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828 Woodward Rd , �, Oi�Ef�ATION �ERMIT or ice se n v Davie County Heaith Department; *CQP File Number 139454-1 .�'J�S`�"� 210 Hospital 5treet � r .f�'` �� P.O. Box$d$ - . Counfy ID Number. �'��-�''� Macksville NC 27028 Evaivatea For. NEW Phone:336-753-6780 Fax:336-753•1680 Township: App�icant: Mike WilkeslMW Construction Propertyowner. 7g properties Address: 232 Carrington l.ane Address: 6221 Ramada Dr �dv� Winston-Salem �dY� Clemmons State/Zip: NC 27127 State2ip: NC 27012 Phone#: (336)764-8488 Phone#: (9�3)426-2266 Pro ert Location 8� Site Information Address/Road #. Subdivision: Phase: Lot: 828 Waodward Rd. Mocksville NC 27028 Directions structu�e: OTHER hwy 158 East, left on Main Ch Rd. right on S. Angell Ftd. Left on Woodward, cross I-40 long drive off to #of Bedrooms: right #of People: `WaterSupply: Exis'ritvGwe�� *System ClassificationlDescription: 'IP ISSUed by: 7YPE 111 A,CONV SYSTEM>480 GPD(EXCLUDING SFDj *CA issued by: Saprolite System? (�Yes QNo DeSign FIOw: � 0 � , GRAVITY•PARAt.LEL d-box Pump Required? _ DistributionType: ��' � (�Yes (�No Sail Apptication Rate: � . a 'Pre-Treatment: Drain fleld N�rification Field S�• ft• xSystam Type: ��LTRATOR QUICK 4 STANOARD No. Drain Lines Installer: Tony Ball Total Trench Length: a 5 0 ft• Certification#: ��0 7rench Spacing: g Inches O.C. � Feet O.C. "EH S: 2t4o-Nations,�abert Trench Width: 3 Inches � - �Feet Oate: � 6 / 1 0 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soi1 Cover. a 4 Apprava[Status Inches Maximum Trench Depth: 3 6 � Approved[� Disapproved , Inches �Aaximum Soil Cover. � 4 Inches CDP Fi�e Number 139454 - � County ID Number: Se tic Tank Manufacturer. Lat. . � l.ong: STB: Gailons: Insta�er: Date: � � Certification#: " *EH S: 'Fiiter Brand: ST Ma�cer. ❑ Yes ❑ No Date: � � Reiniorced 1'ank: ❑ Yes ❑ NO App�raval Status , � � � 1 Piece Tank: ❑ YeS ❑ No C1 Approved CI Disapproved Pump Tank Manufacturer. Instaaer: PT: Ce�tificaGon�: Gallons: *EHS: Oate: i � Date: � � RiserSeaied ❑ Yes ❑ No Riser Height: ❑�YeS � ❑ No (Min.6 in.) � � Appc+aval Status :� � Reinforced Tank: ❑ Yes O No �p Approved� Disapproved 1 Piece Tank: ❑ Yes ❑ NO Suppiy Line Pipe Size: inch diameter instaaer. P�e Length: feet Ce�tification#: *Schedule: '`EHS: Pressure Rated ❑ Yes ❑ No Date: � 1 Appraved flttings ❑ Yes ❑ N4 Approrral Status D Approved❑ Disapproved Pump Type: Instaqer. Onsing Volume: — �a� Certification#: Draw Dow�: Inches 'EHS: 'Chaa�: � � Date: Valves Accessible ❑ YeS ❑ NO Flow Adjustment Vatve ❑ Y8s ❑ No Check-valve ❑ YeS ❑ No Approval Status Pvc unions ❑ Yes ❑ No ; p Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ NO CDP File Number "��`�� '� County fD Number: Electric E ui ment NEP�AA 4X Box ar�quivalent ❑ Y�5 ❑ No instatter: Bnx 12 inchesAbov� Grade ❑ Yes ❑ No Cectification ri. flax Ad�.To Pump Tank ❑ Yes � N t� Conduit Seal�d ❑ Yes ❑ No *��'' Pump t�anuatlyOperabte ❑ Yes ❑ No "Activafian M�thod: Date: _ � , � � � � ��Apprt�v�t StaEus � �� AlarmAudibJe ❑ Yes � NO ❑ A�pTOV@C�CI DiS��?pTOY@d Alarm visibte p Yes � No 2140•NaGons,Robert *Opera#ion Permit compteted by: Authorized State A�ent: Date of lssue: � 6 / 1 (b / a fd 1 6 Owner/Applicant Signature; This system has been installed in compGance wRh appticable NG General Statutes:Article 11, Chapter 130A, Rules ior Sewage T�eatment and Dispasa1,15A NCAC 18A .190p�f. Seq.,ar�d all conditians of the tmprovement Permit and Gonstruction Authorization.This property is seNed by a Np�t�i a s�wage septic system. Rule.t961 requires that a Type �'�II�A- septic system meet the following criteria: M�imum System Rev�wt By7he Local Healfh Depa�tm�nt: �� Management Entity: ow�vER Mt�imum Sys#em Inspectianfirtaintenance Fr�quency By�ertified aperator: N!A Reporting Frequency 6y Certif�ed Clperatar. �� Rule .1961 requires that a Type IV and V septic systems designed fiora homeibusiness owner m�st ma�n#ain�valid cant�act w�h a pubtic management e�tirywi��a c�rtifi�d operatoror a private certifi�d oper�tar focthe lifia af the s�ptic system. Rute .196i requires that Type VI septic systems des'rgned far a homedbusiness ownec mUst maintain a valid contract with a public management entity wi#h a certified operator for#he liFe af the sept�c system. Rule. t961 (2)(e)requires a contract shall be executed between the system owner and a management ent�y prior ta the issuance of an Operatian Permit for a system required to be maintained by a public ar private management ent�y, unless the system ownerand certif�ed operator are the same. 7he contract shall requirg specit`�c reguiremenf� formaintenance and operation, �esponsibiit�s af the awnerand systems operator,pravisians that the contrack shal! k�e in effect for as long as the system is in use, and aCher requirements for the continued proper perform�nce of the system, R shafl atso be a eond�ion of the Operation Permit that subsequent owners of the systems execute such a contraci. �Hand Drawing Olmport Drawing **Site f�lanit�rawing a�#ached.** OPERATICIN PERMtT 139454 - 1 Oavie C�unty Fiealth pepartment CDP File N umber: 210 Hospital Street p.o.Bax s�s County File Number: Mocksville NC 27028 D�f�: / / ►,....L...1 4� � �..si.�..l Q Ineh Dra�viu� Drawing Type: Operation Permit Scale: . . . . 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' 3 _ -_ ___ ..,.._... .$_.. . .._ � .... i ' ' � i ; ; ; e i � j � I ' t � 7 b 3 , s p . . _ . . . � .. >.__ ,..,.. . ,,, p__ ,,.,., ,,,.._ ,_,. ..,_. �..,_ _, _,., ..,��,_ _._�.,< .,.,, ...... .._.,w_.�_, .�...�.,.,_. „�._,.�. ,..,.....<...,...�,.�.�._.,.._., .... _,.., .,..,..:.. .. € j j � � i 3 I I I � _. �., .,.� i .�.._ .._� ..- -+� ._ _... _ _. ; � . ; ,.__ -•-... � ,�, ..-r--........,. � , 1 � � ` , � v ,__m ,�,.E_�, .t ,..�m.,� _ � .._��.��_a.�..� _,xm_.._�.r„ .��_ ., �s w._ H .� ,.�_,�w_,� �_�a�,.�. �..,. .,_ .��. � ...,_ ,,.�_,�,,__ T��=��. � �,,..�..a.,�.�.,ro� _ � ' ' �` '� HEALTH DEPARTMENT RELEASE For otf�e use on�v *CDP File Number 139454-1 µ�,,,F„ Davie County Health Department �° r„'s�, . .. �� _ . . . � 210 Hospital Street County IDNumber: � �� y� �� P.O. Box 848 Evaluated For: NEW •�O�iww>w?P� � �� Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VPrLID � a i � 4 i � � a � UNTIL: Applicant: Mike Wilkes/MW Construction Property Owner: 79 Properties Address: 232 Carrington Lane Address: 6221 Ramada Dr City: Winston-Salem City: Clemmons State/Zip: NC 27127 , State/Zip: NC 27012 Phone#: (336) 764-8488 Phone#: (913)426-2266 Proaertv Location&Site Information Address82$Woodward Rd. Subdivision: Phase: Lot: Road# Mocksville NC 27028 OTHER Township: *Structure: Directions #of Bedrooms: #of People: hwy 158 East,left on Main Ch Rd.right on S.Angell Rd.Left on Woodward,cross I-40 long drive off to right 'Water Supply: EXISTING WELL Type of Business: Storage Basement: �Yes�No _, Total sq.Footage: No.Of Employees: a *Proaosed Improvement: Two septic systems exist on the property for the main house.Each are for two bedrooms.The original structure has been removed.A new home is to be constructed for 5 bedrooms with the addition of a swimming pool. cn�r�r�r: •Release Conditions aamer�;�9 The existing septic system for the main level of the house is too close to the well to meet proper setbacks.Add a new 1,000 gallon septic 390 tank at least 50 feet from the well and tie into the existing septic lines.Additional septic lines must be added to account for additional bedroom.Keep all construction traffic off of all portions of the septic systems. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? O Yes O No ApplicanULegal Reps. Signature: "Date: � � "ISSUed By: 2�40-Nations,Robert *Date of Issue: 0 � � � 4 � a 0 1 5 Authorized State Agent: � `r'"' **Site Plan/Drawing attached.** �Hand Drawing O Import Drawing HEALTH DEPARTMENT RELEASE � � �d�sv�,, Davie County Health Department CDP File Number: 139454 - 1 , �y 210 Hospital Street �� P.O.Box 848 County File Number: .,, - �,� - � `�c� Mocksville Nc 2�o2s Date: _0.�./.0.4,/,a.0,1.5, ��^^�x n.�r�M �"'°" �Inch Scale: O B�ock = ,ft. Drawing Type: Health Department Release � O N/A , , , y1 „o �' ..... , � _ . _ �c 1� . ,_ , :__ . r ._._ ..c1 , � � � , �. �_ � . . , ;_. ,_ ,....... _... , _... __... _. � _. �.,., �.... b �: � �� , t��U ' � � M .. � � .. .,..... _ _..._..... ' ,........ . '.._....... .. .... � ; ',. �,.... ._.�� '0.0 �_�O. a/ �,K ; _. _ . , _ , :_ _ � . 1�.� . . . n. o _�,. , 6 � ' �c� . �� . ____ _. . � _ _ . . , . ; , � - , _ . , , � , � � .. _ ._ __� _ _ . __ , , . � , , ,"� : Q _ � "� ��r � , � ,;. , _ . _ _ _ .. , , _ , ' _ : . , _ : _ _. . � _ _ _ ; ' � ; _ . , ; _ : _ __ � ___ __ : � _ ._ ; ; ��'' ,. ' __ `� �`�`' �, __ _ _ __ c �' , _ `Y�� f bd �' �� _ , , L�-� . __ __ . w : . � ____ _ :__ ' . � ' ' tr- _ ; ;__ _ _ . _ _ ... Page 2 of 2... ;,_. _ . ' � HEALTHDEPARTMENT RELEASE �a��o� Davie County Health Department 210 Hospital Street CDP File Number: 139454 - 1 �� ` "'� P.O.Box 848 y ��I" ' � Mocksville rvc 2�o2a County File Number: `C*�n�ri`�� °w"'"�`"" Date: .�.a l 0 4 / a 0 1 5 Drawing Type: Health Department Release Page 2 of 2 . � � � + ��-l� ��Z� , . � . , RECEIVEI? . ��//U . Date: ....+ � Da�e County Health epar en��" �, 4�;a j� Environmental Health Section � „ -, � � �A� P.O.Box 848 = . ,��"� � � � ��i�� C� ,�" . � -� 210 Hospital Street i, �� p U��. ��t�� Courier# : 09-40-06 � ��d� � Mocksville,NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WA5TEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection S � N� �lti,�1 c)l�r S Phone Number 33 6 ` 3�S�—Z-D '�" Home Name: a�-• l�� a,� U c� ( ) �3 ��0-S (Work) Mailing Address:�. n. ��c �� (7•�.e�) � - 3�� — l_.�,,,.��,1 l �. N •C.. Z-7�z3 Detailed Directions To Site: `'�U Y i 5 g � � w c�'�s` � N �O �o o� �r�Gt,�� .C,/� C �c� S � Z — �-1 C� o--� �oo c�-�c.�c�- �Z-� ��S �t �e.,�--e�c� ��`f-.''c�,�eSL_ -� � � r'� . �.,,�.- Property Address: �.Z� o�+�w 1 flD��e. S w�� C-- Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: � Type Of Facility: Date System Installed(Month/Date/Year): � Number Of Bedrooms: � Number Of People: � Is The Facility C�rrently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: �C�'�� Co/�'��i� IV� �''��G�'B-� � e k'S1�k} �Q �� J Please Fill In The Following Information About The NEW Facility: Type Of Facility: �e.� ��•b� \ ,�i:� �Number Of Bedrooms: J� Nutnber of People � Pool Size: ?C Z Garage Size: �� X ��Other: Requested By: Date Requested: � � � (Signature) For Environxnenta�Health Office Use Only Approved Disapproved Comments: Environmental Health 5pecialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check oney Order # Amount:$ � Date: J� Paid By: Received By: Account#: � '7':7' Invoice#: r �l�� l 5 �T/ ' '_ BFAfl CREEN ESf�iFS .. ' j MaNq�11�I�N � � �.�� . SI r,ai t ..._ -�__,4.._.. >��"�'��...P,..,°`�'::,:w, � � �. I � r �dr '� _ YI� �� Q r9��e w�p u I / �e.. n �SRE� ...� �..........,.. ,�a t4 �I � — a — .,m ,,,,.m. b�..K.�, .�� ...�.«. 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Davie County Health Department 'CDP File Number 139454- 1 � , r�Q� 210 Hospital Street 3`� '' � � P.O. Box 848 County ID Number_ G r b �`'°"""' j` Mocksvilte NC 27028 Evaluated For: NEW Phone: 336-753-6780 Fax: 336-753-1680 Township: Applicant: Mike Wilkes/MW Construction Property Owner: 79 Properties Address: 232 Carrington Lane Address: 6221 Ramada Dr �aY� Winston-Salem �aY� Clemmons State2ip: NC 27127 State2ip: NC 27012 Phone#: (336)764-8488 Phone#: (913)426-2266 Pro ert Locatton 8 Site Information AddresslRoad #: SubdNisan: Phase: Lot: 828 Woodward Rd. Mocksville NC 27028 Directions structure: OTHER hwy 158 East, left on Main Ch Rd. right on S. Angell Rd. Left on Woodward, cross I-40 long drive off to #of Bedrooms: right #of People: 'W2tef SUpply: EXISTING WELL 'IP Issued by. 2140-Nations,Robert "System Classif�ation/Description: 'CA isSued by: 2140-Nations,Robert Saprolite System? Q Yes Q No Design Flow: 1 0 0 * GRAVITY-PARALLEL Distribution Type: (eq.d-box) Pump Required? , QYes QNo Soil Applicatan Rate: 0 , a a 5 =Pre Treatment: Drain field Nitrification Field 4 4 4 S4• n- �System Type: �NFILTRATORQUICK4STANDARD No. Drain Lines 1 Installer: Tim Beeson Total Trench Length: 1 1 1 ft• Certification#: Trench Spacing: _ �Inches O.C. x Feet O.C. EH S: 2�ao-Na►ions,Robert T�ench Width: Inches — 3 �Feet Date: 1 0 � 0 a l a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Status Maximum T�nch Depth: 3 6 Inches � Approved O Disapproved Maximum Soil Cover: a 4 Inches CDP File Numbe; 1394,54 - 1 County ID Number: Se tic Tank Manufacturer. shoaf lat. � STB: 760 Long: , Gallons: 1000 I(1St811@�: Tim Beeson Certification#: Date: 0 6 / 1 5 / a 0 1 4 'EH S: 2�40-Nations,Robert "Flltef Bf2nd: POLYIOK Dual PL-122 With Pipe Adapter ST Maricer ❑ YeS � No Oate: 1 0 / 0 a / a 0 1 4 Reinforced Tank: ❑ YeS � NO Approval Status 1 Piece Tank: ❑ YeS � No O Approved ❑ Disapproved Pump Tank I�Aanufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: / � Date: � � RiserSealed ❑ Yes ❑ No RiserHeight: ❑ YeS ❑ NO (Min.6 in.) Approval Status Reiniorced Tank: ❑ Yes O No O Approved O Disapproved 1 Piece Tank: ❑ YeS ❑ NO Supply Line Pipe Size: inch diameter Insta(ler: Pipe Length: feet Ce�tification#: "Schedule: "EH S: Pressure Rated ❑ YeS ❑ NO Date: � � Approved fittings p Yes ❑ NO Approval Status ❑ Approved ❑ Disapproved u ui e e t Pump Type: Installer: Dosing Volume: — G�� Certification#: Draw Down: Inches 'EHS: "Chain: Date: � � Valves Accessibte p Yes O No Flow Adjustment Valve ❑ Yes ❑ NO Check-valve p Yes ❑ NO Approval Status PVC unions Q Yes ❑ No p Approved� Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ YeS ❑ NO CDP File NumbeF 139Q54 - 1 County ID Number: Electric E ui ment NEMA4X Box or Equivalent p Yes ❑ NO Instailer: Box 12 inches Above Grade ❑ Yes ❑ NO Certification n: Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Seated ❑ YeS ❑ NO *EHS: Pump ManuallyOperabte Q Yes ❑ NO *Activation Method: Date: � � Approval Status Alarm Audible ❑ Yes ❑ No O Approved O Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert 'Operation Permit completed by: Authorized State Agent: ��—Z — Date of Issue: 1 0 � 0 a � a 0 1 4 This system has been installed in compliance w�h applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A _1900 et. Seq.,and all conditions of the Improvement PeRnit and Construction Authorization.This property is served by a sewage septic system. Rule .1961 requires that a Type septic system meet the following criteria: Minimum System Review ByThe Local Healih Department: Management Entity: Minimum System Inspection/Maintenance FrequencyByCertified Operator: Reporting Frequency By Certif�d Operator: Rufe .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywrth a certified operatoror a private certified operator forthe life of the septic system. Rute .1961 requires that Type VI septic systems designed for a homelbusiness otivner must maintain a valid contract�vith a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shatl be executed between the system owner and a management entrty prior to the issuance of an Operatan Permit for a system required to be maintained by a public or private management ent�y, unless the system o4vnerand certified operator are the same. The contract shall �equire specific requirements formaintenance and operation, responsib�ities of the owner and systems operator,provisions that the contract shal! be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. ft shall also be a condQion of the Operation PeRnit that subsequent owners of the systems execute such a contract. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** , , OPERATION PERMIT Davie County Health Department CDP File Number: 139454 - 1 210 Hospital Street P.o. Boxsas County File Number: Mocksvilie tvc 2�028 Date: / / , Q Inch Dra�vioQ Drawing Type: Operation Permit Scale: , . . OB�ock = .ft. QN/A . . . _ _ __.. `` _ _ _ _ _ _ _ _ _ _ �� _ __ _ _ ' _ � ' � : _ ._ '� _ _ _ _ _ __ __ _ . __ �4 _. _ _ . _ _ ._ . : ` : , , � � � __ _ _ _ _ __ _ _ _ : _ _ _. _._ _ . _ . _ _ � _ _ _ _ . _. _ __, _ _ _ _.1 _ _ . _ '. � !. . ,� _ _ _ _ . : . _'_ �V _ f __ � _ _ � . � �3 __ �_ _ . _ _I _� � � , _ _ _ ...� � G ,- , P�1 � _ _ � , � 5 � _ _ _ ,_. _ _ � _ , ;1_ �,��,cc a_ ^ �.�, � �� .. � � _. � , ._ _ _ _. � ___ _ _ � � ' _ _ _ _ _� _ _ _ _ �u _ _ ( __ o W _ � a � : _ _ _ _ c�- _ � _ _ __ _ I _ _ _ _ _ _ _ _ _ __ _ _ _ _ . . • � CONSTRUCTION Forottice use oniv � "CDP File Number 139454-1 AUTHORIZATiON °"�°-+� Davie Count Health De artment ,� ""'' Y A County tQ Number: � �'�� 210 Hospital Street Evaluated For. ' NEW �°.��,.r P.�. Box 848 TOwnShip: Mocksville NC 27�28 PER�YIIT VAUD UNTlL: Phone: 336-753-6780 Fax: 336-753-168Q 0 � � 1 � / a 0 1 9 Applicant: Mike Wilkes/MW Construction Property Owner: 79 Properties Address: 232 Carrington Lane Address: 6221 Ramada Dr City: Winston-Salem Cdy: Clemmons State2ip: NC 27127 State2ip: NC 27012 Phone#: {336)764-8488 Phone#: (913)426-2266 Propertv Location � Site Information Address/Road #: Subdivisan: Phase: Lot: 828 Woodward Rd. Mocksville NC 27�28 Directions 5tructure: OTHER hwy 158 East, left an Main Ch Rd. right on S. Angell Rd. Left on Woodward, cross I-40 long drive off to right #of Bedrooms: #of People: "Wet6r SUpply: EXISTING WELL • System Specifications Minimum Trench Depth: SitB CIBSSif�CatiOn: Provisionally Suitable a 4 (nChBs Sa rolite S stem? Minimum Soi1 Cover. p y QYes QNo � a Inches Design Flow: 1 � � Maximum Trench Depth: 3 6 Inches Soil Appl�cation Rate: Maximum Soil Cover: a 4 0 . a � 5 Inches *System Classif'�cation/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE I!A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) �eptic Tank: 1 � � � Ga�lons "P�OpOS2d SyStefll: 25%REDUCTION 1-Piece: QYes (QNo Pump Required: QYes QNo �tv9ay Be Required N itrification Field 4 4 4 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1-Piece: QYes QNo Total Trench Length: 1 1 1 GPt�ri—vs-- ft. TDH ft. Trench Spacing: _ 9 �Inches O.C. Oosin Volume: _ Gallons � Feet O.C. � Trench Width: Inches — 3 gFeet Grease Trap: Gallons Aggregate Qepth: Pre-Treatment: ONSF OTS-I OTS-fl inches SepticTank InstallerGrade Level Required: �I �II a(I) QIV CDP File Number ,139454 - 1 Counry ID Number: ❑ Open Pump System Sheet RepairSystem Required:�YeS ONo. QNo, but has Available Space @p81P SYSt@t11 7rench Spacing: Q Inches 0_C. 