■��■■������■■��■��■■������■■■����s�■
■�■■���■v�■■�■�■■��■��■■�■s■�����■■�►�■��■���■■�■■■��■��■■■����■��■
■�■■��■■■�■■�■�■■��■�■■■���■�■��■■■���■��■s����s�■■■�■�■■■■����■�■s
■�■���■■■�■■■■�■■�■■�■■■�■■■�■��■■■���■������■■�■■■�����■■■������■■
■�■���■■��■■���■��■■■■���■■■���������■�■■���■��■■���■�►�■■������■■
■■■���■���■�������■■■■�������■e■■����t�■■���■���■���■■�►����■■■o■■
■■■���■���■�■�■■�����■��■■���■�■ ■■■�������■■■�■■���■■■■u����■�■■■
■■■�■■■���■■■�■■�■■■■���■■■�������■■��■■■���■■■■■■�■���■�����■■e�■■
■■■������■■�■�■��■���■��■■��■■�■■��■■�■■���■■�■■■��■■��■n���■■�■■■
■■�■■■■���■■�■■■■■��■��■■�����■■���■■�����■�■�■���■���■���■■e■■■�■
■■���■��■■�■■■■�■■��■��■■��■■�■■��■■�■�e�■����■��■■■��►.���■■■■�■�■
■■�■■■��■■�■■■■�■■��■�■C:����■■■■�■■■��►���■■��■���■■�sI■���■■■v■■�■
■■�■■■■■�����■■�■■�����■Y►!�■�����■■■�■11����■■■■■�■��//�■�■■■■■■�■�■
■�■■■■�����■�■��■���■��■���e��■��■■��■����■���■����■�n���■■■������■
■�■■■■����■■■■�■■�����■■�■■��■�■ ■������■■���■������t�■���■������■■
■�■■■�■■■��■�■�■■��■���■�■■■�����i����n�■■�■■■v�����n■■������■e■■■
■�■■■�■■�������■■�■■�■■�■■■����■■■��■��t■■�■■■��■■■��s�■■■����■■■■■
■���■�■■■�■����■��■■����■■■����■■■��■�����■���������■■.■�����■■■■■
■■■���■■��■����■��■■■■���■��■��■■��■■�����■��v■�■���■■■►����■■■■■■
■■�■�����■■�■■■��■■�■��■■���■�■■���■�■�����■��►�■■��■���■�►�����■■�■
■■�■■■���■■■■■■�����■��■■���■■■■�����■����■���r■■�■■■�������■■����■
■■�■■■■��0���■■�■���■�■■■���■■■�������i��■■��11■�e■■■�����■■►■����■
■■�■■■■�■�����■�■■�����■■�■�■■■■ ■■��■�11■����1���■■■����■■■■\\���■
■��■■■��■■�■�■■�■■��■������■■�■��■����L�11■���\���■■�����■■■■�H���■
■■■����■■■■■■■��■■����■■������■��■■��■�u>>��������■■■����e■■■■��i���■■
■��■■■�■■�■■■■��■■�■■■■■��■■��■�■s■��■�a���t��..-.i����■■■■■■���i�■■■■
■�■��■■■■�■■���■■��■���■�■■■����■■■����■�i1��■�l�l��■����■�■■■��l�'!�■■■
■�����■■■�■■���■��■■��■��■■�0���■■��■��■��\■■■\�\1�■��■■��■�����G1■■■
■�����■■�������■��■■����■■■����■■���■�■■�]\1■■���i��■■������■■�l'�:�■�■
■�■���■�������■■�■�■�■�■■■��■■■■■��■■�■���\�������■■��■O�■■■■\��Il�■
■■■�■�■■�■■���■■�■■■�■e�■■��■■■■ ■■■■■■�■\\���■���■■�■■�S�■■■l��1�■
■■■���■��■■�■�■■���■■■������■■���■■■■e■����■�■���■■��■�■■■■■��r�■
■���■■■�������■■�■■�■■��■���■■■■��■■■�■���■������■■■����■■■■■�����i■
■■�■■����■��■■■�����■������■■�■���■������■���■���■■����■■■����■�:�■
■■�■■■■�■■���■■�■■��■��■���■■����■■�����■■�■���■■������■■����■■■�i■
■�■■���■■■■■���■■■��.�■■�■���■����■�■■�����■■��-.����■��������■■■�i■
■�■■����■�■■■��■■�■���■�■■���■�■����■■■■��■■■��■■��,�■�����■��■■■�i■
■■■���■■��■■■��■��■■�■���■�����■■����■■■����■������■►������■■■��■■��■
■■����■��■����■■����■■������■�■■ ■■�����■���■����■■���■eo�■■■�������
■�o�■■■������■■��■■�■���■��■■�■��i■■�■��■■���■���■■���■■■■■����■■■►�
■■�■■■��■■�■�■■�■■��■�■■���■■�■��■■��■��■■��■■�i�■■�■►�■�■■����■�■■��
