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159 Finn Hollow Lane Lot 3is�yera�tKa ATC Number: 4421 size: see As stated In 15A NCAC 18A.1969(5) accepted Systems may also be usedd AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I l of G.S: Chapter 130A, Wastewater Systems, Section 1900 Sewage a tment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW CO CTIO V L17A PERIOD OF FIVE YEARS. dal Health Specialist's Signa Date: .TE OF COMPLETION OTE** a issuance of this Certi& e'ofCompl ion shall i�-dir�elsystem described on Improvement/Operation Permit as been installed in compli ice with Artic A 1-of8 ". hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall n NOWAY taken as a��arang� tee that the system will function satisfactorily for any given period of time. V� R] Qk)rl/ 4 5'p Cl►�i . -540aF jG00gaj ,Ai r `1' 110 Septic System Installed By: Health Specialist's Signature: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTDA ENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003722 Tax PIN/EH #: 5870-44-2211.03 Billed To: Richard Sutton Subdivision Info: Browder/Sutton Div Lot # 03 Reference Name: Larry McDaniel Location/Address: Cornatzer Rd -27006 is�yera�tKa ATC Number: 4421 size: see As stated In 15A NCAC 18A.1969(5) accepted Systems may also be usedd AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I l of G.S: Chapter 130A, Wastewater Systems, Section 1900 Sewage a tment and Disposal Systems). THIS AUTHORIZATION FOR WASTEW CO CTIO V L17A PERIOD OF FIVE YEARS. dal Health Specialist's Signa Date: .TE OF COMPLETION OTE** a issuance of this Certi& e'ofCompl ion shall i�-dir�elsystem described on Improvement/Operation Permit as been installed in compli ice with Artic A 1-of8 ". hapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall n NOWAY taken as a��arang� tee that the system will function satisfactorily for any given period of time. V� R] Qk)rl/ 4 5'p Cl►�i . -540aF jG00gaj ,Ai r `1' 110 Septic System Installed By: Health Specialist's Signature: DCHD 05/99 (Revised) i " DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Soctiorl P. O. Bos 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003722 Tax PIN/EH M 5870-44-2211.03 Billed To: Richard Sutton Subdivision Info: Browder/Sutton Div Lot # 03 Reference Name: Larry McDaniel Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: see plat ATC Number: 4421 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construption of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the i;suance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT 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 Hc13seE #People Z #Bedrooms 3 #Baths 2 - Dishwasher: Dishwasher: ET� Garbage Disposal: Washing Machine: 121�� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #,13People #People/Shift #Seats Industrial Waste: Lot Sizee Water Suppl� oz Design Wastewater Flow (GPD) (� Site: New Repair ❑ �� 1 System Specifications: Tank Size 1000 GAL. Pump Tank GAL. Trench Width 3L Rock Depth 49 „ Linear Ft. . As stated In 15A NCAC 18A.1969(5 Other: tn-npo4ff10�Ux z'S / accepted Systems may also be used Required Site Modifications/Conditions: I-1STNL.L- t� � i C�i�/ S GTI— } / 4—iiQL> IMPROVEMENT/OPERATION PERMIT LAYOUT- PPR ED EFFLUE TI F L=RL RISER(S) IF 6 -BELOW FINISHED GRADE. ****NOTICE: Contact a represent rive ofth a oun Hea'Department for final inspection of this system between >{30 a.m. t 9:30 a.m. or 1:00 p.m. to 1:30 in. on the da of instal ation. Telephone is (336)751-8760.