Loading...
1884 Liberty Church Rd , � . _, . . _._ .� . • � � DAVIE COi�NTY ENVIRONMENTAL HEALTH �jI - � �� P.O.Box 848/210 Hosprtal Street l�/� Mocksville,NC 27028 '�n�� '"' ' (��6)753-6780/.Fax#(336)753-1680 � ` .y� kk � OPERATION PERMIT � Acc�unt #: 990005739 . :.'��x Pl[�t.%EH#: 5813-11-2541 , , � Billc�To: Jason Parsons Su�idivi�iQrt.lnf�:� � . � � . .. ,� � . R�fer�E�ce Nam�: _ . .. . . _ ��:;L,ocationiAddr�ss: Liberty Ch Rd-27028 . F'roposec� F;��i€ity: �tesidential .:: ., ;: ,:; �� •,��Pcb�er�y�Siz�: 6 Acers � ., _ , . .:.;� ;.: f�TC Nu�rtber: 5818 . ,, , • **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. ' � � .�- �+ ' System Tyge:_�� S.T.Manufacturer bCt� Tank Date 0'7 Tank Size,�DGb . Pump Tank Size � � System Installed By:�(�(�F� ��i�,SD(�l E.H. Specialist: /t�c.,� Date:�/2. , � GPS Coordinate: T� . ' . . � `�� � � • . �. . � � . cT -/ . . � � . ' � ,� � , � . � �7 : � �� � " . ,......�..`� . �� * ` � ' ti�% . � � r � . �� � . 1 � . - . -� ��`�� . ` 3��,J C �3 � . , � � �' -�SZ' � � ' , o' , - , . DCHD 11/06(Revised) , . . • . DAVIE COUNTY ENVIRONMENTAL HEALTH '� �' f P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION }�cc��a�t #�: 990005739 . •.: '��x PI�/�H�: 5813-11-2541 Bifled To: Jason Parsons _ . S��irlivi�iorz Infa;:., . - Referer�ce Nan�e: _ . .. _� :LacalioniAddress: Liberty Ch Rd=2Z028 . . . Prapused F��:ility: Residential . :;.., ; ::=, �;.;.P�ap�:t �z�: �Ace�r� , ,,. . . < :. :,. . �TC; �g'g rt��ype: � ew epair ❑Expansion � ���1�����'I'his���orization to Construct(ATC)MUST�BE ISSUED'by the Davie County Environmental � Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G:S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT-IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat " or the intended use change. 1 Residential Specifications: #Bedrooms�#Bathrooms�'1 � #People�Basement❑ Basement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size�_ Type of Water Supply: ❑County/City [�Well ❑Community Well � System Specifieations: Design Wastewater Flow(GPD)'^1�� Tank Size�GAL.Pump Tank�GAL. U Trench Width� 9 Max.T ench epth 2� �� Rock Depth�Z�� Linear Ft.���OnU. Site Modifications/Conditions/Other: /i� �� 3 �2�"i6�"�'y� ✓ � Contact the Davie County Environmental Health Section for tinal inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. _ l�C�c��Q`�-Z��'►1,tq�c . � � ..� , f� . J / � ��� \ � O / � Environmental Health Specialist ' Date: � DCHD 11/06(Revised) ` _ ` , .�iuuo�e� ��� ' ' � . Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005739 Tax PIN/EH#: 5813-11-2541 � Billed To: Jason Parsons Subdivision Info; Address: 1884 Liberty Church Road Location/Address: Liberty Ch Rd-27028 City: Mocksville Property Size: 6 Acers � Reference Name: Propo.�s,���r�'�jt��e��d���j��ent Permit DOES NOT authorize the construction of a wastewater system, An p Authorization To Construct a wastewater system must be obtained from this office prior to the � construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: �New ❑Repair ❑Expansion Permit Valid for: �5 Years ONo Expiration � Resideutial Specifications: #Bedrooms L/ #Bathrooms� � #People�Basement0 Basement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �U�/ Type of Water Supply: ❑County/City �Well ❑Community Well Site Modifications/Permit Conditions: � S stem T e LTAR Initial � Q Re air ,� �� . � Site Plan • � `�� ! \� � � Jv , " � - � ' � � . Environmental Health Specialist � • Date� i.p.l 1-06 � - - . . � ; ' c� ��-/1 �a�-a� When '- _ : � . 2�y �o �� �: APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health `P.O.Box$4$/210 Hospital Street ` Mocksville,NC 27028 '`(336)'153-6980/Fax(336);753-1680 �� P�� Application For.