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164 Linda Lane Lot 7Dav 7-016 WARNING: THIS IS NOT A SURVEY Ali data Is provided as Iswhhoutwarra�dy or guarantee of any Idnd ehherexpressed or implied Including but not Ilmhed to the Implied vamntim of merchantability orgmess for a parthularuse. Ali usersof Davie County's GIS webme shall hold harmless the [all Parcel Information: County or Davie, North Carolina, Naagents, eonsu tents, contractors or employees from any and d claims or causes of action due to Parcel Number., 16160A0007 Township: Mocksville NCPIN Number: 5758141121 Municipality: Account Number: 8305614 Census Tract: 37059-805 Listed Owner 1: BRAGG WILLIAM K JR Voting Precinct NORTH MOCKSVILLE COUNTY Mailing Address 1: .156 LINDA LANE Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag. District: No Legal Description: LOT 7 CAROLINA HOME PLACESECTION ONE Fire Response District: MOCKSVILLE Assessed Acreage: 0.62 Elementary School Zone: CORNATZER Deed Date: 9/2015 Middle School Zone: WILLIAM ELLIS Deed Book IPage: 2015EO913 Soil Types: GnB2,GnC2 „ Plat Book: 0005 Flood Zone: Plat Page: 196 Watershed Overlay: DAVIE COUNTY Building Value: 108980.00 Outbuilding & Extra Freatures Value: 0.00 Land Value: 20000.00 Total Market Value: 128980.00 Total Assessed Value: 128980.00 Davie County, Ali data Is provided as Iswhhoutwarra�dy or guarantee of any Idnd ehherexpressed or implied Including but not Ilmhed to the Implied vamntim of merchantability orgmess for a parthularuse. Ali usersof Davie County's GIS webme shall hold harmless the [all County or Davie, North Carolina, Naagents, eonsu tents, contractors or employees from any and d claims or causes of action due to A� NC - orarldng omof the use or Inability to use the GlSdata provided by thiswebstte. C OPERATION PERMIT. or ice se nv Davie County Health Department *CDP File Number..232635 1 �x 210 Hospital Street :. 5758141121 P.O. Boz 848 County ID Number: . MocksvilWe - = NC27028 Evaluated For-EXPANSION', - Phone'. 336-753-6780 Fax: 336-753-1680 Townshipi Applicant:.. - Susan E.-Willcox and William K Property Owner. Susan E. Willcox and William K Address: 156 Linda Lane Address: 156 Linda Lane ; City:=:Mocksville City: Mocksville - .State/Zip: • NC .=27028 State/Zip: NC 27028 'J - Phone #: (3316)-751=0723 Phone #: (336).751-0723 . Property Location & Site Information _Address/Road#: r Subdivision: Carolina Homeplace - Phase: Lot 7 ,•, 164 Linda Lane I,-"Mocksville NC 27028 Directions ' Hwy 64 East, on John Crotts Rd. 2nd road to Structure_ SINGLE FAMILY' M .left right Linda Lane # of Bedrooms: 3 # of People: *Water Supply:' Puauc "' ^•'• m.,:: *IP Issued by *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS - - *CA Issued by:. 2140 Nations, Robert- - Sapro_ lite System? O Yes ' ® No Design Flow .. WA Pump Required? `*Distribution Type: O Yes Qg No � _ Soil Application Rate: . 0 02 7 * rJ Pre-Treatment: Drain field ration Field. 4 ` 3 6 S4• ft.". *System Type: INFILTRATOR QUICK 4. STANDARD No. Drain Lines 02: Installer: Randy Miller Total Trench Length: 1 0 9 ft.11281 i Certification #: Trench Spacing: _ 9 Inches O.C. . 2399 - Eldridge, Titian Q9 Feet O.C. EHS: s y Trench Width: _ 3pinches ® Feet 1 a/ a 9/ a 0 1 6 Date: Aggregate Depth: inches _ Minimum Trench Depth: 3 6 Inches - Minimum Soil Cover:oZ L} Inches Approval Status Maximum Trench Depth: 3 6 _. ®Approved ElDisapproved. Inches Maximum Soil Cover: a 4 Inches Page 1 of 4 CDP File Number 232635 - 1 County ID Number: 5758141121 Septic Tank ! Manufacturer: Lat. Long: Page 2 of 4 STB: Gallons: Installer: - Date: / /' Certification#: 'EHS: - "Filter Brand: ST Marker: ElYes ElNo- Date: Reinforced Tank ❑ -Ye s ❑ No - 4ppro`val'Status 1 Piece Tank: El' Yes ❑ NO ❑Approved ❑ Disapproved ) . . Pump Tank _. Manufacturer::. `� Installer: - PT: Certification - #: '_::Gallons: 'EHS: Date: i / - / Date: Riser Sealed ❑ Yes ❑ No Riser Height ❑ _ Yes ❑ No (Min. 6 in.) Approval Status 9 Reinforced Tank ❑ Yes ❑ No: • , Approved ❑ Disapproved;' ZPiece Tank:_❑ -Yes--. _-❑_No .,. Supply Line - ` "Pipe Size: inch diameter \ Installer: - - Pipe Length: feet Certification #: _ ' *Schedule: "EHS: Pressure Rated ❑' Yes ❑ NO Date: Approved fittings El, Yes El No Approval Status — ❑'Approved ❑ Disapproved. Pump Requirement Pump Type: Installer: Dosing Volume: - Gal Certification #: Draw Down: Inches 'EHS: `Chain:. Date:. Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval Status PVC unions ❑ ' Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No Page 2 of 4 CDPjFile Number 232635 - 1 County ID Number: 5758141121 ;^ A Alarrn Visible 0-, YeS-- ❑ No 4 2399 - Eldridge, Tiffany Operation Permit completed by: — .. _....._,....AuthorizedStateAgent:' d" i _. Date of Issue: 1 a/ a 9 I a 0 1 6 ..Owner/Applicant Signature: ;!This -system has-beeminstalled"in compliancerwith applicable NC General Statutes: Article 11, Chapter 130A, Rules for- __ is _:SewageiTreatriment'and. Disposal,_15A NCAC=18A::::1900 et. Seq., and all conditions of the Improvement Permit and ._ iConstruction.AuthorizationaJhis property is served by aTYPE ul O: sewage septic System. =- _ r -,Rule A961 -requires that Type TYPE III Gseptic system meet the following criteria: -� _ Minimum_System Review By The Local Health Department: NIAI Management Entity, OWNER C:.MinimumSystem Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A _ . >. Rule..1961-requires. that a -Type IV and V, septic systems designed for a home/business owner must maintain a valid contract - with. a public:management entity with: a'certified operator or a private certified operator for the life of the septic system. " Rule1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. _ -- Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ® Hand Drawing O Import Drawing l: **Site Plan/Drawing attached.** Page 3 of 4 NEMA 4X.Box or Equivalent El Yes ❑ NO Installer: Box 12 inches Above Grade El Yes ❑ NO Certification #: Box Adj. To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ . Yes ❑ No / --_.. - *Activation Method: _._. Date: J =;3 Alarm Audible, ❑Yes , .. ❑ No ❑ qp"prof ;^ A Alarrn Visible 0-, YeS-- ❑ No 4 2399 - Eldridge, Tiffany Operation Permit completed by: — .. _....._,....AuthorizedStateAgent:' d" i _. Date of Issue: 1 a/ a 9 I a 0 1 6 ..Owner/Applicant Signature: ;!This -system has-beeminstalled"in compliancerwith applicable NC General Statutes: Article 11, Chapter 130A, Rules for- __ is _:SewageiTreatriment'and. Disposal,_15A NCAC=18A::::1900 et. Seq., and all conditions of the Improvement Permit and ._ iConstruction.AuthorizationaJhis property is served by aTYPE ul O: sewage septic System. =- _ r -,Rule A961 -requires that Type TYPE III Gseptic system meet the following criteria: -� _ Minimum_System Review By The Local Health Department: NIAI Management Entity, OWNER C:.MinimumSystem Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A _ . >. Rule..1961-requires. that a -Type IV and V, septic systems designed for a home/business owner must maintain a valid contract - with. a public:management entity with: a'certified operator or a private certified operator for the life of the septic system. " Rule1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. _ -- Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ® Hand Drawing O Import Drawing l: **Site Plan/Drawing attached.** Page 3 of 4 Page 4 of 4 P1 P2 P3 Page 4 of 4 P1 P2 P3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 / For Office Use Only 'CDP File Number. 