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330 Woltz Ln OPERATION PERMIT or ice se n v � ,.•g"n, Davie County Health Department tCDP Fiie Number 139894-1 � �� a. 210 Hospital Street � � P.O. Box 848 County ID Number: �`°-�' Mocksville NC 27028 Evaluated For. NEW Phone: 336-753-8780 Fax: 336-753-9680 ' Township: Appiicant: Wishon & Carter Builders Property owner: Matthew and Melinda Montsingei . ... , „ „ . Address: PO Box 1719 Address: PO Box 2033 City: Yadkinville ��tv� Advance State2ip: NC 27055 State2ip: NC 27006 Phone#: t��)4fi9-2162 Phone#: Pro ert Location & Site Information ss/Road . 3�Q Subdivision: Phase: Lot: g Woltz Lane v NC 27006 Directions s�ructure: SINGI.E FAMII.Y Hwy 64 East left on Hwy 801, got to Peoples Creek Rd. on right beside Elbaville Ch. the right on Burton #of Bedrooms: 3 Rd. Left on Waltz Lane Lot off to right. #of Peaple: 'Water Supply: NEw wE�� 'IP Issued by: 2t4o-Nauons,Robert `System ClassificationlDescription: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR d80 GPD OR LESS) tCA issued by: 2140-Nations,Robert Saprolite System? Q Yes Q No Design Flpw: 3 6 �I = GRAVIN-SERtAL Pump Required7 Distribution Type: QYes �No Soil Applicatian Rate: � a � *Pre-Treatment: Drain field Nitri6cation Field 1 4 4 0 Sq• �• "SystBm Type: �NFILTRATORQUICK4STANDARD No. Drain l.ines a Installer: Lennon-Triangls BaCkhoe Total Trench LengEh: 3 6 0 �. Certificaban�: �.�n� �p$��g: _ g �Inches O.C. , Feet O.C. �EN S: 2325-Mitchell,Brittany Trench Width: 3 Inches - , . �Feet Date: � a / 1 1 1 a 0 1 4 . Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover. Approv�M SEatus Inches Max�mum�Trencr� �eptn: a g incnes � C� 'Ap�ro�retl�l �Disappro�red Maximum Soit Cover: Inches CDP File Number ��9894 ' � County ID Number: ' • Se tic Tank Manufacturer. Shoaf Lat. �* � STB: s'rB�so Long: , G allons: �ppp I�StaG2f: Lennpn-Triangle Backhoe Dat�: g � � g $ � a � 1 � Certificatian#: 'EH S: 2a25-Mitchet�,erittany 'Filter Brand: Date: . 1 a I i i / a � i 4 ST Marker: ❑ Yes ❑ No - - - � - - � � - - Approval Status Reinforced Tank: ❑ Yes O Na 'p Approvetl p Dis�pproved 1 Piecae Tank: ❑ Ye5 ❑ No Pump Tank ManufBCturer. Inst�ller': �-�nnon-Triangte Backhoe PT: Certi�cation#: Gallons: 'EHS: �ate: / 1 Date: � � F�iserSeated ❑ Yes ❑ Na RiserHeight: (� Y!�S ❑ NO (Min.6 in.) Approval Status'" ' einforced Tank: ❑ YeS O No O Approved❑ Disapproved 1 Piece 1'ank: ❑ Yes ❑ No Supply Line Pipe Size: 4 inch �iameter Installer: Pipe length: 6 a feet Certi6cation#: ��H�: 2325-Mitchell,Brittany *Schedule: 4p Pressure Rated ❑ YeS ❑ No Date: 1 a ,� 1 1 � a 0 1 4 Approved fit6ngs p Yes ❑ No Approval Status � Approved❑ Disapproved Pump Type: Instalier: Dosing Volume: - �a� Ceriification#: Draw Down: Inches *EHS: 'Chain: f l Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment valve ❑ Yes ❑ N o Check valve ❑ YeS ❑ No Approval Status ' Pvc unions ❑ Yes ❑ No D Approved❑ Disappraved Vent Hole ❑ Yes ❑ No Anti-sipho�n Hole ❑ Yes ❑ NO • CDP�File Number �39894 - 1 County ID Number: , Electric E uI ment NEMA 4X Box or Equivalent ❑ Yes 0 No Installer: Box 12 inches Above Grade ❑ Ye5 ❑ NO Certification#: Box Adj.To Pump 7ank ❑ Y8S ❑ NO Conduit Seated O Ye� ❑ No *�HS: Pump Manually Operable ❑ Yes ❑ No =Activation Method: Date: � J , Approval SE�tus Aiarm Audibie ❑ Yes ❑ NO ❑ Approvetl❑ Disapproved Alarm Visibla ❑ Yes ❑ No 2325-MitclieU,Brittany 'Operation Permit completed by: � i a / i i 1 a s i 4 Authorized State Agent: ��7�"- Date of Issue: This system has be�n installed in compliancg with applicable NC General Statutes;Article��, Chapter 930A, Rulss for Sewage Treatment and Disposal, 15A NCAC 18A .1900 et Seq„and aU cnnditions of the Improvement Permit and Construt�ion Authorization.This property is served by a�F i�A. Sewage SeptlC SyStem. � Rule .1961 requires that a Type ��A• _ septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A �� Management Entity: OWNER � _ _ Minimum System InspectionJMaintenance FrequencyByCertified Operator: wA Reparting Frequency By Certifisd Operator: wA__� Rule .1961 requires that a Type IV and V septic systems designed for a homeJbusiness owner must maintain a valid contract with a public management entitywith a certi�ied operatoror a private certified operator forthe life ofthe septic system. Rule .1961 requires thak Type UI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic sy5tem. 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. 7he contract shall require specific requirements far mainte�ance and op�ration,respon$ibilities of tFre 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 pertormance of the system. It sh�ll also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. �Hand Drawing Olmport Drawing ;��. *�Site PIanlDrawing attached.�* OPERATION PERMIT 139894 - 1 � Davis County Heaith Department CDP File Number: 210 Hospital Street � P.o.aox sas County File Number: ' MoCksville NC 27028 Date: 1 a / 1 1 / a 0 1 4 Q inch DrawinQ Drawing Type: Operation Permit Scale: . . . �N�A k = .ft. ______ __ � __.— ______ � — , i f ' � � I .._._!____ _____ _____I____._� __I._---- �._ , �w�___�_.___� _.__. ! _1----- _� ._------ �___ , ____ __�_..�_...�._,___� r_��_�_��_ �� .�(��______� _..�. _-___�_'-_�.� �._�. _ .�..� � � ; � 3 ' � _ � � _._---- .------- _____- ----- __. _�_.--.—.--_._._. _._ _—_ _.�---- -----.---.�_-- _-----�--_...._ ----------�.--..-- ---.--.a— ---- ---------- -----._ _----�------.--.---- —l_.._..--- , � �� . ...... ....... .. .. ....... 9 .......� ..�. � .��___._�°�_. ...._.�_� --- . �__--_-- .�.... ....� �.....__ _____.�.: ...... _ . .... ... _.�;. ._ �_ ..I -- -- ...---. _.._.._._._�. _� _- �_--......� ._._.�_ _._.�....__._. � � � � r..�.._._.....� �__ _'-____� __.. _..._._.._ � � i � � � � _ __._� I_e � �_��.._ _.�.��_�!� �__�_ ��'�,_:�. ____.�___.�� .� � � I i � � I I _ I � �" i _ � � ' —.�; .�.�..I� I �. �... �____� �. �__� _�. . . _�._ _ ..� .._� � �_ � � �ry _'______� _?__.— ___��__ �__._ __�______�__�� _____I __.__ ___. , � ..._... I I I I_�____�� I � � �_ �____ �! � • 1 �- - - - _____.� _ _1_ }..._._____. � ;��_____�.� .._____ __��._ —�_�_ � �__._�_ !_a��_m _�� _� �__ _.!_____i �—�--_ �—___._�_,___ __ �____ � I � 1 S� � � � ' 2�ud� ' ! t � �_�_ _� �_ _ ; _ _,_,� -: , ; i _ . . �S��l � � C�. ._I_._ � � � I�'� I __�__ � �. �. ��.. t ..