�CSite Evaluation/Improvement Permit f I Authorization To ConsVuct(ATC) ❑Both l Type of Application: ,�Q�iew System ❑Repair to Existing System [JExpansion/Modification of Existing System or Facility `�1� g1 **'IMPORTAN7*'*THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed $�ON $ Contact Person f Billing Address Home Phone Q/n� - 7 � City/State/ZIP o Business Phone G� � 1 Name on PermidATC if Difj'erent than Above Mailing Address City/State/Zip PROPERTY[NFORMATION *Date House/Facili Comers Fla ed g �� �� NOTE: A survey plat or site plan must accompany this application. Included:X Site Plan (1PIat(to scale) (Permit is v lid for 60 mry wrth site plan,no expiration with complete plat.) Owner'sName l�� PhoneNumber336�i�1.�7321� Owner's Address City/State/Zipn'1�SV►{I� �tc. a�a�B' Property Ad ress i Ci Lot Size ,Tax PIN# � Subdivision Name(if applica ) Section/Lot# Directiorns To Site: TA+CE G81 N Ni�, r��les TWtN L,ef r- oara L.,,{,�-n, Chq,��� . . 0��1 •, MIICS '� ��4 j.�bdt� C�.�. 'futRN WTo 'FA�2!'�1 /lp If`E#+ answer to any of the following questions is"yes",supporting documentation must be attached. . Are there any existing wastewater systems on the site? ❑Yes�No Does the site contain jurisdictional wetlands? ❑Yes[INo Are there any easements or right-of-ways on the site? I IYes�No Is the site subject to approval by another public agency? I_�Yes�No Will wastewater other than domestic sewage be generated? LIYes ONo IF RESIDENCE FILL OUT THE BOX BELOW • #People #Bedrooms 1-{- #Bathrooms Gazden Tub/Whirlpool p(1'es CJNoo Basement:�(Yes ❑No Basement Plumbing: �1'es C]No IF NON-RESIDENCE FILL OUT THE BOX BELOW , - Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showets #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: �(Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:I:I Counry/Ciry Water �C New Well []Existing Well ❑Communiry Well Do you anticipate additions or expansions of the facility this system is intended to serve?f]Yes X No Ifyes,what type? ' � This is to ceRify that the information provided on this application is true and'correct to the best of my knowledge. I understand that any permit(s)or ATC(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. I hereby grant tight of entry to the Authorized Representative of the Davie . ealth Department to conduct necessary inspections to determine compliance with applicable laws les. 1 under d that 1 am r ponsible for the proper identification and labeling of property lines and comers and lo ting and ing stak' the h e/facility location,proposed well location and the location of any other amenities. P rty owner's or wner's legal representative signature • ' Site Revisit Charge � ' . ' , Date(s): � � � Client Notification Date: Date EHS: Sign given �Yes ONo Account# �/� ! Revised I 1/06 Invoice# �7' O `" � � � ____� � '��� '�� t !� 1 r � I --i---- �_,_� _ i�- - �.- 1 -_-�--- t �_ I ,- ---i-=�-- 1-- ' -- - ----� - - - -i- � � - �- � ---�---�- ,-- , , _ � '_ , � _� , ; ,� . , ; , ; _, ; __._ _.:.___�__ �_: -_--i-- -�_: --- ,_---,�- -��� �----�..._�_-�..--,----� - - �--- � ----- -!-- � - z!- � � __ _ _ ; � -�� , E i � � i ' i-� -i- -�-�. I -, ; , i , � ,. ;__-�--__�_� -! �-_. __ _�- �-- �-- -�-- ; --�- �----�.---+-- ► .�-- � , - j --�.i�__-� --- �-- �--� ._ , , � � I G� ; , ; � � ; � i �'�s���-( ���/_ ; � , ;: _� ( __!. .._ :.-- ------ �---�r- ! -�---'--_._a - -�-�-- �- ---�--..:_l.___a .__ _:_ ,__..-E— ' ----�.: ._(._/!._'_. - � � � - - � i , i � i �..__ �. �_ __ _�_. _ __ �-:__��_ , i : _� _+�_:_ � ._ _�__ �___a_. _� �_.� � _ 4 _ �___ � __ ;_._ �. __ . �____� _ _ _ __. �__.. , , i � � � � ,-. �.. �. � ` , � � , I �. � __�_ ( � I _._.__�-------- __. .:_._ _._._ ._ _._.� _-----._ ____-- - -.�- ---- --- -� - - --'- - --_ _._ ___�. - --- ___ _ .-- ; � ' � I I , �, � ! �� � __._� , � , ; , ; } ; 1 ,- , - , ;� , � , , -�----'-_ _��_____._..._�. �--__; ___�_,.._!._._.