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455 Will Boone Rd • � OPERATION PERMIT or ice se n v Davie County Heaith Department *CDP File Number 161212-1 ��r�� 210 Hospitai Street K5-000-oo-o�s � � P.O. Box 848 County ID Number` ' � �`��'� Mocksviile NC 27028 EvaiUated1Fo NEW Phone: 33fi-753-fi780 Fax: 336-753-1680 /� Township: / Applicant: Scott Smith Proper�y Owner: g,�rbara Hellard ` Address: 82g Piedmont Drive Ad �ess: 491 Wili Boone Rd .� ��v� l.exington ��v� Mocksville StatelZip: NC 27295 S�aterLip: NC 27 28 Phone#: {336)782-1647 Ph� e#: Pro ert Location & Site Info-rmation AddresslRoad#: Subdivision: Phase: Lot: Will Boone Rd Mocksville NG 27028 Diractions Structure: SINGLE FAMILY Hwy 601 South Left On Deadmon Rd. Right On Will Boone Rd.Lot right across from #452 #of Bedrooms: 3 #of Peaple: 2 'Water Supply: PUBI.IC *IP Issued by: 2�4o-Nations,Robert 'System ClassificationlDescription: TYPE II A.CONV SYSTEM{SINGLE-FAMILY OR d80 GPD OR LESS) 'CA issued by: 2140-NaUons,Robert Saprolite System? QYes QNo Design Flow: 3 6 � * N/A Pump Required? Distribution Type: QYes QNo Soil Application Rate: � � � 5 •Pre-Treatment: Drain �+eld Nitrification Field 1 3 � � Sp' �' `System Type: �NFILTRATOR QUICK 4 STANDARD No. Drain Lines 3 Installer: B��yciay�on Total Trench Length: 3 a 8 �• Certification#: Trench Spaang: _ 9 incnes o.c. gF28t O.C. *EHS: 2�4o-Nations,Robert Trenc�Width: 3 Inches — , - gFeet Date: 1 a / 0 5 f a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 � Inches Minimum Soil Cover. a 4 Approval Status. lnches Maximum Tr�nch Depth: 3 s tncnes E�l-�4pproved� Disapproved Maximum Soil Cover: a 4 Inches CDP Fils Number 161212 - 1 Caunty ID Number: K�-000-oo-o�s Se tic Tank Manufacturer. Shoaf Lat. � STB: 760 Long: Gallons: i000 Instailer: B��Y��ay�on Certi6cation#: Date: g3 f a6 la � sa `EH S: 2�40-Nations,Robert `FIItBf B�aild: POLY�OK Dual PL-122 With Pape Adapter Date: . 1 a I � 5 1 a e x 4 ST Marker: ❑ Yes � No ' ' ' � ' � � - ' Reinforced Tank: ❑ y�s � Np Approvai Status 1 Piece Tank: ❑ Yes � No �) ApProvetl[� :Disapproved Pump Tank Manufacturer. Installer: PT: Ce�tification#: Gallons: 'EHS: Date: � � Date: � � RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Ye5 ❑ NO iMin.6 in.� ' �pproval�tatus einforcedTank: ❑ YeS ❑ No p Approved❑ Disapproved 1 Piece Tank: ❑ YeS ❑ NO Supply Line �ipe Size: inch diameter Installer: Pipe Length: feet Certi6cation#: "Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No oate: r � Approved fittings ❑ 'YQS ❑ NO �� Approval.Status � Approved❑ Disapproved Pump Type: Installer: Dosing Volume: - Ga� Certification#: Draw Down: Inches *EHS: =cr,a�n: 1 1 Date: Valves Accessibte p Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check valve ❑ Y8S ❑ N 0 Approval Status' Pvc unions p Yes ❑ No D Approved❑ Dis�pproved vent Hole ❑ Yes ❑ (Vo = Anti-siphon Hole ❑ YeS ❑ NO CDP File Number '�6121�- 1 Caunty ID Number: K�-000-oao�s Electric E ui ment NEMA 4X Box or Equivalent � YES ❑ NO instalier: Box 12 inches Above Grad� Q Yes ❑ N� Certification#: Box Adj.To Pump Tank p Yes ❑ No Conduit Sealed O Yes ❑ NO 'EHS: Pump Manuaily Operable ❑ }�gg ❑ NO sActivation Method: Date: l f 'Approvai StaEus Alarm Audibie ❑ Yes � Na p Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit complete8 by: Authnrized State Agen : ��""�--�"''��"~" Date of Issue: � a � � 5 1 a 0 1 4 This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, �5A�ICAC 18A .1900 �et. Seq.,and all conditions of the Improvement Pe�rnit and Construc�ion Authorization.This property is served by a�rYpE n A. sewage septic system. Rule .1961 requires that a Type �'E��A� _ septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A �__ Management Entity: owt��R �� ___ __,_. __ Minimum System InspectionlMaintenance FrequencyByCertified Operator: wA Reporting Frequency By Certified Operator: wA _ N Rule .1961 requires that a Type IV and V septic systems designed for a homel'business owner must maintain a valid contract with a public management entitywith a ce►tifisd operatoror a private certified operator forthe life of the septic system. Rule .1961 requires thatType VI septic systems designed fora home/business owne�must main#ain a valid contract with e public management entity with a ce�tified operator for the life of tha septic system. Rule. 1961 (2)(e}requires a contrac#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 sha11 require specific requirements farmaintenance 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 nther 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 Olmport Drawing **Site Plan/Qrawing a##ach�d.'r*' OPERATION PERMIT � � � Davie County Nealth Department CDP File Number: 161212 - 1 210 Hospit�l Street K5-OOU-00-078 P.o.Box 848 County File Number: Mocksville NC 2�o2s Date: / ! Q Inch Drawing Drawing Type: Operation Permit Scale: . (�N�Pck — .ft. _.___.__ ________ � � : , �,.__.�________�___._� _ _.._ ___ ___.. I I 1 � ' ; � ,_._._...,._____:_____i____ i._._.._!-- + _ ? __._!____.l._ � ___.�.._._ _ _ �_ _�� _____� �� i � __ � i ��,��._ . -- � . ) � � � � � � � ;_ ___ __T�..__ .__.�__-.--.- _- -.------.-:-------. . ---- � r ------- - - ..._- ------- --- �. . .. ; �� --.--.- --.._....._ �- --�........... ... ----- ------� � � � I i 1 � . .._ � � � � �. �_._ � , --�------ -.---- ----�.---.------I.------_..�..._._-.� .--�-------�--__..._ _.._..._t.._.��_._ _ � � . i -.--- _._.. _ . , , __. _a_...,_. .---__. - ---F----_ .... _ .._ . . _ . __. . I � � � � � � i � U r � � � � � � .. � __ . ,_ _____ ._ ..._ - --___________._..._.__._____.,_____ , _ _ _ . _ ; � _� __ �___. _.�_.__ ..__._._. _.__._�_ _.. _ , _ _�. _.�_. _- _ , � � ¢ � � � � ��____�_._ � � ._�___�� I _ � .��__.__�.. � � c,��_ _ �.—._�_ _ __ ► ... � _ _ �__I__ ____.._. � ___�_ � � _ _� _ _ �_ �__ ._, ��... �� --�� \,___� �__�___.�___�_.__ �� __ ��_ �� _ , ��.__� _ _ __ , __ ______ _� _.:�.._._� � � � � E �� __ I � �_�� [�__I_�_ �_��_� �� __.�,___ _i�. �I___ !� _ �_ _ � � � � �- �� ,;,. � _ � _� � � � �_____._� ��_ �_ � ��,_� __-�-�__� _ .� _. I I I I � , I I I ��- _,. �_ _'� _! I._� _ _� � _. .� _� .. __._r ! � _.._._._r.._.._I._ ._.__ __......._..�......._.___...__�.► .._I._ ... .._.. I. ..._.. ..... .I �. _.� ..._.�.. ._...I..._ _.. _._.__ _. _._ .__ _.. _.. .. . . . ..r_..._.--- -f------ - � ---'�^ , � � � .�_._. �__._.. ._.. � � � ...--- ___.�._. ._�. .___._._..�_ _..___•_..__ _•..__-.- -.¢.__'_----• .____•. . . ..