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128 Rockwell Ln / . /�o � DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O.Box 848/210$ospital Street. pA� Mocksville,NC 27028 ��(a��� , (336)753=6780/Fax#(336)753-1680 tiau� I ORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION R��Y�ab � Acc�unt #: 990005699 7�x P1�tl�H#; E5-000-00-033-14 Billed 70: Yadkin Builders Subdivis9ori Info: � Referer�ce Name: Janice Ayers ____ _ ___ LocationfAddress:--Rockwell Lane-27028 �'2 - Propassd Facility: Residence Proper#y Size: 1.2 Ac ATC NUmbeP: 6062 Site Type: ❑New ORepair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental . Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. � Residential Specifications: #Bedrooms � #Bathrooms� #People � Basement� Basement plumbing❑ Non-Residential Specitications: Facility Type #People #Seats :Square Footage(or Dimensions of Facility) Lot Size �, i� Type of Water Supply: �County/City ❑Well OCommunity Well � System Specifications: DeSign Wastewater Flow(GPD)ot�� Tank Size�GAL.Pump Tank�/��GAL. �� � Trench Width 3��. Max.Trench Depth�� Rock Depth� Linear Ft. �� Site Modifications/Conditions/Other: , �,��i '� 5�� Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30=9:30a.m.on the da ofa stallation. Tele hone# 336 51-8760. � . -�.� � � S r �` � `�' ,, � . La-t l � I � � � U � �-+� d � �\� � . P.cs�I��L ( G.u-, •� �� � � � �Cc�u s-e r.�.�✓v ---: � ----; . P,�6,�� � I�� S�� ► �'� a. ¢ „ � �. h . � �� � � a . o � � o� � o . � � � - � Environmental Health Specialist Date: � ��'7 � � � . . � J, DCHD 11/06(Revised) ' '�� .�.., ....�_ �....._--- {- �„p,.....,�---�"""""� � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street. � ;Mocksville,NC 27028 . ' (336)753-6780/Fax#(336)753-1680 �- AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accc►unt #: 990005699 - '�ax PlN.�EH#: E5-000-000-3313 � �i(Icd To: Yadkin Builders _ Subdivision lr�fo: Rockweil Valley Lot# 1 Refer�r�ce Nan�e: . Loca#ioniAddress: Rockweil Lane-27028 f'ropased Fa�iiity: Residence Pro�er#y Size: 1.90 Ac ATC Ntltllb�i: 6058 � Site Type: fBN�w ORepair OExpansion **NOTE**This Authorization to Construct(ATC)MLTST BE ISSUED by the Davie County Environmental , Health Secfion prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Secrion.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat. ,, or the intended use change. Residential Specifications: #Bedrooms � #Bathrooms a #People �7 Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats :Square Footage(or Dimensions of Facility) Lot Size �•� Type of Water Supply: LTCounty/City ❑Well ❑Community Well � �DO System Spec�cations: Design Wastewater Flow(GPD) a�{� Tank Size '�Q�GAL.Pump Tank �� GAL. '' Trench Width 3�,� Max.Trench De th 3 G Rock De th� Linear Ft.. ` �� (�� � —T�s stated in 15� b��8,1.1����51 _l Site Mod�cations/Conditions/Other: accepted Systems rnay al�o be.used '��j�'�,ea�G�1�v� Contact the Davie County Environmental Health Section for final inspection of this system between ' 8:30=9:30a.m.on the da of installation. Tele hone# 336 751-8760. � � � � � �4 � / � __' ��lr t� � b � Hoc�g.. � / (—� e�� ` �r�� ` ��r�� I_J.Q�,� �cB p � v �o� ��-� ��� 1 � �-� �a5�� -� 1-0�� . �-�� ���..�1 , � ` t ._ . �. .,�. Ko _ _ _ � _ , �i(/�P U��� �f/1�e. C.