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158 South Madera Drive Lot 11OPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: RPS Custom Builders, LLC Address: PO Box 277 City: Mocksville State/Zip: NC 27028 Phone #: (336) 816-1293 *CDP File Number 233520 - 1 5749634406 County ID Number: Evaluated For: NEW �ownship: /Property Owner: RPS Custom Builders, LLC Address: PO Box 277 City: Mocksville State/Zip: NC 27028 Phone #: (336) 816-1293 Property Location & Site Information Address/Road #: Subdivision: McAllister Park S Madera Drive Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 4 *Water Supply: PUBLIC *IP Issued by: *CA Issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Phase: Lot: 11 Hwy 158 East right on Sain Rd. right into McAllister Park Left on Chandler right on Madera *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field Sq. ft. 4 3a8ft. 9 0Inches O.C. ®Feet O.C. 3 6 (gInches 0 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK STANDARD Installer: Brian McDaniel Certification #: 11181 *EHS: 2325 - Mitchell, Brittany Date: 0 5/ 1 0/.1 0 1 7 Approval Status 0 Approved ❑ Disapproved CDP File Number 233520 - 1 / Manufacturer: shoat STB: 760 Gallons: 1,000 Date: a/ a 0/ a 0 1 7 *Filter Brand: ST Marker: ❑ Yes ❑ NO Reinforced Tank: ❑ Yes ❑ No \ 1 Piece Tank: ❑ Yes ❑ NO Manufacturer: Pump Type: PT: Gallons: Date: / Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes / Pipe Size: Pipe Length: *Schedule: 40 Pressure Rated ❑ Yes Approved fittings ❑ Yes ❑ No ❑ No (Min. 6 in.) ❑ No ❑ No County ID Number: 5749634406 clog UT117 Lat. Long: Installer: Brian McDaniel Certification #: 11181 *EHS: 2325 - Mitchell, Brittany Date: 0 5/ 1 0/ x 0 1 7 Approval Status ❑X Approved ❑ Disapproved Pump Tank Installer: Brian McDaniel Certification #: 11181 *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply Line 4 inch diameter Installer: Brian McDaniel 0 6feet Certification #: 11181 *EHS: 2325 - Mitchell, Brittany ❑ No Date: 5/ 1 0/ a 0 1 7 ❑ No Approval Status ❑X Approved ❑ Disapproved / Pump Type: Dosing Volume: - Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ NO Anti -siphon Hole ❑ Yes ❑ No Installer: Brian McDaniel Gal Certification #: 11181 *EHS: Page 2 of 4 Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 233520 - 1 County ID Number: 5749634406 NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer: Brian McDaniel Box 12 inches Above Grade ❑ Yes ❑ NO 1118 1 Certification #: Box Adj. To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ NO *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible El Yes ElNo ❑Approved ❑ Disapproved Alarm Visible El Yes ElNO 2325 - Mitchell, Brittany *Operation Permit completed by: Authorized State Agent: Date of Issue: 5/ 1 0/.1 0 1 7 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 111 G. sewage septic system. Rule .1961 requires that a Type TYPE 111 G. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the 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 for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long 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. 9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3of4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 233520 - 1 County File Number: 5749634406 27028 Date: / / O Inch Scale: O Block O N/A Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit 5749634406 Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 CONSTRUCTION AUTHORIZATION * =S` 4- Davie County Health Department 1- 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753.6780 Fax: 336-753-1680 Applicant: RPS Custom Builders, LLC Address: PO Box 277 City: Mocksville State2ip: NC 27028 Phone #: (336) 816-1293 Address/Road #: S Madera Drive Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 it of People: 4 *Water Supply: PUBLIC / For Office Use On1y *CDP File Number 233520-1 County ID Number. 5749634406 Evaluated For. NEW �, Township: IT VALID UNTIL: 0 a/ O a/ 2 0 2 2 Property Owner. RPS Custom Builders, LLC Address: PO Box 277 City: Mocksville State/Zip: NC 27028 Phone #: (336) 816-1293 Subdivision: McAllister Park Phase: Lot: 11 Directions Hwy 158 East right on Sain Rd. right into McAllister Park Left on Chandler right on Madera Minimum Trench Depth: 3 6 Site Classification: ProvlslonallysuitaWe Inches Saprolite System? OYes eNo Minimum Soil Cover. a 4 Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0. 