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701 Williams Rd . � _ , , . . ' ' , Irv��-1 1 .I- fmi�- , • ' DAVIE COUNTY ENVIRONMENTAL HEALTH � . ' P.O. Box 848/210 Hos ital Sh�eet ��C�1�� P Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT � Account #: 990002312 Tax PIN/EH#: 5768-67-6490 Billed To: Wendy Workman Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 , Proposed Facility: Residence - Property Size: 26 acres ATC Number: 4813 **NOTE**The issuance of this Opera;i�n 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 inNO WAY be taken as a uarantee that the system will function satisfactorily for an given period of . time. �.-. �,�� .��� — U ,��G, � � �j r[! System Type: �� S.T.Manufacturer . ��/ Tank Date� Tank Size Pump Tank Size ( C � � a�'���� n , .. -�'� System Installed By: � E.H. Specialist: Date:�� f � � C's .;� � �c-� � . � ��� t. � �� �� � -� � � � ��, ' �,� << � � �Q J � � ��� _.— ��.� ��5��� r,— t __'\ �� �uc'KT �. ` � / � -�--_ / ��.,r .� ,�. ,� . .. �_ � � --� , : �d . ' . � DAVIE COLTNTY ENVIRONMENTAL HEALTH , 3+D� ` P.O. Box 8487210 Hospitai Street �I � Mocksville,NC 27028 � (336)751-8760 Fax#(336)751-=8786 AUTHORIZATION FOR WASTEWATER SYSTENI CONSTRUCTION Account #: 990002312 Tax PIN/EH #: 5768-67-6490 Billed To: Wendy Workman . Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 Proposed Facility: Residence Property Size: 26 acres ATC Number: 4813 **NOTE**This Authorization to Constnict(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. i � Residential Specifications: #Bedrooms� #Bathroomsf � #People � BasementB'Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) LotSize �G�.�� Type of Water Supply: OCounty/City Ca'Well OCommunity Well s System Specifications: Design Wastewater Flow(GPD)��-� Tank Size f�GAL.Pump Tank�GAL. !r (' "1 Trench Width�(s Max.Trench Depth ,3� Rock Depth�_ Linear Ft. �3;:� � t���ir��`�h r �;��-���ti�`�"t� Site Modifications/Conditions/Other; ' ���� '��� a ��'� �G���' "' � r �� -�r�c +��-,,�--��i!1.r`h u � ���-,�'`��s.f:,if'�'�- Contact t e Davie County Envir nmental Health Section for final inspection of this system between 8:30-9:30a.m. on e da of installation. Tele hone# 336 751-8760. S 1 � ��� � 3 '3 X �� F. �c��� . � L'v�.x. 1� /�`t�-+�g�' b-� v ,— r ��p �r�� �� s{���r:� � - --- ��s�. . c�r tu� ��-z��:� �9�.��. �� , - - . � r� � `tivc'��;��5� �Z� � ��� � � � � ( �� � -?( �s , Q, , , , � , ",-� �iivu-onme al ealth Specialist Date:�- — � ��� n�J.�.�(�,)+P�7�ff'1/�Az,;cr�rll � � � � , '�' � DAVIE COTJNTY ENVIRONMENTAL HEALTH • � P.O. Box�48/210 Hospita.l Street ' ' Mocksville,NC 27028 (336)751-8760 Fax#(336)751;8786 AUTHORIZATION FOR WASTE`VATER SYSTEM CONSTRUCTION rlccount #: 990002312 Tax PIN/EH #: 5768-67-6490 Billed:To: Wendy Workman . Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 ' Proposed Facility: Residence Property Size: 26 acres ATC Number: 4813 Site Type: L�11vew ❑Repair ❑Expansion **NOTE**This Authorizatiori to Constnict(ATC)MUST 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��S #People�Basement❑ Basement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size l�- Ce C�-e 5 Type of Water Supply: ❑County/City C�Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) 3�2 U Tank Size�GAL.Pump Tank�GAL. �l f� ! �� �` � Trench Width 3� Max.Trench Depth 3� Rock Depth � a Linear Ft. (J Site Modifications/Conditions/Other: r,` �t.