, �
/ � � i
-
�
� � - �avie Countr��CeaCth �epartment
NUMB��g98 and�-fome �-fealth�gency
N�1 Pv�MPRa.�p2� �nvironmental.�Cealth Sec�-ion
�F��C,'C�336�5 P.o.soXc RIER#O-40-06 STAEET
MOCKSVILLE,N.C.27028 �
PHONE:(704)634-8760
• June 10, 1998
Philip Allen ivey
c/o Sricegood-Wall
Attn: liackie KcDaniel
854 Valley Rd.
Mocksville, HC 27028
Re: Site Evaluation
Ralph Road/12 Acre Tract
Tax PIN: #5769-33-9442 .
Dear Client(s):
As requested, a representative from this office visited the aforementioned
site on June 8, 1998. Based upon the information provided on the application
for a site evaluation and after the evaluation vas completed, the site xas
found to be provisionally suitable for the installation of a modified,
oversized on-site sevage disposal system.
Before any permit(s) can be issue�' the appropriate applicationls) must be
• filled out and the house/mobile home locat2onts) staked off.
If you have any questions, please feel free to contact this office.
` Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
JBJvd
Enclosure(s>
� ° ' _ . Q ����
,
�
. �� - -�-�un 9� �.
_ �_,.. unty Health Department . �;,�.��F�����
� ..�`r��* � q �-'�``��'..�
�`� � 6 ental Health Section . Y�� �
, ��� .�
, �s�� M: � .
t �� • ��-A �, . �=
� '•�� Y � � P.O. Box 8�18 � ��<:���,� ��t� ���F
� ; � �: ���� �
,.�,� ��� �{ ' ��v 1 p 2009 210 Hospital Street ���"„'� �
�,Q��f�, ourier# : 09-40-06 `�
�T lti �,�rt�,t t,���rtN ` t�
��.�:_���` �����, n} �L ` ocksville, NC 27028
,,,;-� ?
��..:., �
Plio�ie:(336)-753-6 I'ax:(336) -753-1680
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
�. .
� Name: ���� T U'�� _ Phone Number (Home)
Mailing Address: �i �i I�(t! �.��'k�=-t�.�C �-Ca �l�" ��!� ��Z- f7�:j �l'L. (Wark)
,- Z' '
���ll 1��� �, �V C, %ti`���`a(��
Detailed Directions To Site: � C►/ti(L' �}T'��r2 �j� j C, �/��,,pf- j �Q�j��,y��r /y/r�
i� C����> C`r���k- � ;�=/�--'1� . �>;= �':�t,�r�'n�:�; / ��i�s r �c�f�/�
�� >�J �/tz f/i �-�=�"��✓2 c�zn;s �t�% � C� ���'
Property Address: i� OCL ' �
Please Fill In The Following Information About The EXISTING Facility: �1` �6iY!� N�v�/2 �G{//-�.
Name System Installed Under: �f7/��//� .�U��I Type Of Facility: O�SP �� ��l[t-'
a Date System Installed(Month/Date/Year): Z � Number Of Bedrooms:�'l _Number Of People: �
Is The Facility Currently Vacant? � No If Yes,For How Long?
Any I{nown Problems? Yes No If Yes,Explain: �/dT �S(�f l�, /VO hov�� ��er �/�-��e a�
�ja�'�`�N
'Q� Please Fill In The Following Information About The NEW Facility:
�Q� Type Of Facility: �L�����'��L�-'%IJh /?I'�'�L r"/� Number Of Bedrooms: � Number of People �'� .�
Requested By: /L�.l' ��,,;, Date Requested: I/�/� , ��i`
(Signature)
; � For Environmental Health Office Use Only
Approved �isapproved . , / .
