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138 Rockwell Ln _. __ __ __ _ . _ • ' ~ � OPERATIt)N PERMIT or ice se n v �„` . Davie County;Health Department xCDP.,File Num6e� 161039 1 . _ .... :., � ' 210 Hospital Street , �s�ooQ,000=33�s � � ,County ID.N�nber,. P.O. Box 848 � :� '�''►�,�►' . ,: . Mocksvilte NC; 2�028� ; Eva►uated„For NE1N Phone:336-753-678p Fax:336-753-1fi80 Township: Applicant: Y�dkin Buiiders Property Owner. Chtis�artd Lee Kasyb Address: 258 Ralph Rd Address: 24g Gilbert Road ��Y� Mocksville ��Y� Mocksvilis statelZip: NC 27028 state2ip: NC 27028 Phnne#: {336)4fi7-7061 Phdne#: (336)575•1977 Pro e Location 8 Site Infarmation AddresslRoad#: Subdivision: Phase: Lot: Rockwell Lane Macksville NC 27028 Directions stn,cture: SINGLE FAMILY Hwy 158, left on Farmington Rd to Pinebrook Dr on right, Rockwell Lane on left #of Bedmoms: 2 #of Peopis: "Water Supply: PUBLIC 'IP issusd by. 2140-Na�ons,Robert 'System Classificatan/Descnption: TYPE Itl B.SYSTEM W/SINGIE EFFLUENT PUMP 'CA issued by: 2tao-Natans,Robert Saprolite System? QYes �No Design Flow: a � � •Distribution Type: �MP To GRAVITY Pump Required? �Yes Q No Soil Application Rate: � , 1 5 'Pre Treatment: Drain fleid N�rification Field 1 6 � � SQ'ft' `System Type: �NFILTRAT�RQUICKd STANDARD No.Orain Lines a Instaqer. B�fan McDaniei Totai Trench�ength: 4 0 0 ft• Certification#: Trench Spacing: _ g inches O.C. ,_,� �,_,,,_, �Feet O.C. 'EH S: 2140•Nations.Rabe�t Trench Vlfidth: _ 3 inches . � F�c oace: � ale9 / aeis �� W Aggregate Depth: inches Minimum Trench Depth: 3 6 _ inches Minimum Soii Caver. a 4 Approv�l;�tatus �� lnches h�R ' , � Mazimum T�nch De th:' ` ' � a�,�� , � p � 6 inches � 3ApPr�;rreti��3�s��pprove� , �,� k Maximum Soil Cover: a 4 inches _ _ _. __ _ _ __ __ __ _ __ _ _ _ CDP File Num6er "�6�039 - 1 County ID Number: ��3315 ' � �_ Se tic Tank Manufacturer. S� �'at' � Long: STB: �60 - Gail�ns: �0(to lnsta�er. ��an McOaniei Date: 1 0 / 1 8 / a 0 1 4 Ce�tificatian#. 'EH S: 2144-Nations,Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter Date: .� . a / 1 9 / a � i s S7 Marker. ❑ Yes � No � - - . . . . . . Reinforced'Tank: ❑ YeS � N 0 �:? �"'� Approv�ai Sfetus� � ; 1 �iece zanx: ❑ Yes D NQ � �[� �►pprove��sap�rovetl �� Pump 7ank Manufacture� Shoaf ��r Srian Mcdaniel pT: 42 Certification#: Gallans: 1250 'EH�� 214U-NaGans,Robert o�te: � s / sala � sa n�te: � alx � la � � s R�ersealed p Yes ❑ No � � RisecHeght: � YBS ❑ NO (Min.6�in.) ��:�� Approv�l S#�i�s��'.��«� ;� � � � Reinforced Tank: ❑ YeS I� No � �� ` � � �� ` �� ApprovedCl=Disap�tro�r,�� ° ' 1Piecs'��nk: Q Yes ❑ N� �� , � �k� � Supply i.ine . P�e Size: � inch diamete� Insta�er; ��n McDantel Pipe length: � 9 � feet Certi6c�tion#: xEH�: 2140-Natiats.Rqbert *Schedute: ap Pressure Rat�d � Yes ❑ 1�0 DatQ: � a � 1 9 � � f� �. 5 Approved fdtings p Yes ❑ NO r �A � r�, Appnoval Stat�us�$- �) Approved�:Q�sapprave� :��- Pum p Type: �0��r fn�ta�er. s��Mcoantel Dasing Votume: - ,�� Certification#: Dtaw Down: fnches `EHS: 2140-Natians,Robert "`Cha�tt: STAINLESS � a / i g / a � 1 5 Date: Valves Accessible p Yes ❑ NO � Flow Adjustment Vaive p Yes ❑ N4 check-valve � Yes ❑ �lo �. ' ��` approvel Status�� '� �" , � � ,��f � - PVC Unians Q Yes ❑ N0 9 �� , , ,��d�r��r�Appro�r�etl(��s�pPm'++e�! �F � Vent Ho1e � Yes ❑ N o ��,m��,. �, f ,� � o��. �'' Anti-siphon Nole p Yes ❑ No _ _ .. _ _ __ _ . _ _.. __. _ �DP File Mumber �61039 - 1 County ID Numbet: E5-000-000�3315 Electric E ui ment NEMA 4X Box or Equivalent Yes � No insta�er. Brian McDaniet Box 12 inches Above Grade YeS ❑ �a Certifica6on#: Box Adj.Ta Pump Tank [+� Yes; ❑ No Conduit Sealed (� Yes ❑ No `"EHS: 2144"-Nations,Raber�= Pump ManualiyOperable � Yes ❑ NO 'Activation Method:PIGGYBACK: 'Date: 0: ;� I � 9 I �, � 1 5' ;Atarm Auditile �. Yes; � No ��roxa�s�atus � �� Approve�C��D�sa�pproved ; Aiarm visibie [� Yes ❑ No �{. 