�-- �-�- --_�_ �__ _�_..__ -- = --- ' --- —i.- - - -- --- -- -- ._,..--- i ; � ;` ' � . _.--.� i _ �� r- __ �: 1 . � � � � � , � ...._ . I �---------- - -- � :'... .. ' . . . �__� . --, � � � , '__ [_ �_ �--..--� -.,._ __ '::_.� .--! ---A ---;:- ---.i ��._-1 i � i_ .�__ �_ �__ ;. __ _ _ 1___. - , _ , , , ,- _ __ __ , I � � , . , ; , , � . � � � , , , -+----I- �--`--- �- -�I--__ �_�_-i-- - �-__'-- '-- ---`'-- ----_,...._ _� ... � , _��__ ..- -- --. +__.. �__:L.. - —_L:---�---;---_�._.... I � i � � � � I ' � I I ! ( � i i � i � � � i � I � .:J 1---_ _ .-- - -- ------._.�_:___.. ,_- - --- ---�--- I , �_. ._I_..__! _1�_:_ _._ J_ .__. � - ! � . �_ � ! .__' _ � .. - -- -'-- _`- _ � � , , � , , ; .. _ _ _ �.. 1 ; , � . .__ ; � � .. � . � � � . _ i , � , � � -�-----_ �- - ' ' , ; --- --__ _____ -�_. i_._�_ _..� __� _1=... � i , � ___ -- .;:._ _..�,�_�___-�-- ;.___ i ' _ � ' i I , � i i � _E !_ � _.. 1 ___�_�. _E I___..__._�-__-�-�: �__._ _�__ � i a � � �-_._.�..- -�-- -- --,--� - __. __. � -_ _ .--�_�t _____ i �i ._ t � , � _ i � ; � __ , _ '--- - __:.�__ � � ,_ _..��_� - �.__..:.1__. ___�___I_�_ ----.. __ L__ _-.-�- --' - - - - ��-_.__..__ }!__ � , �--= �_:_. i _:_. _.'--.. �:__ . _ _�_�_ --�_._G,S?r'S,,.S'_�__—_�._.- ---�--- ' � r. ; , , � .-!- --I-- � 1�;___ 1 � ; . ._� � � � �! � , � r '�5,� __ ' _ � , _ -.; -- i .. � � � . _.._ � ._� --1-: 1 � : , _,:.Q���� _ _ � � i , _._ _l_._.._ __--1_.. �_ ,_;- -' -.-- -- x '--� _._ � -._. ; -�- --- -- ' _,- -�_!_.�_ .. .. . _.�._. , �--- � I - I - - � I ! � h � i ( I i � , i , 1 � � ' _ ,.. _.. _ - - -=:._ __ � � �; . � I ----� ___ ____ _. _�. - —._._ _ I - ,---- ---- ._..._ _ ' �4_4 _ __ ---- 1_.__� L._ � -i---! _.; . , i , � , - _. ._ -- -----�:__._.-------�--._. ----.. _ _:.-.I___. -----:--�1-,---. ___�,----�- ------- .�_.-_� __- --. - - �- _ � - -.�1�_--.� _!:�.__ I., ' � i I � , � � ; I j i ,_ � I ; , � , � � � �-- -----1.____� __ � ,. , --��_ _� .__� i�-- � �._"" / `- --L i_-_ J._ __ __._ � � � � � � � f , i , , --� --__1 _ _ __ :_,:_._ .� _,___. _._,.- �::-�_ - --. � ._C:. � _:_� -- - -�_ �-- ---� ---, -{----r _-_ � � , � � -- -� ___ .__ � . . ' i I � i �. � ` '+ � '�6 a.l-';�� �9,� ' ' , i � ; i � � , �_ __--------._.____ � ___i_� .._ . --�_ _-__ ( _ _._�.:� �----�� -- ' __I_ � _ ..__ � �___' _ ___�-_.__I__ � �_;�_ .___'__� � � ; � I _ ! : � , i _.�___ � _, � � � �_-- �.�__. _. - � � � � - -��-___� -: � - � � ; � � � , ���-��--�----'���� ��---- � � � ' � ����� � �---. �._ __ __ , , �_.--. . ��-- ---�--�-_�_- _�___ _____�: � �.__, � � �_ �i._�___..� . . .--- --._.. � _ _ _�____,�-- , _ � , , , ._ _ �.:- - , --._--�--_- �--�� , _ � � , ; , � � -- i— ` �_- - -�-- ' �---- ---- -_J_.._----i._- --- ; - � a-- �._--- . .__� .::_l_._ �— �----) �---- _ ___.._ __.__. � , � ; i � � � � ' � ' � � i r ---; ; , � --__;_ ..' ,- - --:__ .___ _,,___ _.__;. ��__ �_ ._�-- --- � �:_._..._- ---- � -�-._ �_ _-� -; -- --- - � f-- -� - i �� � � ; , , , - - , � ; ; � , -� I i �� , -- - .___ . --�--.- ---�--j---�- - ----- - - -�--- _.�-- � �----�----t�----�--- -- _�:__.: _�.__.�---�-- � , - 4- -��--- - � -- , , j i � ;,p ; t- � � i � � ; , i ; , � � _ _�_. _!:_:_..�_�i---.: ��._'l/�- _: L--_I_ 1 :_.I---.:� --- -. -�:- -- -i------ �---- --�---�-- � ' --�--- ' - `--- _._- -----� - ---- �� - - � � i � ► ; , � I 4 ' - , , i ' I -----_i. ___�.__�:____�__ �_---'`C ---- ...-'--�---�-----___�. --�--_�_._ � - � -- -_ _i_—� _��._I-- - - -_... ; , � i � � , � -_ ; , , � i.- i._ ' , � ; -; ( � , � , ; , ---.-____�--�----,--- -��__:_ __.�_ _ ___ __�_.. �_-�---�_---�----�--! -� - _ --.-- __�-.-- -_. _� --�- -��--------_�-- - _- , � , ; , , , , , , � � � � , ' ' ' ' � ' � : l �_ i^ � � '----.�__� � � .�_--- ---- - � I--� + -a---�----! ! � � � � � - --,--� ;- -�,- � --;--- ----�--- ---� --i ; � -;- � � - �- -� ;---,-----�-_--, __._ _.