701 Williams Rd .
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, • ' DAVIE COUNTY ENVIRONMENTAL HEALTH
� . ' P.O. Box 848/210 Hos ital Sh�eet ��C�1��
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Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT �
Account #: 990002312 Tax PIN/EH#: 5768-67-6490
Billed To: Wendy Workman Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028 ,
Proposed Facility: Residence - Property Size: 26 acres
ATC Number: 4813
**NOTE**The issuance of this Opera;i�n Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"
but shall inNO WAY be taken as a uarantee that the system will function satisfactorily for an given period of
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System Type: �� S.T.Manufacturer . ��/ Tank Date� Tank Size
Pump Tank Size (
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System Installed By: � E.H. Specialist: Date:��
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. ' . � DAVIE COLTNTY ENVIRONMENTAL HEALTH , 3+D�
` P.O. Box 8487210 Hospitai Street �I �
Mocksville,NC 27028 �
(336)751-8760 Fax#(336)751-=8786
AUTHORIZATION FOR WASTEWATER SYSTENI CONSTRUCTION
Account #: 990002312 Tax PIN/EH #: 5768-67-6490
Billed To: Wendy Workman . Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028
Proposed Facility: Residence Property Size: 26 acres
ATC Number: 4813
**NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
i �
Residential Specifications: #Bedrooms� #Bathroomsf � #People � BasementB'Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
LotSize �G�.�� Type of Water Supply: OCounty/City Ca'Well OCommunity Well
s
System Specifications: Design Wastewater Flow(GPD)��-� Tank Size f�GAL.Pump Tank�GAL.
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Trench Width�(s Max.Trench Depth ,3� Rock Depth�_ Linear Ft. �3;:�
� t���ir��`�h r �;��-���ti�`�"t�
Site Modifications/Conditions/Other; ' ���� '��� a ��'� �G���' "' � r ��
-�r�c +��-,,�--��i!1.r`h u �
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Contact t e Davie County Envir nmental Health Section for final inspection of this system between
8:30-9:30a.m. on e da of installation. Tele hone# 336 751-8760.
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",-� �iivu-onme al ealth Specialist Date:�- — � ���
n�J.�.�(�,)+P�7�ff'1/�Az,;cr�rll � � � �
, '�' � DAVIE COTJNTY ENVIRONMENTAL HEALTH
• � P.O. Box�48/210 Hospita.l Street
' ' Mocksville,NC 27028
(336)751-8760 Fax#(336)751;8786
AUTHORIZATION FOR WASTE`VATER SYSTEM CONSTRUCTION
rlccount #: 990002312 Tax PIN/EH #: 5768-67-6490
Billed:To: Wendy Workman . Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028 '
Proposed Facility: Residence Property Size: 26 acres
ATC Number: 4813 Site Type: L�11vew ❑Repair ❑Expansion
**NOTE**This Authorizatiori to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms � #Bathrooms��S #People�Basement❑ Basement plumbing�
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size l�- Ce C�-e 5 Type of Water Supply: ❑County/City C�Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) 3�2 U Tank Size�GAL.Pump Tank�GAL.
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Trench Width 3� Max.Trench Depth 3� Rock Depth � a Linear Ft. (J
Site Modifications/Conditions/Other: r,` �t.^�tnd in �5t, ��^_�� �rE'•,.:+.�.i?s:�l
F:Cc��3t�d `��v:;t�:+;�s '��.��v :±�c� �`�. i.�:3�
Contact the Davie County Environmental Health Section for final inspection of this system between �
:30–9:30a.m. on the da of installation. Tele hone# 336 751-8760. '"�
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Envuonmental Health Specialist Date: L '— ���
. DCHD 11/06(Revised) �
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' � ' ' � , DAVIE COLTNTY ENVIRONMENTAL HEALTH �1a�.,��4' ���
. • P.O.Box 8481210 Hospital Street (�
Mocksville,NC 27028 n;��`Q,��Q �
(336)751-8760 Fax#(336)751--8786 11� �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990002312 Tax PIN/EH #: 5768-67-6490
Billed To: Wendy Workman Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028
Proposed Facility: Residence Property Size: 26 acres
ATC Number: 4813
*�NOTE**This Anthorization to Constnict(ATC)MiJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S:Chapter 130A '
Wastewater Systems, Section.1900 Sewage Treatm.ent and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
i
Residential Specifications: #Bedrooms� #Bathrooms�#People � Basement asement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size �0.�-'� Type of Water Supply: ❑County/City ell ❑Community Well
System Specifications: Design Wastewater Flow(GPD)3(,C.(� Tank Size�dpOGAL.Pump Tank�GAL.
