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135 South Madera Drive Lot 28DAME COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990001248 Billed To: Mike Hester Building Co. Reference Name: Proposed Facility: Residence OPERATION PERMIT Tax PIN/EH #: 5749-63-6767 Subdivision Info: McAllister Park Lot # 28 Location/Address: Sain Road -27028 Property Size: ATC Number: 4560 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: S.T. Manufacturer? Tank Date 3—Z -Q Tank Size Pump Tank Size System Installed By: SfljQ,1\4A, "Speciali l 7 n� DCHD 11/06 (Revised) 71 ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street 1 ' Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990001248 Tax PIN/EH #: 5749-63-6767 Billed To: Mike Hester Building Co. Subdivision Info: McAllister Park Lot # 28 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: ATC Number: 4560 **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G. S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type bt #People #Bedrooms 3 #Baths 3 Basement w/Plumbing: ✓Basement/No Plumbing Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size O.7j Type Water Suppl yy{{;; Design Wastewater Flow (GPD)— d Site: New✓Repair System Specifications: Tank SiAC100 GAL. Pump Tank ^ GAL. Trench Width—�' Trench Depth F' Rock Depth N Linear Ft 0 ' Other, ae i� � �i1C�71d� t:5%— , L� �DySTiQl�jVrOr•1 A%,3 Required Site Modifications/Conditions: /"RTIC L' - O N c4H MV.'Contact the Davie County Environmental Health Section for 8:30 — 9:30a.m. on the day of installation. Tel y© 115' €?IC Iin' 300 0 Abp. nal inspection of this system between Pte, L1�►= hone # (336)751-8760. —M�,a ICS R4&1 Q ARS. 1-C> 1!'3 L7i Sl C�tJA ► +�1� i .7 �Lr�t�1 [a sl; r Environmental Health DCHD 11/06 (Revised) u Y f fes` jr If 331-6-5 G.,.a:iwt..a...smY.�r- ,�+ r � .,.«y' � YAW e "��° � „�..- ...�1 �� ✓ rq 325.62 ' j J,---•---✓ _..�' , ""wi .... s.�- �`� � 5 r� � F i3..— � vim='' �>"u•Sa�`.`T;�� , aa-e i # " : 4 Jan 03 07 10:58a Mike Hester (336) 499-0950 s r- i 1031 3u' p.l (Y} i f E l OC -5 rZ n ec4r l_ nO�vG Cl-, '? 9 5- r} -C -(/(a LG/ ' �1��f9/�.r 4, A ar V APPLICATION FOR SITE EVALUATION/Ih1PROVEh1ENT PEI Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 �AQ LOT 2 7 APR 7 3 ?005 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: E Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: l'H,ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: Ud' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms � '3 - � #Bathrooms 3/0is1iwasher []Garbage Disposal Washing Machine ❑Basement/Plumbing ❑nasemont/No Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) S. Type of water supply: ILd'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-Nei If yes, what type? ***IMPORTANT*** CLIENTS,1fUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BESUB.4f1TFED by the client witli THIS APPLICATION. Property Dimensions: A_�; ,n Ia4ell Tax Office PIN: i71`�- Property Address: Road Name c is r'J'� City/Zip If in a Subdivision provide information, as follows: Namc: Section: / Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: L" G( -'b" IDI < <.. Date home corners flagged: This is to certify that the information provided is correct to the best of my lalowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use cliange, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all changes incurred j•on: this application. I, hereby, give consent to the Autliorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ' 13 r D S� SIGNATURE / ` °-'—• ��, ��' TIIIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn_/�k Site Revisit Charge Datc(s): Client Notification Date: EHS: I �j G Account No. %b 9% V U 0 2 S Revised DCIID (05103 Invoice No. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. to the INFORMATION BULLETIN for instructions. (Refer 1. Name to be Billed !