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362 Allen Rd■ Lei i Lei i' Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27428 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Roy Lee Hodges Address: 127 Embrace lane City: Mt. Airy StatelZip: NC 27030 Phone #: (336) 345-1799 AddresslRoadw 36a Subdivision: Allen Road Pump Required: OYes @No ( May Be Required Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 4 *Water Supply. NEW WELL Foroflice Else=QnlV °`CDP File Number 238712-1 County ID Number: 5729289655 Evaluated For. NEW "j- ownship- PERMIT VALID UNTIL - 0 5/ 3 0/ a 0 a a Property owner: Donna Kray Trivitte Address: 296 Ralph Ratledge Road CAY: Macksvlle Stateizip., NC 27428 Phone #: Phase: Lot. Directions Hwy 601 North left on Allen Rd. lot on right Minimum Trench Depth: 3 6 '1144eClassiflcation: Provisionally Suitable Inches Saprolite System? QYes QMinimum Soil Cover,No Inches Design Flaw.4 $ Maximum Trench Depth. 6 Inches Soil Application Rate: 0 ^ a 7 5 Maximum Soil Cover: a 4 Inches *System Class ificatiantpescription: '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: a Yes e N o Down 7 ^f4 Pump Required: OYes @No ( May Be Required Nitrification Field 1 7 4 Sq- tt. Pump Tank: Gallons No. Drain Lines 5 1 -Piece: QYes ()No Total Trench Length: 4 3 6 ft. CPIs} vs _ ft. TD Trench Spacing: _ Feet taches O.C.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment ONSF OTS -1 LITS -1I Septic Tank installer Grade Level Required- 01 011 0 Ill Q IV 1} Down 7 ^f4 CDP File lumber 238712 -1 County Ifs Number: 5729289655 Cl Open Pump System Sheet Kepalr system Keguirea: Tes C, NO UNO, Out: nas Hvailaole ,>pace rFteDatr System Trench Spacing: Inches 4. "Site Classification: Provisioraffy suitable — Feet O.C. Design Flow, 4 8 Trench Width= s _ 3 Feet Soil Application Date: 0 a 7 Aggregate Depth: inches "System Classification/Description: TYPE Ili G. OTHER NON -C(71 V, TRENCH SYSTEMS "Proposers System. 25%REDUCTION Nitrification Field 1 7 4 5 5q. ft, No. Drain Lines 5 Total Trench Length: 4 3 6 ft. Minimum Trench Depth. 3 6 Inches Minimum Soil Cover, a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 2 4 Inches *Distribution Type: GRAVCTY- SERIAL Pump Required: Oyes @No OMay Se required Pre -Treatment: ONS1r OTS -1 QTS -11 "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of stealth Department. "Permit Conditions The issuance of this permit bythe Health Department in nowayguarantees the issuance of otherpermits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization forWastewater System Construction shall bevalid for a person equal to the period of witdity of the improvement Permit. not to exceed five years, and may be issued at the same time the Improvement Permit issued (NCGS 130A -=(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, falstfied or Changed, or the site is altered, the permitor Construction Authorization shall become inwlid, and may be suspended or revoked (.1937(g)?. The person owning or controlling the system shall be responsible forassuring compliance with the laws, rides, and permit conditions regarding system focation, Installation, operation, maintenance, monitoring, reporting and repair (1$38(b)). Applicant/Legal Reps_ Signature Required? Oyes @No ApplicanVLegal Reps. Signature: Date: "Issued $ : 2140 - Nations. Robert Y Date of Isssue:. 