230 Staya Way (3) Davie County,NC Tax Parcel Report Friday,November 18, 2016
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Parcel Information
Parcel Number:-..: D50000001701 Township: Farmington
NCPIN Number:._ 5842521769 Municipality:
Account Number: 82532397 Census Tract: 37059-802
Listed Owner 1: STANBERY BRYAN TIMOTHY Voting Precinct: FARMINGTON
Mailing Address 1: 230 STAYA WAY Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay: DAVIE COUNTY QD
Zip Code: 27028-0000 Voluntary Ag.District: No
Legal Description: 12.019 AC OFF CEDAR CREEK Fire Response District: FARMINGTON
Assessed Acreage: 12.05 Elementary School Zone: PINEBROOK
Deed Date: 11/2010 Middle School Zone: NORTH DAVIE
Deed Book/Page: 008420395 Soil Types: EnB,MsC,WATER
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 123030.00 Outbuilding&Extra 4510.00
Freatures Value:
Land Value: 115430.00 Total Market Value: 242970.00
Total Assessed Value: 242970.00
9 AIip All data Is provided 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
�OUNC NC or arising out of the use or inability to use the GIS data provided by this website.
OPERATION PERMIT or se nI
v
Davie County Health Department *CDP File Number 219664-11
210 Hospital Street 5842521769
1,. County r.
P.O. Box 848 �
ID Number
Mocksville NC 27028 Evaluated For NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Bryan Stanbery Property Owner: Bryan Stanbery
Address: 230 Staya Way Address: 230 Staya Way
City: Mocksville CRY: Mocksville
State0l): NC 27028 'State/Zip: NC 27028
_Phone : (336)703.8973Phone;r: (336}703-8973
Propertv Location 8& Site Information
Address/Road#: = Subdivision: Phase: Lot:
�j Staya Way Lane
Mocksville NC 27028 Directions
Farmington Road to Hubert Rd right on StayWa
-Structure � SINGLE FAMILY � � - 9 � y'
Lot in front of Nikkis Way
#of Bedrooms: 3
#of People:
*Water Supply: NEW WELL
*IP issued by. `2140-Nations,Robert *System Classification/Description:
TYPE III G.OTHER NON-COW.TRENCH SYSTEMS
*CA issued by: 2140.Nations,Robert
Saprolite System? OYes QNo
Design Flow: 3 6 0 *Distribution Type: GRAVITY-SERIAL Pump Required?
QYes (DNo
Soil Application Rate: 0 1 7 5 *Pre Treatment:
Drain field
rNo.
on Field 2 0 5 7 Sq.ft. *System Type:
Lines 5 Installer: William Rueben Clayton III
Total Trench Length: 5 1 4 ft- Certification#: 2694
Trench Spacing: _ 9 Inches O.C.
• Feet O.C. EH S: 2140-Nations.Robert
Trench Width: _ 3 Inches
Feet Date: 1 1 / 0 8 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. a 4 inches Approval Status
Maximum Trench Depth: 3 Inches
6 ®:Approved Disapproved ,
Maximum Soil Cover:
2 4 Inches
CDP File Number 219664 - 1 County ID Number: 2521769 s
Septic Tank R
Manufacturer. Shoat Lat.
STB:- 760
Long:
Gallons:
1000 Installer. William Rueben Calyton III
Certification#: 2694
Date: 0 9 / 1 1 / .2 0 1 6
*EHS: 2140-Nations.Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker: El Yes NO
Date: . 1 1 / 0 8 / x 0 1 6
Reinforced Tank: ❑ YeS ® No Approval Status
1 Piece Tank: ❑ Yes ® NO
®-Approved❑ Disapproved
Pump Tank
("Manufacturer Installer
PT: Certification#:
Gallons: *EHS:
Date:
/ / Date:
RiserSealed ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ No {Min.6 in.)