__:_ t_1- -;--E . .__.-_;-- --1- .,---�---�----� ��_�_- -�- ----, --;_---�: .--� �- ;--- _. - � - ! � - � -� - __ -�- ---- ' -'--- - - �_ . _-- --- _ ______ __--t _._�- -- . _ _�----- - __--� _ � �-----�_.:_�--- � -1- - - � - , i , , � � ; i � � � � ; - ; , _; ----; ; � � � � , , � 1 ; i I � � � ;- , � , ; -- .a._ _I_ � � �----I �---- - -_ i__.l_.-�.- ' --- � -;-- . i ..- �-- --.i - - ---1 --- ',---- -- --i_ _. !---._ � ._:. __.._�. .:_ � � � � � r ,___. : , � � _ � I i , � � _ i ' � ..�� � , � I � � . - - � � -- --I---��-- -- _i ___._: _.___ ;---�--...i ,..--•---�-- _---�- - --,,� .,_._ �__._ � � _ � � ( a _. --- - � � ' ' ' ' � ! , ' ; � , , f �: � � � ; j i � � � i � _,__ _,. _._ .- -- - -- ---�---� ---. ----- ._._I_:_ .- -L --- --- -- --- - -- -- - _�_.-�-- -- --- - ----- - ---- � � � , ; , , ;- . � � I � ��� � � ; ' _ _�. . _ � , � , , � ---_ _,____ __. ___ _._ J---.- -- --- _t__ ._ ._� _�-----�- _:___ i---�---� -- � -�- - --l__ . __�_- _--�----- � _^__ � ' � . �. ; _ � . _�____.�__ .., __' _--1-_-_ ' _��_.._' ____ ' I � ' ' � � i i � _' _�---. .___ _-•- --_..�_._..__.1 ------ ---�-I I I � a.-� ! -- - - - --- � ._._ _....------ � �, , I ' � � � i � � � i I � I � I ; i `, i , : , I -''-��H`--- •-'_ _.._ - ---�----�-.__.a _ _-- �---.._1_:._..1 . .._! ,--...�-_.1 ----�_ �---- i___... i _. ._� �_._._�_ ..� _. _ ___ � i ` � � . , 'i .-'_ I 1 � -._ � ` . �. � � , � i � � :'"�_:_ _... ___ ! ._..�. _-�_._� __�...__.�._ :�_: .�_._ ' I.:__i _.. �:_:_ � �-_.._l:_._�__.:_�_. ; .__,�_ i_�_; .__, ;�_ i ; L _ ._- --- , ; ; i i �LtwL� I � I. ..._. . ._ � . ' , `1 _..,. . I I + .. I . . _ _.._ �.__.._., �1_'___" '__.. .__ ( '"' �_.�_' i i � �_ I__ 1 �_ � ___ � ""j I'""� __i�_.. � __._I_' __! _ ).....__ _ ' _'_ ; ir881 ; , . ` + __ _._ I .._'. ( � � � ; � i � i � � � i I , i � � � � � " i i i „� , ; � ;; � i i i � � ' � �,� ,. � ��� �'�;� `i ' � i____ . ,. 4 ; . . .i � i I � � . �i . ! � f . I �� � . � � ��� � I _._..�.-- I--- � ( �-.__I���_ L_..�..1.__ ' �._�.---�--- _ - _I __�l �-- ; � : -�--�r- - ...__._ ._•.___._. I .• ' � _. .._--... . . . . Y..� , �-- . . �- . -. ,- --' , � '-, �-"-- - .-'- . 1 4� � . � � � � � .. � .. � � . . . . . . .8 � � . .. � . � � . . �\�$ � � .. .. � . . . k ��e 188 F� t�µ �� � �� � , �} �� t �� ��x � � � `� �;�� �:��" ,�"'��—.�,-- _ � � �. ��. ��►�D'f'C �"3,�CC$$ �� ;� z�,��,��n�-��- x �� k.� �n�� � :Y'�° � �� � , _...� r ,•��r'�,���x'��F�� t � ��� �� �� � ������ ������ ��. �� ;� _ �� �, � ��� f� �H�. � .� "�� � � �,�` � ♦,� ''.i�' ��'r'/ ��� ���� �'' �,'' � ��.�' r !,`.' ��. �>�' � �.%/,• �E,',,/'' ;�/;.�; �`yL :�r �� } `��'' =;�'�`� i.`.� /..��'�, �' y yA'�n �,.�'#1 J LIBERTY CHURCH RD'�'' \'¢4 1 iJYF ::I� I'� / � � � � � . /,` / !�! f } "�" / .��./�,�, � ,rf"`� ,!�.� /" ��; s'' !;• . . � y} �s�, . � �//y'�� j�: � " �l/�''�r . � � � f � � . .��f�,,✓!' i !��� f� :� � . . :� .. � :� �f '- ,,,�'� � � �,: / r f: , t ��.r/ z� > y �k t�� �`'r�����`f�f/,� �f.'`��r ; . k �,.� �k��,� �eM`"'m,� . ��� .e�'�� �.� �'���"ti.n"",,,..,,� ''�/J f�'' 'y ^ . . . ��' ''� �. ,�ag.,��� � 3 ��c.�v�'" . . . � �'+ret ���� �+,�� � ��� � � �� � � ���� � � �� z�� a � "`«,��� ��� ��s a �O"nr � _ ����. a �+'�����'� �'�����s. � . . . . � � ��k� a� �'���� ������ � ����� � 1 � � ������ � ������ � . . � � e '��� Q 8 � ' �1�������� �����ti �� ..c,a�L�x �� �.. . +� �. ,',. ��.�..�'r .. '��., �''�'--..._ __. ...: �. r..i. �. '.. '��� �.: %°.: __ ' ' ri`1�'5,�� jy� ` �. ��t jr� p�,ti �F,�I{,� �I' - __- 1�� FCj`, �/t' -�. r"` � kL l� �`�t5ti� r 1�� I 7 ____-_-~�T � 'Q �_ �� I ` �� �� _ �� + -r��y�t i' / - �� � �� -- +I I S �, � /�-7 f°2c7F�S�p � ��'� �y �—J H��SiT,E �� �� ''� � � �s �k �I�I ��1 'i � �\ � 9r'��So L ���� �� �� �� y� I� � i i' �\ �}�� ii � � � iill � . � � I� �\ \ III �� �� 1�: .