193 Potts RdOPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753.6780 Fax: 336-753-1680
Applicant:
Alex S. Nail
Address:
197 Dulin Rd
City:
Mocksville
State/Zip:
NC 27028
Phone #:
(336) 407-8551
Address/Road #:
Potts Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by. 2140 - Nations, Robert
*CA issued by: 2140 - Nations, Robert
Subdivision:
Design Flow: 3 6 0
Soil Application Rate. 0 - 3 2 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 195099-1
5880-14-1784
County ID Number:
Evaluated For. NEW
Township:
/"Property Owner. David Carter
Address: PO Box 2324
City: Advance
State/Zip: NC
Phone #:
27006
Phase: Lot:
Directions
Hwy 158 east, right on Hwy 801 going south, left on
Potts Rd. Property on left
*System Classification/Description:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? QYes (QNo
*Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
QYes (DNo
*Pre Treatment:
Drain field -
1 0 8 3 Sq_ ft.
3
a 7 1 ft.
9 Inches O.C.
Feet O.C.
3 Inches
Feet
inches
Minimum Trench Depth: 3 6
Minimum Soil Cover. 2 4
Maximum Trench Depth: 3 6
Maximum Soil Cover: a 4
Inches
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Brian McDaniel
Certification #: 1118
*EH S: 2140 - Nations, Robert
Date: 0 3/ 1 4/ 2 0 1 6
Inches Approval Status
Inches 1E Approved ❑ Disapproved
Inches
CDP File Number 195099-1
Manufacturer. Shoaf
STB: 760
Gallons: 1000
Date:
l
a/
1 1/
a 0 1 5
*Filter Brand:
POLYLOKPL-122 With Pipe Adapter
ST Marker:
❑
Yes
El
No
nforced Tank:
❑
Yes
CJ
No
1 Piece Tank:
❑
Yes
[E
No
❑
No
Flow Adjustment Valve
❑ Yes
Manufacturer.
126
Gallons:
County ID Number: 5880-14-1784 ,
Lat.
Lang:
Installer: Brian McDaniel
Certification #: 1118
THS: 2140 - Nations, Robert
Date: 0 3/ 1 4/ 2 0 1 6
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
Date:
/
—
/
RiserSealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (Min.6 in.)
Reinforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ No
approved fittings ❑ Yes ❑ No
Pump Type:
Installer.
Certification #:
*EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Supply Line
Installer:
Certification #:
IEHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
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
❑; Approved ❑ Disapproved
Vent Hole
Anti -siphon Hole
❑ Yes
❑ Yes
❑
0
No
No
-CDP File Number, 195099 - 1
Electric EaulDment
County ID Number: 588x14-1784
NEMA 4X Box or Equivalent
❑
Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
No
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
"EHS:
Pump Manually Operable
❑
Yes
❑
No
"Activation Method:
Date:
Alarm Audible
❑
Yes
❑
No
Approval Status
p Approved❑ Disapproved
Alarm Visible
❑
Yes
❑
No
2140 • NaUons. Robert
'Operation Permit completed by:
Authorized State
Owner/Applicant Signature:
Date of Issue: 0 3/ 1 4/ 2 0 1 6
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 II A. sewage septic system.
Rule .1961 requires that a Type TYPE IIA septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entitywith a certified operator or a private certified operator for the life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 195099-1
County File Number: 5880-14-1784
27028 Date:
Olnch
Scale:. OBlock
ON/A
CONSTRUCTION
AUTHORIZATION
=•�"L' Davie County Health Department
210 Hospital Street
•,� ;„,• P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Alex S. Nail
Address:
197 Dulin Rd
7
City:
Mocksville
State/Zip:
NC 27028
Phone #:
(336) 407-8551
For Office Use Only
*CDP File Number 195099 - 1
County ID Number: 5880-14-1784
Evaluated For: NEW
Township:
0 7/ a 0/ a 0 a 0
"�Property Owner: David Carter
Address: PO Box 2324
City: Advance
State/Zip: NC
Phone #:
Property Location & Site Information
27006
Address/Road #: Subdivision: Phase: Lot: `
Potts Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 158 east, right on Hwy 801 going south, left on Potts
# of Bedrooms: 3 Rd. Property on left
# of People:
*Water Supply: PUBLIC
Page 1 of 3
Minimum Trench Depth: a 4 Inches
\Site
Classification:
Provisionally suitable
Minimum Soil Cover: 1 a
Sa rolite System?