__� � .__.__ � � . __ _.�. _.._� . . � __ j ...r,�. N�5`� ..� �. � � � ��, _.._ � ._._.. ; � � ____ ______ _ ___�_�.____! _._._._ ��_;_____; �,_.!:_ . l. ..__.�.t ... � !_ s .__�___._!_._..___._ �___ : __.__�__ _..� a ___ _ a ._. _ � � ,_ _ � � ___ � ,_ _ � � � � � � � c} �� _.�. _._...�.�. _.r _ , I ! I� � i � C �__ _ � ' ; � � ,._ �__��.. � _�.. _ ...,�;_ ..__ � � ��_______.�...�.�..�� ._� �_�_._.�_��_ �_____..� - i - �._._.r._. ___ �_�___�__��=%��_�� .1� � �_ �_�_,__;__�_ � �......_ ____I__��_�I I� ��._�____I�__._� � . � �D ��_�___. __:�_ ��. ��:_.___. .....I .____��—__ _______�______�____�_ ___..�:....� �.___ _._____�____..�...._ ��.__.._.__ ..__.....� .» �. ...__ ._...��___�..._. � ___.__ . .._ ; ....._. ; � � � � �i � ______ .___�_. ___.I____..�_______ . ____I.____C_ .�________. __�___�.._�______IT___�______. � � __ _�._---- . ___. � ___ ___ ______ x �� ii � , '�. ...._._......., _._._...__...... . .......... . ..........._�€._._ . ......._ '»-"'--_.a..... ......... _.___......�,.._T._......_'_._ '�.,._._._._..,.._._.._____�._......______�..__""_"__.•_w_'"__ _____---'. t... . �`.......,...._.. I � � I I I � C � � A_ _ � � � — �_ � ' ' I I � � � � � I � � ' � ,� ____I � ��►__i� __ �:�� _ _ � � � � C_ �� i� � �� _ __� ��' ; �ti � ; b�—- � 4..�. � �,`- _� _ 'T��__ I �� _.._...�� __..a' _ ,�l � i � I� � � I ; I I ___ � mm�o _ _ II I � . � � � -- ..., -� " ' ' ' ' ,{, i I � ` t -- — ; --- - ' � ��1 C�'��►bo�S QY�� , � � _...---._�._.,._....._�__-----�---__ �__._-' _---!_._.......!-�_,._-�-------, __._.i,m.__�____.�_._.___.._.__...!__..__.!..._......� .._..�_�._......__�_.�.------�_....____�.__. : ._.. � � � ' ' AUTHORIZATION 'CDP File Number 139894 -1 ��°� Davie County Health Department County�D Number ��' � r-�. �, ..�- r� 210 Hospital Street Evaluated For. ' NEW `.,��w; P.O. Box 848 Township: � Mocksvilie NC 27028 PERMIT VALID UNTI�: Phane: 336-753-6780 Fax: 336-753=1680 0 7 � 3 0 � a 0 1 9 Applicant: Wishon 8�Ca�ter Suilders Inc/Mark Property Owner. Matthew and Milanda Montsinger Cotbert Address: PO Box 1719 Address: PO Box 2033 Cdy: Yadkinville City: Advance . State2ip: NC 27055 State2ip: NC 27006 Phone#: {336)469-2162 Phone�: Property �ocation 8� Site informatton Address/Road #: Subdivision: Phase: Lot: 6 Woltz Lane Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East left on Hwy 801, got to Peoples Creek Rd. on right beside Eibaviile Ch. the right on Burton Rd. Left #oi Bedrooms: 3 an Waltz Lane Lat off to right. #of Peop{e: "Water Supply: NEw wE�L SYstem Specifications Minimum Trench Depth: a 4 Site Classification: Ps Shaitow Placemenc Inches Minimum Soil Cover. 