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188 Bobbitt Rd OPERATION PERMIT or se nly a Davie County Health Department *COP Fite Number 191822-1 210 Hospital Street a6-000•00-071-02 . P.O. Box$48 County ID Number. Mocksville NC 27028 Evaluated For: REPAIR Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Michael Deal Property Owner. Michael Deal Address: 188 Bobbitt Address: 188 Bobbitt -Cky: Advnce Cly: Advnce StatefZiP: NC 27006 State/Zip: NC 27006 Phone#: (336)416-.1217 . Phone#: (336�41 1217 PropeLtj Location & Site Information Address/ Road#: Subdivision: Phase: Lot: 188 Bobbit Road Advance NC 27006 Directions _ Structure: SINGLE FAMILY hwy 158 to Farmington Road right onto Bobbitt road 2miles down on left #of Bedrooms: 3 #of People: *Water Supply: EXISTING WELL *IP issued by. *System Classification/Description: TYPE III S.SYSTEM W/SINGLE EFFLUENT PUMP *CA issued by: 2140.Nations,Robert SaproliteSystem? QYes ONo Design Flow: 3 6 0 * PUMP TO GRAVITY Pump Required? Distribution Type: + Yes ONo Soil Application Rate: 0 2 2 6 *Pre Treatment: Drain field rNkrnificatiion Field 1 6 0 0 Sq.ft. *System Type: INFILTRATOROUICK4 STANDARD n Lines 3 Installer: Brian McDaniel Total Trench Length: 4 0 0 ft. Certification#: 1118 Trench Spacing: 9 Inches O.C. • Feet O.C. *EHS: 2140-Nations.Robert Trench Width: 3 Inches gFeet Date: 0 8 / 2 4 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches (711 Minimum Soil Cover. a 4Inches Approval Status Maximum Trench Depth: 3 6Inches ® Approvetl Disapproved Maximum Soil Cover: a 4 Inches CDP Fite Number 191822 - 1 Septic Tank County ID Number: D6-000-00-071-02 Manufacturer. Lat. Long: STB: ' Gallons: Installer. Date: Certification#: *EHS: *Filter Brand: ST Marker ❑ Yes ❑ No Date: Reinforced Tank: ❑ Yes ❑ No Approval Status Piece Tank: ❑ YesO No ❑ Approved❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: I Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes 13No (Min.6 in.) `' Approval Status j einforced Tank:.❑ Yes ❑ No 71 Approved❑ Drsaproveii 1 Piece Tank: ❑ Yes ❑ NO Supply Line 7Length-: : inch diameter Installer Cfeet CertificationShedule: *EHS: Pressure Rated, ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO y - Approval Status ❑ Approved C] Disapproved Pump ReqUiremgnt Pump Type: Installer Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval,Status PVC Unions ❑ Yes ❑ No ❑ ApprovedE Disapproved; Vent Hole ❑ Yes ❑ No Anti-siphon Hole .❑ Yes ❑ No CDP File Number 191822 - 1 County ID Number: D6-000-00.071.02 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes 11 No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No THS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No ❑ Approved❑ Disapproved Alarm Visible El Yes 11 No - T 2140-Nations,Robert 'Operation.Permit completed by: 14 Authorized"State Agen - Date of Issue: 0 8 I 3 1 I a 0 1 5 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 by a TYPE nl B. sewage septic system. Rule.1961 requires that a Type TYPE III B. septic system meet the following criteria: - _Minimum System Review ByThe Local Health Department: 5YRs. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA _ Reporting Frequency By Certified Operator.NIA - . - Rule.1961 requires that a Type IV and V septic systems designed fora 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 fora 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenence 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. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** ` OPERATION PERMIT 191822 - 1 Davie County Health Department CDP File Number: 210 Hospital Street D6-000.00-071-02 P.O.Box 848' County File Number: Mocksville NC 27028 Date: 1 / 0 Inch Scale: . p8lock ft. ra Dwing Drawing Type: Operation Permit ON/A Q _ �3� [a<-- 511 ° �.. • CONSTRUCTION fiorOffice Use Only AUTHORIZATION 'CDP Fife Number 191822.1 °=• Davie County Health Department County ID Number D6-000-00-071-02 210 Hospital Street Evaluated For., REPAIR .��. P.O. box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 3 / 1 1 / 2 0 2 0 Applicant: Michael Deal Property Owner: Michael Deal Address: 188 Bobbitt Address: 188 Bobbitt City: Advnce City: Advnce State/Zip: NC 27006 State0p: NC 27006 Phone#: (336)416-1217 Phone#: (336)416-1217 Property Location & Site Information r18 ress/Road#: Subdivision: Phase: Lot: 8 Bobbit Road vance NC 27006 Directions Structure: SINGLE FAMILY hwy 158 to Farmington Road right onto Bobbitt road 2miles down on left #of Bedrooms: 3 #of People: "Water Supply: EXISTING WELL System Specifications Minimum Trench Depth: a 4 Inches rDesign ssification: Provisionally Suitable Minimum Soil Cover. System? OYes ®No 1 a Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: Maximum Soil Cover: 0 a a 5 2 4 inches "System Classification/Description: 'Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: Gallons 'Proposed.System: 25%REDUCTION 1-Piece: OYes ONo Pump Required: OYes ONo OMay Be Required' Nitrification Field 1 6 0 0 Sq ft Pump Tank: Gallons No.Drain Lines 4 1-Piece: OYes ONo Total Trench Length: 4 0 0 ftGPM—vs— ft. TDH Trench Spacing: _ Oinches O.C. ,_,9, Q+ Feet O.C. Dosing Volume: Gallons Trench Width: — 3 @Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required:01 011 0111 OIV Dan& I of Z CDP File Number f9182:1- 1 County ID Number. D6-000-00-071-02 ❑ Open Pump System Sheet Repair System Required:OYes ONo ONo, but has Available Space rDllesign System Trench Spacing: Q Inches O. . ification: — Q Feet O.C. Trench Width: Inches w: Feet Soil Application Rate: Aggregate Depth: inches .� . Minimum Trench Depth: *System Classification/Description: Inches Minimum Soil Cover. Inches *Proposed System: Maximum Trench Depth: Inches Maximum Soil Cover: Nitrification Field Inches Sq.ft. No. Drain Lines *Distribution Type: Total Trench Length: ft. Pump Required: Oyes ONo OMayBe Required Pre Treatment: ONSF OTS-1 OTS-11 "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 ofthis 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 wrwastewater systen construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and maybe Issued at the same time the Improvement Permlt Issued(NCG5130A-336(b)).If the Installation has not been completed during the period of validity of the Construction Permit,the Information submitted In the application fora permit or Constructlon Authorization Is found to have been Incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become Iniad,and maybe suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rides,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1930(b)). Applicant/Legal Reps.Signature Required? Oyes ONo Applicant/Legal Reps.Signature' Date:, *Issued By: 2140-Nations,Robert Date of Issue: . 0 3 / 1 1 / x 0 1 5 Authorized State Agent: -i Malfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION ' Davie County Health Department CDP File Number: 191822- 1 210 Hospital Street D6-000-00-071-02 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 3 / 1 1 / 2 0 1 5 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock Q N/A t r - - c � _ _w a 1 cas lAk w4o— -00-07162- Davie County Health Department '(0�►s.' Environmental Health Section P.O. Box 848 s„ 210 Hospital Street O U �'t Courier# : 09-40-06 R 1911 Mocksville, NC 27028 Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: i �fG�'/ ��o I Phone Number �.2,6 1217 (Home) Mailing Address: 0 61 / (Work) ✓ Z 7�a .Email Address: 4&40 1(94Z;1-4e' ,If P.J Detailed Directions To Site:. b/Cr I- 1-c r r&-eeli Property Address: Y.a al) wee . Z %fib Please Fill In The Following Information About The EXISTING Facility: F Name System Installed Under: Type Of Facility:+ Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No .If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: P Co Number Of Bedrooms: Number of People Pool Size: ZD ( d Gara e e: Other: Requested By: Date Requested: /z (Signature) For Environmental Health Office Use Only s Approved Disapproved . .,... / r,. Comments: C42 2'lr �I 't '� � 4/2X Environmental Health Specialist Date: *The signing of this.form by the Environmental Health Staffis 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:$ Date: Paid By: Received By: Account#: Invoice#: (b& F ti aIact Ile XA ' b r W za` NeW ��a9r� _ . _ . 14ovSe s Cod a Davie County Health Department o 1836 Health Section P.O. Box 848 C� 210 Hospital Street O U �� Courier# : 09-40-06 1911 Mocksville, NC 27028 Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: Phone Number 336- y/ - Z l (Home) Mailing Address: Y OW0 A4 (Work) d�anGe, ,�uG a �ao6 Email Address:V%Ok �( 'Acg't Mc'A�i 6 r th Detailed Directions To Site: �� TO 4- OAj 1 t Property Address: g �O�?►'J t �- J Gyl c ?Toa Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: t V%A i A Type Of Facility: Date System Installed(Month/Date/Year): l q q 7 Number Of Bedrooms:_F> Number Of People: 'l { Is The Facility Currently Vacant? Yes No` If Yes;For How Long? Any Known Problems? Yes ®o If Yes,Explain: Please Fill In The Following Information About The NEW Facility:ll�'t' k- '�� L01't6h K&OHef- Type Of Facility: r'1 cs+r &tt)-imm Number Of Bedrooms: 3 Number of People_ Pool Size: Garage Size: e Other: Requested By: �� Date Requested: (Signature) For-Environmental Health Office Use Only Approved) Disapproved s: 'Environmental Health SpecialistA( n Date: ly *The signing of this form by the Environmental Health Stafflis 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: Cas"Chheckk Money Order # Amount:$ �/ ++ 06 Date: Paid By: Received By: Account#: ! Invoice#: r7�Ll DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Secion PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION ❑ Name '�;,� *►.�,n sJ Phone Number: ='sa�' %`( �� (Home) ome Mailing Address � '��,� t(� �_ .,2+. '� ';' 7 (Work) tJ�i.>:'�s /rler 41/L P.�Cy Z7ld <eylr7me' .l i a l n .tir.T ZCA ark,+/arkce- Z?o00,6 Detailed Directions To Site: -t-t- __;9 -9c'62;%+ . Property Address: l38tit�'�4ai�c CZ�1 . f4 vAA?--- Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under: - +*+ 'J Type Of Dwelling: (-6u�- Date System Installed(Month/Day/Year): Number Of Bedrooms: 3 Number Of People: Z— Is The Dwelling Currently Vacant? Yes❑ No If Yes,For How Long? Any Known Problems?Yes❑ No,9._ If Yes,Explain: Please Fill In The Following Information About The New Dwelling: _ §v�_ Type Of Dwelling: N er-(N Bectroo 2 X 3 o Number Of People: Requested By: 4---` Date Requested: R�&q (Signature) 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❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #: y >a,. vHZIATIbN NO i� '� DAVIE COUNTY HEALTH DEPARTMENT /r - y'/l 40 ._� Environmental Health Section PROPERTY.INFORMATION Permittee's f P.O.Box 848 Name: on /A4 =— P rt Mocksville,NC 27028 Subdivision Name: ! J Phone,# 336-751-8760 Directions to property:' fz LiJ; �1�':f Section: Lot: AUTHORIZATION FOR 2?vc�L.� WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION — Road Name: 'lip: ?o a **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 Fom�/AuthorizationNumber•should be presented to the Davie County Building Inspections:, Office when applying for Building Permits. " (In compliance with Article I I of G.S.Chapter 130A.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' 1&71-4 4 y` '.IS VALID.FOR A PERIOD OF FIVE,YEARS. EiXliONM NTAL HEALTH SP IALf T . DATE ISSUED OF •° # 'r" =�"' �" DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Penmittee'� Name: { !; / i '1Mf 1% Subdivision Name: Directions to property: l..`- f.�, f f'r Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:# Road Name r t) (4 d Zip: :+ **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 1 I.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 ENVIRON &AL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE. INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE _ #BEDROOMS S #BATHS_C #OCCUPANTS 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){- , �/ANEW SITE REPAIR SITE D . . 7t ' SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK - GAL. TRENCH WI ROCK DEPTH -'(V LINEAR FT OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE* Sid , **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. xxxxxxxxx- OPERATION PERMIT SYSTEM INSTALLED BY: V" AUTHORIZATION NO. 7 OPERATION PERMIT BY: / DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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) t .♦ r` .;r. .s .�. j "( �• YP y1 r.`-. T1s ref b j;•r'y ..'y - a -r `,_: k _ v �y , • M .' �a DAVIE COUNTY HEALTH DEPARTMENT _ y f IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittees f� M Name: r� +��.Tj �` }'� Subdivision Name: Directions to property: Section: Lot: IMPROVEMENT " PERMIT Tax Office PIN:# Road Name:is Zip: **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 1 I 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. RESIDENTIAL SPECIFICATION:BUILDING TYPE A/ #BEDROOMS #BATHS e---#OCCUPANTS GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY 14Vf /1 DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE 4 SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH� ROCK DEPTH/,V LINEAR FT OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER• *RISER(S) IF 6" BELM) FINISHED GRADE* rte,. f f "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. xxxxxxxxx OPERATION PERMIT SYSTEM INSTALLED BY: i �11J � 4 AUTHORIZATION NO. ? OPERATION PERMIT BY: Ems/' „ '/ DATE: r ' "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCEy; ? WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A } 3 GUARANTEE THAT THE SYSTEM WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. �t DCHD 05/96(Revised) Ix S _ ✓ y DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME � N<< /l-it/NAW PHONE NUMBER ADDRESS /ems r�d66rSUBDIVISION NAME X?Wel• ?i7ao G LOT # DIRECTIONS TO SITE j ee- a1,*46,Z a/ yutdu Zo Zee, • r DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY gj!;M - NUMBER BEDROOMS 3 NUMBER PEOPLE SERVED TYPE WATER SUPPLY GvG!/ SPECIFY PROBLEM OCCURRING DATE REQUESTED �' �''� INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, d that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 tva�} t.- }>'/St :4 i y..... F . ...... ::�:.' �//�i•/'�''/ • — — .t .. . AUTHORIZATION No: - DAVIE COUNTY HEALTH DEPARTMENT Jt. Ti Environmental Health Section PROPERTY INFORMATION Permittee's P.O.Box 848 Name: ' ,� ' 070'd-f/ Mocksville,NC 27028 Subdivision Name: �.d• /�� Phone#:704-634-8760 Directions"to property:' _ Section: Lot:' AUTHORIZATION FOR /'-� Y.