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569 Markland Rd OPERATION PERMIT or ice se ny . Davie County Health Department 'CDP File Number 188136-2 ~ - 210 Hospital Street P.O.Box 848 .County ID Number. Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Todd Zimmerman rAdd roperty owner: Todd Zimmerman Address: 5204 Mount Hope Drive ress: 5204 Mount Hope Drive CkY _ Winston-Salem ly Winston-Salem State2ip:' •.`, C.:P-� 27107 State/Zip: NC 27107 Phone#: x.(336)671-2768 1. Phone#: (336)671-2768 PropeEly Location & Site Information Addtess(Road #: a, Subdivision: Phase: Lot: Markland Ro Advance "`` " 27006 Directions Structure: .SINGLE FAMILY Hwy 64 East, left on Hwy 801, left on Markland Rd across from William Ellis School. on the right. #of Bedrooms: #of People: *Water Supply: NEW WELL *IP Issued by. 2140-Nations,Robert *System Class ification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP *CA issued by: 2140-Nations,Robed Saprolite System? OYes ONo Design Flow: 2 4 0 * PUMP TO GRAVITY Pump Required? Oisttibution7ype: ( Yes QNo Soil Application Rate: 0 a 7 5 *Pre Treatment: Drain field Nitrification Field 8 7 3 Sq *System Type: INFILTRATOR QUICK 4 STANDARD No.brain Lines 4Instaper: ChadesDriggers 4Total Trench Length : ' a a 0 1&35 Certification#: x Trench S a m Inches O.C. P g — 9' gFeet O.C. EH S: 2140-Nations.Robert .. ,. Trench Width binches Feet Date: 0 8 / 1 1 / 2 0 1 6 ''Aggregate:©epth: inches ' 1 dJY T Minimum T,,,nch Depth A3 < 6 Inches Ainimum Soil Cover . a 4 Inches APP alhStatus` ... _ Maximum Trench Depth: 3 6 Inches ® Approved Disapproved Maximum'-Soil Cover: a 4 Inches w _, CDP File Number 188136 -2 Septic Tank County ID Number: Manufacturer. Shoaf Let. STB: 760 Lang: Gallons: 1000 Installer Charles Odggers Date: 0 6 / 0 1 / 2 0 1 6 Certification#: 1845 *EH S: 2140-Nations,Robert *Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker. El Yes D NO Date: 0 8 / 1 1 / 2 0 1 6 Reinforced Tank: ❑ Yes ® No Approval Status , 1 Piece Tank: ❑ Yes L7 No ® Approved❑ Disapproved Pump Tank Manufacturer. Shoof Installer Charles Driggers PT: 363 Certification#: 1845 Gallons: 1000 *EH S: 2140-Nations,Robert Date: 0 4 / 0 9 / 2 0 1 6 Date: 0 8 / 1 1 / 2 0 1 6 RiserSealed Q Yes ❑ NO ---------------- Riser Height: ® Yes ❑ NO (Min.6 in.) ry Approval Status Reinforced Tank: ® Yes ❑ No ® Approved❑,Disapproved 1 Piece Tank: p Yes ❑ No Supply Line Pipe Size: 2 inch diameter Installer. Charles Drigers CPipe Length: 3 1 1 feet Certification#, 1845 THS: *Schedule: 40 2140-Nations.Robert Pressure Rated M Yes ❑ NO Dater 0 8 / 1 1 / 2 0 1 6 Approved fittings ® Yes ❑ No Approval Status ® Approyed DxDlsapproved Pump e e (' Pump Type: zoeler Installer. Charles Driggers Dosing Volume: — Gal Certification#: 1845 Draw Down: Inches *EHS: 2140-Nations,Robert *Chain: STAINLESS Date: 0 8 / 1 1 2 0 1 6 Valves Accessible El Yes ❑ No Flow Adjustment Valve 0 Yes ❑ No Check-valve ® Yes El No Approval Statusj" PVC unions 0Yes El No ❑`,Approved❑ Disapproved Vent Hole E Yes ❑ No Anti-siphon Hole p Yes 0 No CDP File Number 1$8136 -2 County ID Number: Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No =Activation Method:PIGGYBACK Date: Approval Status- Alarm Audible tatusAlarmAudible El Yes ❑ No ❑ Approve 0 Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nation.Robert 'Operation Permit completed by: Authorized State Age t: Date of issue: 0 $ / 1 1 / a 0 1 6 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 NCACI8A .1900 et, Sep.