�....._.... .. _ .._._ ..._.._ _._. _._ ._._..._ .. .._ . __.._ . . ... ..._ _ . .. .._. . ...__ ._.._._ .__..__.._.... ... ._.. _ ._.,___ _.�..._ _ : ...� ._.�.. _ ... . _ ..�.. _.�_ .._. ._, � _� � ! . � �_.� I.�_ _� _�_ . � � _� 1_ �_�_ _� �--�- I � � I I _ � �4,_� —�—!'�� I �� i � ,_,..�......_� ��1�.� � �.,� o �_ _�_ �..�._.� ________ .� � ' , : , , ; ` ( t _ ______ � _._. .,_____ _.__._ ,__ � � _ -- -- . � � � � �_.. �_.._..__,_ _ _ � _._.__ _ _ __(�_____.._! �._ �.�,_�-_._t-�----., _ .�. r _._�_ _ _I ._ �;_ __ � I� _ �_..�...__.___. _..___�_�� 1�I '`�_____I _ _`'�_ _m �_mm__mm_ _�� I 1 r I t �� I�� i ( .... ...�� _--,_ ..I_,.; .,w.�. ..,..�. ,,..1,,.... �._�.�... ,,,._._��._.__�__.,_ _�._..__--�--__._�.,.,,...,� _... �........ .....!_._... ...._. ...., _ _., ,,. .,,.,.,_ I �; � � � � �_ I _�_______, I 1 I I � __,_ �_____ —_-� � --� _ __________.._. ____..__ � _____�r_____�_____ _____ � __ ______� �---- --__ _ _---- � , , �_ __ ___ � I � ___. ._� __�_ ..__�_� ___--��;�j: -__--�---__I_ ._._ ______ ..._�___ �_�_ __.�_ _�_ � ._ _ � _ . _. . __ , . � � , __ � t_ __ ,_ _ _ . _I _ _�_� I I I I I _�--�—� � I � � � �._I_ � . `� 1 � � tI � � � � � � _ � � .� � #_l � �1 i 1� _� � � I � :_. _ �_,f ► I�1�_��_��__ �__�____.j__ ��_ _ _ � �_ � � ,_ _� �___.�____� { ► �_____�_� � � i ► � �� __�. I I i ; ( I�� I _.� . _..._____._ .__... .._..�._�...�_.__'_.___ --.--- � C ---___ . --__�___----.---- _._.._ ____._ --.---. ___I___I � I � __ ��._..�_........ ........�._.._.�m_m___ � ...._._�_.__.....�.. �...........�_____I�..___...�_......._�_...... � ......... ... �_ �........ � .._mm_�_ .......� .......1.1_�1 � ....._�� _._..�..... �ON�TRUCTION For ottice use on�v ' AI�THORIZATION *CDP File Number 161212- 1 ��'� Davie County Health Depa�tment County ID Number: K5-Oa0-0o-078 � `�, ' ��` 210 Hospital Street Evaluated For. NEW �.�,��.� P.O:Box 848 Township: Mocksville NC 27028 PER�,11T VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 1 0 / a 9 � a 0 1 9 Applicant: Scott Smith Property Owner: Barbara Hellard Address: 828 Piedmant Drive Address: 491 Will Boone Rd C�y: Lexington City: Mocks�ille StatelZip: NC 27295 State2ip: NC 27028 Phone#: {336)782-1647 Phone#: Property Location 8� Site Information AddresslRoad#: Subd'nrision: Phase: Lot: Will Boone Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 South Left On Deadmon Rd. Right On Will Boone Rd.Lot right across from#452 #of Bedrooms: 3 #of People: 2 *Water Supply: PUBUC Svstem Specifications Minimum Trench Depth: a 4 Site Classif�caiion: Provisional�y Suicable Inches Minimum Soil Cover. 1 a Saprolite System? QYes QNo Inches Design Flow: 3 6 � �vlaximum Trench Depth: 3 6 �nches Soil Application Rate: � , a � 5 Maximum Soil Cover: a � Inches *System Classification/Description: 'Distribution Type: TYPE II A.CONV SYSTEM(SINGLE-FAMILY�R 48�GPd OR LESS) Septic Tank: 1 � � � Gallons 'PropoSed System: 25%REDUCTION 1-Piece: QYes QNo Pump Required: QYes QNo QMay Be Required N rtrification Field 1 3 0 9 Sq. ft. PumpTank: Gallons No. Drain Lines 3 1-Piece: QYes QNo TotalTrench Length: 3 a � � GPM—vs-- ft. TDH Trench Spacing: _ 9 Qlnches O.C- Dosin Volume: _ Galtons QFeet O.C. g Trench Width: Inches _ 3 SFeet Grease Trap: Gallons Aggregate Depth: � � � inches Pre-Treatment: QNSF OTS-I C�TS-I) Septic Tank Installer Grade Level Required: 01 �II �ll) �IV Page 1 of 3 CDP File Number 161212'- 1 County ID Number: K5-o00-00-078 ❑ Open Pump System Sheet Repair System Required:OY�S ONo ONo, but has Available Space epair Svstem Trench Spacing: Q Inches O.C. "Site CIeSSIfiCation: Prov,sionally Suitable — 9 Q Feet O.C. Trench Width: �Inches Design Flow: 3 6 � — � Feet Soil Apptication Rate: Aggregate Depth: inches � . a a 5 Minimum Trench Depth: a 4 "System Classification/Description: Inches 'fYPE II A.CONV SYS7EM jSINGLE-FAMILY OR 480 GPD OR LESS) �inimum Soil Cover. 1 a Inches P�taximum Trench Depth: 3 6 'Proposed System: 25%REDUCTION Inches Maximum Soil Cover: a 4 N drification Field 1 6 � � Inches Sq. ft. No. Drain Lines 'Distribution Type: GRAVITY-SERIAL 4 Total Trench Length: � � � ft Pump Required: QYes ONo �May Be Required Pre-Treatment: ONSF OTS-1 OTS-II 'Site Modifications No grading or canstruction activity is atlorved in areas designated for system and repair�vithout approval of Health Department. �� 7 'Permit Conditions The issuance of this pertnit 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. q; 2 This Authorizatlon tor Wastewater System Construcdon shall bevalid for a person equal to the period of validity of the ImprovemeM Permit,not io exceed tivi2 years,and may be lssued atthe sametime tt�Improv+ement Permit Issued(NCGS�30A-336(bj�If the installation has not been completed dudng the period af validlty otthe Construction Pertnit,the iMormation suhmitted in theappllcatlon tor a permlt or Construction Authorization is found to have been incorrect,falsified or changed,or the siteis altered,the pertnit or Constructbn Authorization shall become invatid,and may besuspended or revoked(.1937{g)).The person owning or corttrolling the system shall be responsible tor assuring compliance with the taws,rules,and permit conditions regarding system Ixation,installation,operatlon,maintenanc�monitoring,reporting and repalr (1938(bj). ApplicanUlegal Reps. Signature Required? OYes �NO Applicant/Legal Reps. Signature� Date: � � 'ISSUed By: 2�40-Nations,Robert Date of Issue: 1 � � a 9 � a 0 1 4 Authorized State Aaen� t�talfunction Log QYes OHand Drawing Olmport Drawing � **Site Plan/Drawing attached.** � Page 2 of 3 • • CONSTRUCTION AUTHORIZATION � � Davie County Health Department CDP File N umber: 210 Hospitai Street P.O.Box 848 County File Number: K�-000-oo-o�s Mocksville NC 27b28 Date: 1 � l a 9 / a � 1 4 � Qinch Drativin� Drawing Type: Construction Authorization Scale: . . , OBiock = .ft. QN/A _ '�-ib 1 b d� .�� '� zi '' 3 � _ _ � l da� _ _ � � ' � _ + � .� {��r � ��N � � ---� � � oo� � �� r I3 , r� a p +o`� �1 d � 5� �:�•� c':�,•��. �� Cr �_ � d S� � s Paae 3 of 3 _ � IMl�F�OVEMENT PERMIT ForOffice Use Onlv *CDP File Number 161212- 1 '�'�� Davie County Health Department �..--, �F Q� County ID Number:K5-000-00-078 t�, ; 210 Hospitai Street �� .�� P.O. Box 848 Evaluated For: NEW , .�...- �...,..,..