^�tnd in �5t, ��^_�� �rE'•,.:+.�.i?s:�l F:Cc��3t�d `��v:;t�:+;�s '��.��v :±�c� �`�. i.�:3� Contact the Davie County Environmental Health Section for final inspection of this system between � :30–9:30a.m. on the da of installation. Tele hone# 336 751-8760. '"� ` � �6�`�� � � � �I�� I u.�� C-� P�� �` �` ,�.� � 3�3� �7 11� � (5) i �.a` x 3 �. � ,�.� s ,� .� I � r a� .��� � -t ` � (�t�.5� f�-c f al1 � �- �3°` L� , - � � � � 6; � �, �j� ���V m Ql�y �c ��'"'I/� '`l�i �` !"": I �, gd r. {.�a� .)�F,-� :, G (r��-'_""` _`--I . � �,�-� � f–C � � � �t't��`�u.l �� �`� � �u� ����GY� � � �,ob � ' �,��� . , _ Envuonmental Health Specialist Date: L '— ��� . DCHD 11/06(Revised) � ' � ' . ' � ' ' � , DAVIE COLTNTY ENVIRONMENTAL HEALTH �1a�.,��4' ��� . • P.O.Box 8481210 Hospital Street (� Mocksville,NC 27028 n;��`Q,��Q � (336)751-8760 Fax#(336)751--8786 11� � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002312 Tax PIN/EH #: 5768-67-6490 Billed To: Wendy Workman Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 Proposed Facility: Residence Property Size: 26 acres ATC Number: 4813 *�NOTE**This Anthorization to Constnict(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 Treatm.ent 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. i Residential Specifications: #Bedrooms� #Bathrooms�#People � Basement asement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �0.�-'� Type of Water Supply: ❑County/City ell ❑Community Well System Specifications: Design Wastewater Flow(GPD)3(,C.(� Tank Size�dpOGAL.Pump Tank�GAL. ,r �� Trench Width� Max.Trench Depth ,3� Rock De th� Linear Ft. �3� ,�� �staied in 151� NCl�C '�BA.�G us�u� SiteModifications/Conditions/Other. S��E�� o3,,�g-�,,;,- +, r:,sJ Contact t e Davie County Envir nmental Health Section for final inspection of this system between 8:30—9:30a.m.on e da of installation. Tele hone# 336 751-8760. (, � 133 X3` �.,��� ��� � 1��.� 1 I /t��5� b-� � � � �80 r�� �� s���r.�. : , - ---- �ws� I � ctt�cu� ��-�p�e`� .�9�.��. � , - - � � ~`�vo'c� i;� �� r �� ��tr ,`q l . � La , .J( �� c �c � , � � � . "�-�"j ERvironme al ealth Specialist : :��. , Date: �- — � —�j �Y.���,r�r�tl'7/�.,;�Prll ' � .APPLICATION FOR SITE EVALUATION/IMPROVEMENT PE �'�, � Davie Couniy Environmental Health (�j, P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 D , � Z��a _ (336)751-8760/Fax(336)751-8786 ��GB Application For: p Site Evaluation/Improvement Permit ❑ Authorization To Construct(A C) Rt�k�r,���`y�� Type ofApplication: I�'I�Tew System ❑Repair to Existing System ❑Expansion/Modification o xisting yste v i ity ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED LTNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed �J�tC�\��I wcJ r��d`(�Cr!1 Contact Person ��fi��y . Billing Address�7 �� �l;\�`,c�m� `'�`Xa_<<� Home Phone ��(��,�� �)�/Q- �(�, 3�� City/State/ZIP �'����p,�1 L e-� N L ���OQ(v Business Phone 70z/ . (,� �-(r,/ � f Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name\1�,�r� U-`�ca<�C�-r�� r Phone Number�"�([3 p y p`i-3�J`�� Owner'sAddress C� ;1\.rxm�� City/State/Zipa��VGrlc�, ;UC �7COro Property Address""" '.a fi � ��� City Lot Size�, c•,L_ Tax PIN#5°710�(,��p �p Subdivision Name(if applicable) Section/Lot# � �� Directions To Site: ���� -�u �. ;�ti � �;c: � 'C �:n � � � �u '��\\�lm ct. � �'�5� c\s.v�. e�,-� e��- ���'�e� �:�� (' ; ��... �. � 1 ,• \ c 4ti��'i. 4�t r�, c _(��.,r� �7G(p