2 7 5 Maximum Soil Cover: a 4 Inches "System Cless faatan/Description: *Distribution Type: GRAVITY -SERIAL TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Septic Tank: 1 0 0 0 _Gallons 'Proposed System: 25% REDUCTION 1 -Piece: OYes ONo Pump Required: OYes @No OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: QYes ONo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing: _ 9 0Inches O.C. g Dosin Volume: _ Gallons (� Feet O.C. Trench Width:3 OInches Feet Grease Trap: Gallons Aggregate Depth: - inches Pre Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 0111 OIV Donn 1 M1 CDP File Number 233520 - 1 County ID Number. 5749634406 ❑ Open Pump System Sheet uired:@Yes ONO ONo, but has Available Space *Site Classification: provisionally Suitable Design Flow: 3 6 0 Soil Application Rate: 0 2 7 5 'System Classification/Description: TYPE III G. OTHER NON -CONY. TRENCH SYSTEMS 'Proposed System: 25% REDUCTION Nitrification Field 1 3 0 9 Sq. ft. No. Drain Lines 4 Tota( Trench Length: 3 a 7 ft, Trench Spacing: _ 9 Onches Feet O.C. Trench Width: Inches 3 Feet Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches 'Distribution Type: GRAVITY -SERIAL. Pump Required: OYes GNo OMay Be Required Pre -Treatment: ONSF OTS -1 OTS -II "Site Modifications 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 bythe Health Department in noway guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe Issued at the sametime 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 maybe suspended or revoked (.1937(g)). 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)). Applicant/Legal Reps. Signature Required? Oyes @No Applicant/Legal Reps. Signature- Date: , / *Issued By: 2140 -Nations. Robe Date of Issue: 0 a / 0 .1 / a 0 1 7 Authorized State Agen Malfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: County File Number: 5749634406 Date: 02/02/2017 Olnch Scale: OBlock ON/A • -- - - I .. dWW � I I ... b . . . .............. I -� __ t_ E I ]j j t 5 a r CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. sox 848 Mocksville NC 27028 CDP File Number: County File Number: 5749634406 Date: .02/0.2/2017 Click below to Import an image from an external location: Drawing Type: Construction Authorization IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL; 2/212022 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant. RPS Custom Builders, LLC Address: PO Box 277 CRY: Mocksville State/Zip: NC 27028 Phone #: (336) 816-1293 Address/Road #: S Madera Drive Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 4 *Water Supply: PUBLIC Property owner: RPS Custom Builders, LLC Address: PO Box 277 CRY: Mocksville State/Zip: NC 27028 Phone #: (336) 816-1293 Subdivision: McAllister Park Phase: Lot: 11 n: Provisionally Suitable SaproliteSystem? OYes QNo Design Flow: 3 6 0 Soil Application Rate: 0 - 2 7 5 *System Classification/Description: TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS 'Proposed System: 25% REDUCTION Directions Hwy 158 East right on Sain Rd. right into McAllister Park Left on Chandler right on Madera Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes QNo Pump Required: OYes (D No OMay Be Required Pump Tank: Gallons 1 -Piece: OYes ONo Repair System Required: 0 Yes ONO ONO, but has Available Space Repair System .Site Classification: Provisionally Suitable Soil Application Rate: 0 - 2 7 5 *System Classification/Description: TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS *Proposed System: 25% REDUCTION Minimum Trench Depth: 3 6 Inches Maximum Trench Depth: 3 6 Inches Pump Required: OYes QNo O May be Required Page 1 of 3 CDP File Number 233520 -1 'Site Modifications County ID Number. 5749634406 ❑ 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 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. Site Plan The Improvement Permit shall be wild for 6 years from date of Issue with a site plan (means a drawing not necessarily drawn to scale that shows 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 surface waters). Plat The Improvement Permit shall be wild without expiration with plat (means a property surveyed prepared by a registered land surveyor, drawn to a scale of one inch equals no more than 60 feet, that includes: the specific location of the proposed facility O 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 subdivislons 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 sadsfy the conditions, the rules, or this article. This permit Is subject to revocation If the site plan, plat; or intended use changes (NCOS 130A335(1)). 