Approval Status
Reinforced Tank: D Yes O No p,Approved D Disapproved
1 Piece Tank: _D Yes 60 No
a K1 Pie ..,
Supply Line
Pipe Size: inch diameter Installer:
CPOe Length: feet Certification#:
'ENS:
*Schedule:
Pressure Rated ElYes ❑ No Date;
Approved fittings ❑,Yes ❑ No Approval Status
.❑ Approved D Disapproved
Pump e ui e e
Pump Type: Installer:
Dosing Volume: - Gal Certification K:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve El Yes El No
Approval,Status
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ NO
Anti-siphon Hole ❑ YeS ❑ NO
• CDP File Number 219664 - 1 County ID Number: SU2521769
Electric Equipment
("'NEMA 4X Box or Equivalent El El Installer:
Box 12 inches Above Grade El Yes El No
Box Adj.To Pump Tank ❑ Yes ❑ No
Certification#:
Conduit Sealed ❑ Yes ❑ No "EHS:
Pump Manually Operable ❑ Yes ❑ No /
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No p Approved❑ -Dtsapproved'
Alarm visible Te
❑ NO
2140•Nations.Robert
*Operation Permit completed by:
Authorized State Ag t: Date of Issue: 1 2 / 0 $ / a 0 1 6
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal;15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE III G, sewage septic system.
Rule .1961 requires that a Type ,TYPE 111 G. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
_ Minimum System Inspection/Maintenance Frequency ByCedified Operator:
N/A
Reporting Frequency By Certified Operator.NIA
Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entitywith a certified operator forthe life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit fora system required to be maintained by public or private management entity, unless the
system ownerand 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 tong 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
219664 -•1
Davie County Health Department CDP File Number: .;
210 Hospital Street 5842521769
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
p Inch
Drawing Drawing Type: Operation Permit
Scale: . puck ft.
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. ' Well Construction Perm it For Office Use Only
Davie County Health Departm XILI&P '`COP Fite Number 219664
210 Hospital Street
f� 7,Q PIN Number 5842521769
P.O. Box 848 tiatet
Mocksville NC 27028 Tax Lot M Tax Block#:
Phone:336-753-6780 Fax:336-753-1680
Evaluated For:WELL
PERMIT VALID UNTIL: 7/20/2021
Property owner: Brian Stanbery Applicant: Brian Stanbery
Address: 230 Staya Way Address: 230 Staya Way
City: Mocksville CRY: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: (336) 703-8973 Phone 9: (336) 703-8973
Property Location & Site Information
rddress/Road#: - Subdivision: Phase: Lot:
ay Lane *Proposed use of Well:
le NC 27028
If Other:
Latitude
Longitude Directions
Site Address: Staya Way Lane Directions: Farmington Road to Hubert Rd right on Stay
Way. Lot in front of Nikkis Way
Well Contractor Information
Drilling Contradorr Driller Registration
ermit Conditions
*Permit Co ditions
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 complywnn existing regulaticns.The siting of approved well construction
area(s)by the Health Department is to provide protection from the knavn 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 Issuei 0 , 7 , / , a , 0 , 1 a , 0 , 1 , 6 ,
Authorized state Agent: QHand Drawing Qlmport Drawing
Owner/Applicant Signature: **Site Plan/Drawing attached.**
WELL CONSTRUCTION PERMIT 21.8664,.
do Davie County Health Department CDP File Number:
210 Hospital Street 5842521769
i P.O. Box 848 County File Number.