2140-Nations.Robert "Qperatian Permit completed by� Authorized State Agent� Date of Issue: � a / 1 9 � a 0 1 S Owner/Applicant Signatu�e: This system has been installed in aomptiance w�h applicable NC General Statutes:Article 11,Ghapter 130A, Rules for � Sewage Treatment and Disposat,�5A'NCAC 18A.1900 et. Seq.,and ap condi#ions of the Improvement PeRnit and°_�� Constn,ction Authorization.This property is served by a T�%PE In e. sewage septic system. Rule.196t requires that a Type ��8� septic system meet iha foltowing criteria:< M�imum System Review ByThe Local Heatth Department: ��S• Management Entity: OWNER Minimum System tnspectionlMaintena�ce FrequencyByCertified Operator: wn Reporting Frequsncy By Certified Operator.wA Rule.1,96t.�equires that a Type 1V and V septic.systems desgned fora hometbusiness owner.must maintain a valid contract w�h a public management entiryw�h a ce�tified operatoror.a private certified operatorforthe life ofthesept(c system. f�ule.1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a velid confract with a public management entity with a certified operator for the life of the septic system. Rule.1961,(2)(e)requires a contract shell be executed between the system awner and a management entity prior,to the issuance ofi an:Dpe�atan Pemnit for a system:required ta be maintained bya public or pmrate management ent�y,unless the system ownerand certified operatorare th,e same. The contract shall require specific requi�emen#s forma�tena��ce and operafion,'responsiblities of the;ownerend sys#ems.operafor,provisions thatthe contractshall be � effect for as l�ng as the system is in use,and otherrequirements for ttre:continued proper performarrce of the system. It shall sEso t�e a cond�ion of' the Operation Permit that subsequent owners`of the systems execute such a contrad.. OHand Drawing Olmport Drawing ,. **Site P[anlDrawing at#ached.*'� ��-'�� _ _ _ _ _ .. . _ _ _ _ _ _ OPERATION PERMIT "I61 D�9 ' 1. Davie County Heaith Department CDP File Number: 210 Hospitat Strest ES-400-000-3315 P.o.Boxsas County File Number: nnacresvii�e Nc 2�028 Date: ! / �. � Qinch Drawin� Drawing Type: Operatian Permit Scale: . O��ck = :fi�. C7 � , , _ _ ,�j" �, '�,''"+�'�''� ' � I � �- �. � � . � � T _.. _ � .� . .� � _ �� _ _ _ : I I � � ,� � __ � � � � , C' � I � . :a — �- t � ��1� � �`i� � 1�� - � .�- : � , - � � � i s_ � � � � � .� ..� ._.. ___. .�.. � , �..�r, ��..... .��,,, ��,��.. .� M...�..� �.,,� � .. ��.�..� �.....�...� ., �H�:.�.� � �� a � �..�.r�...�.�..�,,,,. + �c _�I._ � __ _ _ _ � � � � � � � � �E � � � . .___.. � � � �� I � �� , �� . �� , —� � � � . _ � _ .� __ . �. .� �� i _ .� � � �:o:,��,�. ,�.-�-l1 L..-�- � , � . _, � _ , r , _ _ �� _ __ �.._...�.�.. ._�_.. _ �...�.. �� .�__.. �.�. _ ___..._ . — � � , , , � � • • CONSTRUCTION Foroftice use on�v • �� ^ • - AUTHORIZATION •CDP Fite Number 161039- 1 �,�.°~-'�`� Davie County Health Department County ID Number. ES-0oo-000-s3�5 � ` i:� � 210 Hospital Street Evaluated For. NEW �.,,��.