**** ry �� S \ A/ lop Imo' Environmental Health Specialist's Signature D �6 DCHD 05/99 (Revised) 02/11'/2009 21.10 7048924705B , B K..WELL:DRILLING � a M%14IP�: ldf7W/!— iatr� �%i r, r NSM Cw1Ye D�sonmt orEovkft"lM wA NMI ftftwmes. Divirion orwgw qwi we:I1. MUTn w...... by 1. WELL COf"RACTOR- l Wd rmw Nan. STREET ADOREss .3Zovq�-o GjJ a906/jeSfl//��f c"wToww etft Zp Ca.o nt.Mwr L WELL WORMATMW SRE WELL M 1411 Wle,p.) GTATEWELL FER n" meOT OmOrOTHER PERM .p.IP.v6.i— _ WELL USE(Ch.acBerk RslpeW W.lerSypy�� OATIE DRRLED A2;1 D TIME COM 00 Aep PMr' 7. WELL LOCATION: e cm: d cDUNrr 10,9Vl L — ��`"Y ^'��• ��4..rbArriw4 eueuwe.. pw DP cera) TOPOORAPHx;/LANDRArnt1O 13Sgw DVdW M}( DRIB D06M (a�et.Awa.1.64oq LATITUAl DE Mq b. Y�A�Dea, LONpRWE_ _ Y.� hpmw [Afift*ADnsitud MNW. 130n DTWgF4PMeMV fk "-.t./,wrmul be abo.n en a (lSOSSppllep.TM .Sldispb 016 Mm,/noI odq pP'4) 4.WrLL0w ER _ OWNER'SNAW�'�, STREET AOORM . Clya Town 811r Zp Coy 1�-� AI.. Col.- Fhaw eertw L WELLKWTAMB- a TOTALOEFIEI:-.3 S' 6. OMWELLREPLACEELDa. WELL??•-bES TD NO�— e: WATMLEVd.S.Iar > Topo(CwkV: FT. ove (um'+•MAbTopdc,i ) CL TOP OF CASH 8 PT. Ab.wlsr. 8wbW 'Top d C.eFS 1en.Ma1 eutr tAwrlad au(.e. nwy wales . Mrlwlo. L, leLaAr�TMh 1sA NCAC zc.a a VIRo(YPwlk �O SIETHODOFTEST�� Iai ROMN ,r. OlS11FecTKft Tn*z PAGE 01 a• WAV zpa ovey F�T.L /,p To Fm it TO • Plam To l CASM; T��+L� From To Thk6w.q Ran D 'T� F�LTo FL To 7. GROUP DqM 1 ,y Ran 0 To S9.r`fvo M� — RML—TCL—Ft v FMmL—To —FL"�-.�- e, eCNEHC DyN►� 'pwnew ams Fran �b " kL h , brL L AAM(ORAVELFACR: Dip1h. Sbxe 41ll.riw Fq. To��_ rL Fla. To te. DRaL90 LOG �f n . � L17 O r Dmv • ter T' 100 MeM► CpRFTRMTTM wBL WAS COMML OD 0 ACCOFAMA . W h N MOAC IC W RU OD/i1RR1RIM 6/AM0ra05. NOlIMTA 00" OF T1M . A#Cft IaeE/ ®ToT1Er1[V,pTyl�, �P ldl�c �..�:L � 1 �3 0, TURF OF CERrIFlED vV C06 E BnbinR the Orlphtel to the QMslon of Water Qua[My within 30 Aaya. Attn: Inrom;aoon MpL, - 1il17MON ServleeGnter—RetftkNC2760M117 Phone No.(611)733.7o15exta6S. Form Min Res. TM DAVIE COUNTY WELL CERTIFICATE OF COMPLETION CHECKLIST Applicant: ��v��� c�o Q�w� JVC4,,fi� File#: Site Address: i,,rz Xl -- /d1 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 No What is the Grout Depth? . ft. If No, Explain: What is the Grout Thickness? z in. What is the Type of Well? Was a Well Screen Installed? What is the Casing Type? Type of Drilling Fluids Used: What is the Casing Depth? � % ft. Well Grout Inspection Date: /�� 1 —o % What is the Well Diameter? 6e. in. GPS Coordinates What is the Well Depth?— ft. EHS ID: 2,1V6 / Well Head Inspection ' Vent? Is There an Access Port? Is There a Is There a 4" Pad? Is There a Hose Bibb? i What is the Casing Height? 1 73 Is There any Grout Settlement?� What is the Static Water Level? ft. What is the Yield? Db GPM Is the Well Contractor ID Plate Complete? Is the Pump Installer ID Plate Complete? Contractor Name: Pump Installer. Name: 5" a5 AIle- Contractor Certification #: 3 4 Date Installed: ) —'23 —vQ .Depth of Well: '� $ 5/ 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: 'JO 1--11' 01 Static Water Level and Date Measured:_ Date Well Completed: Well Head Inspection Date: 1 I EHS ID: ) 114 . Construction Completed Date: I %'Z--0 9 Contractor Reports Received Date: Sample Date: Results Mailed Date: Certificate of Completion Dat (d —O 9 Authorized Agent: h W �4i ' Ax- Lit O 50'x' I � , Z x i xx .4 3e xx Y, S& I )e.Lld.