U :11'r,rn� �crc 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 QNo Does the site contain jurisdictional wetlands? ❑Yes �No Are there any easements or right-of-ways on the site? ❑Yes BNo Is the site subject to approval by another public agency? ❑Yes �'No Will wastewater.other than domestic sewage be generated? ❑Yes 0No IF RESIDENCE FILL OUT THE BOX BELOW #People �� #Bedrooms �_ #Bathrooms �� Garden Tub/Whirlpool ❑Yes C�1�To Basement: Gd'Z'es ❑No Basement Plumbing: ❑Yes C�1No 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 • Typesystemrequested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water f�New Well ❑Existing Well O Community Weli 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 pernut(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 Deparhnent to conduct necessary inspections to determine compliance with applicable laws and rules. 1 understand that I am responsible for the proper identif cation and labeling of property lines and corners and locating and flagging or s:aking the house/facility loca ion,proposed well location and the location of any other amenities. � �. `� �� � � � '� � i Site Revisit Charge Property own�r s or owner's legal representative signature �,"�`Q.�1'ULt� LC, I�Q.C� �f. '.�'-Q,Vi�S Date(s): t _ (, � j Client Notification Date: e Date '�%V'G,�, �jC,SA-{'hQ,tt,�" �C!�`�"ic-� Gi� EHS: 1,e ��5 ��o• f�;l l C��� _ Sign given ❑Yes ❑No ���- �b�.S.� Li,{�1C� �(�r� Accou t# � Z Revised 11/06 1 ,��� y�I� ' Invo�# _�` " _`(✓ f �', � a�-a� � � �� GoMaps GIS Page 1 of 8 . � �"`— "`NlQNl11"!K LN� ��� J� �--_.,.�._..._.,� d':; <i ' ��,, `'�.. - ��� ;� �� ������ ; - 3 �s ix F� �i� a`� +J �':�ae�._ � d' Q v � � ^� , Y� ��.,,�r-n � - --� � w ��-�"�' � Q �~ ;�:-=--�-- „-xi..�.Y,_i .�..��` � .,�- _M.�,e . ._ - �� ��;y� . �. �.._ _..��1YILLIACIS_RD a ��. �_.�..�,- ,>�. .�.. _.��-�--�-� � . €._.. - .ao�aa� ,� • � ' �hftp://maps.co.davie.nc.us/GoMaps/map/map.cfin?CFID=4144&CFTOKEN=82492116 2/4/2008 1'-- � y �, t� Oi 'US`37� y� ''D ��, 3S� 52' ctOta� ; �'� �,°. '�,��,+ •tv� � ��� .� ' *, � /� C c� � � �B�SO�Vb� G � '� �S � ��. �" 33�1 2} • �ont tr Y — "�� �-- �r---•------ 8$'dZ•24' E . &7 .,� �p � L. � J,,, 2 t � t' f.Ptt � � �� � �`� `. � — � ,'�'' ��� J`'` '�' .�'i� � �� � *� ���q, -w o`/�' '�'� ':�! w �• '+�i 'S'� '" 9./ ��: 3` �.>, '"r� �P � � t� �j � �. � � `�-' � �'l�la � • q f, N -� � ,j a�tKE PQ1,lf R CDMf'ANY •', .. �o ,.•�;..., w A D B l 3 6. PG 5!� C�!'' �?`•' l .+ s:` 1l.B 97. Ptt 83� �t.� .o \`r� °` � !� RCf D�rG. t+lf3 4-�,31 � +�_b�3 � ��'.,., d'�,, � 4 �, � `�t� • � t C?t a�, aR�a = 2b .�33 ACRE S �z• ,., ��.� ,��t �' .! ; tivC��1DtNG 3.Sb2 AC�tCS tN RA1LRCiAD �?�u � *:.,��� .r t� N "�,� �O ! "�' Cf -- 'j• ��'<'p' ��{��� �+ -�! ._._ m -- - "'� CMC Q�MO 111ot�1lu1��l�t i iNC v�� �'p ��. . � � � �Lt �'6� ,� STM 2�4r48 6�0 n� ��. � • '� a° 0 ., _�..... w\�,� �L i ��� �L!1�� t ¢�r �t i e�a r�--�-- � �' N� i b t 0 � � --�..._ � � �.�!a. N BQ'��'t!Q' �# !�►$1 .'�2' cTpiA� ) r' �ASE BCaRI nt�1 �� art«��f i d.��`f�. 2�1•9�.�3 �' � �, � �;� � . ,, ,,•,.�, ,� . � r Q+i .