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340 Richie Rd , Davie County,NC ' — / Tax Parcel Report Thursday, February 23, 20]7 Ix 495 15 55 351 45 447` 166. 276 529 215 THIS IS NOT ASURVEY Parcel Number E30000005101 Township: Clarksville NCPIN Number: 5821886894 Municipality: Account Number: 61048000 Census Tract: 37059'801 Listed Owner 1: R|CH|EMARY NELL Voting Precinct: . CLARKSV|LLE Mailing Address 1: 351R|CH|EROAD Planning Jurisdiction: Davie County City: MOOKSV|LLE Zoning Class: O/YV|ECOUNTY R' O State: NC Zoning Overlay: Zip Code: 270284924 Voluntary Ag.District: No Legal Description: 13456ACFUCH|ERD Fire Response District: WILLIAM FiD/VV|E Assessed Acreage: 12/63 Elementary School Zone: WILLIAM RDAV|E Deed Date: 10/2015 Middle School Zone: NORTHD/V/|E Deed Book/Page: 010030040 Soil Types: K8rC2.GnB2.RnD.MoC Plat Book: Flood Zone: Plat Page: Watershed Overlay: OAV|ECOUNTY � ���na Building 9Q7OO d|nQ�a|um` OOO ' ' Outbuilding�~FvemtuomaValue: ' Land Value: 87740.00 Total Market Value: 187440]30 Total Assessed Value: 104820.00 All data Is pro Ided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NC or arising out of the use or Inability to use the GIS data provided by this website. - 14 OPERATION PERMIT or ice se nv s Davie County Health Department *CDP Fite Number- 219660-1 .� 210 Hospital Street 5821666894 r P.O.Box 848 County ID Number Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Townshi p Applicant: Mary Nell Richie Property owner: Mary Nell Richie Address:- 351 Richie Rd Address: 351 Richie Rd City: Mocksville City: Mocksville StatefZip: -NC 27028 State0p: NC 27028 Phone#: (336)998-3771 Phone#: (336)998-3771 Property Location & Site Information Address/Road#: c3gQ Subdivision: Phase: Lot: Richie Road -- Mocksville NC 27028 Directions Hwy 601 N. to Richie Rd turn right approx. 1 mile on "Structure SINGLE_FAMILY g #j left across the road from 351 Richie Rd of Bedrooms: 3 #of People: *Water Supply: NEW WELL 1113-Issued by 2140-Nations,Robert "System Classification/Description: _ _ TYPE III G.OTHER NON-CONY.TRENCH SYSTEMS *CA issued by: 2140-Nations,Robert SaproliteSystem? QYes tNo Design Flow: 3 6 0 *DistIributionType: GRAVITY-SERIAL Pump Required? QYes QNo Soil Application Rate: 0 a 7 5 *pre Treatment: - Drain field N trification Field 1 3 0 9 SQ *System Type: INFILTRATOR QUICK 4 STANDARD No. Orcin Lines 3 Installer: daretisalmons Total Trench Length: 3 a 7 ft. Certification#: 2652 Trench Spacing: — 9 Inches O.C. Feet O.C., *EMS: 2140-Nations,Robert Trench Width: — 3 Oin tes Date: 1 0 / a 0 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Approval Status, Maximum Trench Depth: 3 6 ® Aper©ved© Disapproved Inches : . Maximum Soil Cover. � 2 4 Inches CDP Fite Number 219660 - 1 County'ID Number: 5821666894} Septic Tank ' Manufacturer. Shoaf Lat. Lang: STB: 760 Gallons: 1600 Installer: Darrell Salmons Certification#: 2652Shoaf Dater 0 9 J 0 5 / x 0 1 6 ' *EHS: 2140-Nations,Robert 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker El Yes 0 No Date: 1 6 I a 0 I a 0 1 6 Reinforced Tank: ElYes ® NO =Approval Status 1 Piece Tank: ❑ Yes ® No ® Approved❑ :Disapproved: Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: 'EHS: Date: / I Date: RiserSealed ❑ Yes ❑ No Riser Height: El Yes ❑ No (Min.6 in.) APProvalStatus Reinforced Tank ❑ Yes ❑ N0 D roved 0,Disapproved. 1 Piece Tank: ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: THS: Pressure Rated_❑ Yes ❑ No Date: I I Approved fittings ❑ Yes ❑ No Approval Status [� Approved❑= Disapproved Pump equirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches THS, *Chain: J J Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No :Approval Status PVC unions El Yes ❑ No ❑ Approved❑ Disapproved Vent Hale ❑ Yes ❑ No Anti-siphon Hale ❑ Yes ❑ No CDP,File Number 219660 - 1 ' County ID Number: 21666894 Electric Equipment NEMA 4X Box or Equivalent C1 Yes ElNo Installer: Box 12 inches Above Grade E3 Yes 1:1No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No01 9000 ❑ Approved❑ 131sapproved y , Alarm Visible ❑ Yes ❑ NO � " 2140-Nation,Robert *Operation,Permit completed by: __Authorized State Agent: Date of Issue: 1 0 2 0 2 0 1. 