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125 Drayton Court Lot 18OPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Neil Townsend/Wishon & Carter Address: PO Box 1719 City: Yadkinville State/Zip: NC 27055 Phone #: (336) 469-2290 *CDP File Number 232630 - 1 County ID Number: Evaluated For: NEW �ownship: /Property Owner: Marc & Dawn DeRose Address: 2401 Vincent Rd City: Winston-Salem State/Zip: NC 27028 Phone #: (336) 469-2290 Property Location & Site Information Address/Road #: Subdivision: McAllister Park 125 Drayton Court Mockville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC *IP Issued by: 2140 - Nations, Robert *CA Issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Phase: Lot: 18 Directions Hwy 158 right on Sain Rd. Right into McAllister Park, left at stop sign, 1 st right , then 1 st left on Drayton Court, on the left *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field 1 3 0 9 Sq. ft. 5 334ft. 9 0Inches O.C. (9 Feet O.C. 3 Olnches (9 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK STANDARD Installer: Darrell Salmons Certification #: 2652 *EHS: 2140 - Nations, Robert Date: 1 1/ 1 4/.1 0 1 7 Approval Status 0 Approved ❑ Disapproved CDP File Number 232630 - 1 Manufacturer: shoat STB: 764 Gallons: 1000 Date: 1 0/ 0 8/ a 0 1 7 *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker: ❑ Yes ❑X No Reinforced Tank: ElYes \ 1 Piece Tank: ❑X No \ \Piece Tank: ❑ Yes ❑X No Manufacturer: PT: Gallons: Pump Type: Date: / Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes / Pipe Size: Pipe Length: *Schedule: Pressure Rated ❑ Yes Approved fittings ❑ Yes County ID Number: septic i anK Lat. ❑ No ❑ No (Min. 6 in.) ❑ No ❑ No Long: In Installer: Darrell Salmons Certification #: 2652 *EHS: 2140 - Nations, Robert Date: 1 1/ 1 4/ x 0 1 7 Approval Status ❑X Approved ❑ Disapproved Pump Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply Line inch diameter Installer: feet Certification #: *EHS: ❑ No Date: ❑ No Approval Status ❑ Approved ❑ Disapproved / Pump Type: Dosing Volume: - Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ NO Anti -siphon Hole ❑ Yes ❑ No Installer: Gal Certification #: *EHS: Page 2 of 4 Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 232630 - 1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: Alarm Audible ❑ Yes Alarm Visible ❑ Yes *Operation Permit completed by_ Authorized State Agent: Owner/Applicant Signature: County ID Number: ❑ NO Installer: ❑ No Certification #: ❑ No ❑ NO *EHS: ❑ No Date: Approval Status El No ElApproved ❑ Disapproved El No 2140 - Nations, Robert Date of Issue: 1 1/ 1 9/.1 0 1 7 This system has been installed in compliance with 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 Permit and Construction Authorization. This property is served by a TYPE iii G. sewage septic system. Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System 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. Rule .1961 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. 9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3of4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Dr Drawing Type: Operation Permit -T CA �p5 tilt CDP File Number: 232630 - 1 County File Number: Date: / / O Inch Scale: O Block O N/A 5 4-e- 1 Cj , ,*, 0 Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Applicant: Address: City: . StatefZip: - . Phone #: CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Use Only "CDP File Number 232630-1 County ID Number: Evaluated For. NEW �11T_ oc1736fiir VAI OM 111\Irlt . Phone: 336-753-6780 Fax: 336-753-1680 1 a/ a 0/ a 0 a 1 Neil Townsend/Wishon & Carter PO Box 1719 Yadkinville NC (336) 469-2290 27055 Property Owner: Marc & Dawn DeRose Address: 2401 Vincent Rd City: State2 ip: Phone #: Site Informatio Address/Road #: Subdivision: McAllister Park 125 Drayton Court Mockville NC 27028 Structure SINGLE FAMILY # of Bedrooms: 3 # of People: 'Water Supply: PUBLIC Winston-Salem NC (336) 469-2290 Phase: 27028 Lot: 18 Directions Hwy 158 right on Sain Rd. Right into McAllister Park, left at stop sign, 1st right , then 1st left on Drayton Court, on the left System Specifications Pump Required: QYes @No OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 7 1 -Piece: QYes ONo Total Trench Length: 3 a y ft GPM—vs— ft. TDH Trench Spacing:9 Inches O.C. Dosing Volume: _ Gallons _ Feet O.C. g Trench Width:Inches — 3 " gFeet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI OII OIII OIV 1 0-4 Minimum Trench Depth: 3 6 Inches Site Classification: Provisionally Suitable Saprolite System? QYes 9No Minimum Soil Cover. a � Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0.2 7 5 Maximum Soil Cover: .1 4 Inches 'System Classification/Description: *Distribution Type: GRAVITY -SERIAL TYPE III G. OTHER NON -CONY. TRENCH SYSTEMS Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25% REDUCTION 1 -Piece: O Yes Q N o Pump Required: QYes @No OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 7 1 -Piece: QYes ONo Total Trench Length: 3 a y ft GPM—vs— ft. TDH Trench Spacing:9 Inches O.C. Dosing Volume: _ Gallons _ Feet O.C. g Trench Width:Inches — 3 " gFeet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI OII OIII OIV 1 0-4 NaJrnA0 Lc;/— /7 �j APPLICATION FOR SITE EVALUATION/IhIPItOVEAiCNT PCRh1IT � 0 Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street APR Mocksville, NC 27028 2005 (336) 751-8760 IVVlRO NMF rAl ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEA INFORMATION IS PROOVVIDED. /l Refertothe INFORMATION BULLETIN for instructions. 1. Name to be Billed ,"C�-lu.•zC �STlp r� Contact Person Mailing Address ('n 1f1� t f<�E"?,r Home Phone City/State/ZIP Lam+ +`� Y• le-- --t7.163 Business Phone �fG) 7' 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 13Site Evaluation 11Improvement Permit/ATC ❑ Both 4. System to service: 2—House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Typo system requested: 0- Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,,_, � Washing _�� � #Bathrooms ODishwasher ❑Garbago Disposal Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks _ # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: 1i Seats Estimated Water Usage (gallons per day) S. Type of water supply: 113'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? 17 Yes ❑ mN If yes, ►vliat type? ***IAIP0RT11N7'*** CLIENTS AfUST COAIPLETET ir. REQUIRED PROPERTY INFORAIATION REQUESTED BEL01V. Either a PLAT or SITE PLAN MUST BESUBA117-TED by the client ►vith THIS APPLICATION. Property Dimensions: A , 2 fr;'f-f-ec . WRITE DIRECTIONS (from Mocksville) to PROPERTY: /!2-PTax Office PIN: it �% V!2- Property roperty Address: Road Name 5/4;)j City/Zip,tr If in a Subdivision provide information, as follows: Name: I /+,- Section: Block: Lot: / Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension t,• revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or clianged. I, also, understand that I nm responsible for all charges incurred fi•onr this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and o►vned by to conduct all testing procedures as necessary to determine the site suitability. DATE � ' l.3 �' O � SIGNATURE e � ` �-�-^-� TIIIS AREA MAY BE USED ICOR 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: EI -IS: Sign givcn-10—D Account No. D D a a-5" Revised DCIID (05103 Invoice No. . DAVIE COUNTY IIEALTII DEPAIZTME, NT Environmental Health Section Soil/Site Evaluation APPLICANT' INFORMATION PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH #: 5749-63-6844.18 Billed TO: Richard Short Sybdivision Info: McAllister Park Lot # 18 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: as platted Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slo e % ?Q HORIZON I DEPTH 2 Texture group Consistence F, Structure Mineralogy Emil HORIZON 11 DEPTH 1 -33 Texture group Consistence S4 :5 Structure 3 Mineralogy5 HORIZON III DEPTH Texture groupG Consistence Structure 3 Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 1s EVALUATION BY: S(�J� LONG-TERM ACCEPTANCE RATE:yys—,,,D5 OTHER(S) PRESENT: REMARKS: WAryQ 1n/S —1D ISS `c _�J N 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 toffs 