� ' �,iu,• znl� �� l Contact Person �� %� v' Mailing Address i,�� / -I I f' �E? C�� l' �J 4— Home Phone City/State/ZIP 7.16 .3 Business Phone -V6 7' 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: E Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: l'H,ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: Ud' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms � '3 - � #Bathrooms 3/0is1iwasher []Garbage Disposal Washing Machine ❑Basement/Plumbing ❑nasemont/No Plumbing 7. If Business/Industry /Other: verify type # Commodes # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) S. Type of water supply: ILd'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-Nei If yes, what type? ***IMPORTANT*** CLIENTS,1fUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BESUB.4f1TFED by the client witli THIS APPLICATION. Property Dimensions: A_�; ,n Ia4ell Tax Office PIN: i71`�- Property Address: Road Name c is r'J'� City/Zip If in a Subdivision provide information, as follows: Namc: Section: / Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: L" G( -'b" IDI < <.. Date home corners flagged: This is to certify that the information provided is correct to the best of my lalowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use cliange, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all changes incurred j•on: this application. I, hereby, give consent to the Autliorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ' 13 r D S� SIGNATURE / ` °-'—• ��, ��' TIIIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn_/�k Site Revisit Charge Datc(s): Client Notification Date: EHS: I �j G Account No. %b 9% V U 0 2 S Revised DCIID (05103 Invoice No. APPLICANT IN#ORMATION Account #: 989900035 Billed To:. Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.28 Subdivision Info: McAllister Park Lot # 28 Location/Address: Sain Road -27028 i Property Size: as platted Date Evaluated: Q S Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �1` 9 ��Ic, v 111,1 a 6,ZYA REMARKS: ��_1 LEGEND EVALUATION BY: OTHER(S) PRESENT: rid 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 ois VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet 01 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 Mineralogx 1:1, 2:1, Mixed Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface `. Saprolite - S(suitable), U(unsuitable) 1 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 - gal/day/ft2 DCI ID 05/99 (Revised) Landscape • HORIZON I DEPTH Texture group Consistence IN 0 KIM ISA N WR We! 5510: 710M HORIZON 11 DEPTH Texture group Consistence Structure Maw, .HORIZON ��a��s III DEPTH Consistence HORIZON IV DEPTH ConsistenceWRIT ��r•yc��■�� SOIL WET -N -ESS WIN W R01 M V ICLASSIFICATION NOR SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �1` 9 ��Ic, v 111,1 a 6,ZYA REMARKS: ��_1 LEGEND EVALUATION BY: OTHER(S) PRESENT: rid 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 ois VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet 01 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 Mineralogx 1:1, 2:1, Mixed Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface `. Saprolite - S(suitable), U(unsuitable) 1 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 - gal/day/ft2 DCI ID 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION . X31 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut ;s ' FACTORS®©©©00 ' 140RIZON I DEPTHStructure Consistencc • _ ontom 0 u -m• W,mFM HORIZON 11 bEvrH Consistence Mineralogy HORIZON III DEPTH Consistence Consistence ��■��s SOIL WETNESS NINE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nosc 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 Dist 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 - Crib GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 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(unsuitablc) LTAR - Long-term acceptance rate - gal/day/ft2 11-1 — ne Inn /I) -..