-� P.O. Bax 848 Township: Mocksville NC 27U28 PERMIT VALID UNTIL. Phone:336-753-6780 Fax:336-753-168Q 1 0 � 1 4 � a 0 1 9 Applicant: Yadkin Builders Property Owner. Chris and Lee Kasyb Address: 258 Ralph Rd Address: 249 Gilbert Road City: Mocksville City: Mocksvilie State2ip: NC 27028 StatelZip: NC 27028 Phane#: (336)�67-7061 Phone#: (336)575-1977 Propertv Location � Site information Address/Road#: Subdivisan: Phase: Lot: 3 Rockwell Lane Mocksvills NC 27Q28 Directions St�ucture: SINGLE FAMILY Hwy 158, left on Farmington Rd to Pinebrook Dr on right, Rockwell Lane on left #of Bedrooms: 2 #of People: . "Water Supply: PUBuc Svstem Specifications Minimum Trench Depth: 3 g Site ClassifiCatiOn: ProvisionallySuitable Inches Minimum Soil Cover. � $ Saprolite System� QYes QNo Inches Design Flo�v: a 4 � Maximum Trench Depth: 3 6 �nches Soil Application Rate: � _ 1 5 Maximum Soit Cover: a � Inches "System Classification/Description: 'Distribution Type: PUMp To GRAVITv TYPE I{I 8.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 � � � G allons "Proposed System: 25°/aRE�UCTiorv �-piece: OYes QNo Pump Required: QYes QNo QMay Be Required Nrtrification Field 1 6 g (� Sq, ft. Pump Tank: 1 0 0 f� Gallons No. Drain Lines 4 1-Piece: QYes QNo ToialTrench Length: 4 � � � GPM—vs— ft. TDH Trench Spacing: _ 9 Qlnches O.C. Dosin Volume: � Gallons (��Feet O.G 9 Trench Width: Inches _ 3 _ �Feet Grease Trap: Gallons Aggregate Depth: � � - � inches Pre-Treatment: ONSF OTS-) C�TS-II SepticTank InstallerGrade Level Required: �I �I) 011) �IV Page 1 of 3 G[�P Fii�Number 161039 - 1 CoUnty ID Number: E5-000-000-3315 � ' � ❑ Open Pump System Sheet RepairSystem Required:�YeS QNo 4No, but has Available Space _ epair Svstem 7rench Spacing: Q Inches O.C. 'Site CIaSSIfiC8ti0f1: Provisionally Suitable � Q Feet O.C. Design Flow: a 4 � Trench Width: _ � Q��c tes C� Aggregate Depth: Soil Applicatan Rate: � 1 5 inches ` R�inimum Trench Depth: 'System Classification/Description: 3 � Inches 7YPE 111 B.SYSTEM W/SINGLE EFFWENT PUMP Minimum Soil Cover. 1 $ Inches Maximum Trench Depth: 'PropOsed System: 25�/,REDUCTION 3 6 lnches Maximum Soil Cover: Nitritication Field 1 6 � � a 4 Inches Sq. ft. No. Drain Lines 'DistributionType: PUMPTOGRAVITY 4 TotalTrench Length: 4 � � � Pump Required: �Yes �No �May Be Required Pre-Treatment: ONSF OTS-I OTS-II 'Site Modifications No radin or construction act'ait is atlowed in areas desi nated for s tem and re air without a `*' 9 9 Y 9 ys p pproval nfHealth Department. �• 7; "Permit Cond(tions 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. «� ,�., 2{ This Authorizatlon for Wastewater System Construc�on shall be valld tor a person equal to the period of validity of the ImprovemeM Pertnit,not to exceed tive years,and may be(ssued at the sametlme the Improw�nent Permlt issued(NCGS 130A-336�b)}.If the installatton has not been completed dudng the period ot wlidiry of the Construction Permit,the IMormation wbmitted In the applicatlon tor a permit or Construction Authoriza�on is tound Lo have been incorrect,falsified or changed.or the site Is attered,the pertnit or Constr�tbn Authorization shall become in�lid,and mry be suspended or revoked(.1937(g)).The person owning or corrtrolting the system shall be responsible taassurirg complfance with the laws,rules,and permit conditlons regarding system Ixa�on,installation,opera�on,maintenance,monitodng,reporttng and repalr (1938(b)). ApplicanULegal Reps. Signature Required? OYes �NO Applicant/legal Reps.Signature: Date: � � 'Issued $y: 2140-Nations,Robert Date of Issue: . 