NC 27028
Mocksvilte Date: 0 7 / 2 6 / .1 a i fi
0Inch
Type: Well Permit Scale: , , OBlock
Drawing
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VY APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
J� P.O.Box 848/2110 Hospital Street
,Mocltsvllle,NC 27028
(336)753-6780/Fax(336)7S3-1680
Application For: 0 Site valuation/improvemeni Permit 0 Authorization To Construct(ATC) VE oth
• Type ofApplication:grew System 0Repair to Existing System OExpansion/Modification of Existing System or Facility
***1A?PORMA719*THIS APPLICATION CANNOT AE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed�Q , A_ �b Contact Person Q Al
Billing Address IQQA_ � _ Home Phone 'Z
Citylstale2lP Business Phone
Name on PermittATC if Different than Above lKim
Mailing Address Ci /State zi
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE; A survey plat or site plan must accompany this application. Included:WSite Plan CPlat(to scale)
(Permit is v lid for 60 months wi site plan expi ion with complete plat.) p,��7
Owner's Name f 1 Phone Numbc r a l l
Owner's Address City/Stat'/Li
Property A4dress tatty 1
Lot Size / el or f Tax PIN# I l '
Subdivision Narrte(ifa plicable) Sectiowlot# f•
Directions To Site: 5 N-Pro n(L ap
If the answer to any of the following questions is"yes",supporting documentation must be attached. �t l
Are there any existing wastewater systems on the site? Oyes tt Q
Does the site contain jurisdictional wetlands? Oyes tato
Are there any casements or fight-of-ways on the site7 Oyes 34.
Is the site subject to approval by another public agency? ayes;
97N
wastewater other than domestic scaage be generated? 0 Yes fYlCo
-'
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpoo)OYes o -
Basement:Dyes Wo Basement Plumbing: OYes
1F NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building_ #People - -
#Sinks #Commodes #Showcrs #Urinals -
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY:: #Seats
Type system requested: RConventional DAcccpted Oinnovative OAltemative OOther
Water Supply Type 0 County/City Water VNew Well OExisting Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes WK,
If ycs,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 fatsiiied or changed I hereby grant right ofcnuy to the Authorized
Representative of the Davie County Health Department io 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
Io ting and Ilagg' r stakit the houselfacility location,proposed well location and the location of any other amenities.
Props owner's or owner's legal r sentative signature Site Revisit Charge
Date(s):
3 Z0� Client Notification Date:
Date I EHS:
Sign given ayes ONo Account# 1 `t'" 4
Revised 11/06 Invoice
it
APPLICATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name / L%n&rq Contact Person
Address 151 OLM Home Phone
City/State/ZIP Business Phone & 3Ca 71 7'
Email pL
Name on Permit if Different than Above
Mailing Address Z9() !Sj3t� el City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey1 or site plan must accom any this application. Included: Site Plan 0Plat(to scale)
Owner's Name !t f r uam S .II be-ez, Phone Number
Owner's Address- City/State/Zip
Property Address o?30 ,S' 0-After. City -AMa X23-
Lot Size _L cO u.gA& Tax PIN#
Subdivision Name(if ap licable) Section/Lot#
Directions To Site: 4
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 k�--_ 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. 1
By signing this application,the applicant signifies that they understand the tenns and conditions and that they=ive permission for
Davie County Environmental Health representatives to perforin necessary field evaluations and procedures dccmcd necessnr% to
determine the best location for a well.
41�n-
Signed Date
7130.'09 Account
lnvoice= We .�
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APPLICATION FOR PRIVATE WELL PERMIT
Davie County Environmental Health
P.Q.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
***IMPORTANT **
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TFIE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name / 1' &rq Contact Persontm
Address Home Phone
City/State/ZIP Business Phone ��(�2-71 9;L- 7-1
Email Q
Name on Permit if Differem than Above
Mailing Address Z30 S�2ua L QAd City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey 1 t or site plan must accomga—ny this application. Included: - Site Plan UPlat(to scale)
A Owner's Name-� f' . n.�am �TGL�L�rt l Phone Number
Owner's Address City/State/Zip
Property Address_eQ30 ,S' City-
Lot Size /-06 gzg2t.t_ Tax PIN#
Subdivision Name(if ap Iicable) Section/Lot#
Directions To Site:` �r'�I4rl � ICO t'c, = t q
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 terns and conditions and that they d=ive permission for
Davie County Environmental Health representatives to perforin necessary field evaluations and procedures deemed necessni7 to
determine the best location for a well.
