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169 Salem Church Rd "' OPERATION PERMIT or ice Se n v ' ,��e .: Davie County Health Department 'CDP File Number .175198- 1 ���� ;����� 210 Hospital Street ����� � ,l2-000-00-0�1 � � � P.O. Box 848 County ID Number: ,, � ' ° ���^"'� Mocksville NC 27028 EvaluatedFor: NEW „ Phone: 336-753-6780 Fax: 336-753-1680 Township: . Applicant: Salem United Methodist Property Owner: Salem United Methodist Address: 169 Salem Church Rd Address: 169 Salem Church Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)492-7116 Phone#: (336)492-7116 Pro ert Location & Site Information Address/Road#: Subdivision: Phase: Lot: 169 Salem Church Rd Mocksville NC 27028 Directions structure: CHURCH Salem Church Rd off of Davie Academy #of Bedrooms: #of People: "`W8t@I'SUpply: EXISTING WELL *IP Issued by: 2140-Nations,Robert "System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? O Yes �No Design Flow: * GRAVITY-SERIAL Pump Re uired? a 4 � Distribution Type: Q Yes �No Soil Application Rate: � . 3 � 5 *Pre-Treatment: Drain field Nitrification Field � 3 � Sq.ft. *SySt@tll Typ@: INFILTRATOR QUICK 4 STANDARD No. Drain Lines a Installer: Ben crotts Total Trench Length: a 4 ( ft• Certification#: Trench Spacing: _ g Qlnches O.C. *EHS: Q9 F8@t O.C. 2140-Nations,Robert _ ��nches 0 8 / � 4 / � 0 1 5 Trench Width: 3 Feet Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 � Inches Minimum Soil Cover: a L� Inches Approval Status Maximum Trench Depth: 3 6 Inches � Approved❑ Disapproved Maximum Soil Cover: a 4 Inches Page 1 of 4 CDP File Number 175198 - 1 County ID Number: J2-000-oo-oli � Se tic Tank Manufacturer: snoat Lat. . � ` Long: STB: �so . Gallons 1000 Installer: Ben Crotts -- Date: QJ 5 / Qj 4 / a 0 1 5 Certification#: *EHS: 2�40-Nations,Robert "Fllt@�6�et1d: POLYLOK PL-122 With Pipe Adapter ST Marker: ❑ YeS � No Date: . 0 $ � a 1 � a 0 1 5 Reinforced Tank: ❑ YeS � NO ����'�G''��0�������"��� �u������������� ����'''� J�a �i � � ,�-. r� u� d ��� ��i N t ii'4��ia�in r +�"` 1 PieceTank: ❑ Yes � No �����������: App�rb�e�ti � � �7��ap r��_�t����t��� F�{Iiil�����q�p,�l��"IN�'N`� �,i, ��a ( ii�t7ij�kNl�i��Il�u����'�".�_� 5,��7he�iE''� Pump Tank Manufacturer: Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: � � Riser Sealed ❑ Yes ❑ No R�.SP.P�"�P.�ghl. ❑ i PiS ❑ NO � � , ua � � �aa?�y0`�� d� x� i s�Do-�FpY'�-a� "�� Min. 6 in. �� � �p S�atus�� � �� Reinforced Tank: ❑ YeS ❑ No ������ ����` ������������ �� � ` � �; � �}�pp�c%r�edG��Disapp�,ou�d � � 1 Piece Tank: ❑ Yes ❑ No � -`� �= ����=,��z�� ��rt���`����� Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ YeS ❑ No Date: � � �+!.=�' �r,"�ar A� � � �':c""�^�� i i r ;.��-� Approved fittings ❑ Yes ❑ No �������������A�pr�vat Statu�; ���, ������� '����C1 Approrretl� ^� ��)���ppr�ve'd��.= I�`=`—�—£�� v��c��� �.�w��`�_�� ` `�`a _ °����_ �— � � ��_� :��� � Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: � � � Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve p Yes ❑ NO Check-valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No Page 2 of 4 CDR File Number 175198 - 1 County ID Number: J2-000-00-011 - Electric E ui ment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: � � �° . Approvaf Stat�s` � ` ,`�° ���� Alarm Audible ❑ YeS ❑ No � �� � '� ��`" � ❑ ApprovedCl�D�sappr�rr�d�� _ Alarm Visible ❑ Yes ❑ No r�i��„����_ ��bg������ ' 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: Date of Issue:_ � 8 � a 4 � � � 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 nPE n A. Sewage SeptlC System. Rule.1961 requires that a Type nPE��A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N�A Management Entity: owNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certi�ed Operator: N/A Rule.1961 requires that a Type IV and V septic systems designed for a home/business 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 private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance 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 O Import Drawing x��,�; **Site Plan/Drawing attached.** $ ���� Page 3 of 4 OPERATION PERMIT 175198 - 1 ' Davie County Health Department CDP File Number: 210 Hospital Street J2-000-00-011 + P.O.Box 848 County File Number: Mocksville NC 27028 Date: / � �Inch Drawin� Drawing Type: Operation Permit Scale: . ' p N�A k .ft. - -- ------- --- ---�------ ------- ------------ - ------------ -- — T___ I 1_______ �______1_ �____�___�_____ � __ __ : ____.___ _ �' _�u��______ ____I �- � __ � __ _�______ ___ _ ___________ __ _ _ _. _ _. � _ _.___.. . _____ ____.___. ______ _........... . ....... . ....... ___ :____ .. ......_._ ____..__.._.___.. _ __ _ ._.... ._ __ _ . ._ .._.. .. _ _________ �. 1 _-� _ __ ______ ___._ .___ _______ _______ ____ _-___ ___ ___ ___ � � �_ _ ___ �____ _ _ I � ! i _ � r� � __. _- - --_ !_ � ____ __, _.._. ---- -- ; I � � ; � , , j � �___ _________ _________ ___:__ � ____ :___ ______ _.___� ____�_____� �__ __ _______ _;_____ _ _____. , t � � � � 3 � r � i -�- I � ; � ; — _— . � — T -----1 --�---Q--.__. �__ ____. � ,- � � ( . --_ _ �„c��— � \, �I`� 3 � to \ � �-��� -----— -, _ �--- __------- -- ---_ --- __ �y----- - \ ,�� � � _ — - _ —_ _ _ ! _ ;_� —. � � -- �s' ��`�-�-- ____ _--- -- --__. __ _ __. -----. � -�-- � ; i � i i � � � ; � � � � � �. ----- --�-- — ��------ � � _ . __ ;__ _----� _ _ __ ..----. _ ------- � ' �-- i � � � .�----- --- ---- __ ______ ._.._ ___ ---____ ---____..._ _--- _ ___ . __ ___ __ _, _____ __ __—. � _ , I ��. � i _...... � :��1 � I i i '\ i ._..._�.– ! ---- � , ��� - ----- ------ -- --- ....._ ____ ; -- - _._..... ` ------ ---_ _� ---- i ------ i -- � -.i . � - -_- , _�`_ � - �- - � ------ -------��-- -------_, Q �( I ----________ __ _------------------.--------------- __---- ____. C � � , . i ---- ---- - ----- _---__---------�------- --------_------_ ---- _____ -------- _------ � - � � i -C_ , - _ _ _- � --------i_ ___I_-----_ __-� __ _----- ______:. I � 1���1 � _ ._ _ ._ __��.�C_�=__.-J_ ______ ______ _____________ ___. Page 4 of 4 P1 P2 P3 __ ___ CON�TRUCTI4N �or oifice use t�n�v A r� AIMTH�DRIZATIO►N "CDP file,Numbe'r 175�98-�' ' �•''�`� Davie County Heaith Department County ID Number:�2-oao-aap11 � 210 Hospital Street Evaluated For. �NEW �.•�,,,. P.O.Box'$48 Township: � Mocksville NC 27428 pE�rr va�ia uNri�.. Phone: 336-753-6780 Fax:336-753-1fi80 0 a � �) � � a � a 0 Applicant: Salem United Methodist Property0wner. Salem United Meth�adist Church/Jack Koontz Church/Jack Koontz Address: 169 Salem Church Rd Address: 169 Salem Church Rd C�y: Mocksville C�y: Mocksville State2ip: NG 27028 State2ip: NC 27028 Phone#: {336)492-7116 Phone#: (336)492-7116 Proaertv Location � Site Information AddresslRoad#: Subdivision: Phase: Lot: 169 Salem Church Rd Mocksvitle NC 27028 Directions SfNctu�e: CHURCH Salem Chu�ch Rd off of Davie Academy #of Bedrooms: #af Peopie: , "Water Supply: EXISTING WELL Svstem Specifications Minimum Trench Oepth: a � Site Classificatan: Provisionally Suitable Inches Minimum Soii Cover. Saprolite System? �Yes QNo 1 a inches Design Fiow: a 4 0 Maximum Tr�ench Depth: 3 6 inches Soil Appiication Rate: � . 