• � � ��1� � . f�` • � DAVIE COUNTY HEALTH DEPARTMENT � • • ' Environmental Health Section / '`� � • . � , P.O.Boa 848/Z10 Hospital Street c`� �- '. ' Mocksville,NC 27028 � `-�� (336)751-87G0 �� IMPROVEMENT/OPERATION PERMIT ��. Account #: 990002312 Tax PIN/EH#: 5768-67-6490 Billed To: Wendy & Dale Workman Subdivision Info: ,Z�Jo �, Reference Name: Location/Address: Willliams Rd-2� Proposed Facility: Residence Property Size: 26 acres **NU'1'��'�ii�giriproveirient/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type 1"� #People � #Bedrooms S� #Baths'�� Dishwasher:� Garbage Disposal: ❑ Washing Macfiine:� Basement w/Plumbing: ❑ BasementlNo Plumbingie' Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD) .�� Site: New� Repair❑ System Specifications: Tank Size,��GAL. Pump Tank GAL. Trench Width(�(Rock Depth��Linear Ff,.�l��` Other: Required Site Modifications/Conditions: I1�IPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G "BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depariment for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-87G0.**** r Environmental Health Specialist's Signature: i Date: ��'�� �� DCHD OS/99(Revised) . '•` � , • . � ' DAVIE COUNTY HEALTH DEPARTMENT . �• � Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (33G)751-87G0 � Account #: 990002312 Tax PIN/EH#: 5768-67-6490 Billed To: Wendy & Dale Workman Subdivision Info: Reference Name: Location/Address: Willliams Rd-270�c Proposed Facility: Residence Pro ert Size: 26 acres ATC Number: 3173 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** T'his Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,S ion.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWAT N�UCTION IS VALID FO PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: �j ^� `'�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) ` ,��,, ' _ . • ' �ir�uc�ano�u Fos s��Evaivanont/iMPRov�tFxr P�iwT&a D I� � . � '� � . Davte County Health Department �5 � � . • Environmenla/Hea/tfi Sectlon � �' P.O, Box @48/210 Hoapital 9treet Moeksvills, NC 27028 U��r � (336}751-8760 � � �";�2 ` �, f ***ZI�ORTANT**� THIS APPLICATION CANt70T BE PROC�78BED UNLE3$ AIt_I, THE jJ�, INSORbATI�N IB PROVIDED. RePer to the IN8'OR2�►TION $ULLETIlI foriiIatzudt'�'pn ��HF,qj 1. Name to ba Billctd U�)���`� ���� �r���� Ceniaat Rerson �-n`�� �C � Hnilinq �lddrooa y� 1V1 NC. �"l�� , l'1�� ��arv\ soma ptwne �J�i - ���.. �3� City/3t3t8/ZIP f'iO��P�L�� I��. ����Ln Suainess Photfe ��/'r �� p` �i'��� 2. Nams on PeTmit/ATC if Ditferont thsaa Abavo � Hailinq Addresa City/9tate/zip 3, Application For: "QCSite Evaluation p Improvement Permit/ATC D Hoth a. syetam ao 9e=vice: �House Cl Niobile Home n Husinese ❑ Iadustry ❑ Other 5. If Reaidonca: A �@ople � _ � Bedrooms � r Hathxooms J — 1 �'Diahxasher I,j/Gazbaqa Mapo�a2 41'Waahinq 2lachine U Haaement/Plumblriq (•t�Haaom�ant/Jio Pltwbinq 6. IL Busineas/Indct�tsY/pt2+er: SpociPy type � PeeDjo � 3inks N Comm�odes t 6howorr � Vrinala A Watas Coolers IF FOODSLrRVICE: 1{ SBats �stimated Wates VaaQe (qallons per day) 7. Type aP water supply: fl County/City 6�We11 ❑ Coammuaity o. Do yau anticipatt udd➢tioos or ezpansioas of the facillty thls system is intended to sen�e? D 1'es C�'Ffo If yes,wliat type? "**IMPORTANT*'�}CLIF;NTS MUST COMPLETETH� REQUIRED PROPERTY lNFORMAT[ON REQUESTED BELOW. Either e PLAT or SI7'E PLAN MUST BESUBMl7TED by the client with THIS APPL[CATION. �� Property Dimensions: � �`��S WRITE DiRECTIONS(from Mocksv;lle)to PROPERTY: TaaOflice PiN: ��--� L�� �~I b 4 `1l� C�� �as�. �•c� c� `.._e.�-� Property Address. Road Name VJ\\.g(y�� �cr c�. �C� �O C C���0.�'Ze c' '�c'�,o.T_ City/Zlp��� a-�ooco �.��� ��.�.