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156 Primrose Rd Lot 14 OPERATION PERMIT or ice se rt v Davie County Health Department *CDP File'Number 136705-11 ~- 210 Hospital Street os-09UO-014 •1- P.O.Box 84$ County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township FApplicant: DICK ANDERSON Property Owner. DICK ANDERSON Address: 225 WINGHAVEN LANE Address: 225 WINGHAVEN LANE City: MOCKSVILLE City: MOCKSVILLE State2ip: NC 27028 'State/Zip: NC 27028 Phone#: (336)492-7579 Phone#: (336)492-7579 Property Location & Site Information Address/Road #: Subdivision: MARCHWOOD Phase: Lot: 14 156 Primrose Road ADVANCE NC 27006 Directions Structure: 1-40 EAST TO HWY 801 S TURN RIGHT, GOT TO _ --- - SINGLE FAMILY ._ PEOPLES CREEK RD, TURN RIGHT ON OLD #of Bedrooms: 3 MARCH RD, THEN LEFT ON L MARVH FERRY , #of People: 2 TURN RIGHT ON PRIMROSE *Water Supply: PUBLIC *tP Issued by. "System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? QYes ONo Design Flow: 3 6 0 'Dist ribution Type: GRAVITY-SERIAL. Pump Required? OYes QNo Soil Application Rate: 0 - 4 *Pre Treatment: Drain field rNkrification Field 1 1 0 8 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD n Lines 3 Installer: Donnie Lakey Total Trench Length: 3 1 6 ft• Certification#: 1108 Trench Spacing: — 9 Olnches O.C. ,� Feet O.C. *EH S: 2140-Nation,Robert 3 Trench Width: Olnches Date: 0 7 / 3 0 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 4 8 Inches Minimum Soil Cover. 3 6tnches ApprovalrStatus' "'.MaxmumiTrench Depth: 6 0 Inches ® ApprovedCI DisapproveMaimum Soil Cover. 4 8 Inches CDP File Number 136705- 1 County ID Number: G9-090-x0'014 Septic Tank Manufacturer. shoat Lat. Long: STB: 760 _ Gallons: 1000 Installer Donnie Lakey Certification#: 1108 Date: 0 4 / 3 0 / x 0 1 4 *EHS: 2140-Nations,Rout *Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker. ❑ Yes R No Date: 0 7 / 3 0 / 2 0 1 4 Reinforced Tank: ❑ Yes ® No Approval Status Q Approved❑ Disapproved 1 Piece Tank: ❑ Yes ® No -r Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes _ ❑ No (Min.6 in.) AppaiStatus Reinforced Tank: ❑ _Yes ❑ No p Approved❑5-Dlsapproved 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer Pipe Length: feet Certification#: *Schedule: "'EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Approval Status ❑ Aipprovetl❑ 3Dtsapproved Pump Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve El Yes ❑ No Apjarovel3tatus PVC unions ❑ Yes ❑ No ❑ Apprtaved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole F1 Yes ❑ NO CDP Fite Number 136705- 1 County ID Number: G9-090-do-014 Electric Equipment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer. Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank El Yes ❑ NO Certification#: Conduit Sealed ❑ Yes ❑ No *ENS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No Q Approved Q Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by: _ Authorized State Agent: Date of Issue. 0 7 / 3 0 / x 0 1 4 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for - - Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq..and all conditions of the Improvement Permit and s Construction Authorization.This property is served by a TYPE 11A sewage septic system. Rule.1961 requires that a Type TYPE 11,k septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NtA 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 fora home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed 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 ently 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. O Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 1367-05- 1 Davie County Health Department CDP File Number: 210 Hospital Street GM90-dO-014 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Operation Permit Scale' ' ON A k 3� - --- ---------- I - � I JN FT OPERATION PERMIT F*CDP ice se nv o Fes, Davie County Health Department Number 136705-2 210 Hospital Street Gs-osadaot4 P.O.Box 848 umber. Mocksville NC 27028 Evaluated For. EXPANSION Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Brandy Morton Property owner: Brandy Morton Address: 156 Primrose Rd Address: 156 