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Trench Width� Max.Trench Depth ,3� Rock De th� Linear Ft. �3�
,�� �staied in 151� NCl�C '�BA.�G us�u�
SiteModifications/Conditions/Other. S��E�� o3,,�g-�,,;,- +, r:,sJ
Contact t e Davie County Envir nmental Health Section for final inspection of this system between
8:30—9:30a.m.on e da of installation. Tele hone# 336 751-8760.
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"�-�"j ERvironme al ealth Specialist : :��. , Date: �- — � —�j
�Y.���,r�r�tl'7/�.,;�Prll
' � .APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE �'�,
� Davie Couniy Environmental Health (�j,
P.O.Box 848/210 Hospital Street �
Mocksville,NC 27028 D , � Z��a
_ (336)751-8760/Fax(336)751-8786 ��GB
Application For: p Site Evaluation/Improvement Permit ❑ Authorization To Construct(A C) Rt�k�r,���`y��
Type ofApplication: I�'I�Tew System ❑Repair to Existing System ❑Expansion/Modification o xisting yste v i ity
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED LTNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed �J�tC�\��I wcJ r��d`(�Cr!1 Contact Person ��fi��y .
Billing Address�7 �� �l;\�`,c�m� `'�`Xa_<<� Home Phone ��(��,�� �)�/Q- �(�, 3��
City/State/ZIP �'����p,�1 L e-� N L ���OQ(v Business Phone 70z/ . (,� �-(r,/ � f
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pernut is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name\1�,�r� U-`�ca<�C�-r�� r Phone Number�"�([3 p y p`i-3�J`��
Owner'sAddress C� ;1\.rxm�� City/State/Zipa��VGrlc�, ;UC �7COro
Property Address""" '.a fi � ��� City
Lot Size�, c•,L_ Tax PIN#5°710�(,��p �p
Subdivision Name(if applicable) Section/Lot# � ��
Directions To Site: ���� -�u �. ;�ti � �;c: � 'C �:n � � � �u '��\\�lm ct. �
�'�5� c\s.v�. e�,-� e��- ���'�e� �:�� (' ; ��... �. � 1
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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 QNo
Does the site contain jurisdictional wetlands? ❑Yes �No
Are there any easements or right-of-ways on the site? ❑Yes BNo
Is the site subject to approval by another public agency? ❑Yes �'No
Will wastewater.other than domestic sewage be generated? ❑Yes 0No
IF RESIDENCE FILL OUT THE BOX BELOW
#People �� #Bedrooms �_ #Bathrooms �� Garden Tub/Whirlpool ❑Yes C�1�To
Basement: Gd'Z'es ❑No Basement Plumbing: ❑Yes C�1No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats •
Typesystemrequested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water f�New Well ❑Existing Well O Community Weli
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes � 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 pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Deparhnent to conduct necessary inspections to determine compliance with applicable laws and rules.
1 understand that I am responsible for the proper identif cation and labeling of property lines and corners and locating and flagging
or s:aking the house/facility loca ion,proposed well location and the location of any other amenities.
� �. `� �� � � �
'� � i Site Revisit Charge
Property own�r s or owner's legal representative signature
�,"�`Q.�1'ULt� LC, I�Q.C� �f. '.�'-Q,Vi�S Date(s): t
_ (, � j Client Notification Date: e
Date '�%V'G,�, �jC,SA-{'hQ,tt,�" �C!�`�"ic-� Gi� EHS:
1,e ��5 ��o• f�;l l C��� _
Sign given ❑Yes ❑No ���- �b�.S.� Li,{�1C� �(�r� Accou t# � Z
Revised 11/06 1 ,��� y�I� ' Invo�# _�` " _`(✓
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• � DAVIE COUNTY HEALTH DEPARTMENT
� • • ' Environmental Health Section /
'`� � • . � , P.O.Boa 848/Z10 Hospital Street c`� �-
'. ' Mocksville,NC 27028 � `-��
(336)751-87G0 ��
IMPROVEMENT/OPERATION PERMIT ��.