t7 ��
Signed Date
7/30.'09 Accountn'
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_.� CONSTRUCTION For office use only
AUTHORIZATION *CDP File Number . 2966 -
Davie County Health De��LE� county ID Number.502521769
,t
210 Hospital Street
Evaluated For: _ NEW
.� ,. P.O. Box 848 �°t6� Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 7 / a 0 a 0 a 1
7Ad
ant: Bryan Stanbery Property owner. Bryan Stanbery
ss: 230 Staya Way Address: 230 Staya Way
City: Mocksville City: Mocksville
StatelZip: NC 27028 Stateaip: NC 27028
Phone 4: (336)703-8973 Phone#: (336)703-8973
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
Staya Way Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Farmington Road to Hubert Rd right on Stay Way. Lot in
front of Nikkis Way
#of Bedrooms: 3
#of People:
"Water Supply: NEW WELL
System Specifications
Minimum Trench Depth: a 4 Inches
Site Classificatbn: Provisionally
Sa rolite System? Minimum Soil Cover.
p y OYes ( No 1 a Inches
Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 1 7 5 Maximum Soil Cover: a 4 Inches
"System Class ifcation/Description: "Distribution Type:
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 Q N o
Pump Required: OYes @No OMay Be Required
Nilrifieation Field a 0 5
Sq.ft. Pumplank: Gallons
No. Drain Lines 4 1-Piece: OYes QNo
Total Trench Length: 5 1 4 ft GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 . @Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 . Feet Grease Trap: Gallons
P _ _
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 011 0111 01V
Dane% 1 of Z
CDP File Number 219664 - 1 County ID Number. 5842521769 .
❑ Open Pump System Sheet
Repair system Required:@Yes - 0 N ONo blit has Available Space
rDesign
System
Trench Spacing: 9 Q Inches 0.0
ification: Provisionally Suitable Feet O.C.
w: 3 6 0 Trench Width: Q Inches
Soil Application Rate: 0 1 7 5 Aggregate Depth: inches
Minimum Trench Depth: a q, Inches
*System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY 011480 GPD OR LESS, Minimum Soil Cover. 1 2 Inches
Maximum Trench Depth: 3 6 Inches
"Proposed System: 25°!o REDucTION
Maximum Soil Cover, a 4
Nitrification Field 2 0 5 Sq. Inches
ft. - -
No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 5 1 4 ft Pump Required: Oyes @No (' May Be Required
Pre Treatment: ONSF OTS-1 OTS-11
"Site Modifications
No grading or construction activity is allowed in areas designated far system and repair without approval of Health Department.
'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.
i '
This Authorization for wastewater System Construction shall be valid far a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be Issued at the same time the Improvement Permit Issued(NCGS 130A-336(b)�If the installation has not been
completed during the period of validity of the Construction Permit,the Information submitted in the application for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permit or construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the systern 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: Date of Issue:
2140-Nations,Robert 0 7 / 2 0 2 0 1 6
Authorized State Agent: Malfunction Log OYeS
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@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number:
210 Hospital Street 5842521769
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 7 1 a e / s
Q Inch
Drawing Drawing Type: Construction Authorization Scale: QBlockpN1A
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CONSTRUCTION AUTHORIZATION
J Davie County Health Department
t 210 Hospital street CDP File Number:
UD P.O.Box 848 5842521769
t od Mocksvitle NC 27028 County File Number.
ClickLow to Import an Image from an_exter al-location:- DraminType:Construction Authorization
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'IMPROVEMENT PERMIT Fo�officeuseonly
"CDP File Number 219664- 1
Davie County Health Department
County ID NUmber:5842521769
210 Hospital Street
P.O. Box 848 Evaluated For. NEW
Mocksville NC 27028 Township:
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 7/20/2021
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
Applicant: Bryan Stanbery Property owner: Bryan Stanbery
Address: 230 Staya Way Address: 230 Staya Way
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)703-8973 Phone#: (336)703-8973
Property Location & Site Information
('Address/Road 9: Subdivision: Phase: Lot:
Staya Way Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY = Farmington Road to Hubert Rd right on Stay Way.
