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151 Rockwell Ln _ _ _ _ _ _ _ .. _ _ _ _ __ . • OPERATION PERMIT or �ce se n v '�w . � � . . �.� . * � .. �3�� 2D10 Hospital Street �th De artment CDP.File Num6�er��8�i2 P.O.Box 848 County 10 Number;. , ; . '� . : �`°�' Mocksvilie NC; 27028: Evaluated.For. NE1.N Phone:33&753-5780 Fa�c:336-753-1680 Township: ', Appiicsnt; Robert Lauwers P�perty awner Human Service Alliance : Adaress: 433�N. Main St Address: 249 Gilber#Rd ��v, Mocksville ��Y= Mocksvilis statelZip: NC 2?028 state2ip: NC 2�028 Phone#: (336)99$-397'! Phone#: Pro e Location � Site Information AddresslRoad#: Subdivisan: Phase: lot: Q Rockwell Lane Mocksville NC 27028 Directions scructure: SINGIE FAMILY 158 to Farmington Rd. tum left, ri�ht+on PinebroQk Dr. runs into Gilbert Rd. on left #of Bed�oms: 2 #of People: 'eWate�Supply: PUsuC "IP Issued by. 2�ao-t�ar�ons,ttobert 'System Classifkatan/Oescriptian: TYPE III B:SYSTEM WlSINGIE EFFLUENT PUMP •CA issued by: 2�ao-Nat;ons,Robert Saprolite System? QQ Yes �No Design Flow: a q � RDistribution Type: �MP TO GRAVITY Pump Required? QYes QNo Soil Apptication Rate: � , a =pre Treatment: Drain fleld N�rification Field 1 a � g SQ•�• 'System Type: �NFILTRAT�RG�UICK4 STANDARD No.Drain Lines 4 Instaper. �rian Mcoantel Total T�ench Length: 4 0 0 �• CertificaGon#: Trench Spacing: _ 9 Inches O.C. •EHS: 2�40-Na�ons.�tober► ` ,�.� �Feet O.C. Ttench Width: _ 3 gF�t S oacs: � s / a � laeis _ , Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches �� Minimum Soil Cover. a 4 Approva��tatus� '� �� , Inches �Maximum 7�nch De th• - � ':�� p • 3 6 , � 'APProvea L��'D��appro�ed ��° Inches Maximum Soil Cover. a ,� - inches _ _ _ _ _ _ _ _ _ _ __ . _ ._ _ __ CDP Fite Number 1$7�3 ` � County lD Num�er: E�-oon-oQ-as�-�2 ' . Se tic Tar�k Manufacturer S� Lat. Long: STB: 760 "_,_, . Gallons: �� InstaQer. B��McOaniel D��: 0 4 / a 0 / a 0 1 5 Certification#: 'EH S: 2148-Natiats,Robert *Filter Brand: POLYLOK PI.-122 With pipe Adapter ST Marker. ❑ Yes � No Date: . 0 . 8 / � 0 / a 0 1 S ,� �, � � �� a�. Reinforced Tank: ❑ Y�S 0 NO '� �� Piece Tank: O Yes G7 No � y '� Appro�ed O Dasappnove� � $7��; z� ' r�iv. �:,� �� Pump Tank MBnufaCtur�r. �Shoaf InstBpe�: B�n McDanief PT: 42 Certification#: Gallons: �25d *EH�; 21aa-Nacions.Robert Date: ea 1 � 1l a � s � p��e: � s / a � / a � �. s RiserSealed � YeS ❑ NO RiserHeight: 0 Yes O No {Min.6 in.} �� rAppir�vsl St�tus ��' �� , . � r+� Reinforced Tank: O Yes CI No �1 Approved�i Disap�+toveti 1 Pieoe T�nk: p Yes ❑ No � � �u��,<<a� �.�, � g 4 ,��, t �,��q � � ��.�� . Supply Line Pipe Size: a inch diameter insteaer. ��n McDanlel Pipe Length: 4 9 1 feet Certincation#: 'EH S: 2�48-tVations,Robert *Schedute: 4p Pressure Rated � Y�S ❑ No Date: � $ � a (� � � 0 1 5 Approved f�ttings [] Yes ❑ No �`;� ` �,Ap,nral Status ' �� =Cl �pproved�� isap�rroved '_� ,*, "��`�.� W 4��r-. ,��°� , �i,�i� .��.�,a ,, Pum p Type: zosier Insta�er. Brtan�ic�antel Dosing Volume: - �� Certificatian#: Draw Down: Inches `EHS: 2140-Nations,Robert *Chain: srEutv�Ess g g / a (� / a 0 1 5 Date: ,_,_, Vafves Accessibie p Yes ❑ NO Flow Adjustment Valve p YBs ❑ No �na�k�a�►� a Y�s ❑ No �� ,�y��;�� ,� �� Pvc unions �p Yes� ❑ N o�. � � �I Approired C� D�sapproued � �� - v'.� . .- . ..,. . .. a��' �—�„ ` �� o�� :�,�� °4.e�`�. �� ' , . .,,.. .� ,.,�,. - ent H��e O Yes ❑ No Anti-siphon Hole � Y�S ❑ NO _ � _ _ _ _ _ _ _ _ _ � CDP File Number 187�� - '� County ID Number: ��'000-�-a�3•y2 Electric E ui ment NEMA4X Box or Equivalent [� y�$ ❑ Na instaMer. Box 12 inches Above Grade p Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump ManuailyOperable ❑ Yes ❑ No *Activation Method: Date: , � l . .�: � .� �� _ � � Approtiral Sfatus. . ' AIaRn'Audible O Yes; � No t � l��.i4pprove�� DEsappirov�ed' � ' Alartn visibls ❑ Yes ❑ No 2140-Nations,Robert "Operation Permit complefed by� Authorized State Ag ,��'= Date of Issue: � $ � a 6 / a 0 1 5 OwnerlApplicant Signatu�e: This system has been instatlsd in compliance w�h appticable NC Generat Statutes:Article 11,Chapter 130A, Rutes for Sewaga Treatment and Disposal,15A NCAC 18A,19�et.Seq.,and aq conditions of the Improvement,Permit and Gonstn�ction Authorization.This property is senred by a�F pi B, sewage $eptic system. Rule.1961 requires that a Type ��$• septic system meet the foUowing criteria: Minimum System Review ByThe Local Health Department: 5�$� Management Entity: OWNER Minimum System InspectionAVlaintenance FrequencyByCertified Operetor: wA Reporting F�equency By Ce�tified Operator.wA .1.96t�equires that a Type IV and V septic sys#ems desgned tora home/business owner must maintain a valid contract with a public management entity w�h a ce�tified operatoror a private certifed operato�forthe tife of the septic s�ystem. �ule.1961 �equires that Type VI septic systems designed for a hom�lbusiness owner must maintain a valid cantract wfth a public management entitywith a ce�tified operator forthe liFe of the septic system. Rule. 1961,(2)(e)requires a contract shaU be executed betwesn ihe system owner and a managemen#ent�y priorto the issuance of an��peratio�Permit for a system required to be meintained by a pubGc o�private management ent�y,unless the system awnerend certified operatorare the same. The contFact shall require spscific requirements formeintenance and operatian,`responsibiities of the owner.and systems,operetor,provisions that the`cont�act shall be a� effect for as long as:the system is in use,and otherrequiremenfs forthe;continued proper performance of the system. R shall also tie a candkian of the Operaition Petmit that subsequent owners of the systems execute such a contract. OHand Drawing 4lmport Drawing � �,.; **Site PIanlDrawing attached.