1 � � 1 4 � a 0 1 4 � Authorized 5tate Agent: � Malfunction Log QYes QHand Drawing Olmport Drawing **Site PIan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 161Q39 - 1 „ . Qavie CountyNeaith Department CDP File Number: � • ' 210 Hospital Street P.o.Box 84s County File Number: E5-000-000-3315 Mocksville rvc 2�02$ Date: 1 0 1 1 4 I a 0 1 4 � Q inch DrawinQ Drawing Type: Construction Authorization Scale: . . 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' . � . �. -}_ �...'_.'_" _' ' "_ ' �� ; �L� � � � , .. ._;_ __. __. _ -.:-- � -- .___s,,. , �� - -- - - - y __ . ._. _.. � �,'7� -� ' -� ,no�-f ; � � • �''Z'S � , b�' ' ' O`'� s ; ' ; 1 , . _ ; .. ._ __ ._.._.__ . _.._ , _ � �I O_..�-._' � �/ � � , . _. _.. . .. .... . _ ...: .. _ _..`. . . : . _ . :.. —� -- —.__ _ . ,_.. _ _ . _ — ; , . . . : _ . .... —� _— , : ; � ; ; , C,� � . , i , . . _ _ . _. . :. ._ _ , _. .. — —. .__ . _ _ _ . , . . _ _ : _ _ _ � _ . ,. _ . . _. : , : � , , , ; � i ,,, , ' --�. , ' ; , � , r,,, , ' _ _.. . . . _. . _.,. _ _ .._� - �- • - - - - - - . __ _ _ __ . _ ; !� ; ; y ,� . _S _� : �s~' g.. ; ;�-�'q �'� , _ _: . .._.. .._ .: .__M . . .._. : __. _., ,._ . _ _ _.. _ . . ._. _ _�. .. i r.... � . , '. . �aS �.. ; ��-^�"'+ .SJ , ; : , . ; ; .._... _ . _..:. __ ;_ ___, _ _ __. , _ _. .. ..._. � - - - _._. . _ _ . , � ; . ;_ '. '. '..� ' � 4 , , �+ � , , , ., _. . . ... . _. _ . . . . ._ . . . . . _ ._. . . ._ , �� 0 � _ ._ _ ._._ ..: . . _. . . _: ... . : , : :a.. , , � .. ,� ' , , . ...... . ._ ._ _.... .. _.. .._ .. . ._. _._ .. .. .. ._,..- ---�� -.. ..___. .. - -- __. .._. i7 . _. . i---.. ,__..__.... -. . , r.� , ,�- ` 9, , ' , : , . , . : � � , , , , �,' ' ' C"! :�_ . ..- ._ , , : , . ._ _ . _ . , ._ . _ . ; O� �_ ' � __.__.� . : ._.._ * . __, .__.,.__ ._; __..,__ _; . ._.__.__>_._ ,_. ,___.;_ __ _.___._ __ __.__ . _ _ .. _ . _ , _ . _ _ . __ _.. . __ . . . _ . _. . _ __ Paae 3 ot 3 „ t •• • • • ' a. __.._„r . ��PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC��+'��,� � ” Davie County Envirnnmental Health � � ��1 � P.O.Boa 848R10 Hospital Street A�1 � ��,t�'� Mocksville,NC 27028 ,��a b.,� (336)'753-G780/Faa(33�753-1680 tC3 � Application For. ❑Site Evaluation/Improvemerrt Permit H Authorization To Construct(ATC) 0 Both Type of Application: ONew System ❑Repair to Fxisting System ❑FxpansionlModification of Existing System or Facility •*'IMPORT.4NT"'THIS APPLICAT[ON C.tNNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION . ' Name to be Billed �I�D�KlN �I 1 l.�f' Contact Person ��lp�� JF�0 W.f Billing Address 7�� Home Phone � City/State/Z� �p C K�,V l�(,�,T./�I, • 2"f(��j$' Business Phone — 0 Name on PermidATC if D�erent thHn Above S�}'M�i Ma7ing Address City/State/Zip PROPER'TYINFORMATION *DateHouse/Fac�7i Comers a ed OCfoh¢rZ 7�Dl�f NOTE: A survey plat or site pisn must accompany this application Included Site Plan lat{to scale) (Pemiit is valid for 60 mon th site lan,no expiration with complete p1aG) Owner's Name�: �� ' � � ii Phone Number3_�'� 7 Owner's Address E/ City/State/Zip IL�C' . • PropertyAddress C L CityMOGk I Lot Size •2 Tax PIN# C OOOd 00 Subdivision Name(if applicable) O iC1�� ection/Lot# 3 D'uections To Site:� N