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167 Hilton RdNorth Carolina State Laboratory Public Health 306 Box 28047 ,7 306 N. Wilmington St. Environmental Sciences Raleigh, NC 27611-8047 ham://siph.ncpublichealth.com Microbiology��e �; �i�3 -8695 9733'7834 Certificate of Analysis NOV 0 3 2011 Report To: Name of System: DAVIE CO ENVIRONMENTAL HEALTH LEONARD COATES 167 HILTON LN. P O BOX 848 MOCKSVILLE, NC 27028 MOCKSVILLE, NC 27028 EIN:566000295EH COURIER #: 09-40-06 Starl-iMS Sample ID: ES102511-0115001 11111111111111 I I 1111111111111111111111111111111111111111111111111111111111111111111111 IN ES Microbiology ID: 31451 GPS Number: Sample Description: Comment: Environmental Microbiology - Colilert Profile Collected: 10/24/2011 11:45. Andrew Daywalt Received: 10/25/2011 08:20 Susan Beasley Sample Source: Well Well Permit Number: Sampling Point: Well house spigot Method: SM 9223B Test Name: Colilert Analyte Test Result Analyst Date Total Coliform, Colilert Present Susan Beasley 10/26/2011 E. coli, Colilert Absent Susan Beasley 10/26/2011 Report Date: 10/28/2011 Reported By: Susan Beasley Explanations of Coliform Analysis: If coliform bacteria are Absent, the water is considered safe for drinking purpose. If coliform bacteria are Present, the water is considered unsafe for drinking purpose. Presence of E. coli (bacteria) generally indicates that the water has been contaminated with fecal material. It must be remembered that a water analysis refers only to the sample received and should not be regarded as a complete report on the water supply. - 1 ► DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section` PO Box 848/210 Hospital Street Mocksville, NC 27028 1 Phone: (336)751-8760 ON-SITE WASTEWATEZ CERTIFICATION FOR DWELLING (Check One) REPLACEMENT V} REMODELING ❑ RECONNECTION ❑ Name: l .Ia r V ,N -Phone Number: �?No - 4qr? - C (Home) Mailing Address:Ila %N; i�f 0 L19AC (Work) sy IIP NC 2rjo;;Xs Detailed Directions To Site: Property Address: ---sCA&\1C Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: Type Of Dwelling: K, L Date System Installed(Month/Day/Year): a3 Number Of Bedrooms- Number Of People: y Is The Dwelling Currently Vacant? Yes ❑ No a" te If Yes, For How Long? Any Known Problems? Yes ❑ No.O''— If Yes, Explain: Please Fill In The Following Information About The New Dwelling. Type Of Dwelling: ��1� ` Number Of Bedrooms: Number Of People: Requested By:o�W=4_ Date Requested: 3 ' y (v (Signature) For Environmental Health Office Use Only Approved l"Disapproved ❑ Comments: r.�D _1 L►- 1 r-� C� ls=� A �.S CiV r`�-N r.) ► .1 Environmental Health Specialist I--- , v / I ___1 Date �I I *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a I euarantee(extended or limited) that the on-site wastewater system will function properly for anv given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: Paid By: Received By: Account #: Invoice #:� Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002711 Billed To: P. Clark Williams Reference Name: Proposed Facility: Residence ATC Number: 3443 Tax PIN/EH #: 5718-22-7791.PW Subdivision Info: Location/Address: Hilton Lane -27028 Property Size: see map Cm - AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATT U VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur e: fl CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. ja M t�g �► Re-1-T- 0 Pe-1-r 0 53�` r_3Vu,1 Z Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) �Z3 1✓ i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 ,(336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002711 Tax PIN/EH #: 5718-22-7791.PW Billed To: P. Clark Williams Subdivision Info: (Q Z Reference Name: Location/Address: Hilton Lane -27028 Proposed Facility: Residence Property Size: see map r ATC Number: 3443 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type M• �DAA F, #People L— #Bedrooms #Baths �-- Dishwasher: 12"" Garbage Disposal: ❑ Washing Machine: d Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size s�Q`� Type Water Supply W12-. Design Wastewater Flow (GPD)OlSite: New 135o" Repair ❑ System Specifications: Tank Size1000GAL. Pump Tank GAL. Trench Width 2 L,�' Rock Depth 1Z Y,inear Ft. Other: y 1ST9-1 &)Tio,3`� ,5� r iS I4t-1- la S 9'o.c. moi. P/LPo5ttLa kc-- , 71Vt�i 61j2, �- `QQsG�.