5 Authorized State Agent: Malfunction Log QYeS }Hand Drawing 01mport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Suet P.O. Bax 848 Mocssville NC 27028 1.16 Drajving Drawing Type: Construction Authorization CDP File Number: County File Number: 5729289655 Date: e 5/ 3 0 l a 0 1 7 Q Inch Scale: , 081ock ON1A CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.Q. Box 848 Mocksvfile NC 27028 GDP File Number: County File Number: 572928%55 Date: _05130 /2017 Click below to Import an image from an external location: drawing Type: Construction Authorization Well Construction Permit � a Davie County Health Department 210 Hospital Street P.Q. Box W Mocksville NC 270328 Phone: 338-753-6780 Fax: 336-753-1680 Property Owner: Donna Triuette Address: 396 Ralph Ratledge Rd Cfty: Mocksville State/Zip: IVC 27028 Phone #: Applicant: Roy Hodges Address: 127 Embrace Lane Cly: Mt. Airy State2 ip: NC 27030 Phone 4: (336) 813-4042 Property Location & Site Information ,ddresslRoad 9: Subdivision, Allen Road Mocksville NC 27028 Latitude Longitude Site Address: Allen Road Phase: Lot: *Proposed use of Well: If Other: Directions Directions-, Hwy 601 North left on Allen Rd. lot on right Well Contractor Information Drilling Contractor Driller Registration Kermit Conditions mid Conditions Well tocafice, construction and protection must meet all state and local regulations anif must be inspected and approved try an arthorized representative of the Locat Health Department The permit may be revoked atany One for failureto comply with existing regulations, The siting of approved %yell constr tion area(s) tzy the Health Department is to provide protection from tate known possikte sources of contamination. The approved weti area(s) may not be changed without written permission frwn an authorized representative of the Local Health Department, No voivarne of quality of water is guaranteed by the Health Department_ `Issued By: 2140 - Nations, Robert *Gate of Issue, 0 , 5 � / � 0 � � 0 1 7 Authorized state Agent: THand Drawing 0Import Drawing Owner/ApplicantSignatu **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT Davie County Health Department 210 Hospital Street P.C. Box 848 Mocksville Drawing Type: Well Permit NC 27028 CGP File Number: 23$712 County File Number. 5729289655 Date; 05 1 3 0 1 2 0 17 0Inch Scale: 01310ck O N lA = ft, 0-- q ^f ri WELL CONSTRUCTION PERMIT Davie County Health Department 210 Hospital Suet P.O. Bax 848 Mocksville NC 27 128 CDP File Number: County File Number: 238712 5724289655 Date: ,, / . /20 17 Drawing Type: Well Permit IMPROVEMENT PERMIT .� Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Ilse Only 'CDP File Number 238712-1 County ID Number. 572928M5 Evaluated For: NEW Township - Phone. 336-753-6780 Fax. 33F-753-1680 PERMIT VALID UNTIL; 5130/2€22 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Roy Lee Hodges Address: 127 Embrace Lane city-, Mt. Airy State2ip: NC 27030 Phone #: (336) 345-1799 Address/Road #: Allen Road Mocksville Structu re: 9 of Bedrooms: 9 of People: 'Water Supply: ff"EW1 -1 SINGLE FAMILY 4 4 NaN WELL Subdivision: stem [son: Provisionally Suitable Saprolite System? ()Yes (*No Design Flow: 4 8 0 Soil Application Rate: 0 2 7 5 System Classification/Description: TYPE III G. OTHER NON-GONV, TRENCH SYSTEMS =Proposed System: 25% REDUCTION property Owner: Donna Kay Trivitte Address: 296 Ralph Ratledge Road City: Mocksvlle State/zip-, NC 27028 Phone: Phase: Lot: Directions Hwy 601 North left on Allen Rd. lot on right Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: 0Yes ONo Pump Required: QYes (E)No 0May Be Required � PurnpTank: Gallons 1 -Piece: Repair System Required: Yes ONo ONo, but has Available Space Repair System 'Site Classification: PravisionallySoitaNe Soil Application Rate: 0 a 7 5 "System Class ificatnfDescription: TYPE III G. OTHER NON-GONV. TRENCH SYSTEMS "Proposed System: 251% REDUCTION ()Yes ONo Minimum Trench Depth: 3 6 Inches Maximum Trench Depth. 