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258 Vanzant Rd . � � . � , " � � Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(33�751-878G WELL PERMIT Account #: 990004448 � Tax PIN/EH #: 5719-02-4177-Well Billed To: John Watkins Subdivision Info: Reference Name: , Location/Address: 258 Vanzant Road-27028 Proposed Facility: Well Property Size: 2.50 Acres ATC Number: 0006 Actions of the employees of the Davie County EH Section shall in no way be talcen as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any factJcircumstances upon which this permit was issued. Permit Type: New[�epair ❑ Abandonment ❑ .�a�� Proposed Well Location Diagram �cCe ' icate of Completion Diagra,�n �" Cc✓� 2c�.,�t ( ��J -'�'` t2- ! �,��X = W¢'i 1 � ���� � 1'i� ' � (4� � � � �' V� � • �� �,c��,,,r �y �p7 �— � t � l� l wG c � tJ' ; l�� i � vu5�' �'- .r �t��` �'��o�� � 0 4! � � .-- ""'" —� � � �p� ��O � ( C��'{.(i I � `�, � 0 � C� ( �,�ta f �'� ��h �' _ � , � - ,�,� '� � ti v . _ _ , � ���� vLt �- � �, i� hC �� Comments: hn . � Q �� ci�"t Driller: l Glc� . ���+ tJ P� l,l-e U S V..�eLt f� -Ps � �'P� �4cks � Certification#: 3� 3!Q /3�uU�cc� �j �� GroutInspected: �' 3 �—� J Well Head Inspected: �D '?� / GPs coor ' s: 3 S� tl. 0�� � / T 3 EHS: Date:� EH . ✓ ate:����� W.P.�_og r��Uo GU�f��.S�mp/� %��.°� . � , ' ' � , � , _ � • , � Q � ATION FOR PRIVATE WELL PERMIT � � � avie County Environmental Health �,.) � �QQ� P.O. Boz 848/210 Hospital Street ` � �' Moctcsville,NC 27028 ��`ti.. Ju , ,,���N 336)751-8760/Fax(336)751-8786 �' ,., n�Rr;E���P�\ � ' D���` v ***IMPORTANT*** THI APP ION CANNOT BE PROCESSED UNL�SS ALL OF T�REQUIItED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed ��1���iJ �� /�c-/� 5 Contact Person .�f�iv J�11�/,ti' -S Billing Address }�C"� ,�'�'�� �f I � Home Phone_ S�Ji ��O f �j t�'� City/State/ZIP�)2�0 t".,�5��/.L,CL /� C� `�a'' Business Phone � Name on Permit if D�ferent than Above � Mailing Address CJ �� , City/State/Zip /�'�c�'C,�SUj11� /yC ��� �7 �� PROPERTY INFORMATION *Date House/Facili Corners Fla ed NOTE: A sutvey plat or site plan must accompany this application. Included:,� Site Plan ❑Plat(to scale) Owner's Name ,�j�/,f J !"2�i�-i�'�....-= Phone Number.S t�� a����%%jc`f� Owner's Address City/State/Zip Property Address��'c`j �/,�d{/�'7— r?,/� City JZ��'L-f� �'%�� Lot Size ���.�,_��ci^,�-�S Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: /, 1s1 �tJ�<S�`"v�l T .� �'�_�,� ii'�n.�-�s"�-.J''�• � DEVELOPMENT INFORMATION Pernut 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 properly lines � with dimensions,the specsc 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 sigcvfies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary „ to determine the best location for a well. l � `�� --" �---� � �'�D Sign Date Site Revisit Charge Date(s): Client NotificaUon Date: EHS: 7/1/08 Account# � Invoice# ���� . `� , . ' ' , , .' �,,_,, � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751=8786 AUTHORIZATION FOR WASTE�VATER SYSTEM CONSTRUCTION Account #: 990004448 Tax PIN/EH#: 5719-02-4177 Billed To: John Watkins , Subdivision Info: Reference Name: Location/Address: Vanzant Road-27208 Proposed Facility: Residence Property Size: 2.50 Acres ATC Number: 4762 Site Type�w ❑Repair ❑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 plumbit�g8'"r Non-Residential5pecifications: Facility Type #People #Seats ' Square Footage(or Dimensions of Facility) Lot Size�.