121 Shutt RdOPERATION PERMIT
Davie County Health Department
+ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Engineered Building Systems,
Address: 5198 Riverwest Road
City: Lewisville
State2ip: NC 27023
Phone #: (336) 946-2146
Address/Road #:
Subdivision:
121 Shutt Road
Mocksville
NC 27006
Structure:
SINGLE FAMILY
of Bedrooms:
5
# of People:
5
"Water Supply:
PUBLIC
r
"CDP File Number 195647-1
G8 -120-e0-011
County ID Number
Evaluated For. NEW
Township:
/'.'Property Owner. Denise Conrad
Address:
City:
State2 ip:
Phone #:
Phase: Lot:
Directions
64 east left on hwy 801 north about 5 miles on right
past Ellis School
IP Issued by. 2140 -Nations, Robed "System Classification/Description:
TYPE III A. CONY SYSTEM > 480 GPD (EXCLUDING SFD)
*CA issued by: 2140. Nations, Robert SaproliteSystem? OYes eNo
Design Flow: 6 0 0 " GRAVITY -SERIAL Pump Required?
'Distribution Type: Oyes QNo
Soil Application Rate: 0 , a 7 5 *Pre Treatment:
Drain field
Nkrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
a 1 8 a Sq. ft.
8
5 4 7 ft.
2Inches O.G.
Feet O.C.
3 Qinches
Feet
inches
Minimum Trench Depth: 3
0
Minimum Soil Cover. 1
8
Maximum Trench Depth: 3
6
Maximum Soil Cover.
2
4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Frank Transou
Certification #:
*EH S: 2140- Nations. Robert
Date: 0 1/ 1 3/ a e 1 6
CDP File Number 195647 -1
Sentic TanK
County ID Number. �G8-120.80.011
Manufacturer.
$h0a{
Date:
Lat.
❑
No
964
Date:
❑
Long:
STB:
Yes
❑
No
RiserHeight: ❑
Yes
Gallons:
1500
nforced Tank: ❑
Yes
Installer.
Frank Transou
Date:
0 7/
a 6/
a 0 1 5
Certification##:
*EH S:
2140 - Nations, Robert
*Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker:
El Yes
0
No
Date:
0 1/ 1 3/ x 0 1 6
nforced Tank:
❑ Yes
®
No
Approval Status
[E
Approved ❑ Disapproved
1 Piece Tank:
❑ Yes
C1
No
Pump Tank
Manufacturer. Installer:
PT:
Date:
Gallons:
❑
No
Date:
❑
No
RiserSealed ❑
Yes
❑
No
RiserHeight: ❑
Yes
❑
No (Min.6 in.)
nforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
approved fittings ❑ Yes ❑ No
Certification #:
*EH S:
Date:
Date:
Approval Status
❑ Approved ❑ Disapproved
i J
/ Pump Type: Installer.
Dosing Volume: - Gal Certification #:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes
❑
No
Flow Adjustment Valve ❑ Yes
❑
No
Check -valve ❑ Yes
❑
No
Approval status
PVC Unions ❑ Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole ❑ Yes
❑
No
Anti -siphon Hole 0 Yes
❑
No
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
/I For Office Use Only
*CDP File Number 195647 - 1
County ID Number: G8 -120 -BO -011
Evaluated For: NEW
Township: /
Mocksville NC 27028 PERMIT VALID UNTIL: ,
Phone: 336-753-6780 Fax: 336-753-1680 0 7 l a 4/' a 0 a 0
Applicant: Engineered Building Systems, Inc.
Address: 5198 Riverwest Road
City: Lewisville
State/Zip: NC 27023
Phone #: (336) 946-2146
Property Owner: Denise Conrad
Address:
City:
State/Zip:
Phone #:
Location & Site
I--
Address/Road
Address/Road #: Subdivision: Phase: Lot:
Shutt Rd
Mocksville NC 27006 Directions
Structure: SINGLE FAMILY 64 east left on hwy 801 north about 5 miles on right past
Ellis School
# of Bedrooms: 5
# of People: 5
*Water Supply: PUBLIC
Page 1 of 3
Minimum Trench Depth:
a \
4 Inches
Site Classification:
Provisionally Suitable
Saprolite System?
O Yes (gNo
Minimum Soil Cover:
1 a Inches
Design Flow:
6 0 0
Maximum Trench Depth:
3 0 Inches
Soil Application Rate:
a 7
5
Maximum Soil Cover:
1 8 Inches
*System Classification/Description:
"Distribution Type:
TYPE III A. CONY SYSTEM > 480 GPD (EXCLUDING
SFD)
Septic Tank:
1 a 5 0
Gallons
*Proposed System: 25% REDUCTION
1 -Piece:
O Yes ® No
Pump Required: O Yes
®No O May Be Required
Nitrification Field
a 1
s
a
Sq. ft. Pump Tank:
Gallons
No. Drain Lines
6
1 -Piece:
OYes ONo
Total Trench Length:
5 4 5
GPM --vs-- ft. TDH
ft.