Q. �. N o N e-E FT If the answer w arry of the following questions is`�+es",supporting dceianentation must be attached. Are U�ere azry existing wastewater systems on the sitc? �Yes�o Does the site contain jurisdictional wedands? ❑Yes o Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agenc�l OYes o Will wastewater other than domestic sewage be generated7 ❑Yes No IF RESIDENCE FILL OUT TI-�BOX BELOW #Peo le #Bedr�ms #B ms Garden Tub/Whirl ool OYes o P P Basemenk❑Y��o Basement Plumbing: OYes o ff NON-RESIDENCE FILL OUT Tf�BOX BELOW Type of FacilityBusiness Total Square Footage of Buildin� #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)� FOODSERVICE ONLY: #Seats Type system rcquested: ❑Conventional �Accepted ❑Innovative ❑Altcmaiive ❑Qther Water Supply Type:H County/City Water �New Well ❑Existing Well ❑Community Well Do yau anticipate additions or expansions of thc facility this system is intended to serve?0 Ycs �io Ifyes,what typeT This is to certify that the information provided on this application is true and cornct to the best of my knowledge. I understand that arry permit(s)or ATC(s)issued hereatter are subject to suspension or revocation if the site is altered,the intended use changes,or if the infortnation submitted in t6is application is falsitied or changed I hereby grant right of entry to the Awhorized Rcpresentative of the Davie Courny Health Depaztrnent to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locay an g ing staking the uselfacility location,proposed well location and the location of azry other amenities. / owner's or o�mer's legal representative signatiue Site Revisit Charge Date(s): `�"Z.—�r� Client Notifiption Date: p� EHS: Signgiven OYes❑No Account# l�� I 0�9 Revised 11/OG Invoice# �p-- 1f��S _ � � �oT � �.... ? 6 To�o 1 . . _. � � - I�S �" 4U.�' 2� 1 � �8 � � i .� � - ��. : '�. fi � .-. ��r�- . . < . . . � . � � '� 1-0� 3 � � � � . ►�_ " , _ , . � �. . �� . � � w � �s' ----T �V�rc�. � �� o�e��w,�Y. . - � SCw� . ,: ,,. V � - - . � � - \ - , . , ''�` '. . � � !� � 1�S . , , , �� t - � � -I#�� 28 � . i �' ' �� F�loced ... - �J � 's �� . � . . � � Ler h . I � . � � 7-Bor w/Cup Fnd � � • ' i ` E+isfinq Grave! Dr!�e ?-11--1 T-12 . � -"'_' __ ' _ _ __" _ _ .. ' . __' ?-Bor w/Cap Fntl lormerly T-Bor w/Cop Fnd L-22 T-Bor w/CaD Fnd "-Bar .jCop a Stone O a Wolnul Tree Con�rol Comer ~- 0.10' Nort� of P�L Reference PB i l � PG 159 � Gravel Drive Crossed P/L 0.10' ' LOT 4 I 6 469 Acres +/- Inclusive of orea in S.R. 1437 R/W I J1 Rockwell Lari,e , I 50' (25' each side C/L) j Privote Access, Utility ec ISeptic System Easement �p� L-16 Total IRS I gj IRS 'O <0.0' iRS 261.SE' J ' Plocetl �` in Line T��t I � NRCI' �'; �:' LOT 3 ;1 PB911 ITract 1 Revised � � 2g8 Acros +,- ROCKWELL VALLEY � "� �� IRS �-20 Total iR5 Phase I es Reference: P9 11 O PG ' ` s i�S zs�_iZ' \� p Ploced n � o m Lme C/L 50' Easement = P/L '!01 LOT 2 � I �� 1 J 98 Ac�es +/- �• J I wa�'E� 1� -. W �R L-19 Tolal IRS S� �� r,a o IRS 26621' I� N Pbced m Line I S4_6 SE-, LOT 1 � f r- - -- -�n �, - I s�Pc��r��o „ � � �` ROCKWELL VALLEY s ��I easem�� #s �� c/� ao� Phose I m � �� Septic System Easement o N I �_�q � I Reference: PB 11 O PG 246 _y � — — � `�I (75' eocn siae or c/L) � �J �q_3 � SepL< Areo � � � �`�'� -- Eosement N2 �� IRS �� 5' Negclive ��4_ _ SA-I i w Access Easemenl m _ _ �-z4 ^, (See Note �5) 29.82� i Septic Preo Eosement A7 I�� -- 5E-3-+ �i � T-�� "'��°U �ug T-Bar w/Cop Fnd in Line � � — T-7-3 �y_�Q —�- ...