�i ��' ✓ WASTEWATER Tax Office PIN:# ��a SYSTEM CONSTRUCTION Ab _ } Road N �OU6l RU. Zip: **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: EN IRONMENTAL HEALTH SPECIALIST DATE ISSUED DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION R' Permittee's Name: a` 'r�"s,'r `i•'• P Subdivision.Name: V Directions to propertySection: Lot: IMPROVEMENT �r PERMIT Tax Office PIN:# 'a.. y Road Name: rsl 7� f 7. Zip: **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 I 1 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 SP CIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE A #BEDROOMS —T #BATHS j:f,�#OCCUPANTS_ GARBAGE DISPOSA16�or No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY �y//� DESIGN WASTEWATER FLOW(GPD) �l d NEW SITE. REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZV—!L41 GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH�i' ,Of LINEAR Fr.---5-P 0 J REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT Y;"a C f' l;, /000Sal **CONTACT A REPRESENTATIVE OF THE DAVIE C NTY'HEALTH DEPARTMENT MR 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)634-87F0. OPERATION PERMIT SYSTEM INSTALLED BY: :Y4. o MA` AUTHORIZATION NO. /�! OPERATION PERMIT BY: DATE: owl **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 BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHID 05)96(Revised) • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PEI PAR F Davie County Health Department Environmental Health Section P.O. Box 848 SP 2 6 1997 Mocksville,NC 27028 (704) 634-8760 y ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed AZA-�� .nru►4H •3Z Contact Person SA+A Mailing Address V aS 5666`k V ' Home Phone Qca t.�kZq City/State/Zip 0A2&n4e— W— Z1ooV Business Phone 0 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ]Site Evaluation [ ]Improvement Permit&ATC 04 Both 4. System to Serve: @C]House [ ]Mobile Home [ ]Business [ ]Industry [ ]Other 5. If Residence: #People #Bedrooms -S #Bathrooms L z LK]Dishwasher[)t]Garbage Disposal bQ Washing Machine [ ]Basement/Plumbing [ ]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: [ ]County/City [K}Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes DgNo If yes,what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED:***IMPORTANT**?a0VLVkT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. 'Property Dimensions: �'{ } A<� WRITE DIRECTIONS(from Mocksville)TO PROPERTY: Tax Office PIN: # D of d _ oac7 _ W71 •o2. 0 15q!� Sc •� '[�,g a,�tsaw ttd Property Address: Road fame 188 4JA4 A �• � �� : 3 c+r+�l+e.S -1'a ��- � L� city/Zip Pbue ncre. NGS ckwa a+� t'�q i� S�.a►� t.�nxvt-� If in Subdivision provide information,as follows: Name: ; 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 "P9 At-r14- Thr WAAr*J 733: to conduct all testing procedures as necessary to determine the site suitability. DATE q til(91 SIGNATURE •� Revised DCHD(06-96) THIS AREA MAY 13E USED FOR DRAWING? YOUR SITE PLAN: F vr ,,-.• ,. `ia,+..:,. ...�..r ryrr;.a. �..•.. - .- ..,, ,s f.:. ...�..: •.a :7t:� �,. a; .y... # r+ nt. fr es .., ,r. a ,. v .. .x . 7 -,....i ,.. ,'lr: ,.,. .. ... .; .. �} .. , ..• '::a ', ::-t> P �r. , :,..:. :. .. nr e i .: .-ir,.. , .., ...:. .,i.1.-t- ., -.rv.�. .. .,�.fi 1:1.�.' •T:. :..b,. L� c.: .. C � (. Y 4 - P - a`. ... .t,.z . -„ :.,. ... .,5 <. ,- ! .,.,`F: /., _. ..:. „M _.:. d t? ..n ., ,rr ,: �N`' ..n,.. ,; r. .. r..•sY p,. t'A { i. , tri a-..r::,_ .M_ ..1...- ,�. 