��- ���� It(a a Subdivision provide Inf�rntatlon,as toliotivs: ���.a�� �c��(�,,�70.S5 1Vame: l�c� � e e.e.� cnaC� O:� c', Y"���d�_.�..�i� �n ��a', 0.c roSS Sectiun: Block: l.�nt: Date Property Fla�ed; �—�� ��o� ��ocv� .1D(� �:\\.0.mS This is tu ccrtify that the informadon pravided is correct to the best of my knoH•ledgc. I understand thst uny permit(s) issuetl hereafter ure subject to suspension or revocation,if the sile plans or intended use change,or if the infarmation ��� . submltted in this application is falsiiied or changed 1,atso,undtrsland tha!1 am rtsponslble jor alI cha�ges lncurrert jrvnr Ihis applJcarlon. i,hereby,gtve consent to the Authorized Representative of fhe Davic County Hesith Department to enter upon above described property located In Davie Connty and owned by V�Q_.c�.� �`�O���a� to condnct sll testing procedures as nccessary to determine thc sfte saitability. DATC�—�b— �o� SIC NATURE � i�'"— TNIS AREA MAY BE USEU FOR DRAWINC YUUR SITE PL�4N(Include all o e follo�ving: Exisiing and proposed property lines snd dtrnenstons, structures, setbacks, and septic locetions). _ Site Revisit Ch�rge Date(s}: y , ..... ��"� i �1 Clicnt Noiification Datc. � s � _ j t � EHS: � ' ��''' ��. ( 2_--. Acconnt No. .�=� .,, ' / ✓ Revised UCHD(Q7/99) Invoke No. �,.�� � � �d � .. ' �: . 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U J�. , �+ p �D � �6\ � STA 234•�8.60 rv 'v��\ o b\ ' � v h �\ � � --`_" _ �/1 L L l AMS RpA D � ✓' \ ieo�-"=_— R ND. 161 O '� �oa> >s�-- N 88'4g'po' � ' �st.ea 1481 .92' :Tp1A� 1 BaSE BCAR�N(�� .�P��. 231 •94.73 . � QR S�IKIff l \ O ' �.`�o \� p1C.HARD W w1LL iA1�S � � �►'*� • � DOPdTHv W)LLIAMS ' . D.B. 81. PG. 1?4 D.g. a8. PG. 373 \ �: \ ' ' R[f. D�++ti. N0. a_634 ,\(��� \ • . DUKE POWER COMPANY �� � ; . � O.B 96. PG. 407 \ ' '� REf O1rG. N0. d-634 " D-3061 , ! ' � ' � �' ' � - - • DAVIE COUNTY HEALTH DEPARTMENT � ' ' '� " - � � , Environmental Health Section - ' Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002312 Tax PIN/EH#: 5768-67-6490 Billed To: Wendy & Dale Workman Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 Proposed Facility: Residence Property Size: 26 acres Date Evaluated: � '/.� �� t� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �Pit Cut FACTORS 1 2 3 ` � 5 6 7 Landsca e osition ,� L Slo e% HORIZON I DEPTH � (�—3"2_ Texture rou C: L Consistence r �. Structure kY� IG D l� Mineralo .,r ,� HORIZON II DEPTH ,� % `' ?l," — � Texture rou C L Consistence ✓ ►�J , Structure ('r �,' Mineralo �' �� = /' HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence � Structure c+� b Mineralo �� l SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE '� '' CLASSIFICATION S 5 LONG-TERM ACCEPTANCE RATE r SITE CLASSIFICATION: EVALUATION BY: �G�,- >-" LONG-TERM ACCEPTANCE RATE: --C OTHER(S)PRESENT: �� REMARKS: � -I 5��'P' LEGEND — D 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 Texture 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 Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet 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 Mineraloav 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) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/99(Revisejti) � ■������������■�����������■■�������■■���■�■�����■�■��■■������o���s■ ■�����■�����������������■■�������■�■����t������������������������■ ■■�����■��■��■��������■■���■■�������������������■■����■�����■�■�■ ■������������������������������■ ■������������������������������■ ■�����■����■������■■■■�■����■����■■■�■�■�■��■��■���■�������������■ ■����■�����■������������■■�������■■■�������■����������■��■�������■ 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''^` ' -� (�a h►5 C�D1�1.