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179 Nellwood Court Lot 1• CONSTRUCTION AUTHORIZATION =Davie County Health Department 21,0 Hospital Street P.O. Box 848 Mocksville NC 27028 r For Office Use Oniv "CDR File Number 187841.1 County ID Number. N5-000-00-077-01 Evaluated For -NEW \ Township: PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 1/ 1 5% 2 0 2 0 Applicant: Joe Bailey Property Owner: Joe Bailey Address: PO Box 965 Address: PO Box 965 City: Mocksville City: Mocksville State0p: NC 27028 State0p: NC 27028 Phone #: (336) 97876559 Phone #: (336) 978-6559 inches Property Location & Site Information PUMP TO GRAVITY /Address/Road 9: 179 Neliwood Court Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC Subdivision: McAllister Park The Oaks Phase: Lot: 1 Directions Hwy 158 right on Sain Road, right into Macallister Park turn right on Nellwood Ct to cuidesac � /Site -classification: Minimum Trench Depth: .1 4 Inches Provisionally Suitable Saprolite System? OYes *No Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Solt Application Rate: 0 - a 7S Maximum Soil Cover:2 4 inches *System Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE Ili B. SYSTEM WISINGLE EFFLUENT PUMP $optic Tank: 1 0 0 0 _ Gallons *Proposed System: 25% REDUCTION 1 -Piece: OYes, ©No Pump Required: oYes ONo ()May Be Required Nitrification Field 1 7 4 5 SgJft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 5 1 -Piece: OYes QNo 1 Total Trench Length: 4 3 6 ft GPM vs— ft. TDH Trench Spacing: Inches O.C. g 9 Dosing Volume: _ Gallons Feet O.C. Trench Width:inches 3 Feet • Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: QNSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: OI On 0111 OIV 4 of Q APPLICATION FOR SITE EVALUATION/IMPROVENIENT PEI Davie County Health Department Environmental Heath Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 APR 7 3 ?005 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THEA MM -"' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruction . 1. Name to be Billed L'L •zRCA I�1 I0 r-1— Contact Person 3;1 t— Mailing Address S4— Home Phone - 6 L City/State/ZIP �� � ��''� ��', ,4-716: Business Phone �d 7 * 6 Y 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Fite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: L-H,,ousse ❑ Mobile Home El Business El Industry El Other S. Type system requested: 113' Conventional ❑ conventional modified ❑ innovative 6. If Residence: #People ? # Bedrooms/ ,� ,�_ #Bathrooms LKDishwasher ❑Garbage Disposal LBWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /other: verify type # People # Commodes # Showers # Urinals IF FOODSERVICE: #1 Seats S. Type of water supply: County/City # Sinks # Water Coolers 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 ❑-N-0 If yes, what type? ***IMPORTANT*** CLIENTS AfUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN A1UST BE SUBAf17"fED by the client with THIS APPLICATION. Property Dimensions: la'{fP Tax Office PIN: # Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: ?fit L Section: / Block: Lot: y WRITE DIRECTIONS (from Mocicsvillc) to PROPERTY: Date home corners flagged: L/- %Z,;I- OS This is to certify that the information provided is correct to the best of my knowledge. I understand that any perinit(s) 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 ani responsible for all charges incurred from 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 site suitability. DATE• 13 - D SIGNATURE TRIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and purposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s): Client Notification Date: EBS: Sign givcn_,L�)D Account No. ! y 9700 %0° d3'S Revised DCHD (05103 Invoice No. ` _ 7 APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size: Community Auger Boring Pit PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.01 Subdivision Info: Richard Short Lot # 01 Location/Address` Sain Road -27028 Date Evaluated: Iz�lt�-S Public f Cut I FACTORS 1 2 3 4 5 6 7 Landscape position [._ t_ Slope % Z HORIZON I DEPTH ©.