3 a 5 Maximum Soii Cover: a 4 �nches "�System Ciassificatan/Description: *Distribution Type: c�uvmr-SERIAL TYPE 11 A.CONV SYSTEM(SWGLE-FAMILY OR 480:GPD OR LESS) Septic Tank; _ . . 1 fd 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: QYes QNo _ Pump Requir , - � iQNo QMay Se Required N�rification Field 3 3 8 Sq.�. �k: Gallons No.Drain Lines a .ce:QYss QNo ; TotalTrenchLength: a � 6 � GPM vs— ft. TDH Ttench Spacing: � lnches O.C. 9 � Dosin Volume: _ Gallons. — Feet O.C. 9 , _ Tr�nch Wdth: _ _ . ` � Qlnches � - - - - - . - - • - 3 - C.��Feet Grease Trap: Gallons Agg�egate Depth: inches Pre Treatment: ONSF CjTS-1 C,�TS-1) SepticTanklnstallerGrade.LevelRequired: Q( (�1) f�!!I C?IV Dflnn 1 nf t COP Fite Number 1751 J8 - 'I Connty tD Number.';J2-0oo-UO-011 ' ❑ Open Pump System St�eet RepairSystem Requir+ed;�Yes ONo ONa,but has Availabie Space ep�ir Svstem Trench �pacing: Q�����5 Q• • *Site.ClSssifiCetiOq: Provisiooatly Suitabte – � (�1 Feet O.C. _ . , . Trench Wid#h; QInches Design Flow: a 4 � , . . – ,�, �1 Fest Aggregate Dept6: Soil Application Rate; � . 3 inches '� MinimumTrenchDepth: a 4 "System CtassificataniDescriptian: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480:GPD;C3R LESS) Minimum Sol Cover. � a r�ChBS M�ximum T�nch Dep�th: 3 � Inches *Proposed System: 25%REDUCTION Maximum Soil Couer. a 4 N�rifrcation Fietd . . lnches 8 $ 0 Sq.ft. No.Draia Lines "Dist�bu#ionType: GRAvlTY-SERIAL a TotaiTrench length: a 6 6 �" Pump Requir�d: QYes, QNo QMay Be Required . . . . . P�-Treatment: �NSF C7TS-1 C?TS-1) "S3te Modtfications No grading>or construction activity is allowed in,areas designated for s�rstem and repairwithout appravat of Health DepartmQnt: % "Permit Conditions The issuance of#his permit bythe Heaf#h Department in no waygua�ntees the issuar�ce of a#her permits.The permit holder is responsibie forchecking w�fh appropriate govemmg bodies in meet�ng theireequirements. � This Authorizstion ior Wastewater Syst�Ccnstruct�cn shall b�vaqd for a person equal#�the p�ertod ot vaiidity otth�tmprovem+�t�t Petmit,n� to exceed tive y�ars:and may pe issuecs at tt�e sameticn�u�e,�mprovement P�m�t is�uea�Hccs 13oA=�36(a)�.,lt met�sta�latton h�s not tseen "' compdeted diuring the peria!'oi validity atthe Gor�structton Permitr the lrt!'aa�mmatlorr suanitted in the applicaiioni�a pe�rmit ar Ca�struc�ian Auttwrization is found�have been i�orrec�ta�sif�ed o1'changed,ar ltre site is altered,the permk arGeanstractlon Anthaizati�st�all becctnr� tnrraitd,and may be susper�i�d e�r revok�d�.�sa�tgl),me p�rsan c�minq or earr�t»mu�rx��e syst�rr,snau�rrexpnnsi�e torassurir�cor�pn�,ce wftt�the laws,rutes,and p�ermft aanditions regaMir�g system#ocatlon,inst�llation,aperatla�,mahtenanc�m�it��ing.�porting arid tepair (18�8(b�). , ApplicantlLegal Reps.Signature R�quired? QY�S QNO AppiicanflLegal Reps.Signatur+e� Date:,�,�, � �„ � , "issued By: 2�40•Nations,Rot�ert pate of lssue: � � � 1 a 0 1 5 AuEhorized State Agent:�� .-�.— Malfunctian I.og �Yes �t��.�: ��:��: t�Hand Drawing +�lmport Drawing **Site PIanlGrawing attached.