Comments: CG � � r.rC�r �-�C.---
��V��'l
Environmental Health Specialist Date:������ �'/�
*The signing of this form by the Environmental Health Staff is iri 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 # �� �� Amount:$ . �00'.d'� Date: '2 ZZ �
Paid By; Received By:
Account#: t �j �►� Invoice#: 1�31}
�Sv ,� ,._.. w►n . ..• ,i / .. _ / 4.✓/ . '
�- - '
Account #: 990000693 Tax PIN/EH#: 5769-33-9442
Billed To: Philip Allen ivey Subdivision Info:
Address: 854 Valley Road Location/Address: Ralph Road-27028
City: Mocksville Property Size: 12 Acres
Reference Name: Mackie McDaniel
Proposed Facility: Residence
` � '''�� � �'_� : Davie County Environmental Health . �
� " - P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 '
(33�753-6780/Fax(33�753-1680
WELL PERMIT �
.
Account #: 990003367 Tax PIN/EH#: 5769-43-2368 ' -
Billed To: Phil Ivey Subdivision Info: 2�1 ��l�h �l'
Reference Name: Location/Address: Ralph Road-27028
Proposed Facility: Residential Well � Property Size: 11.8 Acres
ATC Number: 0081 .
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 facdcircumstances upon which this permit was issued.
Permit Type: New Q Repair ❑ Abandonment ❑
/I Proposed Well Location Diagram Certificate of Completion Diagram �
/ �
' �
l `
� �
. 3 �
F �-�-- �
-_ ,� , �
Comments:
M` Driller:�Q��_��cnC�tl�i1
p � �� Certification#: r��lp
�I�VL.�i'i 1J�V�a 1 VI�,1�1pf Grout Inspected: C
Well Head Inspected: � �d _
ti ' GPS C ordin tes: � —° . /S���� _ 'r�Z
j EHS: ' Date: EHS: Date:
_ l�. �� o ��Z �
W.P.7-08 : ���^'_''"1 � �
�
• , ,
, ,� �
., a'
' �����,/� ICATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
��N Q 7 2��� P.O.Box 848/210 Hospital Street
�/� Mocksville,NC 27028
BY; `v�� (336)753-6780/Fax(336)753-1680
***IMPORTAN7'''**
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name P���- =v�y Contact Person
Address 3�q L'�2 i ER G R E��c f� Home Phone (3 3 d) �`jVA �`�58�
City/State/ZIP '1�►Q��rUc�. ,IU,c. Business Phone �33Co) 4?Z-SS9 L
Name on Permit if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION���' � *Date House/Facility CornersFlagged �p-7�`�
NOTE: A survey plat or site plan must accompany this application. Included: ��Site Plan ❑Plat(to scale)
Owner's Name P H��. ���� Phone Number( 3 3CQ) Q`I Z-8 3�'r
Owner's Address 3 �9 8���-C,e/c�K 2D City/State/Zip__AAvrbuc�.,rV.G .Z� Oo4
Property Address �/K/�fl �t..0 City. /�pC�viGl.,G_ �cJ�'.
Lot Size !1•�3 ��5 Tax PIN# ��
Subdivision Name(if applicable) Section/Lot#
Directions To Site: C otivArzE,C. �t,p p Rl.i�/ r/z D
G��E,� S�'" �eiu.E oN �c.1(zNT �9ST ,e�� c„�f I'� ti`M�-N7'
DEVELOPMENT INFORMATION
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 �
Do You Intend To Install A New Septic System On This Site? YES NO ✓
TERMS AND CONDITIONS: �D 2S�
This a lication must be accom'an/ied/b"a lat or site lan of the ro e that includes the existin and ro osed ro e lines
PP P Y P P P P rh' g P P P P rh' �
with dimensions,the specif c 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 the best location for a well. •
(�c�-C � 0(� � 0� � �l .
Signed • Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
7/30/09 Account# c�(0 7 �
Invoice# �
�
- --- -- - --------- --- — --- - - ------------- -------
v1AP5 -Davie County NC Public Access Page 1 0
O R����t�` �`_` �_ \ !; l�]
Click Here To Start Over
• .� , ,, �.� �/ �+'� Quick Search:(County I[
., --� � � �;�� Activ� Layer: � tlse f�1�p Tip�
�U K� � � � � PARCELS (Map Tips Availabie) T +
317�
j J
J
, �
����� - . � . � .. �
-: � . �' , .... �: . . _ _. . . .. .. . .