�il/f�fr� /1d �r � ' . �p � O � ��� Environmental Health Specialist Date: � � ? � �y DCHD 11/06(Revised) � � � � 7 � '0�" � �`' � � � d � G . � �( � � 7��'��� ��� Q � \ . � � . � p ,5�� �v a �� (� V' � � � �, � — � � �� w-c �( � D� � �J • Q r ,.. _ _.. � DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O.Box 848/210 Hospital Street. Mocksville,NC 27028 pA� (336)753-6780/Fa�c#(336)753-1680 �'�a"�`� y�ace: � R�;Y�b ; ORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005699 �'ax Pi�.�EH#: E5-000-00-033-14 Billed To: Yadkin Builders Sufadivisiar� Ir�fo: � Reference Name: Janice Ayers � LocatianiAddr�ss: Rockwell Lane-27028 -�2 Propas�d Facilify: Residence Pfo�er#y Size: 1.2 Ac ATC Nu�'lb�!': 6062 Site Type: ❑New ORepair ❑Expansion **NOTE**This Authorization to Construct(ATC)MtJST BE ISSUED by the Davie County Environmental .' Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms � #Bathrooms� #People � Basement0 Basement plumbing❑ Non-Residential Specitications: Facility Type #People #Seats �:Square Footage(or Dimensions of Facility) � Lot Size �, � _ Type of Water Supply: J�County/City ❑Well OCommunity Well � System Specifications: Design Wastewater Flow(GPD)d��� Tank Size I�d�GAL.Pump Tank�/��GAL. �, � Trench Width� 1VIax.Trench Depth� Rock Depth� Linear Ft. d�� � Site Modifications/Conditions/Other: �,�j�('j '� S�� Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30=9:30a.m.on the da ofa stallation. �Tele hone# 336 51-8760. � - � . � S T ^ –;- (...o'f � � � — � �' � � _ � U � � n � v r ��� � � K-C7 G�l.t�e(,� �tM � ��. �r C�U rj-e GIti-a/1� ^� � � . ��b�� � _ �• , S�� ► �� � .� , n v � h . o �'' � � e �� o . � ` � - ( Environmental Health Specialist Date: � �'t'�J� � DCHD 11/06(Revised) � ' � � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � � (336)753-6780/Fax#(336)753-1680 . OPERATiON PERMIT . Acc�u�t #: 990005699 Tax Pi[�lEH#: E5-000-00-033-14 Biilcd To: Yadkin Builders Suf�divisiorl Info: Refer�nce Na��e: Janice Ayers LocatianiAddress: Rockwell Lane-27028 � Z Prnpased F'at;iEity: Residence , Pro�er#y Sizs: 1.2 Ac �TC Nurnb�r: 6062 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed � in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but shall in NO WAYbe taken as a guarantee that the system will function satisfactorily for any given period of time. � , ��� �Glo�� �� '� � I�1 System Type;. S.T.Manufacturer Tank Date Tank Size �, 6 O� Pump Tank Size �U Bedrooms: �'^ Z p c I��d J!j��— �— �1.�-1H n�— System Installed By: � <NsN�nstaller# Date: r�-( '� � GPS Coordinate: .� - � .� : —I �,�O c � �� � � � � �� � ,s � r� ;s � � .� , , . � �. � _ � � � R�k , s��.1ee ' p ( O G�V.+�1( �� . ` � � T . (,Y�� Q "� . O� � � � v � � �� f � 0 . �� � � 0 Environmental Health Specialist Date: DCHD 11/06(Revised) . � � i l � � j � v . . ; i �8� Acres ��— � _�t N ,�� � LOT' 3 ; �r � __y � � �� IRS� �-20 T�ta� �F� N� t � ��o �� $o- �nT z �nt = P/L �l� �, � ,��P�ic��r: ' 1�' �55 ���y ' , � �l}DKIn� (3Uilj�r2f �50; � r52' 258 ►24r-('�l- � ; � a6 ;-;Z;�wSg +-C�A�E MoGK��t�, ���' ;��I , �f�lc S`-15i�rn guDfj M��Aouts � IRS �,5 �A-��2 Ul�� 33�-�67-706/ t� 0 266.%i ' 1� � � �w nr�rc..` ! JA-+v�c� A-`��ce.s �l�t -'��f7� , � y 1 — � � - C/L 30' �1 I t; ,° System Easement v- � , �+�� � � � �ach side of C/L) � --' ; i �. � u � 3 � ��S�L� 1RS �� �\ �- L-24 �..,�._.:��.,.. �... �� � T Y� VQ' ---- - - P � \ .� �.r �-��� s�' `� ..-.. am c-'�- Q Lr�— i A i �� T -9 7- 10 � T-5 � _4 � � �.. — �. � .