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE III 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: N/A 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 entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homefbusiness owner must maintain a valid contract with a public management entitywith 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 formaintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as tong 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. OHand Drawing 41mport Drawing **Site Plan/drawing attached.** OPERATION PERMIT 188136 -2 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! / Q Inch DrawingDrawing Type: Operation Permit Scale. ' ON A k I I I I I I { l � I I t-7-�- I L k 1 • CONSTRUCTION For Office Use Only �- AUTHORIZATION *CDP File Number 188136-2 °"�'F• Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: NEW •� ,,,. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 1 1 7 / a 0 a 0 Applicant: Todd Zimmerman Property Owner: Todd Zimmerman Address: 5204 Mount Hope Drive Address: 5204 Mount Hope Drive City: Winston-Salem City: Winston-Salem State/Zip: NC 27107 State/Zip: NC 27107 Phone#: (336)671-2768 Phone#: (336)671-2768 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Markland Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Hwy 801, left on Markland Rd across from William Ellis School. on the right. #of Bedrooms: 1 #of People: *Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 (Saprolite e Classification: Provisionary suitable Inches S stem? Minimum Soil Cover: ay OYes �No Inches ign Flow: a 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: a 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%u REDUCTION 1-Piece: O Yes ®No Pump Required: ®Yes ONo O May Be Required Nitrification Field 8 7 3 Sq.ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: a 1 8 ft GPM--vs— ft. TDH Trench Spacing: Inches O.C. _ — Feet O.C. Dosing Volume: Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 O III 01V F' Page 1 of 3 `t CDP File Number 188136 - 2 County ID Number: ❑ Open Pump System Sheet Repair System Required:®Yes O No O No, but has Available Space Repair System Inches O. . Trench Spacing: g O *Site Classification: PS Shallow Placement — ®Feet O.C. Trench Width: Inches Design Flow: a 4 0 _ 3 Feet th:De p Soil Application Rate: 0 a 7 5 Aggregateinches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: a 4 Inches Maximum Soil Cover: 1 a Nitrification Field 8 7 3 Sq.ft. Inches No. Drain Lines 3 *Distribution Type: PUMP TO GRAVITY Total Trench Length: a 1 8 ft Pump Required: ®Yes O No O May Be Required Pre-Treatment: O NSF 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. RBm��9 750 *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. ReTB 2000 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 permit 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(A 937(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 ONO Applicant/Legal Reps. Signature Date: *Issued By: 2140-Nations,Robert Date of Issue: 1 1 1 7 a 0 1 5 00, Authorized State Agent: Malfunction Log OYes >>' 4 ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 188136 -2 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 11 / 17 / .2015 O Inch Drawing Drawing Type: Construction Authorization Scale: 00 Bloc i . ifi a i. C� I - - - 1 G I 0 -- --- --------- -- - --Page 3 of 3 - � -.._.— � �- P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 188136 - 2 P.O.Box 848 Mocksville IVC 270 County File Number: Date: .1.1./ 17 / .1 0 15 Click below to im ort an image from an external location: Drawing Type:Construction Authorization �6 Ne Ice d �O r� c�6 `1 SDG f � �p ( Page 3 0 3 � T" (,f _GlPa P2 -7 Ce b L,o©v 4 i APPLICA ION FOR SITE EVALUATION/IWROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(33�6)753-1680 Ap n For: ❑ Site Evaluation/Improvement Permit uD'A thorization To Construct(ATC) ❑Both Type of Application:.❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANTINFORMATION . Name / o c%/ 21�, Contact Person soly)'� Address 205/ 1`4 vvn� v t"✓� Home Phone_ __33G--6-71 -,7 7-6 9' City/State/ZIP Wj'n s fee, S&-W4, dfe- X21417 Business Phone NA Email 10del,Z,'Mm'errnurL 61 r1 , �yAEmail: sG.►�� Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/FacilityCorners Flagged (�� b NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name �,.4"" �i914 N-� Phone Number ?34-4171 '.2-769"Owner's Address 5,26ef Ou City/State/Zip 61/i /Ue- ;C-710 PropertyAddress 500 glpGk, 14114 r AV 4n'd PAJ- City_4c/vu n tte �c� Lot Size Tax PIN# r l?- OD- o�3 Subdivision Name(if applicable) 1l A Section/Lot# /�l� Directions To Site: 'Von i= v.'1 — � 5'e d A41ti-X14 kd i2aa If the answer to any of the following questions is"Yes",supporting docuipentation must be attached: Are there any existing wastewater systems on the site? Yes No Does the site contain jurisdictional wetlands? Yes 7TNo Are there any easements or right-of-ways on the site? Yes X No Is the site subject to approval by another public agency? _Yes�No Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People I Bedrooms f— #Bathrooms 1 Garden Tub/Whirlpool ❑Yes XNo Basement: ❑Yes ANo Basement Plumbing: ❑Yes ANo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water Pew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑ Yes X No If yes,what type? This is to certify 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 charges,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules I understand that Iam responsible for the proper identification and labeling of property lines and comers and locating and flagging r'` or stakih a house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Prope •owner's or per's legal representative,signature �Y Date(s): 1,6 1,0 Client Notification Date: Date ., EHS: .j., Sign given DYes ❑No Account# Revised 11/06 Invoice# e■■■C ■■■■�■e■■■ii■�.�■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■ ■■� ■■■■ v■■■■■r■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e Mu MMEMM■MMMEM MEN MOM ■■■■■■■■■■■■■ 'moi ■■■■■■■■■■■■ NONE MEN ■ i■■■■■■■■■■■a M■■ ■■■■ ■■ ■■■��r ■■■■■■w■■■■■■���u■■■■■■■■■■■■■■ EMELo"I i r Mc�■■►�.SO■ ■'moi ■e�u■■� �'�■■� ■■■■■■■■■ ■■ ■■ _ MEN Ill MEN Ill �■■■■■■■yA NNE ■■. ■■■■■■� OMEN ■■■■ME M■■■■■■N■■� [��.�■■■II■ ■■■■■■�■ ■■■ ■■■ ■■■■■■■■� ���■■■■r ■■' ' ■■■�a�u IRS ■■■■ ■e■■■■■■ I■■M■E ■■■■r�_ !,� ■M�.N■■■■■■■tea■E■■■�O ■■■■■ N■■ ■__ �iM■■■■■■■..�N■eelc ■■e■■■.■e■■■■■■�.■�■■ ■■■■■ . i■■■M■■■■N■■■���■s- ■■■■■■■■■■■■■�■■■■■■e■ ■■■ ■ ■ E■■■■■■■NON■■■■■■■■■ ■■■■■■■■■■■e■■■■.■■■ ■■■ ■■■■■■■� ■E■iM■■■■■■®■■■■■■■■■■■�ODNE ;■■■■■■■■■■■■. ■E■ ■■■■■■ ■■�E■■■■■■N■■■■■■■■■■■■■■■■■._on�■■■■■■■■■■■■ ■■■■ N■■RE E■EiEE■■EEE■E■■■■■■■■ENE■■■■■■■�■■�■.■■■■■■■ n Ill No ■■ on �r. ■■■■■■■■■■■■■■■■■■■■■■e■M■■■■■e■■■Na�■■ ■■ ®■ - ME■■ve■■■■■■■■■■e■■M■■■■M■■M■■■ ■■■ rush ■M ■® e��M _ a ■®■o■■■e■■■■■■■■■■■■■MM■■■� ■■■■ 0M �E■M ■■■■e■■ ■■■iso■�■■■■s■N■■■■■■M■■■■■■■■■■■■■■ MEMO ■ IMOM ■■ �■M■ .. ..■■.■o■■■■M . . 