����"`�%� Type of Water Supply:�nty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)r��Tank Size{��AL.Pump Tank GAL. Trench Width �+ Max.Trench Depth �+ Rock Depth 1Z�� Linear Ft.�(�� Site Modifica i ns/�ditions/Other: � � r ! � / 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. ��l ����� ��t�P � �4s st�ted in x5A NCAC 1R�1.19Q�3(B) ����j�����j� �ccepted �yst�ms rr�ay atso be used . � �p o a o�� � ��,y.3�� �v �e� ���l�Z ��` �� -Q.(,�.� '�l� ���s' �'� - � f,,, �.-�T' � �,��. �-� �� � .$ \ � � •�v �� � � ��� , ��` v �� Enviro ental pecialist�s���,��.����__Date: �� nf'Hn 1 (Revi�edl 'r ' . .. ' s ` ' • DAVIE COUNTY - WELL CERTIFICATE OF COMPLETION CHECKLIST Applicanfi __�p�nh �� r�}'� k ;� J File #: �� C�j (,p Site Address: �-S Q`j � �GU��� �� Subdivision: Lot: Permit Type: New Well� Well Repair Well Abandonment Other Facility Type: Residential �ood Service Church Commercial Other Initial Inspection _ Were Setbacks Maintained? Yes V No What is the Grout Depth?�C..r ft. If No, Explain: What is the Grout Thickness?�_ in. What is the Type of Well? �n�1�-� c� Was a Well Screen Installed? ° What is the Casing Type? ���c,u�;�� � �"�� Type of Drilling Fluids Used: What is the Casing Depth? ft. L��'�`` Well Grout Inspection Date: �' 3 � ��' What is the Well Diameter'? ,���in y" �I�titi•�" GP�S Coordinates: What is the Well Depth? ft. EHS ID: 1 �{� Well Head Inspection Is There an Access Port? Is There a Vent? Is There a 4" Pad? �-� Is There a Hose Bibb? What is the Casing Height? Is There any Grout Settlement? What is the Static Water Level? ft. What is the Yield? GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name: Pump Installer Name: Contractor Certification #: Date Installed: Depth of Well: Depth of Pump Intake: Casing Depth and Inside Diameter: Pump Horsepower Rating: Screened Intervals: Opening for Piping &Wiring >_12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: Date Well Completed: Well Head Inspection Date: EHS ID: � Construction Completed Date: Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Date: Authorized Agent: � �(�'`���T�� �ESIDEIVTIAL wi��corr�vcrxoH�coRn - .�� 1C.� • ' , a . � 1'S .r Norih Caro(ina llc ent of Environmcnt nnd Nntvral Ra,�ou�cs-Division ot'Wuter ali ,� � .� �� �j ./ Qu �Y ` .., �'`''^���"�� WELL CONTRACi'OR C�RT�CA�ION# �-0 J b 1.1NEL1.CONTF2AC'TOR: . f. DISINFECTIaN:Type �'fi Amount� S L"IL� ��" Pih/ .U, ��-/�W/1 g. WATER ZONE3(do�h): � ._ I Well Contractor(Individueq Namo �rom 7s�To �_ F�om}� To Yadkin WelX Compariy, Inc. From !SFl �To i3 9 ' —�'r''o�l"^ To Weil Contrador Company Namo From To F�om To STREET ADDRESS 1908 Hamp�onville Road 6. CASlNG: Thfcimess! � Daplh Dlamoter WelDht MaterfaS HamAtonville NC 27020 From_-� To �� R. ��. " p�'�,' �/� Jr� CftyorTomi State ZtpCode Ftom�To��R.h�rd��� ..S��R_.�(?