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228 Palomino Road Lot 7Davie County. NC Tax Parcel R ennrt Thursday, January 26, 2017 WARNING: THIS 1S NOT A SURVEY Parcel Information Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: H909OA0007 Township: Shady Grove 5789834916 Municipality: 8305266 Census Tract: 37059-804 DINGLER WENDELL L Voting Precinct: EAST SHADY GROVE 4950 DOCK DAVIS ROAD Planning Jurisdiction: Davie County CLEMMONS Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27012 Voluntary Ag. District: TRACT 7 HIDDEN MEADOW Fire Response District: ADVANCE 5.73 Elementary School Zone: SHADY GROVE 7/2015 Middle School Zone: WILLIAM ELLIS 009950144 Soil Types: PaD,PcB2,PcC2,ChA Land Value: Total Assessed Value: 0007 Flood Zone: 238 Watershed Overlay: DAVIE COUNTY Outbuilding 8r Extra Freatures Value: Total Market Value: No 91w.tAAli data Is provided as Is without warranty or guarantee of any Idnd either expressed or implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to �pUp1'S4 NC or arising out of the use or inability to use the GIS data provided by this website. OPERATION PERMIT F�CDP,File ice se n v Davie County Health Department umber 194257-1 210 Hospital Street 5*44340,16P.C: Box 84$mber:. Mocksville NO 27028Evaluated, For: NEIN Phone: 336-753-6780 Fax: 336-753-1680 Township; r Applicant Lori©n and Lori Dingler Address: 4950 Dock Davis Road City: Advance SWOOP: NC 27006 \ Phone #: (336) 462-6107 Address/Road #: Palomino Road Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 4 'Water Supply: NEwwELL *IP Issued by. *CA issued by: 2140 - Nations. Robert 2140 - Nations. Robert Property Owner: Lorion and Lori Dingier Address: 4950 Dock Davis Road CRY: Advance State2lp: NC 27006 one #: (336) 462-6107 Subdivision: Hidden Meadow Phase: Lot: 7 Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 Nitrification Field No. Drain Lines Total Trench length: Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 801 South Left on Peoples Creek Rd at Church, left on Dublin in Shamrock Acres, right on Irshman Place, end of road System Classification/Description: TYPE It A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SaprotiteSystem? 0Yes (�)No *Distribution Type: GRAVITY- PARALLEL (eq. dbox) Pump Required? QYes f)No *Pre Treatment: T 1 7 4 5 Sq. ft. 5 4 3 6 ft. inches O.C. Feet O.C. inches 3 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Sail Cover a �...: 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 2 4 Inches *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Brian McDaniel Certification ##: *Eli S: 2140- Nations. Robert Date: 0 2/ 1 8/ 2 0 1 6 GDP File Number 994257 ` 1 County [Q Number: 5789-834916 Dosing Volume: - Septic Tank. ' Manufacturer: Shoaf Inches Lat. - STB: 760 Long: Gallons: iQOt} Installer. Brian McDaniel Date: 0 8/ a a I a 0 1 5 Certification #: Flow Adjustment Valve ❑ Yes ❑ *EHS: 2140 - Nations, Robert *Filter Brand: POLYLOK PL -122 With Pipe Adapter ❑ Yes ❑ ST Marker: El Yes 0 No Date: 0. 2 1 8% 2 0 1 - Reinforced Tank: E]Yes E NO ❑ Yes ❑ AppravatStatus Anti -siphon Hate ❑ Yes ❑ No Approved ❑ Dlsappripy 1 Piece Tank: D Yes BNa - Pump Tank Manufacturer: Installer: PT: Certification #: Gallons: THS: Date: % Date: RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min. 6 in.) v Approval Reinforced Tank: D Yes D No _ Q Approved 3 Qisipproveci 1 Piece Tank: ❑Yes D No 4 E Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: *Schedule: THS Pressure Rated ❑Yes ❑ No Date: Approved fittings ❑ Yes ❑ N4 - ADDrtlltat Status, Pump Type: installer. Dosing Volume: - Gal Certification f#: Draw Down: Inches `EHS: *Chain: f Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-vatve ❑ Yes ❑ No ApprovaleStatus PVC unions El Yes ElNo isapprcretl Vent Hale" ❑ Yes ❑ No Anti -siphon Hate ❑ Yes ❑ No CDP FileNumber 194257-1 tiectnc eaumament County ID Number: 6789-834916 NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes O No Certification #: Box Adj.To Pump Tank ❑ Yes O No Conduit Sealed ❑ Yes O No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Alarm Audible ❑ Yes O No Alarm Visible ❑ Yes O No 2140 - Nations, Robert *Operation Permit completed by. Authorized State Owner/Applicant Signature: Approval Status