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1183 Baileys Chapel Rd � �E , • I Y ' Davie County Health Department ��s jfi Environmental Health Section ' � ,.. . .,.� � "�� P.O. Box 848 • � . < ' � � � � ,��, 210 Hospital Street �� O U, �� Courier# : 09-40-06 � � Mocksville, NC 27028 � Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name:��Q��'�C��I /1C�i-P ,C �r Phone Number 3��p �O 1 SO�Q c3- (Home) Mailing Address: � ��3 1�C�i �P1•1 c � � �3l� 7 1(D ��1G'� (Work) . , A.�C- a �p(p Email(�YY\QY�Q► Pt�i rl � Q o(•�� Detailed Directions To Site:�,Q_� e G2�S't 1��'t' �''� �� -`�� Pri \e.0 S ��(2Q� l� '\ �"{ ��c.•�SR F?�In \ Q� � Property Address: Please Fill In The Following Information About The EXISTING Facility: �e (��S l� Name System Installed Under: Type Of Facility: Date System Installed(Month/Date/Year): �-[ a.�'> Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Y s No If Yes,For How Long? Any.Known Problems? Yes No If Yes,Explain: Please Fill In Th ollowin Information About The NEW Facility: Type Of Facili : ! I��1�l (� � Number Of Bedrooms: Number of People �Requested By: � Date Requested: • � � (Signature) For Environmental Health Office Use Only pproved isapproved Comments: Environmental Health Specialist Date: q�/Z�/3� *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # � Amount:$ ;�D� OC� Date: Zy /3 Paid By: Received By: Account#: Invoice#: �J�� 2�,�� -�- ��. � .'✓y r�, '�� .'i - �= ��z�'''�' . . . ' � ��zg l 3 � � c�lo(�� . , �f , �,f.� �� ,{` .�' � �. � - � �"_�,.. t.. �,. ��a� � � , ,„�. �� ,��, �� - a � �� . �°� �- _ -- � � .}.:: �:�-� l'_ �,.r.�. - ,�.a��'�� _ �� ✓= \ ' � oPb�F AlPdata is provided as is without warnnty or guanntae of any kind either expresaed or implied inoluding but not limited lo the implied '='� '�� Y; warranties of inerchanG6ility or fitness for a particular use.All users of Davie County's GIS website shail hold harmtess the County of �(I N� Davie,North Carolina,its agents,consulWnts,contractors or employees from any and all claims or causes of action due to or arisfng out of ` the use or Inability to use the GIS data provided by this website. P rI Clted.J U I �5, 2013 � ` Cr.1�VSTRUCTlON For ottice use on�v AUTHORIZAT`ION *CDP File Number 122378- 1 ' °''�w`' Davie Coun Health De artment H8•0000004105 . ..-., � � ''� P County ID Number: � u � �� °:��`� 210 Mospitai Street Evaluated For: HDR/VIIWC �� •� P.O. Box 848 • �•"' Township; �......,: MOCkSville NC 27028 PER1.tIT vAUD UF�TIL: Phone: 33fi-753-6780 Fax: 336-753•1680 0 7 � 2 6 � 2 0 1 $ Applicant: Amanda Poindexter Property Owner. Amanda Poindexter Address: 1183 Baileys Chapel Road Address: 1183 Baileys Chapel Road C�y: Advance CdY: Advance StaterZip: NC 27028 State2ip: NC 27028 Phone#: (336)909•5062 Phone#: (336j 909-5062 Propertv Location 8� Site Information Address/Road #: Subdivision; Phase: Lot: 1183 �aileys Chapel Rd 4 _ . _ _ . Advancd NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 East, right on Hwy 801 , Baileys Chapel Rd. on left, house on right. #of Bedrooms: 3 �of People: 4 'Water Supply: Puauc Svstem Specifications Minimum Trench Depth: 2 4 Site Classificatan: PS Inehes tvlinimum Soi! Cover, Saprolite System? QYes �`jNo Inches Design Flow: 4 8 p tvlaximum Ttench Depth: 3 6 Inches Sail Application Rate: Frtaximum Soil Cover: fl _ 3 Inches 'System Classif�catan/Description: 'D�Sif1bU110t1 Typt;: GRAVfTY-PARAILEL(eq,d-box} TYPE II A.CONV SYSTEh1{S1NGlE-FAll41�Y OR 48�GPD OR IESSj Septic T�nk: Gallons 'Proposed System: 25°Iti REOUCTION 1-Piece: Q Yes Q No Pump Required: �)Yes (�No Qh9ay Be Required Nrtrification Field Sq. ft. Pump Tank: Gallons No. Orain Lines 1-Piece: QYes QNo Total Trench length: GPI�A—vs-- ft. TDH 5 0 n. Trench Spacing: _ ("jlnches O,C. _ QFeet O.C. Oosing Volume: G�Ilons Trench Wdth: _ Q Inches 6 �,1Feet Grease T�ap: Gallons Aggregate Depth: � - - inches Pre-Treatment: QNSF C3TS-I OTS-II SepticTanklnstallerGradeLevelRequired: QI QI) �III �IV ►,...... , ..�� .1� � , • ��.�. ... ��.�" . 1 . [ �- � . � ' � �ie County Health Department �o�►s j� �� '� , ��ironmental Health Section � _ , �� , P.O. Box 848 �+ 1 • ...� : CE � � � � ,.,�"�, 210 Hospital Street . : �,�� O� �'�. Courier# : 09-40-06 �"' � �� -; Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name:��y�(� �o ind.e�.-�e,� Phone Number �U� �� (Home) Mailing Address: � � � �i'ti� I-2t,�S ��_,c,�I �I � � �U 'C`t�l�0 (Work) . �v�� V'C. �'1 dp(� Email Q�IrYI�'t e� � p v i n �, eko(��t� Detailed Directions To Site: �1Z� 2�S"r ��"�� tn 1''1 LS� � �.27�'r �Yl � �.1�, S Ll�a � CZ�I ( 5� �o�S� C9Y. � Q� Property Address: ��[�QQ—�'[)'�Crf�-Q� Please Fill In The Following Information A6out The EXIS�TING�"'acility: ��rys�� q I�,,- �/ IJ�U iL( � r2, �S—..`._ Name System Installe1 Un1cr: ��U./U1!l� �l'/�� l./1�(��r/.��f f�l� �ype�f Facility: Date System Installed(Month/Date/Year): ��5 Number Of Bedrooms: � Number Of People:� Is The Facility Currently Vacant? Yes � If Yes,For How Long? Any.Known Problems? Yes No f Yes,Explain: Please Fill In The Following Information About The NEW Facility: ^ Type Of Facility��(�(��N dro��s �'"��1� Number Of Bedrooms: � Number of People� �Requested By: q ' �1�1��p{�� Date Requested: - (Signature) r�� For Environmental Health Office Use Only Approved Disapproved Comments: 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 ,(extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # U Amount:$ (, •� Date: 7—�J�� Paid By: , y`�P�}C Received By: � Account#: �(��,�G Invoice#: �l�L� � . C.�� Z3�� . � , �`� ��' � zgl3 � � �lo( � . � �� _ _=- . _., . � � , .