*--,I% 0 DAVIE COUNTY ENVIRONMENTAL HEALTH 1 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT /35- S Aadefa Pk, Account #: 990005760 Tax PIN/EH #: H519OA0028 Billed To: Grover Cooke Subdivision Info: McAllister Pk Lot # 28 Address: 135 S Madera Dr Location/Address: 135 S Madera Dr -27028 City: Mocksville Property Size: 0.748 Reference Name: Grover Cooke Proposed Facility: upgrade/expansion- res **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. t System Type: li S.T. Manufacturer_, M Tank Date !�_ Tank Size 6O( Pump Tank Size -,— System Installed By: ( a TW( E.H. Specialist: Wa,®ate:Zd Z(5/Z 4 GPS Coordinate: DCHD 1 1%06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH ' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005760 Tax PIN,EH #: H519OA0028 Billed To: Grover Cooke Subdivision Info: McAllister Pk Lot # 28 Reference panne: Grover Cooke Location/Addres8: 135 S Madera Dr -27028 Proposed Facility: upgrade/expansion- res Properly Size: 0.748 ATC Number: 5833 Site Type: ❑New ❑Repair [XExpansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms 6 # Bathrooms # Peopled BasementC�3asement plumbing0---- Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: Q"County/City ❑Well ❑Community Well r �;'l�oY'o-� pl System Specifications: Design Wastewater Flow (GPD) 3� $ Tank Size �� 666GAL. Pump Tank 10,GAL. S /I� a Trench Width_ Max. Trench Depth 3� Rock Dep Linear Ft. ©d d( a Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between � ��+`V ~ 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. �b 0 f�ew�eJue 1� Ifer -�ror►� eX�Si.',�� 5epj1C rtOa k, (0110CCfoz-o'-f" 3� C. 0 f s 5•epf 1,�t4 e5 T✓�✓l? ,i/tcJ yavr AAd aAJri;.H 366 'd� %:nP `ld &61d d ex,SY,� �iL� � Sys1 �,�, • 3a `i �' 1 eLJ ►,'O°q 74 j CL d `� t p� Gd5 16-7-11 Environmental Health Specialist � Date: DCHD 11/06 (Revised) • Davie County Environmental Health ` P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005760 Tax PIN/EH #: H519OA0028 Billed To: Grover Cooke Subdivision Info: McAllister Pk Lot # 28 Address: 135 S Madera Dr Location/Address: 135 S Madera Dr -27028 City: Mocksville Property Size: 0.748 Reference Name: Grover Cooke Proposed Facility: upgrade/expansion- res **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. I Permit Type: ❑New ❑Repair AExpansion Permit Valid for: R5 Years ❑No Expiration / Residential Specifications: # Bedrooms # Bathrooms '7 # People 3 Basement/Basement plumbing[ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): ` O t��a� Type of Water Supply: ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: S Site Plan c� System Type LTAR Initial Repair0-3 ITI � y s Q s :30o' Environmental Health Specialist_ i.p. 11-06 °U Vel -e Joe n Joe 3 BII o 515 ares IJI� Date 16-7-11 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street �� P/�► Mocksville, NC 27028 A SEP 2 b 2ui� 0 .(336)753-6780/ Fax (336)753-1680 ppli or: ite Evaluation/Improvement Permit ❑ Authorization To Construct t gype kation: ❑New System • ❑Repair to Existing System �Expansion/Modification of Existing System or Facility ``ll � n-21 iii ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE -REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Namemole_ !'. Contact Person C VCAJe_' CZOJe�2— Address _ �. %%� ,-� ►� Home Phone _33(-93 — D City/State/ZIP M2j<S V4 //',t- /(%G r? 7e9.7, ' Z4!8rs Phone Name on Permit/ATC if Different than Above fi1i-�e:;{a� Mailing Address City/State/Zip 1'KUYI:�K 1 Y 11N 1' UKN1A 1 IU1N � Date House/Facility Comers NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site Ian; no expiration with complete plat.) Owner's Name � i'Ovt r lrGi � Phone Number -3-3 r1.3` Owner's Address /3cS�, ",,4 �l �Y City/State/Zip `�JGc/%5 t/j/�e , /✓G �70Z��r Property Address /SS's. M4 ,Pt re, D✓ CityA(16A51/1//e./VG > Gz -' Lot Size p , 7gcX Tax PIN# 37 4r! -(p3 - &M-1 Subdivision Name(if applicable) 71 'Ca 4-r Section/Lot# 62 Directions To Site: /S9 JL� w A -1, m �i�� P k IPn rreCC 14x�I RO Adc'2. If the answer to any of the following questions is-"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? vYes _No -No Does the site contain jurisdictional wetlands? Yes Are there any easements or right-of-ways on the site? _Z