O Approved O Qisapproved Date of Issue: 0 a/ 1 8/ a 0 1 6 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 It A. sewage septic system. Rule .1961 requires that a Type TYPE IIk septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: NIA Reporting Frequency By Certified Operator: NIA Rule .1961 requires theta Type 1V and V septic systems designed far a home/business owner must maintain a valid contract with a public management entity wkh a certified operator or a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management 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 bya public or private management entity, unless the system owner and certified operator are the same. The contract shalt require specific requirements formai ntenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for es tong as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing 0Import Drawing **Site Plan/Drawing attached.** Drawing OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Type: Operation Permit 1 CDP File Number: ' 194257.1 County File.Number: 57$9-83.4916 27028 Date: 1 Q Inch Scale: 0131ock ON/A l tj II �li. I I I I IILLI i � lbwl_ �l I II ' II II I I�� I II II ;I Illi Address/Road #: Palomino Road Advance Structure: # of Bedrooms: # of People: *Water Supply: 11,1191MU1111-%, SINGLE FAMILY 4 4 NEW WELL Subdivision: Hidden Meadow Phase: Lot: 7 Directions Hwy 801 South Left on Peoples Creek Rd at Church, left on Dublin in Shamrock Acres, right on Irshman Place, end of road CONSTRUCTION Minimum Trench Depth: For office Use Only Site Classification: Provisionally Suitable AUTHORIZATION "CDP File Number 194257-1 Saprolite System? QYes QNo Davie County Health Department Minimum Soil Cover. County ID N,jmber. 5789-83-4916 Design Flow: 4 8 0 210 Hospital Street Maximum Trench Depth: Evaluated For: NEW •.�,..• 'P.O. Box 848 Maximum Soil Cover: Township: *System Classification/Description: Mocksville NC 27028 PERMIT VALID UNTIL: GRAVITY - PARALLEL (eq. d -box) Phone: 336-753-6780 Fax: 336-753-1680 OR 480 GPD OR LESS) Septic Tank: 0 6/ 0 4/ a 0 a 0 Applicant: Lorton and Lori Dingier Property Owner: Lorton and Lori Dingier Address: 4950 Dock Davis Road Address: 4950 Dock Davis Road City: Advance City: Advance State2ip: NC 27006 State/Zip: NC 27006 Phone #: (336) 462-6107 �P�honee (336) 462-6107 0Yes QNo Property Location & Site Information Address/Road #: Palomino Road Advance Structure: # of Bedrooms: # of People: *Water Supply: 11,1191MU1111-%, SINGLE FAMILY 4 4 NEW WELL Subdivision: Hidden Meadow Phase: Lot: 7 Directions Hwy 801 South Left on Peoples Creek Rd at Church, left on Dublin in Shamrock Acres, right on Irshman Place, end of road Dana I M14 Minimum Trench Depth: a 4 \ Inches Site Classification: Provisionally Suitable Saprolite System? QYes QNo Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25% REDUCTION 1 -Piece: QYes QNo Pump Required: QYes QNo OMay Be Required Nitrification Field a 7 5 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: 0Yes QNo Total Trench Length: 4 3 6 ft, GPM—vs— ft. TDH Trench Spacing:'0Inches _ 9 O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 0 Inches _ . Feet Grease Trap: Gallons Aggregate Depth: inches - Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 oil 0111 OIV / Dana I M14 CDP File Number 194257-1 County ID Number: 5789-834916 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONO, but has Available Space e2 System Trench Spacing:9 Onches 0. . 'Site Classification: Provisionally Suitable — Feet O.C. Trench Width; QInches Design Flow: 4 8 0 —` 3 V Feet SoilAggregate Depth: Application Rate: 0 - a 7 5 inches Minimum Trench Depth: a 4 Inches *System Classification/Description: Minimum Soil Cover. 1 a Inches 'Proposed System: Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Nitrification Field 1 7 4 5 a 4 Inches Sq, ft. - No. Drain Lines 4 "Distribution Type: GRAVITY- PARALLEL (eq. d -box) Total Trench Length: 4 3 6 ft Pump Required: Oyes (jNo 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 by the Health Department in no wayguarantees 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 same time the Improvement Permit issued (NCGS 130A -336(b)} If the installation has riot been completed during the period of validity of the Construction Permit, the Information submitted In the application fora permit or Construction Authorization is found to have been incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall became Invalid, and maybe suspended or revoked (.1937(8)). 