� 3L 36 �_468-4440 Ftom To Ft. �_ •�tJ�te�+ Area code- Phono numbor � ���OM 2.WELL INFORMATtON: 7. OROUT: Depth Matertal Melhod g '"^�" / � � From_�7o�_FT. in� �n., � ��VJ� 517E WELL ID�pf applbable)� �1 From `3 To��,R. _ �,r'y/��l_l.,.Q, STATE WELI PERMITi�(if applicable) r Ftom To Ft. T�--_ DWQorOTHERPERMIT�('rfappGcable) 8. SCREEN: Depth Dfameter SlotSize Materfal � From-- To R. In. In. WELL USE(Check App!lcable Box}: Reskienifal Water Supply From To R. In. in. DATE b}�LLED 7' 3�' �� From To R. tn. in. TIME C�MPLk�i'ED ���vv �❑ �[�C g, SANDIORAVEL PACK: 3.tAIELL LOCATION: �P�h Size Materlai - From To Ft. Cf7Y: f"��cti/��.� �2 COUNTY ���1� �rom To Ft. 2 ���' �/..•r� .�anf � From 7o Ft. (Streei Name,Numbers,Community,Subdrvlsbn,Lot No.,Parcel,7Jp Code) TOPOGRAPHIC/L,AND SETTING: 10,pRIILING LOG � �Slope ❑Valtoy pFFat ❑Rldge ❑Other ' From To � Formation Description � (checkappropriatebox} � ._.. �� • ! lATI7UDE 3 ;�, ,.�'}` `l.��. Mayboindcgua, s0 . _ 170� � � '• I minutra,ecconds or /� ,�',Lf?, LONGITUDE � J .�` (� �r in a dccimal frnmat �7U '— .',ZV;Q,'� _So�r}- (.,/�c.�i�F,t. Lalitudc/longitude source: �i'GPS OTopographic map (localhn of tvel musf be shotim on a USGS lopo map and . aRached to fhFs fimt i/notusing GPS) 4,INELL.OWNER . OWNER'SNAME T��i,, �cJq�"��� S7REET ADDRES3 Y�° !�'�X ///(� �t��kr�„llz �,v� .2 7c�2Y city or Towr, state ztp cods . LSQ 1 j- 2..0�- J =) }: ] �if- fiarial Np, Si�a o f Area code- Phone number �/� �� � �,� 12. REMARFCS: 6.WELL DETAtLS: ��� � a. 70TAL DEPTH: _ ��.,���. ��M'�� -�M '+' � Ja �.S b. DOES WELL REPLACE EXISTING WELL? YES❑ NO� / '!DO HERESY CF.fi11FYlHATT}iiS W ELl WAS CANSTFtUCiED IN ACCOfiDANCE WtiN c. WATERLEVELBelow7opofCas[ng: '�'�U Ff', tSAItGUC2C,WEtLcoNsrRUC11oN5TANDAADs,ANo7HATACCPYOFTNIS (U59'+'i(AboveTopofCasing) RECARDNASBEENPR DEDTOTHEWELLOWNER. d. TOP OF CASINO IS � FT.Above Land Surface• / Uyvf3�'n�� 7-.3/— l��f `Top of casing terminated aUor bolow Iand sudace may requfre S(GNATURE OF CERTIFIED WELL CONTRACtOR DATE a varfanco In eccbrdance v�tf►15A NCAC 2C A118. /� e. YIELD(gpm): �v METHOD�FTEST �r P�P � `� �T�2..(f,W ,,U, Q�own PRINTED NAME OF PERSON CONSTRUCTING 7HE WELL ���� ��I Submit the orig nal to the Divistan of Water Glualtty wlEhin 30 days. Attrs:(nformation MeG, Form cw-�a 1817 Mdil Servlce Center—Ralelgh,NC 27899-1617 Phone No.(819}733 7015 ext b88. Rev.7�os ' Da�e site visited 7-2 2 -v,�{ by n /; 't - ' Y �'g • . . . ���+f��A �.-� J�.,,�1 � l�o�.; l�yl . • ��i C/,ke r � �S R`°` %�.%.r f �v 2 c k c'.�' 'S ' i 9. 5 � y� ly so=. ; /�1n�i't✓ � ° .. DAVIE COUNTY ENVIRONMENTAL H�ALTH � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT � Account #: 990004448 Tax PIN/EH#: 5719-02-4177 J �,��1�� Billed To: John Watkins Subdivision Info: Z�j� �Q Reference Name: Location/Address: Vanzant Road-27208 Proposed Facility: Residence Property Size: 2.50 Acres ATC Number: 4762 **NOTE**The issuance of this Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Trearinent and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: �,�� 4 S.T.Manufacturer s�4.� Tank Date Q-�0 Tank Size� Pump Tank Size N�,p.. SystemInstalledBy: �q,�_�1'1.`��l,� E.H. Specialist: Date: IZ'y'�� � � l...ti►b le.�. 