** ���g�o�� CONSTRUCTION AUTHORIZATION � Davie County Health Depa�tment CDP File Number: ' 210 Hospital Street • P.O.Box 848 " County File Number: J2-000-00-0�1 Mocksville Nc 2�o2s Date: 0 a / 0 a / a 0 1 5 �Inch Drawin� Drawing Type: Construction Authorization Scale: , , , O B�A k - .ft. � � .�t/�'� — �f. ���—/ \ ��� �� ���� • � � �` �� �. . } � y � . — a S-�,bt _`{� ,_r• -- ----c Y u. . ---__ � i L�l, -v —� � � - �f U ; __ I._��`_�_ � _____��-.____ �__ � �_ __. _�.— --_ __�. _`-��f G-- _-- _ � k � �----�-- -�J ,� 6 �,d � �•c,� n � � � � � i � � � ^ ; � � i _ _ _ _ c�r--- -- -__ __ __ _----t— ___ j _ _—_ ___ ,,,,� _ --- __-- --_ -- � i ` ! I ! �, � ; ._ �! � '`�7 � i � ST � I � - �� � - - - � - i � � � - - - / ���.4 , _-- --- -- _ _____.-_ _-- - --_ _ �---- _ _ __-------- _�Y ------- --- --- ___ _--_: I i I - — — . I _ - � — — � �._ ! - / i � � � � � I _ � � ; _ ; / � �� � � � � � ____-._ _____�-- -- --� / __ ---- ---------- - - ; - --- _ _ ------___- --a � � �; i � ! � I ; � i I i � � -----—---- - � -- _ __ . ___ __ ---_._ ____-- __-- - - ------ I ----__. _ --- ..__. _ Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION � � � —� � Davie County Health Department 2�o HosPitai street , CDP File Number: P.O.Box 848 ��� _ /� J2-000-00-011 Mocksville Nc 2�ozs County File Number: S�' D ��/QC�� �fi � �� Date: .�.a /.0.�. / a0 1,5. Click below to import an image from�n external lo ' n: Dra ng Type: Construction Authorization � � �� - : �� � � � � � � . � � ► � � � - �t ` � ►� � � �o v � / � � ' - , ` 43 ` � �� � S ` � . ��JU �� i�—P � , 4/ 3�1�"�` � G8 N� � � 1� . . . ..._.......... . ........ . ... O � S � � � � Page 3 of 3 P1 P2 • � IM�PRtJVEMENT PERMIT Fa�o��gu� o�i� "CDP File Number 175198-1 • �+�• Davie County HealthDepartment `'� �� � Counfy ID Number J2-000,00-011 � 270 Hospital Street y Evaluated For. NEW '� � � P.O. Box 848 '�.,...►• Mocksville NC 27028 Township: Phone: 336-753-6780 Fax:336-753-1680 pERMIT VALID UNTII: 2I�I2OZO '�NOTE TO INSPECTiONS DlVISION: Building Permits cannot be Issued with this improvement Permit. _ _ _ _ _ _ _ _ . . Applicant: Salem United Methodist Property Owner. Salem United Methodist ,., . ,. . ., . .., . ., . ., . Address: 169 Salem Church Rd Address: 169 Salem Church Rd ��Y= Mocksville: ��Y� Mocksville State2ip: NC 27028 State2iP� NC 27028 Phone#: {336)492-7116 Phone#: (336)492-7116 Pro ert Location � Site Informatlon _ Address/Road#: SubdNisan: Phase: Lot: � 169 Salem Church Rd Mocksviile NC 27028 Directions stn,cture: CHURCH Salem Church Rd off of Davie Academy #of Bedrooms: #of People: "Wate�Suppiy: EXISTING WELL. S stem S ecifications nitial S�stem "Site�e�I�ICetpI1: provisionally Suitable Minimum Trench Depth: a 4 inches Saprolite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: a 4 0 SepticTank: 1 � � � Gallons Soil Application Rate: g . 3 a 5 1-Piece: QYes QNo `� � Pump Required; QYes QNo QMay Be Required "System Classificafan/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pum p Tank: Galtons LESS1 __ : "Proposed System: 1-Piece: QYes QNo Repair System Required:OYes ONo ONo, but has Available Space Repair SVstem "Site Classificatbn: ProvisionallySuitabte Minimum Trench Depth: a 4 Inches Soil,Appticatan Rate: ° Maximum Trench Depth: 3 6 Inches 0 . 