1 � Saprolite Sysfem� QYss QNo Inches Design Flow: 3 � � Maximum Trench Depth: a $ Inches Soil Application Rate: � . a 5 Maxirnum Soit Cover. � 6 Inches "System ClassificationfDescription: "DistributionType: GRAVITY-SERIAL TYPE If A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) �eptic Tank: 1 � � � Gaflons "Proposed System: 25%REDUCTION 1-PreCe: Q YeS Q N o Pump Required: QYes �No QMay 6e Required Ndrificatson Field 1 4 4 �J Sq. ft. Pump Tank: Gatlons No. Drain Lines 3 1-Piece: QYes QNo Total Trench Length: 3 6 � ft GPM—vs— R. TDH Trench Spacing: _ g Qlnches O.C. Oosin Volume: _ Galtons . QFeet O.C. � Trench Wdth: Inches — 3 . �Feet Grease Trap: Gallons Aggregate Depth: � - � inches Pre-Treatment: QNSF OTS-1 �TS-II Septic Tank tnstaller Grade Level Required: �I �II �(I) Q IV Page 1 of 3 —_. . .... ............ .�--- . . ...va...•� �v �•u��vv�. • � � ' ❑ Open Pump System Sheet . RepairSystem Required:OYes ONo ONo, but has Available Space � R�pair Svstem Trench Spacing: Inches O_C. `Site CIBSSIfiC2tpr1: PS Shallow Placement 9 � Feet O.C. Trench Width: �Inches Design Flow: 3 6 � _ 3 �, Feet Soil Application Rate: Aggregate Depth: 0 . a 5 inches ` Minimum Trench Depth: a 4 *System ClassificationlDescription: tnches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a inches Maximum Trench Depth: a 8 "Proposed System: 2$�/a REDUCTION lnChes Maximum Soil Cover: 1 6 Nrtrification Field 1 4 4 0 Inches Sq. ft. � No. Drain Lines *Distribution 7ype: GRAVIN-SERIAL 3 Total T�ench Length: 3 6 � � Pump Required: QYes �No �May Be Required Pre-Treatment: ONSF 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. R•' 7; `Permit Conditions The issuance of this perm it by the Health Depa►tment in no way guarantees the issuance of other pennits.The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. °"• ,..< 2( Thls Authorizatlon tor Wastewater System Constrtiction shall be valld tor a person equal to the period c?valldiry of the Improvemerrt Permtt,not to exceed flviz years,and may be Issued at the sxnetime the Improvement Petmit iswed(NCGS 130A-336(b)�.If the Installation has not been completed durtng the period at vaUdity of the Construction Permit,the IMormatlon wbmltted in theappltcatlon for a pertn(t or Constructlon Authorization is tound to have been incorrec�falsffied or changed,or the site Is altered,the permit or Constructkn Auchorization shall become invalid,and may besuspended or revoked(.1937(g)).The person owning or coMrolling the systen shall be responsiWe forassuring compliance with the laws,rules,and permit condltions regarding system location,installation,operation,mafntenance,moniCoring,reporting and repalr (1938{bj). ApplicanUlegal Reps. Signature Required? OYes ONO ApplicanULegal Reps. Signature: Date:, � � �ISSUOd By: 2T40-Nations,Robert Date of Issue: � � � 3 0 � a 0 1 4 Authorized State Agent: .—r-- Malfunction Log OYes �Hand Drawing Olmport Drawing **Site PlanlDrawing attached.** Page 2 of 3 � 1 JyO�'i - I Davie Gaunty Health Department CDP �ile Number: ' 21Q Hospital Street - P.o.Box sa8 County Fife Number: . • Mocksville NC 27o2s Date: 0 7 / 3 0 I a 0 1 4 Q Inch Dra�vin� Drawing Type: Construction Authorization Scale: . . �N�A k - .ft. O _ _ _ _ _ _ _ _ _t,�--a � �_ �_ _ _ _ _ _ _ _ ��-� u � �; �•-� � _ _ _. , . _ __ __ �c � _ _ 1 �- � N ( . _ . G� rJ� � � . . .�,, ,. . `��.. , , . _ , � �-Q . R�' _ _ � �_ _ _ . �' � ��' . _ ��_ � _ __. _ _. __ ._. _ _. __.,. : _ _ _ . _ _ ��r"��, ..� : _ _ _ � ; _ /_ _ . .