_ . . , . . . . � -��+1 . .. ... .
- � �-. .. - . .
.. , 1 � -. � Q _" ..
-' ,- . � . . � ' . V � .
. _ __s. ,,. _ ... '. - . . .� . - �
v
.� � - � � . . . .. .. .. ' ..-
�,,,f^,� �, � s� : � '�I
�,.: �, b �
� F� .�
�
- �� �' Q �,� `
��
-. -. .. N ..� � .� � . �-...�..� .
�'�`¢� � �� ,_ �
Q.P�' � �^ -^
r � �. . _
�
�
i ?23,� 1 O
\ — �:
_
-
� _.v _ _ .
�, ` � u.�^�p
`.. �• —� -�o
_
�� � � � � �
�" � 1 ��e� � _
` � � . a
1 , �
?��� r � _ �
--. -
. . 1 J;,a.� .. � . . . . � . . . . .- .
_ _
. . - . � _.. ...
�� ... - _. . ... . . . _ .
���_.. ._ �� _ . � ..
.. .. . � � . . . � . . . . . .
�
� � - . . . . . � � . . - - .. .
�
. . . .� . �-.. .. -�� . .� - �
� ... .� . ._ . . . . � � • .... a .. , •`
.. �- . . � . ; . . .
� �://maps.co.davie.nc.us/gomaps/map/Index.cfin . :�6/6/2C
.:=drb,,...�,�.
�.:. �-��, �
',�/= i ��
� "---�� '' 3''" „f ESIDENTIAL �V�LL CONSTRUCTION R�CORD
�� �, �=��� �.� , ��C���
� :};, �� .
• �_ �,�,���:�• �c°f,: North Carolina Department of Enviromnznt and Natural Resources-Division of�Vater Quality ��
4'�""""��`S� 1V�LL CONTRACTOR CERTIrICATION# 3 C93(,q JUI_ 15 2011
�,,�,�.,,,�
DAVIE CUUN r YyEA�fh��NHkfMEN,
1.WELL CONTRACTOR: Q g. WATER ZONES(depth) 6 S�n
f/a��liew ./� U/0�✓�7 Top 7.Sr Boftom 78 � Top�Bottom
Welt Contractor(Individuai)Name To p .� 7.� � Bottom�7� '�� Bottom
YADKIN WELL COMPANY. INC. � ' Top eottom -rop eottom
Well Contrac[or Company Name Thicknessl
1908 HAMPTONVILLE ROAD � 7. CA51NG: �epth Oiameter wei�ht materia�
Street Address ��
; Top�_Bottom�Ft.��ts ��-1! ,�l/�.
HAMPTONVILLE NC 27020 ; Top 6S eottom�_Ft. 6.1,r" p,/� 6a!'� �S'�C..�
CityorTown 5tate ZipCode Top Bottom Ft.
c 336 � 468-4440 �
Area code Phone number 8. GROUT: Depth Material Method
2.WEIL INFORMATION: Top�Bottom 3 Ft. i�� ��,1� �
WELL CONSTRUCTION PEP.MIT# O� � � Top�_Bottom3Z Ft.� ' _S/„y�J �
OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft.
SITE WELL ID#(if appiicable) ����3 g, SCREEN: Depth Diameter Slot 5ize Material
3.WELL USE(Check Appiicable Box): Residential Water Supply� Top ottom Ft. in. in.
DATE DRILLED G -2�-// Top Bottam�Ft. in. In.
TIME COMPLETED 6,��lS AM❑ P(� Top Bottom Ft. in. in.
4.WELL LOCATION: ; 10.SANDIGRAVEL PACK:
,� �f � Depth Size Mate�ial
Cffl':� �"Y�h,�� COUNTY ✓ � � Top Bottom t.
/� Top Bottam Ft.