3 , , , , "System ClassificataNDescription: Pump Requi�ed: QYes Q No Q May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 17�198- 1 County ID Number.J2�aoaoaoiy �'Site Modifications ❑ Open Fin Sheet No grading or construc6on act'aify is aliowed in�reas designafed for system and repair without approval of Health Department. . . *Permit Conditions The issuance of this permit by the Heaith Department in no way guaran#ees the issuance of othe�pertnits:The perm�t hoider is responsible for checking w�th appropriate goveming botlies'in meebng theirrequirernents: � : Site Plan ThB�����t Permit shall be vaHd fo�5 years from date oi iss�with a site ptan(means a drawing nat necessarfly drawn to scate that shows the existing and proposed property Unes with dimensbns,the IocatIon of thetacili#y and appurt�ances,the � site forthe proposeii WasiewatersysEem,and the loca�on ofwater supplies and a�cewatefs�. Plat The�mpravement Permit shall be vaild without eacpiration with piat(m�hs a propecty survEyed pre�aned by a regfabered land surveyar,drawn to�scale ot one inch+�quats no mor+ett�n 60 fee�'tttat lnciude�the s�ecific locaticn ofthe propos�d tadlity � iso means,fo subdivi lon lots approved by the locai p annir�g autlfority and r�co�itied with ft�ounty register o deeds,a cop y . of the t+�corded subdi�risions platthat is accompanied by a site pian that is drawn to scale). Thepeparlment and Lacal Heatth Departrnent may impose conditloris on the Issuanceand may reuoKe the permits tor tailure+af the system to sattsy tt�canditions+the rules,ar this artfcl�This permit is sub,�ectto revacatlon if the sim plan,pla�Qr inGended , _ _ use changes(NGGS 13QA�335(t}).7he peraon owning oraorttrolling thesystem shaii de�sponsiblefora�wr3ng aompliaace wlth the laws,n�es„and permit oond'rtitxfs regarding systen location,'instailatlon,operaiion,maintenanc�monfb�dng, rep�ting,and repatr(.1938tb)�. ApplicanULegat Reps.Signature Required? QYeS Q,NO Appiicant/Legai Reps.SignaturB: Date: � � *Issued By: 2�40-Nations,Robert Date of Issue: � a � 0 a / a 0 1 5 Authorized Stafe A eni�-l'����"�---- OValid without Expiration? 9 �'Create CA? �Hand Drawing Olmport Drawing ' i� • v�!n **5ite P[anlDrawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 17519$ - 1 ' • • Davie County Heaith Department CDP File Ntlttlbe�: • 210 Hospital Street J2-000-00-011 P.o.Box 8as County File Number: Mocksville rvc z�oz$ Date: i l Q Inch Drawing Drawing Type: improvement Permit 5����' ' ' ' ' �N�A k ' ' ' 'ft. _ C� . ' � _ _ _� _1_;u!,�� _ � �1 � �-� � I _ / � � _ . _ _ _ ' � `; _r� �' ___ _ � . � � �: _.. -- _ _ ' � -�1r_-{� • �fi .._` ;�.�. �N� � � • ( -�+r � ' . _ _ � -r -� _ _ . _ �l__ __ .,_ , �----- , � � - _ . �._ � ��-� � :� _ �� ��� ` I - � �� � /� _ �___., _�., �. .. �� ` � . . . ' � APPLICATION FOR SITE.EVALUATION/IMI'ROVEMENT PERMIT&ATC ___�iCE� Davie County Enviroame.ntal Health ' � � P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 9p�' (336)753-6780/Fax(336)753-1680 Application For. d Site Evaluation/Improvement Permit ❑Authorization To Conswct(ATC) ❑Both 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 BIJLLETIN for instructions. APPLICANT INFORMATION NametobeBilled�i�1.P�,,, yn,7� xpoTlfa�'S�GS�w�ontactPerson ;T� A-e� �'.�./.la�,,,?z� Billing Address � � d Home Phone City/State/ZIP ���E,���� C ���B�ct�Phone C 2<-G Name on PermidATC if Di,�j''erent than Above ' Mailing Address City/State2ip vj �¢ /VG PROPERTY INFORMATION *Date House/Facili Comers Fla ed NOTE: A survey plat or site plsn must accompazry this application. Included:❑Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiradon with complete plat) Owner's Name ` Phone Number Owner's Address City/State2ip yyl�t�/lSvj,C .2 �('.