--�cr�--�� __ — — �d T_8 _ r_ _ — T_ � —T�5 T-4 � � _ � -i � ook Drive � r r A i° m a G� I A i I � � � N U1 N N N N 1437 Z N N � N T � A Z O N N ^ � O p O Z A � I 0 � ^ I N � rt �C. � o O n O ublic R/W °" _ -' � " '" � �^ .� r A n \ � � A Z Q m (r r �o I 4 � 2� avement Width ° o f s ' � -. s ' ' � " � �, 1 ,i � . . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health � P.O.Bog 848/210 Hospital Street , Mocksville,NC 27028 (33�753-6780/Fag(33�753-1680 Application For: � Site Evaluation/Improvement Pernut ❑ Authorization To Construct(ATC) ❑ Both Type of ApUlication: ❑New System ❑Repair to Existin�System OExvansion/Modification of ExistinQ Svstem or Facility ***IMPORTANT'�**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI-�REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BUL�.ETIN for instructions. APPT.TCANT TNF�RMATT(�N Name V Contact Person E�:/t-�__� Address Home Phone��(o— '1Z2,��Z City/State/ZIP �- Business Phone 'v��v—qal 8� 3�7/ Email.S.u��.t.�!/.�Qu..� � � . � Name on rmiVATC if D�erent an Above Mailing Address City/State/Zip PROPERTY INFOI2MATION *Date House/Facility Comers Flagged NOTE:_ A survey plat or site plan must accompany this application. Included: ❑ Site Plan �Plat(to scale) (Pezmit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Nam� "�/� /=6G��es ' Phone Number Owner's Address ' . Clty/State/Zlp - Property Address , , City � Lot Size � a�_. Tax PIN# �'S�/ �/7SG� z�'. Subdivision Name(if applicable) Section/Lo -_ - " Directions To Site: ,�`� r- ,.�,r�2 � 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 �o Does the site contain jurisdictional wetlands? . Yes �iQo Are there any easements or right-of-ways on the site? ' Yes �/1Qs . Is the si,fe,subject to approval by another public agency? � _Yes ✓No Will wastewater other than domestic sewage be generated7� Yes� TF RF,�TAENC;F,FTT T,ni TT THF,RnX RF.T #People .? #Bedrooms #Bathrooms Gazden Tub/Whirlpool ❑Yes o Basement: ❑Yes o Basement Plumbing: ❑Yes C�do 7F�]�TnN-RF�TDF,NCF.,FTT�,(JIJT THE�iQX�3EI.,OW Type of FacilityBusiness Total Square Footage of Buildin� #People # Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption� FOODSERVICE ONLY: #Seats Type system requested: CJ(;onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:�ounty/City.Water ' ❑New Well ❑Existing V✓ell � Community V�eil Do you anticipate additions or ezpansions of the facility this system is intended to serve? � Yes No �y � If yes,what type? � This is to certify that the information provided on this application is tiue and correct to the best of my]mowledge. I understand that any permit(s)or ATC(s)issued hereafter aze 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 Health Departrnent to conduct necessary inspections to determine compliance with applicable laws and rules. I unders d that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging " ' or staki the house/facility lo tion,prop sed well location and the locarion of any other amenities. Prop owne or leg representative signature Site R�Yisit Charge Date(s): f� /' � Client Notification Date: � Date EHS: Sign given DYes �No Account# �52� Revised 11/06 Invoice# � S3/� _ . - \ , ,. � � '`I , • '��;�� APPLICATION FOR SITE EVALUATION/IMPROVEMENT Davie County Environmental Health P.O.Box 848/210�Iospital Street '`�`1 � - Mocksville,NC 27028 ' AU(,' � � 2�G8 ;� _ (336)751-8760/Fax(33�751-8786 � V i.