Account #: 990002312 Tax PIN/EH#: 5768-67-6490
Billed To: Wendy & Dale Workman Subdivision Info: ,Z�Jo �,
Reference Name: Location/Address: Willliams Rd-2�
Proposed Facility: Residence Property Size: 26 acres
**NU'1'��'�ii�giriproveirient/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An ALJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type 1"� #People � #Bedrooms S� #Baths'��
Dishwasher:� Garbage Disposal: ❑ Washing Macfiine:� Basement w/Plumbing: ❑ BasementlNo Plumbingie'
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply� Design Wastewater Flow(GPD) .�� Site: New� Repair❑
System Specifications: Tank Size,��GAL. Pump Tank GAL. Trench Width(�(Rock Depth��Linear Ff,.�l��`
Other:
Required Site Modifications/Conditions:
I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G "BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depariment for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: i Date: ��'�� ��
DCHD OS/99(Revised)
. '•` � , • . � ' DAVIE COUNTY HEALTH DEPARTMENT
. �• � Environmental Health Section
P.O.Bog 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-87G0 �
Account #: 990002312 Tax PIN/EH#: 5768-67-6490
Billed To: Wendy & Dale Workman Subdivision Info:
Reference Name: Location/Address: Willliams Rd-270�c
Proposed Facility: Residence Pro ert Size: 26 acres
ATC Number: 3173
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,S ion.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWAT N�UCTION IS VALID FO PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: �j ^� `'��
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit
has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD OS/99(Revised)
` ,��,, ' _ . • ' �ir�uc�ano�u Fos s��Evaivanont/iMPRov�tFxr P�iwT&a D I� �
. � '� � . Davte County Health Department �5 � �
. • Environmenla/Hea/tfi Sectlon � �'
P.O, Box @48/210 Hoapital 9treet
Moeksvills, NC 27028 U��r �
(336}751-8760 � � �";�2 `
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***ZI�ORTANT**� THIS APPLICATION CANt70T BE PROC�78BED UNLE3$ AIt_I, THE jJ�,
INSORbATI�N IB PROVIDED. RePer to the IN8'OR2�►TION $ULLETIlI foriiIatzudt'�'pn ��HF,qj
1. Name to ba Billctd U�)���`� ���� �r���� Ceniaat Rerson �-n`�� �C �
Hnilinq �lddrooa y� 1V1 NC. �"l�� , l'1�� ��arv\ soma ptwne �J�i - ���.. �3�
City/3t3t8/ZIP f'iO��P�L�� I��. ����Ln Suainess Photfe ��/'r �� p` �i'���
2. Nams on PeTmit/ATC if Ditferont thsaa Abavo �
Hailinq Addresa City/9tate/zip
3, Application For: "QCSite Evaluation p Improvement Permit/ATC D Hoth
a. syetam ao 9e=vice: �House Cl Niobile Home n Husinese ❑ Iadustry ❑ Other
5. If Reaidonca: A �@ople � _ � Bedrooms � r Hathxooms J — 1
�'Diahxasher I,j/Gazbaqa Mapo�a2 41'Waahinq 2lachine U Haaement/Plumblriq (•t�Haaom�ant/Jio Pltwbinq
6. IL Busineas/Indct�tsY/pt2+er: SpociPy type � PeeDjo � 3inks
N Comm�odes t 6howorr � Vrinala A Watas Coolers
IF FOODSLrRVICE: 1{ SBats �stimated Wates VaaQe (qallons per day)
7. Type aP water supply: fl County/City 6�We11 ❑ Coammuaity
o. Do yau anticipatt udd➢tioos or ezpansioas of the facillty thls system is intended to sen�e? D 1'es C�'Ffo
If yes,wliat type?
"**IMPORTANT*'�}CLIF;NTS MUST COMPLETETH� REQUIRED PROPERTY lNFORMAT[ON REQUESTED
BELOW. Either e PLAT or SI7'E PLAN MUST BESUBMl7TED by the client with THIS APPL[CATION.
