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135 Thoroughbred Lane Lot 22Applicant: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons Statefzip: NC 27012 -- Phone #: (336) 624-7791 Address/Road # /0o Thoroughbred ane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC *IP Issued by. *CA issued by: 2140 - Nations, Robert for voice use Unty *CDP File Number 199145-1 C416OA0022 County ID Number Evaluated For NEW Township: //Property Owner: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons State/Zip: NC 27012 Phone #: (336) 624-7791 ierty Location & Site Information Subdivision: Whip -O -Will Design Flow: 4 8 0 Soil Application Rate: 0 - 1 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Phase: Lot: 22 Directions Hwy 601 N. right on Hwy 801 turn right on Cana Road, right on Brangus Way ,,,Left on Meadowlark Lane, right on Thoroughbred Lane on the Left *System Classification/Description: SaproliteSystem? OYes QNo *Distribution Type: GRAVITY - PARALLEL (eq, d -box) Pump Required? QYes QNo *Pre Treatment: Drain field a 7 4 3 Sq. ft. 5 6 8 6 ft. 9 ()Inches O.C. (DFeet O.C. Oinch 3 Feet s inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Willian Rueben Clayton Certification #: 2694 *EH S: 2140 - Nations. Robert Date: 0 5/ a 4/ a 0 1 6 Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: p 3 6 Inches Q App Maximum Soil Cover: � a 4 Inches OPERATION PERMIT Davie County Health Department t 210 Hospital Street y P.O. Box 848 Mocksville NC 27028 Phone: 336-763-6780 Fax: 336-753-1680 Applicant: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons Statefzip: NC 27012 -- Phone #: (336) 624-7791 Address/Road # /0o Thoroughbred ane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC *IP Issued by. *CA issued by: 2140 - Nations, Robert for voice use Unty *CDP File Number 199145-1 C416OA0022 County ID Number Evaluated For NEW Township: //Property Owner: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons State/Zip: NC 27012 Phone #: (336) 624-7791 ierty Location & Site Information Subdivision: Whip -O -Will Design Flow: 4 8 0 Soil Application Rate: 0 - 1 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Phase: Lot: 22 Directions Hwy 601 N. right on Hwy 801 turn right on Cana Road, right on Brangus Way ,,,Left on Meadowlark Lane, right on Thoroughbred Lane on the Left *System Classification/Description: SaproliteSystem? OYes QNo *Distribution Type: GRAVITY - PARALLEL (eq, d -box) Pump Required? QYes QNo *Pre Treatment: Drain field a 7 4 3 Sq. ft. 5 6 8 6 ft. 9 ()Inches O.C. (DFeet O.C. Oinch 3 Feet s inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Willian Rueben Clayton Certification #: 2694 *EH S: 2140 - Nations. Robert Date: 0 5/ a 4/ a 0 1 6 Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: p 3 6 Inches Q App Maximum Soil Cover: � a 4 Inches CDP Fite Number 199145-1 by Manufacturer. Shoaf STB: 760 Gallons: 1000 Date: Oal a4 /,2016 *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker El Yes B No Reinforced Tank: [] Yes M No Piece Tank: 0 Yes 0 No Manufacturer. PT: Gallons* Countv ID Number: 'c4 1 60A0022 Lat. Long: Installer William Rueben Clayton Certification 4: 2694 *EHS: 2140 - Nations, Robert Date: 0 S/ 2 4 / 2 0 1 6 Pump Tank Date: / / RiserSealed E] Yes 0 No RiserHeight: 0 Yes 0 No (Min.6in.) nforcedTank: 0 Yes El No lPiece Tank: El Yes 0 No Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated C1 Yes n No Approved fittings El Yes El No Installer: Certification 9: *EH S: Date: Upply Line Installer: Certification,"": "EHS: Date: Pump Type: Installer: Dosing Volume: Gal Certification 4-4: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible 0 Yes 0 No Flow Adjustment Valve 0 Yes El No Check -valve El Yes EJ No _- App roval Status:,,:,-,, PVC Unions El Yes 0 No :13 Approved C1 PP, Dlsa roved Vent Hole El Yes 13 No Anti -siphon Hole El Yes E3 No CDP File Number 199145-1 �_[=1�i�ll�i=i! 111111L�111. County ID Number: C4160A0022 NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No / "Activation Method: Date: Alarm Audible ❑ Yes Alarm Visible ❑ Yes 'Operation Permit completed by; Authorized State Agent'. El No Approval Status ❑ Approved ❑ Disapproved ❑ No 2140 • Nations. Robert Date of Issue: 0 5/ 2 4 / 2 0 1 6 Owner/Applicant Signature: 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 bya sewage septic system. Rule .1961 requires that a Type septic system meet the following criteria: Minimum System Review ByThe Local Health Department: Management Entity: Minimum System Inspection/Maintenance Frequency By Certified Operator: Reporting Frequency By Certified Operator: Rule .1961 requires that a Type IV and V septic systems designed for a hometbusiness 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 condilion of the Operation Permit that subsequent owners of the systems execute such a contract. Hand Drawing Olmport Drawing **Site Plan/drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Operation Permit CDP File Number: 199145 -1 County File Number: C4160A0022 Date: Q Inch Scale:. QBbck A. I QN/A t { ! f CDP File Number: 199145 -1 County File Number: C4160A0022 Date: Q Inch Scale:. QBbck A. I QN/A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Use Only *CDP File Number 199145-1 County ID Number: C416OA0022 Evaluated For: NEW ,.Township: P Phone: 336-753-6780 Fax: 336-753-1680 0 1 / 0 8/ a 0 a 1 Applicant: Terry M. Summers Property Owner: Terry M. Summers Address: 6637 Gentry Circle Apt 104 Address: 6637 Gentry Circle Apt 104 City: Clemmons State/Zip: NC Phone #: (336) 624-7791 Address/Road #: Thoroughbred Lane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC City: Clemmons 27012 State/Zip: NC Phone #: (336) 624-7791 e Information Subdivision: Whip -O -Will 27012 Phase: Lot: 22 Directions Hwy 601 N. right on Hwy 801 turn right on Cana Road, right on Brangus Way ,,,Left on Meadowlark Lane, right on Thoroughbred Lane on the Left Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches \Site Saprolite System? O Yes (& No Minimum Soil Cover: 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 1 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S f Tank *Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: a 7 4 3 Sq. ft. ep c 1 0 0 0 Gallons 1 -Piece: OYes ®No Pump Required: O Yes ®No O May Be Required Pump Tank: Gallons 7 1-Piece:OYes ONo 6 8 6 ft, GPM --vs-- ft. TDH Inches O.C. 9 Feet O.C. Dosing Volume: _ Gallons 3 Olnches Feet Grease Trap: Gallons inches Pre -Treatment: O NSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01011 O III 01V Page 1 of 3 CDP File Number 199145 - 1 County ID Number: c416oAob22 ❑ Open Pump System Sheet Repair System Required: (&Yes ONO ONO, but has Available Space Repair System Trench Spacing: 9 O Inches O.C. *Site Classification: Provisionally Suitable — (9 Feet O.C. Design Flow: Trench Width: R Inches 3 4 8 0 _ . Feet Aggregate Depth: Soil Application Rate: 0 1 7 5inches u Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover: 1 ) LESS) Inches Maximum Trench Depth: 3 6 *Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 7 4 3 Inches .2 Sq. ft. No. Drain Lines 6 *Distribution Type: PUMP TO GRAVITY Total Trench Length: 6 8 6Pump Required: ®Yes O No O May Be Required ft. Pre -Treatment: O NSF OTS -I OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Remaning 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. Rema�i�g 2000 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 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(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? O Yes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140 - Nations, Robert Date o' f I_Ssue: 0 1 / 0 8 / a 0 1 6 Authorized State Agent: Malfunction Log OYes (9) Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION bavie C&unty Health Department CDP File Number: 199145 - 1 210 Hospital Street County File Number: C416OA0022 P.O. Box 848 Mocksville NC 27028 Date: 01 /08 /,2016 0 Inch Drawing Drawing Type: Construction Authorization Scale: 00 Block N/A . ...... ......... ........ 