� ENV��-�."" Application For: �Site Evaluation/Improvement Permit ❑ Authorization To Construc �,�'6`t�j�`'y'��q'�j..,_J Type of Application: �Iew System ❑Repair to Existing System ❑Expansion/Modification of Existing �t3Y Fa�ility ***IMPORTANT***THIS A.PPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMA.TION BULLETIN for instructions. A.PPLICANT INFORMATION c �¢,c-4 Brt,�`e ��iz-s � Name to be Billed `_,�� ' ' �c'•. " ` Contact Person �,Yr'�� .-7 Billing Address "'" ,� i'c�c'/� �~ . Home Phone ��1�� ' �s"`�L?i �ity/State/ZIP ��G��;��'-i L jl�c= /� ' � ��`��-�1:1� Business Phone ' jC��-/�3� Name on PerniidATC ifDifferent than Above Mailing Address � City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: � Site Plan OPlat(to scale) (Pemlit is valid for 60 months widi site plan,no expiration with complete plat.) Owner's Name �',(/`,�, /�if�i' 1�:Z.:s Phone Number Owner's Address i�U�l1�.-�- City/State/Zip Property Address G�� _� City Lot Size Tax PIN# ..�""�S j/ (�'7`�32.2 Subdivision Name(if applicable) :--- y, � '+S �7. 5 Section/Lot# O Direct'ons To ite: S� - - -�� ,� '? ;,� �-9 IJ� �'-�c.'_ �i '�' �� - , S� ' !� �^. :,i/G� � ✓GS '� � . '� . If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any e�:isting wastewater systems on the site? �Yes�No Does the site contain jurisdictional wetlands? ❑Yes S1No Are there any easements or.right-of-ways on the site? ❑Yes$INo � Is the site subject to approval by another public agency? OYes�No Will wastewater other than domestic sewage be generated? ❑Yes�9No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Batlirooms Garden Tub/Whirlpool �Yes �No Basement: �Yes ❑No Basement Plumbing: ❑Yes No . `. i ; , �_� � -. ; TF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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:. Ct�Conventional 6d'Accepted �Innovative ❑Alternative ❑Other Water Supply Type: f�County/City Water 0 New Well DExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C7 No If yes,what type? Tliis is to certify that the infomzation provided on this application is true and correct to the best of my laiowledge. I understand that any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes, or if the infom�ation submitted in this application is falsified or clianged I hereby grant right of entry to the Authorized Representative • of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and niles. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging �r staking the house/facility location,proposed well location and the location of any other amenities. f , .- ...' �7, � ��,�.;,:�f--� � .��- E:� � Site Revisit Charge �`�"Property ot�mer's oc owner's legal representative signature Date(s): �-- �� — �'�_ ClientNotificationDate: Date • EHS: '—=�i-� Sign given CJYes ❑No Account# , nevised 11/06 Im�oice# ` ` + ". ' DAVIE COUNTY HEALTH DEPARTMENT � � � - Environmental.Health Section ,. � . Soi1/Site Evaluation APPLICANT INFORMATION PROPEIZTY INFORMA�ION Account #: 990005156� Tax PIN/EH#:' 5841-97-7322.10 Biiled To: Ellen Furches Subdivision Info: Furches Farms Cot#�0� � Reference Name;ry . . Location/Address: Pinebrook School Rd:27208 Proposed Facility. Residence . ``Property Size:•` 7.14 Acres Date Evaluated: f/� '',�v �� _ � � � ' Water Supply: On-Site Well Community Public ��^~ -Evaluation By: Auger Boring Pit /r Cut C FACTORS � �6 � G Landsca e sition � L !