�. � ) / � � r �O � Z7 ' � � .0 '�� p � (n N N (n � � Z N (J� O� Z 0 �`? � � 7 � � o � � .,- ,.- � Q � c �. � m C ,,, _ C� „ Furches Reference: PB 11 � PG � � Ns � E-20 �o � i 'G 38 � 'G �!0 'G �11 C/L 50' E=asement - �'/l-"� --- ifl �I 1� � � � t,oT I �� � � J IR5 li co o i j 1� N � I ..__ \ —� _a � SA-G $�. 1 � .!1—�-- — !; � I `� 5aptic Aroa � �u' Easemant {�3 I � C/L 3Q' l c¢n .___. �I � S�tstem Easement } a- I � SA-12 �� cvf (15' cacl� side of C/L) � --� --”. , � SA-3 N Septic Areo � �, � 1 T� - - [asement Y�?_ �Q� 1 � 1RS �r� `_"__. c,� U� Sn- i 1 L-24 IQ Septic Area EasernEnt �1 °' � �_3 — �� f � �----- � R� � � cn T-Bar wfCap fnd in line '�� v 4 �-- ""..i'"'�"'w �-- ---�--�--.�.--wi--G�w.aw..--�w'-«... � T��� +- SA-10 �. ` " _ L�I- -`._. p 'K-Nail Fnd T-8 � � -' � � T_�___ T I �_ — a--a----,-� •- .-.e ..�...._._ �... ....� .... � ze bro ok ..�ri� e � `� �� � � I f ln N n� (/7 `Y T1 A � ..-+ ._ . .. � 4- " APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health , P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Applicatiion For: ❑ Site valuation/Improvement Permit Ef Authorization To Construct(ATC) ❑ Both Type of'Application: �ew 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 1NFORMATION , � Name ����� ���LO� Contact Pers n �u p�� ���D��'`�f Address (�� Home Phon City/State/ZIP OC�C,S' i D . • 2.'70 Business Phone 3 - 7�— Email GtL��C(1'1 1Al e o��1oc�. CDI'Y1 Name o PermidATC if Different than Above • Mailing Address S�✓1�r'c 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 �v�NlC.�' ���/�,S Phone Numbex Owner's Address ( SG���'s � /�(� L- City/State/Zip W.S- r� G Property Address_fip'� �. 4�CKu�ICGL ,¢GG�c� City /uQi[�CSt�fl�[-�. ' Lot Size �•Z C('� Tax PIN# ��j-�_b�.,b3�_�[1 Subdivision Name(ifa plicable) OCKI�J�l.L � Section/Lot# �' Directions To Site: � ft1Qv1�) f� J�/o � �K.oO�G 1'L -� - OGKW l�li VA'�'V� o�'�l 1��� Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 2 #Bathrooms ?i Garden Tub/Whirlpool ❑Yes 0'No Basement: ❑Yes o Basement Plumbing: ❑Yes 0'�10 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 ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:�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 B'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 corners and locatin d flagging o staking the house/facility location,proposed well location and the location of any other amenities. __-L���--- - Site Revisit Charge Property owner's or owner's legal representative signature, . !�- 1�/' Zl��� � Date(s): -Client Notification Date: Date EHS: ��� 5 � __ � 1� Sign given ❑Yes ❑No Account# • �l!���.� Revised 11/06 Invoice# T rca c t � ' �� .-__-�___`._ ;l �� ,� R e v�s e d 1.288 Acres +/- -�+ . %�in8, Tax lot 33.0� ROCKWELL,VALLEY � � �% � , Tax Lot E-s Phase I �� �RS L-20 Totol IRS n/f Ellen C: Furches Reference: PB 11 � PG � N IRS 281,t2' WB 20.08–E-20 ' r `r Placed DB 6�S � PG 38 �o �' in Line DB 63 � pG 40 � � �t LOT 2 I DEPAF2TMEN7" D8 63 � PG 41 C L 50' Ecsement = P L � 1� � �, 1,198 Acres +/– � �� - � � � � .._.,, IRS L-19 Total IRS w o IRS 266.21' 1 �' Placed •_,.,, 'r in Ltna ', ., .. _ ._...� .__. _.__. z.�� :.-1 '� SA-6 SE-1 . t , �-- , .. L0'T , 5eptic Areo � �""R�}G�14�.�1.1, VALLEY � �j'I Easemont �3 1 i . C L 30' tn � � —* �� Septic S stem Easement �. Phase ( � � �"12 � Y � Reference; PB 11 � PG 246 N ^r --+� � '~ � W� , (15' each side of C/L) � N � 1� septto;e� m v� . � �� .. `�asement �2 :!