232635 1 County ID Number: 5759141121 Evaluated For. EXPANSION Township: , PERMIT VALID UNTIL: 1a/19.10a1. Applicant:. Susan E.. -Willcox and William K Property Owner: Susan E. Willcox and William K Bragg Jr Address: 156 Linda Lane Address: 156 Linda Lane :.City: Mocksville 1 City: Mocksville -_- --- State/Zip: ""NC 27028. State/Zip: :;Phone #. ` (336) 751-0723 phone #: Property Location & Site Inform Address/Road #: _ Subdivision: Carolina Homeplace 164 Linda Lane :Mocksville NC 27028 "Structure: SINGLE FAMILY # of Bedrooms: . 3 # of People: NC (336) 751-0723 Phase: 27028 Lot: 7 Iwy 64 East, left on John Crotts Rd. 2nd road to right .igda Lane \ `Water Supply, PUBLIC System Specifications Ce- Minimum Trench Depth:3 6 n: Provisionally suitable Inches,Minimum Soil Cover: a /� Inches ,? OYes' .®No i Maximum Trench Depth: 3 6 -.3' 6 0 . Inches Soil Application Rate: 0 ' a 7. 5 . Maximum Soil Cover: a 4 Inches 'System Classification/Description: *Distribution Type: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS _ Septic Tank: 1 0 0 0 Gallons "Proposed System: 25% REDUCTION - 1 -Piece:, OYes ®No Pump Required: O Yes ® No Q May Be Required Nitrification Field, 4 3 6 Sq, ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: OYes ONo Total Trench Length: 1 0 9 ft GPM—vs-- ft. TDH Trench Spacing:Q Inches O.C. 9 ® Feet O.C. Dosing Volume: _ Gallons Trench Width: _ 3 O Inches ® Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment:. O NSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: O 1 011 O 111 O IV Page 1 of 3 CDP File Number 232635 - 1 County, ID Number: 57581,41121. o ❑ Open Pump System Sheet Repair System Re wired:®Yes O No O No, but has Available Space Repair System O . 9 . Site Classification: Provisionally Spacing: Inches O y suitable _ ® Feet O.C. Design Flow. 3 6 0 - l Trench Width: _ 3 Inches Q ® Feet Soil Application Rate: ; 0 . a �_ rJ f Aggregate Depth: inches ti *System Classification/DescMinimum Trench Depth: 3 6ription: Inches TYPE 111G. OTHER NON CONV. TRENCHSYSTEMSMinimum Soil Cover: a 4, Inches Maximum Trench Depth: 3 6 Inches *Proposed System: _ 25%.REDUCTION - _ - NitMaximum Soil Cover: a 4 nfication Field - Inches 1 3 0 ` g ' Sq. ft... No. Drain Lines 3 *Distribution Type: GRAVITY -SERIAL Total Trench Length: _ 3 a ft._ c /Pump Required: Oyes ®No O May Be Required Pre -Treatment: O NSF QTS -1 OTS -II *Site Modifications -- No' grading or construction activity is allowed -in areas designated for system and repair without approval of Health Department. w 750 *Permit Conditions -. The issuance of this permit by the.Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. R v o 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validityof the Improvement Permit, not - to exceed five years, and may be Issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). If the installation has not been completed during the period of validity of the Construction Permit, the Information submitted in the application for a permit or Construction Authorization is found to have been incorrect, falsified or changed; or the site is altered, the permit or Construction Authorization shall become - invalid, and may be suspended or revoked (.1937(9)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ®No Applicant/Legal Reps. Signature- Date: - *Issued By: 2140, Nations, Robert Date of Issue: 1 a I 1 9 I 2 0 1 6 Authorized State Agent. Malfunction Log OYes (9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 Page 3of3 Pi P2 Drain Field: Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: System Final Inspection Log: -kfnrmoa 4000 P1 P2 P3 RwneNbp 4000 `R rWnWg I � RanWNp 4000 4000 =i GJ 4000 P1 P2 P3 RwneNbp 4000 Page 3 of 3. . P1 P2 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Cornpliance with G.S. of North Carolina Chapter 130 Article 13c S/ey. ge at/rte/,t and Disposal Rules (10 NCAC 10A .193344--.1968) Permit Number Name v • i' ri S'�� — Date 1r5�� 4 4 :2 Location I ®�� Subdivision Name 1,c2, C/ Lot No. --27. Sec. or Block No. Lot Size - House ✓ Mobile Home __ Business - Speculation No. Bedrooms It No. Baths No. in Family ._ Garbage Disposal YES NO ❑ Spe�ifi�s for ~y�m: Auto Dish Washer YES NO ❑ !