vies _No Is the site subject to approval by another public agency? Will wastewater other than domestic sewage be generated? _Yes _No _ Yes ✓�o IF RESIDENCE FILL OUT THE BOX BELOW # People 3 # Bedrooms _(�_ # Bathrooms Garden Tub/Whirlpool Plfes ❑No Basement: 0'es ❑No Basement Plumbing: Lues ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventionalccepted ❑Innovative ❑Alternative- ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [5'No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of any 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 Represent ' e of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and es. I un=St t I am responsible for the proper identification and labeling of property lines and corners and Pd fgagginthe house/facility location, proposed well location and the location of any other amenities. ll/Y ro rty wne s or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Da EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # • DAVIE COUNTY HEALTH DEPARTMENT j Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION „I'Wj� RTY INFORMATION Account #: 99005760 Tax PIN/EH #: H519utsvozQ Billed To: GrolI er Cooke Subdivision Info: McAllister Pk Lot # 28 D_foronrn Alnmw (�rZar r,nnkP. Location/Address: 135 S Madera Dr -27028 Droposed Facility: upgrade/expansion- res Property Size: 0.748 Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTO S 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH o-37 Texture group G Consistence Structure k Mineralogyx HORIZON H DEPTH - y$ Texture group G SGL Consistence 5 P {;r Structure k Mineralogy HORIZON III DEPTH Texture group Consistence Structure . Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPT CE RATE 3 . SITE CLASSIFICATI0 EVALUATION BY: LONG-TERM ACCEPT CE RATE:y OTHER(S) PRESENT: REMARKS: �/ Landscape LEGEND Position R - Ridge S -.Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope V - Convex slope . T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamsand 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 ONSTSTFN , MQi&t . VFR - Very friable -Friable FI -Firm VFI -Very firm EFI -Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP Slightly plastic P - Plastic VP -Very plastic Structure SC - Single grain M Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 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( nsuitable) Soil wetness - Inches fro 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) TTAR - T.nna-term nrrPnt nrP rate - on1hinp/fO r\lnTIT% nc1nc in___.__j ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■c■:aM■ ■■■nec on ■■Nee■e■■e■■■■e■■■■■■e■e■■■■■tl■■ ■■■■■ i ■■ ■ ■■■N■e■e■■■■eeee■e■eei■ee■■ ■■■■■e■■■ i ■ i ESE i■■■■ i■■■■ ANNE i■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ Emmummmummu mus MENNEN MUMMEMMEENNEM MEMMEMEMEMMEM NOMMEMEEMEMEM ■■■■■■■■■■■■■ ............. APPLICANT INFORMATION Water Supply: On -Site Well Evaluation By: Auger Boring DAVIE COUNTY HEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Community Public +' Pit Cut FACTORS Baa®o©�■�® Landscipe position HORIZON I DEPTH Texture group Consistence 0 sM, 0 E a ,AE Aaff_9W Structure �.�N& I .. Mineralogy Texture group Consistence HORIZON III DEPTH Texture group WAVE M1 Consistence wwwol aJamam Mineralogy HORIZON IV DEPTH Consistence SOIL WETNESS SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:-�c�� OTHER(S) PRESENT: 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 ois VFR - Very friable FR - Friable F, - Firm VFI - Very firm EPI - 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 Mineralogy 1:1, 2:1, Mixed oc Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) 1 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 - gal/day/ft2 ALUATION/IMPROVEMENT PERMIT & ATC )unty Environmental Health lox 848/210 Hospital Street VIocksville, NC 27028 51-8760/ Fax (336)751-8786 5--/90A,G j rmit ❑ Authorization To Construct(ATC) ❑ Both (isting 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 BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Oi d c t' fl e S T L rl !j �+/C n �- I C L,. Contact Person ' 41 %Ir e Dyes Ao Billing Address CR -0 0cf'- }-- Home Phone 3 3 x/17-1/- 01) So City/State/ZIP t --t7 rt,, 3 c,;l -c : AX, t'. J 7 0,}- 3 Business Phone 3 i L 3 , f - 1 k(16 Name on Permit/ATC if Different than Above, Mailing Address PROPERTY INFORMATION *Date House/Facility Corners Fl=-Yed / L - ot r-- c> P' NOTE: A survey plat or site plan must accompany this application. Included: & S"ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan no expiration with complete plat.) Owner's Name S --e el4 c - e Phone Number Owner's Address City/State/Zip Property Address City 14► Lot Size 103 � 'x 3 I a ` Tax PIN# Subdivision Name(if applicable) A c � / Ir i" J P/4 -1C Section/Lot# ol- DirectionsJo Site: 1.S k "f -c:, S #-a I --L--1 ? ' --1 d S C, k-." fie '1-- e 4- s 07) A Avi ,,r1, i If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Dyes (moo Does the site contain jurisdictional wetlands? Dyes Ao Are there any easements or right-of-ways on the site? Dyes 2No Is the site subject to approval by another public agency? ❑Yes j?No & Will wastewater other than domestic sewage be generated? Dyes f IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms 3— Garden Tub/Whirlpool 8 -es ❑No Basement: P -Yes ❑No Basement Plumbing: gales []No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: B'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: fyCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0-p o 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 f r the proper identification and labeling of property lines and corners and locating and stagging or staking the Ouse/f ility 10 ti n, pro sed well location and the location of any other amenities. Z-�Xfl Site Revisit Charge Property er's or owner's legal representative signature Date(s): _ �'�_ �} cr Client Notification Date: Date EHS: Sign given Dyes ❑No Account # JZTO Revised 11/06 Invoice # 5 ,vrvd AV 6t T- ZS APPLICATION FOR SITE EVALUATION/IAIPROVEAlENT PERAIIT S 0 LV Davie County Health Department V EnvironmentalHeaith Section P.O. Box 848/210 Hospital Street APR 7 3 Mocksville, NC 27028 2005 (336) 751-8760 fN�RON Mr .41 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE -7R INFORMATION IS P,ROOVVIDED. /1 Refertothe INFORMATION BULLETIN for instructions. 1. Name to be Billed �/LCC�I�c•;r_1� Contact Person Mailing Address (C> �1�� / 1 Lf7 J' �Si— Home Phone %-� ' C>•.Z 7� City/State/ZIP L:.�� h%� F�' �1+'L 716 S Business Phone -41e) 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 13 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 2-H-ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: M Conventional ❑ conventional modified ❑ innovative 6. if Residence: # People ? # Bedrooms �� ®54� � - � #Bathrooms 12Dishwasher ❑Garbage Disposal ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) S. Typo of water supply: lE1'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 13 -mu If yes, what type? ***IAiPORTANT*** CLIENTS DIUST COdiPLETE THE REQUIRED PROPERTY INFORIWATION REQUESTED BELOW. Either a PLAT or SITE PLAN 1T1UST B SUR.4f1TTED by the client with THIS APPLICATION. Property Dimensions: i) n f t" .1 I " Tax Office PIN: #7 ��' 3 .2 Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Namc: Section: Block: Lot: c� 1VRITE DIRECTIONS (from Mocksville) to PROPER'T'Y: A- fes..:y► d— "D, , of lqA cP to!.- c c. Date home corners flagged: This is to certify that the information provided is correct to the best of my k.no►vledge. I understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, narderstannd that I ain responsible for all charges iacurrcif from this applications. I, licreby, give consent to the Autliorized Representative of the Davie County IIcalth Departnient to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE t,3- OS SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EIIS: Sign givcn_AL Account No. ft % / O O ° 3 S Revised DCIID (05103 Invoice No.