`, ` I ti � `--_ � --- - i -- �. �' -_ �ii I� " j"=�`\- ' #.27 LIBERTY CNURCH RD � n� i I � I -.h.- II - �'�____—__� ^ `^�-- __ __�� _J �__�- � � .,' \ f � _ I �� � • i� i��� y �� r �1 ��� j .�� `-� S_�.� I �'� 1� - _ f� '� - _ �� __� }� r� r ,` �� i �\ � � .. �. . , , , ' �' �� � � ' ' DAVIE COUNTY HEALTH DEPARTMENT Environmentai Health Section Soil/Site Evaluation APPLI NT INFO MA ION PRt,I� ERTY INFORMATION Account #: 99 005739 Tax PIN/EH#: 5813-rr-z Billed To: Ja n Parsons - , Subdivision Info: Reference Name: Location/Address: Liberty Ch Rd-27028 Proposed Facility: Re idential Property Size: 6 Acers Date Evatuated: � Water Supply: On-Site Well Communiry Public Evaluation By: Auger.Boring Pit Cut FACTO S 1 2 3 4 5 6 7 Landsca e sition Slope% . o v HORIZON I DEP"TH Texture rou G G " Consistence -� Structure _ Mineralo "� � HORIZON II DEPTH Texture rou 'i 'G . Consistence % Struc[ure Mineralo HORIZON III DEPTH ' Texture rou • . Consistence � Structure / Mineralo HORIZON IV DEP'TH Texture rou Consistence Structure Mineralo SOIL WETNESS " G '� RESTRICTIVE HORIZ N SAPROLITE CLASSIFICATION LONG-TERM ACCEPT CE RATE ,22 SITE CLASSIFICATIO � EVALUATION BY: � LONG-TERM ACCEPT CE RATE: � � ,_ OTHER(S)PRESENT: . '�C�S�/I. �/c�s REMARKS: �! LEGEND i,andscaoe Position . R-Ridge S-Should r L-Lineaz slope FS-Foot slope N-Nose slope , CC-Concave slope V-Convex slope T-Terrace FP-Flood plain H-Head slope • � . � ' � S -Sand LS -Loam 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 S'ON I�TRN . , II'IQist VFR-Very friable -Friable FI-Firm VFI-Very firm EFI-Extremely firni � � � NS-Non sticky SS -Slightly sticky S-Sticky VS -Very S[icky NP-Non plastic SP Slightly plastic P-Plastic VP-Very plastic �� SC-Single grain M Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic lyIineralo� . 1:1,2:1,Mixed 1Ysits� � Horizon depth-In inches ' Depth of fill-In inches , ' . Restrictive horizon-Thic ess and inches from land surface Saprolite-S(suitable),U( nsuitable) ' Soil wetness -Inches fro 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) TTAR -T.nno-term arrPnt nrP ratr_ oal/Aa��/ft7 r��rm ncinc m__.:__�� i _. � ' , . , ' -� •.� , � � Davie County Environmental Health � ' P.O.Box 848%210 Hospital Street � �. Mocksville,NC.27028 � , (336)753-6780/Fax(336)753-1680 WELL PERMIT � � Accou�i #: 990005739 . '��x PI��EH#: 5813-11-2541 - �iile;d `Co: Jason Parsons .,.- SuE�di�risiort In�a: ' R�fer�E�ce Nar��e: ., �� . . LocationiAddr�ss: Liberty Ch Rd=27028 . �.. , . . , Pro�c�see3 F�ci€ify: Residential �, ; ,,; � `-. : ° Prn�er#.y Siz�: 6 Acers , :-� � ' °�„ , � °�Actions o�f th�mpI yees of the Davie County EH Section sHall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any facdcircumstances upon�which this permit was issued. , Permit Type: New� Repair ❑ Abandonment ❑ Proposed Well Location Diagram . Certificate of Completion Diagram � . �\* . d�'��`l+ � �X , I� . _ �5 � V 1r � � � � �k . �� t . . � 1.G _ � . � � � � . L � ��Q , I /�, ^ � Comments:�Q /VE� Driller: .� j � . �1' �(� Certification#: �o�J 7� � Grout Inspected:���5/J .�� Well Head Inspected: �(p•D�.y�//�(�0°�9 2�f,� GPS Coordinates: � EHS: U Date: Q�l EHS: Date: � . �3C�/l3 /�?�i���G�v�G, D� T - � � Z2 �J w.P.�-os �. : j I�r�S��-�� ���I�.�.l� , ���(° p� , � � • . -. -. . �. ��W� PLI ATI N FOR PRIVATE WELL PERMIT � AP C O Davie County Environmental Health /�,.�� `� P.O.Box 848/210 Hospital Street �'�/� � � Mocksville,NC 27028 I'��� (336)753-6780/Fax(336)753-1680 ( ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION � �— ����5 Contact Person M h5t-�--� Name - Address 8$ � ,e�. Home Phone 33l0 �4�� ' �3�'� City/State/ZIP oC�GSU �' NG a.��aB' Business Phone 33�-�/03� la.'1 1 Name on Permit if D�ferent than Above Mailing Address � �`+ �.��Ja�'E+..