�C.hLLY,� APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 00 Z ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Name to be Billed QA vim J . 01 //-� Contact Person m,1 rrrr t Zo92z>" S Billing Address / 75 PQxk www WJ, Home Phone 336- H`Y`l- It IhC 33G� S 13 City/State/ZIP )%VA-JCF i )VG. Q7006 Business Phone 336 998-.x,- 17 Name on Permit if Different than Above Mailing Address City/State/Zip PKVPEK1 Y 1Nr VKMAI K N 'Date ttouse/racnrty Lomers Ptaggeo NOTE: A survey plat or site plan must accompany this application. Inc Ynded:.F4 Site Pl ❑Plat (to scale) Owner's Name Li1+�D J' mA077d ZOANNA M. r"A✓ml' Phone Number 336- - LPN- if I16 Owner's Address 175' i 0Kr_ysevj L • City/State/Zip PDLUq� NL• a700t Property Address 31 FSWd t -OL.) Lh!• City. "--tbVRnlcs: Lot Size 1.7 ACE -C d- - Tax PIN# 51170 - 9`13,2 - ;26 —&z) Pro Subdivision Name(if applicable) Section/Lot# P,lrccst 7t GYooe0000s07 Directions To Site:0-60ZtJA'TZfr_ ' RD TO 13F4yzu /,NMP 7ynn' L. oR lsoierN tr7+✓ Oeu.mtJ Ort DEVELOPMENT INFORMATION Permit Type: New Well X- Well Repair Well Abandonment Other (specify) Facility Type: Residential ` Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES T— NO -A Do You Intend To Install A New Septic System On This Site? YES _Y,— 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 marldng the property lines and comers. The applicant is responsible for malting the site accessible. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for David County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. 12-/5-o8, Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 3 $7 Invoice # 0 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New 1p� Repair ❑ Abandonment ❑ Proposed Well Location Diagram Certificate of Completion Diagram 9 JW eu Davie County Environmental Health ` P.O. Box 848/210 Hospital Street (' Mocksville, NC 27028 02� (336)751-8760/ Fax (336)751-8786 WELL PERMIT Account #: 990003857 Tax PIN/EH #: 5870 -44 -3226 -Well Billed To: David & Joanna Martin Subdivision Info: Browder/Sutton Div Lot # Reference Name: Location/Address: 131 Finn Hollow Lane -27006 Proposed Facility: Well Property Size: 1.7 acres ATC Number: 0021 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New 1p� Repair ❑ Abandonment ❑ W.P. 7-08 Proposed Well Location Diagram Certificate of Completion Diagram 9 JW eu a (wh r1rC- �a w.eel Driller: omments: Certification #: C Grout Inspected: Well Head Inspected: GPSCoo nates: N3 'J�•Q ��(21 EHS./ " "�% Date: EHS: te: ��-30 (j$ W.P. 7-08 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account`#: 990001995 Tax PIN/EH #: 5870-44-2211.03 Billed To: Robert Stone Subdivision Info: Browder/Sutton Div Lot # 03 Reference Name: Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: see plat Date Evaluated: Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % p HORIZON I DEPTH Texture group Consistence I' Structure Mineralogy- , l HORIZON 11 DEPTH Texture group G Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: r 1� LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: A(_al OTHER(S) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope 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 mdq VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed N010 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 - gal/day/ft2 DCHD 05105 (Revised) MAY -24-2006 07:33 RM LARRY.MCDAMIEL.SUILDERS. 