Trench Spacing:
_
9
R
Inches O.C.
Feet O.C. Dosing Volume:
_ Gallons
Trench Width:
3
Inches
Feet
_
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: O NSF OTS -1 OTS -11
Septic Tank
Installer Grade Level Required: 01
O I I 0111 O IV /
Page 1 of 3
CDP File Number 195647 - 1
r
*Site Classification: Provisionally Suitable
County ID Number: G8 -120 -BO -011
❑ Open Pump System Sheet
ired:®Yes O No ONO, but has Available Space
Design Flow: 6 0 0
Soil Application Rate: 0 a 7 5
*System Classification/Description:
TYPE III A. CONV SYSTEM > 480 GPD (EXCLUDING SFD)
*Proposed System: 25% REDUCTION
Nitrification Field a 1 8 a
Sq. ft.
No. Drain Lines 6
Total Trench Length: 5 4 rJ
ft.
Trench Spacing: 9 O Inches O.
® Feet O.C.
Trench Width:— 3 Inches
Feet
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
0
Inches
Maximum Soil Cover:
1
8
Inches
*Distribution Type: GRAVITY - PARALLEL (eq. d -box)
Pump Required: OYes ®No O May Be Required
Pre -Treatment: O NSF OTS -1 OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. --i-9
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. Characters
2000
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and may be Issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). If the installation has not been
completed during the period of validity of the Construction Permit, the Information submitted In the application for a permit or Construction
Authorization is found to have been incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become
Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes O No
Applicant/Legal Reps. Signature* Date:
*Issued By:
Authorized State
2140 - Nations, Robert
Date of Issue: 0 7 / a 4/ a 0 1 5
Malfunction Log Oyes
(9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CDP File Number 195647 -1 County ID Number: GS -120•80.011
Electric Eauloment
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:
Alarm Audible
❑
Yes
❑
Na
Approval Status
❑ Approved ❑ Disapproved
Alarm Visible
❑
Yes
❑
No
J,
2140 - Nations. Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: B 1/ 1 3/ 2 B 1 6
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by.a TYPE III A. sewage septic system.
Rule .1961 requires that a Type TYPE IIIA. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator.
WA
Reporting Frequency By Certified Operator WA
Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a homelbusiness 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 OlmportDrawing
**Site Plan/Drawing attached.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
MocksviUe NC
Drawing Drawing Type: Operation Permit
CDP File Number: 195647 " 1
County File Number: G8420-1130-011
27028 Date:
Q Inch
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 195647 - 1
County File Number: G8 -120-B0-011
Date: 07 /a4/.1015
0 Inch
Scale: O Block
0 N/A
. I i
Page 3 of 3
P1 P2
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 195647 - 1
P.O. Box 848 G8 -120 -BO -011
-
t7 - 1 6 Mocksville NC 27028 / County File Number:
7� )�6)Gj7��.. Date: .O7 / a4 / aO15
�(�7 Ll
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Page 3 of 3
P1 P2
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
a P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Engineered Building Systems, Inc.
Pete Tillev
Address: 5198 Riverwest Road
City: Lewisville
State2ip: NC 27023
Phone #: (336) 946-2146
/ For Office Use Onlv
'`CDP File Number 195647.1
County 1D Number: G8-120-Bo-oly
Evaluated For: NEW
Township:
00011IT \i AI In 11111T11
0 7/ a 4/ a 0 a 0
Property Owner: Denise Conrad
Address:
Cay:
State/Zip:
Phone #:
Phase: Lot:
Directions
64 east left on hwy 801 north about 5 miles on right past
Ellis School
Minimum Trench Depth:
Address/Road #:
Subdivision:
Shutt Rd
Site Classification: Provisionally Suitable
Mocksville
NC 27006
Structure:
SINGLE FAMILY
# of Bedrooms:
5
# of People:
5
"Water Supply:
PUBLIC
/ For Office Use Onlv
'`CDP File Number 195647.1
County 1D Number: G8-120-Bo-oly
Evaluated For: NEW
Township:
00011IT \i AI In 11111T11
0 7/ a 4/ a 0 a 0
Property Owner: Denise Conrad
Address:
Cay:
State/Zip:
Phone #:
Phase: Lot:
Directions
64 east left on hwy 801 north about 5 miles on right past
Ellis School
Pump Required: OYes @No OMay Be Required
Nitrification Field a 1 8 a Sq ft Pump Tank: Gallons
No. Drain Lines 6 1 -Piece: OYes ONo
Total Trench Length: 5 4 5 ft GPM—vs-- it. TDH
Trench Spacing: Inches O.