� _ Davie County Environmental Health P.O.Boz 848/210 Hospital Street d r r.Q,q���� Mocksville,NC 27028 (336)751-8760/Fax(33�751-878G �"( �'n� WELL PERMIT `����g� Account #: 990002312 � Tax PIN/EH #: 5768-67-6490-W Billed To: Wendy Workman Subdivision Info: Reference Name: , Location/Address: 701 Williams Road-27006 Proposed Facility: Residence/Well Property Size: 26.993 Acres ATC Number: 0010 Actions of the employees of the Davie County EH Section shall in no way be taken 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 fact/circumstances upon which this permit was issued. Permit Type: New Repair ❑ Abandonment ❑ -�. C Proposed Well Location Diagram Certificate of Completion Diagram � � S i � _ — � � \ , --. �Qo � 1 � p,��� � � `.�� _ .�,o, \ � ,���� I `� � �_► \ � I _ �-- � 1 ` s � 1 � I � �,�tl �- d i o ' � - �� ' � . J � g�` � � � � a � o � 7� TL `�' � � � ti, �. � � 'i l ��� _ _. o,� ���C �� �`e� ��c. � - � . � � F,�1� � . i �r n d Comments:n11,�„ �� C c�►M.n�y W.�� c�\� Driller: � �� �-�_� - ��• �— t A..n ��� c_�x 1� ('�l-r� Certification#: � 2� 3�/ � Grout Inspected: j� �^�� �l y �g Well Head Inspected: � — I�—' � � GPS Coor ' ates: 1� '��'��-�-?S�80 a�. I6 EHS: � ��� ate: �"�� E Date: �"'lG-� W.P.7-08 Aug 19 08 � {�n �D 'e ounty Environmenta 3367518786 p.2 • � �Q •V � �� Q � e . � �. . � ti S� APP ICATION FOR PRTVATE WELL PERMIT t,�\� ``jl�o J;�Lj� DavP.O.Boz 848/2 0�Iospita7 St�reet th E �t� . eP Mocksville,NC 27028 , (336)751-8760/Fax(336}751-878b . ***INIPORTAN?'�** THIS e,PPLICATION CANNOT BE PROCESSED UNL�ESS ALL OF THE REQiJIRED INFORMATION IS PROVIDED. APPLICANT IlVFOiZMATION ' Name to be Billed �i�. c��P Contact Person ���y U,Oc''�rrw�rl Billing Address 7b 1 u•�.\ :o,mS Home Phone 33(0-`ly O-3(r�3�J : Ci�Lv,'State/?Ii' ��vac�ce ,�JC- c�"7c�(� FsusinessPhone '�o�/- (��g- (�1\\ Name on Permit if Di�erent than Above Maili�ng�.ddress CitylState/Zip PROPERTY INFORMA'I'�ON *Date House/Facility Corners Fla ed i NOTE: A sur�-ey-plat or site plan must accompany this application Included: = Site Plan OPlat(to scale) � � 4wner's Name � U�:\\:Q � ,r'r�a�l Phone Number 3�-�1�{D�3(„3y ' , i Qwncr's Address`7 U :\\°o.n�s oo. CitylStatelZip��»,neTC� �'lUbCo .; � Property Address �b\ VJ�\.ArnS 'u.oa CiLy���r��e i � Lot S�e �co,qa� �C Tax P1N� 5���s'c�`� (aUq O � Subdivision Nazne(if applicable) Sectiom/I.ot�# DirectionsToSite: (d�1 -4o Cor�•�-zec Roae\ �on\Q�=�r� �.a� �,,,.c� �`.�`n�- o� �o \}J�\�. �c� r� \rz b l�'�\.arn DEv�I,OPMENT INFORMATION Permit Type: New Well ✓ Well Repair Well Abandonment Other(specify) Facility Type: Residential ✓ Food Service Chwch Comrnercial �ther Are Tliere Any Septic Systems Current�y On Thc Site? YES 1�0_� Do You Intend To Install A New Septic System On This Site?YES_� NO TERI�iS AND CONDTTIONS: T�is spp!i�tion m�,�M bP accempanied.�y a plai or site�!an.