��
Property Dimensions: � �`��S WRITE DiRECTIONS(from Mocksv;lle)to PROPERTY:
TaaOflice PiN: ��--� L�� �~I b 4 `1l� C�� �as�. �•c� c� `.._e.�-�
Property Address. Road Name VJ\\.g(y�� �cr c�. �C� �O C C���0.�'Ze c' '�c'�,o.T_
City/Zlp��� a-�ooco �.��� ��.�.��- ����
It(a a Subdivision provide Inf�rntatlon,as toliotivs: ���.a�� �c��(�,,�70.S5
1Vame: l�c� � e e.e.� cnaC� O:� c', Y"���d�_.�..�i� �n
��a', 0.c roSS
Sectiun: Block: l.�nt: Date Property Fla�ed; �—�� ��o� ��ocv� .1D(�
�:\\.0.mS
This is tu ccrtify that the informadon pravided is correct to the best of my knoH•ledgc. I understand thst uny permit(s)
issuetl hereafter ure subject to suspension or revocation,if the sile plans or intended use change,or if the infarmation ��� .
submltted in this application is falsiiied or changed 1,atso,undtrsland tha!1 am rtsponslble jor alI cha�ges lncurrert jrvnr
Ihis applJcarlon. i,hereby,gtve consent to the Authorized Representative of fhe Davic County Hesith Department
to enter upon above described property located In Davie Connty and owned by V�Q_.c�.� �`�O���a�
to condnct sll testing procedures as nccessary to determine thc sfte saitability.
DATC�—�b— �o� SIC NATURE � i�'"—
TNIS AREA MAY BE USEU FOR DRAWINC YUUR SITE PL�4N(Include all o e follo�ving: Exisiing and proposed
property lines snd dtrnenstons, structures, setbacks, and septic locetions). _
Site Revisit Ch�rge
Date(s}:
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��"� i �1 Clicnt Noiification Datc.
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� ' ' '� " - � � , Environmental Health Section
- ' Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002312 Tax PIN/EH#: 5768-67-6490
Billed To: Wendy & Dale Workman Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028
Proposed Facility: Residence Property Size: 26 acres Date Evaluated: � '/.� ��
t�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring �Pit Cut
FACTORS 1 2 3 ` � 5 6 7
Landsca e osition ,� L
Slo e%
HORIZON I DEPTH � (�—3"2_
Texture rou C: L
Consistence r �.
Structure kY� IG D l�
Mineralo .,r ,�
HORIZON II DEPTH ,� % `' ?l," — �
Texture rou C L
Consistence ✓ ►�J ,
Structure ('r �,'
Mineralo �' �� = /'
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence �
Structure c+� b
Mineralo �� l
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE '� ''
CLASSIFICATION S 5
LONG-TERM ACCEPTANCE RATE r
SITE CLASSIFICATION: EVALUATION BY: �G�,-
>-"
LONG-TERM ACCEPTANCE RATE: --C OTHER(S)PRESENT: ��
REMARKS:
� -I 5��'P'
LEGEND — D
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 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
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
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 blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloav
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 with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-gaUday/ft2
DCHD OS/99(Revisejti)
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02%14/2008 01:58 7046383178 ELAINE WILLIAMS PAGE 01%01
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_ Davie County Environmental Health
P.O.Boz 848/210 Hospital Street d r r.Q,q����
Mocksville,NC 27028
(336)751-8760/Fax(33�751-878G �"( �'n�
WELL PERMIT `����g�
Account #: 990002312 � Tax PIN/EH #: 5768-67-6490-W
Billed To: Wendy Workman Subdivision Info:
Reference Name: , Location/Address: 701 Williams Road-27006
Proposed Facility: Residence/Well Property Size: 26.993 Acres
ATC Number: 0010
Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this
well will produce water of any particular quantity or quality or for any amount of time. This permit is valid
for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there
has been a material change in any fact/circumstances upon which this permit was issued.
Permit Type: New Repair ❑ Abandonment ❑
-�.
C Proposed Well Location Diagram Certificate of Completion Diagram
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��� c_�x 1� ('�l-r� Certification#: � 2� 3�/
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Grout Inspected: j� �^�� �l y �g
Well Head Inspected: � — I�—' � �
GPS Coor ' ates: 1� '��'��-�-?S�80 a�. I6
EHS: � ��� ate: �"�� E Date: �"'lG-�
W.P.7-08
Aug 19 08 � {�n �D 'e ounty Environmenta 3367518786 p.2
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� ti S� APP ICATION FOR PRTVATE WELL PERMIT
t,�\� ``jl�o J;�Lj� DavP.O.Boz 848/2 0�Iospita7 St�reet th
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eP Mocksville,NC 27028
, (336)751-8760/Fax(336}751-878b
. ***INIPORTAN?'�**
THIS e,PPLICATION CANNOT BE PROCESSED UNL�ESS ALL OF THE REQiJIRED INFORMATION IS PROVIDED.