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)} Applicant/Legal Reps. Signature Required? Oyes (!Mo Applicant/Legal Reps. Signature*, Date: *Issued By: 2140 -Nations, Robert Date of Issue: 0 a/ 0 a/ a 0 1 7 Authorized State Agen OValid without Expiration? O Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Improvement Permit CDP File Number: 233520 -1 County File Number: 5749634406 Date: / / Q Inch Scale: , 081ock QN/A — ft. IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 233520 -1 County File Number: 5749634406 Date: 0 2/ 0 2/.2.0.1.7 J Click below to import an Image from an external location: Drawing Type: Improvement Permit APPLICATIONJEOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Oct, ` Davie County' Environmentt►I�Health�'` `' jG•,; ' ' P.6 1- ox 848/210IIospital Street'` 1 J Mocltsville,,NC °27028 (336)753=6780/ Fax.(336)753-1680 _.:.... . Application For: ❑ Site Evaluation/Improvement,Peimit uthorization To Construct (ATC) ❑ Both Type of Application: ❑New S stem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTB$'PROCESSED UNLESS -ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION. BULLETIN,for instructions: APPLICANT INFORMATION Name 6&Y4Contact Person r ti Address . . Home..Phone City/State/ZIP Business Phone r Z Email tV - Email: 64JuC Name on Permit/ C if Different than AboveJ4 Mailing Address r' City/State/Zip PROPERTY INFORMATION P ' _' '*Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany thisl application. Included: ❑; Site Plan &Plat(to scale) (Permit is valid for.60 months with ite plan, no expiration with complete plat.) Owner's Name S IL j, Phone Number . o Owner's Address O e-City/State/Zip C Z %D7 S Property Address It M,0a6 D 6119 -City , C f� • (LL Lot Size 0 Z ' Tax PIN# C% Subdivision Name(if applicable) Section/Lot# ( / Directions To Site: L �'D f l; . b. 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 Wo Does the site contain jurisdictional wetlands? _Yes ` v1 o Are there any easements or right-of-ways on the site? ,Yes vo Is the site subject to approval by another public agency? Yes %.No Will wastewater other than domestic sewage be generated? Yes +1Xo TF RF4TT)FNC'F, FTT.T, (AUT THF. Rox RFmw # People -- L� - - _ # Bedrooms #,Bathrooms - Garden Tub/Whirlpool ❑Yes Basement: ❑Y sS NKo Basement Plumbing: Yes.: N40 IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total .Square Footage of Building # People # Sinks # Commodes # Showers #,Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility .water consumption) FOODSERVICE ONLY: # Seats Type system requested: ❑Accepted ❑Innovative ❑Altemative. ❑Other`---" Water Supply Type: 911clounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes RANI 0 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 permit(s) IP(s) or CA(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. Permits issued will expire 5 years from the date of issuance. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the je-ation of any other amenities. owner's (# owner's legal Revised 11/16 1-17-17 signature Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 1)-23✓�/ Invoice # Davie.CoUrlty, NC Tax Parcel Report Monday, February 22, 2016 30 m 14 3 18 0 12 4305 o i o ,,x.655. 300 n I Q let OzG it - I- C) .� .167 63 I All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the he warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold Davie County, NC 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 by this website. WARNING: THIS IS NOT A SURVEY Parcel Information.' Parcel Number. H519OA0011 Township: Mocksville NCPIN Number. 5749634406 Municipality: Account Number. 82525783 Census Tract: 37059-805 Listed Owner 1: TYCON INC Voting Precinct: NORTH MOCKSVILLE COUNTY Mailing Address 1: 350 GRAND COURT Planning Jurisdiction: MOCKSVILLE City: WINSTON SALEM Zoning Class: MOCKSVILLE OSR State: NC Zoning Overlay: Zip Code: 27104 Voluntary Ag. District: No Legal Description: LOT 11 MCALLISTER PARK Fire Response District: MOCKSVILLE Assessed Acreage: 0.53 Elementary School Zone: MOCKSVILLE Deed Date: 112006 Middle School Zone: SOUTH DAVIE Deed Book 1 Page: 006460338 Soil Types: GnB2 Plat Book: 0008 Flood Zone: x Plat Page: 253 Watershed Overlay: - Building Value: 0.00 Outbuilding & Extra 0.00 Freatures Value: Land Value: 45000.00 Total Market Value: 45000.00 Total Assessed Value: 45000.00 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the he warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold Davie County, NC 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 by this website. APPLICATION FOR SITE EVALUATION/IAIPROVBIENT PERIT Davie County Health Department EnvironmentaiHeaith