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 i P - Plastic VP - Very plastic Structure 'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy i PR - Prismatic Mineralou 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 - gal/day/ft2 DC.1 IIS 05/99 (Revisal) CDP File Number 232630 -1 } County ID Number: ❑ Open Pump System Sheet Required:('Yes ONO ONO, but has Available Space *Site Classification: Provisionally Suitable Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS 'Proposed System: 25%REDUCTION Nitrification Field 1 3 0 9 Sq. ft. No. Drain Lines 3 Total Trench Length: 3 a 7 ft. Trench Spacing: Q Inches 0. 9 (.)Feet O.C. Trench Width: 0Inches 3 Feet Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 2 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 2 4 Inches *Distribution Type: PUMP TO GRAVITY Pump Required: &Yes ONo OMay Be Required Pre Treatment: ONSF OTS -1 OTS -II *Site Modifications _ No grading orconstructionactivityis-allowed in areas designated forsystem and repair without approval of Health Department *Permit Conditions The issuance of this permit bythe 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. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be Issued at the sam a time the Improvement Permit Issued (NCGS 130A -336(b)). If the Installation has not been completed during the period of validity of the Constructlon 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(g)). 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? Oyes Applicant/Legal Reps. Signature: Date: _ / / *Issued By; 2140 - Nations. Robert , Date of Issue:. 1 2/.1 0% 2 0 1 6 Authorized State Agent: �—""� Malfunction Log OYes @Hand Drawing Oimport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: County File Number: Date: 12/20/2016 Qinch Scale: pBlock nN/A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O. Box 848 Mocksviile NC 27028 County File Number: Date: 12/ 20 /,2 0 1 6 Click below to import an image from an external location: Drawing Type: Construction Authorization I IMPROVEMENT PERMIT �.� Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERRIIT VALID UNTIL: 12/20/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Neil Townsend/Wishon & Carter Address: PO Box 1719 City: Yadkinville StatefZip: NC 27055 Phone #: (336) 469-2290 Address/Road #: 125 Drayton Court Mockville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3':-- # of People: *Water Supply: PUBLIC Property owner: Marc & Dawn DeRose Address: 2401 Vincent Rd City: Winston-Salem State/Zip: NC 27028 Phone #: (336) 469-2290 lerty Location & Site information Subdivision: McAllister Park Phase: Lot: 18 Provisionally Suitable Saprolite System? QYes No Design Flow: 3 6 0 Soil Application Rate: 0 2 7 5 *System Classification/Description: TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS *Proposed System: 25% REDUCTION Directions Hwy 158 right on Sain Rd. Right into McAllister Park, left at stop sign, 1 st right, then 1 st left on Drayton Court, on the left Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: Pump Required: Pump Tank: 1 -Piece: Repair System Required:@Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Soil Application Rate: 0 a 7 5 u *System Classification/Description: TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS *Proposed System: 25% REDUCTION QYes ONo QYes @ No O May Be Required Gallons QYes ONo Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 3 6 Inches Pump Required: @Yes ONo O Maybe Required Pagel of 3 CDP File Number 232630 -1 County ID Number: *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. _- *Permit Conditions The issuance ofthis-permitbythe .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. Site 0, -site The Improvement Permit shall be valid for 6years from date of issue with a site plan (means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the -site forthe proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land 0 surveyor, drawn to a scale of one inch equals no more than 60 feet, that Includes: the specific location of the proposed facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy of the recorded subdivisions prat that is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions, the rules, or this article. This permit Is subject to revocation if the site plan, plat, or Intended use changes (NCOS 130A.335(f)). 