- O Texture group Consistence Structure Mineralogy HORIZON II DEPTH q Texture group 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 .3 SITE CLASSIFICATION: ` LONG-TERM ACCEPTANCE RATE: 0.3 REMARKS: a '-b�v) Oj 'Zai V. Landscape Position EVALUATION BY:11�. OTHER(S) PRESENT: Por 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 .We NS - Non sticky NP - Non plastic FR - Friable FI Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S - Sticky VS - Very Sticky SP - Slightly plastic P - Plastic VP - Very plastic truct rc '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 nci in oslgO (R(wised) CDP Fite Number 18741 -1 County ID Number. N5-000-00-077-01 , Required:OYes ONo ONo, but.has Available S *Site Classification: Provisionally Suitable Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 4 Total Trench Length: .4 3 6 ft ❑ Open Pump System Sheet Trench Spacing: _ O 9 Inches 0. e Feet O.C. Trench Width: Inches 3 +� Feet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches '`Distribution Type: PUMP TO GRAvi1Y Pump Required: *Yes ONo 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 far checking with appropriate governing bodies in meeting their requirements. ,y This Authorization forWastewater System Construction shall bevalld fore person equal to the period of %alldity of the Improvement Permit, not to exdeed five years, and maybe Issued at the sam a time the Improvement Permit Issued (NCGS 1304-336(b)). If. the Installation. has not 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 orConsb=lion Authorization shall became Invalid, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responslbleforassuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: _ Date: *Issued By: 2140 -Nations, R rt Date of Issue:.. 1 6/ 2 0 1 5 Authorized State Agent: Malfunction Log OYes efiand 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: 187841 -1 County File Number: N5-000-02277-01 Date: 01/16/2015 Q Inch Scale: 013lock — .ft, QN/A vi 5 I_ UT 1 1 1( or it 4 �i� Ili _ill vi 5 SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street T��J ,�,,,V 2 7 2��0 Mocksville, NC 27028 l (336)751-8760/ Fax (336)751-8786 provement Permit ❑ Authorization To Construct(ATC) ❑ Both ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS.APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed COI &;%)cr3 4 T,1z . Contact Person Hl'dig e/ e- /Vo.,le flelS Billing Address PO 40k, Ay Home Phone 70,Y -,4;3 -OXO City/State/ZIP M C Business Phone .336.--3179 - S>�43 (Cc// Name on Permit/ATC if Different than Above. Address YKUYLKl Y 1Nt'UKMAIIUN City/State/Zip �llate House/racility comers NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan)(Plat(to scale) (Permit is;}alid for 60 months w.th site p n, no expiration with complete plat.) Name (1 1 i`� e G(�� S Pho e umber 5111)x - Owner's Owner's Address c? City/State/Zip J? Property Address <..,:,Q� City_ � � Lot Size Tax PIN# lE -% -�� C� s q Subdivision Name(if applicable) Section/Lot# Directions To Site: 16"W- -7—,2alu 2,;! tW 4- 4AI re; k Prlis f J KilYo 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 -P o` Does the site contain jurisdictional wetlands? ❑Yes B' 6 Are there any easements or right-of-ways on the site? ❑Yes Si1b Is the site subject to approval by another public agency? ❑Yes QNlo Will wastewater other than domestic sewage be generated? ❑Yes Ml' o IF RESIDENCE FILL OUT THE BOX B LOW. # People _ 9 # Bedrooms # Bathrooms Garden Tub/Whirlpool Etres ❑No Basement: ❑Yes ❑NoA)% 4 Basement Plumbing: Flo /j/ fA 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 Type system requested: UConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? BE \ • 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 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 and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or aking the ouse/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or er's legal representative signature Dt /I/ -v27,- y� Date a e(s). Client Notification Date: EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004186 Tax PIN/EH #: 57149-53-8619.01 Billed To: Cool Spring Builders, Inc. Subdivision Info: _Blaek forest Lot # 01 Reference Name: Michael Moorefield Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: see map Date Evaluated: v' i l' -s) -7 - Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1'330 01331 1332- 4 5 6 7 Landscape position Slope % HORIZON I DEPTH E} - - -2-2 Texturegroup_ G Consistence _ Structure Mineralogy A; . HORIZON II DEPTH 2 _ Texture group C_+ Consistence , Structure - S Mineralogy v2 HORIZON III DEPTH Texture group Consistence .� Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS .� RESTRICTIVE HORIZON - - SAPROLITE l i CLASSIFICATION LONG-TERM ACCEPTANCE RATEU= C� C5- Qz SITE CLASSIFICATION: PS EVALUATION BY:-'-a�� �" LONG-TERM ACCEPTANCE RATE: �� OTHER(S) PRESENT: REMARKS: 9' l% K1' 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3yet 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 rtes Horizon depth - In inches bepth 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) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well Auger Boring_ PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.01 Subdivision Info: Richard Short Lot # 01 Location/Address: Sain Road -27028 Property Size: 5 acres Date Evaluated: Community / Pit V L-Olr 2- Public Cut SITE CLASSIFICATION: Ps LONG-TERM ACCEPTANCE RATE: ' REMARKS: EVALUATION BY: 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 Mois 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) Landscape position m .3 1.HORIZON ..'��_-_-_--__-i I DEPTH Consistence Naay= vaIwo i►ON����� HORIZON II DEPTH ConsistenceMineralogy HORIZON III DEPTH RF410 TAP Consistence Mineralogy WON Texture group Consistence SOIL ESS • • ' SITE CLASSIFICATION: Ps LONG-TERM ACCEPTANCE RATE: ' REMARKS: EVALUATION BY: 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 Mois 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) APPLICANT INFORMATION Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation On -Site Well Community Auger Boring Pit -1 L; ' L4t PROPERTY INFORMATION 2 o 2 cam; Public ✓ Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % L420 14ORIZON I DEPTH Texture group Consistence ' S Structure A k Mineralogy HORIZON Il DEPTH 19 -Lllo -7 Z71 Texture group n 0L GL Consistence *7,- S SS Stnicture 53 SaviC Mineralogy HORIZON III DEPTH Texture group G Consistence + S Structure c Mineralogy HORIZON 1V DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION g . LONG-TERM ACCEPTANCE RATE (7 D SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: �t b c -At"_ 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 ois 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 DCI ID 05/99 (Revised) i DAVIE COUNTY IIEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: On -Site Well Auger Boring LbT 41 PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.01 Subdivision Info: Richard Short Lot # 01 Location/Address: Sain Road -27028 5 acres Date Evaluated: 111110:5 - Community 11110 Community / Pit V Public Cut FACTORS 090 Landscape position Slope % HORIZON I DEPTH Texture group Consistence WAM, Structure r���■-�������� Mineralogy 27M I 069M HORIZON Il DEPTH Texture group Consistence Mineralogy Texture group WnA Mineralogy HORIZON IVDEPTH WE Texture groupMineralogy Consistence Structure SOIL WETNESS�����■s-�� • -.4 WSJ SAPROLITE SITE CLASSIFICATION: 1°� LONG-TERM ACCEPTANCE RATE: 0 '5 REMARKS: EVALUATION BY: JOqC &:nOCAA1:1 N— OTHERS) 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 ois 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/112 DCI ID 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEhIENT PERK TC Davie County Health Department DEC 16 EnvironmentaiHeaith Section 2004 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVWONMEWA(HEALTH (336) 751-8760 DAVIECOUW ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for >iinnnss�tructi/aons. I. Hama to be Billed / /char:� ��� � Contact Person Mailing Address �� t� � �f'F � )'}- Home Phone -7-;L V- 6'j -7S City/State/ZIP LU1 n/.Siti"/r_,re k1 C ,42/D j Business Phone 4/6-7 mac% 2. Name on Permit/ATC if Different than Above Mailing Address City/State/zip 3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: 13 -House ❑ Mobile Home ❑ Business ❑ industry ❑ Other 5. Type system requested: L7 Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People # Bedrooms 3 "U/ # Bathrooms 151ishwasher ❑Garbage Disposal ' Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Othor: verify type #People # Sinks # Commodes # showers # Urinals 0 Water Coolers IF FOODSERVICE: #�Seats Estimated Water Usage (gallons per day) 8. Type of water supply: 13 eaCounty/City ❑ Well ❑ Community, 9. Do you anticipate additions or expansions of the facility this system is intended to serve? [I Yes G—N-o Ifycs, what type? ***IMPORTANT*** CLIENTS A1UST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELONV. Either a PLAT or SITE PLAN MUST BE SUBAIITTED by the client with THIS APPLICATION. Property Dimensions: - '10 A:LEe- 41-i. e — WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN: # 7 7qg- 4.3 - b?qV It, Property Address: Road Name 3 -2b 50'1TeP e c, is n1 Cityizip If in a Subdivision provide information, as follows: � Name: ACA41�,.PZ RT� Section: Block: Lot: 1 Date ]ionic corners flagged: V.)` `.` *.