�I j I : . . • ' . r . ` . '' �S.A–.s — � ,. iRS w 5' Negativa . � Septic Area Easement �t ,� �--- L-24 Acceas Easement R/W ��S T-Bar w/Cap.Fnd 1� L�ne !�� '� J'N (See Note �5) 29.82' —_—... .., ... - '— Ep T-7-"i """"•""'-"�-� w...j.,..�,,,_ v 2� 7-Bar w/Cap Fi '-SA-10 .� ... ..�...�.... ... .. ..� �..�.� EP "�- --------- R�W PK-Ncfl Fnd , - ____""" "':~ , �� T-8 ------ .... .� � 7-5 T~� �. T-9 �,. ... r`� ... ..� ..� «.. �.. .�... Pzne`bro��k „�ri.ve r �, -� �y . Z N N � N � �/� � �� V��� S'• 3437 � N � N �� �j: O .7��n' .�i. �, a ��+' �, oi Curb �:' 6Q' � �/ °,� �c��.E. � �� a n� ��k'c�( Curb PUb�IC R W . vai 1•'ala t � y°� :� �' t�+ ,, o� m a`� � �-'"i \° 1 "ii�ir' 20 +/- Pavement'Wfdth �$� �' � . ���� � + - +� � �� 20'-N, ,��i u��1<<�n�a � �' �r ao � � � � .; i�l u� . . V p � • : . �.�►A�.. �` � � � 1�0�� bf nl Uuult x � m^'�+ N N� ,'i7 � ��,,��k �� P2ne bro o k � y �� � � �,�;r uook Tax Lot�33.10 ��.� �t � �� u, � Tax�lap E-5 �.J �i'���Z � ' �� � � � � �.�I 11(15�i1 � ' .art . � rt�.�N �,, ii,,,, � ��/#=£Ilen C.:Furchea a�v i��� . . . fi �i'8,10 � PG 255 �� R o ac� � ��� ,::WB.2d08-�-E-20. N ��r M,�rk ,;, a ii���„r��rv oun���Mor►< b6 63 :(� PG:38 � . D NOTES: n u,�„�I �,�,u�� .; � QB 6�:t� p�.:40 : �..Lti . 1��3� 1. 2onfng: R-20 ��� iW�,�i�io�, rna��tui :< pg g� q� �G .�.� � 2. Mtnimum Bullding Se •l�h, I►phufhriiiat tlnx , i•��v �c�+���, c,�nnn uui . ' Tt'4�k 5 Front: 30'� Rear. 3p ... .: 's ; •�.`' ; . ` . : :;o RC TES FARM AT PINEBR 3. Wate�rshed_Classiftca OOK . ►�..._ � • . . . . . �I � . ` "`�� t . . � �,� � 1 •�'"��� APPLICATION FOR SITE Ev,ALUATION/IMPROVEMENT P ��jT & � ` i C" Davie County Environmental Fiealth �� "Lr � � 0 �' � �� zp��� e � P.O.Boz 848/210 Hospital Street by,• . Mocksville,NC 27028 � . (33�753-6780/Fax(33�753-1680 Application For: Site Evaluation/Improvement Pernut ❑Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ORepair to Existin�System OExvansion/Modification of Existing Svstem or Facility ***IM1'ORTANT*#*THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIItED INFORMATION IS PROVIDED. Refer to the INFORMATIOI�I BUL�,ETIN for instructions. APPT.TCANT TNF(�RMATT(�N Name �� V Contact Person E�:/t-��� Address Home Phone_3�(0— 7'Z2,�'�9Z City/State/ZIP �- Business Phone 3�(o--qg g,..3�?/ Emai !/ . Q?i�,� Name on rmidATC ifD�erent an 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 pla�) Owner's Nam� "�/� /=����s Phone Number Owner's Address City/State/Zip ��/����� ��O� Property Address , . City ' �" - Lot Size � �. Tax PIN# �8�/ 9'��� ��• � � 2 ' Subdivision Name(if applicable) SectioniLot# Directions To Site: ,�`� V 1►— � If the answer to any of the following questions is•"Yes",supporting documentadon must be attached: ' � � Are there any e�tisting wastewater systems on the site? Yes �o � � Does the site contain jurisdictional wetlands? . Yes V1Qo Are there any easements or right-of-ways on the site? _,Yes �/1Q ��� �� Is the site,subject to appioval by another public agency? _Yes �o �� . Will wastewater other than domestic sewage be generated? Yes� TF RFCTnFNC,E FTT T,nITT THF.RnX R ,T.