** �� _ _ _ _ _ . _ _ _ � GPERATION PERMIT ' Davie Caunt�Heatth Oepartment COP File Number: 187843- 1 210 HOSpital Street ES-000-00-033-12 P.Q.�x� Cour�ty File Number: Mocksvilie N� 2�02$ o�t�: � r � Qinch Drawin Drawing Type: Operation Permit S��e" ' ' . dN�k = . .�. � _ _ _ � _ �. � , _ _ __ ..=�'_ •�� ' --+- - - � .,�,,, ` ' lv � �. .� ��..�:.... _��_ , . �to : , I l I ; ' I I ', ._ �. . .� . _ .� .... - , � � ► -� � , , , , � �� . . _ � . .�� .� ��.�.�....�� :�_ ..�,�, ��..�... �.....�..� .��.�. �: .� �� ..�.� .��.___-�_ � , ., c� �} I �� .. � _ _ . _. . �o b _ .: } � � � ��,� � w . _. _ _ _ I f � � � _ _� �. ��.I.. . , -�� I � , _t�. .� _ �� .� � ! �� ' _.�... _ . .: .� � : _ .___l _ . _ _ �.:::.�.. ��` _ _ � �� _ _ _ _ �� _ _ . � - , �,,:-�,�-�----. , _ _ � __ _ � _ _ .�_._._.....�._��._�._�..� . . . � .��. . _ _ ._..___�W...._ V �. _ , l..�._ ..( � � . • - � CONSTRUCTION For office use on�v AUTHORIZATION *CDP File Number 187843- 1 . �•"�•� Davie County Health Department County ID Number. E5-000=00-033-�2 � , ,� 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 5 / 1 8 / �� 0 a 0 Applicant: Robert Lauwers Property Owner: Human Service Alliance Address: 433 N. Main St Address: 249 Gilbert Rd City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �336)998-3971 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: 4 Rockwell Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY 158 to Farmington Rd. turn left, right on Pinebrook Dr. runs into Gilbert Rd. on left #of Bedrooms: 2 #of People: *Water Supply: Pusuc Svstem Specifications Minimum Trench Depth: a 4 Slte CIeSSIfICBtlOf1: Provisionally Suitable Inches Saprolite System? �Yes �No Minimum Soil Cover: 1 a Inches Design Flow: a 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: � _ � Maximum Soil Cover: a 4, Inches *System Classification/Description: *DIStfIbUtI0f1 Typ@: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 � Gallons *Proposed System: 25%REDUCTION 1-Piece: �Yes �No � Pump Required: �Yes QNo Q May Be Required Nitrification Field 1 a 0 � Sq.ft. Pump Tank: 1 0 � 0 Gallons No. Drain Lines 3 1-Piece: �Yes �No Total Trench Length: 4 � � ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. — g �Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches _ �Feet Grease Tra Gallons P�. Aggregate Depth: inches Pre-Treatment: O NSF OTS-I O TS-II Septic Tank Installer Grade Level Required: �I �II �III �IV Page 1 of 3 • [ E5-000-00-033-12 � „' � CDP File Number 187843 - 1 County ID Number: _ ' ❑ Open Pump System Sheet Repair System Required:�YeS O No O No, but has Available Space Repair Svstem Trench Spacing: g �Inches O.C. *Site Classification: Provisionany suitabie — �Feet O.C. Trench Width: QInches . Design Flow: a 4 � — 3 Q9 Feet Aggregate Depth: Soil Application Rate: � . a inches � Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 � Inches Maximum Trench Depth: 3 6 Inches *PfOPOS@C�SySt@fTl: 25%REDUCTION Maximum Soil Cover: a 4 Nitrification Field a 1 � � Inches Sq.ft. No. Drain Lines 3 "DIStI'IbUtI0f1 Typ@: PUMP TO GRAVITY Total Trench Length: 4 0 0 ft, Pump Required: �Yes Q No Q 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. R ma�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. Reme��9 2000 Thls 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 lnformation submitted tn the appllcation for a permit or Construction Authorization is found to have been incorrect,falslfied or changed,or the site is altered,the permit or Construction Authorization shall become invalld,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shatl be responsible for assuring compllance _ with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reportfng and repafr (1938(b)). ApplicanULegal Reps. Signature Required? O Yes �NO ApplicanULegal Reps. Signature� Date: � � 'ISSUed By: 2�40-Nations,Robert Date of Issue: � 5 / 1 8 / a � 1 5 Authorized State Agent: Malfunction Log OYeS �a; �>; �Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 , � , ' . ' CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 210 Hospital Street E5-000-00-033-12 P.O.Box 848 County File Number: Mocksville Nc Z�o2$ Date: 0 5 / 1 8 / a 0 1 5 �Inch Drawing Drawing Type: Construction Authorization Scale: , . ' p N/A k ' .ft. T--�---- -1—�---f I�r----�-- ��T� , � � � ; , .k � i � - � � � �;.. � � �� i � � � � �y�,_� , , __ _. _ . ___ --- -- __ _ � __p'�_ , __ � _�_ I.__.. f_ .�,,,� I I —. __ _ -- ---------�--- ------------ ------------ ---------� - - - - --- ---------- ----- -------------------- -----�-------------__-- ___ ; � I--- - - � ; � I _ ; � � I � i � . � � I b,_._ ' -- �----- � _ _. _- �---}—�---. —_ -------��jT' -/ --- ---- �--��t- j I ___ __ _ � f.. _ ; I I / � I ; � � �� ` � .. ..... . _.__ ;- --- — --- -- - - _ I_ _� _-- ------.__ .. _....._./��_._.. -- �-- -.. 1�........ ........_. ....... . ... ___... . ... ; / / �� I __ __ _________ � _ i � _ __ �_ —_ — �------___. __. � _. _ —1,� : � � � ---- ---- - -_ ----- __ �_ -- - -. _ ___ _--�---_ __ _ __. � _�_ �� --- _ ; � � _ �.