'SitB CI25SIfiC8ti0I1: Provisionally Suitable — g +� Feet O.C. Trench Wdth: Q Inches Design Flow: 1 � � 0 _ � �Feet Aggregate Depth: Soil Application Rate: � a a 5 inches � tvtinimum Trench Depth: a 4 *System Classification/Descriptiorr. Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches tvtaximum Trench Depth: 3 6 ��ches *Proposed System: 25��,RE�uCTioN Maximum Soil Cover. Nirtrification Field_ ______ , a . 4 . tnches 4 4 4 Sq. it. No. Drain Lines "Distribution Type: GRAVITY-PARALLE�(eq.d-box} 1 TotalTrench Length: 1 1 1 Pump Required: QYes �No OMay Be Required ft. �re-Treatment: ONSF �TS-I �TS-II _ _____._-_.. _.__. "SiteModifications No grading or constn�ction activity is allawed in areas designated for system and repair without approval of Health Department. ��' 7; 'Permit Conditions The issuance ofthis pennit bythe Health Department in no wayguarantees the issuance ofother permits.'The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. °'� Ae! 2( Thls Authorizatlon for Waslewater System Construc�on shall be valid for a person equal to the period of validity of the Improvemerrt Pertnit,not to exceed ffve years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)).If the Installation has not been compieted during the period of uaUdity of the Construction Permit,the ir�famation wbmitted in theappllcation tor a permit or Constn�ction Autho[izafion Is found Lo have been Incarrect,talsiflec!or changed,or the site is altered,the permit or Constructbn Authorization shall become in4alid,and may be suspended or revoked(.1937(g)).The person otivning or corttrolling the system sha11 be responsible for assurir�g compliance with the laws,rules,and permit conditions regarding system Ixation,installation,operation,maintenance,montLoHng,reporting and repair (1938(b)). ApplicanULegal Reps. Signature Required? pYes ONO Applicant/Legal Reps. Signature� Date: � � *ISSUed By: 2�40-Nations,Robert Date of Issue: H � � 1 7 � a 0 1 4 AuthoriZed State Agent: �� —� Malfunct�n Log OYes � OHand Drawing Olmport Drawing **Site Plan/Drawing at#ached.** ��.,�� ..a� � � CONSTRUCTION AUTHORIZATION , • Davie County Health Department CDP File Number: 139454 - 1 210 Hospitai Street P.o. Box$as County File Number. Mocksville Nc 2�o2s Date: � � � 1 � / a 0 1 4 Q Inch DI�WIria Drawing Type: Construction Authorization Scale: . . , QBiock = .ft. QN/A �_ ��`_ . _ � . t,�c� _ _ . � _ _ � � _ _ _ _ . _ _ � _ . 4 �._ e . _ _� _ . � _ _ � . . .�._ _ . _ _ C .`� _ . _ :, ._ _ _ _ . wW - _ _�� _. _ ___ . . : ; . : : - �,,"� --_ __ _ ._ _ -- �� . . _ _._ J _ _ _ _ � � _ _ _ _ � �, � .... _ , _ _ �,. . � _ _ _ ��` �, __ _ _ , __:� a ` � _ _: ,,_ � '�� ._ _ _ .� d . _ __ _ : �� ¢ �o �- 1M�PROVEMENT PERMIT ForOfficeUseOniv *CDP File Number 139454- 1 ��"�� avie County Health Department r�-. �j ��, County ID Number. � t� ; 210 Hospitai Street '�� P.O. Box 848 Evaluated For: NEW 'vra„",;:r• Mocksville NC 27028 To�vnship: Phone: 336-753-6780 Fax:336-753-1680 PERL�IT VALID U��TIL: 7I'I7IZO'I9 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Mike Wilkes/MW Construction Property Owner: 79 properties Address: 232 Carrington Lane Address: 6221 Ramada Dr ��Y� Winston-Salem ��Y� Clemmons State2ip: NC 27127 State2ip: NC 27012 Phone#: (336) 764-8488 Phone#: (913)426-2266 Pro ert Location 8 Site Information Address/Road #: Subdivision: Phase: Lot: 828 Woodward Rd. Mocksville NC 27028 Oirections structure: OTHER hwy 158 East, left on Main Ch Rd. right on S. Angell �of Bedrooms: Rd. Left on Woodward, cross I-40 long drive off to #of People: right 'Water Supply: EXISTING WELL S stem S ecifications Initial S stem 'Site BSSi �C8 i0�: Provisionally Suitable PAinimum Trench Depth: a 4 Inches Saprolite System? �Yes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 1 � � Septic Tank: 1 � � � Gallons SoilAppl�ation Rate: 0 . a a 5 1-Piece: QYes QNo u Pump Required: QYes QNo Ot,Aay 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: Q Yes 0 N o Repair System Required:�YeS ONo ONo, but has Available Space Repair Svstem "Site Classification: P�ovisionalty Suitable F�linimum Trench Depth: a 4 Inches Soil Application Rate: � , a a 5 Maximum Trench Depth: 3 6 (nches 'System Classif�ation/Description: Pump Required: QYes 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,•139454 - 1 Counry ID Number: • ` "Site Modifications ❑ Open Fill Sheet No grading or constn�ction activity is allowed in areas designated for system and repair without approval of Health DepaRment. :.' 7: "Permit Conditions The issuance of this permit by the Health DepaRment in no way guarantees the issuance of other permits.The permit holder is responsible for checking�vith appropriate governing bodies in meeting their requirements. `'' ■f� 7; S ite P lan The Im�ovement Pennit shall be va�ld tor 5 years from date of Issue with a 51te plan(means a drawing not necessarity drawn to O scate that shows the existing and proposed property lines with dimensbns,the location of thefacitiry and appunenances,the siLe brthe proposed Wastewater system,and the Ixa�on ot water suppties and surfacewaters). Plat The Improvement Permit shall be valid without expiratlon with plat(means a property survc3led prepared by a registered land O surveyor,drawn to a scale of one inch equals no mwethan 60 feet,that Includes:the specitic Ixatfon of the proposed taality and appurtenances,the site tor the proposed Wastewater system,and the location of water suppUes and surface waters. Ptat also means,for subdivision lots approved by me txal planning authority and recorded v�ith tl�e counry register of deeds,a copy of the t+ecorded subdivisions plat that is accompaNed by a site plan that is drawn to scale). The DepartrneM and Local Health Departrnent may lmpose conditions on the issua�e and may rewke the permits for failure of the syst�n to satlsy the condiUons,the rules,ar fhis article Thls permit is subject to rewcatia�if the sitie plan,plat,or intended use changes(NCGS 130A�35(�).The perso�owning or controtling the system shall be responsibte torassuring compliance with the laws,rules,and pertnit conditlons�egarding system Ixation,installatlon,aperation,maintenance,monitoring, reporting,and repair(.1938(b)� ApplicanULegal Reps. Signature Required? OYes �NO ApplicanUlegal Reps. Signature: Date: � � 'ISSUed By: 2�40-Nations,Robe�t Date of Issue: 0 � � 1 7 � a 0 1 4 Autnorized state A9ent: OValid witho?t Expiration? OCreate CA. OHand Drawing Olmport Drawing **Site PIan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 139454 - 1 - ,' Davie County Health Department CDP File Number: ' � 210 Hospital Street P.o. soxsas County File Number: Mocksville rvc 2�oza Date: I / Qinch Drawin� Drawing Type: Improvement Permit Scale: , . QB�ock _ QN/A ft. _ _ _ _ _ _ _ _ __ __ _ . __ _ __ _ _ _ . __ _ _ _ _ _ ._ _ ��c � . _ - _ _ _ _ _ _ w-� _ _. _ � L �� {� __ _ t0 4 ,.� � � 'f _ _ _ _ . �� , ; _ _ : '\ _ _. : ' _ __ _ b� �i : . �- `� `.� _ _ __ __ _ : _ _ � _ ' _ �3 _ _ . _ _ , _ o ' . +�� _ ��,� � � � _ _ __ , _ ��v _ � _ _ � __ __ � � _ � _ _ _ u�� _ _ � _ . _ _-_ __ _ _ _ _ �� _ __ _ _ _ _ _ _ _� . _ ; ' c�� ` ' _ � � � � _ _ . _ _ _ ,� _ _ _ _ .. � _. _ _ _ � _ _ _ _ _ � _ _ _ __ _ ___ _ _ __ _ __ _ _ _ � _ _ _ _ _ _ : �� _ r _ _ � _ . ___ _ . . _ ___ _ _ Page 3 of 3 _ _ __ 4-.,..:.M.a ..) " � . , . .� i 3 3 � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health � P.O.Box 848/210 Hospital Street ��'��►'� Mocksville,NC 27028 �� _ 30 � (336)753-6780/Fax(336)753-1680 � �� Application For: � Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ORepair to Existing 9ystem ❑Expansion/Modification of Existing System or Facility ***IMPORTAN7***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED --- _ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions: " _ "` - APPLICANT INFORMATION � "'ti. '�' /t'1/�E G✓/(. r �.✓ G�o�ST. 1' Name n'1 Contact Person �"'�� .p � Address Z. �Z -4-�r��..� G�/ Home Phone 76�� City/State/ZIP Gv-�, NL Z'��'2-'7 Business Phone ?�'�f/�' b ''� . ,�. Email /ht.✓t�KES/9' 9 6.�.,AiG . Go.�-- -�' ' � Name on Permit/ATC if Different than Above 7 2aP�2?i�-S --- Mailing Address � Z2� /��+�R �� City/State/Zip C��..�5 z7 i�2 PROPERTY INFORMATION *Date House/Facilit Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: C�ite Plan ❑Plat(to scale) / (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name � ��! P2oPb2--TiES Phone Numbe��7/3)�C26- u6� Owner's Address 2L I /z,q-rv�}.�A �- City/State/Zip CLF+-��-,t 27 ��Z Property Address �Z (o wo oow�n.� City r�b c.�elN`�' Lot Size �O� �9�n�s 'f- Tax PIN# o0o u�o�� Subdivision Name(if applicable) Section/Lot# Directions To Site: (o0 1 6✓ Specify Problem Occuning: Wy l�Ol N� rl�ve� �N ��W/� � /U�N ��g�'l / dN ��OQ/� - Y' IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: OYes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE L O T THE BOX LOW Type of FacilityBusiness u.< <� � otal 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: CCe"onventional ❑Accepted �Innovative ❑Alternative ❑Other _ _..__. _______ .. _____.____ .... .__ ___.__.__.________. _.._,_._.. .__._._�.....__._____.,.__..____.__ ___.._____ � � . Water Supply Type: ❑ CountyiCity Water x�E isting Well ❑ Community Well 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 permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating a flag 'ng or sta ' ouse/facility location,proposed well location and the location of any other amenities. / Site Revisit Charge Property �v r' r owner's legal representative signature Date(s): �_� 3 � C(ient Notification Date: 1)ate EFIS: < Sign given ❑Yes �I�10 Account# •J�� Revised 11/06 Invoice# � • - , .. . � Davie County Health Department . ��i�r�' Environmental Health Section �., «� : , �,.<�:: � '`:�.,.:� P.O. Box 848 � '� `". . * �� ;��,. 210 Hospital Street �,�� ' .. C? �,. Courier# : 09-40-06 � ; IJ 1`� . . .. Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION . (Check One) Replacement Remodeling Reconnection `-,� /1'�i/� � Name: �!✓�' �iJ,�i't-✓C-«'�r� �✓i c./t�� Phone Number ��'�O `��y y 1�-� (Home) Mailing Address: '�-3� l:A.��2-��+w"�r-� Lr.J (Work) . ,-- (/Vr v�S-z�.--- ,�-�-c,.��.�-. Email Address: �v1 1..��/[.c-�S /�j,S�1 �1�lre .Cr�ez^, DetailedDirections To Site: /.�� f ( �J Q•v �w'A�� , (r�' o.-/ �'✓��'� Property Address: �,? �0 � • C - Please Fill In The Followinglnformation About The EXISTING Facility: Name System Installed Under: Type Of Facility: , Date System Installed(Montt�/Date/Year): � �� 0 � Number Of Bedrooms:_�Number Of People: Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? Yes �No� If Yes,Explain: L/ � Please Fill In The Following Information About��T,�'Facility: �2 k /�` /�' 4 b Type Of Facility: ��- ��j'✓��-�� .�.�� Number Of Bedrooms: (� Number of People Pool Size: Garage Size: Other: �Requested -*�'� Date Requested: -�� b5" C �Sig � . For Environmental Health Office Use Only Approved isapproved Comments: YVQi 5 Z�J�"� l�. � � ._..�-�%G . T Environmental Health Specialist Date: — a-� ^� *The signing of this form by the Environmental Health Staff is in no way iritended; nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By; Received By: Account#: Invoice#: � � . , � �! � �1 �` �� ,��`' , ......�,..��._. r � �, ,-,-1 i_ ., � �`� �� r , °� �� ,.r ,' , � ��,;�, - --��' : ��' � � � w,:-�,.� , I � �� ;� � � �� _ - �� '� �._ ,�.. �y; �v� � ,}. �T _��t,,�� . .. } �;�� ' �� > ��, , , ,: � = _.— l,�---� � . -��r�___.��` . �: ��, � __,`.._��--� ,, z ----_.� °� af �;�� > —,--�:�_.._.__,�.-�- � �� . � , , .�---��_ :� _ 1' ` �� '�.......-=.�� t' a `r h,, , � � `�> < � . , : . y . ' � �, , �� - � � � _ ,�; (j1L ohe,�,iF All data is provided es is wlthout wananty or guarantee of any kind elther expressed or Implied including but not Iimlted to the implfed � - � ��' � warcanties of inerchantability or fdness for a particular use.All users of Davie County's GIS website shall hold harmless the County of U N ° � � Davie,NoRh Carolina,its agents,consulWnts,contrectore or employees from any and all claims or causes ot action due to or arising out pri nted:May 29, 2014 � of the use or Inability to use the GIS data provided by this website. . . ..,� x� ,. .� �--- ��i�� _�,�.- ..w..7 tl./�ro �,�les�1,G��.'"' _ :;. . , � DAVIE COUNTY HEA�TH DEPART�NT � ' ;= :%"� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION � ` "NOTE: Issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c � Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)"" P@�Rllt NUrY1b@� Name„[!/Cl�9a[C G�J! ��icet��-- Date�� .. :•;.3 Rf'G� BdX f S'�/lJec,f'sl!//.�, Location _ —�o�� Subdivision Name Lot No. Sec.or Block No. Lot Size �ra�� House— �Mobile Home_ Business Speculation No. Bedrooms�No. Baths�No. in Family�_ Garbage Disposal YES � NO ❑ Specifications for System: Auto Dish Washer YES. NO ❑ `�O� /�� , Auto Wash Machine YES NO ❑ ��t ��Q Type Water SuPP�Y ��.e1'1P _ '7.�',e X ��.?�` ,�w`�"t�,,,,_ 'This permit Void if sewage system described below is not instalied within 36 months from date of issue. � � L a.E't �S� " \\ � �a �j,� �..y x' - �. : �� . ,.,,;," Improvements permit by�_ , � 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Ntiifnber:704-634-5985. Final Installation Diagram: System Installed by t; w' " - - - ------ ��° �� L7 -- � _ _ � .�.� ��,�--- _ ��.r.�._ � Certificate of Completion �Date � � � 'The signing of this certificate shali indicate that the system described above has been installed in compiiance with the standards set forth in the above requlation,but shall in NO wav be taken as a au�rantPP that thP cvcfPm u��ii r��r�� 'a��0.qIZAT:oN No: � �� ;j�•��DAVIE COUNTY HEALTH DEPARTMENT �' �f "l�'l�j'J _ ___ . ,: - , Environmental Health Section PROPERTY INFORMATION Permittee's P.O.Box 848 Name: �. �//f''i� ��1��/E. Mocksville,NC 27028 Subdivision Name: Directions to property: !3 .�K .d�1lJr,�l1.r/YI/'(�,F�� AUTHORIZA ION FOR Section: Lot: ,r� . I WASTEWATER . 'f�� '�/+4 SYS7'EM CONSTRUCfION Tax Office PIN:#��L-�-��'/5 ` Road Name: �Z�p: Z�DZ� **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pemtits.This FomJAuthoriiation Number should be pre.sented to the Davie Counry Building Inspections Office when applying for Building Permits. (ln compliance with Article I 1 of G.S.Chapter 130A,Wastewater Systems,Section.1900Sewage Treatment and Disposal Systems) / •w*NOTICEr*•THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION - 6 � � IS VALm FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SP CIALIST DATE ISSUED RESIDEN[7AL SPECIFICAITON:BUII.DING 1'YPE #BEDROOMS #BATHS #OCCUPANfS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY 7'YPE �N p��PI,E'� M PEOPLFJSHIFf / #SEATS INDUSTRIAL WAS7'E:Yes o�No) IAT SIZE�� TYPE WATER SUPPLY 1��DESIGN WASTEWATER FLOW(GPD)�NEW S1TE�REPAIR SITE SYSTEM SPECIFICATIONS:TANK SIZE�,GAI.. PUMP TANK GAL. TRENCH WIDTH.._s�L ROCK DfiPTH_.�� LINEAR Ff� OTf�R REQUIRED SIT'E MOD[FICATIONS/CONDI'I'IONS: IMPROVEMENTPERMITLAYOUT *A�� FLUEAJT FILTEF�� #RI5ER(S! IF 6" B�L05d FINISHED �aRpD�� _ � '�..__�� 1� "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECfION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(7�17(i&�t&'JEdIt x (33�i 3 751—E17fi0 OPERATTON PERMIT /� �� /� � SYSTEM INSTALLED BY: l..�J�� —u7J.l�e�..),"_�i 2tK-� (J C33G�to3 -SF�ZZ ��s—,1'r �.2(Ln.c� . � � Snc.�� o � ��i k� � -��z'• AUTHORIZA7ION NO. �,�� OPERATION PERMIT B pq�; � "'1'FIE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH S DESCRIBED ABO HAS BEEN INSTALLED N COMPLIANCE Wf!'H 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 FUNCT[ON SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. ' DCHD OS/96(Revised) � � . � . . . . . . . . '�9 Pr�o.��s . ,.. DAVIE COUNTY HEALTH DEPARTMENT .�-`�' ' �� ` `'� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �%� "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Tre tment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name � r''�[�9 �o p �_� C' ,%, � _ Date `�� %' , . ., cTc Location � G� CY _ Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ _ Business _— Speculation No. Bedrooms �/ _ No. Baths �%� No. in Family ��-�?" � _ Garbage Disposal YES � NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ _ ,� ; ,- . • - Auto Wash Machine YES ❑ NO � `- `'� ' " �� '�! � �`�-" � � • Type Water Supply __— ' � `This permit Void if sewage system described below is not installed within 36 months from date of issue. � t ` 't` '. � , , , ___. , ` _ ._.._, , , � � _� 1 `, � , `, , ; , : , ��. _ _ ___ __._..___.___ ._.. _ ; � ,-� � � j !�� ` _ ^ /y.i .-- �,., 11�, �, �� ' Improvements permit by -- = ' "Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. � � f Final Installation Diagram: System Installed by ��` ` � ��' -�-, ��% ` � "; \ � � i � � � � � r_. i � � ' �� c } � �`� � � �, �n 4' �/ 1 � � �� '!' y. �� I r � j� i � I - -- , _ r'—� � ' ,/��-� \ � , , �--- � . . ��. � .�, � � �' , , , ,� _ . ��,y� � 8'� Certificate of Completion,__-��/ � � ! '" � Date #The�signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. ` Appraisal Card Page 1 of 3 DAVIE COUHTY NC 7 14/2014 4:2l:39 PM 9 PROPERTIES LLC RetYrtVAppeal Notes: W-000-p0-015 � r. � 26 WOO�WARD RD ' ' UNIQ ID 10552 3DZ793 D210.i27 ID N0:5830462815 C GOUNTY TH7((SOOy,FIRE TAX(100) CItRD Nd.1 of 3 ° cval Ywr:2013 Tax Year:2015 647.663 AC WOODnARO RD 615.560 AC SRC=Inspectlon � ralsed b 19 at 07 07 2008 06003 WOODWARD '1W-06 C- E%-AT- LAST hCT10N 201�071� v CONSTRUCTICN DETA2L MARftlT VAW! DEPRECLITION CORRtLATION O!�VAWF � O oundatlon-3 � �E Swndard 0.2600 ^ ontlnuoue Footln 5.0 5 D Ar�a UA RATE RCN EYB AYB DElICE TO MI�RKET 9 uG i100r SySCERf-4 01 Di 8 069 215 IS0.50 22�101 98 198 %GOOD 74.0 PR 6UILDINO VALUE-CARD 405 8 � ppG 8. xtalOr Walls-12 TYPE:Sfnqte fartNtY ResWEndal Slnple Family Nesidentia� ►R'00/XF YAW!'CAR� 298.66 m ARfCRLANDVAWE-Cwi[D 1,SO1,OA N tuao on Concrcte Block u•� 57pRIE5:5-Itsnch w/CasaMnt AL lU1RKlT VAW!-CMtD 2,705,5 � ooflnp Struaurc-06 r rrc ular Cathedral I3. /►L AVPNAISED VA4.U!-CARD 2.705,56 ooflnq Love►-11 11L APpMISlD YAW!-►ARClI 2,976,�8 late 11. ntxfor Wall CanstrucUon-6 AL PRESEMT tKE YALVE-PARC[L3,787,1 uctom]nhrlor 32. AL YALU!DEFERREe-�ARCCL 3,189,78 nterior Floor Cover-16 AL TAl(AeL!VALUE-rARCEL 1,787,1 erreao E SM 29. PRYOR ntlrb�Fl00�Cover-19 � �� 0 UttAING VALUE 1,315,76 estlnp Fud-03 XF YALUE 369,37 s 1.0 ND VALUE 1,596,03 � EHT USE VALUE 231,54 eeUno TYP�-a+ • ot Water 5.0 EIIRED VALUE 1,)64,4D � O7AL VAI.UE 3 281 1 . Ir ConGitfonmp Typa•03 lntrol 4.0 edraoms/BatnroomsJMaN'-Bsthroorm vErtMIT 5�1 19. CODE OATE NpTE NUMBER AMOUNT BedroOm! EAS•5 FUS-0 lL-0 OUT:YVTRSM : � stnrooms SALl4 DATA 8A5-,4 FUS•0 LL-0 . FF. INDIGT! � i � • HaY-esthrooms �T= DEED SAL[S „ BAS-1 FUS•0 LL-0 AG[ R TY►! �RIC! � 4] 93 11 01 WO Q l 297 � eAS-0 FUS•0 Ll-0 0813 6]9 12 WD G 1 � AL POSNT VALU! IS5.00 2 20 4 00 WP E i n 0 . 