-� Required Site Modifcations/Conditio- OFFykC &- �� ck, Q� IMPROVEMENT/OPERATION (L. PE MIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Cot a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. o 1p.m. to 1:30 p.m. on the day of installation. Telephone# its (336)751-8760.**** 1;vc X YGE.f ��1 a r 1.1 taiiv Environmental Health Specialist's Signature: DCHD 05/99 (Revised) RZO. tia A Q; (3 r Date: APPLICATION FOR SITE EVALUATION/IM PROVEN! ENT PERMIT & r Davie County Health Department En14ronmentaiHeaith Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 D L APR 2 1 2003 I ENVIRONMENTAL HEALTH DAVIE COUNP.' ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. .•T. Name to be Billed R L: L R IL W LL.. i ! JM� Contact Person 22 Q 1 Mailing Address ?ORome ARA .Ih..� Home Phone :City/State/ZIP 1 •ItJ�✓IG�lfrcrG Ne "Ir2aag Business Phone 2. .Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ite Evaluation mprovement Permit/ATC Both 4. System to Service: House Mobile Hom Business Industry Other 5. If Residence: # People_ # Bedrooms # Bathrooms Dishwasher- Garbage Disposal washing Machine Basement/Plumbing Basement/No Plumbing 6. If Business/Industry/other: Specify type # People # Sinks # Commodes # Showers # Urinals ' # Water Coolers r IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City Well Community 8. 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: d80. O X WRITE DIREC'T'IONS (from Mocksville) to PROPERTY: Tax Office PIN: #J 1 pZ p� % 9i' - 12JT ON CIREOV HILL 0, a0 Td &t* Property Address:. Road Name H 1 LTO N LANE AGi-oc i A �"i. 1 '- a O FAST City/Zip_ CKsyl44J NCa'1 AoJE 8a/0GL-S 7/AX 6AN67WdI If in a Subdivision provide information, as follows: QA) Qin/E hemelwle 9.0 00"r r1 % 1, t1•: , Name: ; To SMY llA04i- dw -rar (.T. 6 O -to cm r HI LT -w . ��ffr'�5T artot ' Section: Block: Lot: Date home corners flagged: W15/03'"` 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 an: 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 '5T., oK, LZOLIJ to conduct all testing procedures as n cessary to determine the site suitability. DATE � I O 3 SIGNATURE THIS AREA MAY BE US FPR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, tructures, setbacks, and septic locations). Sign givens ro A3 Account No. ao Revised DCHD (07/99) I 0 Invoice No. T l SQ �A' P� �7 LEZ6 MZ0 (VOTOZ) W6000000zr zt000000zr V96Z g) 000000zr IEeLI d99T 9009 S _ DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Tax PIN/EH #: 5718-227791 Subdivision Info: Location/Address: Hilton Lane -27028 see map Date Evaluated. is— I I �3 Account #: 990002711 Billed To: P. Clark Williams Reference Name: Proposed Facility: Residence Property Size: FACTORS 1 2 3 4 5 6 7 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % Jr, HORIZON I DEPTH — I C) Texture group."L-- Consistence ( S S S Structure C-Vl CK MineralogyI: HORIZON II DEPTH I 1'6 l2__2_(,, ��- Texture groupG Consistence ; Structure Mineralogy 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE IO O SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE. REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 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 DCHD 05/99 (Revised) sa"& I W sa"& I