� _ � _ . _ _ __ _. _ /� 6 _ :_ . ,__ _ . . _ _ _ _ _ _ _.__ ._ _ _� _ . . _ . .._ . : :__ _. . _:___ _ _ , r�, 4 . , _ _ . _ __. _. _ __ _ __ ._ . ___ :__ ...� __ �� ., . . . ; . __ Paae 3 of 3 � � 'IMPROVEMENT PERMIT ForOffice Use Onlv 'CDP File Number 139894- 1 ��'u"'t� Davie County Heaith Department � '� �' �. - � � r��" 210 Hospital Street County ID Number. ��t. ,� P.O. Box 848 Evaluated For: NEW �«�� Mocksville NC 27028 Township: Phone: 336-753-6780 Fax:336-753-1680 PERf.11T VALID Ut�TIL: 7�30�2��9 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Wishon & Carter Builders Property Owner: Matthew and Milanda Address: p0 Box 1719 Address: PO Box 2033 �dY= Yadkinville �dY= Advance State2ip: NC 27055 State2ip: NC 27006 Phone#: (336)469-2162 Phone#: Pro ert Location 8� Site Information Address/Road #: SubdNision: Phase: Lot: g WoIt2 Lane Advance NC 27006 Directions structu�e: SINGLE FAMILY Hwy 64 East left on Hwy 801, got to Peoples Creek #of Bedrooms: 3 Rd. on right beside Elbaville Ch. the right on Burton #of Peopte: Rd. Left on Waltz Lane Lot off to right. `Water Supply: NEW WELL S stem S ecifications Initial S stem 'Site aSS1 1C8 to(1: PS Shallow Placement Minimum T�ench Depth: a 4 Inches Saprolite System? �Yes �No Maximum Trench Depth: a $ Inches Design Flow: 3 6 � Septic Tank: 1 � � � G allons SoilApplication Rate: 0 , a 5 1-Piece: QYes QNo u Pump Required: QYes QNo �May Be Required 'System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pum p Tank: G allons LESS1 "Proposed System: 25%REDUCTION 1-Piece: QYes QNo Repair System Required:OYeS ONo ONo, but has Available Space Repair Svstem 'Slt@ C18SSifiCetlOft: PS Shallow Placement PAinimum Trench Depth: a 4 Inches Soil Application Rate: g . a 5 FJlaximum Trench Depth: a 8 Inches 'System Classificatan/Description: Pump Requined: �Yes Q No Q May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 1•39$94 - 1 County ID Number: � "Site Modifications ❑ Open Fill Sheet �io grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. :.: 7: �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 goveming bodies in meeting their requirements. `'' ,,,. 7; $It�a� The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a dnwing not necessarily drawn to scale that shows the existing and proposed property ttnes wlth dimensions,the Ixation of thefuitity and appurtenances,the site forthe proposed Wastewater system,and the Ixation of water supplies and surtacewaters). Plat rne Improvement Permlt shall be valid without expiration wit�plat(means a properiy surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equats no morethan 60 feet,that includes:the specftic Ixatlon ot the proposed tadlity and appurtenances,the site for the proposed Wastewater system,and the loca�on of water suppties and surtacewaters. Plat also means,for subdivision lots approved by the Ixal planning authority and recorded v�it�the county registerof deeds,a copy of the recwded subdivfsions plat that is accompanied by a site plan that is drawn to scale). The Departrnent and Local Heatth Departinent may lmpose conditions on the issuanceand may revoke the permits