• Mocksville NC 27028 Township: Phone:336-753-6780 Fax: 336-753-1680 PER1.11T VAIID UtJTiL: 10/29/2019 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot bc issued with this Improvement Pertnit. Applicant: Scott Smith Property owner: garbara Hellard Address: 82g Piedmont Drive Address: 491 Will Boone Rd C�Y� Lexington �aY� Mocksville State2ip: NC 27295 State/Zip: NC 27028 Phone#: (336) 782-1647 Phone#: Pro e Location 8� Site Information Address/Road #: Subdnrision: Phase: Lot: Will Boone Rd Mocksville NC 27028 Directions stn,cture: SINGLE FAMILY Hwy 601 South Left On Deadmon Rd. Right On Will �of Bedrooms: 3 Boone Rd.Lot right across from #452 #of People: 2 'Water Supply: PUBUC S stem S ecifications Initial S stem 'Site assl �Ca pn: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprotite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 � Septic Tank: 1 � � g Gallons Soil Applicatan Rate: � . a 3 5 1-Piece: QYes QNo " Pump Required: QYes Q No 0 May Be Required 'System Classification/Description: NPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pum p Tank: G allons LESS) "PfOpOS@d SySt6m: 25%REDUCTION 1-Piece: QYes QNo Repair System Required:QYes ONo ONo, but has Available Space Repair Svstem "Slte C18SSIf�ati0n: ProvisionallySuitable t�Ainimum Trench Depth: a 4 Inches Soil Application Rate: � , a a 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: QYes Q No Q F,�ay 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 ,169212 -'1 County ID Number: K5-000-00-078 =Site Modifications p open Fi�t Sheet No grading or construction activity is allowed in areas designated for system and repair�vithout approval of Health Department. :.' 7: xPermit Conditions The issuance of this peRnit by the Health Department in no�vay guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ::'. 7: Site Plan rne Improvement Permit shall be valid for 5 years irom date ot Issue with a site pian(means a drawing not necessadty drawn to O scale that shows the existing and proposed property lines with dimensions,the Ixation otthefacility and appuRenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters). P�at The Improvement Permit shall be valid wlthout explration wit�plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equats no morethan 60 feet,that includes:the specific Ixation of the proposed fadlity and apputtenances,the st�e tor the proposed WasLewater system,and the tocation of water supplies and surtace waters. Plat also means,for subdivision lots approved by tl�e Ixal planning authority and recorcled v�ith the county reglsterof deeds,a copy oithe recarded subdivfsions platthat is accompanied by a site plan that is dravm to scale). The Departrnent and Local Health Departrnent may Impose conditions on the issuanceand may rewke the pertnits tor failure oi the system to satisTy the conditi�s,the rules,or fhis article This pertnit is subject to rewcation if the site plan,plat,o�InLended use changes(NCGS 130A335(�).The person owning or coMrolling the system shall be responsible torassuring compliance with the laws,rules,and permit canditions regarding system Ixation,i�stallation,operation,maintenanc�moniboring, reporting,and repair(.1938(b)). ApplicanULega1 Reps. Signature Required? OYes �NO ApplicanULegal Reps. Signature: Date: � � 'IssUed By: 2�40-Nations,Robert Date of Issue: 1 0 � a 9 � a 0 1 4 Authorized State Agent: �„��=�— — OValid without Expiration? C�'Create CA? OHand Drawing Olmport Drawing **Site PIan/Drawing attached.