6UILDINIi AD7USTfi[NT8 587 767 12 WO E I o Iz� 3 Size O.B70 53f zi5 f w0 C t o u�ll 5 CUSTH 1.�50 e h� D�sl 5 F�tCTOR 5 1.100 ,;� ffOTAL ADJUSTMENT FACTOR 1.3 HEIITED ARfA 7,�b6 , �fOTAL QUALITY 1NDEI( 21 NOTlf attachrtient fp Resent use appllatbnMOUSE S RREGUUtR GATE OCKED SUlARlA V1ilT ORIO�Mi ANN OEP Y� 06/X*D!P 7YPf GS ARG �K RPL CS D! lSGRIPTIO �NIC! COND AT6 EY6 MT! ODND YALU 1�S 6 36 36 D5793 = LF GREEN 100,000. _ L 1 199 S 1 5000 GD 147 Oq gglp S ZEBO 2 1 43 16. 1 _ L 199 199 5 3 255 EB S 10 OS 91t0 1 OMGE 1 2 15. 1 _ L 196 199 S 5 208 0 30 CO 22 = �GE 3,07 30. _ L 00 00 S 7 6�51 DD 7 10 02 6321 SP PAYING 0,2 3. _ l 00 00 S 10530 �_mp��E 10 N PAVING 3 I,3 �. L 00 00 S �60 �� masslve 9.�1 � MGE � 193 62. 1 L 199 5 5 6961 UBAREA AL Od xf YALU[ 298 66 �� 11,34 1,224,10 � UADING DIMlNSIONS 9A5�6365 FGD�1�7� OEB�IiGISMlDD�2100fPTOs300 . ND SNFORMATION TNER ADJUSiMENTS LAND T07AL IGHEST Af1D U5E LOCAL FROH DlPTM/ LND WND ND NOTES � UN3T LJ1ND YNT TOTAL AO7USTED U11/D LAND � lST.USE COP! ZOlRMG TA6! [P SI2t MOD �ACT RF AC LC TO dT 7YPE YRYCE UNifS 7YP AD)ST UNTY►RIC! VALU! NOTlS ' RURAL AC O3T0 6036 D 0.5350 4 0.6900 O6'►00+DO-15•30 RV 6,300. 645.69 /lC 9•76 2,33�.7 150103 ND � OTi1L MARKET LAND DATA ` 645.69 1 SOl 64 Rl HOMSITE 5000 0 0 1.0000 5 2.5000 6,300. 3.00 AC 2. 15,750• 4725 1100 1 1.00 Gitl[1 ' S230 0 0 1.0000 5 1.0000 590. 206.79 AC 1. 590. 12200 GRIIII 5330 0 0 1.0000 5 1.0000 385.0 124.42 AC 1. 385. �790 GRi N 5910 0 0 1.0000 5 1.0000 40. 1�.83 AC 1. �0. 59 RST[I 6210 0 D 1.0000 5 1.0000 270. 251.1 AC 1. 27U. 6779 RST Ill 6310 0 0 1.0000 5 1.0000 230. 25.75 AC 1. 230. 580 UBMERGE� 9500 0 0 1.0000 5 1.0000 1,000. 20.3 AC 1.00 1,000. 203 ake OTAL PRESEfiT USE OATA 645.69 311,66 http://10.100.4.41/Tax/AppraisalCard.aspx?page=l&idP=1410485&pageCount=3 7/14/2014 Appraisal Card Page 2 of 3 DJIVI!COUN7Y NC 7 1� 2014�:2s:39 PM 9 VRO�ERTI[4 LLC RehrNAppe�l Nota: G4-000-00-415 34 WOODWARD RD UN1Q ID 30552 2793 D210-P22 ID NO:S630462815 COUNTY TAX(100),FIRE TAX(100) CARD NO.2 oI 3 dl Year:2013 Tax Year:2015 617.663 AC WOODWARO RD 645.560 AC SRC=]nspectlon raised 19 on 07 07 2008 D6003 WOODWAIID TW-06 C- EX•A7- LA57 ACftON 20140714 ODNSTRUCTION D[7AIL MARKET VALU! D[VRECGTION CORRlLATION OR VAW! ndatlan-1 StanOarC 0.2800 � ER. BASE Floor System-4 O Mea A RATE RCN EYB 11Y8 REDENCE 70 MARKE7 , ood�• S• Dl 01 2 143 9tl 68.60 14702 198 198� %Gd00 72.0 [Y0.6VILDTNO YALUE-CARD 105 85 xLerto'W�IIs-1� TYpE:Slnpk FamMy ResldenUal Sinpk Famlly Resbenttal �R��X�YAWE-fARD idi AvM E 24. ARKlT LJ1ND YAW[-GRD ng Structuro-03 STOAIES:1-1.0 Story AL MARKl7 VALUE-GRD 105,85 abie ' 8. �ollnp Cover-03 phak or Com oslUor�SMn k 3. AL APP WIISED VALUE-GRD 105,85 1nDef1W WaN COnstrYQlat-S TAL APPRAISCD YALU!-PARCLL 2,976,4E alf/Sheetrodc 20.0 xnterlor Floor Cqver-08 �eet Vln /taminrta 6. AL PRESENT USE VALU!' 1.787,1 Merld'Fbor Covtr•1� ARCEL p, OTAL VALU!DE�l0.RCD-PARCEL 1,169,78 ��_� AL TAXASL!YAW!-PARCEL 1,787,1 kctrk 1. estlnQ Typ�•10 PR70R eat Pu 4. UILDING VALUE 1,715,7 Ir Gondltlanln0 Type-03 E%F VAWE 769.77 � g, ND VALUE 1,596,03 �W��'� +--1 4---+6-+ RESfN7 USE VALIIE 231,5� 2 0 12. 6 I F O V EFERRED 4ALVE 1,3N,� �� +-1 2--t i I OTAL VALUE 3 2e1 1 n5-3FU5-OLL-O 1WDD I I I athro0mt t T 2 I BAS•2FU5-OLL-0 1 1 2 2 6 d I 2 M-�� I I I S -0 FUS-0 lL- I I j = PlRMIT +�•SS---+-�1��-+S-i�12--+ t6-+-7-t ropE DATE NOTE NUMBE(t AMOUNT S-OFUS-OlL-O IFOD ISAi I TAL PO2NT YALUE 92. Y I = I � , I OUT:MRRSND: lUILDINO AD]UST}IlNi'� I I I SALlf OATA . :� 3 Slze 0.9 = I I �. . I ' 3 AVG 1.0 = 2 . = ORD ATE DElO INDICAT[ � )D�fi S FACTOR$ 1.1 I = I OOK AG! TYP! I ALER PRIC OTALAD]USTMENTFAC�OR 1.07 = I = AL Ql1ALITY IHDEX 9 I I I I i I �"�s"'i"13"�"""""4�""'•""'+ HEATEOAREA1,79� 6F0� 6 ��s +'---""--44-"""'---; WNER SU6ARG YN1T OAIG 9� SIZE ANN DEP 91� OB/X�DlPlt � D A lSCR.SrT70 N ►Rtt! COND /ACT M7E COND VALU TYP! ARtA 4�i RVL CS AL 06 X�VALVE 1 7 30 1227 0 79 � 1207 OP 39 3 953 DD 19 260 DtlPIAC[ 1-None M�� 2,76 47,01 ALS UriDINOCIMENSIONSBAS=W7FOP�N22W6S22Eb W6N22W1456WDD=W32536E12N36S516WS7W13FGD=W15S26E15N26 526Ei)FOP:56E�tN6WN E�IN26 . ND 2NWRMATION ER D�USTMENTS AND LAND TOTAL IGM[bT AN US[ LOCAL FRON o[wiH/ LND CONo O7lS CA UNiT LJ1ND UryT TOTA� Ao)YSTlD LAND LANG E5T USF COD! ZOlRN6 TAGC E SIZ! MOD FACT Rf AC LC TO OT TYP! PRICE UNITS TYP AD75T UN�T Yf12CE VALUE N07lf OTAL MARKET LA(ID DATA OTAI irtlSENT US!DATA . . _�.. . . . . � . .� ��i�� _�/��- 7 /��o r`�eS L� � '� - � , ' DAVIE COUNTY HEAl�TH DEPARTM NT � , � '�- , y, �= � .p*?? IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �V'� *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c � � Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Pet'111it Number Name,�C�q�� L�1l�h!« Date � . .. ..� Location _ �fG� ,,B�X fS�'/�oc,�s'�!//,�, —��o �� 1- -- g 2� (.I�OQc�uJ� — Subdivision Name Lot No. _ Sec. or Block No. Lot Size._..�d�� House _.r� Mobile Home _ _ Business _— Speculation No. Bedrooms �_ No. Baths _� No. in Family_.�_ Garbage Disposal YES NO ❑ Auto Dish Washer YES. NO Specifications for System: � �I�:O d � ��-� -2��+x� Auto Wash Machine YES NO � � Type Water SuPP�Y 1��— --- ?� '� X �/�.~ ��'�`�� "This permit Void if sewage system described below is not installed within 36 months from date of issue. .� Q�'e .�"� � � �y � ,� f ` � �� ', � M1f .. � U�� !!.�li! ' . �:., Improvements permit by _� 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone fV�itnber: 704-634-5985. Final Installation Diagram: System Installed by_ � ; �: _ - y� l`�� - r--� ___ --- � � -��,.� -��-`_" ��-�- ; � Certificate of Completion �_ Date �� __ #The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. • . F�� r � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ^�,�t . � Davie County Health Department �;t t'' � - � Environmental Health Section . �C��,� �.••' � . P. O. Box 665 �y�� ' Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone � "—" 1. Permit Requested By � �-��-�e C.�.�Q�c�•-•s e s �� Business Phone �q B ^°13�� 2. Address�-� � � oK-- °�5 ��' �o�-�s � .1�p. �� . C_ 'Z1 o a�3 3. Property Owner if Different than Above Address 4. Permit To: a) Install�Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House ✓Mobile Home Business Industry Other b) Number of people '�- ' 6. a) If house or mobile home, state size of home and number of rooms. House Dimension� '—" Bed Rooms a�� Bath Rooms 3 Den w/Closet � b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water-using fixtures: commodes � Q" urinals — garbage disposal � lavatory � � showers 3 washing machine � dishwasher \ sinks � 8. a) Type water supply: Public Private ✓ Community b) Has the water supply system been approved? Yes No ✓ 9. a) Property Dimensions — b) Land area designated to building site �S D Qc�'e� c) Sewage Disposal Contractor �o�' ��e�-� �'� 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �o What type? This is to certify that the information is correct to the be of knowledge. � r,,,.... '�'o��'� / , '� Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD(6-82) �' � .� � ' pAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 �' ` -SOIL/SITE-EVALUATION-- - v _ . !w._......,..w�..�.,........ ., .. _ -.._.. ,.. __._. ._ .__... � �� _. � Name /-��1�'� � Date ; �� Address Lot Size I`�(I FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position C ,5-� S S S '`�PS'�j PS PS PS •-�i� U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) • � PS PS PS PS � U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS � U U U 4) Soil Depth (inches) S S S S pg PS PS PS U U U 5) Soil Drainage: Internal S S S S pg PS PS PS U U U External S S S S pg PS PS PS � U' U U U 6) Restrictive Horizons lj �y. 7) Available Space � S S S g PS PS PS � � U U U 8) Other (Specify) � S S S pg PS PS PS � U U . U 9) Site Ciassification U—UNS T BL S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: � , ��' � .�`� Described by Title , S/�/�'� Date��'� SITE DIAGRAM 1�� DCHD(6-82) . . . , . _.s � 4 I ; , DAVIE COUN : . . _ . �C�� C��f� l�.-�lil.c� Permittee' " r-} � � TY HEALTH DEPARTMEN f � Nam :-��'%-Ip��j'�'i .�J✓/,�`/,.�c`.;�''i�:�- Environmental Health Section PROPERTY INFORMATION � n�(� T�. .� ��'�{; � �,� j . P.O. Box 848 �-'f�7-' �3` �� l� - " , e ✓ �� ? � � a, f� �irections to property: � S�r' f �^��%'��'�%'�, <s Mocksville, NC 27028 Subdivision Name: � r :�,, T Phone#: 336-751-8760 �`' - %'°" Section: Lor. AUTHORIZATION FOR WASTEWATER Tax Office PI1V`#" � ��- / �. �` � SYSTF.M CONSTRUCTION - AUTHORIZATION NO: �4'� �� A Road�me:��'�'�r�'�'/� , **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) J / r'i�,� �:-` ----�� ,,,,�' , . 7./ ,..,� _�, ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION �,�`:��:� �"� r.�',., ''�€�_ ',�� /w�`�.'� IS VALID FOR A PERIOD OF FIVE YEARS. _ ENVIRONMENTAL HEALTH SPEC(ALIST DATE ISSUED G,I RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS f`�� #BATHS #OCCUPANTS�_GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER.SUPPLY /�/1'9�/DESIGN WASTEWATER FLOW(GPDJ—�Y� NEW SITE REPAIR SITE �'"� ,� u SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH y�y� ROCK DEPTH /-� LINEAR Ff. .�� OTHER �"' �� ' �� REQUIRED SITE MODIFICATIONS/CONDITIONS: ' _.--�---�'^�� IMPROVEMENT PERMIT LAXOLIT'� � /_""""-�..`, �� , _ f _ . '� ' � . l-'.. '*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT � , � `} SYSTEM INSTALLED BY: � ;.�u" . �� AUTHORIZATION NO. �� OPERATION PERMIT BY: DATEi /�� YG�-C7'a` "`�THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTTCLE 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. DCHD 01/02(Revised) ��-c� ra,�.�?.. • (�•�,,,) ��..e.�� o� 6N/ ° � ' � - DAVIE COUNTY EN�GIRONMENTAL HEALTH SECTION � . � _ ' - �� APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) � NAME ��t'��"`'�� '��`��t` PHONE NUMBER � �o � ��-� � ADDRESS � ��--� I :t� � � ��- SUBDIVISION NAME � � A �CS U bGl� /'�� ' - LOT # � l / � DIRECTIONS TO SITE (� v J �'r' � C��- � �—�� - � � � -e, _ — J `��- � 2s-�-e��V a-k-� T DATE SYSTEM INSTALLED�� 4 NAME SYSTEM INSTALLED UNDER h''-��'`` �' TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED � TYPE WATER SUPPLY L.��-PiGI SPECIFY PROBLEM OCCURRING Y1,'Q-`�' S J`-�-'� S �`P/""' '_ `�- �Q.-� r4� J 9 -7�' L c��,,.,.,C,- �Q�..-� `�•�-,�.�I /`o-c n� � � Li DATE REQUESTED � '� .3 INFORMATION TAKEN BY L>L _ M N Thia ia to certify that the information provided is correet to the best ot my knowledge,and that I underatand 1 am responsible for all charges incurred irom this application. � SIGNATURE OF OWNER OR AUTHORI AGENT � Rev.1 J93 �--E:w'_" R I � �.a►�-- a`- a�.1� � /Q�-�— � � ��...-._:._� w . . + ' DAVIE COUNTY HEALTH DEPARTMEfdT ' � ��s`"� � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION „ . '•� '�� "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c '� Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name ��q�EC �!! �� - Date �"��,�� ,�f� B�x 9's' /�'lo�,�sr��j.�. Location � _ �� --�-t`—� �-r�l� ---, , Subdivision Name Lot No. Sec. or Block No. Lot Size �r��C House —1� Mobile Home ___` Business __ Speculation No. Bedrooms �— No. Baths _� No. in Family__�_. Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES, NO ❑ /� O� / � / �-/J,��., Auto Wash Machine YES NO 0 �� ~�� Type Water Supply c �•�P - ___— ?� d X �/�•~ ��'�`��`� r `This permit Void if sewage system described below is not installed within 36 months from date of issue. .0 ��'e .�/ . �� y � f � � � . . � � �� ;�'� .. �. Improvements permit by —_�,�� -- *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by— .;, _ _. ___ � �f� �� . �77 __._____-_- / o� -C��`.� el��""_ ��G�,.�.�t--- � � � . �_ Certificate of Completion � Date ��(_a 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. �; �^ i . �J �::��`C -'�... : � 8,;; 'i '�. - - � _ '--sm �t�� . i y � �s a;�_� s �, � ti � �' " — � � ' ti :� , � " � _ _ ��' �, r � . °,� � �� r.. -� � � , � �� ; a� � :� `� � �� , . J , :: - . = ��i s�� .-< _ , , I Y� ��i - . . ;1 t � ^&�. � k� ' � f� _ ` ' x . ♦ �� z . � . � . . y) �i �1 � ��' k�;. t . �� . . , �^ a. `�E. �# � � �� #� S`: s . � � � .� � . >y .' �.. . � ��. i � � � - ;� �' � � , � 1:. ' '� '�..i� �� . II � �. ' �. �. �,z= � �� I �= . ',�"'', ' �h " �� . . {.t� ' � �e�� . . �'•� I . , .P. < < _ .� - ._ :: - �� w`y',� �I � �� g r �� n � i � �„ �' @»�� a � �� _ � t i� � � ��' _ w � �� . ,xl �9i-- — — � I � . . . . ... . "�° - . � : d$'i � . .... . . . .. . . . ... . �. . , r � I `� ��"' I i � . . m . . .. .. $ . � � "`�. �'� � ...a N � .. .. . � � �� . s„ � ___� � .�� i �`� __— � m i , m � , ;m � i ;: ; .' , � _` ; ` —�— � �:' i 'Y' ��, y - .� � � .� � � .� s ` �` �' � � ^�� , � � � � � �� II `._ � � . \�` __-_ i � .Teb �`� }w _.`.._. . �. _ � � . . II `�� >� � . �. �M, . ' - . . I `� _. .. � l ' . .. . . ' �;_ �1 � �� , �� , - �� . � �: �� \ 'A ��3 aE ��1R �`_ ' ' , ' Lt�f . , �� : . � A � � � .� � � . � : �� r� ,w � ,< k ' t , ! _„ , ---------� �� l� NO ' � ----� . : '_ ---- <, � � _ II �,. - -- -_ :� �� - � � � I --------- : ` l� �\ � SWEET CREEK T , , _, : ; �, , _ �� o �t � e =` � � '�� ,_ >� �_--- �� : : _ . � I ----,.. . � ,c; � � _ _ , I , . � ; _: _ �� ro � °i , '�_ i __ ---_ _ - — _ __ _ _ ____ — — � lr. _.. .;ti-y: ,., , .� . . .�' '�t�_t�.�4 , •—"m. 'tvP ;�. . . �k , - . . . . ^ . .. �. ti o—' �f� ..�':,.-a.�a.«.,.: Y.. .,. .. a.,f', ..�., .s < �.. ��,:, y.,.4 . ; y � . . . . .. ,. _ AUTH�IZATION NO. �'� HEALT DEPARTMENT ' ��'/ � ,,,� '� �,� DAVIE COUNTY H /' - -. Environmental Health Section PROPERTY IIVFORMATION Permittee's /j /f � P.O. Box 848 Name: (a . f"�r/r`i'� �,,�i.��/� :. Mocksville,NC 27028 Subdivision Name: ` Phone# 336-751-8760 Directions to propeRy: �� ,d��lJ�;�//aTi(�,f�� Section: LoL• AUTHORIZATION FOR WASTEWATER •C � � r �/ � `�' 1 � SYSTF.M CON TRUCTI N �Office P1N:#�G-�-��~ � VV�� Road-Name:,�'..A'!� , �Zip: Z�OZ� **NOTE**T'his Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Artide 1] of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) � �, ` / �.,,,_,,,..., � �. ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION f, ;,�1, �'"'��,,��"� !,� d� � IS VALm FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ��;.. 4 - � . ... .. , . , _.. . . . ... . . . , . . . . � � . .-. . �... . . . . . . ._.a . .. ..�� ._"'' � .. . „ ' � `'.... .� • ,� . . . ..,.... � . ...... g� '�� e�.xr;., -W � ?' � �.;,� ��'r� DAVIE COUNTY HEALTH DEPARTMENT ��C�'�C�'/ � `R~� � TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION v��_- - PeFrriittee's, � ,•r , ,�^ ,...._.,�Iame: � �..ti � 4��; � T;'�� - ,I� Subdivision Name: , Directions to property:_�r�� i%;. %!��`:.�,�r (�,r t,� Section: Lot: IMPROVEMENT " � ,��,{r, � ,,�, �j PERMIT T�x Office PIN:# ti .�'.�- '��_- f�`�*'�'.l s' t� ' � �) r ,1 � �G lo i%V U�'�(��.� Road�ame . ''�`, f�,�!` .:,..r"��'Zip: ,Z 70Ze� **NOTE**This Improvement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system.An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTONmust be obtained from this Departrnent prior to the construcpon/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) 1' > , ,�r}'� . � ��' ***NOTICE***THI.S PERMIT IS SUBJECT TO REVOCATTON IF SIT'E r—s: �+.. �:� � , Y,A'°' sf.'^:/��-� �`"' �i` . PLANS OR TI�INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMENTAL HEALT PSH ECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TIIIS PERNIIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE . �� #�EOPI,E�^�,, #PEOPLF/SHIFT / #SEATS INDUSTRIAL WASTE:Yes o 1�To LOT SIZE�_ TYPE WATER SUPPLY�DESIGN WASTEWATER FLOW(GPD) ��(J NEW SITE / REPAIR SITE „ i� / SYSTEM SPECIFICATIONS: TANK SIZE��GAL. PUMP TANK GAL. TRENCH WIDTH ..�� ROCK DEPTH�� LINEAR FT,/Z�-��/ OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENTPERMITLAYOUT #��AFiL�VED EFFLU�tdT FILTEi�� RIS�RiS) IF 6'� I3�LO,J FIP3ISH�D GRATJ�:-� �`,,,,--�_ �J � **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(7�?¢�763�:&7bOt H !336)751—E37bE� OPERATION PERMIT /� �� ,/ /� SYSTEM INSTALLED BY: 1.��Y l�=-�.�`-J�2-�—� � C33c�1�3 -��ZZ ��c9�T .r-- G��-�� , ; � � - ��,� o ` �� . -�,Z �� f. � AUTHORIZATION NO. ',�r� OPERATION PERMIT B DATE: � •*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH S DESCRIBED ABO HAS BEEN INSTALLED 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. ' DCHD OS/96(Revised) - --.__..,....,�yo��r��wVtNltlV1 wtltMif &AIC �.�...__..�-_-�-.------�--.,--_ : _. Davis Counry Health Depafinent � ; �� ':';;_ � � ' ' ' - EnvfronmentalKe,althSe+ctfon � ��'"�"�'�m � "' P.O. Hox 8�8/210 Hospital Street � ��9 y�J `'� �Ioaksville, 11C 27028 � v �336►751-8760 ot tiRo��r!�PITAI HEALTN . .,,k �� ***IIKPORTRNT�*t TiiI9 APPLICATION CANNi�T HE PROCESSED L1NLE33 ALL INFORMAT202i IS PROVIDED. Re�er to the INFORMATION BDLLETIN �or instructions. .. etzme to bn $�i�ea aont.aet rerson ,[%/�i7 ��JY�.�''c�,� !lailinQ 1►d�dreai ��,1JVJc 1 f,,�,�� Hame phane ��X `.1�,��] city/statela=r ��-L�aP�,��^jI /2�.� su�sn�. phone C. Name on t�e=ait/ATC i! Diltnrent than l�bwe 1lailit� 71dd=ess Cilp/8tiate/t�p �. �lppliaation Soz: L1 Site Evalnation 0 Ia�rave�ment Permit/ATC 0�th �. system to service: 0 House 0 Mobile Home 0 Snsinestt 0 Iadus�ry �7'Other �� e. If Itesidenae: � People � Bedrooata / Bathrooma �_ 0 Dishrasher O Oasbaqe Disposal p ltashinQ Hachiae 0 8asement/Plnabinq 0 Basement/No Plumbinq 6. i! 8nsiness/industry/other: spec!!y type � peopie _� t SiN�s ____�!_ � Ccamodes �_ f Showers � Urinale ; Nater Coolers IF �OOD3ERVICE: � Seata Estimated ilater Uaaqe iQalions per day) 9. �rp� of xater supply: 0 Connty/City B'itell D Co�aauni�y e. oo you anttctpate addltiona or e:pxn'[ons of the[acility thb eyUem ta intended to�e�vei []Yes [] No 1!yes,what type? """/MPORTANT"••C1,ILNTS J1lUST C�OJIlPLETETHL► REQUIRED PROPLRTY iNFORMATION REQUESTED BELO W. Eit6er a E'LAT or S1TE I'I.AN MUST BESUBdt117'ED 6 the clleat ett6 TEi1S APPLlCAT10N. Property Dimensione: ��s9G� W1tITB DOtECT10NS(fmm Mocicsville)to PROPSRIY: Ta:Oitice PIN: # S'��5 G�' '�-(,�c��08�� Prnperty Addr�ds: Road NAme ��n /✓t��/1f/3r�� City/Zip 1�� /(/, 1�in a Subdivisioa�trovide inl'ormation,as follow�: �� Name: Section: Block: Lot: Datt Prnperty Flagged: �� 'r� � Thi�3s to certify that tbe ioiormation prnvided i�curnect to Ihe btst M my knowiedga 1 underat�nd Ibnl�ny permif(s) i�sued 6ereatfer are sabject to au�pen�ioa or revceatioa,if 16e aite pluis or intended uae c6ange,or 1t the informatton submitted tn thia applicatlon ia fid�itied or chatnged I,also,anders�tand that 1 am�eapo�slble jor a!