1� e; 3 3 2'C1uw �? `b. �a'F i � �— � cr� � 0. �� r G °` 9 �?c�*L , j 1��'_�� � N j ' � �� ° y �u o . � � � � -d� �� �� o�, Z3� DCHD 11/06(Revised) � , ' � F , �GL� V d,1� ' , . ,, DAVIE COUI�'TY ENVIRONMENTAL HEALTH /� r/�f G�C f 7 ' P.O.Bo�848/210 Hospital Street �v� �a Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004448 Tax PIN/EH #: 5719-02-4177 Billed To: John Watkins Subdivision Info: Reference Name: Location/Address: Vanzant Road-27208 Proposed Facility: Residence Property Size: 2.50 Acres ATC Number: 4762 Site Type: i ew ❑Repair ❑Expansion *�NOTE**This Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(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 plurnbin�gs'� - Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size Z.��� Type of Water Supply:�nty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��Tank Size `�AL.Pump Tank GAL. Trench Width �, Max.Trench Depth �� Rock Depth �Z�� Linear Ft.��Qp Site Modifica i ns/Cg�di�ons/Other: � r y� ' ,— - j.: 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. -��j �������u� ` _ e������� � As st�ted in �5A NCAC 3R�1.19Ei9(�i) 1 �ccepted �ystems rnay also ba use�d 't� � �ap' �O'�� " 6��y.3�� Y� � � �i2 �� -�►� �� J, .��. ��5 �r �'��,�,�. - -�.��'> �°� . � .� � �•J � Z� � � �,�,�. Enviro ental pecialist��*��,� � �.�� Date: �� DCHD 1 (Revised) GoMAPS -DaviE Coun�y NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Q�a�t� Click Here To Start Ouer Quitk �ear^th:{Caunty ID [ ,.. . +} ="� � � � � �� �"" � Actiwe L�a3rer. ❑�' f}se I+lep 3rps �I� ��'�� � i�: � �:�'' � �' PARGELS(Map Tips Available} ,�� Map La�yers � Re$ults � 2 �S4 � 1 �` �� � ��s�t 1 �� �. j :��}, {�r 3?$� i7$ S, 218,�� � `� —�7�1101 p� .��;'` y ,�� �� ��" ti �ti� � � y�' �°'' �sS �„ �yZ .A�p` � w� ,�:" .`4 l � / 1�1 g :r'�e �� � „5�'� �� �53 �� � � „� ��,,„, � ,n � �� S ,,. A �,.�. , _'� , ,�.r ti ,�� �� s ';�� �� � ��p�� 2 �--,4.,�5�`�_.�1i�Q`�'O-� ` ��!j�a. �')� ..�� ��'� � ,� �A�tp.���" �� + V" � � �i� �",��p O�W �r r� � r�^N ri'�� ���'�^M i". ��• � i � � ,287 8�, O. r`I 1 1,� a„x ry . p.q �'" rJ�, � "'� � a�_ _ ��� � � f �� � �� , m �� � � '�" � t �r' � � �!� f ;�. �7�_ sai 300 1t 203�`' I fi �7f� �0� t � , 145ft � I:" r DAY'SPRING LVAY� http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 12/4/2008 � � � � � � � LICATIO SITE EVALUATION/IMPROVEMENT PERMIT & ATC ��� SEP 2 5 2001 Davie County Environmental Health P.O.Box 848/210 Hospital Street �,MRO�MENTAi.HE���; Mocksville,NC 27028 DAVIECOUNN (336)751-8760/Fax(336)751-8786 pp ication For: ❑ Site Evaluation/Improvement Permit ,�Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System OExpansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed � � ' — � v}�' .5 Contact Person Billing Address � � Home Phone , SL��' ' " � f ci �'%7 City/State/ZII' ����Jyj/,� iU •�J ��� � Business Phone ���,� Y Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged �--ZS�� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is va d for 60 months with site plan,no expiration with complete plat.) Owner's Name ��,qJ ���„V S Phone Number J�Q/ ZQ'- Owner's Address City/State/Zip Property Address City Lot Size Z.,Sa • Tax PIN# $ l -0Z - �77 Subdivision Name(if applicable) ection/Lot# . � Di ections o ite: �U/t/ (t� / � �N � ��lV2a� �/�� d7ll (1�-1 �� .•----�-- �zl'�.�I �n/L��i � If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes.�10 Does the site contain jurisdictional wetlands? ❑Yes o Are there any easements or right-of-ways on the site? ❑Ye�o Is the site subject to approval by another public agency? ❑Yes�No Will wastewater 6ther than domestic sewage be generated? ❑Yes�o IF RESIDENCE FILL OUT THE BOX BELOW #People _� #Bedrooms �_ #Bathrooms�� Garden Tub/Whirlpoe�Yes ❑No Basement�--�Yes �No Basement Plumbing:�Yes �No 1F 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 systemrequested; onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water L'�New Well ❑Existing Well � Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pertnit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the infonnation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to conduct necessary inspections to deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or stakin e house/facility location,proposed well location and the location of any other amenities. � ' - -�""�� Site Revisit Charge Property er's o owner s lega representative signature - t � Date(s): _ � 2� ��� Client I�Totificatiori Date: _ Date F,HS: __ Sign given C:Yes ❑No Account# L"���� Revised 11/06 Invoice# �3- _ ;� . I�/( �: . • . . _, . . . . - ft ... � . . � ��{ r� . t , , . . • . _ . � • �.-�; ' ' _r:�:. ;r � . rr r {i:" . t �' . �r� 7�f^„� :�:�`N e� �i.r� � �,4-��'�..dwSYf .�±3�,r^,.�. Y.1' . . . . r%- � � � � ' � � C s-. ' ..: . }':�''1 " .. '•' S � Y ..-4 ��1't �'t ��'' !�9�1 .:Ir,;.et.,.,V.. .. ... ;.: 11 i5,::: f�♦. � r r - J � �'��.air3�c�fi'�4r:FM�r}�"i�'��f"ia;ft� .?hs,r ... . � , � � � 1� r . " �- �.r ,� }';i:,:;,t�4r�fYn(��v .t.�..:.r..� - 1 .✓ �a,., �;�i, � � L ;�„K�7''✓F1y.�+"g�C�S.�;l.s's..'�..u-�.�;t !��•', . . � .J c � � 4 �� � � �. ��z �� - �� � � TR. IAf� � � � 4 � . -� .�: .�� � T y .� � � � . �- �� � � . � ..a-�--�' ,s-•, � ,�' � � � � � - _ � � � � � - .,�, . � . � � � � �' �'` � . � . � '� ��� . � � �.�. •�,��..�.----- �, ��P��� . :1 � . . ' �} � �:, �?� '� . I >,\:, , •t. ' i . . ' � . - `�� - . �, �'��' � \M .;3.� � , . _ , � � � �. � �\ c �—' -,. � �... ,,� � I� � ��rh, . � - �' � '� \' i f�o � j 1J � ,�1 � . � j. � � �� � � � a � � �� �%�' � ' � ' � � ,, ., ' �,� 0 � �i, f h + � 1��� K V�� ' , ,� ! !'J�' �y�\ .�v 1}'^�t�?�— r� ' � � � ,�� ' • �• ,rr�� n '+J)0 , i .�IK�c�f.� . � ���\ ...-�- , r�P�uc�►Y �o�sr�EvawAnoN�i�wr�ov���r P �� �� � '� • ,► .'� �� -�/�,/ 5 j Davie County Health �epartment D � fz . , . d'I � Env�innmen[a/Hea/th Se+c�fton 15 ' P.O. Box 848/210 Hospital 8txaet . rs��x$oiiia, rrc z�o2e MAR - 7 2005 (336)751-8760 ***INPORTANT+t** THI3 APPLICATION CANNOT HE PROCE3SED S3 ALI. �E�d1���Ur7�j� INF'ORMATTON I3 PROVIDEA. Refer to the INF'ORMATION $ULLE � � ons. 1, xw. to b. E�ll.a GG/I'ZA U� L . /-/VG/'jn/!N cant,.at ro=4on ��P_4lc/ k-4��...�"./�.�1.-._ ' MailinQ )►ddro�m /J a PAniPRS �A�ve Houw Phono !Q� �(03 ry��f o �s�ie�.�.iEZp mooRCS✓�c�� p]� a�ii7 au.�o.s rhono ���} �jgg a10� 2. Haaw� on P�zmit/]►TC i! Diff�r�nt than ]►bow fSal.linq I►ddrs�• City/Stat�/Lip 3. J►pplication �'or: � Site Evaluntion �O Improvement Permit/ATC IB'Hoth � � � a. syr.t.a to a.roio.: [lYHouse 0 Mobile Hom�a� ❑ Businea�s ❑ Induetry O Other a. It Rosidsnce: � Baopla �r _ t Bedrooms � i Hathrooms ..3 f�Di�h��h�r f] Oarbaq� Disposel �t'Ra�hin4 Haohiao K Basosant/plvabinq C1 Ha��snnt/No Pl�biny b. It Budn�t�/Indu�try/Oth�rs 8p�oity typa t P�aplo 1 81nk• i Camaod�s # Shoovwrs � Urinal• T_ i Nat�r Cool�r• IS B'OODSERVIC�: � 3eata Es�ima�ed W�tar Uaaq4 tQ:iion. p.