3367733724 P.01 '{ WNSITE YENMITp41'C DAVIS County Mwlln Dap+.rmYlll ounty Health eParg 111 Fno8plb/Nn/tha \ p0 0. sondn 448/210 MOepi ttell street 100havil1el NC 2-1026 - (]]61751-41760 N•' 7wi6 Ibb6NLN1tON ZGTI C4f/11D1` pE p/DCiYdiO UltiE96 ALL VAR asou YO� Ld.Nl NalillLad.11 D.wt Zs VR0 4G to Me IMPOpalATZON SULLWrIN tot inatruttlon. 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Ravish Cbarte Ld.Nl NalillLad.11 D.wt LD6: Sita glveA ACCYYYI No. t 9 Revised DCUD (05003 Iuvoicr No. APPLICATION FOR SITE EVALUATION/IMPIIDVEMENT PER VE Davie County Health Department D rr &vironmenta/Health section AUG 2 4 2005 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ENVIRONMrNre: stun. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUTAE)T�"��+ IN IS.PRROVIDED. Refer to the INFORMATION BULLETIN for instructions. NamBilled KtCHAR9 Su-t^t-orJ rr- contact Person Mailing Address 3711- I I.8 -+h S -r II, Home Phone City/State/ZIP 'R KAO V IJTQ 0 I -L 3 T al O Business Phone 3340-99 8 "4i $3 _ a'i I- X12• -O - T3- 2, Name on Permit/ATC if Different than Above Mailing Address City/State/Zip " 3. Application For://Site Evaluation ❑ Improvements Permit/ATC 13 Both .a, system to service: Or House ❑ Mobile Home ❑ Business ❑ Industry, ❑ other S. Type system requested: 19 Conventional ❑ conventional modified ❑ innovative - 6., If Residence: tf People�9 Bedrooms S 1I Bathrooms _ 51Diahwaeher ❑Garbage Disposal lldWashing Machine ❑Basement/Plumbing ❑Basoment/No Plumbing 7: If Business/Industry /Other: verify type N People. If Sinks tl Commodes - A Showers - A Urinals t) Water Coolers IF FOODSERVICE: t) Seats Estimated Water Usage (gallons per day) s. Typo of water supply: County/City ❑ Well ❑ Community 9: Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes K1190 If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOAfPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eithera PLAT or SITE PLAN MUST BESUBA117TED by the client with THIS APPLICATION. 47 ern Dimensions: -:5 1" P LA -K WRITE DIRECTIONS (tram Mocksville) to PROPERTY: TaxorrcBrlN: ii '5s—i `�Z'ZI I py S (oq FoMC- �iXAl3 tZY0 Property Address: RoadName2649 CoIZ14 e � � 16'1-)( aY 2b 7-© City/Zip r40"4#�t FE H C CO2rJ AT j2►J , _ C,u12i.1RIT�l rC i2lj ;z1oob If in a Subdivision provide information, as follows:�� B AV G t-f�I ✓rtVO yQyQ Name: 53 t M/4c t L &V Tien) )Olt/1S)0-0,J jyc IS AT l A W Q V,44 /L41v �r Section: Block: Lot: 3 --Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or hllended'use change, or if the Information submitted in tl1!s application is falsified or changed. I, also, understand that I ani responsible for all charges iacurred from this alplication. I, hereby, give consent to the,Authorized Representative of the Davie County IIeallh Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE % 'o SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE; PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). . Site Revisit Charge Datc(s): Client Notification Date: EHS: 37z2 - Account No. Invoice No. c; e0 3 �O tp S o� X .o T� °o G m m®ma 9�0.t5 S4 � 1