195 Whitaker Rd ' OPERATION PERMIT or ice se n v
Davie County Health Department 'CDP File Number 161221 -3
...R^'t• :
� �� �s. 210 Hospitai Street
� �� P.O.Box 848 County ID Number. �
�''° �' Mocksville NC 27028 Evaivatetl For ��� ;
Phane:33fi-753-6780 F�t:336-753-1680 Tawnship: ,
App�icant: Todd Johnson Generai Property owner. David DiMarco
.,. .. _ _. . ..
Address: PO Box 12$ Address: 150 Nanzetta Way
�dY� Clemmans ��Y� Lewisville
State2ip: �� �7(�12 state2ip: NC 27023
�hor��#: (�36)464-5458 Phone#. �513)300-7217
Pro e l.o�cation � Site I�t'armatlon
Address/Raad�: Subdivision: Phase: Lot:
Whitaker Rd
Macksville NC 27028 Directions
stn,cture: SINGLE FAMILY Hwy 158 easf toward Advance, Whitaker road on
right past tJak Grove
#of Bedrooms. 4
#of PBOple:
*WaterSupply: N�rvwE��
*IP Issued by. 21ao-r�a�ons,Roben "System Classification/Oescription:
� TYPE it A.CONV SYSTEM{SINGI.E•FAMI�Y OR 480 GPO OR LESS)
'CA issued by: 2�40-Natian$,Robert �aprolite System? QYes QNo
Oesigr� Fiow: � g � *Disfribution Typg: ��VIN-SERIfu. Pump Required7
QXes ��Q
S�il Apptication R�te: � . a "Pre Tr�atrnent:
Orain fieid
N�rification Fie1d a �' � � SQ' �' 'System Type: �NFILTRA7dRQUICK4STANDARD
No. Drain Lines 4 Installer. �amie Bames
,
Total Tr�nch l.ength: 4 5 �1 �• Certification#:
Trench Spacing: � Inches O.C.
,�, —„� �Feet O.C, *EHS: 2�ap-Nation�.Rot>ert
T�ench Width: 3 Inches
. .
. �Feet Date: � 1 J a 0 / a 0 1 6
. _ _ ,_,_.�. , . . .
Aggregate Oepth: in�hes
Minimum Trench Depth: 3 a inches
Minimum Soil Caver. a � Apprava[Status
, , In�hes
Maximum Tr�nch peptn: � � m ApProv�c���Qisapproved
„ lnches
Maximum Soil Cover: a 4 tnches
�DP Fite Number '161221 -3 CQunty ID Number: '
Se tic Tank '
Manufacturer. Shoat Lat. . �
STB: 760 long: . -
Gallons: t0oo
lnstalter. �amis Bames
Date: � 8 / 1 3 r � 0 1 5
Gertificatian#;
'EH S: 2140-Nations,Robert
*Filter Brand:
ST Marker: ❑ Ye5 O No
Date: � . 1 � � g / a P� 1 6
Reinforced Tank: ❑ YeS � N0 Appravai Status
1 Piece 7ank: ❑ YBS p Na � Approved❑ Disapproved
Pump Tank
Manufacturer, Installer:
PT: Ce�tification#:
Gallons: 'EHS:
Date: � � Date: � �
R�sersealed ❑ Yes ❑ No
�tiserHeight. ❑ Yes ❑ No (Min.6 in.) ����� AppeavatStaEus x
Reinforced Tank: � Yes 0 No [p Approved� Qis��aprc�v�d
1 Piec�T�nk: ❑ Yes O No
Suppiy Line
Pipe Size: inch diameter Instaper,
Pipe Length: feei Cerkification#.
*Schedule: "EH S:
Pressure Rated CI Y@S ❑ N4 Date: � l
Approved frtting� ❑ Y�S ❑ NO APproval Status
Cl Approved� Disapproved
u e
Pum p Type. Insta�er.