/c/ba�gu lrrcrrrred from tJi�s apptfcwtion. 1,hereby,give conaent to the Autborized Representative o�the Davie Couatp Healtb Dep�rtmenl to enter upoa pbove described prnperfy located in Davie County and owned br to conduct al!testing procedures aa necasary fn detenuine t6e�tte witabillt�. DATE � Q/ �� SIGNATURE ,�.Q-(s' ` TIIIS AREA MAY 8E USED F'OR DRAWING YOUR Sl7'L PLAN(Include atll uf t6e followiug: Eziating and proposed property Ilna and dlmenslons, nruclurcs, aetbuka, snd�eptic locatloas►. Accaunt No. �� Revlsed DCHD(07/98) invoice No. �'�7 , , . ' �� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT'S NAME `'ll�/J�'s�Z P DATE EVALUATED ��'y� PROPOSED FACILITY t 1�r nJ PROPERTY SIZE ��'G SUBDIVISION ROAD NAME Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring }� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L , Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH �' � Texture rou � Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo ' HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION:__'�S EVALUATION BY: LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 tructure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed � � .'r; 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(01-90) ■��■�■��■��■��■��■��■■�■■�■��■��■■��■��■��■�■ ■��■■�■�■�■��■�■■�■��■��■��■��■��■�■��■■��■��■■ ■�■��■■■■��■�■■■��■�■�■■�■■��■■�■�■■�■��■��■�■■��■■��■■■�■ ■�■��■��■\��■��■�■�■��■■�■��■ ■��■■��■�■��■��■■�■��■�■��■■�■ ■■�■�■■��■��■■�■��■��■■�\■�■�■��■��■�■■�■�■■■■��■■■ ■��■��■�■�■■■■��■■■��■■■��■■��■�■��■�■��■■■ ■��■��/�/��■��■■ ■�■��■��■■■��■■��■��■�■■��■■��■�■■��■��■��■■��■■��■ ■�■��■��■■■��■��■��■�■■��■■■�■■��■��■��■��■�■■��■�■■��■■�■ ■��■��■��■■�■�■�■��■■�■■��■■�■■�■��■�e■��■��■��■�■��■�■ ■■�■��■■��■�■■��■■�■��■■■��■■�■■�■��■��■�■■�■■■■ ■■�■��■��■��■��■■�■��■■ ■■■■��■��■�■��■�■��■■ ■��■�t��■�■��■��■��■��s��■��■■��■��■■�■�■■ ■��t��■ ■��■��■��■�■■��■��■��■■��■■■��■��■�t��■��■��■■■�■ ■■�■��■■■��■�■��■�■��■��■�■■��■��■��■��■��■��■�■ ■�■��■■��■�■��■■■■��■��■■�■�■�■■■�■■��■■�■�■��■��■�■■�■■��■■■■ ■�■��■��■■�■�■��■�■��■■��■��■■�■■��■��a��■��■��■■ ■��■��■��■■�■�■■��■■�■��■ ■■�■��■��■■��■��■■�■■ ■■��■��■��■�■■��■■��■�■�■�■��■■��■■■■��■■�■�■�■��■■�■ ■��■ ■�■■■■�■■■■■�■��■��■�■■��■■■��■��■��■��■■■■�■■�■��■■��■��■■ ■�■��■��■■�■�■��■��■■�■��■■��■■��■■��■■��■�■■�■■��■��■�■■ ■�■��■�■�■■��■��■■��■��■■�■�■��■■��■�■��■■■�■ ■■��■■�■■��■�■�■■��■�■■�■■�■��■■�■�■■��■��■�■■��■■■■■�■■■ ■■■�■��■�■��■■��■��■■��■■��■��■�■��■�■■��■��■�■��■■��■ ■�■��■��■��■��■��■��■■�■■��■��■■��■■■�■■ ■��s��s■ ■��■ ■■�■��■■��■�■�■�■■�■��■��■��■��■��■��■��■■��■■■��■■�■■ ■�■��■��■■■■�■■��■�■�■■��■��■�■■■��■��■■��■��■■��■■�■ ■��■��■■■��■�■��■��■■■��■�■■��■■■��■��■��■�■��■■��■■■ ■��■��■■e��■��■�■��■�■�■■�■�■■�■■�■�■■■�■��■��o��■��■■ ■■�■��■■��■�■�■�■■�■��■■��■��■��■■�■��■■�■��■��■■��■■��■ ■■■��■��■■��■��■�■��■�■■�■■��■��■■■��■■�■��■■■�■�■■■�■■■■■ ■��■ ■��■��■ ■�■��■■��■�■�■�■�■��■��■■�■■ ■�■�■■�■■��■■��■��■�■■��■■��■■ ■■�■�■■■��■��■�n■■��■■■��■■�■■�■��■�■■��■��■�■■�■�■■��■��■■■■ ■■��■�■■�■■��■��■��■�■��■��■��■■��■■��■��■�■■■��■��■�■��■ ■�■��■��■■■■■■■■��■�■��■■��■��■■■��■��■�■��■■��■��■■�■ ■■■��■��■■�■■■��■��■�■��■�■■■■■■��■■■�■■�■■�■■��■�■��■�■��■■ ■■�■��■■�■��■��■�■��■�■��■�■��■��■■■��■■��■■■��■��■�■��■■��■■ ■��■��e:.i��r��■ �iiiiii�iiiiii�iiiiiii��iiiii ' �iiiiiii�iiiiiii�iiiiiii�iiiiiii� ■■■��■��■■■■�■��■��■■�■��■��■■■■■��■■■■�i�■��■�■■��■■�■�■■■��■ ■��■��■��■�■��■��■��■■��■■��i�■��■�■■��■��■��■��■■ ■■■■��■��■■■��■��■��■��■■■��■��■■��■■��■■��■��■�■s ■��■��■■■��■■�■�■��■■��■■�■■■■■��■��■�■��■■��■■��■��■ ■��■��■��■��■ ■�■��■��■■��■��■■��■■��::��■■�■�:-■��■�■��■■��■�■��■■��■■■ ■�■■��■��■■��■■�■��■�■��■■■��■�■■��■■��■■■�■�■■��■■■■ ■��■��■■��■��■■��■��■�■��■■v 1��■■��■��■�■■��■■■��■■�■ ■��■��■��■�■��■■■��■■��■��■■��■■��■��■��■��■�■■��■■■ ■�■�■■�■■�■■��■�■■■■�■■�■��■��■■�■�■��■�■�■■�■■��■■�■�■��■ ■�■��■��■��■�■N��■�■��■�■■�■■��■■�■��■��■■�■��■■��■�■��■ ■��■��o��■ ■■�■��■��■��■■�■�■■■■��■■��■■�■��■�■■��■��■■�■■��■■■��■■�■ ■■��■■■/��■�■��■■■��■�■��■�■��■��■��■�■■��■■■��■ ■�■��■�■■�■■■■■�■■�■■■■�■■�■�■�■��■��■��■�■�■��■■��■■■ ■r■��■��■�■■�■��■■�■�■■�■■�■��■ ■■■��■��■■■��■�■■��■■■��■■�■ ■�■��■��■■�■■■��■�■�■��■�■■�■��■■��■��■■■�■�■��■��\■■ ■■��■■■��■■■■�■�■■��■�■��■■■��■■�■�■��■■�■�■■�■■��■�■■��■■��■■ ■��o��■ ■■�■��■■�■�■�■�■■�■�■��■��■��■■��■��■�■■��■��■■■��■■■�■ ■�■��■��■�■■�■■��■�■�■■■■��■■��■��■��■■■��■■��■■■��■�■��■�■■ ■�■��■��■■��■■■■■�■■�■■�■■�■�■■�■��■■��■■�■�■��■■��■■■ ■■��■■��■■��■�■�■��■�■��■�■■ ■�■�■��■■��■��■■�■■�■��■■\��■■ ■��■��■�■e�■�■■��■■■■��i■��■■�■■��■�■■�■��■■■��■■��■ ■�■��■�■��■�■��■��■■��■■��■�■■��■�■■�■■�■��■■��■��■ ■��■ ■■■��■■■��■■■��■��■■■�■■�■■��■■��■■■��■■��■■��■■�■ ■��■��■■��■�■��■�■��■��■��■■��■■��■■■��■■�■ ■�■■��■��■��■�■��■■�■��■�■��■�■�■■�■■�■�■��■��■■��■�■��■■ ■��■�■■■■�■■■�■��■■■■��■■��■��■■t��■■�■��■�■■�■��■■��■■��■■ ■�■��■■��■■��■�■�■��■��■�■�■�■■��■■�■■��■�■■�■��■��■�■��■■ ■��■�■�■�■�■�■�■�■��■■��■�■��■ ■■��■■��■■■■■�■■��■■■��■■��■ ■��■��■ ■■�■��■■��■�■�■��■��■��■�■��■�■��■��■��■■�■�■■■��■■■ ■�■■�■��■��■�■■■■��■■■��■■■■�■■�■�■��■■��t■��■��■�■■ ■■■��■■■■�■■■�■�■■■■■��■■■■�■■�■■■■■■��■�■■■■■�■��■■■�■��■■ ■�■��■��■��■��■��■■��■�■�■��■■��■■�■��■�■■�■■ ■��■■��■■■��■��■■■��■��■�■■��■■�■�■��■��■�■��■��■ ■�■■�■■�■��■�■��■■■�■�■�■■�■■��■ ■■��■■■��■■■�■��■■■��■■■ ■��t�■��i��■��■ ■��■��■��■�■�■�■�■�■■�■�■��■�■��■��■�■��■��■■��■■�■��■�■■��■■ �`ti.-:..:i.�3�✓'n.W�.,". �. �. ..-�- .1,� �-;1' �f�i:'.1.•�i5 � �. ♦ ' ' .. ' :/.��, . i _, _ .l k ____ �.. ._. _-_ r / •f. " f�. _. . ..Y c ♦ .a . . .—�� . c. ' . . : - . y'�Y , , :. w.. .. _ AUT,(-iORI��ITION NO: �� `�� pp' ��,/9 � ,� � "�� DAVIE COUNTY HEALTH DEPARTME.I�1T °"",c'�" "1� Environmental Health Section 1 3 ZY PROPERTY INFORMATION Pertf►ittee's�'t ��/ / P.O. Box 848 ./f�Q Name:_�(7r lf�� t�'hG%�,� ( , Mocksville,NC 27028 `J Subdivision Name: ��r;- '� �� , Phone# 336-751-8760 �J Directions to property: 1 �� CrT�=i'1 f� O'�� Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Offi e PIN:#��r��- ��f _ �5�1 jw SYSTF.M CONSTRUCTION ��.�-�cS �l/.SP/ Roa�Name: �'��"r�"�rir"�/%�Zip:.,.�1r' **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) f / ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �f` �(t!.��i��. �?'�',1�1��' 7 1;�; . �/`,f u"�.� : IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ,-'�--`�+r.+..,_,�......_.,r _._'_.,..,_,�,s��.+,�:-..�•�^s3:s,�.."'a.,�,..-�_..�-_�-e,.�..�. . ^--.,�„7"rpr.R'�t`—T'q,--•r�.-.�..r7"'�'.Ti`T" . . . '."` _�"�T"'� -"` ' `�`�'�`" ` +�__��'��,;� DAVIE COUNTY HEALTH D:EPARTM_ENT pd �`��9 "�'�"� „ � `'� :��-` _ TMPROVElVIENT AND UPERATION PE ' �IY��S PROPERTY INFORMATION ,� .,� � P,erm�[tee's ,�;r,, ,� -Name:= � ,f`%` ��_� �'hz.� -: E �� Subdivision Name: .. f �= � a� ��3 � • .{ . .� � . . � Direc6ons fo property: �� •'!��`/�'.�'f: :� ,� s• Section: Lot: • IMPROYEIVIENT . PERMIT Tax Of�i e PIN;� � .: l� - '�r�: - ,�' ; ` � i Ro�� me .� ��""�•�a��..�-.�..�Zip �.� _, .. _.. , ._. . . _ . _. :> . _. ._ ��u- ,. �, , ,. ,. . .. .,,_ ._ � **NOTE**Ttus ImprovemenrPernut.DOES NOT authorize the constcuctaon or mstallation of a septic tank sysfem or ari,y wastewate��sysiem,An , � �AUTHORIZAI'ION EOR WAS1'EWATER SYSTEM�'CONSTRUCTION must be obtained from this Depaitment;pnor.to.the constr:uction/installation of a system or the issuance of a buildmg perinit. (In:complianee w,ith Art'icle 11 of G.S:Chapter 130A,Wastewater Systems Section.19Q0 Sewage Treatment,and Disposal Systems)�- ��, >***Np,;CE***;TEIIS PERMIT�LS S,UE�JECT T�O REVUCAT'IOO N IF SITE '�ry �f ,f�� r�I^�' PLANS;OR Tf�INTENDED�USE CHA�NGE 1'O t�T•W;ASTiEW�I�TER / ,� ,� �-R : iN�l��._.�la l:'� f�! �4�.�f'�f J � � .p.... � .1 1�✓�.��.'� ' ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED` SYSTEM CONTRt1CTOR4MUST SEE�THI.S-P,E_RMIT�BEFORE` ' INSTAI:LING TI-IE SYSTEM. ` , ` � t,,.,.: RESIDENTIAL SPECIFICATION:BUILDING TYPE� #BEDROOMS_��#BATHS�� .#OCCUPANTS_�GARBAGE�DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLFJSHIFf #SEATS INDUSTR'IAL WA•STE:Yes or No ,=•" = * LOT SIZE :-�� TYPE WATER SUPPLY �I�( DESIGN WASTEWATER FLOW(GPD) ,��'v. NEW SITE' � �REPAIR,SITE' /� '` r SYSTEIvI SPEGIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL. TRENCH WIDTH_�� ROCK DEPTH� LINEAR Ff.� r' OTHER �':LLR'�r'� �� ._IG�� ' � N`vJf/X�� REQUIRED SITE MODIFICATIONS/CONDTI'IONS: �,r/ P (r' K i t 4' i�� l�. ' �,r, ;� �� IMPROVEMENT PERMIT LAYOUT � � � *ADRf�I?V4�3 F�FL.U�iT F2�1'�R� *R�i'�iER tS? IF 6"� HEtOW FEN�T��: .�i Y . . -/R sT�'�'�'� �.' . � . � ... � . �` �� . . � . . . . . . .��! ' I a . � . ' ��.. . � - � i . . .. .__ _ . . . � � iM f T . , .. . . � � . � � �y .S � . , .. . . . . . . . . l � -.. .. � _ A5 **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSsTaEM � BETWEEN 830-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEEHONE#IS(7J�407G9€1(8��; ' ��i�-:c� ��.. . _ T„t, ' ,` OPERATION PERMIT L� t �' � ��f�v� G� "��'��:= C3�`��D� SYSTEM IN . ED BY: • ^��` � - (xJ''/, �,�1 . � . �y�/�` �-1 5' �b 1 5<.T� �O�L1 � � Q�� L l rs s N�T �,+�,.1`��i.�� / � �. �� fA�v� �.1oz �.,a��T�� ;a � ;: 1� � 1�� , _ � � 1 po � -' / i • No-�� °o' . , `yr�t �..� � , s � , �� : . , � G(L�--J� ' <:� � � .. . . �-� � .�... .J� �,.,. . � AUTHORIZATION NO. �"� OPERATION PERMIT Y: DATE: ..��-r , , •� � **Tf�ISSUANGE-0F THIS OPERATION PERMIT SHALL INDICAT,E THAT YSTEM DESCRIBED-.,'_ OVE HAS BEEN INSTALLED IN'COMRLIANC-E WITH ARTICLEII OF G:S.CHAPTER 130A,SECTION.1900"SEWAGE TREATIvIENT AND DISPOSAL&YSTEMS",BUT.SHALL IN NO WAY BE TA'KEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY'GIVEN PERIOD OF TIIGtE. DCHD OS/96(Revised) , � � :� _ .>>-.. . �..,.�:�.�_��:, .�.«.,e,,;:�,.. �:-::.-'--.._,,.,_ .. .�.,,�.:�_.,u....,.. . _�:.;,�.�.�.._:..::,.�.�.,...-�_,.�.U'r..:.; �K.d._.,:. �. ., :..:. �.i.,.,._,:,�.��..,.,-.,:,.x,.,ass... .�_�._.... ......�� , �_�._a ,. .�.��u rru�r.ntt��ll t�tliMll �Ic AIC Davle County Heaith Oeparhnent � � � [� � � �5 .� ` < , � �� S/�� Envimnmentallfealtfi Se+cdon � � �`'/' P.O. Box 848/210 Nospital Street � 2 5 � � G� �l �;� � Mockaville, NC 27028 �:t� �� (336)751-8760 �y��p;��.,��TAL HEALTN � Ef� **�IHPORTAIIT�** THI3 APPLICATIO�N CANNOT 8,L PROCESSED t1NLE83 ALL tiI ' � INE�ORMATIiON I3 PROVIDEO. Refer to the INFORMATIO'N BOLLETIN for instruations. t. Name to be Hilled 6. tt 1 l en M/fb.tn/E L��i,►�� OoAtaat peraon �1 1 en MB'b,r}/,/e NailinQ J�ldress p•O. $ox 19109 • e� p�Q 336-998-3773 City/8tata/tIp C7reensboro, N.C. 27408 Bnsiaesa phone 294-4¢10 t. tlams ott Per.�nLt/l►'tC i! di!lerent lhat� 11Lwe 1Lailinq f�ddrass City/8tate/Lip 3. ]1p�liaatioa Sor: .Y;�Site Evalnatiou 0'i�mprov�ea�eat Permit/ATC �oth 4. sy�tem to sesvice: L�'�House 0 Mobiln Home 0 Busiaess 0 Iadustry 0 Other a. It Residence: i People � i Bedrooaaa Z- � Bathsooma Z- 1��ishrasher U Oarbaqe Disposal C1 Nashinq 1lachine 0 8ase�eat/DinmbinQ 0 Sasement/Mo Pivabing 6. i! 8nsiness/industty/Other: 8pecilY type � peaple � 81nka t Coe�odes / sha+rers * vrinals i Hater Coolers I�' FOOD3ER�TICE: � 3eats Estimated ilater tlsaqe t9allons per day) 7. Tppa of water svQplp: 0 Conaty/City B'�iiell 0 Community e. Oo you anticipate addidow or e:pausions of We faclllty t6b syatem is Intwded to urve? 0 Yea �lo if yea,what type2 ""•IMPIDRTANT"•"CLIENTSJIlUSTCb11IPLElETNE RELIUIRED PROPERTY[NFORMATION REQUESTLD BELOW. Eit6er a PLAT or SlTE PI.AN MUST BESUB1Ltl17'ED b the cllent nIW TIi1S APPWCATION. Plvpetty DimtollOnl: 170 ticres WjtjT$DIREGTIONS(frnm Mocksville)to PROPERTY: TniOfticePlN: # 5830-�¢6-2815 158- Zurn left Masn Ch. Rd. Turn Right pT0�lt1'ly Addt'qsi ROfld NAllit 828 Woodward Rd �nge 1 1 Rd. Turn Le f t on Woodward Rd City��P Mocksville� 27028 1'ropert;y on le,ft at Cow Creek 1Zanch ifi If in a Subdivlaioa provide informatioo,x�followe front of exi st iny house Name: Sectton: Block: Lot: Date Pnupetty Flaggedi 5-25-99 Thi�i�to certffp that tbe informalion provided i�correct to f6e beat of my knonledga I underat�nd that uny permi!(a) issued 6ereafte��re subject to su�pen�ton or rtwocatlon,if t6e site pians or intended uae c6ange,or if the information �ubmitted ln thts appUcalton la fal�illed or c6anged I,also,andersta,rd dJrat I am nr�oas�ib/ejor a/!cbwga I,rcun•ed from thlr appltcatio,r. 1,her+eby,give conaeot to the Aut6orized Repreaentative ot't6e Davie County Healt6 Department �o eoter upon Above described property located ia Davie County und owued b�- io conduct all testing pr�ocedurea as uecasary to determine the site witabillt�. DATE 4/2�/9y SIGNATUR,61 �' THIS AREA 11iAY BE USED FOR DRAWINC YOUR SlTL PLAN(Incinde all ott6e foilowing: L�ating and proposed prnperty Iloa and dimewioos, hn�ctures, eel6acWy and�eptic locattona). Account Na ��O Revised DCHD(07/98) Invoice Na J� • J �, • • �h � . ' • h .� � � � • ' rL , � . .. o � � , � � �� . - ' . � . • . � ; N!P • � � ' • ' ' � �"LAKE s82o . _ . 54/ �S " SEE INSERT � � • 72y 89 f �� . �j L N?GE �� ,pu-'�' ' . Z ► 1 fIP , �• ., . ' • , �_�. 1� C1� . , • o v► � � � � • • o � � °' w��- Q��`"' G � � ' , . �-y, N!P � . � � � O a°� a O M • 2 Nli' , L TD. P Q REA = /70. 127 q �° C RES PG, 654 ! rNctun�s sR. ��o� �v R/W 1 5 P�•' l07 '� JP . �� Q �O� a QP . . -\ . , . .` . . . � � ��• � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT'S NAME //! 'Er✓d�� DATE EVALUATED �/`��`% PROPOSED FACILITY f� PROPERTY SIZE � �/��' SUBDIVISION ROAD NAME Gl��'�/� Water Supply: On-Site Well ✓ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � Slo e% HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH t' 'i Texture rou Consistence . i Structure /1 Z Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HORIZON N DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �� EVALUATION BY: G LONG-TERM ACCEPTANCE RATE:�.��_ OTHER(S)PRESENT: REMARKS: LEGEND � Landscape Position R-Ridge S-Shoulder L-Linear slope FS -Foot slope N-Nose slope � CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head 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 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) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD(O1-90) ' ■■��■■�■�■�■��■��■�■��■■��■�■��■■�■��■�■��■��■■�■��■ ■■��■��■��■�■��■��■■��■��■��■��■■�/■ ■�■�■■■■��■��■��■�■��■��■�e■■■�■��■■�■■��■■��■�■��■■■�■ ■��■ ■��■ ■■��■��■�■�■��■■��■■��■��■��■�■■�■��■��■ ■��■��■�■��■�■��■�■��■�■��■�■��■ ■�■�■��■��■�a�■��■�■�■��■��■�■■��■■�■��■�■��■�■■��■■��■■��■ ■��■�■�■�■e■�■��■��■��■��■■��■��■��■��■�■��■■�■■�■ ■■�■■■■��■�■�■�■��■��■��■��■�■�■��■�■�■��■�■��■�■�■■■��■ ■■�■��■��■��■�■��■�■��■��■�■��■��■��■■■��■ ■■��■��■��■��■�■�■�■�■■��■■■ ■��■■��■��■��■�■��■��■ ■�■��■��■■��■�■��■�■��■�■�■��■��■�■��■��■��■■��■ ■��o��■ ■��■��■��■��■��■■�■��■��■��■■■��■■��■■��■�■ ■�■��■�■��■��■��■��■��■��■��■�■��■��■��■�■�t��■��■�■��■ ■��■��■■��■■�■�■�■��■�■�■��■��■�■��■��■�■��■��■��■��■��■ ■■��■■��■�■�■��■��■�■��■�■��■�■�■��■■��■��■��■��■��■■�■ ■��e��■ ■�■��■■��■��■��■��■■�■��■��■��■■■��■��■��■ ■��■��■■�■�■��■��■��■�■■�■�■ ■��■■�■■��■■�■■��■■■�■■��■�■�■ ■■��■■��■■��■��■��■��■��■��■��■��■��■��■■��■��■��■ ■�■■��■■��■��■��■�■■��■■��■��■�■��■■��■■�■��■■■��■�■�■ ■�■��■��■��■��■��■�■��■■��■■�■■��■■��■��■��■�■■■��■��■■��■ ■�■��■�■�■��■��■��■��■■�■�■�■��■��■��■■�■�■��■��■ ■■�■��■■��■��■��■�■��■■��■�■��■��■■�■�■��■■��■�■ ■��■��■��■��■�■�■�■■�■��■■��■��■��■�■■��■�■��■��■�■�■ ■��■ ■��■��■��■ ■■�■�■■■�■■�■■�■��■��■�■■��■�■��■��■■��■�■��■��■��■■��■ ■■■■��■��■��■��■��■�■��■■��■■��■■��■■�■��■■■��■■��■■�■ ■�■��■��■��■��■■�■�■�■�■��■�■�■��■�■��■��■��■��■■��■��■�■ ■�■��■��■��■�■�■��■■��■��■�■�■■��■■��■��■■��■�■■��■�■�■ ■��o��■ ■��■��■�■�■��■��■��■■�■�■��■�■��■��■■��■�■�■■■�■ ■�■��■��■��■��■�■�■��■��■■��■��■�■��■�■�■ ■■�■��■�■��■��■��■��■��■�■■��■��■��■■�■��■��■■�■ ■��■��■ ■��■ ■�■��■■��■�■�■■■�■�■�■�■�■■��■■�■��■��■■��■■�■■■��■■��■�■ ■��■��■��■■■��■�■�■■��■��■��■��■��■��■�■��■��■ ■��■■��■�■■��■��■■��■��■��=��■��■��■�■��■��■ ■�■��■��■��■■��■��■��■■��%��'/�■■��■�■�■��J��■��■■�■ ■��n��C��`��■ ■��■��■■��■■��■�■■■■��■�I��■�■��■■�■��■�■��■��■��■■�■�■�■ ��7�� ■��■��■■��■■��■��■�■��■��■ii�■��■��■�■��■■�■ ■��I��/I��■��■ ■■■■��■��■■��■��■■��■i�/�■■�■��■��■�■■��■��■��■■��■��S ■��■��■■/�■��■■��■�\�■��■��■■��I■��■■��■■�■ ■��■��■��■��■�■��■��■■�■�■��■��■��■��■�■ ■��■��s�o��■ ■�■��■■■�■■■�■■■�■■��■■■��■■�■■■�■■��■■��■■��■��■��■�■■■��■■�■ ■�■��■�■��■��■��■��■■�■■�■��■ .,a■��■�■■��■■��■�■��■■��■■�■ ■■■��■��■��■��■��■��■■�r��■�■��■��■��■��■�■��■■��■ ■■�■��■��■�■�■�■�■�■�■��■■��■■�►�■��■��■■��■■��■��■ ■��N��r��■��\�■ ■�■■��■��■��■��■��■�■�■�■�■��■■��■��■■��■■■�■■��■■��■■��■ ■�■��■��■■��■�■�■■��■■�\�■��■��■��■��■��■��■■��■■��■�■ ■■�■��■�■��■��■�■��■��■��■�■��■��■��■��■��■ ■■■■��■��■�■�■�■��■�■��■■��■ ■��■■��■�■■�■��■�■��■��■■��■ ■■■�■■■��■■��■■■�■■��■��■��■ ■��■�■��■��■■■��■■��■■��■ ■��■■■��■��■■��■��■■��■��■��■■��■��■��■■■�■��■■��■■��■ ■�■�\■��■��■■�■■■��■�■��■�■��■��■��■��■\■��■��■■■��■■��■■\■ ■■�■��■��■�■��■�\�■�■�■��■��■��■��■��■■��■��■�■ ■��/��/��■��■ ■�■��■��■��■��■�■�■�■��■■\�■■��■��■��■��■■■�■■�\■ ■�■��■■��■■��■��■■��■�■��■■��■��■�■��■��■��■�■��■��■�■ ■��■�■��■■��■��■��■ ■■�■��■�■��■�\��■��■■��■�■ ■■�■��■��■■��■�■��■■�■��■��■■��■��■��■■��■��■��■■��■ ■��■ ■■■��■��■■■��■��■■��■■�■�■�■�■��■■��■!■■��■■�■�■■■��■■■�■■■�■ ■■��■■��■�■��■��■�■�■�■�■��■��■�■�■��■��■�■�■■��■■��■■■��■■�■ ■��■��■��■��■�■�■�■�■�■��■��■�\■�■��■��■��■�■��■��■■■��■■■�■■�■ ■��■��■�\��■��■��■�■�■■��■��■�■��■■��■■■��■��■ ■■■��■��■�■��■�■�■��■��■�■�■�■��■��■�\■�■��■��■�■��■��■■��■ ■■■■�■��■��■�■■��■■\■�■�■■■ ■■��■�■■��■■��■��■��■�■ ■��■��■�■�■�■�■�■�■��■�■■��■■��■��■��■��■�■■��■■��■■��■�■ ■/��■��■�■�■��■��■��■■��■��■��■��■�■��■■ ■��■��\��■ ■■■��■��■■■��■■�■�■��■��■■��■■��■��■��■■��■��■ ■■■��■■��■�■■■�■�■��■�■�■�■■■■��■��■■�■�■��■��■�■��■��■■■��■■�■ ■■�■��■��■�■�■�■�■�■�■�■�■��■��■�■��■��■■�■�■��■��■■■��■�■ ■��■��■��■�■��■��■��■��■��■��■■■��■��■■■��■�■��■ ■��■ ■��■ ■�■�■■��■■��■��■■■��■�■�■�■■■�■■��■■�■■■��■��■��■■��■■��■■�■ ■■�■■■■�■■�■��■■�■■■��■�■�■��■��■■��■�■■��■■��■■■■��■��■�■��■�■ � - . �� o z., �� . . • DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION ~� - - ' APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) Mo�cC 4 NAME��t�C��a e- � �� E-' �Q-/� e PHONE NUMBER -/ / � '�' � � 3 tij ADDRESS ��'�• W � �� a"`u� �cP • SUBDIVISION NAME � � � � G�S t/ //�e LOT # (`� • u DIRECTIONS TO SITE I �-8� � �-ac�'� �� ° fo '�p �.� � _� o � I�-�-�- ? � ,�� ..