APPLICANT IlVFOiZMATION
' Name to be Billed �i�. c��P Contact Person ���y U,Oc''�rrw�rl
Billing Address 7b 1 u•�.\ :o,mS Home Phone 33(0-`ly O-3(r�3�J
: Ci�Lv,'State/?Ii' ��vac�ce ,�JC- c�"7c�(� FsusinessPhone '�o�/- (��g- (�1\\
Name on Permit if Di�erent than Above
Maili�ng�.ddress CitylState/Zip
PROPERTY INFORMA'I'�ON *Date House/Facility Corners Fla ed
i NOTE: A sur�-ey-plat or site plan must accompany this application Included: = Site Plan OPlat(to scale) �
� 4wner's Name � U�:\\:Q � ,r'r�a�l Phone Number 3�-�1�{D�3(„3y ' ,
i Qwncr's Address`7 U :\\°o.n�s oo. CitylStatelZip��»,neTC� �'lUbCo .;
� Property Address �b\ VJ�\.ArnS 'u.oa CiLy���r��e i
� Lot S�e �co,qa� �C Tax P1N� 5���s'c�`� (aUq O
� Subdivision Nazne(if applicable) Sectiom/I.ot�#
DirectionsToSite: (d�1 -4o Cor�•�-zec Roae\ �on\Q�=�r� �.a� �,,,.c� �`.�`n�- o� �o
\}J�\�. �c� r� \rz b l�'�\.arn
DEv�I,OPMENT INFORMATION
Permit Type: New Well ✓ Well Repair Well Abandonment Other(specify)
Facility Type: Residential ✓ Food Service Chwch Comrnercial �ther
Are Tliere Any Septic Systems Current�y On Thc Site? YES 1�0_�
Do You Intend To Install A New Septic System On This Site?YES_� NO
TERI�iS AND CONDTTIONS:
T�is spp!i�tion m�,�M bP accempanied.�y a plai or site�!an.�f c}�e nropem�that inclLdes the exi�o.n�pTvpx�g�pert;-linw
with dimensions,the specific location of the facility and any existing or future appurtenances,the location of an;-cxisting septic
system,sewer lines,a°acer lit�es,any existiug water supp3ies and airy surface waters. The applicant is respomsible for identi�'ying
and nnarking tbe groperty Iines and corners. The applicant is responsible for making the site acc�essible.
By signing this application,the applicant signifies that they understand rhe terms and conditions and that they give permissiori
for Davie Connty Emironmenta]Health representatir-es t�perform ne;.essary field evaluations and procedures deemed necessary
to deterrnirze the best location for a v�•ell.
G�� 7-�/-0 B`
��� Date
Site Revisit Charge
Date(s):
CLient Notification Date:
EHS: �
7/1/08 � Account# �7j�7i
Invoice�t /„/,/„ /
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' ' �-�= DAVIE COUI�TY ENVIRONMENTAL HF.ALTH
• P.O. Box 848/210 Hospital Sh-eet
Mocksville, NC 27028
(336)751-8760 Fax# (336)751.-8786
AUTI-IOI2IZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION
Account #: 990002312 Tax PIN/EH#: 5768-67-6490
Billed:To: Wendy Workman . Subdivision Info:
Reference Name: Location/Address: Willliams Rd-27028 �
Proposed Facility: Residence Property Size: 26 acres
ATC Number: 4813 Site Type: �w ❑Repair ❑Expansion
**NOTE** This Authorization to Consmict(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pernut(s),(in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section.1900 Sewage Treahnent and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,pl�t
or the intended use change.
Residential Specifications: #Bedrooms � #Bathrooms���' #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size �- Gt�Cr�5 Type of Water Supply: ❑County/City GYP/ell ❑Coznmunity Well
System Specifications: Design Wastewater Flow(GPD) �(.2 U Tank Size�GAL. Pump Tank�GAL.
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Trench Width 3 � Max.Trench Depth 3� Rock Depth Linear Ft.