Dosing Vofum�: - ,�a� Certificatian#:
Draw Down: Inches *���'
*Cha�: � �
Date:
Val�es Accessible ❑ Yes ❑ NO
Flow Adjustment V�tve p Yes ❑ No
Check-va�ve D Yes ❑ NO Approvai Status
Pvc unions p �es ❑ No �I Approv�ed Cl I]isa�pproved
V'enk Ho1e ❑ Yes ❑ No
Anti-siphon Hole ❑ YeS ❑ NO
,
CDP Fite Number ��1221 ' � County ID Number:
Electric E ul ment
NEMA4X Bax ar Equivalent ❑ Ye5 ❑ No Insta�er:
Box 12 inches Above Grade ❑ 'Ygg ❑ NO
Certi6cation#:
6ox Adj.To �ump Tank ❑ '(eS ❑ No
Conduit Sealed ❑ Y�S ❑ NO ��H�'
Pump ManualtyOperab�e ❑ yes ❑ No r f
�Activation Method: Oate:
Approva!Status
AtarmAudibfe � Yes O Na ❑ ApprovedC� t�isapproved
Alarm visible ❑ Yes ❑ No
�140-Na�ans.Rob�e�t
''opetation Permit comp�etea by�
Authorized S#ate Agent: Date of issue: � 1 / a 0 / a 0 1 6
OwnerlApplicant Signature:
This system has been instalted in compiian�e w�h appiicable NC Generai Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposa1,15A NCAC �$A.i90Q et. Seq.,and aU conditions of the tmprovement Pem�it and
Construction Autho�iz.ation,This property is�en+ed by a�rpE�t a. ��W�ge s�ptiC s�/Stem.
Rule.196t require�that a"fype T�'�II� septic syStem,me�t the#otlowing criteria:
M�nimum System Review ByThe Local Hsatth Departmenf: �A
Management Entity: Q�ER
Ma�imum System Inspection/Maintena�ce FtequencyByCertified Operator.
wA
Reporting Frequency By Certified Operator.wa
Rule.1961 �equires that a Type 1V and V�eptia sys�#ems desgned fora home/business own�r must maintain a valid contract
wRh a public management entiry w�h a ce�tified operatoror a private certified operat4r fo�the tife of the s�eptic$ystem.
Rule .1961 requires ih�tType VI septic system�designed fora homelbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the li(e of the septic system.
Rule. 1961 (2}(e)requires a contract shall be executed between the system awner and a management enti�y pnior to the
issuanae of an C?pera#an Petmit for e system required ta be maintainsd by a pubti�oir private management ent�y, unless the
system vwnerand�ertiC�ad pperatorare the same. The cantract shalt ret�uit+a specific requirements�ormau�tenance and
operation,responsib�ities of the owne�rand s}�stems operator,pravisions thatthe cant�act sha41`be in �a�fe�t for as long as fhe
system is in use�antl other requirements fQr the cantinued proper perfarrnance of the system. 1t shall also be a�cond�ion of
the`Operatiort Permit fhat subsequent°owners of the systems execut� such a coniracf.
QHand Drawing Qlmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMiT 1G1221 - 3
Davie County Heaith Depaftment CDP File Number.
210 Hospitai SUeet
P.o.aoxsas County File Number:
Mocksville NC 2�o2s Date: / /
�.�
Q Inch
Drawin� Drawing Type: lJperatipn Permit Scale: , . . p���c�c .ft.