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 ONO Applicant/Legal Reps. Signature: Date:. / / *Issued By. 2140 - Nations, Authorized State Agent: Date of Issue: 0 6/ 0 4/.1 0 1 5 Malfunction Log OYes OHand Drawing 0import 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: 194257 -1 County File Number: 5789-83-4916 Date: 06/04/2015 Q Inch Scale: QBlock Q NIA . . .. ... ... .. .. ------------- ... . . . ..... . L -j .... ........... . ... .. - �a III III � III_. I I �_... � IMPROVEMENT PERMIT d Davie County Health Department 210 Hospital Street ., P.O. Box 848 Mocksville NC 27028 rFor Office Use Only *CDP File Number 194257-1 County ID Number: 5789-83-4916 Evaluated For: NEW Township: Phone.336-753-6780 rax: 336-753-1680 PERMITVALIDUNTIL 6/4/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Lorion and Lori Dingier Address: 4950 Dock Davis Road CRY: Advance State/Zip: NC 27006 Phone #: (336) 462-6107 Address/Road #: Palomino Road Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 4 *Water Supply: NEW WELL Property Owner: Lorion and Lori Dingler Address: 4950 Dock Davis Road City: Advance State2ip: NC 27006 Phone #: (336) 462-6107 Subdivision: Hidden Meadow Phase: Lot: 7 Provisionally Suitable Saprolite System? OYes @No Design Flow: 4 8 0 Soil Application Rate: 0 . 7 5 u *System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Directions Hwy 801 South Left on Peoples Creek Rd at Church, left on Dublin in Shamrock Acres, right on Irshman Place, end of road Minimum Trench Depth: a 4 Inches Maximum Trench Depth: 3 6 Inches Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes @No Pump Required: OYes QNo OMay Be Required Pump Tank: Gallons 1 -Piece: OYes ONo Repair System Required:@Yes ONo ONO, but has Available Space Reaair System .Site Classification: Provisionally Suitable Soil Application Rate: 0 a 7 6 *System Classification/Description: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) "Proposed System: 25% REDUCTION Minimum Trench Depth: a 4 Inches Maximum Trench Depth: 3 6 Inches Pump Required: OYes @No O May be Required Pagel of 3 CDP File Number 194257 - County 10 Number: 5789-834916 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimenslons, the location of the facility and appurtenances, the 0 site forthe proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land surveyor, drawn to a scale of one Inch equals no morethan 60 feet, that includes: the specific location of the proposed facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat also means, for subdivision tots approved by the local planning authority and recorded with the county register of deeds, a copy of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale). The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions, the rules, or this article. This permit Is subjectto revocation If the site plan, plat, or intended use changes (NCGS 130A -335(f)). The person owning or controlling the system shall be responsible forassuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting, and repair (A 938(b)j Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: "Issued By: 2140- Nations, Robert Date of Issue: 0 6 / 0 4 / 2 0 1 5 Authorized State Agent: OValid without Expiration? O Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 194257 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5789-83-4916 P.O. Box 848 County File Number: Mocksville NC 27028 Date: J / Q Inch Drawing Drawing Type: Improvement Permit Scale:. OBlock ()N/A = ft. VNIPVPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC 1Q' Davie County Environmental Health v— P.O. Box 848/210 Hospital Street Daae' Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For: ❑ Site valuation/Improvement Permit Authorization To Construct(ATC) ❑ Both Type of Application:'�Q'Iew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIREDnstructons. INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION r Name to be Bille W N V Contact