� G� City/State/Zip u c. NG 7 0�4" PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or�site plan must accompany this application. Included: � Site Plan ❑Plat(to scale) Owner's Name 5o•a � A'L��S Phone Number3 3�'�'9 2'��� Owner'sAddress )gg� �.,►�i.-r� Gn City/State/ZipMaCIZT�1u-�E Nc- a�O�B' Property Address City Lot Size �qC.�s Tax PIN# J� (3� ��.� � Subdivision Name(if applicable) Section/Lot# �3K �� � �82 Directions To Site: Hwk l0�1 I� -�wv+ o�a l�►►x�-r�.C�. 2.�- Aorxb�- S"�►vles bn+� DEVELOPMENT INFORMATION Permit Type: New Well__� Well Repair Well Abandonment Other(specify) Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On T'he Site? YES NO ,7� Do You Intend To Install A New Septic System On This Site? YES .>C 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 specific 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 mazking the property lines and corners. The applicant is responsible for making the site accessible. 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 determine the best location for a we1L I I ►� - ���� Signed . Date Site Revisit Charge �j Date(s): c��" Client Notification Date: `/I \ EHS: " V 7/30/09 ,j�`� Account# 0 � Invoice# � �� � � � � ��'I���l�-��-iv� �-�• . --- I� '�, I � 1 1'�'�� i ��^ � S � �� ----- � '� 1 �`��, ��— � ,�,.., _ 6 Acres E � , , i�y �,'15 � . � � __ i.:.�N:�l.. f. � �i� l �.,.1�1::_;, I �� I ,1\ 5 � l I •-;L �` \ �`t l - -� I I = r � , r �r � ,,;; —._ �e� � .,'� ;: �' ` -- r ��'�- � __,�' � - __ ; � �'y,f � , ;� � .,'f'�.,y � } , �` . `#27 LIBERFY CNURCN RD �`�'4 ti - t � � ~� _ ' � ,t: � i � � ; �� � � , ��1 =� � � .� —_�_ __ ._ __ —� ----- __ ���,-.-�.�� I _- l � l I � ,� ��. -'� I � -�� ' ^ .. . 4�j !� • . � � Q � � � . ,�- �. " � � � �s-t S�wQ�-( ��Fl � � � � - + � � ti . �. . � �' .� �� ' ; . � _ .__. _ ., _ - ._ __.. _. b __ __ . __ . � _ . ..1' ..._ . :_. �.. ,.. _ ��� " � ���� � � '. __. .: '_.. � . _ _ . __ -- _._ ._ . ;. _. ���,� � , � ��� . _ _ _ .. ��S ,� ' : �z:; ' . _ ; _ _ �` _ ti , � � . . • � � Gs x�.� ...� r �s�l'1 � .......-- �: � a��d . � r - � ._ - :,�, � � 4 , . __ , � � ��o e�- �h3� o►� • � . � ,� t � � � _ � � � _ f t� � ' _ � _._ - � 3s'NeH S-N�'►'.� Ot1 H'� ' � �l �tS�1'f � tr88! �,.-" , , ; ��� 1�,3:�t'j ��' ' : :. , ,, ., � : ," � aa'i.s51A1F"y ' . . � . �� w���,a �' � # � •��.�`�� �• ����� �ESIDENTIAL �VELL CONSTRUCI'ION RECORD • �/ �`'�- .: �� �,�+.����c°� Nortl�Carolina Department of Environment and Natural Resources-Division of Water Quali��C E I�/E D �ti,.,,� 4� ���'.r"��"�� �V�LL CONTRACTOR CERTIFICATION# o����'�' JAN 12 2012 1.WELL CONTRACTOf�_`� J g. WATER ZONES(depth): � JC�U �� � . Top_�Bottom PZ( �Top Bottom . Weli Contractor(individual)Name Top ��Y Bottom� Top Bottom YADKIN WELL COMPANY. INC. '- ' Top �'�8 eottom l�o( ��p Bottom Well Contractor Company Name Thickness! 1908 HAMPTONVILLE ROAD � 7. CASING: Depth �iameter we�ynt Material StreetAddress � Top�_Bottom_�Ft.b•�� sa(?�t ��/'G HAMPTONVILLE NC 27020 : Top aottom Ft. ' City or Town State Zip Code Top Bottom Ft. c 336 � 468-4440 � Area code Phone number 8. GROUT: Depth Materiai Method 2.WELL INFORMATION: �7"� SBCS'_ Top v Bottom_�Ft. �-��'� ���-� WELL CONSTRUCTION PERMIT#,�����- .2�fi�� Top �� Bottom 3.� Ft._f���'T�,�, �f''� _.� � OTHER ASSOCIATED PERMIT#(if applicable) Top Bottom Ft. SITE WELL ID#(if applica6le) �iQ-� - �S� 9. SCREEN: Depth Diameter 51ot Size Material 3.WELL USE(Check Applicable Box): Residential Water Supply� Top Bottom Ft. in. in. DATE DRILLED [ -5~"�t°� � Top Bottom Ft in. in. � Top Bottom Ft. in. in. TIME COMPLETED S ��' AM❑ PM�r . 4.WELL LOCATION: 10.SANDlGRAVEL PACK: �� / t Depth Size Material CITY: !'