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122 Winchester Road Lot 12HEALTH DEPARTMENT RELEASE Davie County Health Department I "v f 210 Hospital Street / �j P.O. Box 848 Dau: Mocksville 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Adam Todd Ward Address: 122 Winchester Road City: Advance State/Zip: NC 27006 Phone #: (336) 970-0236 / Address 122 Winchester Road Road # Advance NC 'Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC Basement: F-1 Yes a No 27006 *Proposed Improvement: Barn/storage type building For Office Use Only *CDP File Number 218945 - 1 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 0 6 0 2/ a 0 a 1 UNTIL: Property Owner: Adam Todd Ward Address: 122 Winchester Road City: Advance State/Zip: NC 27006 Phone #: (336) 970-0236 Property Location & Site Information Subdivision: Hunters Point Phase: Lot: 12 Township: Directions Hwy 158 East, right on Gun Club Rd Type of Business: Total sq. Footage: No. Of Employees: Maintain 5 foot setback to any portion of the septic. A short section of the top tail line may be cut and reconnected to meet setbacks 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 Applicant/Legal Reps. Signature: *Date: *Issued By: 2140 - Nations, Robert *Date of Issue: 0 6 / 0 3 / a 0 1 6 Authorized State Agent: lez, **Site Plan/Drawing attached.** ® Hand Drawing 0 Import Drawing chwade s Remaining 616 HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health repartment Release 10 00001'r CDP File Number: 218945 - 1 r County File Number: Date: 06/03 /.1016 O Inch Scale:. , , , O Block O N/A i Drawing Type: HEALTHDEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release Page 2 of 2 CDP File Number: 218945 - 1 County File Number: Date: A 6./.0.3./...0.1.6. �OW O19// GUhel1 yOGt �1'a��d� ' ax is County Health D putinent 'dpi 361"x' Environmental Health Secdon • i 11.0. Box 818 210 Hospital Strcct C .honer : 09-10-06 Mocksvilic, INC 27028 I'1Kxic: 0:36) - 753.6 80 Fax: (36) - 753- 1680 ON-SITE NVASTENVATER CERTIFICATION (Check One) Replacement Remodeling; Reconnection Name; 14114A M Odd W!Ntd Phone Number 33(�- �70- 00(1 (64 �(ilo ti n c) Mailing Address: 1d" (,n�inc�t(sEr�get 5.30-11'9 - 039 (Work) '�J, C 2 (p Email Addre--s: •tM� ��_ t:�c J> �oY Detailed Directions To Site: t' L h'��-i `�-'�� Imm Property Address:- W ; Ie"IC T !?' 77 (:�_ Please Fill In The Followin Information �� bout The EMSTTNG Facility: Name System Installed Under: 1 � T itv Date System Installed (Month. Datc!Year): M ? 'Number Of Bedrooms:-3—Number Of People: Is The Facility Currently Vacant? Yes &C:)) If Yes, For How Long? Any Known Problems? Yes p if Yes, Explain: Please Fill In The Following Information About The JVEt{' Facility: T}peOfFaeiiity: ,rn ($):'r'r4 "/g �� f`{' Number Of Bedrooms: ' Number of People Pool Size: -Garage Size:✓y ��Other: Requested By:Gtr �f Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this farm by the Environmental health Staff is in no way intended, nor should be taken as a guarantee or limited) that the on-site: watitewater system will function properly for any given period of time. Check Money Order Amount:S Paid By: Received By: Account#: ji ( � _Invoice r: 7 HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Adam Todd Ward Address: 122 Winchester Road City: State2ip: Phone #: Advance NC 27006 (336) 970-0236 For Office Use Only *CDP File Number 218945 -1 County ID Number. valuated For: HDR/WWC PERMIT VALID 0 6/ 0.1 / a 0.1 1 UNTIL: I,— Property ,—Property Owner: Adam Todd Ward Address: 122 Winchester Road City: Advance State0p: NC 27006 Phone #: (336) 970-0236 I— _Property Location & site Information Address122 Winchester Road Subdivision: Hunters Point Road# AdvancA NC 27006 Township: Directions Hwy 158 East, right on Gun Club Rd 'Structure: SINGLE FAMILY # of Bedrooms: 3 'Water Supply: PUBLIC Basement: FlYes Q No "Proposed Improvement: Bamtstorage type building # of People: Phase: Lot: 12 Type of Business: Total sq. Footage: No. Of Employees: Maintain 5 foot setback to any portion of the septic. A short section of the top tail line may be cut and reconnected to meet setbacks 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? Oyes ONO Applicant/Legal Reps. Signature; *Date: *Issued By: 2140 -Nations, Robert *Date of Issue: 0 6 0 3 2 0 1 6 Authorized State Agent: **Site Plan/Drawing attached.** G Hand Drawing Olmport Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File N . umber: 218945 -1 County File Number: Date: 0 6/ 0 3/ 2 0 1 6 0 Inch Scale: 0BIock ":L_.ft. ON/A f-d9t: 4 Ui /- ............... F-7 =i Li l i l y ( I � I I I A II I I..... .. . . .. . e- C% WIT J f-d9t: 4 Ui /- Phone: (336) - 753 - 6780 � �jq // urhal MR o e -u PAIDDavie County Health Department onmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name:--& wi bUCt W��Q Phone Number -170-043 u lle%) (Home) Mailing Address: [2 Ld i'\A( ff 33(ojq'9 - 032 (Work) do(re ik . C Wo(o Email Address: �Rri�. W Ocil 1WlC�o"^- Detailed Directions To Site: FL k'nw 106f lam` lm« Property Address: Ida 1/g fyv-- , L 0200a Please Fill In The Followin Information bout The EXISTING Facility: Name System Installed Under: Type Of Facility: 14ase Date System Installed (Month/Date/Year): l Number Of Bedrooms:__,7_Number Of People: Is The Facility Currently Vacant? YesV If Yes, For How Long? Any Known Problems? Yes �p If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: d n 5 1 2 �Q2 i>`� (� ^'� Number Of Bedrooms: Number of People Pool Size: Garage Size: 56Xy00 Other: Requested By: % . Date Requested: 0-5-11( Id a!