77717g77� ... . ....... -4- -7 Page 3 of 3 Pi P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 199145 - 1 P.O. Box 848 C4160A0022 Mocksville NC 27028 County File Number: % b Date: .0.1./.08 /.2016 Click below to import an image from an external location: Drawing Type: Construction Authorization V6 \-\) ( b C) Page 3 of 3 l I C(b P1 P2 THROUGHBRED LANE SITE PLAN LOT # 22 WHIP -O -WILL FARM 410 rp0, " v Q -J: -vv vu it ....... i,r ,,�f r k APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section % P.O. Box 848/210 Hospital Street (<� Mocksville, NC 27028 (336)751-8760 IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: I9 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: -F5- Acres Tax Office PIN: # 5-8 a;L- r /s Property Address: Road Name _ % %crV443 4 /J,,eo( Lei h-'— City/Zip l (OGICSU i al e U(�--- WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Name: Wk -p -0 -Mil FafwS Section: - - Block: _ Lot: ZZ Date home corners flagged: 611 ����► e✓ 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 or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred frons this application. 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 to conduct all testing procedures as necessary to determine the site suitability. DATE 2/Z s/26lc2S' SIGNATURE /{"V (� 10 (ice' THIS 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). Sign given VD Revised DCHD (05/03 `)/ t 5 _ o 5 pv� 5_ C Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. q Invoice No. �� ` ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL PR�O/VI%D,ED. to the INFORMATION BULLETIN for THE REQUIRED instructions. /Refer 1. Name to be Billed I/V• (�Q041`1SC)V) ,Jt-, (/ Contact Person Mailing Address /-7 Nea4ow, Ra Home Phone 1��InSCT�'� o('/�6 T- 7Z02-- City/State/ZIP Mocks.0;t •e_ . AVe— a70Z-V Business Phone -7S72loot 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ,Site Evaluation Improvement Permit/ATC ❑ Both 4. System to Service: �K House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms S # Bathrooms Dishwasher ❑Garbage Disposal Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: I9 County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: -F5- Acres Tax Office PIN: # 5-8 a;L- r /s Property Address: Road Name _ % %crV443 4 /J,,eo( Lei h-'— City/Zip l (OGICSU i al e U(�--- WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Name: Wk -p -0 -Mil FafwS Section: - - Block: _ Lot: ZZ Date home corners flagged: 611 ����► e✓ 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 or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred frons this application. 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 to conduct all testing procedures as necessary to determine the site suitability. DATE 2/Z s/26lc2S' SIGNATURE /{"V (� 10 (ice' THIS 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). Sign given VD Revised DCHD (05/03 `)/ t 5 _ o 5 pv� 5_ C Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. q Invoice No. �� ` i r/ . N IAVA 1 0 K IPA � X0 j6/ �i. � • �': S. Q• ��, 3 i �J / ~ N 4'2 • � S O O A AREA FROM FENCE TO c/ � ? •� E OF C- A CCOOMMOONRAREA C- A i� i 44-40.oo•— we4.3o 00.,x,,, CA �; .♦Qoo• saa•�o.00"� .._—� X34.40' P, -A AREA FR FENCE TO C - A , �D ROAD IS 0. 1 ZI O EDGEROAD N AREA Z n • G� CP IK9 OK (V4 1 -%P - 0 Tow r ��,�• AUTHORIZATION NO:. 0844 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Peslnitt n P.O. Box 848 Name: _�� �' ���r�' Mocksville, NC 27028 Subdivision Name: — V' ro ert : � /" /� r- /�' Phone #: 704-634-8760 Directions to p p y %� � F� � Section: � % Lot: �G.. AUTHORIZATION FOR WASTEWATER Tax Office PIN:#C'� �oL7 e a � SYSTEM CONSTRUCTION - Road Name: ' r , U l7 i� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 71771- 77 Dl -COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS `' PROPERTY INFORMATION ` Nadie: Subdivision�Name: k 4W,;7-4­ Pctio� Section",-fif Lot:oppty�4— UdPROVEM ENT a . PERMITTax Office PIN:# 8 6 L _ Q� Name: Road o Ed **NOTE** This Improvement Permit DOES NOT authorize the construction of 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 ..consmiction/installation of a system or the issuance of -a building permit. (Iii compliance with Aiticle 11 of QS_. Chapter 130A, Wastewater Systems, Section .1900 Sewage, Treatment and Disposal Systems) Z.. .