= �Y) 7. �,rpo ot Mator supply: O Couaty/City �Nell ❑ Community e. Do yon anticipate additioas or e:pansions ot the facility this system is intended to aerve? ❑Yes �o ltyes,w6at type? *'�*/MPORTANT"**CLiEN7'S ML/ST COMPLETETf�E REQUIRED PROPERTY 1NFORMATION REQUF,STED BELOW. Either a PL.AT or SITE PLAN MUST BESUBMI7TED y the clfmt with TIII$APPLiCAT10N. c�aSe ro c.,�KE n��IaZS � Property Dimensiods: 3 AU?CS ITE DIRECTIONS(trom Mocksvill to PROPERTY: �l?0/►7 !►?b�SVtLL�" "f�� Tax Oflice PIN: ' # ��7/�l��� 5~� .� � �wv 6 y 4�ES7 To 17f}NZF�IJ� ROf}� PropertyAddresa: Raad Name ✓Al'V2AI�JT IQOAQ Q/,'((�E' L.E'�r. ?W�2N O r�1"� �AMAr� �O. City/Zip mc�c�KSv�u,� GO �Ou.T ���{ n'1iLE � P�Z�C�T� l�l� lt in a Sabdivisioa provide Iatartnatioa,aa follows: RIG� �Eld u�� �EN LE• �12,L� Sr? 0� � rr,��: fi�K�� STRK�. Section: Block: - Lut: I2atc Property Fl�gged: �^ �� � Thb is to certify that t6e informatioa pravidr.d is correct to the best of my knowledge. I anderatand that any permit(s) issned beresRer are aubject to suspension or revocation,lf the site,plans or intended use c6ange,or if Il�e information �ubmitteci in this application is talsitied or ch�nged. I,a�so,undersland tlrat I am r�sponslble jor al!charg�s incurred from �his app!lcallon. I,hereby,give conscnt to t6c Authorized Representative of thc Davie County Iicalth DepArtment to eater apon abave described property located In Davie County and o�wnecl by �/lA��/ ����') to conduct ali testing procedures as necessary to determine the site suitaUility. DATE 3 "a� �J SIGNATURE ,��D � ����� � 77�IS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Iaclude all of the tollowing: Eiistiog snd propc�ed property line�and dimeosions, structures, setbacks, and septic locations). Site Revi�it Cha�rge ''""�� , Date(a): `—i/' vv Cllent Notification Date: � � ` EiiS• . .�✓ �— � � / / ,,/ �,�o j Account Na ���' s �"1 Reviaecl DCtID(07/99j � Invoice IVo. _ �7 ° , 3 � � . . � t �� � . � �j . 1` � ' i� . '_'�- _ �__��^�. . ,_���-�,____�_ i :_._�y�__�_�.i � � . � .��1, �::�. . 1��.'�).� �Il�/��. / '_��.'�'---'_._,�_� I1:" . . . - ����-� .:1;. . 1 - . �, .,::. �' � � ,:., , ,.� . ��;� ��. 1-\ . .�� , � �� �� � � �-� ' �� ;•' \�� � �� � .. �'. �_ .,� ., ;, � ,,l . _,: 1 •�� ,i�y�;°i:�� �',•. , i:. . . ���`��I',:. ?�. . . i:,::.. . . , �i . _ . .. �� 1 1 iNLI l!!�-`_� ':1:. 1!°:: I'. 'Y . / I . •il � "; , f � � :,,, ,,� _ ,. ;�.; .,;��;;��.:.,�:.�•:�; % , \ �i1(,'�il';:i`,, _- ��IC�tJO1,..-.' .. ...:-. �u�== _... % . \ �.,. . ��':l � � \ _ �. .. .. .. � ._. .�.� �� 1 !;.'11' / � • un:i.vi�C; �.rr. u5z � ���' �i \.1 f I- - - - - -- - - — — . �;'� ^' �. .. ' �� ' ;Jy � �j�'� � .ii 1 (.�i �., � � / ' .. .�. - :� � _ _ �0,__ �.� � � ' . ;� • �.�:. - '._„1,� � ,J I' � � . - ( � �`�' '��� . u ,���. �`� :;��' <� i �� :,�; ; . - _ �,�. r1 i�;. ;,, oc� �,j�..: Z..�-� � �.°�i� � \ `Jj , �. �.` :.; . " � ,,, � � �`�� � � . ,,,,,..,;,.�.,.. �� � ► _ ,��� '� , • � .;,_ -. ,__, �� ';'; .:.�, � � ,,: � ,; �- , ` � -�.� . ,:�,: f , 1'f��,�.fl�,.� . ,: i� s�'� �� �;�-�� ,� �����„����'�� ..._ . .I: � � � � ��'���. . ..; , � o a���� , _ � ;, ;,,� ,;. ; m . � . ;� ;�,, . . . -:� � �,. - . � .;: . _,( ; , _ ,� . . , . � ,,;, ��� ., '` � - '.�r�� � . � � �� \-- r�, _ - . . U �.,-.t' - ,FI:.. �"� . I - � '�', '��y N� � I. � �, ! �.;; � ,,.: i,;.