-C-� � a,. � �.J �� c.v ��( � � DATE SYSTEM INSTALLED � V NAME SYSTEM INSTALLED UNDER � � -Z - � TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED � TYPE WATER SUPPLY l.-.l c�'ZL SPECIFY PROBLEM OCCURRING �� a c��-- � DATE REQUESTED 2� a�- � INFORMATION TAKEN BY��-- � Thia is to certify that the information provided is correct to the best of my knowledge,and that I understand I am responsible for all charges incurred irom this application. � SIGNATURE OF OWNER OR AUTHORIZED AGENT flev.1/93 � ��v-e__ �e-IJ"'� .'' � /�" C o�..� cJ4 �v�-� (.�a o G�c�Jt.0 e(. , , . . � c::_�11 �(,: `��,1.:1 Permitfee's ,'�, � . I�AVIE COUNTY HEALTH DEPARTMENT t.,..._. � I�1ame: ' �. '.'��--=� '�� `'"�'�'��- Environmental Health Section PROPERTY INFORMATION''"`"`` � . " _ P.O. Box 848 Directions to pmperty: ��'!-'�t"'} �� t� '•---t'''`3�` �r�,� �Tocksville,NC 27028 Subdivision Name: =� Phone#: 336-751-8760 ""''. � � ,�,� �;r,.# �r..�,r�r zj�r,.��,� � . � Section: Lot: � r��.. . AUTHORIZATION FOR !�i i',a;;�,( `'f� A._ � G,J �� WASTEWATER Tax Office PIN:# - - , SYSTF,M CONSTRUCTION ALITHORIZATION NO: ��4�� A Road Name�f,�r��'t<�.7= '� :,-� Zip; f��'�� **NOTE**'This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Forni/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) - — /,! :.� i -- / �"��: r'' --^-'� / �,,.-�'' / ***NOTICE***THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION j` / , r" ..� jr"'"'�,� `� ;�I ,�t1�- IS VALID FOR A PERIOD OF FIVE YEARS. —�.--, , . �-�IVVIRO1�iMgNTt1�.;�-1EALTH SP�CIALIS DAT ISSUED t�. l,�/ RESIDENTIAL SPECIFICATION:BUILDING TYPE F{��'d#BEllROOMS �- #BATHS_Z#OCCUPANTS � GARBAGE DTSPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY �� DESIGN WASTEWATER FLOW(GPD) r1�-� NEW SITE REPAIR SITE �--""" '"' �� ' r -�, � SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH �� LINEAR FT. —'`�-�� {� , -- _ E�:�-.N c�-' ___ ____ _-- -„ -- -- OTHER � DIS�k�4PjtJTIcJ� � ___ ( — — ��:� REQUIRED SITE MODIFICATIONS/CONDITIO�S. ' ' � IMPROVEMENT PERMIT LAYOUT 4�! � ,,;� C-1 r,1(::, i �r ✓t �� C"t�'.,�,Tj-! 2 � ,,,,�.....,.�. � o S �:% � � �' ' r�1=��.s �� 1--1 ov s� =► �. � �J��.-�� o � i_ �.,1 Zti�� ;� � � �,N� ro�ca-� - �� "�' � I� �� , �;�,n �Fi.�:c�.i'� ��,�.��. i�..) ��" ��`'r �u-rv c ' SS c�2~,�fL 1 . +i"' L.l:: f�1lJL'-� " � ` �/"� `.,i(,� `7 'fr`:^1 c-H .• i�U"�+' �' C�,�..J'�' �.J 't C3'CL�� '��3`�. �� ` o,.��,�t l r�a c�-r k �; � � � �a�� ,�, . � `�--s.� St.�.IE'+,(a•r. ,. St�2�/�C�rJb *"`CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-130 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760. OPERATION PERMIT �Q c^��, r SYSTEM INSTALLED BY: �7 �K � � � � � � � �S-t- ,L L j tJ �S - t Z °� �SaLI o Q1 Qc �SS�5 J . � 1.n�� i'��`;F-'iC� Lr.F� 7Qi.7'�' c..r1 �F�K 2�� . ��( f�5 �a Tv c..t��% N �� -r Lov�r t,-�e:�E'. No ��L�,'�� °-J�`' �� .� , �oC� ovT o�t� �-�� ,�� Po�� o�� pe,c�� +4 ��c�- �� 2-a�.,r 'e. .,, $ � cJ�°��► ;D . .. � � ? � � �Ac�' - 'TD �t�lu� �'P �c� °`ld�1 � . � ��1� �AQ.r c�F ��c.�.J� . r, ,, �-ju c.�JC,t�2.4�� P�,J;v� AUTHORIZATION NO.��OPERATI RM BY• DATE: `� � ��`THE ISSUANCE OF THIS OPERATION PERMIT S TE HAT HE SYS M D AB E H EN INSTALLED IN OMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"S AGE TREATMENT AND O AL SYSTEM " T SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 07/02(Revised) � �� - ' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION � "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c , Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number ' ` 4 ' "2_- ;'- ►-- 't ,�, , ,M.. Name `�._ :t .il F=�,iti a �_� �, � 1. _ Date ::if:i�.?�; L ation � t ,{l, ;� �.t; _ `� - �� .:.,, r ;, � ,._ �,- � . � , .. _ �_._ _ Subdivision Name Lot No. Sec. or Block No. Lot Size __ House Mobile Home ____.Business �--� Speculation ��;�,:_;,_ No. Bedrooms _ No. Baths _.�—_ No. in Family _ Garbage Disposal YES � NO p_ � � : .�. Specifications for System: �,;z,_� -:,�_r. � t, i3�.r.�. Auto Dish Washer YES ❑ NO �- -�� _ Auto Wash Machine YES ❑ NO �� t ;�"w" �- �-� -t� - "-' '`� ��'` �`- �'""� Type Water Supply �, �-� � __— "This permit Void if sewage system described below is not installed within 36 months from date of issue. .'" � � � ,�,,�r``'� i ,' � / �� r� /��( T_�} / ---__ r � � � _w__._._� �,__...___.__—_..__-�__---- _____ l..__._..__, ��„c.,�► Improvements permit by �_.��.�;3��r.:_.:_�-� v "Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: � System Installed by ��- $�_C'�'�- a � �'F�� /' 1 r_'e��d i ` �,.� ,��' 7 v ' fY 6 � a '�p t-�+�� k � �. �/j 1 1 },r`paZ" � . i` .�r � b`l°� t' } ' '�o , {�' ;ti} ��' ��``� �� a�. 1 �� Date Z.Z� ��K Certificate of Completion � 'The signing of this certificate shall indicate that the system describe above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. •.-:- ~~' DAVIE COUNTY HEALTH DEPARTMENT . " � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ', _ "NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ' ,: Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number ' Name �. _l i� �,-e r u� ., � - Date z _ _•! _ %" .:,�:��i i Location +.�..� �'� _ � . . ',� ., _ _ / ,, �� \ - — ` -- . ' l � Subdivision Name � Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business « Speculation No. Bedrooms No. Baths _�_ No. in Family _ ` � Garbage Disposal YES ❑ NO Q. ; � .,_, Specifications for System: +,;,,,, � ,�,r ,r,,.,___ Auto Dish Washer YES ❑ NO [�-� ` `•�� -� t 4i�,..,_<..,. ti;' U r' - i.�a �� =�; �i." i .:ct_ Auto Wash Machine YES � NO p- Type Water Supply . , ;� ___ `This permit Void if sewage system described below is not installed within 36 months from date of issue. , .,,,,- I ' . `'` , � `^j,S t /�J�'-/ i / _, f I � f� { � � i ____:/ � ___ _..+�____ i t._..._..� .__.�._-_ ..._ _.._._ _. . , �__.. ._l ,� ,,�� Improvements permit by �_�" � � '� i� `Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by ��', • �'� ., -:s� � ,j��..�----- ____ , �. �'r�`'�� , }! , ',' � ��' it'A` {' ��1r� 1.y � ` ✓v.�.`i,l� �1'7 t { �( . QE L`�� ,�...�---t' (� "' , .. (� � f 1 �+l i �� .' �"—_�' � � �1 � �� i �� l� �i � ,ti � L7 ,�I L i . t' E ! i � ' �� 4�': i�' ��l; 1 �� y �'` .i f��._i J --- "_'"' —��_�_____J (' i� � j s - �� , �.__�— _ ' ` 1 ;,F � � � � i t 1 `;';� ,;�, .; ` ..� i (_. _______._-----1 � ' � � � ____, � _ ' " � `I -``! Certificate of Completion '� _ � ��'� � `�� Date � � � __ ;: "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. � • `� DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION - 'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. - � Permit Number Name = � --- Date �� -- Location ` � — Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business _- Speculation No. Bedrooms — No. Baths _ No. in Family _. Garbage Disposal YES ❑ NO ❑ ;- " • - - � Specifications for System: , , Auto Dish Washer YES ❑ NO ❑ ' , Auto Wash Machine YES ❑ NO 0 - • - ' � Type Water Supply __— '`This permit Void if sewage system described below is not installed within 36 months from date of issue. . . . _ _ . . , � ,.. _ .. ; ... _... ._.___.. __. , ' i Improvements permit by -- � 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Compietion — Date #The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. 4' y DAVIE COUNTY HEALTH DEPARTP9EiVT PERCOLATION TEST RESULTS �� _ -�- DATE / �` A3Ai�E 3` �•'�C `" �.C�/✓ - LOCATION �1�'l/1FlL�(f�/�c�� FINDINGS: HOLE N0. _ CUgi9ENTS 1. � �r . � �� `1 i '— ` � r� // �� . � � y� �� . �� .�- ��', /` � r,� 2. �� 7l C✓,��" /�i�'` � �t�� , � l �1�� -;- � , S.,�l�� l, 11�� n� �� 3. r � ,� °� � ,i - .y.�trcYu�'�� _ � �,�, - ��r� s a. a �,�i.� � a� �' � 5. r�,� ��l � t' _1 A,�,� ��✓,�F - 6. �„�� I �- ��`�7� �y: - D 3 LOT IAGR.AI'�i P�� D� �'J �� o , , B� F�� ,� � � �� 5�+ . �, � �� _�� DAVIE COtT:�1TY HEALTH DEPARTMFNT ENVIROIVI+�ETtTAL H�ALTH SECTION �� P.O. HOX 57 `� ,�� MOCKSVILLE, P1.C. 27028 � l�,.� (704) 634-5985 ,y � � STATEf�'�I1'I' FOR SEPTIC TAP�K I�4PROVEMEP�TS PER�'KITS AIVD/OR SITE F:VALUATIONS - TdAP2� � �,t�ry<s. ,�'�`•r'�_ �_,y��• -'S f-'� DATE S��- ��-2�� ADDRESS T•�. ��- "7 ! 3 3 PE�2MIT N0. '?��`'�1� , �a ��s "�4..��n� `�.�?. C�t�c�,.�_�.L�.' :,��'c�� EXPLFIIVATIOIa OF CF:ARGE �:��,c. 'f. �.�c�.t'� � `,��t`• ��_.a r..�`�" - ` . ,��•��• �t1`iL �L!hc.�, '-"'t�, A,��OUNT DtJL �� 5.c32..1 S�1�3ITI�RIAN c._ . ;'1'�.d•-�,� � PLEASE REc1IT THE A$OVE Attii0U:1T OF R�C�IPT OF `i'HIS �'uTATEMEIJT. *NOTICE: Evaluation(�) can n�t b� con��l�ted until payment is rec�ived. Improv�m�nts P�rmi�(s) can n�t bs issued untiil paym�nt is received. . � •CONSTRUCTION Foronce use on�v . . AUTHORIZATION P,A,jD *GOP Fite Number 157919-1 �°=�`� Davie County Heaith Depa�nt ��Z-� � � County ID Number: �-ooa-oo-o�s �" . rt�� 210 Hospital Street aceived b ; � Evaluated For: .:.,. .NEW, ,. �. �.•. P.O. Box 848 a,�,.�-• Township: Mocksville NC 27028 PER��11T VALID UNTI�: Phone: 336-753-6780 Fax: 336-753-1680 1 0 � 0 a � a 0 1 9 Applicant: Ryan Nobie Construction, Inc. Property Owner: John and Joan Woodward Address: 14752 Cool Springs Rd Address: 2295 Cana Road City: Cleveland Crty: Mocksvilie State2ip: NC 27013 State2ip: NC 27006 Phone#: (704)278-1182 Phone#: (336)998-4386 . Propertv Location � Site Information Address/Road #: Subdivision: Phase: Lot: Woodward Road Mocksville NC 27028 Directions Structure: OTHER HWy 601 North, right on Cana Rd. Left on Murchinson Rd. go 200yards turn left on drive (Sign with Ryan Noble �of Bedrooms: Constrtuction) #of Peopte: *Water Supply: NEW wELL Svstem Specifications Minimum Trench Depth: Site Classif�ation: Pro�s�onauy su��abie a 4 Inches Sa rolite S stem? Minimum Soi! Cover. p y QYes QNo 1 a lnches Design Flow: 4 $ � Maximum Tr+ench Depth: 3 6 Inches Soil Apptication Rate: � a � 5 Maximum Soil Cover: a � Inches "System Classification/Desc�iption: 'Distribution Type: PUMP TO GRAVIN TYPE III B.SYSTEM WlSINGLE EFFLUENT PUMP Septic 7ank: 1 g � � Gallons *Proposed System: 25%t�EDUCTlO►v 1-Piece: QYes QNo Pump Required: QYes QNo QMay Be Required NQrification Field a 1 3 3 Sq. ft. Pump Tank: 1 a 5 0 G allons No. Orain Lines 5 1-Piece: QYes QNo Total Trench Length: 5 3 3 GPh1—vs— ft. TDH ft. Tnenc� Spacing: _ 9 �Fe t O C.0 Dosing Volume: Gallons Trench Width: _ Qlnches 3 (��Feet Grease Trap: Gallons Aggregate Depth: - inches Pre-Treatment: ONSF OTS-I C�TS-II Septic Tank Installer G rade Level Required: 0 I 01I a(II �IV CDP File Na�mber �1�57919�- 1 County ID Number. �4-000-00-0�3 • ' ❑ Open Pump System Shest RepairSystem Required:�YeS ONo ONo, but has Available Space _ epair Svstem incnes o.c. T�nch Spacing: "SIt6 Cl2SSifiCeliOn: Provisionally Suitable — 9 �� Feet O.C. Trench Width: Inches Design Flow: 4 $ � — 3 �- Feet Aggregate Depth: Soil Applicatan Rate: � a a 5 . inches `� Minimum Trench Depth: a 4 Inches *System ClassificationlDescription: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a (nChes Maximum Trench Depth: 3 6 "Proposed System: 25%REDUCTION Inches Maximum Soil Cover: a 4 N�rification Field a 1 3 3 Inches Sq. ft. No. Drain Lines 5 "Distribution Type: PUMP TO GRAVITY Total Trench Length: 5 3 3 ft Pump Required: �QYes �No �May Be Required Pne-Treatment: ONSF OTS-I OTS-II "Site Modifications �.. No grading or construction actNity is a(lowed in areas designated for system and repair without approval of Health Department. �•• 7: "Permit Conditions The issuance ofthis permit by the Heatth Department in no wayguarantees the issuance of other peRnits.The permit holder is responsibte for checking with appropriate goveming bodies in meeting their requirements. "' �„ 2( Thfs Authorizatlon for Wastewater 5ystem Constructlon shatl bevalfd tor a person equal to the period of vatidfty of the tmprovemetrt Pertnit,not to exceed five years,and may be Issued at the sametlme the Improvement Pertnft Issued(NCGS 130A-336(b)}.If the Installatlon has not been campleted du�ing the period af valldity ofthe Cor►structlon Permit.the Intormation submltted In theappllcatlon for a permit or Consttuction Autho�za�on is tamd�o have been incorrect,falsified cx changed,or fhe site is altered,the pertnft ar Construction Authorizatfon shall become Invafld,and may be suspended or revoked(.1937(g)).The person owning or cotttrolOng the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system Ixa�on,Installation,opera�on,maintenanc�monitodng,reporting and repafr (1938(bjj, ApplicanULegal Reps. Signature Required? OYes dN0 Applicant/Legal Reps. Signature` Date: � � "ISSUed By: 2�40-Nations,Robert DetE Of ISSU2: 1 Q / 0 a l a 0 1 4 Authorized State Agent: •—�� —� Malfunction Log QYes pHand Drawing Olmport Orawing **Site Plan/Drawing attached.** Paae 2 of 3 : . • CONSTRUCTION AUTH�RIZATION ' , oavie County Heaith Department CDP Flle Nlimbe�: • 210 Hospital Street D4-000-00-013 P.o. Boxsas County File Number: _ _ Mocksville rvc 27ozs Date: 1 � I � a I a 0 i 4 Q Inch Di-asvina Drawing Type: Construction Authorization Scale: . . petock =� . ft. QN/A ____ _ _ _ _ _. _ _ .. _ __ , ' : _._ ..__ . . . . ! : -.��. _ _ I : . . _ , _ _ _ _. . . . _ , . „G � � r; . _ ��,a__ ��/ _ _ __ _ . _ , . _ � . .___ . .. . . .. __ � � _� _ _ � � _ _ , __ . �� __ _ _ __ _._ �� ` _ as .�' ;_ : _ ,_ _ _ __ _ S�� _.. _ ; � : _ _ _ . __ . . __;_ �o_x ,�e _ , � � , � _ _ _ _ _. � � _ � _�._ l_�,,`„/'_ _ . . � � �,�� _ _ . _ ; • : � .__. _ � __ _ __ � �, �z :� , � a _ � _ _ , ` _ � � ._.. _ .. �,, � : � U'.; . u,,,___ �'�1(t/�_ � � �a� a 1 � _ _ _ � � � ` ( g u,�.kS �' ; t � _ '� _ __ _ _�'t" _ _ _ _ _ S-� �° � � _ _ _ , � a 6 a (�,,,.e � 4�'s�" � p �- � .�� _ _ __ �� _ __ �,"� 1 l � -�� p. r �� : � C ( U�� Q ��' P _ _ , - _ _ _ __ _ , •� iMP�OVEMENT PERMIT ForOffice Use Ontv *CDP File Number 157919- 1 �-��`^"� 'Davie County Heaith Department � r�-� j : �,. County ID Number.�-000-00-0�3 r�. , 210 Hospitai Street '�� P.O. Box 848 Evaluated For: NEW . ,.....- �,,.,....• Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERI.IIT VAIID U��TIL: �OI�ZO�9 "NOTE TO INSPECTIONS DIVISION: Building Pennits cannot be issued with this Improvement Permit. Appiicant: Ryan Noble Construction, Inc. Property Owner: John and Joan Woodward Address: 14752 Cool Springs Rd Address: 2295 Cana Road ��Y= Cleveland �aY� Mocksville State2ip: NC 27013 State2ip: NC 27006 Phone#: (704)278-1182 Phone�: (336) 998-4386 Pro ert Location � Site Information Address/Road #: Subdivision: Phase: Lot: Woodward Road Mocksville NC 27028 Directions structure: OTHER Hwy 601 North, right on Cana Rd. Left on #of Bedrooms: Murchinson Rd. go 200yards turn left on drive (Sign #of Peop�e: with Ryan Noble Constrtuction) 'Water Supply: NEW WELL S stem S ecifications nitial S stem `Stte assl �Ca pn: ProvisionallySuitable Minimum Trench Depth: a 4 Inches Saprolite System? �Yes �No hlaximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 � � � Gallons SoilApplicatan Rate: � _ a a 5 1-Piece: QYes QNo u Pump Required: QYes QNo OMay Be Required "System ClassificationlDescription: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 a 5 0 Gallons `Proposed System: 25%REDUCTION 1-Piece: Q Yes Q N o Repair System Required:OYes ONo ONo, but has Available Space Repair SVstem 'Site Cl2SSIf�etloll: Provisionally Suitable Minimum T�ench Depth: a 4 Inches Soil Application Rate: � . a a 5 Maximum Trench Depth: 3 6 Inches Pump Required: Yes No P,Aa be Re uired *System Classification/Desc�iption: O 0 � Y q TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25°lo REDUCTION Page 1 of 3 CDP File Number .'15791g- 1 County ID Number: �-0oo-00-0�3 • ' "Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair�vithout approval of Health Department. �:' 7: *Permit Conditions The issuance of this permit by the Health Department in no�vay guarantees the issuance of other permits.The permit holder is responsible for checking�vith appropriate goveming bodies in meeting their requirements. ;;: 7; S ite Pla n rne Improvement Permlt shatl be valid for 5 years from date oi issue with a slte plan(means a drawing not necessarily dnwn to O spte that shows the enlsting and proposed propetty lines wtth dimens�ns,the locatlon of the tacility and apEwrtenances,the site torthe proposed Wastewater system,and the location ot water suppties and surtacewaters). Plat The tmprovement Permit shall be vatid without e�iration with plat(means a property surveyed prepared by a registered land O surveyor,dnwn to a scale at one Inch equats no morethan 60 feet,that includes:the speciflc location of the proposed facillry and appurtenances,the site for the proposed Wastewater sys4em,and the location of water supplies and surfacewaters. Plat also means,for subdivision tots approved by the Ixal plan�ing authority a�d recorded with the county register of deeds,a capy oi the recorded subdivisions plat that is accompanied by a site plan that is drawn to scate). The Departrnerrt and Local Health Departrnent may Impose conditions on the fswance and mry revoke the permits fw tailure at the system to satisfy the conditians,the rules,or this article This permit is subjectto rewcatlon if the slte plan,pla�orintended use changes(NCGS�30A�35(�).The person owning or controlting the system shall be responsible foraswr3ng compliance with the laws,rules,and permit conditions regarding system Ixation,installation,operation,maintenanc�monitoring, reporting,and repair(.1938(b)). ApplicanULegal Reps. Signature Required? OYes �No ApplicanVLegal Reps. Signature: Date: � � 'Issued By: 2�40-Nations,Robert Date of Issue: 1 0 � 0 a � a 0 1 4 OValid without Expiration? Authorized State Agent: � _� O Create CA? OHand Drawing Olmport Drawing **Site PIan/Drawing attached.** Page 2 of 3 , . IMPROVEMENTPERMIT . • ' �Davie County Health Department CDP File Number: 157919 - 1 ` � 210 Hospital Street D4-000-00-013 P.o.Box 8as County File Number: Mocksville rvc z�o2s Date: I I QlnCh Dra�ving Drawing Type: Improvement Permit Scale: , . , paiock _ QN/A ft. _._ __ _ __ , _._ _ _ _ __ _ _. . _ _ _. . _ _. _ _ _ _ _ __. . _ _ _ _ _ _ _ : � , _ _ � ' _ � _ _ __ _; __ _ _ . _ _ __ : _ _ __ _ _ _ __ _ _ _ _._ _. ___ __ _ _ __ . ___ _ _._ ___ _ _ _ , , � _ __ ' _ 1 __ _ ; _ __ � _ _. _ _ _ __ _ _ __ CSO �� __ __ _ i5o� _ _ _ _ . _ _ __ _ � _ 1�` , ' _ . �r G _ _�� _ . �'� _ _ _ _1 R� , _ _ _ _ � � _ _ - _ _ � ; � _ _ _ �� a✓ rs a C� '. __ ' _ _ ' b _. __ . _� l r �y ; __ c ___ . _ __ _ __ �j a✓H ___ _ _ ___. �Z�� L2" jjCd � ___ _ _ _._ , ` . _ _ ___ . __.__ __- , � �4 _ _ ��` �� • - S-��G , � � � ` a � .P` _ _ _ ,� _ _ ' .c (/�� AR �°. . . . .. . .... . . . .. .. . ... . .. . .. . . ! y � �� . . .._.. �.. .... . . .. ........ ...._; ....... ....... :.... .:.... . ..._. ... . . . .. . ... . �! _.. ... .. ._. .._.._... .. . . ...... . . . . . . �. . � � � _ _ __ __ _ __ __ .Page 3 of 3 _ _. _ __ � • , v • • r 1 � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health ,��CEj ' P.O.Box 848/210 Hospital Street �+D � '. Mocksville,NC 27028 '�e��f (336)753-6780/Fax(336)753-1680 Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) � Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BiJLLETIN for instructions. K APPLICANT INFORMATION ' Name d �, Cg� '�� ,4��—`��. Contact Person .� �db Address �- 0 5 �; Home Phone e �.� 2 City/State/ZIP �c, ae,... 0�3 Business Phone 3 3(� go� �-'7 C�S Email r h , /� �1 Name on PermiUAT if Differen tha �ove �ol,,� a.--4' �•c•� �1 caa�'� Mailing Address a ity/State/Zip �,'blL PROPERTY INFORMATION *Date House/Facilit Corners Fla ed '� / NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Pian ❑Plat(to scale) (Permit is valid for 60 months with site plan,no exp' ation ith complete plat.) Owner's Name ' �,^, �o � Phone Number 33�0 �i L13�(o Owner's Address 7-2`j s City/State/Zip �L(G5�`I�� '7 d� Property Address �- City /V�ee�Sv��t� Lot Size �'a�,�j� Tax PIN# �[�,, �U� �Q_�i3 Subdivision Name(if applicable) Sectio Lot# � r Directions To Site: -� o... --� � ar�l 5�'� �`"� �.. .__ .. .. iVL. �.�d t N� ...l�n Tn �0^ 1� Specify roblem Occurring. 7 . � s� �;�� A� ��.�,�� ee��d,�s , �A�,, �� sy�� , _ � _ _ _ _ _ __ _ _ �.u. ..:z____ .: _ , _.�__:__ IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes �No Basement Plumbing: ❑Yes ONo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building y��V #People �-� #Sinks � #Commodes � #Showers #Urinals Estimated Water Usage(gallons per day) � Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: 1�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water L�New Well ❑Existing Well ❑ Community Wel! 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 permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and es. I understand that I am responsible for the proper identification and labeling of property lines and corners and locatin d gging or staki the house/facili o ion,proposed well location and t}ie location of any other amenities. ' Site Revisit Charge Property owner's or owner's le representative sign re Date(s): � '30 f � Client Notification Date: Date EHS: � � i Sign given ❑Yes ❑No Account# f� ��! . Revised i l/06 Invoice# c . . , � . V_ d � P� � �-�3r�.G � � � . Mkr i Sa h 1,2�, O � �� `��lp �r� � � f�� . b �� / �� },1°ws��' —'' S �� 3 � �l \ �h �' � Q ProPa� �o hr �( � 30�� c_ ►�+-co�., �� `�rn v� , 5�� 7s x�o ,� � /s xysss►,..Q �` �.�� -�o� 60�1� , , � � � „ � _ , ., . , , ,� �.... .<µ ��`� . '�� ,, � -. �: ''r,., t� _: : — , : �._ �� —�-`-,-��j—�--� ` :�� ., . ;� . .. . .. � . ,, _`� �� ,�- � _ '-�,,;� � � � ''�� ,.� AK'�i�• '�� ~�� . :55 "^--- }{ � - � .� .. - �� ; . f� I { . . . � : �. ' ,.. . . ,�� .� °'?$�'t��i 3..�"�< �`,,:y - : --��` � �`�, �. � .. _ , , . . �� .�, ` . � � -:..� �. $ � �� ,, _ _ _ ; : . . , �, ; . � "'�� .. � h � .. .. .. . ,�� . . . ..... . .. . .�. �.��. �;}�-�� - . . . .. . , . � - � . , . . ., �. - , -' �-� � �� - � � .. - �. ,. -:... . _ . I ��.� �`�" � � �-'`�.,'�'' ��, f.:f � , ---�., ' � ' �,._�;...,�""-"�:, �r� , _ ' - � � ��s�� _ _ ; �� : : � � .: � �s .� i � ' -�" --....�..._ ..r,�"` `'''�t�__. : ' _ f�-..: tI�, �Pa�t,c` �`�; � q`. �� no v N�s. s . Printed:Aug 15, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or Impiied including but not limited to the implied warranties of inerchantability or fitness for a pardcuiar use. Aii users of Davie County's GIS website shall hoid harmless the County of Davie, North Carolina,its agents,consultants,contractors or empioyees from any and all ciaims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. Y 1 � � I 1 I • + � ,• , .^ •�. DAVIE COUNTY HEALTH DEPARTMENT ' � w i Environmentc�l Heaith Section i } Soil/Site Evaluation ± I APPLICANT INFORMATION + R RT INF R TIO I 4�J�� D��'�(�� ' �G�vl (�000 G� � �° �� ; _ � � 3 � �o�-a�� . vvo �o o� 3 ' ; �c� ,3/ �a� _ r c{ �� w , �er��s Z � � ; ? ; � � ; f ; q _� 6 r� P:�S ,. / I ^! � i � Water Supply: VV�� On-�Site Well 'v� Community � Public �i Evaluation By: Auger Boring Pit �,'�� (�, Cut � � i FACTOR3 � � 1 2 3 4 5 6 7 ! Landsca e sition I L L L L G-� Slope % ! HORIZON I DEPTH - p � 6� , O— 0 �- Texture grou G L G L G L- ; � � G L ' Consistence SsS� S P : � f S �� SSS � Structure j � � CF ; Mineralo ! j�,p ; HORIZON II DEPTH � � — �' ` �- � ' Texture rou ; cr1 „�4 G C C Consistence ?� � n !• Structure ` - 5 � ; Mineralo �j HORIZON III DEPTH � ' i Texture rou i Consistence ' ' � Structure ' � Mineralo i I HORIZON IV DEP'TH 1 � j Texture rou ! � Consistence ! I f Structure f I � Mineralo i ! SOIL V�fETNESS ' ; RESTRICTIVE HORIZON I I SAPROLITE i ' f CLASSIFICATION 1_ LONG-TERM ACCEPTANCE RATE , � 1 � � ! SITE CLASSIFICATION: � � � EVALUATION BY: � �s r � � LONG-TERM ACCEPTANCE RATE: � •��-� OTHER(S)PRESENT: I I � I REMARKS: ' � ; ; LEGEND nds ape 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 I T�xt�1r� � . ii 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 I SC-Sandy clay SIC-Silty clay C-Clay � � � .ON�ISTF.N . . � � 1l�iSt i � i VFR-Very friable FR-F�iable FI-Firm VFI-Very firm EFI-Extremely firm i '�'e� i � NS-Non sticky SS-Slighdy sticky S-Sticky VS -Very Sticky � � NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic ' ; � I ' E ! i �tructure i ' � SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky ; SBK-Subangular blocky �L-Platy PR-Prismatic i , I i { � Mineralo�v � �, 1:1,2:1,Mixed ! � i LYo.�e� i I . i Horizon depth-In inches - I � 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) ''� �m�n r ___•_—' _----`----'--'- --ii�__.�c.n � � _^"— __.__ ._ . .. � � ' " Davie County Health Department �.�r��.� 214 Hospital Street p M ,� P.O. Box 848 �ru �r��,� , �.� Mocksville, NC 27n28 � �"� Phone. 336-753-G7$0 Fax: 336-753-1680 No�th �aro[ina P�tbtic Health es / zila � i � Ryan Noble Canstruction, Inc. 14752 Cool Springs Rd Cleveland, NC 27013 - *RE; A.pplica�t�on �or impr�veau�ei�t p+�r�nit�'ar; T�Lot. T�$IoCk: Property Site: Woodward Road, Mocksville,NC 270�8 Health Depariment File Na.:157919- 1 Dear Ryan Noble Construction, Inc.; The Davie County Health Department, Environrnental Health Divisinn on � 5 1 e s i a� z s evaluated the above referenced property at the site designated on the plat/site plan that accampanied your im�rovement permit applic�tion. Accordi�ig to your application the site is t�sersre a OTHER �vith-�-des�,g��vastewat�ar-fla�v af-a-�-e-gallans per-day.—TTI�e�va��aati�on tivas done in accardance with the la�vs and niles goveming ivaste�vater systems in I�'arth Carolana General Statute 130A-333 including related sta[utes and�'itie 15A, Subc�apter 18A,of the Nort��arolina Administrative Code,Ru�e.1�00 and related Yules. Based on the criteria set out in Title 15A,SuUc�apter 18A,of the North Carolina Administrative Code,Rule.194Q tkrougf�.I948, the evaluation indicated that the site is ITNSUITABLE for a sanitary system of sewage heatment and disposal. Therefare, your request far an improvem�nt permit is 1)El�'TED. A copy of the site�valuatian i�enclosed. Z`l�e si#e is unsuitable based on the follotiving: 0 Unswitable soil topography andlor la.�ds�ape positi�o�{Rule.1940) �Unsuitable soil characteristics (structure or clay mineralogy)�ule.1941) �0 Unsuitable soil wetness condition (Ru2e.1942) DUnsuitable soil depth(Rule .19h3) ❑Presencs ofrestrictive hnrizon{Rule.1944) ❑Insufficient space for sepric system and repair area(Rule.1943) ❑Unsuitable for meeting required setbacks (Rule.1950) ❑Other(Rule.1946} These severe soil ar site limitations could cause premahue system failur�e, leading ta the discharge of untreated sewage on the ground surface,into sutface�vaters,directly to�round water or inside your structure. The site�valuatian included consideration of possible sit�modifiearions,and modified, innovative or altemafive systems. Ho�vever,the Health Department has detezxnined tbat none of the above agtions svill o�ercome th�severe conditions an fhis si#e. A possible aption mi�l�t be a system desi�ned to dispas$ of sewage ta anQtl�er area of suitable soil or of�site to additional property. r . • For the reasans set out above, the�roperiy is currently class�ed UNSUITABLE, and no improvement permit shall k�e issued for t�is site in accordance with Rule.1948(c). Hn�vever, �the site classified a.s UNSUITABLE may be cl�.ssi�ed as PROVISIUNAI.LY SUITABLE if written documentation is provided that meets the requirements of Rule.1948(d). A copy of tlzis rule is enclosed. You may hire a consultant to assist yau ifyou t��vish ta try to develop a plan under w�ich your site could be reclassif'ied as PRUVISiONALLY SUI�ABLE. You have a ri�ht to an informal review of ihis decision. Irou may request an informal review by the soil scientist or environrnental health supervisor at tlie local healfh department. You may also request an informal re��iew by the North Garolina T)epartment of Health and Human Services regional spil scientist. A request far informal revie�v must be made in 4vriting to tlie local health department. You also I�ave a ri,ght to a formal appeal of t�is decision. To pursue a formal appeal,yau must file a petition far a cc��tested case hearing�vith t��Office of Administrative Hearings, 6714 Mail Service Center, Raleigh,NC 27699-6714. Ta get a copy a�a petiti�n fozm,you may�vrite the C)ffice o£A.dma�nistra.tive Hearinas ar call the office at(919)431-30d0 or from the �QAH�veb site at http:/h�vw.ncoah.com/forms.html. The petition for a contested case hearing must be filed in accordance�vi� the provision of North Caroiina General Statutes 130A-24 and ISOB-23 and all other applicaUle provisions of Chapter 150B.N.C.General Statute 130A-33�(g)pzovides that your}aearing wduld be held iu tl�e county where your paroperty is located. Please nate: If you wish to pursue a formal appeal,yau must file the perition form tivith the Offi�e of Administrative Heariugs`�ITHIN 3p_DAYS 4F TIiE DAT�Q�T�iIS LETTER. The date of this letter is (1511�/2015 . Meering the 30 day deadline is critical to your formal appeal. if you file a�etition for a contested case hearing with the Office of Administrativs Hearings,you are required by la�v(N.C. General Statute 15fJB-23)to setve a copy of your petition on the Office of General Counsel,N.C.T�epartment of Health and Human Services, 2001 Mail Service Center,Raleigh,N.C.27699- 2oai. �o not serve the petition on your local health de,partment. Sending a copy of your petirion to the local �iealth departz�►ent will nat satisfy tt�e �egal requiarement zn N.C. +General Statute 15QB•23 tl�at you send a copY to the Uffice ofGeneral Counsel,N. C. Department ofHealt�and Human Services. Xou�anay call ar write the la�al health depar�meut i£you ne�d axay additiaual infaruzatio�a or�ssistance, Sincerely, ENVI �NMENTAL HEALTH DIVISION � �,R.S 2140-Nations,Robert Environrnental Health Specialist `4�itater and'Waste�cvater Sectian Encl.: (Enclase copy of site evaluatian) (Copy of Rule.1948) N � 1 • i5A NCA+� i8A .��8 SITE �LA�SIFiCATi+()N (d)A site classx�ed as��UI�'�.BLE�nay be used�`ar a ground absarptioz�s�wa�e t�atrnent and�isposa� syste�n�peci�ca�ty iden�q�ed �nRul�s �1.9��,.�956��or.�95'��o�'�is sectic��a system appm�e�u�der �.ule.1�6�if wr�tten documentation, includin�en�ia��r"cn,�,h�dro-geola�ic, �eolos�ic ar�ail studies, indicates to t��i�al l��a��h d�az�trne�t�3�at the pro�os�d s��t�rn car��expe�t�d t��nctic�r�satisfactarily. S��i si�es shall b�r��lassified as PRU'�TSI�I��.��.'Y'��UI�'ABT��f�`the l�cal health d��tttn�nt+3etermin�� t�iac tlie substan�iatin�data indi�a#e t�iat: ��) �,gr�d�a1�s�arptacro s;�st�z��an be inst�li��sn that th��#�lue��t will t�e ncm-p�at�ir��nic, r�a�infe�tia�rs,n��-taxi�,�d, r��n-�az�rdat�s, (2) the ef�l�er�t�cvfll rtat cc�ntaminat�,�r�und�,vat�r ar sr�-face x��ter �nd �3� t�te �ffl�nt��1 nat��ex�osed on t��ground surfac��r be�isG��r,�ed fit�surf�c��t�v�ters wh�r� �t c�uld con�e in�vut�a�t t�i�h p�ople, anirnals,�r�ector�, "�he�tafi�sha��re�i�� ttre s�a�bst�nti�tin,��ata if r�qu�st�d bg=t1�e loc�l healt� dep�ment H��aty I�Ts�te: Auth�rit��G.S. 13U�-�35(��; ��: 3u1� �, �9�2; ��a�d�d-E�-,�pr�� t�--��3;-��uar�].,-��9�. < � � , . .; - ___ , � „� � � � . � , -11PPL1CA`i��ON FOR SI"TE EVALUATIONII��R�VE�IE��1'YLI�;I�IT & ATC ' RECEIVED - ll.�vie�ounty E�nvironmental��alth ,��' j� P.O.Bax 8481210 Hosnital Stre�:i �� , te: �~��/ ��. A��ck.svil�e,NC 27i�2� �:� � ; � (33�)7�3-678Qf Fax{336}753-1 t8p � �� i� �� '� � � t� � ;` ��Pplic�tion kci�-. Site.E�,�.��uationfIrnpra�ement Perniit �' Autli�ri�s�ti�n To CatLstruct(AT'C� � F3cith r: Tvpe of'r�pplic��inn. �il�icw�Sr°s�crn CRepaic to T�xistirig S�stena l�Expansiott'h2adifieaiiun�f�xi:ctin��ystent or Pseility � �, ��, - ```. _ � . _ _ *�*l��.�PC)�'I'rt�'7`'�""`TiIIS APPLIC?1TlUN C�I,'4iYUT fiF,'PHCJC'f:'.5:51;1�1lNI�f;�i'a AI,L OF TIIE R�QGikEt� miFCJRMA�'IUIti I5 PRUVl1)Fi�), Re:fer io ihC�FORh�TIO1�T$L1 i,�T for i 'Itu� tins. `. __._ �� t11'PLl�'.AI��`f'TC�IFC3FtMATIUN ; naro: __ . -,. _, --.. _. �;,��l� __ �_. -T--�- - _ �_ ,__.. Nc�n7c � ,�.,_ �``�� r` ` �d�.� �-��'. �ont,zc F'erson�, �C�� .K �icirlress ,._�� o '� �►` ' H��ms: hc�nc�0....� �-�J'�L I ��, _ (:i tylSt�tcl�I�' r�,tt��».:_ r��: �`7�1`� Iliusiness F� one��s��'� �'7� Lmail _._ �" � , .,� ._ . Na��enn i'enni�If�T ii'.DifJ''c°rc�n th�t A n�'e �oL�,,t � ��,� �oc � ___ _ h•�ailing Addr�ss ' - - ,it��fStaic(Z��._, �Vtt,t',kSv�'��t+ �11C �D� _ _. _ -_ Y1�(7�'LRTY INF(�ILNIAT'IU:�1 __ �`D�3�C Ht3tiSe�F�tcility Cc�rners (?1a��ed � / - \C7'1'�: A survey.plat�r site pinn must accompan��this.tpplic�ti�n. Trtc�udetl: f� Sitc i'lan ❑Ylat{fo scale} (P��rrtiil is�=�lit�for 6fl mnnths witl3�ite�1an,no c�p itian ��it4�cump{c�c.plat.} �}vrner'�Nart7ca._=�, .�. c�a�� I'hone I�uml�er M.'��,+ �j"�`�3'�(d ��flv,rt�er's Address ��i�S C'.A.n;�.i,.�._.��,�._ � .r._."� �.� CCytyl�tatel7i� ;�11�1��,��s�.��..��7C►�-'�' Propclfir�,l�d��rc:�s��,'�1` ��.,,�.,�-�� n _�._ C;it3°_��a�SV�'��t�. � � Lat Stze �`��.�� Tax P�N# ✓1 L� �'��1��'"�� Subcl�ti�Rsio��Nan3e(if'applicable) Scctin jLot7= �� $ —.,.. _ T)irzctionsToSilc: --�? ,6F. 4ri �r+,o,��'LQ� �---�. _.r,.'�' N�w I d� j �t r I ...._. '�'•� �'",��' �� i ( � A7 ��i �� r M ��.._.._..._�!►._..��".._Y1._..._W L,�d�'-__... r`�abr • t�L�/ �"'�1,5!�. .��?l.Cl�S�.�'rohlem Uccurring, � _ � � � c� i � S� sr`�� r��C��r�rne. � 8e�r��r�� . �R�I r5�� S��t ��-Gcs�� I�" I�E�S�Ii)E�`+C��FI��L�(JU`I"l'H H�::I��}��.i.>fJ4�" � __ ...._�. . r__...�._._.�. .._..��a_____ �.w __.� �; Pecrpic #13edraoms �Batktiroams G.irc3en'1'eibl��'hir��ac�l I_Yes ��Vo L�3 isem�.�nt. (±Yes 1-No Bascmcnt Plumbinb�I IYtti I ;N� _� __�.._..�. .. IF I�aN-RESI�r:'�TGE P�.I1L UiTT TI-�C B�X nELO�'4� � .. _...__.._.__,__ ._..�-- ___ Typc of F.tcilit��liusiz»ss �,--,•-r '1'alal Sc�uarc ra�ta�e of Buildin�,�lr ��Peaplc_�� u Sinks ( #Carnmodes � �Shourers I.t Urin�e[s ` Cstittiated t��ater[Jsag�(n�alfons�►er da�•}��A#t��cti c�ocument�tion nt`similar facility��vater ct�nsumptinn� FC)(7ll5�1�1f1��,4�NY.Y: it SCdtS. Typc tiystcm riyucstcd: 'i�Cotrr�cntii�nal I�Ae�e�,ceci �]innavakive lJAtternatiYu �?{lthcr _ 1�1r3t�r'iuppiy TyEre: �:1 Ccauntyl�ity 1�`ater !Rf Vc��tiVel1 Cl�xistin�Va'cl! D t:ommiuuty 41�'cl1 llo yau aruicipate additians or expansion5 afths f�cility this system is ir►t�ncicc!tcr scrvc? L Yes �l'�Na If ves,�r�hax t}�pc`' .__ ,,� This i�tU c�riily� 1.ha��hc inf��rmatic►n prt}ti'i�icti�7n this�ppl�c,3t�on is txt�e and+correct to tlte�cst t�1`m}�knt�v��ledge. I ur��icesf�mt� tliat a�t�r perniit(s�or AT�C{s)issued hereafter are subject to suspeiisinn or revocatit►n i!�lbc sitc is altered,tftc iniCndGcl�tse ch:jnLcs..«r i t itte ir►form�tion sut�otitted in t}�is annlic2�iir►n is falsi�cd or chan�ed. 1 hereh��2r3ttt ri�f�l c�l entrv tn t�ir A7ilhririir.�1 h � • I • . , • , 1 � ( e � ' � , ��,�� 1�� i Sa� i��, �r;d 4'�� U � ��" -� �� ,,/�� 3 '� ��6'�t7 � � �� s'x�o�`�" � � � 1 s x k�� .��e. -�n r �o� � . � �� :i � ' • �' � . �� i � f � , �V�I+�'� �� 1 Sah ��, � �� r'VG ` �+�-C� � �? �� a� i , {�Z�;i "�Q��` � ��C �'C.. �r� , � �1 ..� � \� `r ,�� T�C�"K.... � 7� a � � �� l� �Cw4�s�.� � �tC- ��f �� , . � � � � ' . . . . . . :"1.' . A. � � ' I r � .. .,,... . 1 7 ► • i � hPPL1CA`i'�C?I'�t FOTt SITE EVALUATIOI�III��ROVE1VIEi�`1'PLR;VIIT 8c ATC ll�vie County�:�nviranmental T��;�rlth ,,'� P.{l.Box 8481210 Hos�iital Streei �� A��ck.s��il�e,NG 27025 �:�c�' ; (33fi}753-C�7�i�1 Fax{3�6)753-1�8Q :�ppficlfion k'nr� Site�Ew�afu.�tianlItnprovetnent Fernlit �_ Autf�c�ri�s��ic�n To�-CatLstruct(A'1'C) � �nt�i T}}pe af Applic�2ionR �Nc.v Sy'�icrn L'I�epaie to�xisting,Svsten� L��xpansiot��h2�drficaiion�f�xi�lins;�y�t�rn or�"acitiiy ***l,ti9YUR'1`rt:��7""* T'IIIS AI'PLICATION C:iL'�iVUTBfs PX(J(;f:S.51s7�i,lN[11�SS AL,].,UF TII�R.�QUiR�t� TTrT`ORMATIUI�IS PiLL)Vll)Ntl. Referta the iT�;FORIvIATIOI�'$tTLI.�TIN far in�t�ucti�ns. 1'll'PL1C.A.h�]�'TNFC7RMATION __. _ � .__�_.._ ' �.. _� Namc � �'`~�� .. .� �� .Q�'�. �'"�-'• �:ontzct�'ersan_,_ ..�� "�� , �,ddre�� ys �A��`Oo � y►` 1-�an�c Phnnc�� -y'� � ��2. [.'.itylState,'LII' ±tc.�°��'*-�� `7 r3 4'� Iitisiness F'�lori��J3�i o�.�'a� �-"7�6"� Ltnail i' h ; _ �.�-8�-w.._ Na�y}e on i'�nnitlAT i1�.L7ifJ'�c�rc�r1 th�z Al�iv� �a�h ��.�.., {�aac�� A•tailing Address d'"��15 Ca,�ot . _ _ _ + -. 'it�7(SiatcfZip _ ��l�. - _�� _ ______ __ _ . YK(7PLRT�F INi�C3R.N�A"I'I(U:V __ aT �`D�ttc H+�t�se�F{tcility�orners f�1a��ed � / \L)"1'�: A surr��y�1at nr site�ilnn musi acc�nipan�r ihis upplic;ttiori, Tttclijt3etl: ❑ Sitc Ylan ❑Plat�to scale} ,�P�.�rciiit is�.�alid f�r fi0 rnonths w�ith�ite p1an,na cxp siian,/,��ilt��;unipr��c plat.) Clwner's T�iarnc __`�, � � � �r. �� r5�dv-�C I'hone Iium�ier„�'�� '�f�'�(d Clv,rr�e�r's t1d€lress 7-2`i S ('�:sl� ....�._ __..�. CitylStatel.7.ip G .�s�y�t1.r�+��:.�74� PropCrty�,tldtfrtsw��'�1.,� ��.._....� �� . .....__�_ �it}T.��sc�SV��f e� � Lai StLe�.��d��J 'f ax P!N#� ✓7"-^ ��-^�C�"t�� Subd��'isic�ry Name(if'applicabie} �cciio lLc�tt= --...___ Directions To Sit�:: _ � �, oY. (,.'�rwL . z. �-`�. _�...�' l�+�r 1 a� �� • l .__- — r J . `' �`►� i, • _�_ ��++_ ��i"'\.._t�(`�V�.._C1.�aY_.__'t-�1'� � N� � r+ M�+�1!C� S�cci(y�rc�blem C)ccurring. � " ; � �� sr�� j�� ra�e. � �'P.�rodr�rs . �y� ��sv�� .�vt la�t�s�� __-- � IF I2ESIDE�C�FiLI,(3U`I"'l'k�Hr_k�C�:� }3}:I.,t)1�'�` ,�� Pec�plc —!___. ""��3.3edrooms .��_ . .,..�._._�Batktraa►Yjs Garden'1`c�b.l�Vhirlpc�c��1 I_'Yes �No .� ��3a�;emc.