//�� Auto Wash Machine YES NO 0 - � � ' r/ Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date of issue Improvements permit by 'Contact a r tive of the Davie County Health Department for final inspection of this system between 8:30- 9:30 or 1:00-1:319,P.M. on day of completion. Telephone Number: 704-634-5985. Installation Diag�& System Installed by Certificate of Completion Date–3?E -Z.2� '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. a APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksvllle, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phonel, F- 7,/,/,.377,y 1. Permit Requested By Business Phone 2. Address 3. Property Owner if Different than Above C r 124. CZ4 ("/rc- - Address 2- Address / 4. Permit To: a) Install±_. Alter_.. Repair_ b) Privy_ Conventional_ Other Type— Lround Absorption c) Sub-DivisionSec Lot No. S. System used to serve what type facility: House—✓ Mobile Home— Business_ Industry_ Other_ b) Number of people 2 6. a) If house or mobile home, stale size of hor�ne and number of rooms. - House Dimensions, �� X 3 c� Bed Rooms Bath Rooms 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 urinals garbage disposal lavatory . �,.z --- "' showers washing machine dishwasher / sinks - 8. a) Type water supply: Public Private - Community b) Has the water supply system been approved? Yes.L No - 9. a) Property Dimensions to G X Z27 X / 1Z X ZW6 b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? — This is to certify that the information is correct to the best of my knowledge. �7- K7 @- �, --Y� Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (c.ea DAVIE COUNTY HEALTH DEPARTMENT J' l 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 Date 10'9 4942 Location ��' tl�T //%//',i %�/�Y� /�/✓i SSi . Subdivision Name — Lot Size 3X Ile House Mobile Home _ Business Speculation _ No. Bedrooms a No. Baths a No. in Family Garbage Disposal YES p NO ❑ Specifications for System: Auto Dish Washer YES NONO ❑ ��.�" _�/ (� �cj! 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 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 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT } Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Permit Requested By 2. Address //��/a✓/�fYYf /�� 3. Property Owner if Different than Above Address / 4. Permit To: a) Install.C_ Alter_ Repair— Home Phonel, r qz' 2, 0 -377 ty Business Phone fl�Ostl `� b) Privy_ Conventional_ Other Type_ mound Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House_Mobile ome— Business— Industry— Other— b) Number of people 2 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions �4 X Bed Rooms_ Bath Rooms_ Den w/Closet b) If Business, Industry or Other, State: Number of persons served — What type business, etc. Estimate amount of waste daily (24 7. Number and type of water -using fixtures: commodes z urinals_ lavatory Z showers dishwasher / sinks 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? YesL_ No - 9. a) Property Dimensions 10 6 X z37 "C my, X -2- S b) Land area designated to building site c) Sewage Disposal Contractor garbage disposal washing machine 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. d _7� 32 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-62) DAVIE COUNTY HEALTH DEPARTMENT v ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. 0. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY- DATE RECEIVED &rheL C4"YG / P rrD (office use only) yes no 1. 1 am the owner of the above described property, yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. . yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. 9 �74%` DATE SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: fawner only 12 Owners designated representative — Anyone requesting results — Only those listed below DATE SIGNATURE DCHD (11 /84) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name i///zT Date Address Lot Size ! Cyd L' FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/ Landscape Position 5) 6) 8) 9) S A S S S PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) CCr1� 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 I) Soil Depth (inches) S S S PS PS PS U U U Soil Drainage: Internal S S S PS PS PS PS U U U External S S S PS PS PS U U U Restrictive Horizons Available Space S S S S PS PS PS U U U Other (Specify) S S S S PS PS PS PS U U U U Site Classification .U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: 'Described by SITE DIAGRAM DCHD (8.82( Title Date pate: � jteeelved � J APPLICATION FOR SITE EVA LUATIONAMPROVEWNT PERMIT & ATC Dante Cotmty Enrtronmenta) Health P.O. Box SM210HosptlslStmt M000vine' NC 37035 - - - - (336)7$347$W Fax (376)7S3-IUO - .. Appticefion Fon ihrole EvalunlloMngxoremew Ik+mit Acthmizahm To Cooslmct(ATC) Bab - .. Type orAppiwatim: , New System Repan to Existing System YExpmsWrdModifiatim of Exiting System a fadNty - . !!'fAgORTANfv'"THISAPPL(CATION CANNOrBEPROMSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED, Refer to the INFORMATION BULLETIN for insteue6om. - APPLICANTTNFORMA71ON Name SoWtl $.Wt7t/x 6Wil�iam K.Breaa t7; Comae pason_StcS/n 1Nilune .. A&Imsaf —do- ear W Ptmo —Di23 ., City/Statdl,IP RTotltsrrtley 27024 Phone EmaiI er-610 a_d rurindr.com Email: Nnma onPwridVATC if Djerent thmAbovo ..2 Mai' Address CityistatoZip _- PROPERTY INFORMATION Vate Ilousc/Facility CameraFla ed g11G Ord Aly .. - NOTE Aemveypulorlseplmmwlsdompanytb'uapplieakon. IadU"' Site Plan Put(w sols) (Permit is vdw forgo moths with sit pian, me* w sndrmmpiet plat.) OwmesNameSllfahC. 4Wf l;anvk•0r40ASr.. Mom Numba316-7.SI-07]? Owwesudress_1S1. .ate Cirytswc2i�MOtktVill� UC x9016 ProperiyAdds+14Ti Vint A L"f__ - —" City�Slk155�rLl1G� Lot size I tax A TaxPINN S7SS 1411 AI SubdivisionName(ifaapp�p(I�roab1e) �ymplltL Soctiodl.otN IOrcchansToSite: L13 b4IM4e As. K•i;,tl LSss_rtii A I rl� &.s �)rkli Ra 77 n�(LtndlsL Lan G LLS an ri n h if the answer u anyof the hrlowigggw+aonsieYerjuppo Idocumemiiors roan bepttrckd; -Am them my existing wastcwatr systems on the sitz act No SZp}IG 7A1 X .-• r .Door the err cowaintmsdiotionl wcdmndr7 _Yee L'No Nee DY�a odd_ 1pd•�} --Are thorn anyoasameo6ur righlai-wayamdtedt7. �Ya lllo . i'tl.11 litlG Is the eat subject to approval by soother public agency4 Ya teNo - - - Wip waatewatrothcr tlaa domcsfic lx: mratdt —Yes "o IF RESIDENCE FILL OUT THE BOX BELOW -1=1c ' _ .__ �:-NBmdmana •�. NBat)uooms,A .. GardenTuWWhiripool Yes .. .. Bastmew: Yes V4 Basertsrnl Plumbing: Yes Wro - IF NONRESIDENCE FILL OLTP THE BOX BELOW Type of FamhtylBusiness - : Total Sgttore Foouge of Building #`71`7 ___,_ N Sims N Commodes - N Showers N Urimis Fstimn(edWater Usage (galloraperdsy)(Aluchdocumentation o(similarl'acility water const"TtIon) FOODSERVICE ONLY: N Seals: Type system requested; Wonveatlond Accepted Wwvak Abemaxive Other Water Supply Type: %ZuwylCity Water - New Well Existing Well • • Commtmity Well Do you aotieipate additioms or expansions oflbe facility ibis system b inttnded to ssmv? Yes If