/r� .KSV��II t� COUNTY Cl /ei. Top Bottom Ft. �,'6,��y �� ,��(`� ' Top Bottom Ft. (Street Name,Numbers,Community,Subdivisfon,Lot No.,Parcel,Zip Code) Top Bottom Ft. : TOPOGRAPHIC/LAND SETTING (check appropriate box) • ' ❑Slope ❑Valley ❑Flat�Ridge ❑Other 11.DRILLING LOG . Top Bottom Formation Description LATITUDE ��,°��"DMS OR DD : (� / CC��� , • ' ��,�, —��, - , I.ONGITUDE •,�{(�_°���"DM5 OR DD : _�I� rn'��`�`` "t'd • Latitude/longitude source: �PS Qfopographic map -��� ��r � � ������ (locafion of weilmustbe shown on a USGS topo map andattached to � M'x� fhis form if not using GPS) � � � / 5.WELL OWNER � —��C1 �cr�S o/IS � � Owner Name >�FrSI 1;6u �y �/ /?� � i Street Address � .�CC/i'S t/.�II�, .NC l ' City or Town • State Zip Code / �� # � c336 , �q� -s�5a 336- �03- ra�� � �� � � �`�� Area code Phone number [���_���/1 �- •7� 12. REMARKS: 6.WELL DETAILS: � �a� a. TOTAL DEPTH: b. DOES WELL REPLACE EXISTING WELL? YES❑ NO� ' I DO HEREBY CERTIFYTHATTHIS WELL WAS CONSTRUCTED IN c. WATER LEVEL Below Top of Casing: 3 � FT. ACCORDANCE WITH 75A NCAC 2C,WELL CONSTRUCTION (Use"+"if Above Top of Casing) STANDAROS,AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER. d. TOP OF CASING IS � FT.Above Land Surface' *Top of casing terminated aUor below land sutiace may require t�'�[!I Z a variance in accordance with 15A NCAC 2C.0118. ATUR F CERTIFIED WELL CONTRACTOR DATE e. YIELD(gpm):_��METHOD OF TEST G[« ����'f' � �f Yl/\�`� ' 'f. DISINFECTION:Type HTH �. Amount � Cu S : PRINTED NAM OF PERSON CONSTRUCTING THE WELL Sub'mit within 30 days of completion to: Division of Water Quality- Information Processing, Form GW-1a 1617 Mail Service Center,Raleigh,NC 27699-161,Phone:(919)807-6300 Rev.2/09 Date Site Visited )1- 3- !I By: M�Permit: � 1Vo�� � � �C�Gt�l �o '!� What Is Height of Well Casing? Make Sure 12" Above Ground Level! ! ! ! j-� �F y :,� ., _. ,� ., .._ / f. , y �, A BTT�7�'�r{�[+ 7�77��/�'� � . � .. . . . . . �;, • � '� . l,J1.L.1L1i147'.LVt11.'1L'l. . .� . . . . .. � . . .I ', . � ADDRESS• , , PHONE NUM:BER: �� ,, . �on� � . , N, il�,�r Y . .� �, b �.� �,� ; . C� � , � . �,� I b0 �� ` �- � • , -,a� t,1t ��� � �--- ___ ` , O'��\�c�" pL`\ es�� � � � t �� ���� � ��� �� �r I � � . �p � I q ,�/,.�f'� �`� � � `� a; , O . �c,u ,`hb` � ��I � "o � 1 •� �� �' �� � �f °� ''� - � , �..�_._. o � , ' ' . � . v �` ,x �� �I�gH \� ' ` . � ( �'�`� � � �riGy. � ' � ,`l l � 1 � � • . . (� L�� � l/`'�``i �r�vG� .D����.wqr �d ����� P O.Box 28047 North Carolina State Laboratory Public Health 4312DistrictDrive � � - Environmental Sciences Raleigh,Nc 2�s„-ao4� http://slqh.ncpublichealth.com � '^�an� . Microbiolo Phone: 919-733-7834 "Qe«,,,�„�*' gy Fax: 919-733-8695 Certificate of Analysis Report To: Name of System: RECEIVED DAVIE CO ENVIRONMENTAL HEALTH JASON PARSONS P o Box 8as �����`��°����__ JUN 0 �+ 2013 �� 1884 LIBERTY CH. RD. MOCKSVILLE, NC 27028 ���`� MOCKSVILLE,NC�27ozaDC HEALTH EIN:566000295EH COURIER#:09-40-06 ,�, ��,� �` � " � x x ��� StarLiMS Sample ID: ES052313-0077001� Collected: 05/22/2013 11:00 Andrew Daywalt ������������������������������������������������������������������������������������������* Received 05/23/2013 09:10 Angela Heybroek x����� � � .��_.: �.�, ,�"""'x � ES Microbiology ID: °�Sample�Source: �New Well ��� Well Permit Number: GPS Number: 36°01481 N � Sampling Point` "'Outside spigot 91 � 80°39.266W f� � �'� � � -f ���.�� �� �� �.. � � Sample Description: ��' �; Comment: ,r' � � � Environmental Microbiology-Colilert Profile , 4 .Method;� SM 92236 _ ..� Test Name: Colilert ''�`n'� , , � Analyte �'�` Test Result Analyst Date Total Coliform,Colilert r-�-��--�-�-�Present - --�i ---�----'- —�---.-K��—=�_--���-�-._-�--���LLHLBRASWELL 05/24/2013 � ' � HLBRASWELL 05/24/2013 E.coli,Colilert r� � sent y j ,: ��; �� � � r � ���� �. � � � l. � � .�,r y � � , � � �., � � k � �� �4i�......8 ���' �( �......rv=b>..{ � � � +-...._~-, & u�k.