^. �', Slo % ;;:-.s . 2 � '.. .,HORIZON I DEPTH ;;,� tl-, g � � "l � - �- Z .�. a ,. ,l _ ' _;Texture grou C G L' G G � C G�S C�k-S4�' Consistence �; � U r I; � � �� U / �S :f .�µ` F ��('r T�: Strucfure N, � � � .✓ 1/. • ��' GtiS . v C' � '� � Mineralo "..�d w� .c�( �' �= -!� ��'K P - � � . �,� HORIZONII.DEPTH�_ . vj. . Y • �f-�G' - � G� ,' - -jw' � •- - � Texture rou ,� (` �L� C C. Y`�j�� 'G[.. L Consistence N W � �. t Structure �i < U, ,5 �, y C� ij Il"/(� Mineralo �,d t+, ' ^ ''� . HORIZON III DEPTH G " SG(r Texture rou . � Consistence ': - :` ,� � ,� Structure :'; y a f� Mineralo "`5 � � HORIZON IV DEPTH Texture rou � , �. ,� Consistence � � � b Structure-- � • Mineralo . SOIL WETNESS / � / / j RESTRICTIVE HO N �' �.K" `� y.p '` / SAPROLITE / ./ !� • '1f�' �� '( �t'�. N-Y CL'ASSIFICATION ,�j � LONG-TERM ACCEPTANC E d . f 7 .�/ 7 SITE CLASSIFICATION: EVALUATION BY: ��G`"' °.� LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: . �� S � ' REMARKS• LEGEND Landscape Position . R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope r CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope - T�st.urg . S -Sand LS-Loamy sand '.S,L'•-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silry loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay '• CONSISTENCE �1flis.t VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm },� ., `.� � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky ' NP-Non plastic SP-Slightly�plastic P-Plastic VP-Very plastic a�i'11Ct31L� SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic MineraloQv .' ._ � 1:1,2:1,Mixed � LI�. 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 Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) ' . TTAD T...... ror.., .,....o..�......e��e ....1/,i.,../R7 � Tl�7iT/1C/AG m--•:--�� ' ' ` "°"' DAVIE COUNTY HEALTH DEPARTMENT • • � � , Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION � PROPERTY INFORMATION � �� ,��j�G"�"-'/�'�? � � L �. � /D r_ r��• Water Supply: On-Site Well Community Public Evaluation$y: Auger Boring � Pit y� Cut 1 , :r°� 4;�`; , FACTORS �'f 4 5 6 7 :Landsca e position L Slo ' %' .u'' ';::., � � -' -HORIZON,I DEPTH — 1� �. �"" �'L� " Texture grou G Consistence' �i ; ! ;, y � r Structure ' I> . ' Mineralo . , ;1► c . v 1' .�-..�:HORIZON-II DEPTH a ' - v- ,G �"Texture rou �� '�L. _ K-Consistence ` V� , Structure _�;i : _ ,:lyiineralo ' 1• .� ' ,',':�HORIZON III DEPTH � ' Texture ou " Consistence ° Structure � � •L � � � Mineralo � ` HORIZON IV DEPTH Texture rou Consistence � . - Structure " - Mineralo soIL:WETNEss " .�,5-„ 1 '� RESTRICTIVE HORIZON "' `' -L ° SAPROLITE ��{ CLASSIFICATION (� LONG=TERM ACCEPTANCE RATE � STTE CLASSIFICATION: EVALUATION BY: � ^ �/► - ---;-. ..,�;; ,�s LONG-TERM ACCEPTANCE RATE: � �� OTHER(S)PRESENT: . . . , REMARKS• •V': _ .) J LEGEND T, n s ape 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 Texturg � 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 ANSIST .N . . �1St VFR-Very friable FR-Friable FI-Firm VFI-Very firm � EFT-Extremely firm � � ' . � NS-Non sticky . SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �Lus.tur� SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky �SBK-Subangular blocky PL-Platy PR-Prismatic MineraloQv 1:1,2:1,Mixed lY� Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolit�-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 a 1�( Hn n5m5�RP��P.��