`nt: I�Yes 1-N« BascmcntPlumbin��l IYcs I'No _� ---.. _.�._ . IF I�QN-RCSIDr�t��; I'iLi.C)[JT TIiG IIOX B.ELO`�V Typc of F�tcilily�Liu5izaesS L�r-vti �"1'ulal Sc�uar�1�'o�t�ge af Buildi�tg�� Peaj71C_�_-µ�., u Sinks � #.Cnnimodes � ;�Sl�ourers I.t Urin�ts Csti[i�atecl '�'at�r C�sa�e(�allcros�er da��}!,��I'�.�.?,��;Att��cti c�pcum�ntati�n nt'sirnilar faeilit!��i��•ate�'cUnsumplicjn) Ff)(7ll5�KV1C��4�T��.�Y: �� Scats 7ypc tiys[cm rcyuostcd: �Cntiw`ctytiirn3l nr1`ccti�teci CJinnovative CJr`�lternstiY� �t)thcr__ 1�V3t�r SupErly 1}�E�e: ��! County�tCity 1�`ater I�Vcw bti'e11 LJExisting'V4`cil 0 C.ommunity 4tifcil llo y�att anti�ipat��dditions or expansion�of.the f�cility tkiis syStL'TYL IS 1T1�4I!(ICCI L(};:Cfve,? C Yes �'Nr� If ves,�vhat t�'P�=`' �._ . _ � 'Fhis is to ceriil:y�tha�thc infc�r�natit►n�pr«vici�:�i t�ta Ehi�a��9�calian is t�n►e�tnd cot-rect to�tl�e�cst iyfrn}�k�rS��ed��. I�ur�d�:rtilz�nd ll�at att��erinit(s}or f�TC{s)is�uec�hereafter are s��bject to svspensian c�r revpcatitm ii"�bc siic:is altered,tEtc int�:nded ttse ch:jn�*cs..ifr if ll�e irifnrctyation subnti�d i�i tl�is annlicaiirm is Calsi��d ar chan�ed. I herebl�era�tt ri�hl t�f entrv tn t}ir. Ai�lhnri�,��1 • b0-L�l- 10 13��!U xilUl'1-j7dV !]�H1 AlYL AlI1 .3500��'i l 1� 1-3257 t'ICIIOt7G!YJbI�� r-31� ,�> , _. C.�ROZ�T� I}EP�R�I�tr,�� 0� ��,�'V1�OND@ENT AND NAT�7�L� .YtESO[1�i�1E5 � � ,.. �aor�xc�Tgo��r�x��x xo�o�a��ao'C7c��,o��T��a�c��oN�� , These tivel�s are 'pe»nftted by yule"and do�otreguire an#adividualp¢r►nirwhen construeted in aocordahes with . rhe rules ofISANCAC OZC.OZ00* ;(his tu�tfce must be s[(brr,itteeT nrirrr�o oastruclioh. � �EO��t1V1.AY,AO'CJEOUa CLO��YD�.00P VVELIL� As dcscn'bed iu iSANCA.0 02C.0222 thcso wa1ls circulato potabk water only or 4 nzixture of potabl�watcr an.d p�omnanc�an4in,g additivzs as past af a geothcxuaalbeating and cooling systcm. ' OkZ ' �EOT��2N1A1L��T E�A1�Ts][Ol�C3t,OsJED-1C,001°7•VVFY� As describcdin 15ANCAC 02C.0�3 tbcge wells circulats a rcfrigarant gas as�erC of Q geot��rn4a1 heati�g eud Cooling systc,ni, ' ' N�ORT�Fi CAROLTN"AllBPARTMLNT OF�V1fi0NM�NT.AND NA.TU12AL1tQS0'URCES � ' ,i'rir�C1ea�ly or xy,Qe1'�afot•tnatlon. 11Ye�nfLle,S�cbnetttaZr WtllBe,Tt�tuyncd,4s�cortiplat� � DATE; ��' . �0� PE�NIiT 1'�O. (to be completedby DW� . �. �r�o��oT�.�cr��Loo�e�x�x.�co�B��oN�xxvcxEn ��: ' (1) Aqueous(aspa 15ANCAC 02C.0222): '� 1V'umbcr of�rretis: � (?) Duect P,rcpansion(as per 15ANCAC OZC,0223) I�Tumber ofwells: B. STATU�O�"P�LX.�O'WI`t�It(ohoosa oz�e) -, ' , (1) ' 5�ngleFamilqResi�ce V .Subn�i�tb,9storiontwo(�)Dusiness days prlo�to consa�ctton, (2) Susiuess/Osgauizaiioa S��ihto torm SO days prfoi co coastruc,tion. (3) Govexnment; Statt .Municipal Couuty Ped�rel Submit this forn�30�ys , � prior Eo coush-�tction. C, 'OVEX,I, pWNE�t,—For singla Ys�rvi]y residences list ffiz�rop�cty b�arner(s). For s]1 othess,liat�i�ae of ih.e bt)81T1Gs6,oxgani�ation,or gavamraent aga��y ana pe.x�on dBleg$ted si�gnatura au�hority: ' � . � P � ,� ,� LC.�C � � ivra�g�.aa��s_ S�� w o��w a r��, . � . � �jty: �I��hsr �l�a sffi�: c��, z�,��aa�: 21�2 0��: ��, • pa.q TdeNo.: Cel1 No.• . � EMAILAddzess: FauNo.: � . � • � p. PHXu�ICAL T�OCA.T�UN OF'�YELI+SITE � � , � (1) Yarcelldentif'tcationNumb�r(PII�of well sioe: �T �' 00�C�� County: ' �G'/�„�l_, - • • : V; (2) Physical AddrEss(if diffanmt thsa mailiny�ad6ress); ' ��. 'StatC:NC ZI.�Cnde; . pyV'pfCTIGCIosca Loop Geod+�mnlNoKS�oatlnu(Abvltcd 4/30/20].2) Pagz 1 i �d oc�o ��N Wd6l �� 9�oi �tii �u�� • IOD—L�—' 10 13:�f.l L�MJt'1�t1�v n��1 H1VU A1tf 33007��3 f 1� t—,�u� reee,s/eeey r—s1� . ,� , � . � r . ' �. MA�'S,PX..ANS,ANN�D�PEC�ICATION� � (1) Maps xnust ba sca�ed or othp�✓ise accurately 9ndicatv'distances and oritntations of features located• vNitbin 250 feet of th�injection�cvell(s). La.bel all featutes cica�ly and include a north annw. Attach a site-specxfic map showing the Iocations of the follo�vvia�: � � Pxo�ased�njcotioa�velilooadana o Buildings ��:e d�/� G!� . � Propertyboundaries o Surfacew�C�rbodies ' o ' y�latGt sup�Iy wblls , ' o Sc�tic systems and aasociated sprayirrigation site�,drain�"a�clds,�repair�aas � • Bastizig o�t potential sourcee oFgioun�dwater contsmi�u�iion (2) Plans and s�ed�xcations ofthe sviface a�d subsux�faea coustn�otion detai�s of the wa�l system. ' s�,� �v�tc�.v�z� �--2, , �. TXZ'�5 AN� CONC�II�PTRA7CIOI�S Ob� ADIDxTx'V�� – List any additives chat�1 be used and their eoz�cc�it�anona. Oxil,y ac�ditive8 tliat tha Del�sxlment o�Heaitl�aud Human Services'Division of Pu�b}ic Health del.t�tm�c�es dd not' adVer�e�y a�'eo't humen hoalth sha11 be used. ,A,list o£approvad additives can,be found � on�i�a�e at httn:/fpnrtal,ncde�.rn�g/webfwq/,�ps/�vwro. A.11 ofliex add�tives iequire approval prior to usc. �Tfv-c��[� ' G, , pV�',LT,ID�LLY,Ext�TI'0��'YON(if kliaNn) WeIl Dxalling Coatractor's�1'ame: (rody MuUis) (Matthew BYo�cv� (Milton Cave) . , , . , , ' NG wellbulliug ContracEor Cextificakion No.: 257�-A 3036,A 35�48 A Co:apaayNama: Y.'adlda�ellCompnny,Ina Coutctct�cxsan: DavidBrown.(2195 A) — C,`ity; TT�tptonvil�e Sracte: NC Z�p Cod�2�020 County: 'Y'a�lci 17��TeleNo.: 39(�-468- 4A Ce11No: 936-�74-8736 BMAILAdckoss; o�Ze�'�iiU.et@msn,com FaxNo.: 336-�6R�n4s __ _ _ • H. �]EA,T PY71v�P CONTRACT0�21NFOX�NICATION Co�npany N'ame� �o� � ��Ln'�,� '�hc� A� . `, v-----�o Contact Person• ��n�KC��va BMAII,AddrPss• /�v�9 C�. L� r��a 1, +Mc.f– Aaa�ss: h� N� � � !l ' Caty; +Ei��S'�" � �ip Codc: � Stato�/U C+Couary: �� 1�. �7��"' OfficeTcleNo.: ��4 ft9�2d$� Ce11No.: �auNo.: pWQlCTlGGosc�l-T.00p Oao[hcrmnl Not�fio►eio,ti(�.avi9ed A/90R012) . Yege2 � �d octio �oN Wd61 �� 9�oi �tiz �u�r . �o-c�- l0 1�:�1 rrsuri-nav n�Ki �vli Hln JJ�OJJ'3f1� i-oo� r�1110�JFt/lU�llO'3 r—J1J .d ` �J , ' � � • ' . Y. ��.OTEC'�'i0N--�rovide a brief description of how(1)vuate�su�ply weals;(2�euzfaoa wat�bodi�s;and�3) saptia�yscalmo and a�aooxatdd s�orqy iAi,gatlon sii�9,drain�icicla,or rcyair arcas wriTbin 250 fec�of tho proposcd in�eot{an v✓o]Is will bcprot�cted duiing construction o£t��wc�ls; . . �f ��n��t�'id. il,�e�.e� ;t,,�,.r�Gl s'�'�.� -(`�t�.ce �� .e c c f��,-r� .r. VA'�NCE—PursuanC to 1 SA NCAC O2C.0241 tha Dizectar of the Division o�Water Qn Rlify mAy gtsnt a � vaiiance£�wua applicable well constructiion ox oporataon standazds krovidcd rhat: (1) tiise of Eho well(s)wil�not eatdange�:�Uman heslth and wel£�e or ihe gcoundwa(�,r;and (2) tlutt oonsttuotioa oz opr,ratiou iu a000xdenco wi�ib,e steadards ie not�echnically feasiblc or tha propose,cl cons4�ctionprovidcs Cqual 01 betitcrlxott�don of thc g=ouizdcvat�r. tlay Va�ar�cv roqilast ahould accouaD�y�s11'bm�tta(o�1}1ie not��catlOaXo 6X,pcd)to cVn�un,Hon O�thC 1Cc�ueS� ' 'I73e V3iiattcc cCqtl�9t foxxa t�be aceessed oAline az http-l/portal,ncdenr.�rp�/web/W�/r�yJ��[�yv�ro eirsit� , a�pTic ��s �. SZGN'A�ES-�T'h6�'o�lowing seolion is to be complgtad as required below or by thac pctso��'s authoxixed ' a.ge�a� 15A NCAC 02C,0211(d)rZqui�r.3 signatuscs ea fo11oW9: ' (a) fora corporation: b�'arespn�sib]a ca�ozate o�ee�; � (b) �or a partnership or so1�pro�n-ieforslup: by a general partr►�r or tliz p�opiietor,respectively, (e) for a municipality or a stata,fedaral, or oth�r public ageney: b�exfl�er aprineipal executi�e � officar or rankingpublicly elected official; (� far all ot'he�ce: by t6s well owAe�c; (e) for any other person au'rhoziz�d to act on bchalf of ihe �pplicant: documentation shsll be subno,itted with the no2ificoiion that clearly identi�es thc pe�son, granfs them signature �uthori�j►,aad i�signed and dated by the applicant. , '7 h¢reTiy certcfy, under'penal'ty of law, th4t I havepersonally examin2d and am famtliar wilh fhe inforntgtion � submilCed'in this document and all artachments thereto and thar, based on rny inquiry o�'those individuals imr�ad'tdtcly Y�sponslble for ol5taintYtg said ir}�'or�rtakori,.I believe that the isiforr�atlon is�u�, accurate and co»�nlete. I UYft CWaY2 fhRf t�:ere Qwe Slgn�Ctdri�pe�1Rllles,tnczuding the,�osstbillry offines Gnd�rnprisonm�nr, ,for submitrin�falsz ir�'nrmatlon. rQ' tQ cofu� rate, n:ain�ai�, 'repa�r, cihd�f ap,�i��r�, abdnaon the injeetion wall and all relate�7 purten � cordanc wdrh the ISd NCAC 02G'0200RuCes." [�-r�C�. � t�1Ce r at`Ey Yb /Ayplicaa'E � �� w � r" . print or��peFull N a � � . . 55�natuYe a1,Aatbol•lzed nt,3�E aay , 5 �,�., � e.r }-� � �-� �,_... . � YrJnt or�yi�e�bli Nazuo • DWQ/tJ�C/Closad•�oopGeothermalNoiification(R�vised4/3012012) Page3 � �d OLtiO '�N Wd6l �� 9�oi �tiz ��r � � � � c 1 ti . � 1 � . � ti � a �' {� Q o. � , Q � � � 3 a � � "� . . � � � .9 ° 5 o � � � —+� 3 Y �a � C J `� O � � � � � V � �3� . '� � � � �� . Q � � � ti � � � £ o . /D �" � ° "�' � � �` --� O � '`E-- � h � � � �, s � ui �- s � �— j . � c �-- 3 � ` a ,� � �.. -�. o `+ � r^ � �, N `'') � � �- "'' � � _ 'e � � 1 �� S � 0 •� � �O t� � . � � . � Q � 0 '^ � ` � � V C � 1 � o � � � y e! _ � ts = � C� � � Q � � � � 3 � � ` —t- J � � � � � � v � S � � � � � � O � � ! � � � +� • �� . , - LL! . ' ' � � RECE{VED - � ��[�� t��L��s�t�ucTto� R�c�� r � . - . _ . . . _ � �C+�,�,��NS�'�2YIC�'�OI��27E�0� � . .. . . �ar�t��trs�oxi.Y: . . � This fornt can 6a tued for singlo ormultiple wells n� 1.iVell Canh'acforInformation: ' • • ' r'�-' �� (`I,�v� /� � �„� 1�.�VATER ZONES (: (.. L�� FR04I .To D�SCRIPTION Wc11 ContractorName . ft. ft ' ��(,�� ft ft. • NC VJell Contraetor CertiScation Number 15.OUTTR GSICIG for mulfi-e�sed�vells ORLINER if a llenBle . FROM TO DL�14fIt1'LR TAICI4JLS5 14L�11R7AL adkin We11 Companv, Ince rr: rc ;n. CampanyNarne , 16.7NIYIdRCA51T'GOR•TUBPiIG eotUermalelosed-loo (� e� TROM TO DIAIHETL�R 2'AICIINLSS MATLRIAL 2.Wel]Cansh•ucHonPermitn:�✓�D �� /�.L . ft S it, in. List nl!npplicable ine/!eon.rmrcliar pznnifs(T.a County,Smie,f�arfance,e1cJ � fG {C in. 3.SVel1 Use(cLecic�veIl use): 17.SCItEEN bYatcrSupplyF�c11: rnont TO DIA]HI�,T'ER sLorsia� THICIWL�S9 hIAT�RIAL ' OA�ricultural • OMunicipal/Public ft. tc, in. - , ❑Geotl�erma]($eating/Coolin�Supply) OResidentialWaterSupply(single) ft ft. ,ia. � �Industrial/Commercial OResidential Water Supply(shared) 18.GROUT • „ IROhI TO 11fATLRL�L LM1IPLAC�M1IENTM1ILTI�O➢&AIbSOUNT � OI[f1�3t10ri � � ft. �y iL _ Nou-'rYata•Supply�Ycll: � � ❑Monitoring ❑g�o�uy n• it. InjectiontiYeli: ft ft. • • • ❑AguiferRecharge ❑GroundwaterRemediation I9.SAND/GRAVELPACK ifn l;cable ' .I�F011i TO 1�Li'IFRLiIL T11iPL�CFr4iLNT14iLTHOD oAqvifer Stora�e and Recovery OSalinity Bazriec i� � . �AquiferTest ❑StonnwaterDraina�e • ft iL �Experimental Technolo� ❑Subsidepce Cantrol• ' . 20.DRILLINGLOG attichaddi6aaalsheetsifneausni • �d'EieotliermaT(Closed Loop) ❑Tracer � �onr To DLrSC27PTI0 eolm•hm�dnea toiih�odt e[�'yn eize�eta. ❑Geothcrmal(Fieating/CoblingRehun ❑Other(explainvndar#?IR�marks) fc tt r�� 4.Date�Ye11(s)Completed��We11ID#f �' �� 6 ft � � �t�� l�' '� rGG �^�' ft S"'� ft �a.WeIlLocation: PYlOIlE number � �� r�` ��' . tr. f� . G�:�,�#- �,��,a ?� ��-r�f Le c �. � Faci7iry/OtivnerName �-� FacilityID�(ifapplicable) �y r f� ft • ]S26 ��=a��.1C�/� 2c1 �ci�JV�� 'Q• ft. ft Physical Address,(Sty,and Zip Zl.REn,LlRE;S Ic�n tJ'i r.. � T' ��Q�o r.J / �t:� � County PaselIdentifieatioaNa.(PI1J) . Of 100 S Px $OY'0 Dla. Of 100 S ' �'� . Sb.Latitude aadI,onoitudein degrces/minufes/seconds or dectmal degrees: 2Z.Cerfification• (if�vell field,one faUlnngis sufficient) , 3J� � /�. b��7 N O�o J�e �J b � '' �c�''J�' 'r _ � �r-'��r� • �/ Signeture ofCcrtificd\Vo11 Conhactar D2te 6.Is(are)tiie well(s): �Pet•manent oi• ❑Temporaiy By sto�riig fhLr fornr,I hereby cert�dra!die n�dl(,r)}ras(irere�cotrsltz�cled lit eccordance v�i1h 15,4 NC�IC OZC.OI00 orlSiiNCAC 02C.O1D0 iPe!lCanrtnrcnon S�mvdard,c ond thnt a 7.Zs tIus a repau•fo an existi»g�velI: �Yes OT �0 copy offhis record hns been pravfded to the i+�e11 otvner. Ifthi.r i.r a repair,fll aut hrbrm we![conttructlon/qformalfan mtd acplaiq!/te na(trre of/)�e _ repnir:n�der�.'71 rurmrkrsectlon or an ihe 6nckofr/risfam. 23.Site diagram a1•additional tivell detaiis: ,[ 1'ou may use tho bac]c of ffiis paoe to provide additional well site detaiis or tvell 8.Number ofwells construcfed: � �J � ' constrtiction details. You may also attach additional pages 1f'necessary. Favnukiple ii jectlon ar non iralu•,tuppl�H�e[!s ONLYwilh the sn�ne eonsfruefio�r,you catt submir oneform 5'UBMITTAL 11VSTUCTTONS 9.Totalwell depth belotivland stu�face: J�� (ft) 24a.For AII �Vclls: 5ubmit this form withia 30 days of complction of�vell Farnnrlltpletii�ells!lsfalldeptha/ffii,ffuznl(exnnrple-3�00'm�d2QI00� conStNctlontothefollaWing: 10.5tatictivaterlevelbelo�vtopofcasins: � (ft) Divisinnof'FVaterQuaIity,Tnfoi�natiouProcessingUnif� IfSvaterlevelisabovecati�7o:�se"+" • • I6171YIai15erviccCenter,RaIeigli,NC27699-1617 Il.BoreLale diameter: (iu.) ' Z4b.I�or Iviection�Yells: In addition to szndin�the fonn to the address in 24�a ' above, also sttbmit a copy of this form within 30 days of completion oF wa!! 12.tiVellcovsti•uctionmet]iod: RO�ar'� canstructiontothefol(owin�: (i.e.augu;rotary,cablq direct pusl�,etc.) Divisian of�'Vafer Quality,Underground Injection CantroI P�roei•2m� FOR WATER SUPPLY�VEIS,S ONLY: ' IG36 Mail Serviee Centei•,RaItigL,NC 2�699-1636 • 13a.Yield(gpm) J Methodoftest• A) � 24c.Tor'4VaterSunaiv&Iniecfion'Nells• Inadditiontosendingtheformto the address(es) above, also submit ona copy of this foim tivithin 30 days of 13b.Disinfectiontype: HTH Amount: CUpS �ompletion of well constniction to the county health depadment of the county where constructed. . Foim�] "� � NottliCaro]inaDepaztmantofEnvironmentandNaturalResourcas-DivisionofWatarQualiry RevisedJan.2013 D�-ta Sitg Vzsiteci� �-22-" BV: ��'� . � i. �J r , . � ��'� c .: .. .$�d�'s Name e �� J' �e�,�-++� ��`•��t�t - Owne�� Name• Address< � �� AddreSs• , ��; • h�a � ��-� � � :��; . � Phone Number: �J .��G°�� °c�d g� Phone: �Gvk -' 33�-- ��G- C�j2�' �e7.1 Numver- . - � S fi) f. ��r �� , ��, `��,� . . . � �z � k � � � �. �� . �,'��`' �w wl-� �, �Y� � . . , . � j►�►s` ,�'' L,� � .� G� . _ �' . � ��' c�� . � . g G�.� . . L`��rd ' '� . � ' . �V`� � ' 1 + ' � : C��?�T�1��M�L VV��:��.�0�lSTRlJCT1�l�.REGL�RD ' � �` - ��-�'+��+�'��a'�U�'�'a��'�� ' . .. . • �oiIntcrmlUseONLY: . . - This form ean 6e tued foe aingla or multiple wells . I.'4Vd1 Contracfp rInformation: ' • • ' �n �! }�..�� /� �� Id.WAT'ER ZONES � r t �� L�(�1 FROl13 .TO DTiSCRIPITON W�I1Cont�'actorNamc • �� f�• �� _ ft ft • NCWellConh'ac[arCerti5ca4oqNumUer li.OUTL�RCASING fm•mulfi-casedweUs OItLINER ifa lica ie . FROM YO DL�IiVIL+TLR 7'fiICI4JL+SS 112A7LRIAL Yadkin We11 Company, Inc. ir: rr. ;n. CompanyName , IG.INNFSRCASIIVGOR•TUB G eot�ermalclased-lao • �� A I�'ROM TO DL�ME7IIR 7�IICfIN3LS5 MATL+RUL 2.We11 ConstrucHon Permit:.: � n• i�• �� 'n• ( Li.rl nlf npplicabfe irelleonrinrc(iatpeitnila(!.a Caemty,Sfate,Pm•lanee,eleJ � ft. it. ic. 3.Ti�c]]Use(eLceIc tivel]use): 17,sCFtEEN �` �YahrSupply�Vc11: rnont TO •DL�iTIEI'ER sr.orsrz� THICIWPSS MATL�RIAL ' OAgricultural � �Municipal/Public ft. ft. iu. . ❑Geotiierma](HeatioglCoolin�Supply) ❑ResidentialtiVaterSupp[y(single) ft ft. ,�D• � ❑IndustriaUCanmercia! OResidential Water Supply(shared) 18.GAOUT � PAOhf TO it1ATLRL�L Fa\JPLACL�M1SENThIL+TIiOD&Ah10UK1' � OIrri�ation � �r'� R. p it. Nou-rVater Supply�'e11: ❑Monitoring �Recovery n• ft. ��ontiv�i►: n f�. • • OAquiferRecharge ❑GroundwaterRemedialion I9.SAND/GILIYELPACI{ if� I;oL1e " .FROi1I TO hL�7L�RIdL L�iPLlCC�fI'N'TMLTHOD oAquifer Stora�e and Recovery ❑Salinity Barcicr f� � . OAquiferTest ❑5tormwaterDrainage • fc fF. pExperimenfal Tcchnology ❑Subsidence Control• ' . 10.DTiILLINGLOG alfiehoddiHanalsLectsSfaeeessai • �Eieotliermal(Clo'sed Loop) ❑TC2CEI F1tODi' YO DPSCIt7PTI0N(ealo�•hai�ness soilhoda e irein size etc. ❑Geothermal(Hcatin�/CoblingRehun ❑Other ex lainunder�??I Rtmarks � f� � n f// / / A f�. � ,ft �!9" � / . �ca .�i ( 4.Date�Vell(s)Complet�d:��l�`�b We11ID# ��T�'��..� ' �• � _ C�.' f� � v ft. Sa.We]ILocxtion: Phone numlier n f� GI�,�,� JfU i/ED fZ tt Faeility/Oi'vnerName Fae�7i ty ID'�(if applica6le) ft. ft • g'2 g Wvw d ucr�-S. 2� /�(,,��v,1 l.�. rt. rr. Pl�ysical Address,City,and Zip . 21.REIY.CARFiS IJ�c1t c.. ,f-p — � Counry PuzelIdontiEcationNo.(PIt� , Of 100 S eY' Bore �la. of loo S �� . Sb.L�Htude and Longitudein degrces/miuu[es/seconds or dectmal dagrees: 2y.Certiffcatian• (ifweil Seld,ane IaVion�is suffi cient) ' , J� .S�, C�� N lj�� 37': �'S�l �V G� C�1.*'t 1"'.��`!� . �/ Signature ofCcRiSed Wcll Conh•actor Data 6.Is(ai•e)tLe tivell(s�: �Pe3'1ulneAt ot' ❑Telnpm•a1y gy sio�ing fhfafornr,I hereby cert��/mt the tinel((a)sras(irereJ cotufnrcled li:eccordance irith IS,S NC 4C OIC.0100 orIS,4 NCAC DIC.OI00)Ye!!Cons�nreRon Slmxtmxls ond th�a 7.Is this a repau•to an existiug tiyelI: �Yes or �o copy oJfhls recard has bear provlded to tht u�elf ownn•. If lhia ia n rapnir,fi!!auf,6io�ar N�el!conriruelron h�fornratlan wrd acplal�y the nolm•e oJ7he repairm�der•�2lreniarktsectionoraithebnckofll�i.rfomr. 23.Sitodiad amaraddi&onal�veUdefails: � ( You may use th�bacic of this page to provide additional well site details or�vell 8.Numhei•of'�ve]ls cansh•ucted: vT � ' construction details. You may also attach additional pages�fnecessary. Fa•mad�ipls i�jeatioir or non-orarersuppl+ireJ/t ONLYtivl�h 1Re annre eavtrnclioi,you can subrnir onefo�m. SUBMTTTAL INSTIJCTIONS 9.Total�vell depth belaw]and sui•face: ��o (ft) 24a•�or All Wclls: Submit this form within 30 days of eomplction of well Fotvnu!liptetirelfs!lstnl[deplh.rffd�erenf(ecaneple-3Q200'mrd3Q10D� constiuctiontothefollbwing. IO.Sta6etivaterlevelbclo�vtopofeasin,�: � (ft) Divisionof�VaterQuality,InformatiauProccssingl7nif, Ifwnterleve!lsabovecaring,ii.ce"+" . ' 16I7MailServiceCenter,RalCigll�NC27699-1617 11.BoreLole diameter: � (iu.) ' 24b.S+or Iviection tiVells: In addition to seadin�U�e focm to the addrus in 24a ' above, also sttbmit a copy of this form tivithin 30 days of completion of well 12.YVelleovstructionmetl�od: ROtaz'V constructiontothefollowing: (i,e.augrr;rataiy,caUle,directpusl�,ete.� Division ofti'afer Quality,Underg►•ound Injection ControI Proerxm, FOR WATEIt SIJPPLY 1VELI,S ONLY: ' 163b Mail Seivice Centu;RaleigU,NC 27b99-I63G ,ea� � • 13a.Yield(gpm) � Method af test: "�.� I� Z4c.i+ortiVater SunoTv&Iotection�Velis: In addition to scndin�the form to the address(es) above, also submit ona copy of this form v�ithin 30 days of 136.Disinfection type: HT�I Amount: CU�S completion of weI( eonstniction to lhe county health depadment of the county where constn�ctcd. � � � � . Fatn1 G W-1 North Catoliaa Depaztment ofEnviranment nnd Natural Resow�cos—Divisian af Water Quality Revised lan.2013 D��1'a Sitg V-is9ted: �-�2-�� By: (,��j r � ��/, C s Name: �,d � �� '�� - Owne,r•s: Name: ' . B�'ui� ---- ..