�f c}�e nropem�that inclLdes the exi�o.n�pTvpx�g�pert;-linw with dimensions,the specific location of the facility and any existing or future appurtenances,the location of an;-cxisting septic system,sewer lines,a°acer lit�es,any existiug water supp3ies and airy surface waters. The applicant is respomsible for identi�'ying and nnarking tbe groperty Iines and corners. The applicant is responsible for making the site acc�essible. By signing this application,the applicant signifies that they understand rhe terms and conditions and that they give permissiori for Davie Connty Emironmenta]Health representatir-es t�perform ne;.essary field evaluations and procedures deemed necessary to deterrnirze the best location for a v�•ell. G�� 7-�/-0 B` ��� Date Site Revisit Charge Date(s): CLient Notification Date: EHS: � 7/1/08 � Account# �7j�7i Invoice�t /„/,/„ / � , • , : � C� �C�S Q� ��.i^J2. �� � \\ • �M r ` ����� �o.�-�rY�,a�-1 . . � � .�� �. � �" � • , \� \ � O\ W,\\.P n-�c,. �oq.� � `,.� � �t�A.��.. �;.. , � ,. �� � �� ,, . ,�, � ''� / ---.____ � __...�r.�.. .�.._._.._..__....._ __� ...___......_____......._..._._ ..\ �. _ � ,/ \ ` ����/ ��% /� , , � � �.� ; ��� ° " �c� `o� ; � , � � �jQ,��f��GrA�Fy '�` '. / �<��X . ��s� ,-'� °X' - �' � � �U ;' , , ; �A� � �. �. ,�b�'� �_____'��t{� y�,,�' � �._�-. _.._. �..� � __. � _. _... --• _....,. _.....__.._.,.,......_„.. �a t� ��,,,�.S � � __ ._..._ : ��,�,��r f. . _� ---- ___._.. , - , _� _ . _.._.__..__ _. ... _,._... .,. .. _...___ _._..._. ..____.,... ._ .. .., .. J i C. . _ � � ��� .____�..____..�_:� �a�- �-� sc� �.� -�_, .,_ ' ' �-�= DAVIE COUI�TY ENVIRONMENTAL HF.ALTH • P.O. Box 848/210 Hospital Sh-eet Mocksville, NC 27028 (336)751-8760 Fax# (336)751.-8786 AUTI-IOI2IZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION Account #: 990002312 Tax PIN/EH#: 5768-67-6490 Billed:To: Wendy Workman . Subdivision Info: Reference Name: Location/Address: Willliams Rd-27028 � Proposed Facility: Residence Property Size: 26 acres ATC Number: 4813 Site Type: �w ❑Repair ❑Expansion **NOTE** This Authorization to Consmict(ATC)MUST 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 Treahnent and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,pl�t or the intended use change. Residential Specifications: #Bedrooms � #Bathrooms���' #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �- Gt�Cr�5 Type of Water Supply: ❑County/City GYP/ell ❑Coznmunity Well System Specifications: Design Wastewater Flow(GPD) �(.2 U Tank Size�GAL. Pump Tank�GAL. �� �� �� �� �� � Trench Width 3 � Max.Trench Depth 3� Rock Depth Linear Ft. Site Modifications/Conditions/Other: �,:� ;�t�+�� ir� �'�:; i�a^��; �^f',.�.`==i��?t;,a � e`<CT.�:��nC� �i�fti:;�Y=1elt� �`i%Jf :�':Sl Vt 'll:i:.� Contact the Davie County Environmental Health Section for final inspection ot this system between '��, :30—9:30a.m. on the da of installation. Tele hone# 336 751-8760. -�6��` � `� � .�� , � . c� �� `� • �.�� �'� p`�' r� �3J ��7t �� � ,��« � l /� 0J � l l � J�V` !� � Y* i v1� `-.� . . �\ ,y( �t f , � _. ., . ��+��� � �..� -� ��� fti'��� 1 �� ��lr1 � .. ���` j L� � _ , � � � � �.�} �^ � �' '- / .,.1 Vr C� /� a�� G'�4 C��"!/� "`�1� �� �-.�------ _ � '�i {�c�t. {�0� �'��� � G r ""�" ._.P" I ,� � n � � , J _��„_t � �� r � � � @ i�;t1i���u� � (� � � �� ��'���3 ����' Z � j �j Du , � �y�`� , ,,�,-� ,.--� ____._._ �nvu•onmental Health Specialist ^ Date: L ' ��� DCHD 11/06(Revised) � . Reports Page 1 of 1 . • �., � Davie County, NC ��4=�.� �w����l F2eport �� . ��` �^ -. � � � �,� .�, � � � �y� y ���3. ����� ,�� ����,�����er� ��� � ��,t i z �I e ��Pj� z F � :�� . ��y.��'�j��, "'y k (���� `.�� . §".�' �, �'&X., . ���.. _ ;. 