— _ __ ___- � �►a ��, o�� i „r� 1 a� � I ` �-_ �_._, ,_ � �� _ __ -- ,�° �- _ - -__ , �� `s�,i��:t. _ ____- � s t'_,F��t`'�� _ � � ,- i_ _ �� _ � I - - - � ' � I (\ O PiU�L�' All daW is provided as is without warranty or guarantee of any kind either expressed or implied ineluding but not limited to the implied '-'� i n I'�� 'r, warrantles of inerehantabiliry or fitness for a paRiculat use.All usen of Davie Counry's GIS website shall hoid harmless the County of �U pt� Davie,North Grolina,its agents,eonsultants,eontractors or employees from any and all claims or causes of action dua to or arising out of ♦ .1 G I 1 the use or inability to use the GIS daU provided by this website. P rI I�led.J U I 1 J, 2013 . _ , , . . - �Gth1 No-� ''`N� D�� N� � -� PA�}�,�ie C;c�unt��I.�.ea.ltl� 1_)ep�irtzYicnt ��;b�� i`�ironmcnt��l Hc11d� Scc:�ior� � „ � ,�rt -;f� P.U.Ro.8a�8 RECEI � � �:.,. �,.:.� . �. � �,-L��.y,�,,� 210 x��sp�cat sc��rct :�r:1 r)tt� cc�uiici•r:an.:�o-o(� nw: D�locl:.iti illc,\C 2i�28 t.,r ��n��:(.3;c>>-;s,�-r>,sa r2.:w361-:Sl-878G O\-SITF.�'4'A51'EV4'A'1'El�CE}.t'1'I1�IC�TIUV F(lR D��'FLLING (Check Chic) Replacement Reniadeling Recnnnectinn N�une:,.�^1_�](},�� n�`��r--- ---• E'hoiu Vumber 1�'"� �O� � (Homc) �failu�g Addres�: �, 4 Z� 3 �14� {-�S C�'lt.�.x� � -- � ��fJ 'T"i W l.l� (li'ark) n'+'�u', _�J_Cr._�c��]C�iP �ms�i_.Q�.IrYI()U'1(,�0.�_�t-�lY1 � C�Oi��C�'1 Dctailcd[)ircctionv'1'o Site:Y�,�1�-t 2�+ i e-�'T !n i'Y �s�4 �A'7'-'� �11'` ��1 c� c ��t�,�-� tZd l st ho�s� O� 1 e� I'roTx.TtyAddrecx: __ _------- — -- /�s��"'�C��-`f��y�'LJ Please Fill�n The Folluwing lnfortt�ation Almut'Thc EXI.STl:YG FacilitF•: ��'��C�� ° � /I� � l�i�i,�;cr ` ��,3�� - . Namc Sra-tem Tnsutiled Undzr: �!�L' 1�;(�E f L'i�IESr�/Ul`•_ �(t}fE"f-'r 5'1� �fk'acilin•: GFCcS4% _ natcSp�tcmin.titallcd(M1lon$t'Date;'Ycar}: ___1_-`-a_5 __ ��Unb��r(?I'licdruc�m�: � _ T�uu�berOfT'euple:�_ Is Il�e Fnciliry Cu[rently Vacani? Yts �o_�� If Yzs,For I low Lonb.' _._ — An�•Knaw•n Problems'.' Yes Nu .Tf Yes.Fxplain:_ __,_ Ylease N'ill ln'1'he Follo�i-ing lnfurmatiun About Ttie rtiF.I3'Tacility: y� ^ 'T)�c QfFacility��r f t'u'�� "'�%�'��^ql �/`J�� Ni¢nbcr Ul Bcdronm:: � _KumUer�fYiY>pic �Kryuextcd Ry._�k3��!- l'-`(1� ?�?Y�l�--> llate ltcquwtc:l: - . (Si��nue) For Enviromnc.ntal Hu�I�F�011icc U�c C1nly ArPn��'ed llisappmvcd Curnrncnt5: _. . --- F.m�irarut►cntal f-lcalth Specialis� __ . __. .. Date: *"1'lie;ignin�of this f'onn b��the Envuoiuncntal Hc.illh SIafT'is in no�+•ay inlcndcJ,nor shc�uld bz taken as a guau�mtee L — (cxU:ndcd��r lirnited}tliat tlie on-site�ti��istewalc.v syst«n wil! fun�tiun properly for<my gir•cn period c�f iime_` � i Psymcnt: C:uh Ch�ck hfonev prdcr � �U� :'ltnouut:S�.� •_�O C� .(.}____flatc_ 7-(J"l-3 ' �j/'�,� 1'a:d Ry:_ -i�2 F�;i� '�._ ------Rcccivcd R.'� LI u-C/2l'� Axount a: _ Invoice»: .�� .' �f� �'�Z._:s�j`� .. , . , , , . . . �� _�- . ��`� z� � .� �, ��x � _ - , , �� ,��' �- l �,�'' �� ts ,: .,r.�'•.." �r .� �'�� •N'�� n a�v.crovd��s�...�an.��n.....�y...r�.�.��«.��r..y�.�n.��....�,�.«...i w+�q�rw�..:w�a��;��.a�o�u.��ee eo rM�mv�Ka �^„i'_ ��1 w�n�n�d�of mnelniNaolllq p r�pipsa 1wa p tl¢ular usa.All u.en a!Cm'ic Ccur.tY'�UIS'�c[sik 5�:11 Eoltl�arw'J�a�q�e Onnxy u/ 't:�^� � Vanc.NoM Cardina�iN nyend.c�n,u4.xN�.rnnbwcLn.ww��xrywr/nn.