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` ' CONSTRUCTION For office use on�v
AUTHORIZATION '`CDP File Number 161221 - 1
�.°�'� Davie County Health Department County ID Number:
� �_` � 210 Hospital Street Evaluated For: NEW
�.��,p,,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 5 / 1 3 / � 0 � 0
Applicant: Tood Johnson General Contractor Property Owner: Dimarco
Address: PO Box 128 Address: 3282 US Hwy 64 East
City: Clemmons City: Advance
State/Zip: NC 27012 State/Zip: NC 27006
Phone#: �336)301-9209 Phone#:
Propertv Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Whitaker Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 east toward Advance, Whitaker road on right
past Oak Grove
#of Bedrooms: 4
#of People:
*W2t@f SUPPIy: NEW WELL
Svstem Specifications
Minimum Trench Depth: � 4
Slt@ CIaSSIflCatlOfl: Provisionally Suitable Inches
Minimum Soil Cover: 1 a Inches
Saprolite System? O Yes ($No
Design Flow: 4 8 � Maximum Trench Depth: 3 6 Inches
Soil Application Rate: � a Maximum Soil Cover: a q, Inches
"System Classification/Description: '`Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: 0 Yes �No
Pump Required: QYes �No Q May Be Required
Nitrification Field � 4 0 0 Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: �Yes �No
Total Trench Length: 6 0 � ft GPM--vs-- ft. TDH
Trench Spacing: _ �Inches O.C. _
9 Feet O.C. Dosing Volume: Gallons
Trench Width: _ 3 �Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-I O TS-II
Septic Tank Installer Grade Level Required: O I �II 0 I II O IV
Page 1 of 3
. }.
CDP File Number 161221 - 1 County ID Number:
❑ Open Pump System S„'�eet
Repair System Required:�YeS O No O No, but has Available Space
Repair System Inches O.C.
Trench Spacing: 9 O
"Site Classification: Provisionany suicabie — �Feet O.C.
Trench Width: 3 �Inches
Design Flow: 4 8 � — �1 Feet
Aggregate Depth:
Soil Application Rate: � a inches
u Minimum Trench Depth: a 4
'`System Classification/Description: Inches
TYPE II A.CONv SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 a Inches
LESS)
Maximum Trench Depth: 3 6 Inches
*Proposed System: 2s��o REDUCTION
Maximum Soil Cover: � ,4, Inches
Nitrification Field � 4 0 0 Sq. ft.
No. Drain Lines "DIStPIbutI011 Type: GRAVITY-PARALLEL(eq.d-box)
4
Total Trench Length: 6 0 0 ft. Pump Required: �Yes Q No Q May Be Required
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema��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. °ha'a��e'S
Remaining
2���
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 lncorrect,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 repalr
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes �No
Applicant/Legal Reps. Signature� Date: � �
"ISSU@d By: 2�40-Nations,Robert Date of Issue: 0 5 / 1 3 / � 0 1 5
Authorized State Agenfi �— � Malfunction Log OYes
�Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION 161221 - 1
Davie County Health Department CDP File Number:
� 210 Hospital Street
P.O.Box 848 County File Number:
Mocksville rvc 2�oz8 Date: 0 5 / 1 3 / a 0 1 5
�Inch
� in Drawing Type: Construction Authorization Scale: , , OO B�A k - ,ft.
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Page 3 of 3
P1 P2
;'? CONSTRUCTION AUTHORIZATION �
Davie County Health Department
5 �1 � `� � 161221 - 1
210 Hospital Street CDP File Number:
� G�-) �) P.O.Box 848 `�� C; (�L'��` � �J��G`? l
1 .. � �yi �G' `"� Mocksville Nc 2�o2s County File Number:
- � � �/ �� c-��� � ��/ ��..i' �Lf/ _ Date: .�.5.� .1.3. � a.�.1.5.
7� � � � � , _ � � � �
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Page 3 of 3
P1 P2
` °�� " For Office Use Oniv
�, , ,� , . � . I�II,IPROViEMENT PERMIT *CDP File Number �s�22� - �
�-'u"'�� Davie County Health Department
�` '`�'
� 4�'1•�,�� 210 Hospital Street County ID Number.