_ 9 • @Feet O.C. Dosing Volume: _ Gallons
Trench Width: @Inches
_ 3 Feet - - - -
Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: ONSF OTS -1 OTS -II
1\ Septic Tank Installer Grade Level Required: OI Oil 011l OIV
Pflnn 1 ^f'A
Minimum Trench Depth:
a
4
Inches
Site Classification: Provisionally Suitable
Saprolite System? OYes @No
Minimum Soil Cover.1
a
Inches
Design Flow: 6 0 0
Maximum Trench Depth:
3
0
Inches
Soil Application Rate: 0 2 7 5
Maximum Soil Cover:
1
8
Inches
"System Classification/Description:
"Distribution Type:
TYPE III A. CONY SYSTEM > 480 GPD (EXCLUDING SFD)
Septic Tank:
_
1
a 5 0 Gallons
'Proposed System: 25% REDUCTION
1 -Piece:
Oyes
®No
Pump Required: OYes @No OMay Be Required
Nitrification Field a 1 8 a Sq ft Pump Tank: Gallons
No. Drain Lines 6 1 -Piece: OYes ONo
Total Trench Length: 5 4 5 ft GPM—vs-- it. TDH
Trench Spacing: Inches O.
_ 9 • @Feet O.C. Dosing Volume: _ Gallons
Trench Width: @Inches
_ 3 Feet - - - -
Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: ONSF OTS -1 OTS -II
1\ Septic Tank Installer Grade Level Required: OI Oil 011l OIV
Pflnn 1 ^f'A
CDP File Number 195647 - 1 County ID Number: G8 -12b -BO -011'
air
wTeS Li14U %jl4U' Uul tldb Mvd11d1 le 0
❑ Open Pump System Sheet
I —"— —" %`Gfy
*Site
Trench Spacing:
Q Inches 0.1
9
Classification:
Provisionally Suitable
— Feet O.C.
Trench Width:
QInches
3
Design Flow:
6 0 0
_ V Feet
Aggregate Depth:
Soil Application Rate:
0 - a 7 5
inches
Minimum Trench Depth:
a
4
*System Classification/Description:
Inches
TYPE III A. CONV SYSTEM > 480 GPD (EXCLUDING SFD)
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
0
*Proposed System:
25% REDUCTION
-
Inches
Maximum Soil Cover:
1
8
Nitrification Field
a 1 8 a
Inches
Sq. ft.
No. Drain Lines
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
ti
Total Trench Length: 5 4 5 ft.
Pump Required: QYes @No OMay Be Required
Pre Treatment: O NSF OTS -1 OTS -II
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not
to exceed five years, and maybe issued atthe sametime the Improvement Permit issued (NCGS 130A -336(b)} If the Installation has not been
completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrect, falsified or changed, "the site is altered, the permit or Construction Authorization shall become
Invalid, and maybe suspended" revoked (.1937(g)). The person owning "controlling the system shall be responsible forassuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? QYes ONO
Applicant/Legal Reps. Signature: Date: ` /
*Issued By: 2140 -Nations, Robert Date of Issue:. 0 . 7 / a 4 / a 0 1 5
Authorized State Agen Malfunction Log Oyes
OHand Drawing Oimport Drawing
**Site Plan/Drawing attached,**
Page 2 of 3
- CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 195647 -1
County File Number: G8-120-130-011
Date: 0 7/.1 4/.2 0 1 5
Q Inch
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 195647-1
County File Number: G8-120-BQ-011
Date: .0.7 / 2 4/ 2 0 1 5
Click below to import an image from an external location: Drawing Type: Construction Authorization
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
' P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 7/24/2020
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
For Office Use Oniy
"CDP File Number 195647-1
County ID Number: G8 -120 -BO -011
Evaluated For: NEW
Township:
Applicant: Engineered Building Systems,
11'1 • T' I •
Address: 5198 Riverwest Road
City: Lewisville
State/Zip: NC 27023
Phone #: (336) 946-2146
Address/Road #:
Shutt Rd
Mocksville
Structure:
# of Bedrooms:
# of People:
"Water Supply:
Ierty Locatio
Subdivision:
NC 27006
SINGLE FAMILY
5
5
PUBLIC
n: Provisionally Suitable
SaproliteSystem? QYes QNo
Design Flow: 6 0 0
Soil Application Rate: 0 a 7 5
"System Class ifiication/Description:
TYPE III A. CONV SYSTEM > 480 GPD (EXCLUDING SFD)
"Proposed System: 25% REDUCTION
Owner: Denise Conrad
Address:
City:
State/Zip:
Phone #:
ite Information
Phase: Lot:
Directions
64 east left on hwy 801 north about 5 miles on right
past Ellis School
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Septic Tank:
1 a 5 0 Gallons
1 -Piece: ()Yes ONo
Pump Required: QYes (S) No 0May Be Required
Pump Tank: Gallons
1 -Piece: QYes ONo
Repair System Required: QYes ONo ONo, but has Available Space
r—
.SiteClassil'ication*
Provisionally Suitable
Soil Application Rate: 0 - a 7 5
"System Classification/Description:
TYPE III A. CONV SYSTEM > 480 GPD (EXCLUDING SFD)
"Proposed System: 25% REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: QYes QNo Q Maybe Required
Page 1 of 3
CDP File Number 195647 -
County ID Number: G8 -120 -BO -011
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. `,
Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dlmensions, the location of thefaciltty and appurtenances, the
site forthe proposed Wastewater system, and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land
surveyor, drawn to a scale of one inch equals no morethan 60 feet, that includes: the specific location of the proposed facility
and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy
of the recorded subdivisions plat that is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules, or this article; This permit Is subject to revocation it the site plan, plat, or intended
use changes (NCGS 130A -335(t)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring,
reporting, and repair (.1938(b)}
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date: /
*Issued By: 2140 -Nations, Robert
Authorized State Agent:
Date of Issue: 0?/.1 4/ 2 0 1 5
OValid without Expiration?