� • • .,., . - ��t� Address: . AddreSs a � ' •• . . , "� . � O 1 cY' �@.h,� � a� ' Phone Number: �Phone: \ /�9cv{-t � 33G- ��- C7j2G' cell Number: . � . . . S�� f. f�� 33� �( 3 � �3G � - , . . .Z l x n: i � . ne� . h�� - �� , � �Y^ � . . � � � h�j` ��+ �� G�t� . � ' � . ��/�j G(�'/1(,� �J � , g �.,�`U J . � �+�d , . � � . . �� . � . � • . r � � '. ��T�l�R(�d.�� V�E��..�ONSTRUC�'(ON R�G�1�D ' � �` � �.�g,��N��II�.'��.'�� ' . .. . • �oiIntemal Use ONLY: . . • This fornt can 6e uscd far aingle ormultipin weUs . 1.�VeIlContracto�Intormation: ' • • ' /� /� ! �U �i'— I4.WATERZONES � �i� � � G�V� axonr .To nrsc[urrtoN Wdl ContractorName . �• it. M �5 k�� k� �.G�t s �. � NCWellContraetorCMifiea4auNumber 1 OUTLRCA 7NG formul&-nsed e ORLINER if� lie�Lle . FROM TO DL�14IL'IER TAIQINI7SS d2A'IFRUL Yadkin Well CompanV, Znc� rr: fr. sn. CompanyNaiue , lG-7NNBRCASINGORTUB G( eoWermalclosedaoo IIROM TO DL,IMEiIIA TFI]CIQ'ltrSS MATL+P.IAL 2.4Vell ConstrucNonPermit:: w'°�`U �00 �:f2 tt, ir. in. � Llat nl(npplicnble�pe!!conrtnrc(iar pttmi/a(La Cam�ty,S�aiq Varinnct,ete.J ft it. tn. 3.�ell Use(cLcck�vell use): 17.SCRLEN bYatcrSupply`Vcll: aaoht TO DL�hIL'TER SLOTSJZ� TffiCIWLrSS tATL�RIAL OA�ricu[tural ❑Municipal/Pu61ic ft. f!. in• ❑Geotherma�(Heatiag/Coolin�Supply) OResidential WaterSupply(single) t� it: ,�D- � OIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT PROhI TO 11fAiLitI1L T71IP CL+117ENThI�TI�OD&A14f0UNT �Irri�ation � � � n. v �. , 3 Nou-YVaterSupplytiVc]]: R. it ❑Monitoring ORecovery Injectiontiye]l: fL ir. • OAguiferRecharge ❑GroundwaterRemediation I9.SAND/GR.IVELPACK ifa 15eable ' .FF0113 TO MiTFRLAL T��LlCC�1LNThIETFIOD OAquifer Storaae and Recovery ❑Salinity Barrier f` � . OAquiferTest ❑StortntvaterDrainage • . ft it. ❑Experimental Technology ❑5ubsidence Cantrol• ' , 10.DRII,LINGLOG �ftachaddi6analshectsifaeerssai • �XEeotliermal(Closed Loop) ❑Tracer FR0112' TO DESCPJPTION otor�hardncss sail/rodt e�[rain eae�etc. ❑Geothermal(Heatin�lCoblinPRehun) ❑Other ex lainunder�?21Remazks) f� `i �- �O/. `'.1'�Cy �,'3�/"'•.�"'Q,� ft U' dt /` /'�� G 4.bateSVe11(s)Completed: We11ID# r� �rr. u� � r ��C . , sa.w��iLa«t;oa: Phone number it. ic �l t'.4`T �J!!J i1 E.D' ft ft. FacilitylOwner Nantt Faeility ID'�(if applica6le) it. it • �'2$ Wv.�d cJu� 2�1 /�f�c��v,l �.�. t�. r� Pl�ysieal Address,City,and Zip . 21.REI13AIiSS IJ�LJ'% C'. • (� Caunry Parsel Identi£catioallo.(PIN) , Of ZOO S E�'r $Or2 Dl3. Of ZOO S " `�� . Sb.Latitudc andLongitude in degrcea/miuutes/secands or dectmal ded•ees: 22.Cer6fic�tioa: (if�ve115eid,one lallon�is sufScient) � 3�' S"7, ��3 rr ,...�C�a 3� �G 2. �v _ ��.��'�J � ��- �— �, -'��+� � Signature of Certified��Ve[1 Cont�•actor Data 6.Is(are)tfie tivell(5�: �et'tu;tueAt oi• ❑Te1np01'aly Bysfgnfiiglh�.r fornr,I here6y cert��6at(he wt!!(.rJ 7ras(q�ereJ cautll�cled in eccarda»ce vith IS.!NC�iC 01C.0100 or 15,4 NCAC OZC.OZ00 Nel!Co�rs�nrcBon Slmvdard.r nnd thnt n 7.Is tfiis a repair to an esisting�vel1: OYes or �o copy ojrhl.r record hos bern provlded ro tl�e�t�el!aivner. Ijthis ir n rzpair,fi!!ou(bro��i welL con.rtructro�t htfarn�alian m�d uplain d�e qahnro of//�e , repnir m�da-k71 runorkr aeclio�r ar on!he bnck offhlsfotnx 23.Site diagram or additional tivell details: r /� Yau may use the bacic of this paoe to provide additional well site details or�vall 8.Nvmber oftivclls constivcfed:_ � �J 7 ' construction details. You may also attach additional paoes jfnecessary. For�mr!liple ii jectioir or�rort irvfn•avpplyN'ellr ONLYtvith 7he smne ro�utnmlioir,yau tan submlt onefor•m. „� SU$MTTTAL INSTTJCTIONS 9.Total tivell depth'beiatiy land surtace: S�� (fG) Z4a. For AlI FYclls: SuUmit this form within 30 days of eompIction of�vell Forvnuf�iple tire!!s(Qr alldrptha ifd�uzn�(ecanrplo-3Q200'm�d IQI00� eanstruction to the following. IO.Sta(ictivaterlevclbclotiytopofeas3ng: ' �— (ft) Divisiottof�yata•Qu�lity,Infoi�natianPi'oecssingUnif� Ifivaferlevelfaabovecorino tue"+" - • 1617Ma11Sei•viccCenttr,Ralcigli�NC27699-1617 Il.BorcIlo7e diameter: � (iv.) ' 24b.�or Iniec4ion dls: In addition to sznding tl�eform to the address in 24a above, also submit a copy of this form within 30 days of completion of wall 12.�Ve1lconsti•uctionmetliod: ROtaY'� constnictiontothefollowin� (i.e.augrr;mtuy,eaUle,direcSpusl�,ete.) Di»sion of�'VaterQuality,UndergroundInjeatian ControlProgi•xm, FOR WATER STJPPLY�VELTS ONLY: ' 1636 Mail Service Centa•,Raleigl�,NC 27699-1636 � 24c.�or�Vatcr Suan7v&Iniectlon}Velis• In addition to sending the form to • 13z.Yield(gpm) � Method oftest: �� / �e address(es) abovo, also suUmit one eopy of this form within 30 days of 13b.Disinfection type: HTH Amovnt•_ CllpS complefion of well constniction to the cotuity health depadment of the caunty � whue constructcd. Faim GW�L' �� North Carolina Depaztmaut ofEnvironment nnd NaturalResourees-Division of Water Quality . Reviscd 7an.2013 Da-te Sife V1s� t-gd� �j_22-j� By: ��j r t (�U� C � [ �1 •I _ �-(�;,(., . Owners; Name: ' . �s Name c___ d �_H' ''`� , , • - ",t� Address- . Address e '��; • , . � , . _��.��- �'�'`� �, '; . �Phone: \ Phone Numbez' �G�,k � 33G ��. �r 12C Cell Number: . . , . . S fi� f. (��r. 33��- ��3 � C 3 G� � - . . . � l k n l : rC� 1 . . �� . �� . . Yr � . . . , . � � h�f� ,�,� � � ,� �G�� . . . . . �q. . . ��iz �Q„� �� . � , g �� . . vr�Yd . � � i . . � M1, . . iX- , • . '+ � � , •t . � . C��TH�l��fdl�� L��O�IS�"k�UCTtON RECCI�D � - WIE�,I,C�Ie157['k2UC�'FONR�COR[D • . .. . . � porv��Us�oxis: . . � This form can 6e usod for aingle oc multiple wcUs . 1.�ye]1 Contraetor Iufw'mation: ' • � ' j�J /�� lA.�VATERZONES ��"(� � G�I L�C��L°a i+xoni .To DLSCRIPITON Wc11CanlractorNama . f�. ft. � �s'� � -•�- �r�Y ft f� , ,� . NC4JellContrac[orCertificationNuml�er 13.OUTLrR('A 7NG (armulti-r�su] e s ORL'INER ifa lieaLle . FROM YO DLAhILTL�R TAICIINRSS f�LATPRIAt Yadkin Well Companv, Inc e ir: ft. ia. CompanyNaiue , IG_INC7SRCASINGORTUBL`1G eot�ermaldosed-loo . � PROM TO . �DL�]LIEiIIR '. TF7ICIQ�lLSS MATLP.UL 2.Well ConshvctianPermitR: �-�-l� SL DO_ �''�+� ft! i4 �Q �n• Lf.rf n!!nppllcnble ivd!co»tlnrcfron pu•mtls�.a Comry,Smiq Yorla�ue,efc.J � f4 tt in. � 3.Will Use(cLcdc well use): 17.SCRL+EN tiVatcrSupply�Vdl: nnoni TO •DIATfLTEA storsrz� SHICIINL+S3 I�IATCRIAL fL ft. ia. . ' • ' OA�ricuftural • OMunicipallPublic ❑Geotlierma)(Heatiog/Coolin�Supply) OResidentialWatetSupply(single) te ft: ,in• � DIndustrial/Commercial OResidentia]Water Supply(sharod) 18.GROITT FAOhi TO TSAiL1iL,L T1IIPLACL�h1ENTh1L7fi0D&Ah10UM' ❑Irri�ation ' tt. ft. [( Nou-iYa:er Supply tiVcll: � R. ft. � ❑Monitoring ❑Recovery InjecfiontiVdL• fL ft. • . �AguiferRecharoe ❑GrauadwaterRemediation 19.SAfiD/GILIVELPdCK if� IicaUle ' OAquifer Storage and Recovery OSalinity Barrier .rxonz ft To R ntir�xiaL FMYLlCLMLNTM1IL7AOD OAquiferTest ❑StoimwaterDraina�e � ft ft. �Experimental Tcchnolo� ❑Subsidence Cantrol� ' . 10.bRILLINGLOG attnchadditianalahectstfaecasat • �7Eieotliermal(Closed I.00p) ❑Tracer FItOT4' YO DPSCP.7PTtON col r,hardness soilhadi e,eratn aize,etc. OGeothermal(Hcatin�/Coblin�Rehun OOther ex lainunder#21Remadcs) p it it / 1f �'' fa ft a' f- / lCvt-/ t OY/ 4.Date 1Vell(s)Completed:� 1�� eIl ID#/"'1��y�:r sa.weuLa�at;on: Phone number ` �'"ft 0 ft. � �.� , tc. r� G4 t.�T Jl'!J l!E.1" ft fG Facility/O�vnerNanu Faw7ityID�(ifappliuble) ft. ft. • ,�'2g i�t.7c�-:�d wU� 2� /uac,{��v,l �.o. rr. rt. PLysical Addrass,City,aad Zip . Z� RENIA�tI;5 Ic�Clv'i C. t Couuty PatzelIdentiEcatioallo.(PIN) , ' � !��j of loo s er Bore ' llia. of loo s � r Sb.Latitude andLongitudein degrcas/miuutes/seconds ordcetma]dcgrees: yZ.Certification• � (ifwell Seld,one laUlen�is sufEcient) , 3�' s 7� �J�� rr �fC�� 3 f� �� ( � �v �� `�- ��l-�%� . �,[ Signature ofCecti$ed Wdi Conh•ac[or Dxtz 6.Is(ai•e)tlie titi'ell�s�; a7Yt1'tlllIIeRl' or ❑Tempor�iy By sig�ring fhl,r fornr,I hereby cerl�dtal d�e N�ell(.rJ�ras(�Vtref caruf�trcled tu eccordanet irith]S,!NC.4C 07C.OI00 or IS.4 NCAC 02C.0200 fYd!CaTslnrction Sfmrdards and that n 7.Ssthisarepairtoanesistingtiydl: OYes ar �o copyofthlstecwY7hnsbeenprovfdedtolhe»�ellowner; IJrlda fi n rapair,fr1!o:rt/morm tii�c!!con.rtruc�ion hrfarnrnfion mid esplaiq►he natin•e ojihe . tepnrr smder�21 ranarkr aeclion or a�the bnck oflhirfant 23.Site diagram m•additional n�dl details: j You may uso tha bactc of this pagc to provide additional well site details ar wtll 8.Number afwells constructed:_ � �J � ' � construction details. You may also attach additional pages jfnecessary. Formultlple ii jeclJat a•non trolersupplyweldc ONLYwtth!he snufe eonrtrrrcliou,yau can svbmtr onefarm. SUBMT�TALINSTLJCITONS 9.Tota1 tivell depth'6aiotiyland sui•faec: �� (Ct) 24a.Bor All �Yci1s: Submit this form Within 3D days of eompletion of well Form�d�ipleirdlrllslal[deplltt/fd�u•enl(esnmple-3Q200'mtd3QI0D� conSf[ucttontothefo110Wino: � I0.5tatictiyaterlevcIbelotivtapofeasin�: ' (fG) bivisionof�S'aterQuality,Infozin�tiouProccssingUnit� IjwaterJcvelisabovcca.rino use•'+" • ' 16I7Ma11Se1'v1CCCentet�RaleigL,NC27699-1617 Il.BareLole diameter: � (in.) • Z4b.I'or Iniec2ion tiVeUs: In addition to sending Uie form to the address in 24a ' above,a1S0 Submit a copy of this fotm witl�in 30 days of cotnpletion of wall 12.�Vellconstructionmetliod:_ Rotary constructiontothefo!(owin� (i,e,augrr,rotuy,eaUlq direc�pusl�,ete.� Di»sion of��Vater Quali[y,UndergrounclInjection Conh•al Proer�m, FOR WATFR SUPPLY tVELS.S ONLY: ' � 1636 Mail Service Centet;R�Ieigh,NC 27699-I636 • �3a.Yield(gpm)�� 14Sethodoftest: �L�� Z4c.�orSVaterSunnTy&Iniedion�Velis• Inaddition4osendin�theformto the address(es) above, aiso submit onz copy of this fortn within 30 days of 13b.Disinfection iype: HTH Amount: CllpS �ompletion af well eonstniciion to ihe county health depadtnent of the counly �j` whtre constn�ctcd. . FoimGW-1 y `� � Nortl�CarolinaDeputmentofEnvironmeotnndNaWralRaources—DivisioaofWaterQualiry Revised7an.2013 D��ta Site V1sited: �-22-�C By: (JSZ� , 1 � 1 r �U/) C �� U, �� -�'-�i., • Owner� Name: ' . .��Ys Namec__ - ,. . , .,.,. . - �'t� Addres�s: . Address: ' ' • , . . �,; . . �^ @ 1 cf- �U e.h,� � �� ' �Phone: � Phone Number- �Gvk , 33G� �q�.. �jr t2� Cell Number: . . . S�� .. ��.��. 3S�- �l3 - (3 �$ . . . . � ` k �. � � . ne� . h�;�'' 1�,,�,,r..t � <� , . Yr � . �`� h�j� �,�► r� �� . . �� /y ��{/1(�l �'J � ' g �•��` . . • v4r� � . 3 . . � „! _ � . i)i, , � ' ' � HEALTH DEPARTMENT RELEASE �.��. Davie County Health Department CDP File Number: 139454 - 1 � � � �. 210 Hospital Street � - =� P.O. Box848 County File Number: Mocksville Nc 2�ozs Date: .0,a, /.0,4./,a 0 1.5. �} "�+ui n o+� �� '�QWntivel� Q�I1Cfl Scale: , O Block = .ft. Drawing Type: Health Department Release O N/a _ � � �� `'� a � . � -�s ` � �� d � ��, �, � � � `' � � u� 4 �o � � � � � n � � � . 6 � � � $�� a � � � � � 4 � Q �_. . � � . � 1 I,� � � � ��r� ,�,� y� �,� ��d��' �i `Y�� u� � � � v�� Page 2 of 2 -- -- -- --� - � . ,:> .. C��PQI'iTl�fi� I3,.�'f�.�R�.L'�?�l.hl�`.0 OS�' F.��71'�.�IV'MT�'L�Trl' 131Vt7 ?�T�.��L �E�Oi7S�'C�a • � ' :.. ��'��.'$]tO1�T�r`�T�`��'�'� ��.I�T��]L�Q.)��`��Y��lP�+]E3��+ ]t�f�+��3{�IOI'�}EIC.�� . These yvslls are 'permiued by rule"and do�rotrequire an�dit�idunlpermzYwhen constructed r.�accorrXance with . the rules ofISANC�4C OZC.0�00*, ,'['��s nntice must lie s�bmitrecl prior tn canstr�ction � � • ��T]P�141V1.��.(3�EO�T,�Gfi3O�7EY��,�OP�]L][.s As dtsc�'bsd�.n.iSANC.fi.0 02C,p2��tTaCse vcve]Is circu]ato potab].c watar o�1y or a mixturc�of potah�e watEr and pr.rPoxmanc�cz�hancin,�euidzfive8 as pan of a geot'�czua�Iheatiug and cooling sys�em. ' . O� � . �r��JRIVlAY,�'17.]�CT�+�"c'.�1�r�1V CY,��+�-7C,001"i�F �.X� As descsibcdin 7,5,fiNCAC 02C,0223 these v�rcll�cuet��ata a rcfrigesalat gas as pasC of a geothe�xa��hsaCu�g�d �oaling 8�8t'ra]�,. ' - NOI�TH CAROL�N"A,l�l3P.AR�I�T OF BN�]120I�TMI�.(�T AND NA.xtntF�,�SQ'CJRCES ' Pyir�t Cler�lly or�'yp��fnr�r'aa�o�a. 2Tl'egzLdd d'tcbntrttals�iT�,Ba,I2efci�ncdAslncOrt�plete. IDA'�JE; �–��!` , x0� �'LYtMI��O. (to be completed byDW� . .p.. 'r'SIY'�OF��T�E�L�,�SEA�LOO�'�EILIG'xO+��ON�7C].tUC7�aEI� �c�'Q.T ' (1) Ac,�ueous(as per 15ANCAC 02C.0222.): � Numbcr of Yvells: � (2) :Direc��ansion(as i�ex 15ANC�I.0 OZC.0223) 2�Tum�er of�vells: • �. SrA7CC7�"�JE."PV�Y�L��It(c�oose onB) ' ' (1) ' Sin�1e�ami_lqRsszdence i��ubxuittl�s foTlmi fWo(2)bt�sine5s dt�ys prfo7c to conghuction. (2) �usiness/Oxganxzation Su'bmitthis form90 days prior ro conscrucfzon. (3) Goyp.r�men�; Stafe__��_, .Municipal County �edszal Submit Wis forni 30 da�s , . prfor Eb cousf�-i�.ciion. �, `Cd7��,T., ��t��or singl@ fami.ly resid�cas list tb,G prop�rty o�vruex(s). For all othezs, list n.ame o�t3�e buainc�s,oxgaiz�ation,oa gavem�nez��agency andpexson dalegated signatiura authoairy: —� t n.�' Qn��,v_.,.@ w — , , ( t �6'^�y��_�1,c+1 L� �r ' — �– i � M81�1Rg�1.CZ�ICSS: ��S �N�v c�yu � � � q�� e� �t • City: ��G{'��'Qf ! Q• Sta.te: � Zi�p Code• .W1�'?° oun'Cy: Cti� ci'i • p�.y Te1e No.: Cell I�o.: ' � l P.1vIAJL Address: �ax.No.• . � • ]D, pA�,''�YC��CA`��OTT�1�'6'�L�,SY`X'E � • � . � (1) PaxcelTde�nt�ficat�onNum.�b'r.r(�'Xi�o�psrell sit.�: � �' `��C7 @ �' f'� � ., co;��y; � � �a,,�'�-�— - � .; (2} Physical Address(if difCexeat ths�mailin�addcess): ` � � City: 'StatE:NC Zip Code: pW'Q/CTIC/Closod-T.00p Qeo�ham�sLNoKfict�tio�1(Ttevisad 4/30/2013) 1'age 1 -"' -"—"" "-- "--' ,"""""�+•-�� a vv.i a VtJCIV/ VVV� L N1J . 1 , .�� '' ' • �. IVIA,Y�,k�C.AN�,A�D�P]E��l�ATIOl�� (1) Ma�s inust be scaled or otherwise accurately iudica�Cc'c�istt1nces and oriez�tations of fea.tu��cs located• withi.0 250�eet ofthc�injecrion�cs�ell(s). 'L�.bel all featti�xes cica�l�y and inclnde a north anow. Aifac,h a site-speci�xc map sho�wing tlie locations of tb.e follo'a/ing_ 0 o propose�.injectionwG111ocatzo�a � 0 Buildings ��-� �/� G!� . o pxopatyboundariss o Siu�cewatesbodzes ' o • y�latcr su,p,�ly wells . ' o S�tic eyste�.ns and assoeiated sl�ra�r irrigarion aites,drain�e�ds,or repair ar.c�as n - EXisiiz�g oY potentlal sources of groundwaYer con4auiina�ion. (2) Plans�nd s�eci�cat}ons o�t'he surfaca and st�bsw.�faee cous�uetion detaiIs of Che v✓zll systeui. • � SL':�' ll/!/Ybtv6z� �-�2. . �'. '��,']G3 Ai�7) ��N�T�TI2A7CIOl�I'� 03�� AIDID7(x'�� — List 8ny additives tb.at will Ue used and Yheir coneen:h�ations. dnly a�c�itivea tl�t tho De��artuleat otTTealtlz an.d I�uman Sezvices'Diviaion of Public�ealt'h detesmin�s db not ad'v�sely a�fect human Iieal� shsll tie t�sed. A.�ist of approwed adc�itives can.be found � onli�,e at hft� -/lp4rtal.ncderu.oz g/web/vra/,�ps/�wuro. .A,11 othex t�c�dx�i�es require appiowa�,prior to UsG. ,��'Pa--r2�(� . G. , ,'�+LY,�3�LLE�Z..iIVY'+�YZIY�TYON(if kuo�wn) - Well DY911i.ng Coutractor's N'a�ae: (7od�M[ullis) (MatrlaBwBrbtvn) (�ilfon Cav�) . . . , . ' I�TC VTellbrilTixig Co�tractor Certi�fica�ion No.: 257?-A 3036,A 3548-A Comp�yNamc: 'SZ'aclldn'V�fe1I Compnny,l'na Co�t�ct k'�rsoz�: David Browix(2195 A.) _ _ �#y; �tonvillP State: NC Zin Codc:27020 County:,_Y'a� ��sr Tsle I�Io.: �F1168� 440 Cal1 No.: 936-�74-873G BIv1A�,Addz�ss: chi�e£c�lilrc�a msn.coyn �a�No.: 336-A�6R-�Q�648 H. ,gG+,A;�PYJMJ�.'C�NTR.A.CTO�7�IFOX21V1ATIf�IV' co��.�rr�g• 1��. � �Iz„�, ��.� A �� . � Contact Pe�son' ��K KC�.�b•ti BMAIT,Add,c�R• ��A�2 L� �,��d��1, �f � aaa�s: `�r� �1�, � '7 ' ' , ��- -, C,ity; �'/g�S'j" �� 7p Codc: � State:N C�Cottnty: ��' k•�, _� Office Tnle No.: �� 9�2a��' Cell No.: Fa N�o-_ py�}'Q/UIC/Closed-][.00,p Geothermal Notifica¢io,i(Xze�ised Al30/2012) • pII�6Z .� ` ;l . ' ' • ' . �. k�`�O��C7��0�--Prov:ide a brief description of liow(1)vc+atea�supply vve]1s;(2)suz��ce wate�bodies;and(3) septfa sysCems and associatcd spra�irrigatYon sites,drain:�elds, or rep�ir areas�srit'�Sn 250�ea of��c groposed inject�ou vtrells will be�zotected duiing construcd.on o£t��c�Tls: . , __-�._v_.Y�i�.r��'z�. 1��e e .�� ;t.�.,.�rl/r ��'I.� -(�,�ce ��' �e cc fs�� ', i7��'E—pursuanC to�SA NCAC 02C.024�,the Direc#or of the Division o�Water Qnality naa�grant a � variancs�coui applicable rwell consfsuciao�ox opara�on s�idards,�rovzdcd that: (1.) use of the�ove11(s)�vill not eaadange�-�zuman heslt'h and welfare or t�ie groundwater;and (2) that constniction or operatiou in accoxdan.ce�vvith the atanc�azds is not�echnieally feasibIc or th� proposed cons4�uctionprovides equal o�be�tarprotecrion of the gloundwatea. �lny varianee request should accoax�paz�'�su'braittAl of this n.oti�Zcat�on to ex,�edito cvaluation of the rec;�ues�c, ' '�he va�ianc�request�o�u c�n,be aceesEed onlino at hctp:Nportal,ncdenr_nr�/web/�wc� s,�rw�ro c��nit- . �tolic�.�qxZs g�, ��A3'T�S--The fo]lowiv.g seatzon is to be completed as required belo�u o�by tl�at l�ersox�.'s autf►orized � ageut. 15ANCAC 02C.0211(z)req�ixes signatures as follov�ts: ' (a) for a corporation_ Uy a responsibla corporate off[cer; � (U) �'or a paztnershap or sole pro�iletorslu�: by a gen�xaZ pAriner or tlie p�;opxiator,respectively, (c) �or a municipal�ity or a state, fedaral} ot other public ageri.c�; b�either a.prineipal execu��re • officer or raxxlringpublicly elected of�'ieial; (c�) fo�r a11 othera: by tbe�cve11 ownaz; (s) for a�ay othex pei�on au'tb.orized to aati oz� behal�of iha appJicant: documa�afmtion sb.all be aubnaii�ed with the notification that c�Garly identi�es tl�e person, grants them szgnature autb.ori�ty,and 1g szgn�d and dated b�the a�plicant. , � '7 hereby cerZify, under'psnal'ty of law, thatl hav�persohally ezarninet�and am familia�w�lla the infornaation subrnilted"in this docunzent and'dTl attach1nents rFeereto ana thar, Strsed o�a my �nc�aliry o�'those individa[als 3�rtm�d'fately responstbrs for obtain�,g saicT in}'orn:a�to�t, .1'bel'ieve thct't the inforrnu�lori �.s t7'u4, accuYate and' com,plete. I am aware that there a�e sign�c�a»�penalfies,including the,possibiliay offines and i>nprison��nt, for sarbmit�angf'alse infor�mation- 1'a td cons. erc�te, �zaintain, 'repaar�, crn�'if appYaccable, abandon the injection well and all redaterX purtena� cor�anc yvith the.IS�1 N'CAC 02C 0200Ru1'es." Oy1c� � atilCe r erty �Y1n /Ap�Ticant � � 1.,�. �' \Jc�w �/ � /"` . prinE oi Tj�p e FUIi Na�ha ` � - � . . S9gnatuYc ofAuthol•Ized nt,if aay . ��4.-ti.ti vc• �-' �"� � °'ro� �+- ' � YXint or Tylia�lI Nazna - J�WQ/(JIGCloscd X.flop C3cothcrmalN'o�if cation(Revised M30I2012) Page 3 __'f:��v . � � . 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