�rg�nd sY cbx��or c��w Myyjqn Jue fo t+arr.x�p e ut N o,,,.»M,,,.�:„.,,,��a„,o��b,�,,,,�,�„,M�,�a�. Printed:Jul 15,2013 I -.I . , , . ,• - Construction Authorization For Office Use Onlv � . Davie County Health Department `CDP File Number: 122378-1 �1 210 Hospital Street County ID Number: H8-0000004105 �' Evaluated For: HDR/VWVC P.O. Box 848 MOCkSVlll2, NC 27028 PERMIT VALID UNTIL: 07/26/2018 Phone: 336-753-6780 Fax:336-753-1680 � Open Pump System Sheet Applicant: Amanda Poindexter Property Owner: Amanda Poindexter Address: 1183 Baileys Chapel Road Address: 1183 Baileys Chapel Road City: Advance City: Advance State/Zip: NC 27028 State/Zip: NC.27028 Phone#: home:(336)909-5062 cell:(336)716-4466 Phone#: home:(336)909-5062 cell:(336) Propertv Location & Site Information Address/Road#: 1183 Baiieys Chapel Rd Subdivision: Phase: NEW Lot: Advancd,NC 27028 Directions• Structure: SINGLE FAMILY Hwy 64 East,right on Hwy 801 , Baileys Chapel Rd.on left, house #of Bedrooms: 3 on right. #of Peopie: 4 •Water Supply: PUBLIC Svstem Specifications 'Site Classification: PS Minimum Trench Depth: 24 Inches Design Flow: 480 Maximum Trench Depth: 36 Inches Soil Application Rate: 0.3000 'System Classification/Description: Minimum Soil Cover: Inches TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Maximum Soil Cover: Inches 'Proposed System: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) 25%REDUCTION Septic Tank: Gallons ' Nitrification Field: Sq.ft. Pump Required: OYes QNo O May Be Required No.Drain Lines: Olnches O.C. Pump Tank: Gallons Total Trench Length: 50 ft• OFeet O.C. Trench Spacing: _ Olnches Grease Trap: Gallons Trench Width: _ g OX Feet Septic Tank Installer Aggregate Depth: inches Grade Level Required: Q I O II O III O IV The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checkinq with appropriate qoverninp bodies in meetinq their requirements. 'Permit Conditions: The 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 shall become invalid,and may be suspended or revoked(.1937(g)).Ther person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regaurding system Iocation,installation,operation, Authorized State Agent: Daywalt.Andrew Date of Issue: 07/26/2013 Q Hand Drawing Q Import Drawing ••Site PIanlDrawing attached** Total Time:(HH:MM) Page 1 of 1 ., , . . � � CONSTRUCTION For ottice use on�v AUTHORIZATION "CDP File Number 122378- 1 ��^�S�A�a -�� Davie County Health Department County ID Number: H8-0000004�05 �r '!:�� 210 Hospital Street Evaluated For: HDR/WWC •,;��,,✓� P.O. Box 848 Townshi P� Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax: 336-753-1680 � � / a 6 / a � 1 $ Applicant: Amanda Poindexter Property Owner: Amanda Poindexter Address: 1183 Baileys Chapel Road Address: 1183 Baileys Chapel Road City: Advance City: Advance State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �336)909-5062 