p y
O Yes ®No
Inches
Design Flow:
3 6 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate:
0 3.1
5
Maximum Soil Cover: a 4 Inches
*System Classification/Description:
*Distribution Type: GRAVITY - PARALLEL (eq. d -box)
TYPE II A. CONY SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
1 0 0 0
Gallons
*Proposed System: 25% REDUCTION
1 -Piece: O Yes ® No
Pump Required: O Yes ® No O May Be Required
Nitrification Field
1 0
8
3
Sq. ft. Pump Tank: Gallons
No. Drain Lines
3
1 -Piece: OYes ONo
Total Trench Length:
a 7 1
GPM --vs— ft. TDH
ft
Trench Spacing:
_
g
O
®
Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width:
3
OInches
®
Feet
_
Grease Trap: Gallons
Aggregate Depth:
inches
Septic
Pre -Treatment: O NSF OTS -1 O TS -II /
Tank Installer Grade Level Required: 01011 O III 01V
Page 1 of 3
CDP File Number 195099 - 1
County ID Number: 5880.14-1784
if ❑ Open Pump System Sheet
*Site Classification
Design Flow:
Repair System Required: V Y es v Ivo v Ivv, out nas Hvanaulu o
Provisionally Suitable
� A A
Soil Application Rate: 0 . 3 a 5
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 1 0 8 3 Sq. ft.
No. Drain Lines 3
Total Trench Length: a 7 1 ft
Trench Spacing:
_ 9 O Inches O.
® Feet O.C.
Trench Width:
3 Inches
_ Feet
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
Pump Required: OYes ®No O May Be Required
Pre -Treatment: O NSF OTS -I OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Ch ad
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. R�,� 9
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 (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? O Yes O NO
Applicant/Legal Reps. Signature- Date:
*Issued By:
2140 - Nations, Robert 109 Date of Issue: 0 7 2 0 x 0 1 5
Authorized State Agent: Malfunction Log OYes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
1 04
2
to
................. .................
. ................
. ...............
..........
...........
..............
...........................
11.11, ..............
Page 3 of 3
q
Pi P2
i J. -
it
r
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 195099 - 1
P.O. Box 848
County File Number: 5880-14-1784
Mocksville NC 27028
Date:. 0.7 . / ..2 0. � . a. 0.1.5 .
Click below to import an image from an external location: Drawing Type: Construction Authorization
k,,4
-7
Page 3 of 3
P1 P2
R
CONSTRUCTION •
AUTHORIZATION
Davie County Health Department
f 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
/ For Office Use Onlv
"CDP File Number 195099-1
County ID Number 5880-14-1784
Evaluated For: NEW
�_ Township:
I VALID UN I IL:
0 7/ 2 0/ 2 0 2 0
Applicant:
Alex S. Nail
Property Owner:
David Carter
Address:
197 Dulin Rd
Address:
PO Box 2324
CRY:
Mocksville
Cay:
Advance
State/Zip:
NC
27028 State2ip:
NC 27006
Phone #:
(336) 407-8551
Phone #:
Maximum Soil Cover: a 4 Inches
"System Classification/Description:
Property
Location & Site Information
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY
Address/Road #:
Potts Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
'Water Supply: PUBLIC
Subdivision:
Phase: Lot:
Directions
Hwy 158 east, right on Hwy 801 going south, left on Potts
Rd. Property on left
System Specifications
Pflnn 1 of Z
Minimum Trench Depth: a 4 Inches
\Site
Classification:
Provisionally Suitable
Saprolite System?
QYes QNo
Minimum Soil Cover 1 a Inches
Design Flow:
3 6 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate:
0 - 3 a
5
Maximum Soil Cover: a 4 Inches
"System Classification/Description:
"Distribution Type: GRAVITY - PARALLEL (eq. d -box)
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
'Proposed System: 25% REDUCTION
1 -Piece: QYes QNo
Pump Required: QYes QNo OMay Be Required
Nitrification Field
1 0
8
3 Sq. ft. Pump Tank: Gallons
No. Drain Lines
3
1 -Piece: QYes ONo
Total Trench Length:
a 7 1
ft
GPM—vs— ft. TDH
Trench Spacing:—
9
OnchesFeet O.C. O.C.Dosing Volume: Gallons
Trench Width:Inches
3
—
.