'�� G � P.O. Box 848 Evaluated For: NEW
��.:;;;,•
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax:336-753-1680 pERt.nr vau�uriri�: 1 0/1 712 01 9
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Toc�d John on Generai Property Owner: Roy and Sarah Wali/c/o Tamra„rD
eo►�-��,�� .. . ����,
Address: p0 Box 128 Address: 3282 US Hwy 64 East ��
CQ : Cd • �
Y Clemmons Y• Advance ��1
state2ip: J
NC 27012 State2ip: NC pW' 27006
6 1- �
Phone#: (33 ) 30 9209 Phone�:
Pro ert Location 8 Site Information
Address/Road #: Subdivision: Phase: Lot:
Whitaker Rd
Mocksville NC 27028 Directions
structure: SINGLE FAMILY Hwy 158 east toward Advance, Whitaker road on
#of Bedrooms: 4 right past Oak Grove
#of People:
'Water Supply: nlEwwE��
S stem S ecifications
Initial S stem
"Site assi �Ca bn: Provisionally Suitable
Minimum Trench Depth: a 4 Inches
Saprolite System? �Yes Q No p�taximum Trench Depth: 3 6
Inches
Design Flow: 4 $ 8 Septic Tank: 1 � � �
Gallons
SoilApplication Rate: 0 . a 1_piece: QYes QNo
u Pump Required: QYes QNo Otti�ay Be Required
'System Classificatan/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pum p Tank: G allons
LESSI
"Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Repair System Required:QYes ONo ONo, but has Available Space
Reaair Svstem
"Slte Cl2SSIf�2ti0t1: ProvisionallySuitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: � . a Maximum Trench Depth: 3 6 Inches
'System Classifiication/Description: Pump Required: QYes �,lNo Q t�fay 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 _�61221 -;1 . County ID Number:
11 . . � • •
' YSite Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department_ ::�
7:
xPermit Conditions
The issuance of this permit by the Health Depa�tment in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. �;
7;
Site Plan me Improvement Permit shall be va�id for 5 years from dateof Issue with a site plan(means a drawing nat necessadly drawn to
O scale that shows the existfng and proposed property lines with dimensions,the Iocation of thefacility and appurtenances,the
site torthe proposed Wastewater systern,and the Ixation of water supplies and surtace waters).
Plat The Improvement Permlt shall be valid wfthout expiration with plat(means a propeny sunreyed prepared by a registered land
O sunreyor,drawn to a scale ot one inch equals no morethan 60 feet,that Includes:the specific Ixation of the proposed tadlity
and appurtenances,the site Tor the proposed Wastewater system,and the location of ti+vater supplies and surtacewaters. Plat
also means,for subdivision lots approved by!he Ixal planning authority and recorded with the county register of deeds,a copy
of the recorded subdlvisions plat that Is accompanied by a site plan that is dravm to scale).
The Departrnent and Local Heatth DeparEnent may impose condltions on the issuartce and may rewke the pertnits for tailure of
the system to satisfy the condiUons,the rules,or tt�is article This pertnit(s subject to rewcation ff the site ptan,pla�or intended
use changes(NCGS 730A�335(�).The person owning or coritrolling the system shall be responsibte torassuring comptiance
with the laws,rules,and permit conditions regarding system Ixation,Installation,operation,mafntenanc�monito�ing,
reporting,and repair(.1938(b)).
ApplicanULegal Reps. Signature Required? OYes �No
ApplicanULegal Reps. Signature: Date: � �
=ISSued By: 2�40-Nations,Robert Date of Issue: 1 0 / 1 7 � a 0 1 4
Autnorized state A en : OValid without Expiration?
9 OCreate CA?
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• • • . �IMPROVEMENT PERMIT
- ' Davie County Health Department CDP File Number: 161221 - 1
,.� . . . , •
' 210 Hospital Street
P.o.aoxsas County File Number:
Mocksviile rvc 2�o2s Date: I I
Q Inch
Drawing Drawing Type: Improvement Permit Scale: , . . QBiock _
QN/A ft.