� � __ -_-_-____--�____I_____ _______- _� .___-____ -___ ____- _ _ � ; -----r----- ----t-- ---;--------- - ---- - I — �— — - ----I- ---� — — --� ----I - , - � ��_ � �— --- __ _ I . o 1 i � � � , _ -- - - u.._— s _�- .____ __ .. ��`� I � -� ` o � _ ; _ ' - -t� ��o� ; , � . ; , , , � , i � ; � � � i c� � � ; � � � _ _ ' � � `'�_ - -v ---- � `�., � _ ,_ � _ _ ,<3 �,,� ��f `�-� R�..r _____ ,_-�_ � _ -- ; ---- i__ ____ _ -------- ��--��'`' - - �' '� � � �_U __---- __ _. �_i ��._.�� _�-� � U-I � `�',,��.4 �` j I I __ __-�----- -- -t � � t - ----- _ I j a,,,,lr�c , � � �� --� �-- � +t a— ,� — , ; — ` I � � � i � � �_ ,�� n e �rev�'c' i ''7 �;� 10 4 i�—'�' � i �_ ' " ,�.�.� 'P � i� { V'co �c ' S:e /%, �o� --------.----------- -- - -- -- — -- _ ___ _ ---------- --- ____ . _ . __ ___ _ __ _ ____.__ P 1 P2 Page 3 of 3 . , CONSTRUCTION AUTHORIZATION ' �' ' ' Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 E5-000-00-033-12 Mocksville rvc 2�o2s County File Number: Date: .�.5.�.1.8. �.a.�.1.5. Click below to import an image from an external location: Drawing Type:Construction Authorization � �yn�` / � Y � � / 1 � � A`�` -J ` Q�.� / \ (� V , � � ��, n � h.�� / � � - � � � 1 � � __ -- � � � �� . -- �r e� �01 I � � � � � � � ► � � °� �� . . -- �9 . _, � � � � �� ' �Q� .� , ,c,� � I� � n F � � 1 � � ��J� d u , � JI f� �� o��o�� ,r.��, L � P1 P2 ,o� )an y� S �1 � �: '• • , , • � . ,,- ._ . .� . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health i ��/ P.O.Box 848/210 Hospital Street ��,�1 ��`� Mocksville,NC 27028 ��n� �;� .,}.t (336)753-6780/Fax(336)753-1680 ',}; i Application For: Site Evaluation/Imp�ovement Permit ❑Authorization 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 UNLES S ALL OF TI�REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION . �u�E�s . Name f�o�es- ,— Lc,".,,,�QI-S ContactPerson t�ob¢s'i C-��w�-S Address y 3 3 �v . ,�0.�N s � Home Phone 3 3 to- a 10 - �3 5`i City/State/ZIP M o�.,c 5 v� I I c N c a1�a K Business Phone 33 co-q 3(0-`� 1�\ Email ��b L�..�wers �.C�g M0.�1 • c,o►.�. Name on Permit/ATC if D fferent than Above Mailing Address City/State/Zip ' PROPERTY INFORMATION *Date House/Facili Corners Fla ed 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_s��v.� Vo-�l e� A�c n w� Phone Number 3 3�-9 4�-3�� Owner's Address City/State/Zip Property Address City Lot Size to.y� ACCrzs Tax PIN# ��-�QQ_Q(�'�33- �a, Subdivision Name(if applicable) �eu,t�u L�,,�,� Section/Lot# Directions To Site: Specify Problem Occurring: � - IF RESIDENCE FILL OUT TI�BOX BELOW #People oZ #Bedrooms I #Bath�r oms cZ Garden Tub/Whirlpool ❑Yes o Basement: ❑Y�o Basement Plumbing: ❑Yes QNo' �,,. IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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: C�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: C�County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve7 ❑ Yes �No If yes,what type? This is to certify that the information provided on this application is true and conect to the best of my lrnowledge. 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 locating and flagging or st ' g /facility location,proposed well location and the location of any other amenities. operty o s or owner's legal representative signature Site Revisit Charge c Date(s): �=J "�S� Client Notification Date: Date ' EHS: " { .. �(�� f �In,��G�-- Sign given �Yes �No Account# ( b �✓ Revised 11/06 - Invoice# � � � . � � . Tax Lot 32.03 -� ' , 'fax Map E-5 . ; cker� Jr. � n/f Elizabeth Diane Foster, Trustee under �B.Tucker � Elizabeth Diane �oster Revocable Trust G 21 RB 933 � PG 554 � � � 4 � i � w/Cop Fnd � t� , � Existing Gravel Drive _. T-12 t - ��--------- ---------- -- br w/Cap Fnd formeriy T-8ar w/Cap Fnd i l.-22 � T-Bar w/Cap Fnd T-Ba StAne:� a Walnut Tree ' Control Corner '-- 0.f0' North of P/L " erence`PB t1 � PG 159 Gravel Drive Crossed P/L 0.10' „ _ i � LOT 4 . 6.469 Acres +j- , • inclusive of area in S.ft. 1437 RfW ISoa 5�� I' So --- "t � � - , � � � � J� ��1 .R ck eLl=� Lane �' � ;. 50' (25' ach side CfL) 1 � cess, Utility & ; � - � Snpf System Easement` -. z . .� . ' � - N ti .. ' ' . . � . . . ' # � • . . . �--► �` '�'qp� IRS L-=.16 Total IRS • '" � 40.0' IRS 261.58' �� ' Placed � � in Line : �\ �'- ,Nw ; � LOT 3 � Tract 1 Revised � ,.288 Acres �-�- '�l �� . .^ti ROCKWELL VALLEY , �'� . ._.. Phase � ' . �� RS • L-20 Totat IRS � r� 1RS 281.12' :;':� Reference: PB 11 � PG � `� Ploced . �` � n � in Line l CfL 50' Eosement = P/L ��; - LOT L � f� 1.198 Acres +/- �+ i'' � � '� fRS L-19 Total IRS . �� o iRS 266.21' � N Piaced in Line -- -- LOT 1 � s,a_s sE—t , , Septic Area r, �u` ROCKWELL VALLEY .� I t�'I Easement �3 �d� C/L 30� Phase � "' "�' '� --+ �' Septic System Easement �r u°'i '`� SA-12 f ► Reference: PB 11 � PG 248 N �j 1� -- ---- � j� (15' each side of C/L) -' � r- Septic Area �, � Match Line A ,Match Line A Easement #2 jN� �� 1RS �� 5' Negative � �' Access Easement SA,_i 1 �_24. 29.82' tic Area Easement #7 °' �-- ---- — — ��,�� (See Note #5) SE-3—► T-Sor, /Cap Fnd in Line �<� ... �..-..�-..---- -- �'1 � �. �..�.�- — .� +-SA-t 0 -=�'�'•�.-.r-..�-`_, �_� � L- T-8 T- T-1 � �T-, 5 T"'.�.�..� ... � ^ � rive 6 ' � (�n N N N �/ p N � z O N � Cl� Q� � , 7 .�.() ' � p O ,�•.'V rt .r 0. 