***NOTICE*** THIS THIS PERMIT is SUwrr TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST '. DATE -ISSUED SYSTEM CONTRACTOR MLJST.SEE THIS PIIZMIT BEFORE INSTALLING THE SYSTEM. '. RESIDENTIAL SPECIFICATION: BUILDING TYPE _ # BEDROOMS -S,_ # BATHSa?,--s# OCCUPANTS _r GARBAGE DISPOSAL: Yes or No COMMERCIAL- SPECIFICATION: FACILITY TYPE J # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE. ? � 'TYPE WATER SUPPLY D DESIGN WASTEWATER FLOW (GPD). �6d NEW SITE_ ,-"' REPAIR SITE SYSTEM SPECIFICATIONS:TANK SIZE �MGAL. PUMP TANK GAL. TRENCH WIDTH, ROCK DEPTH LINEAR FT.eGe a' OTHER REQUIRED SITE MODIFICATIONS/CONDMONS:'. . **CONTACT A REPRESENTATIVE OF THE -DA VIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1;00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Petmite8's: r:} Name: Directions toert ro P P Y r, Subdivision Name: , t / Section: Lot: IMPROVEMENT . PERMIT Tax Office PIN:#`��"'�- Road Name ,/ , ' r" ^ . J'f" �:% i � Zlp: 3'` % r1 ' ' ; ' ; • **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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. t RESIDENTIAL SPECIFICATION: BUILDING TYPE _/ # BEDROOMS, ---2,--' # BATHS --- 7 # OCCUPANTS 71— GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY ` DESIGN WASTEWATER FLOW (GPD) moi' NEW SrrE 1!!: REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE U GAL. PUMP TANK GAL. TRENCH WIDTH. ROCK DEPTH LINEAR OTHER %✓ L t rY f%'J.% - l i' ':5 REQUIRED SITE MODIFICATIONS/CONDITIONS: ti L IMPROVEMENT PERMIT LAYOUT , y "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. I OPERATION PERMIT SYSTEM INSTALLED BY: 0 . R) .. AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEMINSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SAA1sL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD 05/96 (Revised)° r �' z APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC ` Davie County Health DepartmentVAPR OWE, F Environmental Health Section P.O. Box 848 F 7 197 (704) 634-8760 Mocksville, NC 27028 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL -- �OsoL THEREQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �j�e) Ste- Contact Person J0 Mailing Address 3/7y -lyAwY Home Phone (110) 760-3S/7 City/State/Zip Gf"VSM-J -i�4tec / it/L 27JOG Business Phone 6.,0) P --7t-0370 2. Name on Permit/ATC if Different than Above +, Mailing Address 3. Application For: f%rSite Evaluation City/State/Zip [A Improvement Permit & ATC [ ] Both 4. System to Serve: [&]'House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People 3 # Bedrooms 3 # Bathrooms 62-S- [ -'Dishwasher [4 -Garbage Disposal [v]"Washing Machine [ ] Basement/Plumbing [v] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: [wl County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [LkKo If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXLWUOF THE PROPERTY MUST BE SUBMITTED WITH TAPPLICATION. Property Dimensions: S r XIS WRITE DIRECTIONS (from6o'c-ksvfl1e) TO PROPERTY: Tax Office PIN: #C��do _ �d _ ')d3 C DIa^1 Ci�tlk�l� Property Address: Road Namev.Qe/X++l6�/tuh � !ic �c cc /� 'iyk+.% L6; o LJ0LIO City/Zip 1AekyES✓L1,c .NG a70;)5 o'J lb- Sa'6 APpkldX 2- M/GAS e�Sl4' If in Subdivision provide information, as follows: Name: fJtT/P Ort//� Section: Lot #: ; 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 or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. 