(� #People .? � #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes o Basement: ❑Yes o Basement Plumbing: ❑Yes C�do ,e TF NnN-RFSTDF,NCF..F1I T,nIJT THF RQX F3EL(�W Type of FacilityBusiness Total Square Footage of Building #People # Sinks #Com�modes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of siznilar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: �onventional ❑Accepted ❑Innovative �Alternative ❑Other Water Supply Type:�ounty/City.Water �New Well OExisting Well ❑ Community V�ell Do you anticipate additions or expansions of the facility this system is intended to serve? 0 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 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 enhy to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I tmders d that T am responsible for the proper identification and labeling of property lines and comers and locating and flagging or s the house/facility lo tion,prop sed well location and the locarion of any other amenities. Prop owne or lega representative signature Site R��tisit Charge Date(s): �� / � Client Notification Date: Date EHS: Sign given ❑Yes ONo ' • Account# ��2 Il Revised 11/06 Invoice# � - :,, L� , � ��� �-�(� \� I� S . � t � - X /� �r C� � �. _ '� , APPLICATION FOR SITE EVALUATION/IMPROVEME '�)�,ER1�I �'�� Davie County Environmental Health �1 � P.O.Box 848/210�Ios�ital Street AUG � 1 Z� Mocksville,NC 27028 �8 . (336)751-8760/Fax(336)751-8786 �DA�E�qI H �, OU, �`1 Application For: �1 Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Type of Application: �Iew System ❑Repair to 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 � (2o6tu�- !3�-�cA. {�wc�-s / � Name to be Billed `_,��tP 1.' " �% " ` Contact Person � Y'��+- -5� —�s . Billing Address l � l' f ,_..rL�'_ i'c'C�,��"��,�� Home Phone �j G/ - `�'r�L��i T- / , �ity/State/ZIP /��G/��]�5 L j l L�= /� � , ��`7t%•�1�_ Business Phone 1�1�y�'.-/��� Name ori�:Permit/ATC ifDifferent than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Flagged - NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Permit is�valid for 60 months with site plan,no expuation with complete plat.) � Owner's Name �',(i,;,�� �;��(=�� Phone Number Owner's Address :i�u F�— City/State/Zip Property Address ���_� City Lot Size Tax PIN# �S tl l r`7`�3Z2 Subdivision Name(if applicable) ,-- H �/�r?5 �], � a Section/Lot# . Direct�ons To ite: S� r - r • N '� • �' ' � /J� y"� �i' ',�'� � � t w � .:..,�� ' 1- I� ,.vz �s. ' J ' If the ans�ver to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on flie site? �Yes�No .�. � .Does the site contain jurisdictional wetlands? ❑Yes biNo ~�Are there any easements or right-of-ways on the site? �Yes�INo , . , . ;Ts the site subject to approval by another public agency? ❑Yes �No , _ '�,, ' � �Will wastewater od�er than domestic sewage be generated? ❑Yes�No ' :.� .. , �:;IF R�SIDENCE FILL OUT THE BOX BELOW ' #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes �No � ' - _. Basement: OYes ONo 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) (Attaeh documentation of similar facility water consumption) ' FOODSERVICE ONLY: #Seats� Type sy�tem requested:. C�Conventional �'Accepted ❑Innovative ❑Alternative �Other Water Supply Type: �County/City Water 0 New Well ❑Eaisting 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 inforn�ation provided on this application is hue and conect to the best of my laiowledge. 