Section P.O. Box 848/210 Hospital StreetMocksville, NC 27028 Z��S(336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEZtEQ= INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. IF FOODSERVICE: It Seats 8. Type of water supply: 0'60unty/City Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 -11 -01 - If yes, what type? _ ***111fP0RTAN7'*** CLIENTSAIUSTC0,MPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BE SUBAM'TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: if pp Property Address: Road Name _ (5/4 ;)J 21 1 City/Zip If in a Subdivision provide information, as follows: Name: M 4-e (- 1%rk- Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners flagged: 41- This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernnit(s) issued hereafter arc subject to suspension or revocation, if the site plans or, intended use change, or if the information submitted in this application is falsified or changed. 1, also, understand that 1 ani responsible for all chaiges incurred frons this application. I, hereby, give consent to the Autborized Representative of the Davie County IIealth 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' 1.3- OS- SIGNATURE ��-'��, ��• TIIIS 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). Sign givcn _46Sk Revised DCIID (05103 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. 1. Name to be Billed,/L i-i�a•z�CA ��1 1 Contact Person �� I� «^ C4— Mailing Address � �:/ -� � 71 e �- ,S `i' Home Phone Z�--� ' O •.2- City/State/ZIP L3,r% j'r�'� `� ��t �1 �`� �Z 7/�'} Business Phone '7/� -:1f') 7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [3 Site Evaluation ❑ Improvement Permit/ATC [IBoth 4. System to Service: 1 -House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type ayatem requested: 0 --conventional ❑ conventional modified ❑ innovative 6. if Residence: # People ? # Bedrooms _3=� #Bathrooms � ,.., � BDishwasher ❑Garbage Disposal 121ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats 8. Type of water supply: 0'60unty/City Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0 -11 -01 - If yes, what type? _ ***111fP0RTAN7'*** CLIENTSAIUSTC0,MPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AIUST BE SUBAM'TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: if pp Property Address: Road Name _ (5/4 ;)J 21 1 City/Zip If in a Subdivision provide information, as follows: Name: M 4-e (- 1%rk- Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners flagged: 41- This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernnit(s) issued hereafter arc subject to suspension or revocation, if the site plans or, intended use change, or if the information submitted in this application is falsified or changed. 1, also, understand that 1 ani responsible for all chaiges incurred frons this application. I, hereby, give consent to the Autborized Representative of the Davie County IIealth 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' 1.3- OS- SIGNATURE ��-'��, ��• TIIIS 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). Sign givcn _46Sk Revised DCIID (05103 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Invoice No. APPLICANT INFORMATION AGgount ##: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.11 Subdivision Info: McAllister Park Lot # 11 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: Community Public Evaluation By: Auger Boring Pit / Cut SITE CLASSIFICATION: WS EVALUATION BY: vim~ LONG-TERM ACCEPTANCE RATE: C)' OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope 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 ois VFR - Very friable FR - Friable Fl - 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 ructurc '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 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 - gal/day/ft2 DCI ID 05/99 (Revised) Landscape position HORIZON I DEPTH Consistence ■r��r�u���������� MineralogyHORIZON Il DEPTH Texture group Consistence HORI_ZON III DEPTH Texture group r.r�rvi■�■�������� Consistence MineralogyConsistence ������������o Texture group Mineralogy SOIL WETNESS SAPROLITE CLASSIFICATI• SITE CLASSIFICATION: WS EVALUATION BY: vim~ LONG-TERM ACCEPTANCE RATE: C)' OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope 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 ois VFR - Very friable FR - Friable Fl - 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 ructurc '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 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 - gal/day/ft2 DCI ID 05/99 (Revised)