0 � • �m�� n p '*i -i = \.- cn a � �^ � °, ��`<. \ �o r'c� , ��c� ~ � z,o m R' r. r c� ' � ° ri c � � � m -o� '} �� o ,p�' � .. m� , � W'� .... . �. .-.. c �� . I , . . . .... ... ... . •� . ; .. i � . . .. . ... ! � - DAVIE COUNTY HEALTH DEPAR NT . � , � Environmental Heaith Section � � Soil/Site Evaluation i � . : _ . �� i �• APPLICANT INFORMATION � � � PROPERTY INFORMATION , ; �b �JGr� �uW �S . �, � �;�,vvtGt,vt .�rvice�� ' � �3� ��- I3 � .. . . �I � _ .. . � � � �� . � . i ; _ � + �.�� .' � . � � ; . �I � . . i . � � ;, � � �. ° Water Supply: On- ite Well � Community � Public , . ; ,Evaluation By: � Aug r Boring � �Pit Cut � � � � FACTORS { 1 2 3 4 5 6 7... - , � ; Landsca e position ( � _ _. . Slope% i � . .. HORIZON I DEPTH � - �� ( � Texture grou � C C; _ . Consistence ' j S U�:r V 1/T- 5 V � ' Structure a . USSi;w G.� ttr � � Mineralo J� . � - ; HORIZON II DF.pTH . � `� -�j�„1,_ I ' Texture rou r � (_ � v- G'�` ! ; Consistence f ., r 5 �r } ; Sttucture ' � 6,� ,N C' i ' � : Mineralo I ,� s� ' i , • HORIZON III DEPTH � � � I ' • Texture ou � � � ! . Consistence � ; � 'Structure i . . I I ; Mineralo � � ; I ' � HORIZON IV DEPTH � i I � Texture rou • , i � Consistence l I ' ' Structure } i -I � Mineralo � i � � SOIL V�(ETNESS j � I I ` � RESTRICTIVE HORIZON C I � � SAPROLITE 1 '7 I � CLASSIFICATION � .� 1 . LONG-TERM ACCEPTANCE RATE , ' ! SITE CLASSIFICATION: EVALUATI� N BY: ' r � ; , I �,, I � � ,,,p ��,�'" . ; LONG-TERM ACCEPTANC�RATE: I�THER(S)rRESENT:;��'''�_,��.��t r�'� � I . , � i • f REMARKS: . � . LEGEND � �l T,�ndscapg Position ; � I ( ; R-Ridge S -Shoulder' ' L-Linear slope FS -Foot slope N�,-Nose slope� � � : C��Cr�oncave slope CV-�onvex slope T-Terrace FP-Flood�plain H i Head slope � S -Sand LS-Loamy sanc� 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 �� ? : � �ON�I�TENCF. 4 NIQ1S� ' ' � � � . VFR-Very friable FR-F 'able �T-Firm VFI-Very firm �iEFI-Extre ely firm � � ! ', � NS-Non sticky SS-.Slig�itly sticky S-Sticky VS-Very Sticky . � NP-Non plastic SP-Slig�dy plastic P-Plasdc VP-Very plastic . . . ' , } . '� , � . Structure I� . � • , : SC-Single grain M-M �sive CR=Crumb GR-Granular .�i ABK-Ang�laz blocky SBK-Subangular blocky L-Platy PR-Prismatic I � I . l , MineraloQv i ! ' 1:1,2:1,Mixed ; ! . � �otes I I , � i Horizon depth-In inches • - �' E • . . Depth of fill-In inches ' , � Restrictive horizon-Thiclmess and inches from land surface ! � � Saprolite-S(suitable),U(unsu�table). i ' , ' ' 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 rovisionally suitable),U(unsuitable) � ; . . iTTAn r �--`'� ^-'--"-'-�" "tN'--ic.n ' 1 _ _ _ __ • CUNSTRUCTION �or oi�ice use on�v � AUTHORIZATION *CDP File Number 187843-� •"�' - Davie County Health Department County ID Number.E5-ooaoo-os�-�2 a� " � � � � 210 Hospital Street Evaluated For: NEW ' �'.��;�. P.O.Box$48 Township: Mocksviile NC 27028 PERMIT vAIID UN71L: Phone:336-753-6780 Fax:336-753-1680 0 5 � 1 $ � a 0 a !b - Applicant: Robert Lauwers Property Owner: Human Service Alliance Address: 433 N. Main St Address: 249 Gilbert Rd CQy: Mocksville C�y: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: ��6)998-3971 Phone#: Propertv Location � Site Information Address/Road#: Subdivisan: Phase: Lot: 4 Rockwell Lane Mocksvilie NC 27028 Directions Stn,cture: SINGLE FAMILY 158 to Farmington Rd. tum left, right on Pinebrook Dr. runs into Gilbert Rd. on left #of Bedrooms: 2 #of People: "Water Suppiy: PUa�iC .�._ SYstem Speciflcations Minimum Trench Oepth: a 4 Site Ciassification: Provisionatiy Suitable Inches Minimum Soif Covec Saprolite System? QYes QNo 1 a inches Design Fiow: a 4 g Maximum Trench Depth: 3 6 inches Soil Appiicatan Rate: � . a � Maximum Soii Cover: a 4 Inches *System ClassificatanlDescription: 'Distribution Type: PUMP T�GRAVITY TYPE lll B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: _ , . 1 0 0 0 Gallons *Proposed System:25%REDUCTION 1-Piece: QQ Yes QNo : Pump Requi�ed: QYes QNo QMay Be Required N�rification Field 1 a � g Sq � PumpTank: l 0 0 0 Gallons No.Orain Lines 3 1-Piece: QYes QNo TotalTrench Length; 4 � � �. GPM vs— ft. TDH TBnch Spaci�g: Inches O.C. 9 g Dosin Volume: _ Gallons — � Feet O.C. 9 TBnch Width: . . _ _ - Qlnches - - - - - - - - . . _ . _ 3 . QFeet Gnease Trap: Gallons Aggregate Depth: _ inches Pre Treatment: ONSF �TS-) �TS-11 SepticTanklnstallerGrade:Level Required: 01 OII OII) (�1V Dsnn i nf Q CDP File Number 187843- 1 County ID Number. �5-000-00-033-12 _ a Open Pump System Shest RepairSystem Requireci:t�?Yes ONo ONo, but has Available Space eaair Svstem Trench Spacing: 9 Q Inches O. . *Site Classification: ProvisionailySuitabte — QFeet O.C. Trench Width: Q inches Design Flow: a 4 � — 3 Q Feet � Aggregate Depth: Soil Application Rate: � , a inches `r Minimum Trench Depth: � 4 'System Classificatan/Description: Inches NPE 111 B.SYSTEM W/SINGLE EFFWENT PUMP Minimum Soil Cover. 