��:� i; � . � ��-c�� r:��::� ,, �•°' •,- 1 � : � : i,i,. ,,:; , ,. ..�. \.; \ '`' ;/ i � ` �i ' . . . '• � ' \. � � � � ' � " - --- - � j �• I • ,.�� , :.,� I �� .. ,;;=,�, . -�,� � : . . \ � /, , , i ' ' I �_ , � i ,; ' � � , ��' �� ��.. ;' � . , '': '. ,.` I � ,. � � , �� � i ' � . I . . ;' ,:: . �., , • . ' • ' . ' DAVIL COUNTY HLALTI-1 D�I'AItTMLNT � � � Environmental Heaith Scction Soil/Site Evaluation S�� �- ��- - �S�-� AYPJ,iC 25 .�. 3 Sz s TaxPIN/EH#: 5���'����M�ORMATION e,: r Billed To: Gerald Huffman Subdivision Info: � Reference Name: �ocation/Address: Vanzant Road-27028 Proposed Facility: Residence Property Size: . 3 acres Date Evaluated: Z.,1 O , �• : .. ... • -�'�}-- Water Supply: On-Sitc Well � Community Public Evaluation By: Auger Boring � Pit Cut �4w �� - � FACTORS I 2 3 4 S 6 7 Landsca e osition �,... Slo e% Z HORIZON I DEF'TH � 2 -� p� ►�s .- Texture ron CL CL �,i_._ 5�;C_ L'L Consistencc $5 �; S S Structurc G - l Mineralo � HORIZON II DEPTH - 2 � ^'3 1 - ��'-� Tcxture rou L►, C �•� e Consistence - - (=� S ; 5 Strvcmre � � Mineralo �, HORIZON III DEPTH .L Ss.- „� Tcxturc rou �� X� GN SC�. C�- t_ C� �, Consistence ' T N�� Structure Mineralo _ _� � �. _ HORIZON IV DEPTH �- �.�. Tcxture rou ScNlYtz � Consistcnce � ('�-p �J Structurc ' � Mineralo SOIL WETNESS RESTRICTNE HOItIZON SAPROI.TTE CLASSIFICATION � LONG-TERM ACCCPTANCE RATE `�, .3 p S1TE CLASSII=ICATION: �`� Y.,• � GVALUATION BY:_���vu-I�-•� LONG-TLRM ACCEPTANCE RATE: ��� ` OTHER(S)PRESENT: REMARKS: '�"P.�Y'..11 ��1 A�t 2�� ' �$1�I- SC�So�"rS:CL, �1� y�:•'k L�GEND ' � �ndsc�pc Position � . , R-Ridge S-Shoulder L-Lincar slope FS-Foot slopc N-Nose�slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Hcad slope Tcx ur S-Sand LS-Loamy sand SL-S�ndy loam L-Loam SI-Silt SICL-Silry clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay ' CONSIST�NC� is VFR-Very friable FR-Friable FI-Firm VFI-Vcry firm EFI-Extrcmely Grm • � � NS-Non sticky SS-Slightly sticky S-Slicky VS-Vcry Sticky , NP-Non plastic SP-Slightly plastic P-Plastic VP-Vcry plastic 'tr urc 'SC-Single grain M-Massive CR-Cruntb GR�Granular ABK-Angular blocky SBK-Subangular blocky PL-Plary PR-Prisrpatic Mincralo�y 1:1,2:1,Mixed Notes � Horizon depth-In inchcs Dcpth of fill-In inches . 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' ��'� ' I , � -. � . \ � '� a�'� �� � ;' , ¢ � . �_, . �����`��:� �,. '� r. �� . - .' . ' �� � . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 / Fax: (336)751-8786 March 21, 2005 Gerald Huffinan 112 Pampas Lane Mooresville,NC 28117 Re: Site Evaluation- 3 Acre TracWanzant Road Tax PIN#: 5719024513 Dear Client(s): As requested, a representative from this office visited the above site March 21, 2005 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. Additionally,please have this new parcel surveyed and locate the property corners prior to making this request. If you have any questions, feel free to contact this office at 751-8760. Sincerely, _ Jeff G. Beauch p, R.S. Environmental Health Section Enc(s) APR, 16. 2007 2:OOPM CBT TRIAD 998 4442 N0, 4340 P. 1 . - . • . L•LLEN G1tUBE,GIu � RFAISOR'.DrokcrAsaoc�ece (336)99&1188 bIriPLT �0�� P VJ.�1.�C L �1�.1. �.