Person Billing Address Home Phone City/State/ZIP " Business Phone Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION *Date House/FacilityComers Flagged ' ;W 15 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 6 months withs'plan o expiration with complete plat.) Owner's Name V ���t a Pho e Number uP� Owner's Address City/State/Zi f Property A ress ►'� t) City ' Lot Size � 7 Tax PIN `5' 919 1 Subdivision Name(ifa$plicable) Section/Lot# I T ��T' Directions To Site: M3ti 0 (t.t'tt !r t)ltt� %Y,6( If the answer to any of the following questions is `ryes", supporting documentation must be attached. ���, (21'. Are there any existing wastewater systems on the site? ❑Yeso fir Does the site contain jurisdictional wetlands? ❑ es o Are there any easements or right-of-ways on the site? es ❑No Is the site subject to approval by another public agency? ❑Yes' 0 Will wastewater other than domestic sewage be generated? ❑Yes $No IF RESIDE CE FILL OUT THE BOX VELOW # People �# Bedrooms W # BatJooms Garden Tub/Whirl ool ❑Yes ❑No Basement: ❑Yes VNo Basement Plumbing: ❑Yes VNo p 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: VfConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water YJ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes V<O If yes, what type? This is to certify that the information provided on this applicatibn'is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed 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 2nd rules. J understand that I am responsible for the proper identification and labeling of property lines and comers and i o ng an gin taking the house/facility location, proposed well location and the location of any other amenities. Pr a owner' wner's legal representative signature Site Revisit Charge n Date(s): !� Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 7 r'v Account # Invoice # ��1qsr ✓& APPLICATION FOR SITE EVALUATION/INIPROVBiEN PEli :;IT & AT Davie County Health Department V �� Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQIITRE3��" INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. t ,1 L,, 1. Name to be Billed �A���CkG1 1�� � �. ' �. Contact Person � ,`, Mailing Addressy . /. ,' u �7 I7 Home Phone City/State/ZIP AelimmtIE Business Phone 3 7 / 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 8 Site Evaluation ❑ Improvement Permit/ATC 1.1 Both 4. System to Service: /House ❑ Mobile Home ❑ Business U Industry H Other 5. If Residence: # People # Bedrooms —1 # Bathrooms 3 U Dishwasher LI Garbage Disposal LI Washing Machine ll Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water /Uu5aa (gallons per day) 7. Type of water supply: ❑ County/City ll Cl Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBA1ITTED by the client with THIS APPLICATION. Property Dimensions: L� ACL6 WRITE DIRECTIONS (from Mocksville) to 1'ItOPIs1i'1'l': Tax Office PIN: # �N't' - `d3- ZZ t`'�' o-7 Property Address: Road Name City/Zip A►�} /�►G4� Z�UQ� C) If in a Subdivision provide information, as follows: C) I dcl � .J Name: 1 c %7we D Section: Block: Lot: Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are 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. I, also, understand that I ant responsible for all charges incurred front this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the sitesuitbi its. ,/ DATE 12 ©? ' ©( SIGNATURE I�J•C[/�— 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). n A C E' d SAY - 8 2002 ENVIRONMENTAL HEALTH OAVIE COUNTY Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: --�Acount No. 73 Invoice No. FACTORS DAVIE COUNTY HEALTH DEPARTMENT 2 3 4 5 6 7 Environmental Health Section L Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002073 Tax PIN/EH #: 5789-83-2266.07 Billed To: Norman Building Subdivision Info: Peoples Ck. Farm Lot # 07 Reference Name: r C5 5 Location/Address: Peoples Creek Rd. -27 06 Proposed Facility: Residence Property Size: see map Date Evaluated: 0 �- Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit 11� Cut Texturegroup FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % 'Z HORIZON I DEPTH 0f Texture group CL SG L Consistence SSS V r C5 5 —C S Structure cla Mineralogy RI HORIZON II DEPTH - "l I - - 7-7- ZTexture Texturegroup Consistence