0Create CA?
01 -land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Improvement Permit
CDP File Number: 195647 -1
County File Number: c8-120-60-011
Date: / /
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IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
CDP File Number: 195647 -1
County File Number: c8-120-80-011
Date: 07/ 24 /2015
J
Click below to import an image from an external location: Drawing Type: Improvement Permit
RECEIVED
APPLICATION FOR SITE EVALUATION/IMPRO N' P �C
Davie County Environmental H
P.O. Box 848/210 Hospital Street ()
Mocksville, NC 27028 cc
(336)753-6780/ Fax (336) 753-1680 tai(
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT'** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed L -Al lesontact Person/
Billing Address ? c,� , �Z Home Phone Q (o - 71 4
City/State/ZIP LPA .� i (e- nlC_ usiness Phone 917- —�
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
FKUFhKI Y 1NVUKMA1IUIN yate House/racrltty corners rtaggea
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months wj h site plan, n expiration with complete plat.)
Owner's Name ' r�u `s r 1�[tt r Phone Number_
Owner's Address City/State/Zip
Property Address UCity
Lot Size r A % Tax PIN#� ! = 1A - —Q
Subdivision Name(f applic 1) Section/Lot#
Directions To Site: _
If the answer to any of the following questions is `Yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
❑Yes ❑No
Does the site contain jurisdictional wetlands?
❑Yes ❑No
Are there any easements or right-of-ways on the site?
❑Yes ❑No
Is the site subject to approval by another public agency?
❑Yes ❑No
Will wastewater other than domestic sewage be generated(.,
❑Yes ❑No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms 9# Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basemen[: ❑Yes o Basement Plumbing: ❑Yes ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building ZZ -Z)6 # People
# Sinks # Commodes # Showers '1 # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: l3-6unty/City Water ❑ New 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?
❑ No
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use
changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am re�sspponsible for the proper identification and labeling of property lines and comers and
locatiipg*nd flagging _or staking the house7racility location, proposed well location and the location of any other amenities.
!E
L-4
owner's of owner's legal rep entative signature Site Revisit Charge
Date(s):
O 7 — ?P" ZP/1— Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # ` 45 q-7
Revised 11/06 Invoice #
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All data is provided as Is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Implied warranties
of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina,
Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use
the GIS data provided by this website.
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil /Site -Evaluation
APPLICANT INFORMATION
pe4t 7i-lley
3?(� 577- W97--
Water
`9g2
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
PROPERTY INFORMATION
Gq-170-P -oo
Community Public
Pit Cut
SITE CLASSIFICATION: V
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: u �')14
OTHER(S) PRESENT: .0�iC— V
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
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
MOM
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely fim
M
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
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
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
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/dav/ft2
chroma 2 or less
nf1i71l nc/nC ln....:....a�
Landscape posit -ion
• •
rr�t��i/rl����■�
•�ril������
Consistencei991",
l�����
MORAMineralogy
IM
HORIZON II DEPTH
Texture
-
Mineralogy
PROT WMA
Texture groupConsistence
Texture group
Consistence
----�--
Mineralogy
SOIL WETNESS
SAPROLITE
CLASSIFICATION
SITE CLASSIFICATION: V
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY: u �')14
OTHER(S) PRESENT: .0�iC— V
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
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
MOM
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely fim
M
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
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
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
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/dav/ft2
chroma 2 or less
nf1i71l nc/nC ln....:....a