_._._ __ __ ____ _ . __.... _ __ __ __. _._ _ _. ___ ____
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Page 3 of 3
.f ' ,� ' ,
. • • t
�PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
. .____--....__�� _-- _..._... . Davie County Environmental Health ... :.. : : y
.. .. .: .. ..:. . __ _ _ -----_ _ _.__.
a��, P.O.Box 848/210 Hospital Street'
��: �t • , Mocksville,NC 27028
���,b � (336)753-6780/Fax(336)753-1680
a � ��._����'�`� �
Application For: ❑Site y�valuation/Improvement Permit Authorization To onsVuct(ATC) Both
Type of Application: 8'New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTi1N7***THIS APPLICATION CANNOTBEPROCESSEDUNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
I � / `onfrx cf+n
Name to be Billed �Od� Johnso�t ��nc�a� Contact Person '�/},fvn/ W E��
Billing Address �J[� �3 l,�( /�,� Home Phone
City/State/ZIP �./r ini►►tsn� �r� 'd.?ca t 2 Business Phone 'S3!�' k G�t•S"�0 S``i3
Name on PeratidATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facili Comers Fla ed � " `f`I`f
NOTE: A survey plat or site plan must accompany this application. Included:0 5ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner'sName�y,'d, �.'�✓Ir,��ca PhoneNumber.5 �,3"3b�'7���
Owner's Address S Q � ��d f a,v City/State/Zip Cr-c+►�:sr�'/le �vG � ��a3
Property Addres ' � / City /3'ipri/cS✓i/10
Lot Size ' Tax PIN# /'!� �U�O_�a i 2�
Subdivision ame(if applicable) Section/Lot# v
�ectionsToSite:Ta,�e. 1sf3-G' �a.� A��- on w�ii��u�.c,� /�,d ti'�i S� pust n��.l� G h,
��!'�d�<rJs rJ's cy�lFho �-e' �'/.Tt� fv �r►d.
ff the answer to any f the following questions is`�es",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes ONo
Does the site contain jurisdictional weUands? ❑Yes�No
Are there any easements or right-of-ways on the site7 ❑Yes ONo
Is the site subject to approval by another public agency? ❑Yes ONo
Will wastewater other than domestic sewage be generated? ❑Yes ONo
IF RESIDENCE FILL OUT TI-IE BOX BELOW
#People � #Bedrooms � #Battuooms� Gazden Tub/WUirlpool❑Yes o
Basement: ❑ es o BasementPlumbing: ❑Yes Q3�o
IF NON-RESIDENCE FILL OUT TI-�BOX BELOW
Type of FaciliryBusiness Total Squaze Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gal(ons per day) (Attach documentation of similar faciliry water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type:0 Counry/City Water �New Well OExisting Well ❑Communiry Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes f,d'No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereafter 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 Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
locating and flagging or sta i the house/facility locatioq proposed well location and the location of any other amenities.
_�'��'�"''�`—t"''�r'���� Site Revisit Charge
�Pcoperty owner's or owner's legal representative signature
Date(s):
��� � � Client Notification Date:
Date EHS: .
Sign given ❑Yes ONo Account#
Revised 11/06 Invoice#
. ' • ,
� � • . '
� IMPROVEMENT PERMIT F��o��e use on�v
*CDP File Number 161221 -1
���^�E�.,� Davie County Health Department
� ,"Y� 210 Hospital Street CountylD Number:
'�,� � ,� P.O. Box 848 Evaluated For: NEW
�,w„„„�
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax:336-753-1680
PERMIT VALID UNTIL: 10/17/2019
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Tood Johnson General Property Owner: Roy and Sarah Wall/c/o Tamra
Address: PO Box 128 Address: 3282 US Hwy 64 East
City: Clemmons City: Advance
State/Zip: NC 27012 State/Zip: NC 27006
Phone#: (336)301-9209 Phone#:
Pro ert Location 8� Site Information
Address/Road#: Subdivision: Phase: Lot:
Whitaker Rd
Mocksville NC 27028 Directions
structure: SINGLE FAMILY Hwy 158 east toward Advance, Whitaker road on