Feet Grease Trap: Gallons
Aggregate Depth:
inches
Pre Treatment: O N S F OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01 011 0111 01V
Pflnn 1 of Z
CDP File Number 195099-1 County ID Number: 5880-14-1784 '
❑ Open Pump System Sheet
:V TCS V IVU %JNU, UUL IIdS HvdI1dUIC 0lJdGC
/Repair System
Trench Spacing:Onches
0.
9
*Site
Classification:
Provisionally Suitable
— Feet O.C.
Trench Width:
QInches
3.
Design Flow:
3 6 0
— V Feet
Depth;
SoilAggregate
Application Rate:
0 - 3 a 5
inches
Minimum Trench Depth:
� 4
*System Classification/Description:
Inches
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover.
1 a
Inches
Maximum Trench Depth:
3 6
*Proposed System:
25% REDUCTION
Inches
Maximum Soil Cover:
a 4
Nitrification Field
1 0 8 3 Sq. ft,
- -
Inches
No. Drain Lines
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
3
Total Trench Length:
a 7 1
Pump Required: QYes
QNo
OMay Be Required
ft
\
Pre Treatment: ONSF
OTS
-1 OTS -II ,
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department.
"Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit not
to exceed five years, and maybe issued atthe sametime the Improvement Permit issued (NCGS 130A-336(b)j 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 maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsibteforassuring 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? QYes ONO
Applicant/Legal Reps. Signature: Date:
'Issued By:
2140 - Nations, Robert
Authorized State Agent:
Date of Issue: 0 3/ x 0/ 2 0 1 5
--— — Malfunction Log QYes
QHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• . CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 195099 - 1
County File Number: 5880-14-1784
Date: 07/20/.2015
Q Inch
Scale: QBiock
QN/A
Ii
.. ........
-----
.............
. .. ........... - -- - - --- -- ---
.... ..........
Ili
- - ----
. ......... .....
III
-
\A I"'
140
III
I.
i
i I..
I
__1
F
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
11
CDP File Number: 195099 -1
County File Number: 5880-14.1784
Date: .0 .7 / ;?0 / a 0 1 5
Click below to import an image from an external location: Drawing Type: Construction Authorization
q7b
loin AL
6,pIrl
? D �
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
For Office Use Oniy
'CDP File Number 195099-1
County ID Number 68$0-14-1784
Evaluated For: NEW
Township:
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL; 7/8/2020
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant:
Alex S. Nail
Address:
197 Dulin Rd
City:
Mocksville
State2ip:
NC 27028
Phone #:
(336) 407-8551
Property_Locatio
Address/Road #: Subdivision:
Potts Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
asslticatlon: Provisionally Suitable
SaproliteSystem? OYes QNo
Design Flow: 3 6 0
Soil Application Rate: 0 3 a 5
u
"System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
"Proposed System: 25% REDUCTION
/-P'roperty Owner.- David Carter
Address: PO Box 2324
City: Advance
State/Zip: NC 27006
Phone #:
nform atio
Phase: Lot:
Directions
Hwy 158 east, right on Hwy 801 going south, left on
Potts Rd. Property on left
Minimum Trench Depth:
a 4
Inches
Maximum Trench Depth:
3 6
Inches
Septic Tank:
1
0 0
0 Gallons
1 -Piece:
OYes
QNo
Pump Required:
OYes
0 N
OMay Be Required
Pump Tank:
Gallons
1 -Piece:
OYes
ONo
Repair System Required:&Yes ONO ONO, but has Available Space
Repair System
.Site Classification: Provisionally Suitable
Soil Application Rate: 0 - 3 a 5
"System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
"Proposed System: 25% REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: OYes QNo O Maybe Required
Pagel of 3
CDP File Number 195099 - 1 County ID Number: 5880,14-1784.