#of Bedrooms:' 3 Lot in front of Nikkis Way
#of People:
*Water Supply: NEW WELL
System Specifications
nidal S stem
"Situ al ssifiica ion' Provisionally Suitable
Minimum Trench Depth: 2 4 Inches
Seprolite System? OYes @No
Maximum Trench Depth: 3 6 Inches
Design Flow: 3. 6 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 0 1 7 5 1-Piece: OYes @No
Pump Required: OYes QNo 0May Be Required
"System Class it`cation/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25°I°REDUCTION 1-Piece: QYes QNo
Repair System Required:@Yes ONO ONo, but has Available Space
rBRepair System
*Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches
Soil Application Rate: 0 1 7 5 Maximum Trench Depth: 3 6 Inches
*System Classification/Description: Pump Required: OYes Q No Q May be Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
"Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number 219664 - 1 County ID Number: 5842521769
*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 shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that stows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valld without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no morethan 60 feet,that includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site plan,plat,or Intended
use changes(NCGS 13oA335(t)).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)j
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps.Signature' Date:
'issued By: 2140-Nations,Robert Date of Issue: 0 ? / a 0 / a 0 1 6
Authorized State Agent. OValid without Expiration?
C3Create CA?
01-land Drawing Olrnport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
'IMPROVEMENT PERMIT
Davie County Health Department CDP File Number: 219664 - 1
210 Hospital Street 5842521769
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: ! /
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IMPROVEMENT PERMIT
Davie County Health Department '
210 Hospital Street CDP File Number: 219664 - 1
P.O.Box$4$ 5812521769
Mocksville NC 2702$ County File Number:
Date: .g 7 / %240.j/ 2 0 1 6
Click below to Import an image from an external location:Drawing Type: Improvement Permit
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
i-116 � ......
Davia County Environmental Health
P.O.Box 84MIO hospital Street
,Alocksvitte,NC 27028
(336)753-67801 Fox(336)753-1680
9 /AppliFor:.0 Site valuation/Improvement Permit 0 Authorization To Construct(ATC) Both
Type of Application:VWcw System 0Repair to Existing System 0 Expansion/Modification of Existing System or Facility
•"1AIPORTANT•••THIS APPLICATION CANNOT RE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed�= S �/- Contact Person Sew t,/Billing Address S ja 1( >2t�_ Home Phone 3.3G,— �A'�F
City/State2lP Business Phone
Aim 5� l' 7
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flogged
NOTE; A survey plat or site plan must accompany this application. Included' ite Plan CPlat(to scale)
(Permit is mad for 60 months%YO site plan expi ion with complete plat.)
Owner's Name f ! Phone NumbeLl&70,g a 17
Owner's Address City/State2i
Property Address try t 2.7 Zc�
Lot Size / (,(A.r Tax PIN# I l
Subdivision Name(ifapplicable) Section/Lot#
Directions To Site: •P 1 N-�(0 N i a
If the answer to any of the following questions is"yes",supporting documentation must be attached. +
Are them any existing wastewater systems on the site? OYts ldwo - - 1
Does the site contain jurisdictional wetlands? DYes tD o
Are there any easements or right-of-ways on the site? Oyes MI.
Is the site subject to approval by another public agent}? Oyes IrN
Will wastewater other than domestic sewage be generated? OYes V.
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms A` #Bathrooms Garden Tub/Whirlpool OYes o _"
Basement:UYes GKo Basement Plumbing: OYes tlt o _
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showcrs #Urinals
Estimated Water Usage(gallons per day) (Attach documentation ofsimilar facility water consumption)
FOODSERVICE ONLY:: #Scats
Type system requested: Anventional 'DAccepted Olnnovative OAltcmative OOther r
Water Supply Type:D County/City Water Aw Well OExisting Weil 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes X.
If ycs,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. 1 understand
that any permits)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 falsiiled or changed I hereby grant right ofentry 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
lo dng and Hagg' r stakil%the house/facility location,proposed well location and the location of any other amenities.