� �+b `�L.r `".t_�t4�a 6.,n �,. s �c.J � � g � p`- � �--� �� � ' f F �� Y� l � � /�F�'� Y � � �s �; �F 3 a � �' . � �. ' ^ �j � �w j ; s k i '�`'" � � � —a�::i�r � � � � ; � ; � , ; _, ° �� � � �� � Re o�ted�B Susan Beasle Report Date: 05/24/2013 a.� ���'�a ����� ��..�:.. ��:�� �� I�� ��,sa�::��;�w�. '�.. TP��_. �__ Y� Y G��,'�/��,� 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. �lli�Pl,� 1'�su.�� ��� �d��p� � North Carolina State Laboratory of Public Health 3�12 Di trict Drve � Environmental Sciences Raleigh,NC 27611-8047 http://sloh.ncaublichealth.com �. �.a�" . Inorganic Chemistry Phone: 919-733-3937 `�c�,N,�'' Fax: 919-715-8610 Certificate of Analysis Report To: ANDREW DAYWALT Name of System: �������� DAVIE CO ENVIRONMENTAL HEALTH JASON PARSONS ��� i � �0,� P O BOX 848 1884 LIBERTY CH. RD.�C HEALTH MOCKSVILLE, NC 27028 Courier#09-40-06 MOCKSVILLE, NC 2702 EIN: 566000295EH x�,: "� ��«_;<� StarLiMS ID: ES052313-0047001 Date`Collected: 05/22/13 Time`Collected: 11:00 AM ADate Received: 05/23/13 Collected�By: Andrew Daywalt �, Sample Type: Sampling Point���'�:Outside spigot Well Permiti#; 91 Sample Source: New Well Temp: at Receipt: 3.5 '� GPS#: 36°01;481N/80°39.266W Sample Description: " ��" `�M1r '�� ��,~� � �� � ° +„, a ��"'� � � Comment: 05/23/13,0910 � � �,� � � � � � � � � �� y � New Well I (Profile) s' � � ay_ ,- � Analyte ,��` Result Allowable Limit Unit Qualifier(s) Arsenic <0.005 0.010' mg/L Barium �°`�F <0.1 2.00 � �mg/L Cadmium ' <0.001 0.005 ,;:� mg/L Calcium �F� ,6 „�_� mg/L Chloride ,�' <5.00 250 �mg/L Chromium ,�i�'' <0.01 - 0.10 {, mg/L Copper ,��.�__ ��_...___�_ __.�:��_.._�.<<0.05.�,,._.._._.�.::��__ .�__:ro._1.3:��._ .._,: �.w._ ��; mg/L Fluoride �., 0.21 4.00 mg/L Iron �� �� �-. � < 0 10 �:� �0 30; �' � mg/L Lead �; , �` � , �'�''-=� _� <0.005 � � �`; ��''•�;0 0�5 � � '� x i mg/L ry � � � � � Z � ' Y { � i 7, �j 7 � � P n'�� . i t e 3 � � �` �1'Yl /�. M8;�t1@SIUI71 C. __. "w.� L, 4 ��_� s� � a �r3����; �.. �<. � �`�,t� e.�� L 9 Manganese x� �¢� <0.03 � � 0.05#�. `-mg/L Mercury �` "� �, _ �<0.0005 $�" ' 0.002 �� mg/L Nitrate ' . � �� �� � � ��9.OQ� � -�� ,� ��.w,`� �10.00�� �� .,' mg/L Nitrite ��n; �.. 'i�, w__ 4 �<010; � ° �:� � .._�; 1.00��_ ` . ._� �a mg/L pH �.._,6.8�.._- ._. _• N/A Selenium <0.005 0.05 mg/L Silver <0.05 0.10 mg/L Sodium 7.30 mg/L Sulfate <5.00 250 mg/L Total Alkalinity 37 mg/L Total Hardness 25 mg/L Zinc 0.05 5.00 mg/L Report Date: 05/31/2013 Reported By: Arno/d Ho// Page 1 of 1 i , � i �`,1`M .� , 19�� ANDREW DAYWALT, REHS Environmental Health Specialist � P.O.Box 8d8,210 Hospital Street Mocksville,North Carolina 27028 : Te�ePho�e:csss��ss-s�8o tate Laborato►�/ Public Health P'�'Box28047 Fax:(336)753-1680 'J 4312 District Drive �e-mail:andrew.daywalt�co.davie.nc.uS �prpgrjta� SCIel7CGS Raleigh,NC 27611-8047 httn'//sl�h.ncnublichealth.com DAVIE COUNTY HEALTH DEPARTMENT M i c ro b i o l o g y Phone: 919-733-7834 Fax: 919-733-8695 - -" --�-��ertificate of Analysis Report To: Name of System: DAVIE CO ENVIRONMENTAL HEALTH JASON PARSONS P O BOX 848 - � 1884 LIBERTY CH.RD. MOCKSVILLE,NC 27028 MOCKSVILLE,NC 27028 EIN:566000295EH COURIER#:09-40-06 StarLiMS Sample ID: ES052313-0077001 Collected: 05/22/2013 11:00 Andrew Daywalt ��,IIIlIIlIII'llllll,l,l�l'll"�lIIIIII,I'II�IIIIIIIIIIIIII,IIIIIIIIII Received: 05/23/2013 09:10 Angela Heybroek ES Microbiology ID: Sample Source: New Well Well Permit Number. � GPS Number. 36°01481N Sampling Point: Outside spigot 91 . 80°39.266W � Sample Description: Comment: Envlronmental Microbiology-Colilert Profile � ' Method: SM 92236 Test Name: ColllerE � Analyte Test Result Analyst Date Total Coliform,Colilert Present HLBRASWELL 05/24R013 E.coli,Colilert sent HLBRASWELL 05/24/2013 � Report Date: 05/24/2013 Reported By: Susan Beasley �'�'Lt��-�a.�.ee,�-r� C' ' 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. -� � (� ,4-r J�� �.�,��� � �3 