�V�� •. (��99&M92 PAX � Ci3�9iD•7692 M0911E cllea.grabb�wldwtUb�nketeou . ,,r.'"::y . � _ AIL.S � 1 • � ,�; '�� a I�� „+ _ 4 — C= • •c _ �TRL1D5 HREALTORS�I Q �' f Adrmu.NC 27006 1 fach OMkv 4lndeyonderny w,��]e .vbb.mm 'I'R.IA�, �tE�,'I`�RS' ����R�� � FAX CO'V��2 SH.EET To: ,_S�� ��',1�-�P From� �� (�(Z[�� _ �o�p�y; EnviroMLn�ai �e�,�.�, Coldwell Bar�ker Triad, Realtors �51��7g4 129 Nc xWy sol s Fax,Number: Advance,NC 27006 � I���� (336) 998-4442 Fa� Date: ��_ (336} 998-_1 t&8 Direct Line � Number of Pages Sent: q`tV" 1�0�2 ��?�,� Regaxd'ang: vA�N�' 'R.D. � �eQS2. f�e IeW �i5 hGW �111 I�I�4S� ��� t� 1Cn6w i ��3 lo ..is ``OK" r � ' e, 1r �1'Cr •�• L,o�' � i S `�t�, . �l. IvL , i�l-h 2 re, � �o-o � �►�d .,. Thah 11.,�, ��.+�- �bh OUR CREDO "We at CoIdwOII Banlcer Triad,ReaIfors Iiave a passion fox real estflte and our cornpany. Wa provide exceptionaI se�vice to our customers,client�and each othher in a profiessional and cowrteous manner wl�ile maintaining the highest standards of honesty and integrity." FRIVATE&COI�kIAENTIAL,The information contained in this fax is privileged and conf dential i�lformation. If you have received tbis fax in ertor,please disregard same and norify sender ae soon as possible.Thank you. APR. 16. 200] 2:O1FM CBT TRIAD 998 4492 N0. 4340 P. 2 . , ,•r� . . . • � ��� DAV�E C4U�I'�'Y H�ALTH AEPAR'�1v1EN'x Environmental Health Section PO Box 848l210 Hosp�tal Street Mocksville,NC 27028 ' ' Phone: (336)7S 1�8760/Fax: (336}751-8786 , ' . March 21, 2005 � Gerald Huffrrzan 112 Pampas T.ane . Mooresville,NC 2811'7 Re: Site Evaluation- 3 Acre Tract/Vanzant Road Tax pIN#: 5719024513 Dear Client(s): ' As requested,a representative from tkiis office visited the abo've site March 21, 2045 to perform a site evaluation. Based oz�the information provided on the Application for Sire Evaluation and after the evaluation vvas comp]eted,the site was found to be provisioz�ally suitable for ihe installation of an on-site sewage disposal system. Before a representative of this office will revisit the site to issue an Improvement PermiUAuthorizatioz�to Con,stiuct,the appropriate application must be completed and submitted to this afifice. The location of the facility the system is to serve must be staked off. Additionally,please have this new parcel surveyed and locate the property corners prior to making this request. T.£you have any questions,feel free to contact this office at 751-8760. '. Sincerely, � 7eff G.Beauch p,R.S. Environmental Health Section �nc(s) APR. 16. 2007 2:O1PM CBT TRIAD 99B 4492 N0. 4340 P. 3 � � � . . , . , ,• �� t�t.oc�a.o4 ToSc N�2 . n/f�D. 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J / , c?G ' / � ,l '� �, - � • � -�"�1�J �J � ;��i (� V / . i i �- � �'�1 �� ��� � _.� � ���� ��h � ( ' � , -� ; , i ; �- , / ; , ; � �� � , ; ,, __ _ . � ,� ; �------ - . � C �3 r ����3 � Davie County Health Department Environmental Health Section Payment Due Now. PO Box 848 (210 Hospital Street) Please Refurn a Copy of the Bill wifh Payment. Mocksville, NC 27028 Your Check is Your Receipt. (336)751-8760 John H. Watkins Account No: 990004448 162 Mollie Road Invoice No: 6263 Harmony, NC 28634 Billing Date: 10/12/2007 Srv Date Service Code ID/�1TC# Description Srv Cost Quan. Extended Cost 10/9/2007 SEPTIC-NEW-R 4762 Vanzant Road-27208 $150.00 1 $150.00 Balance Due Now: $150.00