3 6 Inches Pump Required: aYes @, No (-) Maybe Requi Page 1 of 3 CDP File Number 238712 - 1 *Site Modifications County ID Number: 5729289655 E] 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 of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit molder is responsible For checking with appropriate governing bodies in meeting their requirements. The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to Site �P Ian scale that shows the existing and proposed property lines with tlimensions, the location of the facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters). Flat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land surveyor, drawn to a scale of one inch equals no morethan 60 feet, that Includes: the specific location of the proposed facility and appurtenances, the sitefor the proposed wastewater system, and the location of water supplies and surface waters. Plat also means, forsubdivislon lots approved by the local planning authority and recorded with the county registerof deeds, a copy of the recorded subdivisions plat that is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the Issuanceand may revoke tate permits for failure of the system to satisfy the conditions, the rules, or this article This permit Is subjectto revocation If the site plan, plat, or intended use changes (NCGS 13QA,435(f)). The person owning or controlling tate 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)� ApplicantfLegal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signatu Date: / / "Issued By: 2140 - Nations, Robert pate of issue: 0 5 / 3 0 / 0 1 7 C�Valid without Expiration? Authorized State Age * Create CA? 4)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 238712-1 Davie County Health Department CDP File Number; 210 Hospital Street $729289655 P.o. Box 848 County Fite Number: Mocksvolle NC 27028 Date. / # 0 Incl IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street AMocksville NG 27028 CDP File Number: 238712 - 1 County File Number: 5729291655 Date: 0 5 / � l 7 Click below to import an image from an external location: Drawing Type: Improvement Permit NCDENR Division of Environmental Health On -Site Wastewater Section `Date: e s/ 3 0 t 2 e 1 7 Soil/Site Evaluation "File #: ;� 3 a 7 1 .2 For On -Site Wastewater System PIN 9: 5729289655 *Owner Donna Kay Trivitte Proposed Facility SINGLE FAMILY Proposed Design Flog (.1949) Property Size 1.23 Location of Site Allen Road Water Supply NEIN WELL Evaluation Method nta Pttofile# 1 Ott Landscape PUS Slope % Horizon Depth (N) SOIL MORPHOLOGY .1941 Mineralogy Matrix Mottle Texture Structure Consistence Color Color Other Profile Factors 1 L t % Saprolite: (in) 0-48 C 3-Stng sbk fi s P .1942 Wet. GPS 1943 Depth GPS Capt' rofile Sapral�te:�n) 1943 Depth .1944 Rest, Honzon .1944 Rest. Horizon 1944 Rest Horizon ,1947 Class Ps EHS T.. Nations, RON _1947 Class EHS .1947 Class In EHS Nations, RoIx Profile LTAR 0 7 5 Profile LTAR„___ Profile LTAR 0 7 5- L t 016 5aprolite:(in) "8 C 3 -Sang sbk ti s p .1942 Wet, GPS COPY rofile 1943 Depth_ .1944 Rest, Horizon ..�... .1947 Class PS EHS Nations, RobeI I -T ILPTRIV 0 ? 