(Street Name,Numbe s,C'ommuniry,Subdivision,Lot No.,Parcel,2ip Codz) . To Botfom Fl.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
�lope OValley ❑Flat ❑Ridge pOther 11•DRILLING LOG
Top Bottom Formation Description
LATITUDE °_' "DMS,OR � DD -O->.J�� S'��( '
w=
LONGITUDE '_' "DMS OF�� � • DD ; 3 0 ' I (�e f� S6�SL C„i.n��F
LatitudeAongitude source: �PS �fopographic map �'S�l 7`S � �e�°e �"""S4'
/ �
(location of�vell must 6e sh wn on a USGS topo map andattached to 7S � gU ���" �/'.ec�r.i,c.,
fhis form if not using GPS) . �O�/ 32� � y Gi.�,��
/
5.WELL O'JVNER • �
T�i ► L ��i�� i
� Owner Name �
3� � gr.�r� �� e �� R�o �
Street Address �
��NCa NC�i �L ��V�Co_ I
CiryorTown State Zip Code / SIZE OFF s;gf/'1
c 336� q '��, �Sc�_ J BITSERIALNO: Qsy�o�,
Area code Phone number 12. REMARKS: •
6.WELL DETAILS: ?
a. TOTAL DEPTH: J 2 Z �
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO�' : �DO HEREBY CERTIFYTHAT THIS WEIL WAS CONSTRUCTED IN
c. WATER LEVEL Below Top of Casing: 6!� FT. ACCORDANCE WITH 15A NCAC 2C,WELL CONSTRUCTION
(Use"+~if Above Top of Casing) STANDARDS,AND THAT A COPY OF THIS RECORD HAS BEEN
PROVIDED TO THE WELL OWNER.
d. TO?OF CASING IS -�- � FT.Above Land Surface'
'Top of casing terminated aUor below land surface may require 6-Z$ -�r
a variance in accordance with 15A NCAC 2C.0118. ' SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
e. YIELD(gpm): /0 METHOD OF TEST f � ' �f��� � a�d c,/h
f. DISINFEC710N:Type HTH _ Amount�S : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
/�A i T'�- 1�REW '
Submit within 30 days of completion to: Division of Water Quality - Information Processing, �orm GW-1a
1617 Maii Service Center, Raleigh,NC 27 6 9 9-1 61,Phone:(919)807-6300 Rev.2los
Date Site Visited .,- � By:�_Pezmit: Yes No
�-d Y��` �o z
What Is Height of Well Casing? Make Sure 12" Above Ground Level! ! ! �
, Map Frame Page 1 of 1
Davie County, NC - GIS/Mapping System
o a�'.�� �`Nj �
i C��lick Here To Start Over
�,`�� � . � - �� u . Quick Search:(County ID or Owner N.
�U N� Ma
�, 8 � � PARCELS (Map Tips Available] �
Addre
� � ��. � ��> >�� i 4 ��
�+��� �� �.,, _ �..� —� �',
���, �
-
;`
I �
� �
I FRANK TRL
�—� �
1
I 1�� o.
; �a
i �P�Q
',
,'',
��-
Sp��T GREfK �N
`---- �
-—�
�--- - � ------ 1—_-----
- -� ----------------- �'"l �
Uo181f1 -- - ' � — - �
_____ ' �— `i f ,
http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&Cr'I�OKEN=616408... 6/13/2011
ri 1b �'I u4:4up mrormauon �eivicx�5 ���.,,,,,,,,,,, r..
.' . , .' ��C�Ft �. .
r JUL � 5 � �„
. DAVIE CUUN I Y HEHu hUtrHrci iy�ti�
- Davie Counfy Environmental �ealth
• P.O.Box 848/210Iiospital Street
MocksviUe,NC 27028 . �
(336)753-6780 J Fax(33�753-1680
WELL PERNIIT '
Account #: 990003367 Tax PiN/EH#: 5769-43-2368 '
e�lled To: Phif Ivey Subdivision Info:
Reference Name: Location/Address: Ralph Road-27028
Proposed Facility: Residential Well Property Size: 11.8 Acres
ATC Number: 0081
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that�his
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&om the date of issaance. Tbis 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 'Q Repair ❑ Abandonment Q
/� Proposed Well Location Diagram Certificate of Completion Diagram
/ l •
�
. �
� '
� � �
� �
:
I
� �Jv. '
�
. ��� x � � .
��
. � � "' �•-J " .
' • • " . .v .. . . .
^ .
Comments: � ^ ' '�_ Ariller:
* 0 '4 !'„ �L Certification#•
- f G������1��11.3i��Fri��f Grout Inspected:
Well�-lead Inspected:
GPS Coordinates:
EHS: � Date: EH�• Date•