6 -- Owner/Applicant Sig This system has:been installed incompliance wRh applicable NC General Statutes:Article 11, Chapter 130A, Rules for :_Sewage Treatment and D1sposal;-15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and . Construction Author¢ation.This property is served by a TYPE III G. sewage septic system. - Rule:1961 requires that a Type TYPE III G. septic system meet the following criteria: - Minimum System Review ByThe Local Health Department: NIA M an_ag eme nt.Entity: OWNER Minimum,System Inspection/Maintenance Frequency ByCertified 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 forthe life of the septic system. Rule.1961 requires that Type VI septic systems designed for a hometbusiness 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 Perm it fora system required to be maintained by public or private management entity, unless the system owner and 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 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 CDP File Number: 219660- 1 210 Hospital Street 5821666894 P.O.Bax 848 County File Number: Mocksville NC 27028 Date: Q Inch Scale: , QBlock Drawing Drawing Type: Operation Permit ON/A - {{ I - I a - � , I 1 I CO�I� -rRUC-i10N ForOfficeUse Onty- ` AUTHORIZATION *CDP File Number 219660-1 Davie County Health Department , County ID Number 5821666894 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 0 7 / a 0 a 0 a 1 Applicant: Mary Nell Richie Property Owner: Mary Nell Richie Address: 351 Richie Rd Address: 351 Richie Rd City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)998-3771 Phone#: (336)998-3771 Property Location &Site Information r ress/Road#: Subdivision: Phase: Lot: chie Road ocksville NC 27028 Directions Structure SINGLE FAMILY Hwy 601 N. to Richie Rd turn right approx. 1 mile on left — across the road from 351 Richie Rd #of Bedrooms: 3 #of People: 'Water Supply: NEW WELL System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover: 1 a Saprolite System? OYes tNo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: Maximum Soil Cover: 0 a ? 5 a 4 Inches *System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes ONo Pump Required: OYes @No OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1-Piece: OYes ONo Total Trench Length: 3 a ' 7 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. 9 @Feet O.C. Dosing Volume: _ Gallons Trench Width: Inches 3Feet Grease Trap: Gallons Aggregate Depth: - - inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: OI OII 0111 01V Donn 1 ^f'l CDP File Number 219660 - 1 County ID Ndmberi58216$6894 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: Inches O.0 ification: Provisionally Suitable — E3 Feet O.C. Trench Width: QInches w: 3 6 0 — 3 . @ Feet Soil Application Rate: Aggregate Depth: 0 � � 5 inches Minimum Trench Depth: a 4 "System Classification/Description: Inches TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches "Proposed System: 25%REDUCTION _ Maximum Soil Cover: a 4 Nitrification Field 3 Sq.ft.1 3 0 9 Inches - No. Drain Lines *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 a 7 Pump Required: Oyes QNo OMay Be Required Pre Treatment: ONSF OTS-I OTS-II *Site Modifications No1grading or construction activity is allowed.in areas designated for system and repair without approval of Health Department. i *Permit Conditions The issuance of this permit bythe 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. ; This Authorization for wastewater System Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)�If the installation has not been completed during the period of validity of the Construction Perm%the information submitted In the application for a permit or Construction Authorization is found to have been incorrect falsified or charred,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? OYes ONO Applicant/Legal Reps. Signature: Date: J *Issued By: 2140-Nations.Robert Date of Issue: 0 7 a 0 a 0 1 6 - Authorized State Agent: Malfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street 5821666894 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 7 / a 0 / a 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: , . . QBlock QN/A Ts ► I , . r— _ _.�, CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 5821656894 Mocksville NC 27028 County File Number: Date: 07 / 20 / 2 0 1 6 Click below to import an Image from an external location: Drawing Type:Construction Authorization toc, ��ao6 100 -t � O 11140/1 .l V 'tVeli'Construe#ion Permit For Office Use Only 0., ' Davie County Health Department *GDF"dile Number 219660_. 210 Hospital Street PIN Number 5821666834 P.O. Box 848 •,,a;�.• Tax Lot#: Tax Block#: Mocksville NC 27028 Phone: 336-753-6780 Pax: 336-753-1680 WELL Evaluated For: PERMIT VALID UNTIL: 7/20/2021 a+! r erty Owner: Mary Nell Richie Applicant: Mary Nell Richie ress: 351 Richie Rd Address: 351 Richie Rd City: Mocksville City: Mocksville State2ip: NC 27028 State/Zip: NC 27028 Phone#: (336)998-3771 Phone#: (336)998-3771 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Richie Road *Proposed use of Well: Mocksville NC 27028 If 0the r: Latitude Longitude Directions Site Address: Richie Road Directions: Hwy 601 N.to Richie Rd turn right approx. 1 mile on left across the road from 351 Richie Rd Well Contractor Information Drilling Contractor Driller Registration Permit Conditions *Permit Conditions , Well location,construction and protection must meet all state and local regulations and must be Inspected and approved by an authorized representative of the Local Health Department.The permit may be revoked at any time for failure to complywith existing regulations.The siting of approved well construction area(s)by the Health Department is to provide protection from the knmvn possible sources of contamination.The approved well area(s)may not be changed without written permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the Health Department. *Issued By: 2140-Nations, Robert *Date of Issue; 0 , 7 , / t 2 , 0 1 / , 2 , 0 , 1 , 6 Authorized State Agen : @Hand Drawing Olmport Drawing Owner/Applicant Sign **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT a a Davie County Health Department CDP File Number 2996 210 Hospital Street 5821666894 P.O.Box 848 County File Number. V Mocksvige NC 27028 Date: 0 7 ! 2 0 / 2 0 1 6 « ...� . Q Inch Drawing Type: Well Permit Scale: , Q d A k ft. TIN I 11 I I I I -' I—J——j— E,� APPLICATION FOR PRIVATE WELL PERMIT " Davie County Environmental Health P.O.Box 848/210 Hospital Street DDW O Mocksville,NC 27028 . (336)753-6780/Fax(336)751-8786 ***IMPORTANT""** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed mae-u Ke11 Contact Person Billing Address 2971 ick e R1 Home Phone 3 3&-998'3-7-71 City/State/ZIP C- 9,702Y Business Phone Email e of Name on Permit if Di rent 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) Owner's Name m 2y K1.0_11 "Ric i�, Phone Number 33( -qqS- 37?/ Owner's Address—'R trc-h e '] City/State/Zip �(Csv Ili �f C 27�� Property Address 'R;cht e T L, City MpCjCsd i IIS UC. Lot Size r,/�12,h,,3 c Tax PIN#M,2I , 9%L ' SubdivisionrName(if applicable) Section/Lot# Directions To Site: lo01 M 4D A j,-�,'FA -4urztj le-pr4if appaot . I M QN le F Owns& � 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 The Site? YES N(5—.,,/ Do You Intend To Install A New Septic System On This Site? YES 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 marking 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 well. &2Ae4e� —/0 — 20/G Signed Date Site Revisit Charge Date(s): Tient Notification Date: EHS: 7/30/09 Account Invoice# DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: eGlid, O File #: Site Address: ? CCAl��r/f c% 1� Ad Subdivision: Lot: Permit Type: New Well Well Repair Well Abandonment Other FacilityType: Residential " Food Service yp Church Commercial Other _Initial Inspection Were Setbacks Maintained? Ye ? r/ Yes No What is the Grout Depth. � ft. If No, Explain: What is the Grout Thickness? tr in. What is the Type of Well? ,���//.e0 Was a Well Screen Installed? What is the Casing Type? Mc- i Type of Drilling Fluids Used: What