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? Oyes ONO Applicant/Legal Reps. Signature-, Date: / 'Issued By: 2140 -Nations, Robert Authorized State Age Date of Issue: 1 a/ 2 0/ 2 0 1 6 OValid without Expiration? OCreate CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Improvement Permit CDP File Number: 232630 -1 County File Number: 27028 Date: 0 Inch Scale: 013lock ON/A � � � i� I 1 I 17 �� I I I ��• � I! I, I I I I I ___..___� ��___ i I I� . . . .... .... � I I I I !� I {{� 1 _2 ----- � U1 I T_ C000 —A T- _ �...____.. _ ___ __ .._.___ _ _ E._. __{I ___ ... .......... . _�_.i_ ------ ----------- - ----------!J _ __,i_____:! _ ____ 3_ _ __ _ �4 777 - ------------ -7` ___ _v I_i C-1 C)L -- - ----- -- . .......... ---- ------ ------------ - ....... . - ----- -------- --- ------- ---- ---- IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 CDP File Number: 232630' 1 Mocksville NC 27028 County File Number: Date:,1,2 / 2 0 / 2 0 1 6 Click below to import an Image from an external location: Drawing Type: Improvement Permit APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC 4 Davie County Enyironmental!Health'- . i. P.O."Box 848%210 Hospital Street ,`.I Mocksville,NC-27028 1 (336)753-6780/ Fax 336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) @-Blo-th Type of Application: R ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION C.4NNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for:instructions'. APPLICANT INFORMATION Name n(Y: l Tsmear! _r�L;r,.: 4_( r . Contact Person /✓w.=�= s ��-•-c( Address Qv fi;oe- ►'j l q Home Phone,=y�q_ -Z"Z City/State/Z1P �IQJl�.1„ ✓-t-Z 7- C, i r- Business Phone Email N, I Tn s �.,«I & ' t,9,'s � r.1 P Email: Name on Permit/ATC if Different than Above_ M =c : ; Dc lzv ise Mailing Address -1-clot V.,", —L 2r1 City/State/Zin G1... i__ c_ 1. ____ ..1� -71 r1f1.Urr1K1 T 11Vt'VK1VIAI-WIN '• 'Tvate tiouse/. acuity Comers nagged t1,ZQ- & NOTE: A survey plat or site plan must accompany thisl application. Included: ❑, Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name_�t,(�,,� s (1Q p�E,,,,0 Phone Number Owner's Address 24101..# �[ City/State/Zip Property Address /Z S-_ fro L+_ City- i Lot Size Tax PIN# '7 Subdivision Name(if applicable) til JJ, s Lor i'�1.- _ Section/Lot# /V . Directions To Site: IST 410 Sa: w 2J_ IF,40- M„ 4, idc.41h4l, PCUL , 1-t- -'r e S441, J?3� &f- V- 7- 2 "d Pro rrx L.v�'4 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? _Yes -No Does the site contain jurisdictional wetlands? _Yes X, Are there any easements or right-of-ways on the site? Yes , No Is the site subject to approval by another public agency? _Yes i* Will wastewater other than domestic sewage be generated? Yes IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms .3 #,Bathrooms 3 Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes QNo . Basement Plumbing: - ❑Yes E<o 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: Q'Accepted ❑Innovative ❑Alternative ❑Other ---- Water Supply Type: Y1ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R-fg0 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 permit(s) IP(s) or CA(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. Permits issued will expire 5 years from the date of issuance. 