Structure Mineralogy1 I HORIZON III DEPTH 1 - 30 ow -qv Texture group C • f Consistence r Structure $ K S> k $ Mineralogy HORIZON IV DEPTH 10 Texture grou - SCt_ Consistence S nlrr Os or Structure 2 Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE 12 d SITE CLASSIFICATION: 1 s EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �' OTHER(S) PRESENT: -?;o 1 c -w I REMARKS: ( � ad 1_,DT � LOT LI A 6 e 01-O&Z? 4� I� 174a 1 s 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 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 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 DCHD 05/99 (Revised) Lnr: luso �o� Jo "V t- X L) 33G- ydL-G►c� 9. 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Lorin Dingler Address: 4950 Dock Davis Road City: Clemmons State/Zip: NC 27012 Phone #: (336) 462-6707 / For Office Use Only *CDP File Number. 194257 PIN Number. 5789-83-4916 Tax Lot # Tax Block #: Evaluated For: WELL PERMIT VALID UNTIL: 6/4/2020 F ant: Lorin Dingler ss: 4950 Dock Davis Road yClemmons StatetZip: NC 27012 Phone #: (336) 462-6707 Property Location & Site Information Address/Road #: Subdivision: Hidden Meadow Phase: Lot: 7 Palomino Road *Proposed use of Well: Advance NC 27006 If Other Site Address: Palomino Road Directions Directions: Hwy 801 South Left on Peoples Creek Rd at Church, left on Dublin in Shamrock Acres, right on Irshman Place, end of road Well Contractor Information Drilling Contractor Driller Registration , , , , , I till J Permit Conditions *Permit Conditions Well location, construction and protection must meet all state and local regulations and must be Inspected and approved by an authorized representative of the Local Health Department. The permit may be revoked at any time for failure to comply with existing regulations. The siting of approved well construction area(s) by the Health Department Is to provide protection from the known possible sources of contamination. The approved well area(s) may not be changed without written permission from an authorized representative of the Local Health Department. No volume of quality of water Is guaranteed by the Health Department. *Issued By: 2140 - Nations, Robert *Date of Issue; 0 , 6 / 0 4 a 0 1 , 5 Authorized State agent: @Hand Drawing Qlmport Drawing Owner/ApplicantSignature:�_ �"�`- **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT e� Davie County Health Department 210 Hospital Street ~ P.O. Box 848 Mocksville NC 27028 a+M,. \� Drawing Type: Well Permit CDP File Number: 194251 County File Number. 5789.83-4916 Date: 06104 /.2015 Q Inch Scale: ON/A pN/A ft. E)--^ f) ..s f) I � i d T -I S 1 _ II 11� 1313;' - . f]ri f I _.. _ I _ ._g._Z --- � - --_.. .... .__. ...........�—gtg...... .......... E E .... --•—SOA—If_ tir t { ...._ . _ .. _.._.. --- .._._...._.....-................._.....n_ . __ _. .,..._. ........_._......._ .,.._ ..... ......... _. _.. .._ _ T—I E)--^ f) ..s f) WELLCONSTRUCTION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 194257 County File Number: 5789-834916 Date:06 /04 /.1015 V 4 Jam. Drawing Type: Well Permit AvD APPLICATION FOR PRIVATE WELL PERMIT pDavie County. Environmental Health date; P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name lib t�1 I f i N LG� Contact Person 12.1 N l 1 w -- Address !� S a? Home Phone Z 0-1 City/State/ZIP {1L� S ZZD Z Business Phone ZfoZi�a Name on Permit if Different than Above Mailing Address 'City/State/Zip PROPERTY INFORMATION NOTE: A survey plat ors plan mi Owner's Name V14 6tn l Owner's AddressGG Property Address Lot Size 57 .rjt� UW-,, Subdivision Name(if applicable)_j Directions To Site: *Date House/Facility Corners Flagged this application. Included: ®'Site Plan ❑Plat (to cale) PhonNumbe 2 City/State/Zip_ SCS , kV%, 27 01' 110 City Afr��tSC par," NPJ1_�[ bw &F --,kw1, 7e,►.J . Permit Type: New Well --I Well Repair Well Abandonment Other (specify) Facility Type: Residential V Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES N Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible: By signing this application, the applicant signifies that they understand the 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. Si ed Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account # 2 Invoice #