#of Bedrooms: 4 right past Oak Grove
#of People:
"Water Supply: NEw wE��
S stem S ecifications
Initial S stem
"SIte�L,asSl ICa lOn: Provisionally Suitable
Minimum Trench Depth: � 4 Inches
Saprolite System? OYes f8'i No Maximum Trench Depth: 3 6
Inches
Design Flow: 4, $ 0 Septic Tank:
1 0 0 0 Ga��ons
Soil Application Rate: � , a 1-Piece: �Yes f�No
� Pump Required: �Yes f�No �May Be Required
*System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
*Proposed System: 25°ia REDUCTION 1-Piece: O Yes �No
Repair System Required:(�Y2S O No ONo, but has Available Space
Repair Svstem
"Slte CIBSSIfIC8tI0ft: Provisionally Suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: � . � Maximum Trench Depth: 3 ( Inches
*System Classification/Description: Pump Required: QYes �No O May be Required
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25°io REDUCTION
Page 1 of 3
k J � +
CDP File Number 181221 - 1 County ID Number:
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rama��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. Rama�9
750
Site Plan The Improvement Permit shall be valid for 5 years from date of Issue with a site plan(means a drawtng not necessarily drawn to
� scale that shows the existing and proposed property lines with dimensions,the location of the facllity and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiretion with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one lnch equals no more than 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 fs accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may fmpose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or thfs article.This pertnit is subject to revocation if the site plan,plat,or lntended
use changes(NCGS 130A-335(�).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditlons regarding system location,installation,operation,maintenance,monitoring,
reporting,and repalr(.1938(b)).
Applicant/Legal Reps. Signature Required? OYes �NO
Applicant/Legal Reps. Signature: Date: � �
"IssUed By: 2�40-Nations,Robert �ate of�ssue: 1 0 / 1 � / a 0 1 4
Authorized State Agen�: OValid without Expiration?
O Create CA?
�Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
, : . -� � � '
• . IMPROVEMENT PERMIT 161221 - 1
Davie Counry Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: / �
�Inch
Drawin� Drawing Type: Improvement Permit Scale: . , O Biock _
�N/A ft.
I
� ' �
r—t �l p�.
� �
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Page 3 of 3
P1 P2
.' • ' • .. -
, , , . - .
• . IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street CDP File Number: 161221 - 1
P.O.Box 848
Mocksville Nc Z�o2s County File Number:
Date: .1.0./ .1.�_ /,a,0.1.4
Click below to import an image from an external location: Drawing Type: Improvement Permit
Page 3 of 3 P1 P2
� � : . - ,� : - �- �� � �wc.
�' ` - � � �
��'�,i'I��ICATION FOR SITE EVALUATION/IlVIPROVEMENT PERMIT&ATC /��r, �� � / �,'
'�+:, , Davie Connty Environmentai Heaith �1 j(tU� Wl. �
f/, P.O.Boz 848/210 Hospital Street "A ,� �
n0te� ` v ` � Mocksv�le,NC 27028 ��w
� (336)753-6780/Faa(33�753-1680
Application For. �rte Evaluation/Improvement Permit ❑Authorization To Construct(ATC7 ❑Both
Type of Applicatibn: �New System ❑Repau to Existing System ❑Expansion/Modification of Exisring System or Facility
""'IMPORTANT"•s THIS APPLICATION CANNOTBEPROCESSED UNLESS AGL OF THE REQUIItED
'`� INFORMATION IS PROVIDED. Refer to the INFORMATION BLJLLE77N for instructions.
• APPLICANT INFORMATTON •
. � J ,�. /1
. Name to be Billed �!J�/ �O h rlsfin(l'G'-s1e�'Gf.l� nt t Person ���n h ftiio!'1
. Billin�Address_ P� (3������ Iiome Phoae - - p
. City/State/ZIP [��I�y�roc,�►.9 ,n(� .�?0/3. BusinessPhone �3L,3/�(-�?