for failure of the system to satisty the conditlons,the rWes,or this articte This permit is subject to revocatfon if the site plan,pla;or intended use changes(NCGS 130A�35(�).The person owning or controlling the system shal�be responslble forassuring comp�iance with the laws,rules,and permit conditlons regarding system txation,installation,operaton,maintenanc�monitoring, reporting,and repair(.1938(b)� ApplicanULegal Reps. Signature Required� OYes �No Applicant/Legal Reps. Signature: Date: � � 'ISSUed By: 2�40-Nations,Robert Date of Issue: g } � 3 0 � a 0 1 4 Author�zed state A9ent: OValid without Expiration? OCreate CA? OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 , - IMPROVEMENT PERMIT � ' Davie County Health Department CDP File Number: 139894 - 1 � 210 Hospital Street ' " P.o.Box 8as County File Number: Mocksville Nc z�o2s Date: � � Q Inch Drawing Drawing Type: Improvement Permit Scale: , . . QBiock = QN�A — ft. _ __ __ ., __ _ _ __ __ _ _ __ __ _ __ __. _ _ _ _ _ _.__ . _ _ . __ _ _ _ '__ _ . _ _ _ _ �� . __ . ; _ _. , _ � _ _.` _ _ I W _ ` _ Mtr�' ,�R .3� _ _ '� `��► +" 1 � ' _ _ �' _� �' �'-y _ �,� _ _.� _ � � , ,�J��r'� � ' _ ' � � ._ _ . _ . ___. . _.__ _. _ ♦ : 4 : . _.. _ . _ t . �� _ ` , I _ _ \ J � _ _ : � pJ, I ___ _ _ � � _ _ _ . � . _ _ v��u -�- • __ _ _ � _� _ _ � _ � _ ��G 1 _ _ __ .� __ ___ _ _ _ _ '_ _ _. _ 4�! : _ _ _ . � I _ /��, _ _ _ _ `i __ . __ ___. , _ _ '' _ _ � � � _ ; _ . __ ' _ : _ _ 1" __. _ _.__ . _! _ i _ __ . . �_ _ � � ' � : � : ___ , _ _ � _ __ __ __ _ __ _ _ _ _ .__ _ _ _ _ _ _ _ ___ Page 3 of 3 .. . , " � ' . _ .��V�PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT�i ATC ,p�� Davie County Environmental Health ate: ' I/„ / P.O.Boa 848/210 Hospitat Street Ite��l�,e� .� Data, �s� 1 Mocksville,NC 27028 b ; � (33�753-6780/Faz(336)753-1680 �j Application For: Q'Site Evaluation/[mprovement Permit ❑Authorization To Construct(ATC) ❑Both w /� Type of Application: L'�Vew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility • � .ssIMPORTAN7*'*THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED - �"""� 'a� INFORMATION IS PROVIDED. Refer to the INFOftMATION BULLETIN for instructions. �.� APPLICANT INFORMATION �1� �;Ke � U�'� Q� ; Name to be Billed W�s�wv f �--�c- Q:.,�c�c�- Z..�. Contact Person ��+^�< �l6 c�� E� � �`/�,Q'� Billing Address v ��,u, I'l!y Home Phone LG�l 3 3�--4�9 -�/6.� [��j City/State/ZIP �ja)It,;,.�,,.1/t ^�� '�oS�-�'�!9 BusinessPhone 33G.-G�'7R.,�v3% V,_„ _.._ __= __ -_f�, Name on PermibATC if Difj'erent than Above ' _ 3 Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facilit Comers Fla ed 1 -1�-1 NOTE: A survey plat or site plau must accompany this application. Included:B Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner'sName 1''1w1��,w► '+ M;1�,,,�� Mofs.'�; � PhoneNumber Owner's Address � l3�9„ �.03_7 City/State/Zip �v�.�c.��NL. �'�d�. Property Address lo l (,, lJo 1}�1.,�+� City �.a��c_ Lot Size /o y._�� Tax PIN# S�9 8�1`1 d�o S 1 Subdivision Name(if applicable) Section/Lot# Directions To Site: Ao! S, �.-��i-o�-, ��-; G r�. R;�1-f r�.� (3u�- �� l.z�C{ o..� �J,Z I0.