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Applicant: Vicki Kuhn/NC Country Homes FAddress: er: Edith Bailey Slagel Address: 202 Hidden Meadows Trail 613 Webster Drive City. Mocksville DeCatur State/Zip: NC 27028 State/Zip: GA 30033 Phone#: (336)251-5262 Phone#: (336)251-5262 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Markland Road Advance NC 27006 Directions i Structure: SINGLE FAMILY Hwy 64 East, left on Hwy 801, left on Markland Rd #of Bedrooms: 4 across from William Ellis School. on the right. #of People: *Water Supply: NEWWELL System Specifications - nitial S stem ,Site Classification: Provisionally Suitable Minimum Trench Depth: 3 0 Inches Saprolite System? QYes ®No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 a 7 5 1-Piece:_ QYes @)No Pump Required: QYes QNo QMay:Be Required *System Classification/Description: TYPE III E.PPBPS GRAVITY DOSED SYSTEM Pump Tank: 1 0 0 0 Gallons *Proposed System: 5011/9 REDUCTION 1-Piece: QYes *No Repair System Required:©Yes ONO ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: °3 0 Inches Soil Application Rate: a 5 Maximum Trench Depth: 3 6, Inches C *System Classification/Description: Pump Required: QYes Q No Q May be Required TYPE III E.PPBPS GRAVITY DOSED SYSTEM 'Proposed System: 50%REDUCTION Pagel of 3 CDP File Number 188136 - 1 County ID Number. ' 'Site Modifications ❑ Open Fill Sheet No grading or construction actwity is allowed in areas designated for system and repair without approval of Health Department, r "Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The improvement Permit shall be valid for 6 years from date of issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions,the location of thefacliity and appurtenances,the e site forthe proposed Wastewater system,and the location of water supplies and surfacewaters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land surveyor,drawn to a_scale of one Inch equals no morethan 60 feet,that includes:the specific location of the proposed facility O and appurtenances,the site for the proposed wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,'a copy of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale). The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article This permit Is subject to revocation if the site pian,plat,or intended use changes(NCO$130A-335(f)).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? OYes ONO Applicant/Legal Reps.Signature', Date: *issued By: 2140-Nations,Robert Date of Issue: 0 5 1 8 2 0 1 5 OValid without Expiration? Authorized State Agent:' Ste— �� Q Create CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 188136- 1 .Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box Bas County File Number: Mocksville NC 27028 Date: Q inch Drawing Drawing Type: Improvement Permit Scale: . 0151110 a — ft %0 L W, �I Q IMPROVEMENT PERMIT , Davie County Health Department 210 Hospital street CDP File Number: •188136 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: L0.1, L1.L8 2 0 1 5 Click below to Import an Image from an external location:Drawing Type:- Improvement Permit APPLICATION FOR SITE EVALUATIONAMPROVE•MENT PERMIT&AT ! Davie'CountyEnvironmental Health 'RECEIVED - P.O.Box 8481210 Hospital Street Mocksville,NC 27028 --- (336)753-6780/Fax(336)753-1680 AN 213 2015 Application For. �cw tiorAmprovement Permit Authorization To Construct(ATC) (loth (; H�A L-TH Type of Applieatia ` ysCei AistingSystem Expansion/hindification of Existing System or Faalii "'IMIVRIANI'"'THIS APPLICATION CAN1'OTBE I'ROCF.SSED UNLESS ALL OF THE REQUIRED IiFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name4�(, { t,3' ontact Person_ ' t i AddressN - Phone CitylState2lPBusiness Phone 33(o— 'i90—,DQW37 Email I .C.o^7 Name on P�q KDi r an , Above Mailing Addressl,ti,, CitylStatctZip PROPERTY INFORMATION 'Date House/Facility Comers Flagged 1 NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Plat(to seal (Permit is valid for 60 months with site plan.no expiration with complete plat.) Owner's Name �tE 'ra}-t - Phone Number ott mj . ( -•-S t Owner's Address {ei.9t_ ih%" Div city/State/%W941- GA ECC83 Zip o eriy Address • City Lars Size ;tri1�Q�t0 � TaxPlh'fl 5�t,g g �� ��-600 .bo 063 Subdivision ame(if applicable) T Section/Lot4 Directions To Site: }. at3S�Pialrt- n� '1�Iarkt� * d�.