� Name on PetmibATC if Dperent than Above
Mailing Address CitylState/Zip
PROPERTY INFORMATTON *Date House/Facili Comets Fla ed
NOTE: A survey plat or site plan must accompany this application Included:O Siu Plan ❑Plat(to scale)
(Permit is vatid for 6U nths with site plan,no expiration with complete plat)
Owner's Name R ot,+ ����i S�L1� %��►n.wa S�'ks Phone Number
Owner'sAddrtss�— _ City/State/Zip ��a�n[+,p,� 1/Ci a,+Zpp(n
P��rty aaa�s t��cn_!�►�c a k��Rd c�ty��f o�vs�;��A P ���.�o a�
Lot s;� �s Ae� Taac PIN# s�4��5���70 `TµX �-�5��,l��
Subdivision Name(if appticable) �r�' �-o��� Section2ot#
Directions To Site:
if the answer W azry of the followmg questions is`�es",supporting documentation�st be attached.
Are there any existing wastewater systems on the site? pYes�No
Dces the site contain jurisdictionallvetlands? ❑Yes�No
Are there any easements or right-of-ways on the site? OYes�No
Is the site subject to approval by another public agency? �Yes allo
Will wastewater other than domestic sewage be generated? �Yes�No
� IF RESIDENCE FILL OUT TI�BOX BELOW
#People #Bedrooms #Bathrooms Gazden Tub/Whirlpool�Yes j�'No
Basement:OYes o BasementPlumbing: ❑Yes �(No
IF NON-RESIDENCE FILL OUT Tf�BOX BELOW �
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commndes #Showers #Urinals
Fstimated Water Usage(gallons per day) (Attach documentation of similaz facility water consumption)
FOODSERVICE ONLY: #Seats
Typesystemrequested: �Conventional OAccepted Olnnovarive ❑Altemalive ❑Other
Water Supply 1�e:�County/City Water �New Well ❑E�cisting Well ❑Community Well
Do you anticipate additions or eacpansions of the facility ttus system is intended to servc?O Yes �r No
If yes,what type?
This is to certify tUat the information provided on this application is uuc and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereaRer aze subject to suspension or revocarion if the site is altered,the intended use
changes,or if the infocmation submitted in this application is faisified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Depaztment to conduct necessary inspections to determine compliance with applicable
laws and cul�I undecstand that I am responsible for the proper idea6fication and labeling of pmperty lines and comers and
loca6ng. S�LlggiagoF-staking�lwi acility location,proposed well location and the location of any other amenities.
�J Site Revisit Charge
Pro owna's or o er's legal represenffitive signature
Date(s):
G Client Norificarion Date:
Dat EHS:
Sign given pYes ONo Account� ���/
Revised 11/06 Invoice#
�r � � rn �� I t.i�°\,'���
_ ; \ —__ .._ _ _ _ -_- _- _ — —
�
9/30/2014 • • Gmail-Whitaker rd
, _ •�� , . � .
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Whitaker rd
Robert Nations<Robert.Nations@co.davie.nc.us> Mon,Sep 29,2014 at 4:48 PM
To:tacinnovations@gmail.com
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Robert Nations,REHS " � � ���
Davie County Health Department
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' Environmental Health Section
P.O.Box&48
Mocksville,NC 27028
(33c�)753-�%80 o�ce
(336)753-1680fax
Plcase complctc our customcr satisfaction suivcy:
Da�-ic Cuuntv I�n�ironment.il 1{c��lth C'u.,t�,m�r Satisfacti��n Stu������
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" � ' ' � Y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
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Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit i Cut
FACTORS 1 2 4 5 6 7
Landsca e sition L.
Slope%
HORIZON I DEPTH Gti-� O- � (
Texture grou 3 G L.
Consistence 5 c
Structure S
Mineralo 5 /L
HORIZON II DEPTH " I-
Texture rou � o � G
Consistence C N
Structure �/ /� ,
Mineralo .{� 1
HORIZON III DEPTH �
Texture rou -
Consistence G
Structure 5 1G � �
Mineralo ct-
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RAT . •�-
SITE CLASSIFICATION: � EVALUATION BY: \��
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: W � � � P��
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REMARKS:
LEGEND
j,�ndsca�e Position
R-Ridge S -Shoulder L-Lineaz 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
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VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
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- 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-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
�otes
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 OS/OS(Revised)
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