�e (Signature) For Environmental Health Office Use Only Approved Disapproved Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee or limited) that the on-site wastewater system will function properly for any given period of time. Check Money Order # Amount:$ Paid By: Received By:_ Account #: Invoice #: Date: **NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. AN AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit. (In compliance with Article I1 of B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) NAME 0.,, 6 /i! A,rT"ISD/'," PROPERTY ADDRESS Ott K C1 k L P a %00 41 DATE LOCATION SUBDIVISION NAME N U K—rw PO LOT NUMBER 107- SEC./BLOCK NUMBER RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS —9 # OCCUPANTS GARBAGE DISPOSAL: Yes/No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEDPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No LOT SIZE ?� �f TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) '— TYPE NEW SITE //' REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE 1-422d— GAL. PUMP TANK GAL. TRENCH WIDTH T/ ROCK DEPTH —Z2L LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: *+*THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. IMPROVEMENT PERMIT BY **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FILL 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 (704) 634-8760. OPERATION PERMIT e /qv SYSTEM INSTAO BY AUTHORIZATION NO. 04117.1OPERATION PERMIT BY J`�G' DATE **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 10/95 Davie County Health Department ENVIRONMENTAL HEALTH SECTION P.O. Box 665 Mocksville, N.C. 27028 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION :1 (Issued in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems) ***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.*** N NA V d e S J-6 0 - AUTHORIZATION NUr& NAPE (21 '. ,� , DATE d %� �� 3- 0 � 7 i NAME ON IMPROVEMENT PERMIT (If different than above) SITE LOCATION COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, NC 27028 1., Application/Permit Requested By QlezkG 91V1Q15S=&6 1✓ Mailing Address ,//-/t/,� Home Phone MC) CA�V /C,� %S/ C "70 Business Phone 72 -7 -2. Name on Permit if Different than Above 3. Application for: )(General EvaluationSeptic Tank Installation Permit 4:. System to Serve: Houses ❑Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house,' mobile' home: Subdivision !� a 9+ �(O`'"� Section Lot # /_ Ca2.E3 CG�C��O O� ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing G�tJ�/L-�L (/�3GLLxF��70itJ No. of Bedrooms ' ❑Washing Machine >yv Sc� /� 61,110 &)I&e__ I!' -ie No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6.. If business, industry, place of public assembly, other: No. of People Served No. of Commodes No. of Lavatories No. of Showers Specify type No. of Sinks No. of Urinals No. of Water Coolers Water Usage Figures 7. Type of water supply: Public ❑ Private ❑ Community 8. Property Dimensions LO Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? -NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: /S-9 )C:2eo/71 /S Fr aAJ 7 E A2 4 r-, This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. P� 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to, enter upon above described property located in Davie County and owned by Q ,cert/ S,O 1ct.10= to conduct all testing procedures as necessary to determine said site's suitability or a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1/93) DAVIE COUNTY HEALTH DEPARTMENT `S Environmental Health Section Soil/Site Evaluation NAME /`/�rSo i✓ ADDRESS PROPOSED FACIILTY DATE EVALUATED -c7h PROPERTY SIZE V'I% Xe LOCATION OF SITE Water Supply: On -Site Well _ Community Public L� Evaluation By: Auger Boring Pit Ll--' Cut FACTORS 1 2 3 4 Landscape position IL Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 6 d t - Texture groupL'. L Consistence Structure S 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 ACCEPTANCE RATE SITE CLASSIFICATION: /PS LONG-TERM ACCEPTANCE RATE: I REMARKS: DCHD (01-901 EVALUATED BY: 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 <;lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR- V,. -!7y 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 3C --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(unsuitable) Soil wetness - Inches from land surface to free watef 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