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',a.:.,- WELL S Y • it 0 - ,. } 4 - i rA, s:,. ,�, xi t• �., 1 'At - • R rli .T.et /. - ai^ ., rI r•� %\........... t F T iiAN ��i0 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME &A'!A dl ftjV DATE EVALUATED 3 PROPOSED FACILITY PROPERTY SIZE I�IjA-C SUBDIVISION ROAD NAME9 �� Water Supply: On-Site Well l/ Community Public Evaluation By.: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH V Ap 1' 4 Texturegroup �_ ,� 4 Consistence Structure Mineralogy HORIZON II DEPTH '' $' 'f Texture group Consistence Structure Mineralogy ,o HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 777 175- LONG-TERM ACCEPTANCE RATE 2 2 SITE CLASSIFICATION:- e& P� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: >7 .V y �`— O �/�2 �' �s 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 oist 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 ocHn(oi-vo) ■■■■S■■■N■■■■■■■■■■S■M■■eee■■■■■■■■■■■NN■�■■■■■■■■■■■■■■■■■■■■■■■■■■■■eeee■■■■■■■■■■ SEEN ME ■■■■■■■■■■■■■■e■■eeN■eeee■■■■■■■■■■■■■M■eM■e■■■■■e■■■■■■eee■ee■eeeee■e■■■■■■■■■■■■■■■ ■■■NM■N■■■S■ENSE■E■■■■■■■MSN■■■■■■■■■■■EE■S■■■■■■■■■■■■■■■■■■MMME■■SNM■SSEM■■■■■■■■■■ 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■■■ESN■■■ESENEN■■SEM■■E■■s■■■■■■■■■■■■■■■EEEM■SN■■■■■■■■■■■SOME■■■SN■■■■■■■■■■■ HER ■■■■EeeeeeeesMOE■■■■E■■■■■■■■■■■■■■■■■■■■■■■■■■■eeeeeeee■■■■■■■■�■■■■■■■N■■■■■■■■■■■■■■eeeeeeee■■MM■ ■■OM■■■■■■■■■■E■ESe■■eeee■■e■■■■■N■eeeeMN■ ■■■■eeeee■■■■■■M■■■■■■■eMEe■eee■■e■eeeeeeM■■■■■■■■■■■■■■■■■■■N■MeeON■■■■■■■See■ ■■■Nee■M■■■■■■■M■■■■■■■NMee■eee■see■eee■■M■M■■■■■■■■■■■■■■■■■N■MeMENEM ■■■■E■M■ ■S■■■M■S■MNM■■E■■■■■■■■Me■M■Mee■■■■■Ee■■eeee■■■■■■■■■■■■■■■■■■■■■SeeeM■■■■■■Se■ ■■■■■e■■■eeee■■■■■s■■■■■S■■■■■■■■■■■■e■■EEeeeeeeMMe■■■■■■■■■■■■■■■eeee■■■■■■■■■ • ■■■■■■NM■■■■E■EE■■N■■■NEM■■N■■■■■E■■S■■■■■■■M■■s■■■■ENEEE■E■■NM■■E■S■■■NS■■■■S■■ ■■■■■■■■■■eee■■■■E■■■■■■■■■■■■■■■e■e■eeee■eeeeeee■■■■M■■■■■■■■■■■■■■Mee■■■■■■■■■ . , ..; : . ■■■■■■■■■■■■■Seeeeeeees■■■sN■■■■■■■■�■■■■■■■■■■■■e■■■■eeMEeeee■■■■■■■eeee■■■■■■ ■MM■■■■■■■■■■■■■■■■■eeee■■■■■■■■■e■■ ■■■■■■■■■■■■■■■■■■MNN■EEe■■■■■■■■Mee■■■■■■ APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIf&ATC Davie County Health Department Environmental Health Section P.O.Box 848 Mocksville,NC 27028 3o� � 8 ' 83 J (704)634-8760 r ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS JIU& 1 1 ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed J 1Z mak- A4 ody-- L --J� Contact Person Mailing Address lee -e>0\40k-k OrU • Home Phone q'R6 bel ZA City/State/Zip "V4&C-P— . WC- Business Phone 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 Serve: Cd House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People d # Bedrooms # Bathrooms 2.5 a6ishwasher ® Garbage Disposal Cif Washing Machine d Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(galloons per day) 7. Type of water supply: ❑ County/City i Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes d No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. n Property Dimensions: 13 + A0• I WRITE DIRECTIONS(from Mocksville)TO PROPERTY: ,\ 7 Tax Office PIN: # Ise Oot Property Address: Road Name Ila% ted-• l e% (fid clr•wc-1 City/Zip A?G 1 I r� iw Cie c yt 1 • If in Subdivision provide information,as follows: 1 I Name: Section: Lot #: 1 1 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.1,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 GLA^h - �K"AOA to conduct all testing proced as necessary to determine the site suitability. DATE Z', ( 91 SIGNATURE Revised DCHD(06-96) TAX LOT THIS 7 .03 EASEL ON REE ENT 0 V COPENHAVER 1=��- 59,P. 236 Z Z � ct� � N • cA cn CD Ci a�0 41 1<1 N 0 A -0 V&6- ti sa�s. • Q.�, ! ti s� 0 3 9�0 N 03-20,O2 1= 103 . 17' N 68. 11 -55 w 37. 70# N 23- 11 -57 N 15-5643 W—�_ 36, 4404 TAX LOT N �6-33-54 E 7s. �s 71.02 � w I N 02-37-35 35 10 a Q rn Q � 60-36- 14 E w o J .F 244. 48' z C CENTERUNE I' OF CREEK J 4 >' w..� 7 �• S� IRON NORTH 84 - 27.20 IRON WEST BOUNc RIGHT EASU TAX LOT �3 0