Primrose Rd City: Advance City: Advance State2ip: NC 27006 State0p: NC 27006 Phone#: 1Phone#: Property Location & Site Information Address/Road#: Subdivision: MARCHWOOD Phase: Lot: 14 156 Primrose Road ADVANCE NC 27006 Directions Structure: SINGLE FAMILY 1-40 EAST TO HWY 801 S TURN RIGHT, GOT TO PEOPLES CREEK RD, TURN RIGHT ON OLD #of Bedrooms: 5 MARCH RD, THEN LEFT ON L MARVH FERRY , #of People: TURN RIGHT ON PRIMROSE *Water Supply: PUBLIC *IP Issued by. *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) 'CA issued by: 2140-Nations,Robert SaproliteSystem? QYes ONo Design Flow: 6 0 0 , GRAVn7-PARALLEL d-box Pump Required? Distribution Type: (�• ) OYes ONo Soil Application Rate: 0 - 3 'Pre Treatment: Drain field (No.irDrain cation Field 8 0 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD Lines a Installer: Brian McDaniel Total Trench Length: a 0 0 ft. Certification#: 1118 Trench Spacing: _ 9 Inches O.C. gFeet O.C. *EHS: 2140-Nations,Robert Trench Width: _ 3 Qinches • Feet Date: 0 8 / 1 a / a 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, a 4Inches ApprrnralStatus; Maximum Trench Depth: 3 6 Inches ® Approved O Disapproved ' Maximum Soil Cover. a 4 Inches CDP File Number 136705 -2 County ID Number: G9-090-d0-014_ Septic Tank , Manufacturer. Shoaf Let. STB: 42 Long: Brian McDaniel Gallons: 1250 Installer Certification#: 1118 Date: 0 5 / 0 9 / .2 0 1 5 ` *EHS: 2140-Nations.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes M No Date: 0 8 / 1 .2 a 0 1 5 / Reinforced Tank: ❑ Yes ® NO JA' Approval Status Piece Tank: El Yes ® N0 �® ppprovid❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: / / Date: / RiserSealed ❑ Yes ❑ No RiserHeight: [3 Yes ❑ No (Min.6 in.) A meal status PP forced Tank: ❑ Yes ❑ NO ❑ Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ N0 Supply Line FPipe ize. inch diameter Installer, gth: feet CertificationSchedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings E3Yes ❑ No Approval Status ILLA'o rove d❑ Disapproved Pump equirement rDosing p Type: Installer. Volume: — Gal Certification#: Draw Down: Inches *EHS: *Cham: / Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No ApprovalStatus PVC Unions Q Yes ❑ No ❑;Approved O Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 No CDP File Number 136705 -2 County ID Number: GM90-dO-014 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: Date: Approval Status Alam,Audible ❑ Yes ❑ No ❑ Approved❑ 'aisapproved = Alarm Visible ❑ Yes ❑ No 2140•Nations.Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 8 1 a / a 0 1 5 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for _ _Sewage Treatment and Disposal,15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE 11 A sewage septic system. Rule;1961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified 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 entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system 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 136705-2 Davie County Health Department CDP File Number: 210 Hospital Street GM90-dO-014 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing0 Drawing Type: Operation Permit Scale: ON Ack- ft. I1 t� I FIT s Z7 �_ - CONSTRUCTION For office Use only AUTHORIZATION "CDP Fite Number 136705-2 Davie County Health Department County ID Number: G9-090-do-014 210,Hospital Street Evaluated For EXPANSION P.O.Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 / 0 a / a 0 a 0 Applicant: Brandy Morton r roperty Owner: Brandy Morton Address: 156 Primrose Rd ddress: 156 Primrose Rd City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: 1z one#: Property Location & Site Information r ad#: Subdivision: MARCHWOOD Phase: Lot: 14rose Road E NC 27006 Directions Structure: SINGLE FAMILY 140 EAST TO HWY 801 S TURN RIGHT, GOT TO PEOPLES CREEK RD,TURN RIGHT ON OLD MARCH #of Bedrooms: 5 RD, THEN LEFT ON L MARVH FERRY , TURN RIGHT #of People: ON PRIMROSE "V1/ater Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover: 1 a Saprolite System? OYes ®No Inches Design Flow: 6 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 _ 3 Maximum Soil Cover: a 4 Inches "System Classification/Description: "Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank: _ _ 1 a 5 0 _ Gallons "Proposed System: 25%REDUCTION 1-Piece: OYes QNo Pump Required: OYes @No OMay Be Required' Nitrification Field 8 0 0 Sq. ft. Pump Tank: Gallons No.Drain Lines a 1-Piece:OYes ONo Total Trench Length: a 0 0 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. — 9 . @Feet O.C. Dosing Volume: Gallons Trench Width: 21nehes — 3 Feet Grease Trap: Gallons _ _ Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 7 Septic Tank InstallerGrade.Level Required: OI Oil 0111 01V Dflnn 4 of Q CDP File Number 136705- 2 County ID Number. G91,090-0-0.14 ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space riDesign System Trench Spacing: Inches O. . ification: Provisionally Suitable 9 Feet O.C. Trench Width: Inches w: 6 0 0 — "3, �► Feet Soil Application Rate: 0 3 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 *Proposed System: Inches Maximum Soil Cover: a 4 Nitrification Field a 0 0 Inches Sq.ft. No. Drain Lines 4 "Distribution Type: ,GRAVITY-PARALLEL(eq.d-box) TotalTrench Length: � 0 � ft. .Pump Required: OYes ®No OMay Be Required Pre-Treatment: ONSF OTS-1 OTS-II .Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in nowayguarantees 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 bevalld fora person equal to the period of validity of the Improvement Perml%not to exceed five years,and may be issued at the sane 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 orConstruction 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? Oyes ONo ApplicantfLegal Reps.Signature: Date:.__ 2140-Nations,Robert 0 6 0 a a 0 1 5 Issued By: Date of issue:..._._, Authorized State Agent. alfunction Log OYeS °. @Hand Drawing Oimport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number. 136705- 2 210 Hospital Street G9-090-d0-014 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 06 / 0 a / 2 0 1 5 --- Oinch Drawing Drawing Type: Construction Authorization Scale: . 01310 k ft. �J ��l { I s L. CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 136705 -2 P.O.Box 84$ G9-090-d0-014 Mocksville NC 27028 County File Number: Date: 0 .6 / 02 / 2015 Click below to import an image from an external location: Drawing Type:Construction Authorization ht'r fms2 roktech.ne[daargan; psrri* tml 1 „4 %r• a' �:s'Davir�ovtityl�flff7alitc« z f� File- Edit View Favorites_ Tools Help ii Davie County,NC-OfficL LU Suggested kes c?Davie County,NC-Offrci... » ® U. Page- Safety Tools ` 3584 '// 5418 / ' ,� - fit /�,� 27 O ✓ 7r �s 3:. <XIAS3 J 3 1411 . J ! 6318 9O4d X149 �� 259 <` 't 7202 326a R, 7 v X197 32718 Y _= ff23 �' { r 6 X156 OEi4 1030>- ui 4s, i5 ( 7033 ass; 4128 k i rr; t t`3171 176-' , . 2985 4888 7 2 X138 129 �� 1 ,� In. s ;titi 187 AD 1;0. 229 - -�� J86O r v' Son• O766 ' '�^—^>�•�1•^2�a11 F E.. - 2. G JJ 44'.... LatituEee 339 33' 47,30...Longitudot-83°23' ^2.53' �(atlt.nn9 d000% Izq- b b 9 U W��e� cuwl ple�-c CONSTRUCTION FAXED For Office Use Only AUTHORIZATION •CDP File Number 136705- 1 Dnp: c !� Davie County Health Departme �`j - County ID Number:G9-090-dM14 210 Hospital Street EMAILED Evaluated For: NEW P.O. Box 848 t3 1( t q Township: Date Mocksville PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 3 / 1 0 / a 0 1 9 Applicant: DICK ANDERSON Property Owner: DICK ANDERSON Address: 225 WINGHAVEN LANE Address: 225 WINGHAVEN LANE City: MOCKSVILLE City: MOCKSVILLE State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)492-7579 Phone#: (336)492-7579 Property Location & Site Information Address/Road #: Subdivision: MAR Phase:Phase: Lot: 14 _444 MAPLE VA � S t�E �� Pri 011 iros(fl , O( ADVANCE NC 27006 Directions Structure: SINGLE FAMILY 1-40 EAST TO HWY 801 S TURN RIGHT, GOT TO PEOPLES CREEK RD, TURN RIGHT ON OLD MARCH #of Bedrooms: 3 RD, THEN LEFT ON L MARVH FERRY , TURN RIGHT #of People: 2 ON PRIMROSE 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: Site Classification: Provisionally Suitable a 4 Inches Saprolite System? QYes QNo Minimum Soil Cover. Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 2 7 5 Maximum Soil Cover: Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL 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 3 0 9 Sq ft Pump Tank: Gallons No. Drain Lines 4 1-Piece: QYes QNo Total Trench Length: 3 a 7 ft GPM vs— ft. TDH Trench Spacing: 9 Inches O.C. — Dosing Volume: _ Gallons Feet O.C. g Trench Width: Inches 3 Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 OII 0111 01V Pagel of 3 CQP File Number 1x6705 - 1 County ID Number: G9-090-do-014 • ❑ Open Pump System Sheet Repair System Required:OYes ONO ONo, but has Available Space rDesign System Trench Spacing: Inches 0. . ification: Provisionally Suitable — 9 � Feet O.C. Trench Width: Q Inches w: 3 6 0 — 3 Feet Soil Application Rate: 0 - a Aggregate Depth:7 5 inches .� Minimum Trench Depth: a 4 Inches "System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Nitrification Field 1 3 0 9Sq. ft. Inches No. Drain Lines 4 *Distribution Type: GRAvRY-SERIAL Total rench Length: 3 a 7 ft Pump Required: QYes (DNo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 7' *Permit Conditions The issuance of this 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. *e. 2( 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 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 fora 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)). Applicariftegal Reps.Signature Required? Oyes ONo Applicariftegal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 3 / 1 0 / a 0 1 4 Authorized State Agent: //% alfunctan Log Oyes OHand Drawing Oimport Drawing **Site Plan/Drawing attached.** Page 2 of 3 ' CONSTRUCTION AUTHORIZATION Davie County Health DepartmentCDP File Number. 136705 - 1 210 Hospital Street G9-090-d0-014 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 03 / 1 0 / 2 0 1 4 Q Inch Drawing Drawing Type: Construction Authorization Scale: , OBlock QN/A -;—–; CJ e Paoe 3 of 3 . Dick #Nah"RSoA) Co NST DoT it lq A bVAN C IC 4 o N v 1110 ve I1�R�s� RD -APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC A Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit uthorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION,CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name VIC K N /v Contact Person Address Z2.5- �lifl�, yf_`ry L,v Home Phone City/State/ZIP Business Phoneme T� r` Email Email: Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 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]) ' ,AW ,oJ Phone Number 3% �1 �7Z7 Owner's Address ­­City/State/ZipG Property Address /I/-119b"�/,�LL ,�� City 1/ ,UG Lot Size D• 9f.0 46 Tax PIN#-4Z7"k(v 3z.7/ Subdivision Name if applicable) �O (� pp )/s'lf�it'C'f!(,�1 oe tJ5 Section/Lot# �y Directions To Site: e eR k . 640 1K4& 'VA /9,4&.* 4Xeg 7%eAGN as,E' 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 --We- Does the site contain jurisdictional wetlands? —Yes -�� Are there any easements or right-of-ways on the site? -f s _No Is the site,subj.ect to approval by another public agency? Yes _� Will wastewater other than domestic sewage be generated? Yes • o IF RESIDENCE FILL OUT THE BOX BELOW #People Z- #Bedrooms #Bathrooms3 yz Garden Tub/Whirlpool es ❑No Basement: 91-es ONo Basement Plumbing: [fifes ❑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: E<on-v—entional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: runty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑-Yes 2-Nu 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 corners and lociin d flaggof9aking�the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: I i Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# . t 'etu co v-D zea ; -roof uPoon nn�avt';:utt '•`° oov o;avrr- ra N, i MAP 3134 APPLIC II&V EOR SITE EVAII)A IOM/WIPROVEMW PERMIT&ATC Lio T- 'Wyle County Health Depaftgnt . '.EnvJ/oamentaJifealthSecliorr P.O. Box 848/2111 Hospital Street Mgghev1114. PC 27939 ' (336)751-8760 oeeZ090"A117— TIM APPLICr1TI0N tARWr BF p80CSSSFD MU=S ALL TRS ==RED =rO=xTI01r.L4 7ROv2IISD. Refer to the/�IZIFOH7P=ON B9I.L,STIN for instruction. - .