is the Casing Depth? /47(t ft. Well Grout Inspection Date: What is the Well Diameter? in. GPS Coordinates: What is the Well. Depth? /rUUr/ ft. EHS ID: Well Head Inspection Is There an Access Port? ✓ Is There a Vent? ✓ Is There a 4 Pad? NG Is There a Hose Bibb? What is the Casing Height?g _��, i Is There any Grout Settlement. What is the Static Water Level? _ft. What is the Yield? GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name: l" ad oA �'V'eff Pump Installer Name: Contractor Certification #: '7\O tP Date Installed: Depth of Well: ( ad oc> Depth of Pump Intake: Casing Depth and Inside Diameter: / '-{ / G" Pump Horsepower Rating: Screened Intervals: Opening for Piping & Wiring >_ 12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: Date Well Completed: Well Head Inspection Date: EHS ID: Construction Completed Date: Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Date: Authorized Agent: `l . j f :i i � � 1 •` • APPLICATION FOR PRIVATE WELL PERMIT Davie'County Environmental Health P.O.Bog 848/210 Hospital Street Date. ��O Mocksville,NC 27028 (336)753-67801 Fag(3367751-8786 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed e c Contact Person Billing Address -3,�I 1ichie 2d- Home Phone 3 3l0-gg8'37,71 City/State/ZIP QndGksyi II e W (1- �),7D2Y Business Phone Email �c %e ek Name on Permit if Diff rent than Above Wiling 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) Owner's Name M ey Kln.11 Phone Number 33 L--qq S- 377/ Owner's Address 91 ' -Rh-hie_ IL City/State/Zip 27mg Property Address 2j c ht e "Pr1_ City_kcksv i Il e- me . Lot Size n . 12,&3 SubdivisionName(if applicable) Section/Lot# Directions To Site: toot M 4y -6,go Ic I A 1 ) n p t . I Yh nN l e ; Qr r2oss 4 p_ l 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 The Site? YES NO_�� Do You Intend To Install A New Septic System On This Site? YES 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 marking 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 well. Signed Date Site Revisit Charge Date(s): Tient Notification Date: EHS: 7/30/09 Account# Invoice# IUB y V r � Fes' . y • r ,.. .q a e 297 2 3 ' _ �yy � zsa 32� �g we 11 23r WELL CONSTRUCTION PERMIT Davie County Health Department 219660 F 210 Hospital Street CDP File Number: P.O. BOX 848 5821666894 County File Number: ��`• ""R °" Mocksville NC 27028 Date: .0.7./ ..2 0. ..2 0.1.6. Drawing Type: Well Permit Page 2 of 2 Pi P2 • IMPROVEMENT PERMIT Farofrcevse omv *CDP File Number 219660-1 Davie County Health Department 210 Hospital Street County ID Number.5821666s94 ,. Evaluated For. NEW P.O. Box 848 Mocksville NC 27028 Township: Phone: 336-753-6780 Fax:336-753-1680 PERFIIT VALID UNTIL 7/20/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit. Applicant: Mary Nell Richie Property owner: Mary Nell Richie Address: 351 Richie Rd Address: 351 Richie Rd City: Mocksville City: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: (336)998-3771 Phane#: (336) 998-3771 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Richie Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 N. to Richie Rd turn right approx. 1 mile on - '#of Bedrooms:` 3 left across the road from 351 Richie Rd #of People: *Water Supply: NEW WELL System Specifications nitial S sy tem *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 . Inches Saprolite System? QYes Q 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 QNo u *System Class iftcatioNDescription: Pump Required: QYes (D No OMay Be Required TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: QYes ONo Repair System Required:QYes ONO ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 2 7 5 Maximum Trench Depth: 3 6 Inches u *System Classification/Description: Pump Required: QYes Q No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 219660 - 1 County ID Number: 5821666894 . *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 no way 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 shag be valid for 5 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 thefaality and appurtenances,the O 0 site for the proposed Wastewater system,and the location of water supplies and surfacewaters). Plat The Improvement Permit shag 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 more than 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(%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 7 2 0 2 0 1 6 Authorized State Agent: OValid without Expiration? OCre ate CA. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT Davie County Health department CDP File Number: 219660 - 1 210 Hospital Street 5821666894 P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! Q Inch Drawing Drawing Type: Improvement Permit Scale: , OBIock ON/A I ► I �� 1-01" 4- I -cam ,-L _sem_, o I � i �� IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 219660- 1 P.O.Box 848 5$21666$94 Mocksville NC 2702$ County File Number: Date: .© 7 .1 0 X 2 0 1 6 i Click below to Import an image from an external location:Drawing Type: Improvement Permit y t :i � rQ / APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC s r Davie County Environmental Health PI P.O.Box 848/210 Hospital StreetC,EI rVZ,iD Mocksville,NC 27028 •s• \\\ (336)753-6780/Fax(336)753-1680 Application For:/Site Evaluation/Improvement Permit Authorization To Construct(ATC) Both 6f Type of Application:ANew 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. APPLICANT INFORMATION .p ' / Name to be Billed�� V E-kt 1��c�,e, Contact Person Vo." de-11 Billing Address ' k; Home Phone 31(p- Jn- 277,/ City/State/ZIP s 121 Ile C_ a702% Business Phone Name on Permit/ATC ifDierent than Above &f/ '336 'WU"'fs 73 Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 4-1,0- 201 NOTE: A survey plat or site plan must accompany this application. Included:g Site Plan ❑Plat(to scale) (Permit is valid for 60 onths with site plan,no expiration with complete plat.) Owner's Name lti;� Ker« ichie Phone Number 33(.r- -,:?771 Owner's Address ZLSI c11 1p_ 'R.d- City/State/Zip ICK' x.702$ Property Address city_ftryj�sw►1e me- Lot LLot Size P/D .(a.3 Tax PIN# $4!V= Subdivision Name(if applicable) Section/Lot# Directions To Site:1pa N� 4o 'P-J p) ���0� DN LICROss 4he 12r�,2d 4L .26-1 RIch1A Td. ' 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)(No Does the site contain jurisdictional wetlands? ❑Yes XNo Are there any easements or right-of-ways on the site? ❑Yes Flo 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 A #Bedrooms 5 #Bathrooms:— Garden Tub/Whirlpool❑Yes ANo Basement: ❑Yes XNo Basement Plumbing: ❑Yes o 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: Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:0 County/City Water ` New Well ❑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 1 ca' and flaggin or stakin yse/facility location,proposed well location and the location of any other amenities. t7/"�h egg 14W�) Site Revisit Charge Property o 's o er's le representative signature / Date(s): 6P- /0,,,R eg Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# 101 Revised 11/06 Invoice# 4 co N 327. 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Division of Environmental Health On-Site Wastewater Section - *Date: 0 7 / 1 9 / 2 0 1 6 Soil/Site Evaluation 'File#: 2 1 9 6 6 0 For On-Site Wastewater System PIN M 6821666894 "Owner Mary Nell Richie Proposed Facility SINGLE FAMILY Proposed Design Flow(.1949) Location of Site Richie Road Property Size 12.63 Water Supply NEW WELL Evaluation Method n/a 1 40 Horizon SOIL MORPHOLOGY Profile# Landscape Depth .1941 Other Profile POS Slope 0/0 � (IN) Mineralogy Matrix Mottle Factors Texture Structure Consistence Color Color 1 L 048 C 3-Stng sbk fi s P .1942 Wet. 2 .1943 Depth GPS Saprolite:(in) .1944 Rest. Horizon EHS .1947 Class Psi Nations,Robe Profile LTAR 0 • 2 7 5 L 0-48 C 3-Stng sbk fi s P .1942 Wet. 2 % .1943 Depth GPS Saprolite:on) .1944 Rest. Horizon EHS .1947 Class Ps Cop rofile Nations,Robe PTrAR 0 2 7 5 3 L, 048 C 3-Stng sbk fi s P .1942 Wet. 2 % - .1943 Depth GPS Saprolite:00 .1944 Rest. Horizon EHS 1947 Class PS Copy rofileNations,Robe Profile 0 2 7 5 LTAR,_.., .1942 Wet. % .1943 Depth GPS Saprolite:on) .1944 Rest. Horizon EHS .1947 Class Copy Profile Profile PA R .1942 Wet. % .1943 Depth GPS Saprolde:(in) .1944 Rest. Horizon EHS 1947 Class Copy ofile Profile LTAR Available Space(.1945) S OtherFactors(.1946) PS Site Classification (.1948)Ps Initial LTAR: o 2 7 5 Repair LTAR: o . 