�i'G �'� �]�v Ci'Sh�� If the answer to any of the Following questions is"yes",suppoRing documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes�No Does the site contain jurisdictional wedands7 ❑Yes ONo Are there any ease.ments or right-of-ways on the site? ❑Yes L�Io Is the site subject to approvai by another public agency? ❑Yes f9�Go Will wastewater other than domestic sewage be generated? �Yes BNo IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms .3 #Bathrooms 3 Garden Tub/Whirlpool❑Yes �10 Basement: 9�'es ❑No Basement Plumbing: �Ji'es ❑No 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 Type system requested: G3Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:O Counry/City Water �Iew Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes C3�fo If yes,what rype? 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 iGthe information submitted in this application is falsified or changed I hereby grant right of enuy to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detertnine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locati and flagging or staking the house/facility location,proposed well location and the location of any other amenities. ��`�`�� "�"`y�� 1J"s '"-- Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 7'"��L/ Client Notification Date: Date EHS: Signgiven ❑Yes ONo Account# /��" ` � Revised 11/06 Invoice# - � t � .,.. .. , u � ,�j�..� ,� � . � ; � � , r � r ,.. . � . � . ;f--..•- � 1 �� ... �, ��f �"!a,�as.rarri�:JYd � � � �y S� �� i �--�----�1-�,-�'-._`nr,,. / . . _"'"? �_--, . y .. . .... � :s;�� V� 'l �. � �� -"^--�- ' �r ; \`�� t � ){ � �''�,�_--' )t i �� i- } C , ,�� L�`��I I �i. .'„"--�� I �* � i_,_-., i ;,� �._. ..�:... .._..... ___._.�......_._j � ,��. .��'��--.--.. .._....;' ._.....�r � t �� .... ..� ''�� '•, � !��r � a 1 _... 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Y�•' �'�1 � �;1� v�'e re� ��> All data is provided as is without warranty or guarantee of any kind efther expressed or implied including but not limited to the implied �, ��''� � wartanties of inerchantability or fdness for a particular use.All users of Davie County's GIS website shall hotd harmless the County of �U N� �� ' Davie,North Carolina,its agents,consultants,contrectors or employees from any and all claims or causes of action due to or arising out Pri nted:J u I 16 2014 S of the use or inability to use the GIS data provided by this website. i . � " � DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section �� , . � , . - Soil/Site Evaluation , . , APPLICANT INFORMATION PROPERTY INFORMATION �, W:Sk��nCc�� e�- '7 — 3� — / 3 . �a 1 �f 2 �-h C�-�'� .e � C �� .�� aK��, � Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e position Slope % HORIZON I DEPTH p — �{ — D � Q Texture grou S � .s C G. S G SG Consistence N s�r' ' S . Structure � � S C � L C� Mineralo ' (� ti HORIZON II DEPTH — d Texture rou G. Consistence ,� S' Structure 5� S Mineralo HORIZON III DEPTH Texture rou ! Consistence Structure ' Mineralo HORIZON IV DEP'TH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON ( oc o t f SAPROLITE � CLASSIFICATION ' tJl- t-� �-�- LONG-TERM ACCEPTANCE RATE '� . �� SITE CLASSIFICATION: P� EVALUATION BY: �n� ,,�.