� v1 3�117 PAN peeify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms + _ t#Bathrooms Garden Tub/Whirlpool Yes No Basement: Yes No Basement Plumbing: Yes No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documertsticn of similar facility•.varcr consumption) FOODSERVICE ONLY: z#Seats e! stem requested: Conventional Accepted innovative Alternative Other Water Supply Type: CountytCity Watcr 'ew Wel( Existing Wc11 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No If yes.what type? This is to certify 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 arc 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 right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable. 3 laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the houscfacility location.proposed well location and the location of any other amenities. Site Revisit Charge; Sign given Yes No Date(s): A Revised 11106 Client Noti tg(tte. EHS: • 3\ f • Y,w, �\ :k s.-.. �,♦ }-S h i? � i�'CC l �». ,�.,,,,v..+t+r `�,\.� �,. \ t t K�� � v A�� U C .t7M77,M7 ...._._ ..... _,.__. ... 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'� S � �\ lvC', \t �C 1 !! ti` �` ti ! tea. < �� \ a •''. 1 L � 1� t1a E 1\ A;,7` tit �� * <F' ``ti:\ t ! ti.,.,..,tits J' ._ ,!!..<.. r...t. ,`i,,. ♦ Z _ -}.x,.: - .':�:`-� t i 73� f` 114 j ssa 3497 __ 584 F P811r.PG349 All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied nO W4- )s� warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of U N Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out Pri nted:J an 27 2015 S of the use or inability to use the GIS data provided by this websfte. r DAVIE COUNTY HEALTH 13 AR NT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION II PROPERTY INFORMATION U I Ck I 00 ct ft�2 m�'S Ecilth Balle 'Sla e1 Estate ZT1' �� Z Jennifer Rota ' a t Markland Rd ,1 Acre " • a 1 i•4 1 Water Supply: On- ite Well / Community Public Evaluation By: Aug r Boring -Pit Cut FACTORS j 1 2 3 5 6 7 Landscape position I Slope% HORIZON I DEPTH Texture group Consistence Structure ke j MineralogyQ ,l= HORIZON IIDEPTH — - — I Texture group Consistence E Structure 5-, Mineralogy4 t^^ HORIZON III DEPTH ! Texture group Consistence s Structure MineralogyI HORIZON IV DEPTH I Texture group Consistence Structure MineralogyI j SOIL WETNESS j 3 I 'RESTRICTIVE HORIZON I I i SAPROLITE I CLASSIFICATION j LONG-TERM ACCEPTANCE RATE Q. 2'7 ' O• x-77 1 SITE CLASSIFICATION: I EVALUATI Nn Y. LONG-TERM ACCEPTANC . RATE: ` ApY .- OTHER(S)PRESENT., REMARKS: LEGEND S Landscape Position R-Ridge S-Shoulder' ' L-Linear slope FS-Foot slope N-Nose slope; CC-Concave slope CV- onvex slope T-Terrace FP-Floodplain H Head slope Texture i S -Sand LS-Loamy sant SL-Sandy loam L-Loam SI_Silt SICL-Silty clay loam SII;-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Sill clay C-Clay ! CONSISIENCE, Mflist VFR-Very friable FR-F 'able FI-Firm VFI-Very firm EFI-Extremely firm NS-Non sticky SS-.Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure I SC-Single grain M_M sive CR-Crumb GR-Granular ABK-Ang lar blocky SBK-Subangular blocky PL-Platy PR-Prismatic _ Mineralogy 1:1,2:1,Mixed i • LYotcs y Horizon depth-In inches k Depth of fill-In inches j Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsu�table). 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)