Site Modifications/Conditions/Other: �,:� ;�t�+�� ir� �'�:; i�a^��; �^f',.�.`==i��?t;,a
� e`<CT.�:��nC� �i�fti:;�Y=1elt� �`i%Jf :�':Sl Vt 'll:i:.�
Contact the Davie County Environmental Health Section for final inspection ot this system between '��,
:30—9:30a.m. on the da of installation. Tele hone# 336 751-8760.
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�nvu•onmental Health Specialist ^ Date: L ' ���
DCHD 11/06(Revised) �
. Reports Page 1 of 1
. • �., �
Davie County, NC
��4=�.� �w����l F2eport
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� "VYA(:.`: � � � � �� , `�.1cs Parcel Number. D00000031
rhs n�a, ����p �ior ��� r�vcr.c�y �i' ��� PIN Number: 5768676490 �
� rea' pioperly feuncl trrthin this p ��;, �
�ursdic[�ari, ancJ iv comp�icd from cCount Number: 000082517540
F'cr_ordeii de��d�;, ����Ls, ard ot't�er nublic WORKMAN WENDY
� . -.
!eccids 8nd d<'�t.8. User,of khis mr�p arc� � ,� Listed Owner#1: y�IILLIAMS
hereby notifiecl that the aforementioned �� Listed Owner#2:
pubiic primary infarmat;on sources shcu€�1 Mailin Address 1: 701 WILLIAMS ROAD
be consuited for verification of the
information contained er this map. l'he Mailin Address 2:
County and ma�ping compony assurne no City: DVANCE
legai rc�spansibility for the informaticr� �State: IIN� I
r.ontained cn this map. I
Zi Code: 27006
Notes: Le al Descri tion: 26.993 AC WILLIAMS RD I
crea e: 26.20423000 '
Deed Date: 020010917
Deed Book and Pa e: 003860934
Plat Book:
Plat Pa e:
8uildin Value: 0
Outbuilding and Extra Feature p
alue:
Land Value: 1881Z0
otal Market Value: 188120
otal Assessed Value: 188120
i
http://maps.co.davie.nc.us/GoMaps/reports/report.cfm?CFID=36158&CFTOKEN=82091578 9/4/2008
, • DAVIE COUNTY , :. , . ,
� ''� WELL CERTIFICATE OF COMPLETION CHECKLIST � ' - . �. '
Applicant: File #:
Site Address: Subdivision: Lot:
----�
Permit Type: New Well Well Repair Well Abandonment Other
Facility Type: Residential Food Service Church Commercial Other
Initial lnspection
/
Were Setbacks Maintained? Yes No What is the Grout Depth? 25 ft.
If No, Explain: What is the Grout Thickness? 2 in.
What is the Type of Well? _�,_,/�.� � Was a Well Screen Installed?
What is the Casing Type? P U � Type of Drilling Fluids Used: �i✓r�G���
What is the Casing Depth? (�3 ft. Well Grout Inspection bate: l� 8-va
What is the Well Diameter? r in. . . - GPS Coordinates 35 5`�!17� w�627 r4
What is the Well Depth? �� ft. EHS ID: � I '� v
Well Head Inspection
Is There an Access Port? Is There a Vent?
Is There a 4" Pad? Is There a Hose Bibb? �,r�
,
What is the Casing Height? Is There any Grout Settlement?
What is the Static Water Level? 3� ft. What is the Yield?�� GPM �,'
Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? �GL�
Contractor Name: !Ja t Pump Installer Name: �,�� ��� �
Contractor Certification #: �-3��l Date Installed: t/� --�j 9
Depth of Well: / Depth of Pump Intake: / �O
�
Casing Depth and Inside Diameter��3 � Pump Horsepower Rating: �i
Screened Intervals: i Opening for Piping & Wiring >_12": �_
Packing Intervals (Sand Packed Wells): �
Yield in GPM or GPM/ft.-dd: `a-� aa
Static Water Level and Date Measured: �c,���v�'Date Well Completed: � 6 � �
Well Head Inspection Date: "' 0 —C� EHS ID: 'a. � �
Construction Completed Date: � `�� ��� Contractor Reports Received Date:
Sample Date: Results Mailed Date:
Certificate of Completion D - (J ' D �J
Authorized Agent: i�i G