5 3 L I % Saprolite.0n) 0-48 C 3-Stng sbk fi S P .1942 Wet, GPS Capt' Profile 1943 Depth GPS Capt' rofile Sapral�te:�n) .1944 Rest, Honzon .1944 Rest. Horizon ,1947 Class Ps EHS T.. Nations, RON _1947 Class EHS Profile LTAR 0 7 5 Available Space (1945) PS Other Factors( -1946) Site Classification (.194$) Ps Initial LTAR: e. 2 7 5 Repair LTAR: e. 2 7 s Others Present: Comments Evaluated By: Nations, Robert Qlc Saprolite:(in) .1942 Wet. GPS j Copy rofile .1943 Depth GPS Capt' rofile Sapral�te:�n) .1944 Rest. Horcon .1944 Rest. Horizon .1947 Class EHS _1947 Class EHS P LTARrakle Available Space (1945) PS Other Factors( -1946) Site Classification (.194$) Ps Initial LTAR: e. 2 7 5 Repair LTAR: e. 2 7 s Others Present: Comments Evaluated By: Nations, Robert % .1942 %Vet, .1943 Depth GPS Capt' rofile Sapral�te:�n) .1944 Rest. Horizon _1947 Class EHS Profile LTAR„___ Available Space (1945) PS Other Factors( -1946) Site Classification (.194$) Ps Initial LTAR: e. 2 7 5 Repair LTAR: e. 2 7 s Others Present: Comments Evaluated By: Nations, Robert NCQENR Division of Environmental Health On -Site Wastewater Section Hate: e s f 3 0 12 0 1 7 Soil/Site Evaluation File : 2 3 s 7 1 2 For On -Site Wastewater System PIN : s 7 2 9 2 s 9 6 5 5 Profile 1940 Landscape POS Slope % Horizon Depth (IN) SOIL MORPHOLOGY ,7941 Mineralogy Matrix Mottle Texture Structure Consistence Color Color Other Profile Factors af0 .1942 Wet. GPS s Cagy rbril .1942 Piet. 1943 Depth .1943 Depth GPS Saprarrte:(n) 1944 ResL Horizon EFTS 1947 Class EHS Coplay�rat±l Saprailte:(m) Profile LTAR " - . Comments: i % Saprolite:(in) .1942 Wet. GPS s Cagy rbril 1943 Depth 1944 Rest. Horizon .19.17 ClasS EFTS profile LTA €2 Comments: i saptolde.(1n) .1942 Wet, GPS 9HS Copy, ProfilePtrSfile U ,1943 Depth 1944 Rest. Horizon .1947 Class EFtS LTAR Saprailte:(m) .1942 Wet., GPS Cppgfrptil .1943 Depth .1944 Rest. Horizon 1947 Class EHS Profile LTAR Comments: i ***IMPORTANT*** THIS APPLICATION CAIVNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPT 1(`ANT TNMr)RAAATTr)TQ Name k0V aches Contact Person j1; (0e vk, I", es Address -- 9 Home Phone 33(v -X13 yt; ti City/State/ZIP _ Business Phone Email Name on Permit if DifJ`erent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date;`House/F'acility Corners-F1aQ—ged NOTE: A surve plat or site pian must accompany this application. ' Included: Rtite Plan ❑ Plat '(to scale) Owner's Name 'F`v 'PhoneNumber Owner's Address te de e r. 'City/Stale/Zip Property Address Ttb Ailey WA, City •� s fit Lot Size 1, 237 i4trLs -- -- Tax PIN# 5 Subdivision Name(if applicable) .01 Section/Lot# VA Directions To Site: 601 �J, L4cn Ite,n !` (F DEVELOPMENT INFORMATION Facility Te: Residential t/ Food Service Cliiircli Commercial (specify) Permit Type: p New Well We Repair We Abandonment er ype:_.Other Are There Any Septic Systems Currently On The Site. YES NO Do You Intend To Install A New Septic System On This Site? YES 1/ NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the speck location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marling the property lines and corners. The applicant is responsible for making the site accessible: The plat or map of the site must include, to scale, showing the locations of. all propeity boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads, intersections, streams or lakes within 500 feet of proposed well or well system; (B) all existing wells, identified by type of use, within 500 feet of proposed"well or well system; (C) the proposed well or well system; (D) any test borings within 500 feet of proposed well or well system; and (E) all sources of known or potential groundwater contamination (such as septic tank systems; pesticide, chemical or fuel storage areas; animal feedlots, as defined by G.S. 143-215.1 OB(5); landfills or other waste disposal areas) within 500 feet of the proposed well. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to deternTine the beAlcation for a well. s Signature Owner's legal representative ( � MA Date Site Revisit Charge Date(s): Client Notification Date: EHS: 11/7/2016 Account # Invoice # APPLICATION FOR SITE EVALUATION/IiVIPROVEMENT PERMIT & ATC Davie County Environmental Health U+ CF,VF,i D P.O. Box 848/213 Doaspital Street Mocksville, NC 27028 (336)753-67110/ Fax (336)753-1680 paUe. Application For X Site Evaluationhmprovement Permit O Authorization To Construct (ATC) i3 Both Type of Application: ElNew System ❑Repairto Existing System ❑Expansion/Modification of Existing System or Facility TICS APPLICATI0I11 C-4_7VAr0TBEPR0CFSSDD UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BUTrLETIN for instructions. APPLICANT INFORMATION Name Roy Loo Hod— Contact Person Roy Lee Hodges _ Address 127 Embrance Lane Home Phone 336 345 1799 City/State/ZIP Mt. A 'ry M. C. 27030 _ Business Phone Email moparsbyroy@gmail.com Email: Name on Permit/ATC if Different than Above Mailing Address 1-27 e m b r a n c e lane City/State/Ziv Mt, A T ry N C PROPERTY INFORMATION *Date House/Facility Corners Magi ed 6 NOTE: A survey plat or site plan must accompany this application. -'Included- eSite Plan ❑Plat(to sca e (Permit is valid for: 60 months with site plan, no expiration with complete plat.) Owner's Name n a K a T r i v i t t e Phone Number Owner's ss 3 9 6 R a t h R a Addret l e d e RoadCity/State/Zip M o c k s v i e n cT-028 Property Address J City M o c k s v i l l e Lot Size 1.23 acres Tax PIN# 5729289655 Subdivision Name(if applicable) Section/Lot# Directions To Site: Hwy: 601 to Allen rd west, lot on right Parcel number G30000068201 If the answer to any of the following questions is "Yes",supporting documptitation must be attached: Are there any existing wastewater systems on the site? yes o Does the site contain Jurisdictional wetlands? Yes -14o f Are there any easements or right-of-ways on the site? _Yes 16 Is the site subject to approval by another public agency? _Yes o Will wastewater other than domestic sewage be generated? Yes �o IF RESIDENCE FILL OUT THE BOX BELOW # People 4 # Bedrooms 4 # Bathrooms 2 Garden Tub/Whirlpool UYes Z1No Basement, ❑Yes ERNo ' Basement Plumbing: UYes @No IF NON-RESIDENCRFILL 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: �,Aecepted 01nnovative []Alternative ❑Other Water Suppjy Typ': 0, County/City linter K New Well IjExisting Well ❑ Community Well Do you antiC is ' all :aii7 vi cA�r�tA3i0 :3 Csi ui� ida ,ii`�r ibis SySteiu i5 iuitII : v Cts sCi � i L I eS A Na If yes, what type? This is to certify that theinformati: a t,ro,,ded ;,�, u'sapplication is p"uc and correct to the best of my knowledge. i understand that permits) 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 A,ithori-,Pd Re res tatitrn err C Heal L P ����.. = .he Da -ie C01 Int-, r c�_ux Deparmen< to conduct necessary inspections to detemcine compliance with applicable laws and rules. I understand that 1 am responsible for the proper identification and labeling ofproperty lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other;aimenities. Site Revisit Charge Date(s): Appli iISSI Client Notification Date:o EHS Pro 7 owner's or owner's legal representative signature Date )) r Revised 11/16 Account##Invoice # l.11l I Davie County GoMaps I April 22, 20171'1,128 0 0.0075 0.015 0.03 mi 0.015 0.03 0.06 Sources: Eert, HERE, DeLwre, USGS, Intermap, INCREMENT P, I Japan, METI, Esri China (Hong Kong), Earl Korea, Earl (Thalland), I NGCC, ©OpenStraelMapoontrlbutors, end the GIS UserCommunll Davy