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 f.t IY lid— O� W/1-1— to couct 11 testin procedures as ss to determine the site suitability. DATE / SIGNATURE '7 Revised DCHD (06-96) THIS AREA AIAJ BE USED FOR DRAIVINC7 YOUR SITE PLAN: r " - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION Water Supply: On -Site Well Community, Evaluation By: Auger Boring r11---' Pit W a' d� SECTION___,L_ LOT,2 DATE EVALUATED S ",0' i/ PROPERTY SIZE c_:��/f ROAD NAME ��1>GG✓GrrG� �r Public 41- Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH ^ s� Texture group Consistence Structure ,d 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: gr L a F i/© /q-- LONG-TERM ACCEPTANCE RATE: 1 a REMARKS: 1! 5)l/,"5, , DCHD (01-90) LEGEND Landscape Position EVALUATION BY: ' i' OTHER(S) PRESENT: R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic . 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Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope Texture S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic 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 Environmental Health Section P. 0. Box 848/210 Hospital Street Courier 09-40-06 Mocksville, NC 27028 March 11, 2005 W.G. Johnson, Jr. 117 Becktown Road Mocksville, NC 27028 Re: Site Evaluation/ Thoroughbred Lane Tax Office PIN: #5822-86-5015 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, March 8,2005. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, A e (I � &. C_:;_� /'� __ ZZA - Robert B. Hall, Jr., R.S. Environmental Health Specialist RBH/dlf Enclosure(s) . AUTHORIZATION NO: 0 8 4 4 DAVIE COUNTY HEALTH DEPARTMENT _tEnvironmental Health Section PROPERTY INFORMATION Perf titee','_ P.O. Box 848 Name: �! S���r.' Mocksville, NC 27028 Subdivision Name: /�Phone #: 704-634-8760 Directions to" ro ert : /Xeml /-el /1-1- /.ei'-� Section: Lot: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:#N41400 d C/ - oog � f� 7 Road Name: P,,4 ?' 6 L fd b r`'Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pen -nits. This Form/Authorizadon Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION T_, : r • r 7 } ). , r 17 IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE _//_ # BEDROOMS ? _ # BATHS i.3- # OCCUPANTS T' GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE/J # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE < . TYPE WATER SUPPLY i' DESIGN WASTEWATER FLOW (GPD) ?45� NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ,&aGAL. PUMP TANK GAL. TRENCH WIDTH_ ROCK DEPTH LINEAR FT. ,-"-'e5� OTHER_ Zi t_ `✓.�G�'r.� REQUIRED SITE MODIFICATIONS/CONDITIONS: **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: 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 05/96 (Revised) " bavie County, Ndrtli Carolina Spatial Data Explorer Page 1 of 2 Ct lss6��' Spatial mala £.Wp1@t'er 4tar �S Norlh Carolina Click on the Map to: Map Li %- Zoomin (—' ZoomOut Recenter Map r identify Parcels Drawl Zoom Factor. r'Radius Search (feet) Draw select Parcel Data Find Adjoining Parcels • County /0: C416OA0022 • Account Number.82515410 • PIN., 5822865015 • Legal 110T 22 WHIP O WILL • Owner Name. WRIGHT ZACHARY H • Owner/Address 1: WRIGHT ZACHARY H • Owner/Address 2: WRIGHT MELODY B • Owner/Address 3. PO BOX 26691 • City, State Zip: WINSTON SALEM ,NC 27114 - 0000 • Land Value: $82,060.00 • Building Value: $0.00 • Land Unit / Type: C4160A0022 :/ AC • Deed Book/Page: 00544/0197 • Deed Date. 2004/04/05 • Sales Price: $82,500.00 • Property Address: • County Zoning: • Census Code: • City Code: • Fire District: FARMINGTON • Flood Zone: ZONE X • Flood Community: 370308 • Flood Panel: 0025 C • Flood Map Date. 12-17-1993 r Census Tra City Bound (- County Zor Multi Syi E911 Fire 13 Rood Pane (- Flood Zone r Parcels (- School Dis+ Multi Syi r Solis (�- Town Zonir r Townships Multi Syi [- Voting Prec Infrastructu Driveways T- Rail Lines Street Cent US/NC Higi Multi Syl U N r Aerial Phot Creeks and E911 Addre Fire Depart Schools Draw L MAP Ci This map is prep; Inventory of real 1 within this jurisdic compiled from rel plats, and other r and data. Users c hereby notified th