1 a �pCh@S Maximum Trench Depth: � � �nches 'Proposed System: 25%REDUCTION Maximum Soil Cover. a 4 N�rification Field a 1 � � . . Inches Sq.R. N o. Dra in�ines *Distdbution Type: PUMP TO GRAVITY 3 TotalTrench Length: � 0 � � Pump Requir�ed: QYes �No �May Be Required Pne Treatment: �NSF OTS-I 4TS-II "Site Modiflcations No grading or construction ectivity is allowed in areas designated for system and repair without approval of He�lth Department. � ; "Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarantees the issuance ofother permits.The permit holder is responsible for checking wdh appropriate�overnNng bodies in meetmg their requirements. ; Thls Atrthaizatton#or Wastewater Systen Constructi�n shall bevatld for a peaon pqual to tf�e perfod of validlty oithe Improvemerrt Permlt„nat to exceed tive years,and may be issued at the sametlme the Improvement Pertnit Iswed�NCGS 130A-336(b)�.lt the lnstallatton has not been canpleted dudng tha p�riod oi wltdlty otthe Constructton Perm�,the iMormaUon submitted 1n theappllcxtion far�pe�mit o�Construction Authorizatlon is tourx!tio have been incorreM,Talsifled or changed,or the site Is altered,the permR orConstrucibn Autharizatiun shaU becom� inwl(d;and may besusp�nded ot r�evnkrd(.1937(g)).The pc�son owning a cantrolllr�g ihe systen shall be responslbte fara5suring compq�c� with the 1aws,ndes,and p�ermft condltfons tegarding system loca�on,Installatton,��fl�maintenar�c�m�i0odng.re�orUrg and reQalr (1938(b))._ _ Applicant/Lega1 Reps.Signatur�e Required? QYes C7No Applicant/Legal Reps.Signature- Date:_ � �, � . ,� 2140-Nations,Robert 0 5 � 1 8 � a �1 1 S Issued By: Date of Issue: ,_._, . - - . . . . . Authorized State Agent: Malfunctan Log pYes ,::•`�°�: �r,- �Hand Drawing C7lmpart Drawing **Site Plan/Drawing a#tached.** Page 2 of 3 t� CONSTRUCTION AUTHORIZATiON . � Davie County Heaith Department CDP File Number: . � 210 Hospital Street E5-000-00-033-12 P.o.BoX 8as County File Number: Mocksville NC 2702s Date: 0 5 I 1 8 / a � 1 5 Q Inch Drawing Drawing Type:;Construction Autharization Scale: . . ..Q�N�A k = . .ft. _ � _ 1 � � � , !C _ ��,�� p� - -�-� � .� , - : �` _ - �,-�,�� ' . � � V�� r� � _ _ .�'�� _ _ _ r � }� . � _ ,�,�_ � � � � � /— � �j � � � �� : � _ �_ _ _ 1 � _ �� -- _ . o _ R��'_``j�� -!� � o � �- = _ � � . = -i` _ � - , , , �,o� . _ — , _ — , , , , � �=3__ _ -_�-_ �l - � _: ��,� : _ ___ .�-�►''� Uj `�-' �'` _ -� �� t �R � �� _ _1---.��— � v � v'�' � j � �' - , "� � i _� � ( _ ( � �� 6 _ , . . a� ` -:W �'+„�, �-'-�--�� ..� '�,_ ,,,,� � �� _ �,��, � ��o�� , � _ 1 � � �,c ��-�- , � � � � � � I, ,. � f G M i � t � ► � ' � I 7 jP � -c �i�rc�d �c � S•� L�, � CQNSTRUCTION AUTHORIZATION ' . Davie Counry Healih Department . z10 Hosp�tai str�et CDP File f�utnbet: P.o.Bax s48 E5-�It14-04-C)33-1: Moc�csvine Nc 2702� County File hlumber: L3ate: _g .5 / 1 8 / � 0 1 5 Click bstow to import an image trom an extema)location: Drawing Type:Construction Authorization . ' IMPROVEMENT PERMIT Fo�on��u� o�i,► *CDPFileNumber 1$7843- 'I af�• ,Davie County Health Department '� �� '� County!D Number.E5-opo-oOA��-12 210 Hospital Street '� � � P.O. Box 848 Evaluated For. NEW .�wr,,. Mocksville NC 27028 Township: � Phone:336=753-6780 Fax:336-753-'IsBO pERMIT VALID UNTII.: SI'IH/ZOZO *NOTE TO INSPECTIONS DIVISION: BuIlding Permits cannot be issued with this improvementPermit. Applicant: Robert Lauwers Property Owner. Human Service Alliance Address: 433 N. Main St Address: 249 Gilbert Rd ��Y� Mocksville ��Y: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (336)998-3971 Phone#: _ _ _ __ _ __ ___ Pro ert i.ocation 8� Slte InfoRnation. __ Address/Road#: Subdivisan: Phase: Lot: 4 Rockwell Lane Macksville NC 27028 Dlrections Structure: SINGLE FAMILY 158 to Farmington Rd. turn left, right on Pinebrook #of Bed�uoms: 2 Dr. runs into Gilbert Rd. on left #of i�eopie: 'Water Supply: Pueuc S stem S ecifications nitial S stem *SitB eSsi ICe qn Provisionally Suitable Minimum Trench Depth: a 4 inches Saprolite System? QYes QNo Maximum T�ench Depth: 3 fi Inches Design Flow: a 4 g Septic Tank: 1 � � � Gallons Soil Application Rate: � . a �..p1e�; �QYes (�No " � � Pump Required: QYes QNo QMayBe Required 'System Classif�atioNDescription: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pum p Tank: 1 g g � Gatlons "Proposed System: 25%REOUCTION 1-Piece: QYes �No Repair System Required:OYes ONo ONo, but has Available Space Reaair Svstem "SitB CIaSSIfiCStlo�: ProvisionallySuitable Minimum Trench Depth: a 4 Inches Soil ApplicationRate: � , a Maximum Trench Depth: 3 6 . Inches .—. - "System ClassificationlDescription: Pump Required: QYes Q No Q May be Required TYPE III B.SYSTEM W/S�NGLE EFFLUENT PUMP 'Proposed System: 25%REDUCTION Page 1 of 3 _ _ CDP File Number '187843- 1 County iD.Number. E5-�oaoo-o3�-�2 , *Site ModifiCltio�ts , ❑ Open Fill Sheet No grading or construction ac#'aity is ailowed in areas designated for system and �epair without approva(of Heaith Department� � ,� '�Permit Conditions The issuance ofithis permit by#he Heaith Department in no wayguarantees the issuance of other permits.The pemnit hoider is responsible for checking wrth appropriate goveming bodies in meeting theirrequirements. : $Ite P�an The impravement Permit shall be vatid tor 6 years from date of issue with a site pian(means a dwawing nat necessarily drawn to � scate that shows the exlsting and proposed propetty pnes witlt dimensbns�the locatfon of thetacility`and apputtenances,#he �` site forthe proposed Wastewatersystem,and the location otwater suppUes and surtacewaters). Plat The Impra�vement Permit shali be vatid without expiration wltl�plat(means a property survcyed prepared by a registered land O survpynr,drawn to a scale of one tnch equais no marethan 60 feet,'that