�,�n Property Address S,G.,,,_v City Lot Size Tax PIN# �"�o0 000d l( Subdivision Name(if applicable) Section/Lot# D'uecdons To Site: S�F/Q.jt�C�v.a�.�Pa,�.�a�Ff�v;e— �Q�.r1o� If the answer to arry of the following questions is`�es",supporting docum tarion must be attached. Are there any e�sting wastewater systems on the site? �s ON� Does the site contain jurisdicGonal weUands? ❑Y�s Q�tGo Are there azry easements or right-of-ways on the site7 6Yys❑No yT,�r�-�y�hy Is the site subject to approval by another public agency7 CR'S'es ONo �„n T�/�n,'��.F/�5'�G/i o�- W il l wastewater o t her t h a n domestic sewage be generate d 7 O Yes� IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Gazden Tub/Whirlpool OYes ❑No Basement:❑Yes ❑No BasementPlumbing: OYes ONo IF NON-RESIDENCE FILL OUT TI�BOX BELOW Type of FacilityBusiness � �.v hT al Square Footage of Buildin�#People � #Sinks� #Commodes �M1fH�Showers� #Urinals_�_ � Estimated ater Usage(gallons per ay (Attach documentation of similaz facility water eonsumptio t� FOODSERVICE ONLY: #Seats O , Type system requested: LRConventional ❑Accepted ❑Innovative ❑Altemative OOther �l� � Water Supply Type:❑County/Ciry Water 0 New Well �ting Well �Community Well Do you anticipate addiGons or expansions of the facility this system is intcnded to serve?0 Yes � If yes,what type7 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 hereaRer 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 Health Department to conduct necessary inspections to determine compliance with applicable laws an rules.'I understand that I am responsible for the proper identification and labeling of property lines and corners and locati and fl%ggi�or�ing e house/facility locatioq proposed well location and the(ceation of any other amenities. �y��t� Site Revisit Charge Pro owner s or o er's le 1 representative signature Date(s): � % ��� Client Notification Date: Date � EHS: Sign given ❑Yes❑No Account# •�q � . Revised 11/06 ' Invoice# � l'�1��I � � eh� , _ � Y Y �• r __ ,..� , . . .� •'• , n:� .P, _� ' r� '� v� ' `i': f�F �`� ':!" 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'� ��u��a�.'���c+��`�+�`� ��$'^'��.��t;&� " ,� "F -�1;� ., r*•. �,_ � !�xE ° . y�y' ������.�R,�`m� ��,g,N'��j^�'l,����Y:�,�i��i� �� y .��.. � iJ MS�� ���. � ,., "A,y 1 ,�Yn � � � :$� ,�.,y�'�t,l� �, ,�s�`'� .',",#'�4r t`�"r ';::, ,! , � }� � .`-'� j • . .. � ' - "� � DAVIE COUNTY HEALTH DEPARTP�TT SEPTIC TANK PERMIT .'�v; "... No of Bedrooms �17C� f C-fL � Date � —a — /O This permit is granted t � �� for the instQllation� e ic tank r�t the residence of P � Address �� / , ,� • � T Building Contractor Address Septic Tank Specifications: Length Width Depth Capacity Gal. � Manufaeturer's Name ` ^ �l � Addxess���� ` � No of lines�_ width in. Totcs7. Length �ft. No. of Sq. Ft. � ��i O� Type of filt material Total tons used o'2 A Minimum Requi�ments: House Tr er Tr�nk Cap. 800 Sq. ft. line �+00 _ __ Two--bedroom house 800 ' 600 ,� . ": Three-bedroom house 900 900 No one shall instal2 a septic tank in Davie County without a permit from the Health Officer or his agent. � Date of final approval Si�ned: . �Sanitarian I hereby certify that. the above septic t�nk has been in talled according to specifications. � � Signed• Septic Tank Contractor Note: Make sketch of disposal system on back of sheet and mail to Health Center, Mocksville. .. ...,,..