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 and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Applican s Signature Property owner's or owner's legal representative signature Date Revised 11/16 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # C0t 11010 6 - Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004186 Tax PIN/EH #: 5749-53-8619.18 Billed ,To: Cool Spring Builders, Inc. Subdivision Info: The Oaks at McAllister Park Lot # 18 Address: PO Box 2040 Location/Address: Sain Road -27028 City: Advance _ Property Size: see map Reference Name: Michael Moorefield Proposed Facility: Residence **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. Permit Type: .,p4ew ❑Repair ❑Expansion Permit Valid for: 05 Years Y"" Expiration Residential Specifications: # Bedrooms- # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_� Type of Water Supply: unty/City ❑ Well ❑ Community Well Site Modifications/Permit Conditions: POMP 420W14�1 stem e LTAR Initial, Repair 1 ? Site Plan , ;"',,. (/�'V�ry 0/� �r•174 �J ,07 e 40 01 + 9Z �- * ff*4 l' AgLca 17 �erIS� IF W UP V�sr9#r06, s Environmental Health Specialist i.p.11-06 ION FO 1 �El1�P�,N�t�N �1V1RO�F GOUT. EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health O. Box 848/210 Hospital Street . Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 ApplicatiV;Y-or�'8ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: •KNew 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 BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed n'° 1 �` %� �� ('e'.'i ���'`� n�- Contact Person J -t r' C! � � ' / - j� ,,, a� �'� P/(, Billing AddressO t_�1tJycJ Home Phone 7e Is the site subject to approval by another public agency? City/State/ZIP Will wastewater other than domestic sewage be generated? Business Phone 33& - 51'3 (Cc// Name on Permit/ATC if Different than Above Mailing Address PKUFhX l Y IN 11 UKMA1 IUN "I'Date House/racility Corners 11 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan) fPlat(to scale) (Permit is valid for 60 months w'th site p , nno expiration with complete plat.) Owner's NameL✓� ? t . J_0VC Phone Number Owner's Address 5J-111,1 City/State/Zip /` �r'/�>U Property Address -mac( Ci� Lot Size Tax PIN# 3''(a Subdivision Name(if applicable) O/ZE" Section/Lot# Directions To Site: 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? ❑Yes -2 -None Does the site contain jurisdictional wetlands? Dyes BNo Are there any easements or right-of-ways on the site? Dyes RNo Is the site subject to approval by another public agency? Dyes QNo Will wastewater other than domestic sewage be generated? Dyes Ergo IF RESIDENCE FILL OUT THE BOX BELOW # People `' _ # Bedrooms ' # Bathrooms Garden Tub/Whirlpool es ❑No Basement: Dyes 0No/U1 Basement Plumbing: No /t/1, IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage.(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Vonventional ❑Accepted ❑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 If yes, what type? MIN 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 pennit(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 and flagging or )aking the 1}ouse/facility location, proposed well location and the location of any other amenities. - l �Site Revisit Charge Property owner's or lmer's legal representative signature DtO• Date ae. Client Notification Date: EHS: Sign given Dyes ❑No Account # Revised 11/06 Invoice # rT DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990004186 Billed To: Cool Spring Builders, Inc. Reference Name: Michael Moorefield Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH M 5749-53-8619.18 Subdivision Info: Black Forest Lot # 18 Location/Address: Sain Road -27028 see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1225 L81 35 -to 4 5 6 7 Landscape position Slope % ep 70 ?� HORIZON I DEPTH p - Ci p ;p Texture group 9CL4UILSCL S r Consistence Structure Mineralogy HORIZON II DEPTH -'ZS I Texture groupG Consistence er Structure IYONZ Mineralogy HORIZON III DEPTH ;3D- 3 Z - Texture group GG Consistence S r Structure MineralogyS HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS ..- -� RESTRICTIVE HORIZON — — SAPROLITE CLASSIFICATION ,. LONG-TERM ACCEPTANCE RATE O TTT © p ,Z? SITE CLASSIFICATION: 1 LONG-TERM ACCEPTANCE RATE: REMARKS: Q, )t4 0t1v 5 ,p� + S'o1A►u LEGEND EVALUATION BY: (Q':� OTHER(S) PRESENT: 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 uM, VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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(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 - gal/day/ft2 DCHD 05105 (Revised)