ir�clude�the spiptafic locatian of the proposed fadlity, and appurter�ances,the site ior the proposed WasteWratersysEem,and the IocaSon of watersuppies and sur�cewaters. Ptat also means,lorsubdivislon lols approved by fhe Ix�)planning autl�ority and recorded with the county register ot deeds,a copy af ihe recorded subdiv(sions ptatthat is accampanied by a site plan ttsat ls drawn to scatej. The Departmerrt and Local Heaith Oeparlment may tmpose conditlons on the[ssuance and may rewke the p�em�itsfor failure d the system to satlsfy the conditions,the ruies�a this arttcle This permit ts subjectto revocation ffthe sitie ptan�pia�,or U�ended use changes(NCGS 134A�335(�?.The:person cwning orcoMrolting the system sha11 be responsibiefo�assu�i�g compltance with the laws,n�es�and permit con�itfons regardirig syster�loca�on,(nstaltaticn.opera3ion,mainten�c�monia�ring, repat[ng,and repalr(.1938ib?� _ _ Applicant/Legal Reps.Signatune Required? �YeS �NO Applicant/Legai Reps.Signatur�e: Date: f � *issued By: 2�ao-Nations,Robert Oate of issue: � � f � g � a 0 1 5 Authorized state A9ent: : OValid without Expiration? _ _ Q Create CA? OHand Drawing 4tmport Drawing �� ;� „� **Site PlanlDrawing attached.** Page 2 of 3 . .. IEIAPROVEMENT PERMIT 187843- 1 . Davie County Heaith Department CDP File Number: , 210 Hospital Street E5-000-00-033-12 P.o.eox 8�s County File Number: Mocksville NC 27028 Date: � � Q inch Drawing Drawing Type; Improvement Permit Scale: , . . . ps�ock �N/A = `ft; � f �' _ _ _ �� _ � �v _ _ �� - . _ / � � �d : � �'�� r ., - � � _.�. ,_.�� ____ ,:r� ` . � _.._ � �.� ' ._. � , _ ,, '� � � : � � ' � , / � � I ��-��' _ _ �. �. � , _o_ �' I ____�: v — �--�--�� a= �. _._ _ ��1,_�.`_� l :'Q (�vr � �,,e - -�_ V ,� � _- - - - �..,�.13 � _ � _ _ ` , I �_ � � L v� � ��..�v � ,/ 1 , 1 � L �, : ; �,.,�:�_�c-.,��s�.�-��.— _ • �....,_.�.:� ._1�f i ► � 1-�-; Q d�—� - � --�+— -�—�=�-�:�: �-�-��-d�--�--! - o o , . - _ �-� , ,. -� -�-_- � a ri_^�n ��, IMPROVEMENT PERMIT • � . Davie County Health Deparkroent - 2�o Nosp�tai street CDP File Nsamber; 187843_- 1 P.O.Box sa8 e�-000-oaos3-1: Mocksviile Nc 27o2s County File Number: Date: � s / Zsl � eis Click belowto lmportan imagetrom an extemai Iocation:Drawing Type: Improvement Permit f ....". '_...,� . � � APPLICATION FOR SITE EVALUATION/IMPR0�IEMENT PERMIT&ATC �;�"" Davie County Environmental Health ) / P.O.Boz 848/210 Hospital Street Macksville,NC 27028 '�� (336)753-6980/Fax(33�753-1680 �9a Application For: 0 Sit�Evaluation/improvement Pertnit 0 Authorization To Conswct(ATC) ❑Both Type of Appliration: �New System ORepair to Existing System ❑Facpansion/Modification of Existing Systcm or Facility +*�IMPORTAIV7"'•TiilS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMAT'ION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT 1NFORMATION Name to be Billed YIX�C � �7 U I L�C _Contact Person ��Dd E1 M��'�� Billing Address Home Phone CityfStatelLIP Business Phone � / Name on PermidATC if D�erent than Above � � Mailing Address ' Ci lStatelZi l�� Q� v PROPERTYINFORMATION "DateHouse/Facili CornersFla ed � �3 f� �h�er� � NOTE: A sucvey plat or site plan must accompany this application Included:0 Site Plan �Plat(to scale) (Permit is val' for 60 on site�p�lan,no expiration with complete plat) � Owner's Name ' 0�� +�+ S Phone Number 9+ID'98 Owner's Address 'f � City/Statc/Zip MOGK�1 �70?S • Property Addres City G l , Lot Size � Tax PIN# . Subdivision Name(if applicable) ection/Lot#�_ Directions To Site:�,��Lhj,�.r^ D�d. If the answer to any of the following questions is`�cs",supporting documentati n must be attached. Ate there a�ry existing wastewater systems on lhe site7 OYes�o Does the site contain jurisdictional wctlands7 •DYcs o Are thae atry easements or right-of-ways on the site7 OYcs l�No Is fhe site subject W approval by another public agency7 OYes Ef�to Will wastewater other than domestic sewage be gcnerated? �Ya id�io IF RESIDENCE FILL OUT TI-IE BOX BELOW #People #Bedrooms #B�oms Gazden Tub/Whiripool OYes o Basement:�Yes o Basement Pl�rnbing: OYes o � IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 OAccepted ❑Innovative OAlternative ❑Othu Water Supply Type:�County/City Watcr �Ncw Well ❑Existing Well 0 Community Well Do you anticipate additions or expazuions of the facility this syst:m is intended to serve?O Ycs E No If yes,what type? This is to certify that t6e infortnation provided on this application�is true and correct to the best of my Imow(edge. 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 infartnation submitted in this applicadon 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 tabeling of property lines and comers and locat' a a gin 'staking the house/facility location,proposed wetl location and the location of acry other amenities. Property o�mer's oi o�mer's legal representative signahae � Sito Revisit Charge � Date(s): �J � (� S ' Client Notification Date: Date �S� � j � 7�`�(3 Sign givcn OYes ONa Account# Revised 1 I/06 Invoice t� -Bar w/Cap Fnd formerly T-Bar w/Cap Fnd L-22 T-Bar w/Cap Fnd a St�ne � a Walnut Tree Control Corner �— 0.10' North of P/L ePerence PB 11. � Pc 159 Gravel Drive Crossed P/L 0.10' L�T 4 6.469 Acres +�- Inclusive ofi area in S.R. 1437 R�W r Proposed House i� Ilv� 75, N xtEnsion of Septic R o c kw e ll Toward House� , � C�n,� Pro osed � 50' (25' each