yes, whattype7 This is b certify that the iofommtim provided as this appticdioa is true sad correct to the hat of my Imawlcdge. I understand that my permit(s) orATC(s) issucd hereafter arc subject to suspcasion or revocation if the sit is altered. the intended are changes, or if tba utfmmatioo audoiticd inthis appliwioa is fsldged aehangtd. l hereby grew right of entry w the Authorized Repn: em"ve - oidx Dsvia CauaY tledthi)epartmrntwwnduct rccamry mspcc6amwdekrmias mmpbaxe with applie,Lte usva and rola. I uoderstod that l am responsible for the proper identification and Gbdiog of property lines and mtnenand locating and flagging or the houndfp rgty ogp'pond Well lanioa and the locwim of My otherameoitier. '�'•�. G-�/ site Revisit Charge - Pmperryrowaer'saowmralegal Feismsem3five signature .. .. Date($): lagl�� aKwNn�atan,>ar E31S: e�.t..., V. rot. AtooundN OAVIE COUNTY HEALTH OEPARTMMT IMPROVEMENTS PERIAIi AND CERTIFICATE OF COMPLETION .. 'NOTE• Issued in Comp6arxe with 0 S W North Carolmo Chapter 130 ArlIcte 13C oe ;and 04POW Rules I10 NCAC IDA1 AX�I-A-s�f8/�681jj Permit Number Name (/. J ISL-- �_ Rete Location Subdivision _r Lot No. See or elock 140. i LW Sizey_ House Moblla Rome Business Speculation - No Sedroomt— It No Baths A No in Family_ 2 - AuoDis Washal ,YES NO fl 8oamll Auto Doh Washer - -YES NOD l/� _Auto Wash 1AatdAne YES NO n --...,7YPRWemr..5uppty � JT/,.s - _ – -'This permit Vold i1 tkrrage systam demroad below B aW installed within 36 months tram data of issue. tinprovemanis permit by - 'Cooled a tfve of the Davis County Health Department lot Anal fnbpeCtion of this system between SM - 4.30 or Id70.1, PM. on day of completion telephone Nvmber:704-634-6965 - Tial lnsleaatiwt Orapr - - System tnetaltedby Conweine of Completion 0314 'The zignmg W Mrs certificate shall inSicate that the WSWM desenbed above has been installed in oomptiance with ft standards Set iOrth in the above rugulelion. bol shell in NO way be taken as a yuarame0 that Me system miff function aatiVacwth fa any given period W Hem • APPILICOMON FOR WE EVALUATIONIMPROVEMENTS PERMIT D-� &o "egl% FAVItaimm1w Hoeft socown P. 0. Dox an MOCIerville, H.Q 27026 Y. Perms Paqutlled >� 7 Z Addrm �277"rlx A Abe" O; S Properly OwnsgOwment It" ACWen 4. Permit Tap MOMZ—AlIWc— P001— b1 Privy— Ccm%r&q4t— COW Type_ c) sub-DWaft— — $or-- Lot Nc Bow aw 10 ".a ww " bow. Nowe&,� movie Hom— Bualness— lrxlwsby—olhx— bi Number at POOPIS 8.01 K nom or areas hoew. Btu$ aln of he orb minberafrocam, Bw PM,,L-z,—Sent Rows D" WIC _. '. -. b1 R BuUACOe: irldssky or Otter. State: Numbw o7 parsons asrved whattips bustrAs4N0- COOMW vamm of VAT= "lif P4 fwvmi— T. Nwy6ff and 4" vi wow.Wng lIxturaw. utirads garbage 4115POW Washhg MadhlFbe CUOWA3hWslAkS Typowslor1*0jr Public --' Pt&l&— bi Nae go W$W W*pV ayalm b6w swmvd? Vese— "0-- k ijavW-ar"design" 10 1:011609411A TM is ID cc" M 00 b*mldon IS owfed to ft beat of My knowledge. 01" Owner sigraft" OWNM IS OMMy AEWOtOME FOA coMpliANCIE WITH ALL STATE AM LOCAL LMS Allow 6 days ICW PPOGOSSIP9 DirsolkwO b FNPFtY-' O"W" Address FAr1TnQQ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size AREA 1 ARFA 9 AREA 3 AREA A j Topography/ Landscape Position S S S S PS PS PS PS U U U U ?) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U U U I) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS U U U U Soil Depth (inches) S S S S PS PS PS PS U U U U ) Soil Drainage: Internal S S S S PS PS PS PS U U U U External S S S S PS PS PS PS . U U U U ) Restrictive Horizons Available Space S S S S PS PS PS PS U U U U 1) Other (Specify) S S S S PS PS PS PS U U U. U ) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments:a��'/F Described by SITE DIAGRAM DOHO (6-e2) TitleS�A-1 Date /OD �0 ,)07