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 infomiation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie Cowity Health Department to conduct necessary inspections to detennine compliance with applicable laws and niles. I understand tl�at I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. �r —. i �� /__ '� � < � Site Revisit Charge �`-Propeity oy, ier's ot owner's legal representative signature � Date(s): �,.,-f' _ �� _ Client Notification Date: Date EHS: Sign given ❑Yes GNo: _ • • Account# Revised 11/OG Invoice# �, � , ,_._ ', _ �. r c_+✓ � �� _ — s'`; 1� + �• . - ' rv��ir�ccc+c�'w�aa�:w . �(,A.�jjl:�1`'-�"�(,' ' m+�ti K� .� �- ��- 0� _y._ _ � - r . ��, i �' 7`; 370 �� \l 370 �• I � � - 370 [� � � q� � � �� X . � � �J8 � `� �� � � J1LTN i (�,,, c�� � �7.7 � � �� �� � � � � � �c . i � �� 2� . ` � � � v C��h y -` � � �� W � � C�� a� � 4�p y o� �W a W � N �. . . • 1 �� �'�' � V� y . � Eti ' �' � . . \� �� "�� ti I ^� � �e � hh � W�h '�� � � � �^ � t'� �� � � x�' . � � �' PINEBROOK D�VE' .S:R. >437 365 363 363 457 648 CILBE. q TRACT 5 _ , � � AREA = +-5.92 ACRES AREA lNCLUDS'S R/lI � �A =T��0.45 ACRES � O AREA'INCLUDES R/1I n .. , � � O� 490 `�d � �, � ���� $ ° �� � 4 612 _ � N �� � TRACT 4 .---- ..,r. . � ' • � • � DAVIE COUNTY HEALTH DEPARTMENT �� �, � Environmentai Health Section � Soil/Site Evaluation , , APPLICANT INFORMATION ' PROPERTY INFORMATION . f�cco�nt�#: 990005156 - Tax PIN/EH#: 5841-97-7322.09 ' . - - - __.... _. -., Billed To: Ellen Furches � � Subdivision Info: Furches Farms Lot#09 Reference Namc'" - ;, � , ' � ,� . , ' , �Locati�n/Address: Pinebrook School�Rd.-27208 �Proposed Facility: Residence + PropertySize -.,7.34Acres Date Evaluated: � �--G G�'�� . . , �. ' ,. . , . " jk Z�r�� " � . . � ... . . . ,�,�C1 �y_� _ � • . .'.�' .. . .. !'.w..T � . . , . _ • � . � ' . . . - . � �:. - . �. � ... .-� � _ � . � . . , . . . .. . �. � :"1.,:-f . . ... � . . . � �-" . Water Supply: On-Site Well Community Public �� Evaluation By: Auger Boring Pit Cut � FACTORS ` C � ,�. Q ,�r, Landsca e sition � i- L L L, Slope% • - c, G_'� '� HORIZON I DEPTH 4 - l'i O- f d - L/ � :, Teacture grou �� �; �i j G G � � Consistence � � � ' , �j,(� ,��� Structure � , 7 � cri f�3� � �° a tut oss// !►'�� - -�✓ �� Mineralo • . ." J l�i �i/ L°. � ` ? %) � G' � � HORIZON II DEPTH �� � ✓ L - 7 � - . �/ � Texture rou � �� Consi�tence C t� a � r Structure ` V t a1 �'� Mineralo - HORIZON III DEPTH - - Texture rou L Consistence Structure Mineralo HORjZON IV DEPTH Texture rou Consistence Structure � Mineralo SOIL WETNESS / � ��. '�`' 2 '' RESTRICTIVE HORIZON ` � ,''d� '� �- `l < <'� SAPROLITE / , •i '1 " CLASSIFICATION - t,�l - C.� � LONG-TERM ACCEPTANCE RATE ' ' � , ' SITE CLASSIFICATION: EVALUATION BY: Ga;�,�,�a�'GK � . LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: � -5 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 . Trxttlrg � S-Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam - SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay ONSIST .N . 113�iSL VFR-Very friable FR-Friable FT-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic . r. Structure SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic MineraloQv 1:1,2:1,Mixed . , � Horizon depth-In inches � Depth of fili-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 TAD T....� re..., �....e..�.,,...e..,�e ...,1/.7.,../Ff7 Tl�TTT AC/AG m-.:--�� .. . � - . • . ' •• �.- . ' DAVIE COUNT'Y HEALTH DEPARTMENT . , � Environmentai Health Section � . , Soil/Site Evaluation � ,_:�:� APPLICANT INFORMATION � PROPERTY INFORMATION - �., ,�-('.