side C�L) P cJ T ra e t 1 R e v i s e d Garage ,� Private Access, Utility & `o� Septic Systern Easemer�t ROCKWELL VALLEY 635' ah ,>.,��• � -- � p IRS L-16 Total IRS Phase � v 'n 40.0' IRS 267.58' F2eference: PB 11 � PG �i ' Placed -� � in Line �� LOT 3 l � 1M ; ; / "'�,, c� � 1 .288 Acres +f- r ^ry� / � // o � p �� RS 2L 0 Total IRS C/L 30' / � � N� IRS 281.12' Septic System & Water Line c� �� •o Placed Easement Extension / �'\_ o ��in Line LOT 2 / � r / / /� 1.198 Acres +/- � i" f I _~ � IRS L-19 Total IRS � � o IRS 266.21' ISeptic qrea � rJ N Placed Easement �4 in Line � -- LOT � �-6 S � � t� s�Pt�� F.,ea �I ROCKWELL VALLEY Jal Easement �3 l�r C�L 30� Phase � `n '� —. � Septic Sys#em Easement �t � sA-1z 1 � Reference: PB 11 � PG 246 �+ y � — — � `�I (15' each side of C/L) --� _3 iQ Septic Area � Match Line A Match Line A — "' Ea�ement �2 ��I j l IRS t� 5' Negative SA=17 ��'' Access Easement — — — -+ � L-24 �ry (See Note #5) 29•82� eptic Area Easement #i I°' I 5E-3-+ i — � w/Cap Fnd in Line j�* � �`O .—cn_ ,.. _—�—�.� �— — �� _ � � _ _ . --T-Bcr wfCap Fnd � � ` Existin Grovel Drive ; —�' '��T-11"'"i 2 i ��--------9-------- , . • T-Bar wfCap Fnd formerly T-Bar w/Cap Fnd ` L-22 T-Bar w/Cap Fnd ' a 3tone O a Walnut Tree Control Comer 0.10' North of P/L Reference PB 11 o PG 159 Gravel Drive Crossed P/L 0.10' I � LOT 4 I 6.469 Acres +/- Inclusive of area in S.R. 1437 R/W I �Proposed House w 75, n� _ � I Extension of Septic Toward House--► R o c k2v e ll � � :�a�e Proposed 50' (25' each side C/L) �I T ra c t 1 R e v i s e d Garage y . Private Access, Utility dc ¢0• :. , Septic System Easement � ROCKWE�L VALLEY 635 �� •�'�'�• ,Rs �s rotai iRs � I Phase I � r , v � 40.0' IRS 261.58' � Reference: PB 11 O PG t� Piaced �`� -in Line � . / l� � LOT 3 , � • / �``',, = � 1.288 Acres +/- I. r p v/ 33.01 / sn � IRS L 20 Total IRS =_5 ' � � ' C/L 30' � �! N� IRS 281.12' E 2p c he s � Septic System dc Water Line � � o Piaced , pG 38 `� - Easement Extension / ; �o �. in Li�e � PG 40 -• I � �� LOT 2 � PG41 / } / � . /�/� 1.198 Acres +/- I ' � � i � .� J �RS L-19 Total IRS � ` � o !RS 266.21' Septic Area f ,J �' Piaced I Easement �4 � in Line -- -L-OT � � ,�— sa—s s � , � , septic�a �, �U` ROCKWELL VALLEY ��I Easement �3 1� C/L 30� Phase � �'• I —. � Sep#ic System-fasement '� 1 O PG 246 N S,e,_�2 1 Reference: PB 1 _,� •t — �j (15' each side of C/L) -� �3 ��_ Septic-Area � �NI Match-Line A Match Line A j�j� -- Ea�ement #2 1� ! IRS R� 5' Negative � � \�' Access Easement ��'_ _' —�-->>— — L-24 29.82' ti Septic Area Easement �7 �� — SE-3-► IN� (See Note �5) - - „ I v� T-Bar w�Cap Fnd ia line �C .i 4 �_�" — �. � �r� � � �+� � T-7--i •-SA-10 — — �PK-N�it.�n�`� � � �� T-S ' � �T�5 T"-..� T-9 T-1 U �' � -- � -� ne brook Drive 6 ' � � i i � �' . o S R. 143"7 � � � NN � , � o N � � � N � %� . oZ .�� + �o Id � �+ N ?��c � � UO' Public R/W �� 'O � A '� n n� r �n a � �^ � "" m�`< � �� 0'-�-�- Pavemen�-Width -��n � � � �� + + o � : ..,�� , • . . �� - . . APPLICATION FOR SITE EVALUATION/IM�'ROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33�753-6780/Fax(33�753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) 0 Both Type of Application: ❑New Svstem ❑Repair to$xisting System �Expansion/Modification of Existin�Svstem or Facility ***IMPORTANT***THIS.APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION Bi,TL�:ETIN for instructions. APPT.TCAI�TT TNFORMATT(�N � Name V Contact Person E�:/t,-K�__� Address Home Phone ��(o� 'lZ2.�9'y City/State/ZIP � Business Phone v�(o—gal g- 3 c�`T/ Emai1.S.�[�i�!/.�Qcc� � � . �� Name on rmidATC if D�erent an Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Fla��ed 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 Nam� '�/� /=l.��es Phone Number Owner's Address ^ C1ty/State/Zip Property Address „ _ City -" - � � Lot Size � a.e_.. Tax PIN# �'S�/ �'I'7�� 2� '� Subdivision Name(if applicable) Section/Lot# Directions To Site: .�'� `t►- ' If the answer to any of the following questions is"Yes",supporting documentation must be attached: Are there any e�sting wastewater systems on the site7 Yes �o Does the site contain jurisdictional wetlands? _Yes viGo Are there any easements or right-of-ways on the site? _Yes � Is the sife�,suhject to approval by another public agency? Yes �o Will wastewater other than domestic sewage be generated? Yes� TF RFSTT)FNCF,FTT,T,n1 TT THF,RnX R .T.n #People .2 #Bedrooms #Bathrooms Garden Tub/Whirlpool OYes o Basement: ❑Yes o Basement Plumbing: OYes � TF.N�N-RF�TAF,NC;F.FTT�.CJIJT THE I3nX�EL.OW Type of FacilityBusiness Total Square Footage of Buildin� #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:�ounty/City.Water ❑New Well ❑Existing Well ❑ Community V�e}1 Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes ��No ��N� 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 entr�to the Authorized Representative of the Davie County Health Deparhiient to conduct necessary inspections to determine compliance with applicable laws and rules. I unders d that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stak' the house/facility lo tion,prop sed well location and the locarion of any other amenities. Prop owne or leg representative signatwre Site Re�isit Charge Date(s): `� /' � Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �, Revised 11/06 Invoice# � . t , . ' ' �:`�.,�1 � � r. , , ,. r_f�� ._.,��........ V l. ✓ . . 1 t.. �s, ��a"'`,—....,�, � r-��.. '� � �`v A.PPLI�ATION FOR SITE EVALUATION/IMPROVEME '�i�'ERNxT A''��'.""�-- Davie Count Environmental Health �� - P.O.Box 848/210 Hospital Street AUG I r 2ofl Mocksville,NC 27028 8 . (336)751-8760/Fax(336)751-8786 ��NMfNTq� Dq�ryE�� y� Application For: �1 Site Evaluation/Improvement Permit 0 Authorization To Construct(ATC) Type of Application: �iew System ❑Repair ta Existing System ❑Expansion/Modification of Existing System or ***IMPORTANT**�THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION c�c,� R.c,t�� C-�t�c,e_ {�wC�-s f �1 .�� Naine to be.Billed L.��t F ' —' t'J€ " % Contact Person � ►�s��+- �� 5 Billing Address. / � "�' ' ,� i'c=c// `� � Home Phone �� - `�'�L'i" �ity/State/ZIP ��Zic',�]''S L j'l� /�� ' ��i�`%i��1:Y�_ Business Phone �L��`/��_`� Name on P.,emiit/ATC ifDifferent 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: 0 Site Plan ❑Plat(to scale) (Pemut is�valid for 60 months with site plan,no expiration with complete plat.) Owner's Name - �',(:�/,��,.i� ��^�� Phone Number Owner's Address_ =-�f•.l�v-.�- City/State/Zip 1'roperty Address �;�� _�,_ City Lot Size � Tax PIN# ,$y I��`t 3Z2 Subdivision Name(if applicable) :�- tn �� 1.y�� 5 Section/Lot# I Direct�ons To 'ite: S�' =' • - ' • �� '� �a /J r y�=� f�� •�' � r r;=�� ; ! ,:v� ��' � > If the answer to any of the fellowir.g questions is"yes",supporting documentation must be attached. Are there any eaisting wastewater systems on the site? ❑Yes�No .Does the site contaui jurisdictional wetlands? ❑Yes�No ��.Are there any easements or right-of-ways on the site? ❑Yes�INo ��; �s the site subject to approval by another public agency? DYes IDNo ' ��Will wastewater odler than domestic sewage be generated? ❑Yes�No 'Y� � IF RESIDENCE FILL OUT THE BOX BELOW � . #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: OYes ❑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 documentation of similar facility water consumption) ' FOODSERVICE ONLY: #Seats' � Type system requested:. C�Conventional �'Accepted Dlnnovative ❑Altemative �Other Water Supply Type: E�Counry/City Water ❑ New Well ❑Existing Well � Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes . C7 No If yes,what type? This is to certify that the infornzation provided on this application is hue 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 infom�ation 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 niles. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flag�ing or staking the house/facility location,proposed well location and the location of any other amenities. � �;'�� _� �'�'%�"�"y`��J Site Revisit Charge �..----74.. �"�Fi�operty o�mer's o"r owner's legal representative signature Date(s): �_f� — �_ "' Client Notification Date: Date EHS: Sign given CiYes vNo Account# Revised 11/06 Invoice# a ' � � - u�— to.000�c. � rwiu w�mac roois.r . 'v�.i�ll I( �(J _ . . Yrqd IIOR7G 1 Nvi y �� C �`.0 �'� ... (0.L�11 rF� C�_ II_ U� . � —a�_ � b � r , � =�:.� �� j� 370 ` � �.�/ 370 370 �• � �- � � � �' �� a i � `� � � ' y ��m � �� (7, I �� - �, � i � � �� :� � �� `�� `� � �� w I .. c �� y� � �� w o. �� "��' � ., � ., `L �,� � ��. y .,. �i , � ��' ' p �+ � . � � �� ( � � �� W� `� � � �� 9� . - � PINEgR00K x^ - S„R �R1VE' . >43?' 365 363 365 ., 457 648 �''ll'8�' � TR9CT 5 _ � n AREA = +-5.92 ACRES AREA INCLUD&'S R/fi m TRACT 6 • » AREA = t—f 0.45 ACRES . � AREA�INCLUDES R/lI a` V� n y � O� 490 ' O Gj 1��a � � Ca��, � ❑ � � 612 � N �� TRACT 4 � ..,.,. . _ .. .— — Il�IQIs� 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 - Struct.ui e SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic MineraloQv 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) �TTAD i...... ro.... .,....e..��.+..o��re nn�/��.r/Ff7 � � ' Tl+TTT/�G/AG m._.:__a� , _ .' ; : � � � . � ' DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Heaith Section � Soil/Site Evaluation APPLICANT INFORMATION . j'ROPERTY INFORMATION '� ��-�� .c� . _ . �.� �u� _ ��:.� � - _ -_ �rf ,. Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ,�''f Cut ' ''" ; E; :: :FACTORS 6 7 `' ' 'Landsca e sition � L. l� �, ?5 ,�,:;Slope % .';F . '; �.`HORIZON�I:DEP,TH � . � � " ..— 'Textuie grou ;:= C"i C � C -- Consistence ,,j`r.� , � .,,, . scructure:'�. "J� ' L Mineralo : .,L� �c ' �' :� HORIZON II DEPTH -: - , p� � 2 _ L � Texture rou ' ''�" ` . �,L Consistence: • - S a �` ; � ,5� k S Structure : L /� ' :<::�Y 5 Mineralo '� � ;. . HORIZON�III DEPTH Tezture rou , 1� Consistence- - � {y Swcture " ,. . Mineralo -- �- HORIZON IV DEPTH':: '-`;:� Texture ou �' Consistence ��,� Structure . Mirieralo SOII;tWETNESS ' " � +� . �r � j I, RESTRICTIVEHORIZON f�pQ'` �- �' SAPROI;ITE " CLASSIFTCATION . (�. ' LONG-TERM ACCEPTANCE RATE` �SITE CLASSIFICATION:- '�� EVALUATION BY: ' �r <��1 LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: / �� ! + : • � `r� / 1 REMARKS: ' LEGEND Landscaoe Position R-Ridge S-Shoulder L-Lineaz slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope � Tgxtur� � 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 CONSISTF:NCE �415� 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-Prismatic Mineraloev 1:1,2:1,Mixed L�I4�e� . 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) I TAR-Long-term acceptance rate-gaUday/ft2 DCHI�OS/(15 fRevicP.�l