_ 4 Site Revisit Charge
Propoy owner's or owner's legal Wsentative signature
Datc(s):
011—V1901k, Client NotiRcation Date:
Date EHS:
Sign given OYes QNo Account#
Revised I It% Invoice If
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s Printed:Jun 15, 2016
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of
merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,its agents,
consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided b
this website. i
NCDENR -
Division of environmental Health
On-Site Wastewater Section *Date: 0 a I 1 s I a a 1 6
Soil/Site Evaluation 'File#: a 1 9 6 6 4
For On-Site Wastewater System PIN #: 5842521769
'Owner Bryan Stanbery Proposed Facility SINGLE FAMILY
Proposed Design Flow (.1949) Location of Site Staya Way Lane
Property Size 1 Water Supply NEW WELL Evaluation Method Na
1 40 Horizon SOIL MORPHOLOGY
Profile- Lanscape Depth .1941 Other Profile
Slope% (IN) Texture Structure Mineralogy
Color Color Factors
1 L 0-48 sc 1-Wea abk fi s P .1942 wet.
2 °Io
.1943 Depth
GPS Saprolite:On) .1944.Rest.
Horizon
raEHS .1947 Class Ps
Nations,RotX Profile
LTAR 0 . 1 7 5
.7 L 0-48 sc 1-Wea' abk fi s P .1942 Wet.
2 % .1943 Depth
GPS Saprolite:(n) .1944 Rest.
Horizon
EHS 1947 Class Ps
Cop * orile Nations,Robe LTAR 0 1 7 5
177
3 L 0-48 sc 1-Wea abk fi s P .1942 Wet.
2 °'° - .1943 Depth
GPS Saprolite:00 .1944 Rest.
Horizon
EHS 1947 C135s P$
Copy.Profile Nations,Robe Profile 0 1 3 5
LTAR
.1942 Wet.
% .1943 Depth
GPS Saprolite:(1n) .1944 Rest.
Horizon
011 EHS 1947 Class
Copy rotile Profile
AR
.1942 Wet.
°lo .1943 Depth
GPS Saprolite:Vn) .1944 Rest.
Horizon
is EHS 1947 Class
Copy ofile Profile
LTAR
Available Space(.1945) PS OtherFactors(.1946) PS Ste Classification (.1948)Ps
Initial LTAR: 0 . 1 7 5 Repair LTAR: 0 . 1 3 5 Others Present:
Comments:
Evaluated By. Nations,Robert
NCDENR -
Division of Environmental Health
On-Site Wastewater Section Date: 07 0 0 1 6+
Soil/Site Evaluation Fie#: 2 1 9 6 6 a
For 0n•Slte Wastewater System PIN 9: 5 8 4 2 5 2 1 7 6 9
1940 Horizon SOIL MORPHOLOGY
Profile#t Lahascape Depth .1941 Other Profile
Slope PO �,� (IN) Mineralogy Matrix Mottle Factors
Texture Structure Consistence Color Color
1942 Wet.
% .1943 Depth
GPS Saprolite:(m) 1944 Rest.
Horizon
EHS 1947 Class
Gopy�rofil Profile
LTAR" • .
1942 Wet.
% .1943 Depth
GPS Saprolite:(n) .1944 Rest.
Horizon
EHS .1947 Class
Gopy,P,rotl Profile
AR
lJ LTAR
.1942 Wet.
% .1943 Depth
GPS Saprolite:(n) .1944 Rest.
Horton
13 EHS .1947 Class
Copy rotil Profile
AR
1942 wet.
.1943 Depth
GPS Saprolite:(in) .1944 Rest.
Horton
EHS .1947 Class
Copy-P-rofil Profile
LTAR
1942 Wet.
oda 1943 Depth
GPS Saprolite:00 .1,9oifzonst.
EHS .1947 Class
Copy, rotit Profile
LJ LTAR
Comments:
• V
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