��.CI.I/�� LONG-TERM ACCEPTANCE RATE: D ' � OTHER(S)PRESENT:� S�'��e�t,t�(,c(/L . �I d�/l Gi V�l Cv(�p...� REMARKS: , I�c�1 l t� � A ��e �-e w--eti� t� �H LEGEND j,andscape 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 Tsx�urg 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 S''ONSISTF.NCF. DIS?1St ' VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � NS -Non sticky SS-Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic StrLct�re SC- Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 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) imenr �..__ •--'-'- -----`---- --`- --ii�__.ic.n —^--� .._..,_ ._ . _. 1 ■■■■■■■■■..■■I■.■...■...■■..■■■■■■■■■■■■■■■■.■..■.■■■■■■■.■■■■...■. ■■■■■■■.■■.■.I.■■■■■■■.■■■■■■■■.■ ■■■■■■■■■■■■..■■■■■■■■■■■■...■■■ ■..■.■■■■....'.■■.■■■.■.■.■■■.■■■�■.■■■■■.�■■■.■■.■■.■■.■.■■■.■■■■ ■■.■■■■...■■■.■.■.■..■.■.■■..■■■..■.■..■■.■■■.■■■■■■.■■■■■■■■■■..■ ■■■■.■.■■.�■■■.■■■■■..■■■■■■■■■■■■■■■■■.■■.■■■■■.■■■■■■■■■■■■..■■■■ ■■■■..■■■.I■.■■..■..■■■■■■.■..■....■■■■■...■■.■.■■■.■■■.■■.■■..■■■. ■s��s��■ ■��■�■■��■■��■■��■��■ ■��i�o��■ ■■��i��i��■��■■��■�■��■��■��■��■ ■��■�■��i��i��■��■��■ ■��■��■��■ ■��s��■ ■��n��■■��■■��■�■��■��■��s��■ ■��i��■��■��e��■ ■��n�v�i��■��■��■��■��■ ■■��■�n��i��■��■��■ ■��t��►��■��■��■��t��t��■■ ■��■��n��■��■��■��■ ■��►.��■ ■��■ ■��■��.■��a■■�■��■��■�■■��■��■ ■��1'�r7��t��iii�i�iirtiii��iis��/��■ ■��0�/��%i�'!��■��\�■��■��\��■��■■■ ■��I��O��i�7�1��■��■ ■��iC�i��■��■��■■ ■��■��iC::!��■��■��■��■■ ■��n��■ ■��t��s■ ■�s�■��■�■�n��■��i��■��■��■�■��■■ ■��■��■�■��■i��■��■■��■ ■■��i�■■��i��■��i■��■��■■��to■ ■��■��o��u��■��t�i��■��■ ■��li��1��■ ■��I��■��■��■��1■��■��■ ■��1��\��I��Il��t��■ ■��■��i�■��i��l1�iC�'��/I�\!r�/�■��■��■ ■\�\■��I��■■��11��■ ■��I��\\�■��■ ■��■■�■��'�■��■1��■��I��i�!r\►\��■��■ ■��■��■��■�Ilii��iD;��■��I��■�\i�!0��■ ■��/��0��/��■��iflll�liJ��■��■ ■�■��■�■��■�■��I��rI��■��■��■�■��■ ■��11��■��■ ■��■�I��'��I��■�■��■■��■��■ ��\��11��11��%�� ■��■��■�■��11��■��■��1/��■�■■■��1��■ ■��/�11��/��I�/��/��o��/�/��■ ■��■��i��s�n��■��■■��■ ■��■��■I�■■��\��Y��■��■��■ ■■��e�■��■��w��:��,��■■��■ ■��■�■��t��■�ca�■��■��i��■■��■�■��■ ■■��l:ii��1��/��■ ■��■��■��■��■■ ■�11��'��■��■��■ ■��■��/7��1!!II��i��■ ■�■��■��■■�i��■��l�li�■��1�1//;J■��■��■ ■��■�I��■��■��f11i■��i:��r��■■��■ ■��11��R11��1�/��IG:�/��/��■ ■■��■��i�11■��I��I��t;i�/,��11��■��■ ■��n��e�.....��i��n��■ ■■��■�■�■�■�1��■��■��Il�� ■■ii�i.l�tll��l��!�r�.��■�■��■�■ ■��■��■��■��■��ii■n�u��■��ii��■��■e��■��■ ■��t��■��t��a'�■�■■��■��I��■��11��■��■ ■��I��■��■��!■��I/��■ ��n��u��■��■ ■��■��1i�fiflll��■1��/■��■/��■�■��■■ ■��/��/��!��\��u��/�■ ■��■��0��I■��■��/��■�■��■��■ ■■��I��/■��■ ■��■■��■■■■��■ ■��1��/��■ ■��I��■��■��■��■�\��■��■ ■��ai■��e��■ ■��■��!e��■��■��■��■��■ ■�■■��■��■��■■��■��■ ■��■��■��i��■��■��■ ■��■■��■�■��i�■��s��■��■ ■��t��■ i��■ ■��■��■��■��■��■��■��■ ■��■■��■��■��■��u■��s��t��■ ■��■�■�i■■��■��■��■��■ ■��■�■■��■�i��t��■■ ��n��s��■ ■t��■i��■��i�■��■��■��■ ■��«��■ ■��i■��■ ■�■��■�■ ■��■��!=�CS�:��:�Giiiiiinii�C:��■��■ ■��\��\��li��■��■��■