-... •.. .. —., � .:......: �,,�,,:.:.,. � ,.,_. F...,... ,;,. � ..tN ..�^�.......�.:. � , . . . ... . . ..., , . . . . . . ., � � i , . +1 t�� . . _. ' � , �`�i r . . f �^. 'f`� t � .f -T�:1 � � t , � � .. • , ,�.. .. .. . .-.�� .. ..�. ..� �_ . .._ 1... .. �t_ ._ ... ..._. .._�_ � .. . . , , .C1... ?' . .. � � ' . . . . . , . � ... .. . �.�.• _�V•: ..».� _. ..� . .. ,......... . . . _............... ..,-.. . . . .1... . �. . � ,. _'.� ..�. . .J ..., 1. .{. _ �. ' � .«. 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" ' � -� ' . . • • � DAVIE COUNTY HEALTH DEPARTi-2ENT SEPTIC TANK P T � � . /� / �C�� �SA/�nt ���t �'G`� � �.� No of Bedrooms 1.�17 LJL(�C� � Date �—a — Q This permit is granted to � � � �r for the installat on of a �Se ic tank t�t the residence of�L�n�1Vf��dJ;S'� • 14i Address Building Contractor Address —T, • Septic Tank Specifications: Length Width Depth Capacity Gal.-�.— Manufacturer's N�me � � �� % "' ,r Addxess '� �' � � No of lines� width in. Total Length �f j� ft. No. o�' Sq. Ft. ���t O� Type of filt material � � Total tons used o'�A Minimum Requi�ments: House �r ' er T�,nk Cap. 800 Sq. ft. line �+00 Two-bedroom house 800 ' 600 � , Three-bedroom house 900 � 900 � No one shall install a septic tank in Davie County without �, perm.it from the Health Officer or his agent. Date of final approval Si�;ned: . ^Sanitaxian T hereby certify that the above septic tank has been in talled accordin� to � . specifications. � � Signed• Septic Tank Contractor Note: Make sketch of disposal syatem on b�.ck of sheet and maiZ to HealtY� Center, Mocksville. :��- .'=•`.�%:;•.i= � ��� . . . t+OC'' . .�' ._ '� `; ' .. ... �� _. , t ;�. U '�+."� C ., i%_ { _�..� • ,. . . + „ ` _ .' . r: .. . , 'T `�N . '��: . r �r- .. . . . . 1 . � lr T. •r �..i�rt- -�.. .,, .T.�t:�:� ...'-.�.�."'.�'.—�.'.".�'�"_��...._.��.��.......__.......�... ....._ ( - . ��S f.�l.���(,i• a. � }J��i.:'�:.� ...':Z-� :if: {i1��, F�':r �l.` :.r _.. 'i'3�� j't .j: `'T'.: :��:GI! �ji�f.i_rfr,! � . . 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'-.. � ._._..._'.... -- �----" -- --.._.._....___ . � , '�'=;:G� L:` .��w___._•___.�.�_�.-' --•.,� , � -:_i.�;--•' � .�.,.. ..«�_�_-. , - -��. . - ' � . . i '' + �.7i'O� � '_.__..__ . . .._ti�.^.'.�_�. . t,=ii 'i:: . t' "-lC� C__...._ . _....._i._C:.�._.__j_��_. � i. . .. .. .. . , . . - '' Jt , .�__.�..�._.�...�...__ ._ . , � -i (: . -' k , , .., ._ . . . . . . • ' i..�r. !�\!•_. . .. ;1� . . , ...,•1 . ...J .._ .,.'��1.� .[.., .. .. ..�._ ' . . � . .�f jr�' ` .. � _, a . _e. • . . ._. ..�... ....... _ . . ... . .. . _ .:ta-L.... . ........ �.. . ....-.. ..-....,1_�„ , . ..... • � i { .. • ^ � , . ; . � DAVIE COUNTY HEALTH DEPAR NT � ' J Environmental Health Sectio�n � ' � Soil Site � � i _ / Evaluat�on , APPLIGANT TNFORMATION • ;. PROPERTY INFORMATION i - t � i Salem United Methodist Ch : ' 169 Salem Ghurch Rd � " �, � � -Jack Koontz '_ . . � `��� : 5.600 A:cres : 336 940-7293 � t.:.:�. : , .. . .. :.: , ,, . . . . , , . � . . _ _ _ _- , _ _, _ _ _ - � (._ . . � "-- ' � ; � ' , � � iWater Supply: On- ite Well. Community blic , � � Evaluation By: Aug r Boring � ,Pit � ut � i � 4 FAGTORS j 1 2 3 �} j 5 6 7 , Landsc� e sition L � j . Slope% 1 'Z 1 i ; � ' - HORIZON I DEPTH ' _ 17 � ( i , Texture grou }. . G � .-- � Consistence ' i • ,,� � a � Structure . 