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J' d A ;� �*� ;�� _�, �� "' x� �;����, ��� x � t< �� s,,� :'� a � ' � f r` a . , w r a'� a� r� � � � � r � � � � v � aH �. ��# � ���)�, � 6 .:�. . � ���. �. , e.��� � di'�'� � �„�+Fy.� �-` ,�� � � „ , t cx' ,X' � a � ° �. •� •'.:� � ' �. � �� ��s.'� 3. ,: � E�' ��a a,�':��..,.,�� �� � �3 �� �s . h °� ' ��, fi�T,��^ „ �-�`` �'�,;. .. ' � ` " �'���.. �� .�. s� .� - �� �� ��a, � I L� 1 I:I� _ ` � �^a$'s�%� � ,.�a. ��c" •. � m�T` ,� , - � a re,. wl.S-;.$: ��F � �2� �� " , ,� P �x�,�, xg�. ��� �7 y�4,��y '�r���"A eas� �1%�bi#..; � ,nr � � xa u �°,Ma R � "VYA(:.`: � � � � �� , `�.1cs Parcel Number. D00000031 rhs n�a, ����p �ior ��� r�vcr.c�y �i' ��� PIN Number: 5768676490 � � rea' pioperly feuncl trrthin this p ��;, � �ursdic[�ari, ancJ iv comp�icd from cCount Number: 000082517540 F'cr_ordeii de��d�;, ����Ls, ard ot't�er nublic WORKMAN WENDY � . -. !eccids 8nd d<'�t.8. User,of khis mr�p arc� � ,� Listed Owner#1: y�IILLIAMS hereby notifiecl that the aforementioned �� Listed Owner#2: pubiic primary infarmat;on sources shcu€�1 Mailin Address 1: 701 WILLIAMS ROAD be consuited for verification of the information contained er this map. l'he Mailin Address 2: County and ma�ping compony assurne no City: DVANCE legai rc�spansibility for the informaticr� �State: IIN� I r.ontained cn this map. I Zi Code: 27006 Notes: Le al Descri tion: 26.993 AC WILLIAMS RD I crea e: 26.20423000 ' Deed Date: 020010917 Deed Book and Pa e: 003860934 Plat Book: Plat Pa e: 8uildin Value: 0 Outbuilding and Extra Feature p alue: Land Value: 1881Z0 otal Market Value: 188120 otal Assessed Value: 188120 i http://maps.co.davie.nc.us/GoMaps/reports/report.cfm?CFID=36158&CFTOKEN=82091578 9/4/2008 , • DAVIE COUNTY , :. , . , � ''� WELL CERTIFICATE OF COMPLETION CHECKLIST � ' - . �. ' Applicant: File #: Site Address: Subdivision: Lot: ----� Permit Type: New Well Well Repair Well Abandonment Other Facility Type: Residential Food Service Church Commercial Other Initial lnspection / Were Setbacks Maintained? Yes No What is the Grout Depth? 25 ft. If No, Explain: What is the Grout Thickness? 2 in. What is the Type of Well? _�,_,/�.� � Was a Well Screen Installed? What is the Casing Type? P U � Type of Drilling Fluids Used: �i✓r�G��� What is the Casing Depth? (�3 ft. Well Grout Inspection bate: l� 8-va What is the Well Diameter? r in. . . - GPS Coordinates 35 5`�!17� w�627 r4 What is the Well Depth? �� ft. EHS ID: � I '� v Well Head Inspection Is There an Access Port? Is There a Vent? Is There a 4" Pad? Is There a Hose Bibb? �,r� , What is the Casing Height? Is There any Grout Settlement? What is the Static Water Level? 3� ft. What is the Yield?�� GPM �,' Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? �GL� Contractor Name: !Ja t Pump Installer Name: �,�� ��� � Contractor Certification #: �-3��l Date Installed: t/� --�j 9 Depth of Well: / Depth of Pump Intake: / �O � Casing Depth and Inside Diameter��3 � Pump Horsepower Rating: �i Screened Intervals: i Opening for Piping & Wiring >_12": �_ Packing Intervals (Sand Packed Wells): � Yield in GPM or GPM/ft.-dd: `a-� aa Static Water Level and Date Measured: �c,���v�'Date Well Completed: � 6 � � Well Head Inspection Date: "' 0 —C� EHS ID: 'a. � � Construction Completed Date: � `�� ��� Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion D - (J ' D �J Authorized Agent: i�i G