Phone#: (336)909-5062 Propertv Location � Site Information Address/Road#: Subdivision: Phase: Lot: 1183 Baileys Chapel Rd Advancd NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 East, right on Hwy 801 , Baileys Chapel Rd. on left, house on right. #of Bedrooms: 3 #of People: 4 *Water Supply: PUBuc Svstem Specifications Minimum Trench Depth: a 4 Site Classification: Ps Inches Minimum Soil Cover: Saprolite System? OYes �No Inches Design Flow: 4 $ � Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 , 3 Maximum Soil Cover: Inches *System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons "Proposed System: 2s%RE�ucrioN 1-Piece: �Yes 0 No Pump Required: Q Yes Q No Q May Be Required Nitrification Field Sq.ft. Pump Tank: Gallons No. Drain Lines 1-Piece: �Yes �No Total Trench Length: 5 0 ft GPM--vs-- ft. TDH Trench Spacing: _ O Inches O.C. Dosin Volume: _ Gallons 0 Feet O.C. 9 Trench Width: 6 Inches _ Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: O I �I I 0 II I O IV Page 1 of 3 .r , ., . CDP File Number 122378 - 1 County ID Number: H8-oo00004�05 ❑ Open Pump System Sheet Repair System Required:�Yes O No O No, but has Available Space Repair Svstem Trench Spacing: �Inches O.C. *Site Classification: Ps — 9 Feet O.C. Trench Width: 3 6 ��nches Design Flow: 4 8 0 _ Q Feet Soil Application Rate: � . 3 Aggregate Depth: inches � Minimum Trench Depth: *System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: Inches Maximum Trench Depth: Inches *Proposed System: 25°io RE�ucTioN Maximum Soil Cover: Nitrification Field Inches Sq.ft. No. Drain Lines "Distribution Type: PUMP ro cRa,virY Total Trench Length: 4 � 0 ft Pump Required: �Yes Q No Q May Be Required 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. *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. 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 pertnit 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 �NO ApplicanULegal Reps. Signature• Date: � � "ISSU2d By: 2244-Daywalt,Andrew Date of Issue: � � / a 6 / � 0 1 3 Authorized State Agent: Malfunction Log OYes �Hand Drawing O Import Drawing Total Time:(HH:MM) **Site Plan/Drawing attached.** 0 1 Ho��s 0 0 Minutes Page 2 of 3 S-9-CA'S issued-expansion � .� � � 4 . . � � ' � � ' CONSTRUCTION AUTHORIZATION 122378 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Hs-000000aios Mocksville rvc 2�ozs Date: 0 � l a 6 / a 0 1 3 �Inch Drawin� Drawin T e: Construction Authorization Scale: , , O B�ock = ,ft. 9 YP Q N/A ZGs � � - � • , _ ,� � "�' a -�� , f ' '•�'J1 � • � � � � �� - � . �� ,a , . .� �, � v,U.�a � a.�l �'��' , Page 3 of 3 P1 P2 , . �� . . . � , . , . CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 122378 - 1 P.O.Box 848 H8-0000004105 Mocksville rvc 2�02$ County File Number: Date: .�.�.� �a.6, /.a.0.1.3. Click below to import an image from an external location: Drawing Type: ConstruCtion Authorization Page 3 of 3 P1 P2