��f / �f c�'��� = t�� ` , L,.o� �� Water Supply: � On-Site Well Community Public Evaluation By: Auger Boring ' Pit ,� Cut FACTORS I 6 7 ' .Landsca e sition � L V •.. L Slo % . . '. HORIZON I DEPTH � , �—� .� — Texture grou G G C Consistence .�'r./ � { ,� Structure � "� L Mineralo ,D { �� . ` HORIZON II DEPTH o " 2 L- " Texture rou � `'�" � ' G L � Consistence S D �` ; r 5 k Structure C /� ' �'Y� S Mineralo w HORIZON III DEPTH ' Texture rou 3� Consistence ¢� Structure � Mineralo HORIZON IV DEPTH � Texture rou �' Consistence ' •r l Structure Mineralo SOIL WETNESS 1 `� �� � ��' RESTRICTIVEHORIZON �0'` �- �' - SAPROLITE " CLASSIFICATION (� LONG-TERM ACCEPTANCE RATE SITE�CLASSIFICATION:_��� � EVALUATION BY: �. C� ''j LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: I � �� REMARKS: • � ��Q , LEGEND " T, n c e 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 � ' Texturg � � 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 ' D�ls� . ' .ON4I4T�,N . . VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Fa�tremely firm , 3�'e� � � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic �tt11Ct13T� ' SC-Single grain ' M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic MineraloQv 1:1,2:1,Mixed Notes � Horizon depth-In inches � Depth of fill-In inches Restrictive horizon-Thiclrness 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-gal/day/ft2 DCHD OS/OS(Revised) \� ' . .. � . . F . ''.. � . ... , .�.. . r ... . . . . .. .. ����� ' � .1 " . . `�^ --�- ' DAVIE COUNTY HEALTH DEPARTMENT �f , • ` � Environmental Health Section `i .- Soil/Site Evaluation �y � ' APPLICANT INFORMATION � PROP�RTY INFORMATION� �* Account #:•,99�0005528 Tax PIN/EH#: E5000000330'�-#2. Billed To:�:�Sugar Valley Airport Subdivision Info: Sugar Valley Airport Lot#2 Reference Name: "' Location/Address: Gilbert Road-27028 , Proposed;Facility: Residential Properiy Size: 2.03, Date Evaluated: i'�12�51�Z • . � , y�1'; � Water Supply: = :.�•�On-Site Well Community � Public �-- , Evaluation By: y Auger Boring Pit�. Cut . FACfORS 1 2 3 4 ' S i 6 7 Landsca e sition � ,. Slo % • -, - • O , - . �,: _ HORIZON I DEPTH pp.,; ' _ � - p. , , < , . Texture rou Consistence . : � � Structure � � Mineralo ,Y ;: f , ;(:. , _ . HORIZON II DEPT'H�`. _3 ``•; Texture rou • � , r Consistence = � ..._ L .,. • _ ` Structure' Mineralo 2� `( _ �;,,� HORIZON III DEPTH .;; ';' _ Texture rou � y„�, _ Consistence ' -;,, , Structure ,'i�:,, „, _ ,.Mineralo _ . _ ,� �. :a � _ . ' HORIZON IV DEPTH . � ' �Texture rou . -.�r . , _ . _ - Consistence - rw:.�: ,> . . s . . - �-Stracture . , ; , '. Mineralo � . . `• SOIL WETNESS � c� � RESTRICTIVE HORIZON _ SAPROLITE . . `.. � CLASSIFICATION LONG-TERM ACCEPTANCE RATE � ' . STIB CLASSIFICATION: � EVALUATION BY: � � I(�e '" . —P' LONG-TERM ACCEPTANCE RATE: � ��� OTH$R(S)PRESENT: _`� '�.�i�� - P'�� . � REMARKS• _ : LEGEND i � . Landscape Position ; . R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope ' , CC�-C��oncave slope CV-Convex slope T-Tenace FP-Flood plain f .H-Head sIope : , t 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 + _ . lYiulS� _ � i 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---� &tt.us�tt� : . SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky - SBK-Subangulaz blocky PL-Platy PR-Prismatic , Mineralo�v _ 1:1,2:1,Mixed � , LY4S�S _ . 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) . 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