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in noway guarantees 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 wild for 6 years from date of Issue with a site pian (means a drawing not necessarily drawn to
scalethat shows the existing and proposed property lines with dimensions, the location ofthefacility and appurtenances, the
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
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 plan, plat, or Intended
use changes (NCGS 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
Authorized State
Date of Issue: 0 7/ 0 8/.2 0 1
OValid without Expiration?
0Create CA?
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
5
IMPROVEMENT PERMIT
' Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Improvement Permit
CDP File Number: 195099 -1
County File Number: 5880-14-1784
Date:
Q Inch
Scale: __. 013lock
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M
IMPROVEMENT PERMIT
Davie County Health Department '
210 Hospital Street CDP File Number: 195099 -1
P.O. Box 848 5880-14-1784
Mocksville NC 27028 County File Number:
Date: @7/@8 /2015
Click below to import an image from an external location: Drawing Type: Improvement Permit
pA LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
bete; Mocksville, NC 27028
v ` (336)753-6780/ Fax (336) 753-1680,
-/ �-/ y- /s
Ap n For: ll Site Evaluation/Improvement Permit Athorization To Construct(ATC) ❑ Both
pplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
XAff1* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed1.
X -S 1011-
Contact Person
/ LCX
Billing Address JJJ
D a
Home Phone _331L
/0 -SSI
City/State/ZIP _ /4oc-<SVIt-1E
NG Z7,4
Business Phone 33t,
� L4) -'/Z 92
Name on Permit/ATC if Different than Above
Property Address lo
city _.4,py4 ec
Mailing Address
Lot Size z • Z6 A,,eE5 Tax PIN#
Citv/State/Zin
PROPERTY INFORMATION *Date House/Facili Corners Flagged
/O
NOTE: A survey plat or site plan must accompany this application.
Included: VSite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name U/AV/U 6 c'rER
Phone Number
Owner's Address hO / ZgZq
City/State/Zip,10/A,✓CE ,Vl
27rL5L,
Property Address lo
city _.4,py4 ec
Lot Size z • Z6 A,,eE5 Tax PIN#
Subdivision Name(if applicable)
Section/Lot#
Directions To Site: FiCOJ't lik 1,01 111LLW,4ZE'
-001 5-1witN
L -111C 41.1
M t L, C3 LEFT ON PvT'TS R p, "A.,p is
cL6/aj' 'U
D.v Le: FT
If the answer to any of the following questions is `yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
❑Yes RNo
Does the site contain jurisdictional wetlands?
Dyes Ao
Are there any easements or right-of-ways on the site?
❑Yes G?No
Is the site subject to approval by another. public agency?
❑Yes 04o
Will wastewater other than domestic sewage be generated?
❑Yes P? o
IF RESIDENCE FILL OUT THE BOX BELOW
# People 2 # Bedrooms Z # Bathrooms 7., 3 Garden Tub/Whirlpool ❑Yes Ao
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ia'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 documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: ®'Conventional []Accepted ❑Innovative []Alternative ❑Other
Water Supply Type: 13" County/City Water Cl New Well C1 Existing Well ❑ 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 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 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 I am responsible for the proper identification and labeling of property lines and comers and
I t�andag mg ac facility location, proposed well location and the location of any other amenities.
c e Site Revisit Charge
Property owner's or owner s�epresentative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # 50
Revised 11/06 Invoice #
T
Printed:Jun 30, 2015
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,
North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.
APPLICANT INFORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Alex S. Nail
336 407-8551
336 661-4299
Water Supply: On -Site Well
Evaluation By: Auger Boring
Community
Y
Pit
David Carter Property
Potts Road
2.26 Acers
`7
Public
Cut
FACTORS
1
2
3 4
5
6 7
Landscape position
Sloe %
-�
HORIZON I DEPTH
Ct
0 '
i
Texture groupSG
Consistence
Structure
I
Mineralogy
HORIZON II DEPTH
Texture group
C'1Z
S C
Consistence
Structure
MineralogyG
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
I
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY:'���L
OTHER(S) PRESENT: _A1 re
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
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
ONSIST .N . .
moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely fin
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blo
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surf%ce
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
Classification - S(suitable), PS (provisionally suitable), U(unsuitable)
LTAR - Lona -term acceptance rate - eal/dav/ft2
i chroma 2 or less
nr'ur'k nvnc in.....