2 7 5 Others Present: Comments: Evaluated By. Nations,Robert NCDENR y Division of Environmental Health On-Site Wastewater Section Date: ,e I o / o i 6 Soil/Site Evaluation Fie#: 2 2 9 6 6 0 For On-Site Wastewater System PIN #: 5 s a 2 6 6 6 8 9 4 1940 Horizon SOIL MORPHOLOGY Lan scape .1941 Other Profile Profile# Depth Sops'Vo (IN) Mineralogy Matrix Mottle Factors Texture Structure Consistence Color Color 1942 Wet. % 1943 Depth GPS Saprolfte:(in) .1944 Rest. Horizon EHS .1947 Class Copy�rofil Profile LTAR .1942 Wet. 4l0 .1943 Depth GPS Saptolite:(in) .1944 Rest. Horizon EHS .1947 Class Copy�rofil Profile LTAR .1942 Wet. % .1943 Depth 5aprolde:00 .1944 Rest. GPS Horizon .1947 Class EHS Copy rofil Proale LTAR,__, .1942 Wet. efp .1943 Depth GPS Saprolite:Gn) .1944 Rest. Horizon EHS .1947 Class Copy-P-rofil Profile LTAR .1942 Wet. o� .1943 Depth GPS Saprolite:(n) .1844 t. raEHS .1947 Class Copy�rofil Profile LTAR Comments: • Attach !maga The "Open Drawing Form"button, opens the the drawing form. The "Import"button, attaches the drawing, or other image into the space below. Open Drawing Form Profile: 1 X Y Z Profile: 2 X Y Z Profile: 3X Y Z Profile: 1@ X Y Z Profile: X Y Z Profile: Q X Y Z Profile: X Y Z Profile: X Y Z Profile: Q X Y Z Profile: X Y Z NCDENR ' Division of Environmental Health On-Site Wastewater Section "Date: e / 1 9 I a 1 6 Soil/Site Evaluation 'File#: a 1 9 6 6 0 For On-Site Wastewater System PIN #: 5821666894 'Owner Mary Nell Richie Proposed Facility SINGLE FAMILY Proposed Design Flow (.1949) Location of Site Richie Road Property Size 12.63 Water Supply NEW WELL Evaluation Method n/a 1 40 Horizon SOIL MORPHOLOGY Profile# Landscape .1941 Other Profile Depth Slope% (IN) Mineralogy Matrix Mottle Factors p Texture Structure Consistence Color Color 1 L 0-48 C 3-Stng sbk fi Is P .1942 Wet. 2 % .1943 Depth GPS Saprolite'.(in) .1944 Rest. Horizon EHS. .1947 Class Nations,Robe Profile 0 5 LTAR,_ 2 L 0-48 C 3-Stng sbk fi s P .1942 Wet. 2 % .1943 Depth GPS Saprolite:00 .1944 Rest. Horizon ENS1947 Class Ps . Co rofile Nations,Robe Profile 0 2 7 5 its LTAR,_ 3 L 0-48 C 3-Stng sbk fi s p .1942 Wet. 2 % .1943 Depth GPS Saprolite:(m) .1944 Rest. Horizon EHS 1947 Class Ps Copy-Profile Nations,Robe Profile 6 L 7 5 � LTAR_._, 1942 Wet. % .1943 Depth GPS Saprolitcon) .1944 Rest. Horizon EHS I. 1947 Class Copy..Profile Profile LTAR .1942 Wet. .1943 Depth GPS Saprolite:(in) .1944 Rest. Horizon ra .1947 Class EHS Copy oflle Profile LTAR Available Space(.1945) PS Other Factots(.1946) PS Site Classification (.1948)Ps Initial LTAR: e . a 7 5 Repair LTAR: o . 3 7 5 Others Present: Comments: Evaluated By: Nations.Robert NCDENR ' Division of Environmental Health On-Site Wastewater Section Date: ,e ! e i�a�e 6 Soil/Site Evaluation Fie : 2 1 9 6 6 0 For On-Site Wastewater System PIN 9: 5 8 .1 1 6 6 6 8 9 4 1940 Horizon SOIL MORPHOLOGY Lan scape .1941 Other Profile Profileg POS Depth Factors Slope°�o (IN) Mineralogy Matrix Mottle Texture Structure Consistence Color Color .1942 wet. % 1943 Depth GPS Saprolde:(in) .1944 Rest. Horizon t- EHS .1947 Class COpy�rofil Profile LTAR. . • . .1942 Wet. % .1943 Depth GPS Saprolde:Gn) .194 Rest. on .1947 Class EHS Copy�rofil Profile LTAR r, .1942 Wet. % .1943 Depth GPS Saprobe:(in) .1944 Rest. Horizon .1947 Class EHS Copy rofil Profile LTAR .1942 Wet. % .1943 Depth GPS Saprolde:(in) .1944 Rest. Horizon EHS .1947 Class Copy�rord Profile LTAR .1942 Wet. % .1943 Depth GPS Saprolite:(in) "ltioilzonst. EHS 1947 Class C°py—E',r°tii Profile LJ LTAR Comments: - - Attach Image _ The "©pen Drawing Foran"button, opens the the drawing form. The "Import"button, attaches the drawing, or other image Into the space below. Jv Open Drawing Farm Profile: 1 X Y Z • . -- Profile: 2 X-. Y Z Profile: 3 .7 X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y_ Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z