} ✓1. vee. to be atll.d 161 4 �0��/ d 6,0S'i-�(�eentaet r.c.on l��S[(a../C�TI�A�-g d A a/)Iµxiag Adds.ss -9(,(J/11�(t-ti�✓�ll 4AI (�1fwe thew qq;z--) 77 . ✓city/auca/zn /Ylnf�sl/ttLE- A4(- X7035 t/a„asaaaa nom. 9715-7.",7q ,,-2. Naar on Potnft/ATC i!oLr.rort two Above Naillag add.". City/Scats/LSP Application lar. Ksita.Maluation ❑Imprmroment permit/ATC 0 Both ,-4. sy.tom to arwle.. p0 ttnuse M mobile home ❑ nusineep Ct Muduatry 0 Other .�L. Typo oy.tc rtpo.ated. a Coo-entlooal 0 eoaveatio.al modified © tmwative ors. IIf Xtividenee.�/1 Paerple 1 Madrocam g Bethrooma .1 iQDl,lwaMr t.7wrbopo Dtapeoel a.lia9 NaeWe 01-e %/pl..eM g ❑weme.t1go plr bleq 7, if Duetauo/roduatry/other: varify type 4 People 1 Sink. 1 cmeddea a S]e.ars a Drtnale a Mater Ceelen IL TOODSERYI173t / Seattt 1_tpti_mot9d tf±tPS VVni (9049L2x Ppr d-p) ✓I. Typo of voter.uvp7y, Ge!oun.y/City EI well tJ Comauaity s. Do yo.antlelp.t.edditLeda or expansions of the facility this system is intetdod to serve?(]Yes CTf o r Ifycs,tvhatt 1KP0R7it17—CLICIv?J MUSTCO lGEIE THE REQUIRED PROPERTY INFORMATION REQUESTEO D EltheraPl. guffrED by The client with THISAPPLiCA970N. L---yroperty Dimensions: S S9' pF_JT-WRITE DIRECriOttS Efrom Mdcksvltle)to YROrERTY: e . �l 0-73X Osco PIN: ll70 --ProperI7A44rVW- 99adName !xyPe-eS1C IE rae l Cityrzip rTy -,tJ C� A1/,/ f j70,Zr f in a Subdividen rovide inrorttntim,asfallows; Name: 414 AJ40/1 C- ��C�� Scttton: Block- 14t:_[ ! &,Vale borne eor7eers Baggc.- 15-46tr152 fC�C•G�-•r"� This is to certify that the Information provided is correct to the best of my knowledge.I understand tlrat any perVIII(s) Wiled hereafter arc subject to suspension or revocation,If the site ptans or intended use change,or if the inrorntathon submlttcl to this appliotlaa is fatsifred or draatnl I,rtlsv,rmdGJ?Cnd lhef J anF r aponsFbls jot elf�lrorra lncnrrrd from this application. I,hereby,give eatutot to the Authorized Representative or the Davie County Health Dcpartmtat to enter upon above described property located in Davie County and owned by to conduct all testing procedures as accessary to determine the site sus i -9ZGNATURE , THIS AREA MAY BE USED FOR IM,kWINC YOUR SITE PLAN(Include a0 of the relloeTing: Existing and proposed property Sties end diatens(ons,structures.setbada, and septic locations). Site Revisit CYarfe Date($): Client Notification Dale: EHS. G c Sign given- Account No. Rgvisod DCHD((15!03 invoice Na DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation - APPLICAM�,&AR 85 Tax PIN/EH#: 51Ft 95#NWgV'FORMATION billed To:, Dick Anderson Construction Subdivision Info: Marchwoods Phase 4 Lot# 17 Reference Name: Location/Address: Peoples Creek Rd.-27006 Proposed Facility: Residence Property Size: see map `Date Evaluated: Water Supply: On-Site Well Community Public / PP y� n Evaluation By: Auger Boring Pity v rr Cut FACTORS 1 4 5 6 7 Landscape position Slope% 2 HORIZON I DEPTH — 2 G - 'f G Texture group C Consistence f Structure / 1- S Mineralogy F HORIZON II DEPTH Co I Texture group --T L ConsistenceSN' V S Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE Af !o CLASSIFICATION LONG-TERM ACCEPTANCE RATE •) SITE CLASSIFICATION: EVALUATION BY: v� U✓•�c,� S LONG-TERM ACCEPTANCE RATE: 1-7 OTHER(S)PRESENT: 7AOWdeco REMARKS: P62,00!r.(.e LEGEND Landscape Position R-Ridge S-Shoulder L-Lincar slope FS Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable 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 'SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prisrpatic Mineralogy 1:1,2:1,Mixed iVotes 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 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION;J�LOTZ7— SoiUSite Evaluation APPLICANT'S NAME DATE EVALUATED _ PROPOSED FACILITY PROPERTY SIZE o SUBDIVISION E! G GU,F1� ROAD NAME Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% 61 Ze HORIZON I DEPTH �— Texture group —S,291— Consistence L Consistence Structure r n Mineralogy HORIZON 11 DEPTH Texture group Consistence Structure I Mineralogy /.' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE (/ SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H.-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam . SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE 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(01-90)