1 ' Mineralo � ; ; "'HORIZON II DEPTH � � I � • Texture rou r� C ! � , ; Consistence , { � i ( . • ; Structure - � � � S (� � ` ( . Mineralo � f l ' i • I ' � HORIZON III DEPTH � — Q - ! � Texture ou � ! � Consistence l 1 Structure � ' I � ; Mineralo �' � 5 � 1 � HORIZON IV DEP'I'H 1, � �4 I � Texture ou : Consistence l ' � j Structure j. -� { Mineralo � I � SOIL WETNESS � ! ; ' ; . RESTRICTIVE HORIZON � I � � SAPROLITE l I I � CLASSIFICATION ' I I ' . LONG-TERM ACCEPTANCE RATE 1 i � , SITE CLASSIFICATION: ' . EVALUATI� N BY: � � � f�� � _ � . � P � \/ � � ; LONG TERMACCEPTANC .'RATE: . OTHER{S)PRESENT: �L�4��. �� l)C�� � ; i REMARKS• .. � � . : LEGEND � . J.andscane Position ; � . , 4 • � R-Ridge S -Shoulder � L-Lineaz slope FS -Foot slope N-Nose slope; �' � CC-Concave slope CV- onvex slope T-Terrace FP-Flood plain H�Head slope • . � �d LS-Loam san � SL-Sand loam L-Loam SI-Silt �; � , S S an y c[ y � ; SICL-Silty clay loam SII�-Silty loam CL-Clay loam SCL-Sandy clay lqam ; ' , SC-Sandy clay SIC-Silty clay C-Clay f ' f C'ONSISTENCE ` � �t � ! ' : . VFR-Very friable FR-F�able FI-Fum VFI-Very fum EkT-Exuemely firm _. � , � � � . I � � � NS-Non sticky SS-Slig�ifly sticky S-Sticky VS -Very Sticky ! ; ! ' NP-Non plastic SP-Slig�tly plastic P-Plastic VP-Very plastic � � ` � : � . � � . ' $tructure �� . . SC-Single grain M-Ma�sive CR-Crumb GR-Granular . ABK-Angular blocky� • SBK-Subangular blocky L-Platy PR-Prismatic � ]yIineralo�v • 1:1,2:1,Mixed . . � ; �� � . � Horizon depth-In inches • • • . Depth of fill -In inches C . Restrictive horizon-Thiclrness and inches from land surface . � � , ; , • � . Saprolite-S(suitable),U(unsu�table) � � ' 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{jTprovisionally suitable),U(unsuitable) _ ; � ! . � TTAT T '_� I�_`' "1IJ""fC.i1 '� � �"� . a��._ ..�������� t . � � .-.^��� .. _ � A�praisal Card Page 1 of 1 V -^:., -- , > o�vrzrnuHn xc ���o xo��s:xa:�x�w �LEM YNITED METMOOIST CNURCM , NtluM�pP��MOW: ry,t�ll-OOO-00-013 69 S�tEM CHURCH RD MT:/YMIQ m 1]6% ]0l5500 D66 YN m N0:T/aa615a75 Ownen 511LEM UNiTEO METNODIST CNURCN [OVNT'TiV!(I00),FIRE TAC(100) GRD N0.l ef 1 - wal Yur.2013 Ta�Y�ar.2015 �.I]AC OW UAVIE/�CADEMY 5.600 AC � SRC.In�yMbn nlseJ 6 02 on 09 00]O1001 D�VIE AGDE'n' 1W-01 [I- FR-06 E%-1 �T- lAST11CTION 20f30610 COMSTRUCTIONpFTAII MI10.K[TVI1W! DEMEQ�TION �pRRE4iIOMO�V�WE ,uo.- se.�e.�e o.az000 E1/. MSE � uEFloorSynwn-♦ SE 00 11rea Ul1l MlE RCN EYB �VB REDENCE7p M�0.KET at�rbrWall�•31 ���71 O) I,N2 116 111.36 539105t9]01%0 %GOOD !.0 E�II.�UILDIN6V�LU!-GIID J66660 In911tk I5.00 7yyE;piuNl ��d�� EPR.06/%!VAWE-40.D �10 oofinqSWCWn•07 RKFTIANDYAW[•GRD 16,610 ST'lF:l.l.OSror� OT�LMMIRETV�WF.GIID �IS.l20 eefinq Gr�•03 ntrlaWallGnArvctlen-S OTAL���R�ISEDYAW!•GRD �15,l20 11 hMrock e.� OT�L��►R�ISEDY�W!•�ARCEL 115,130 ntrbr Fbor Covr•73 �Nwaod �.0 utinq FuM-M TI1L►R[SENT YSF YALY[.►�RCEL rtiny Try�•10 OTA�V�LU[O[f[AR[D-��RUL OTALT1UfAlllVAW[-�ARC[� �I5,120 r CenGi4sn4y T1M-Ol �RIO �ntnl 6.00 � � m�rnal Nut!Nr-1 UIIDW G VALVE 3L1,730 B%FV�LUE 7,060 unl inm�.D1 . 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IOGL iRON 0[IfM/ I/ID COND RI AC lC TO OAD YMR IAND YNT TOT�t �D]USilD IAND OV[RRID! tAMO � SF CODF iOMiMO T�6! [A Si2[ MOD F�R OT E ►111C[ UMRS T'� �OIST UMR�111tt V�LU! Y�WF NOTE9 � UMLA O1 0 200 .2U0 { .9800 03�00�00�0 V 6,00.00 .600 AC f.l{ 8,328.10 /66l) 00 Oi11L M�R[[i IAMD D11T� 5.600 �6 HO i - Oi�L PMESFMT YS!D�TA i http://66.226.39.229//ITSNet/AppraisalCard.aspx?parce1=J200000011 11/10/2014