** Page 2 of 3 . IMPROVEMENTPERMIT . . Davie County Health Department CDP File Number: 161212 - 1 210 Hospital Street P.o.aoXsas County File Number: K5-000-00-0�8 Mocksville Nc z�o2s Date: � � Q Inch Drawina Drawing Type: Improvement Permit Scale: . , QB�ock _ QN/A ft. _ _ _ _. __ _ . _ _ _ ___ _ __ _ _ _ _ _. _ _ _ __ _ _ _ _ _ _ _ _. _ _ . _ __. . _, _ , __ _ ; _ � _ �� _ _ _ _ _ , re— ' Q � , . _ _ �' l _ , � �� _ .c � ` S�� _ _ _ __ ' __ __ .,t,� __ � , �b C � 'V► � __ " . _ _ __ �1 _ 6c'� �, ��.r ' � . � _ a _ � _ . _ _ _ � ' _ _ d ... �� _ _ . _ � _ _ _ � _ __ _ _ _ _ � _ _ __ _ _� _ _ __ ' �-� b ��` � oa� e �C�► _ : C'-� ' : , "''C' a g� � S _ _ _ _ ___ _ _ _ _ _ Page 3 of 3 , . � �� U� - � � �y�- � ' . . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&�1� L Davie County Environmental Health �-• � �''�►�.�,,,,, REC,�i'IVE� P.O.Box 848/210 Hospital Street T�ibS I�U' ' Mocksville,NC 27028 �� Dato: �/��D' ,'� (33�753-6780/Faa(336)753-1680 0001VOd b ' t/ �,�,,.� Appiication For: 0 Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) �Both Type of Application: ❑New System ORepair to Existing System ❑Expansion/Modification of Existing S stem or Facility "'IMPORTAN7*"THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED '•"' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �« - APPLICANT INFORMATION �''� 1 Name to be Billed� �e�s�^'�� Contact Person S�o-f}-�_.�'t, � c� BillingAddress $2cG �Zc��sn.� 1�S' HomePhone � City/State/ZIP �5,��}.�„� ►,,L -i^1'Lq� Business Phone `7 459,•([� a � � � Natne on PermibATC if D�erent than Above •c � MailingAddress9l� S� Mc�:r.S'r City/State/Zip �. ,, N•� '1'2Gt1 � � PROPERTY INFORMATTON *Date House/Facili Corners Fla ed 0--7-1 NOTE: A survey plat or site plan must accompany this application. Included:�Site Plan ❑Plat(to scale) (Permit is valid for 60 months wi site q,lan,no expiration with complete plat.) Owner's Name�.�-� �.�,e��4�cX Phone Number Owner's Address�q\ W� �� City/State/Zi [�O�S��lc N.C'2'1OZ�c Property Address." L✓• � R City M v \.. .c_ LotSize��opo� ZQL Ta�cPIN# 4 o0o(�OD l$ — 'JrZ`l'��u S3�'t"� Subdivision ame(if appiicable) Section/Lot# Directions To Site:��1�� Sw�, ca w.o.� R�S��oo..r. ?�► ' lot- gl c2 cr�s� �"ro -i� `�5 Z- If t6e answer to any of the followiag questions is"yes",supporting docum�e tafion must be attached. Are thcre any�zisting wastewatcr systems oa the site? GYYes ON Does the site contain jurisdictional wetlands? ❑Yes�� Are there any easements or right-of-ways on the site? ❑Y��L1No Is the site subject to approval by another public agency? �'Yes ON Will wastewater other than domestic sewage be generated? ❑Yes o ' IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms � #B�fl�u ms_� Garden Tub/Whirlpool OYes o Basement:[7Yes o Basement Plumbing: �Yes�Clo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Buildin� #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(galions per day) (Attach documentation of similar facility water consumprion) FOODSERVICE ONLY: #Seats Typesystemrequested:�Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Watcr Supply Type:�ounty/City Water ❑New Well ❑Facisting Wcll ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve7 0 Yes � If yes,what type? This is to certify that the information provided on this application is true and coaect to the best of my Imowledge. I understand that any pemilt(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 subautted in this applica6on is fals�ed or changed I hereby grant right of entry to the Authorized` Representarive of the Davie County Health Department to conduct necessary inspections to detemvne compliance with applicable and rules. I t derstand that I am responsibie for the proper idcntification aud labeling of properry lines and comers anJ u}g and n � staking house/facility loc ion,proposed well location and the location of any other ameniNes. �� 5"� Site Revisit Charge Property o� r's or owner's le al representative signature Date(s): �b.V.� Client Notification Datc: Date EHS: Sign given ❑Yes ONo Account# � � �� Rcvised 11/06 Invoice# `��1 "" �` � � �. � _ __ _ ___ _ . _ __ _ � �,_` _ �O 11 _ _ __.. . ��b� _ _ . _ _ _. _ - - - _.'_ . _ _. � _ _ -. '`�-- _ . __ _ _ .-- - os _ / .e1-ol,0_ . 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All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina, I its agents,consultants,contractors or empfoyees 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. I ( . ; � � ' . � Y i � ,r • DAVIE COUNTY HEALTH DEPARTM�NT , � ' ' Environmental Health Section � ' � Soil/Site Evaluation � � : APPLICANT INFORMATION � �ROPERTY INFORMATION j Scott Smith KS-000-00-078 ' ' 336 782-1647 Property: Will Boone Rd ,, 2 Acres � ; _ I i ! � , t � � �g -- � �-- ; ; � � Water Supply: On- ite Well Community ; Public ,/"� ; Evaluation By: Au �r Borin Pit Cut g� g � i , FACTORS � 1 2 3 � � 5 6 7 � Landsca e position ( ( ; � Slope % � ; j � HORIZON I DEPTH j ,� — p � ! ( � Texture grou ; G L, � Consistence � � S I Structure i � (� 1 I ; Mineralo ; � HORIZON II DEPTH ( 3 _ ' � Texture rou ; G S G C ' Consistence /y I � Structure ` �`'j ! , Mineralo '' I HORIZON III DEPTH ! j , Texture rou ' ; Consistence � � ° ; � Structure ' ! , Mineralo t ! ; HORIZON IV DEPTH ?, r Texture rou ; � Consistence I � ; Structure � k 1 Mineralo I � + SOIL V�IETNESS { t 1 RESTRICTNE HORIZON I SAPROLITE i 1 '� ' CLASSIFICATION i i LONG-TERM ACCEPTANCE RATE U. � 1 � I SITE CLASSIFICATION: �,�.VALUATI�N BY: � ; i f �( + � LONG-TERM ACCEPTANCE RATE: (/'�� OTHER(S)PRESENT:� ,� � ' � i REMARKS: ; �, i, LEGEND - �� i i,��e PositiQn '. . � ' R-Ridge S -Shoulder i L-Linear slope FS-Foot slope N-Nose slope', � CC-Concave slope CV-�onvex 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 � ' ! � CON�+IST�,NC , j ` M�i�� - i � �� VFR-Very friable FR-F�iable FI-Firm VFT-Very firm EFI-Extremely firm � • , � ; � i � NS -Non sticky SS-Slighily sticky S -Sticky VS -Very Sticky � ! ' ' NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic � � 4 � � � Structure i � SC -Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky! , SBK-Subangular blocky �L-Platy PR-Prismatic � ; Mineralogv ( 1:1,2:1,Mixed � ' LYotes ` Horizon depth-In inches � . ; � Depth of fill -In inches i ; � 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 Classitication-S(suitable),PS(provisionally suitable),U(unsuitable) ; '�. : rmAn r -"- `-�-- -----`----L-`- --��---rc.n { ^^--- ^-•^- •- .