� T This Is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(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. I, also, understand that I ann responsiblefor all charges u:curred fronn this application. I, hereby, give consent to the Authorized Representative of the Davie County IIealth Department to cuter upon above described property located in Davie County and owned by . to conduct all testing procedures as necessary to determine the sites ' i ' DATE SIGNATUtT�QS`L5(,[_ TIIIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Revised DCIID (05103 Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. l s-q� o o zo 5 Invoice No. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health pA� 1 P.O. Boz 848/210 Hospital Street ✓` Mocksrille, NC 27028 Date� (336)753-6780/ Fax (336) 753-1680 i 11�un For: ❑ Site Evaluation/Improvement Permit Authorization To Conshuct(ATC) ❑ Both Type ot'Application: )(New System ❑Repair to Existing System ❑Expansion/Moditication of Existing System or Facility •• •IMPORTAN7"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed -B Contact Person J0 P— 6-11ey Billing Address _ _ Home Phone City/State/ZIP Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip *Date P PROPERTY INFORMATION House/Facility Cornets Fla ed NOTE: A survey plat or site plan must accompany this application Included:t7 Site Plan ❑Plat(to scale) (Permit is valid for 60 months wi site pl . o expiration with complet plat.) 236 9/18 6� Owner's Name Phone Number - Owner's Address AddressCity City/State/Zip a �Property 8 Lot Size T P # r• e -"*e a , Subdivision Name(if applicable) r Section/LoO ot, Directions To Site: ' 6 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? Does the site contain jurisdictional wetlands? ❑ Yes ywo Dyes Wo �6-600-b6-07 ..Q Are there any easements or tight -of -ways on the site? ❑Yes yNo Is the site subject to approval by another public agency? ❑ Yes)lo Will wastewater other titan domestic sewage be generated? ❑Yes Flo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes Mo Basement: ❑Yes KNo Basement Plumbing: ❑Yes ,M4o 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well Misting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes KNo 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 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 and rules. I understand that am responsible for the proper identification and labeling of property lines and comers and I0& and g ' house/facility location, posed well location and the location of any other amenities. i perty owner's or owner's 1 repretative tore Site Revisit Charge ner Date(s): yC Client Notification Date: Date EHS: Sign given ❑ Yes ❑No Account # Revised 11/06 Invoice # -- I Lot.. --•.,,.,_ ..,,� -20x2 1.1,5 I CO N pati t.".' 179 351 r Neliwood Drive Court way 60x61ft 1 .sem J-ot # 1 The Oaks of McAllister Park i ------------ 1' i Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004186 Tax PIN/EH #: 5749-53-8619.01 Billed To: Cool Spring Builders, Inc. Subdivision Info: The Oaks at McAllister Park Lot # 01 Address: PO Box 2040 Location/Address: Sain Road -27028 City: Advance . Property Size: see map Reference Name: Michael Moorefield Proposed Facility: • Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: Xew ❑Repair ❑Expansion Permit Valid for: 05 Years Expiration Residential Specifications: # Bedrooms �'i j # Bathrooms �-S # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 0&-L Type of Water Supply,.�a&unty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: I' K (4--Qo) a) Site Plan fj t-, . System Type LTAR Initial 0,1 L O • Z J Repair 19. ZiJ-- • L` N . a Z`8LZ In Environmental Health Specialist i.p.11-06 r OPERATION PERMIT Davie County Health Department -~a 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Joe Bailey Address: PO Box 965 City: Mocksville State2ip: NC 27028 Phone #: (336) 978-6559 *CDP File Number 187841-1 N5-000-00-077-01 County ID Number: Evaluated For. NEW � Township: /.'Property Owner: Joe Bailey Address: PO Box 965 City: Mocksville State/Zip: NC 27028 Phone #: (336) 978-6559 Property Location & Site Information Address/Road M Subdivision: McAllister Park The Oaks Phase: Lot: 1 179 Nellwood Court Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 right on Sain Road, right into Macallister # of Bedrooms: 3 Park tum right on Nellwood Ct to culdesac # of People: *Water Supply: PUBLIC *IP Issued by. 2140 -Nations, Robert *System Classification/Description: *CA issued by: 2140 - Nations, Robert Saprolite System? ( Yes (2) No Design Flow: Pump Required? 4 $ 0 *Distribution Type: PUMP TO GRAVITY Q Yes ONo Soil Application Rate: 0 - a 7 5 *Pre Treatment: Drain field Nitrification Field 1 7 4 5 Sq- ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 5 Installer: Jamie Bames Total Trench Length: 4 3 6 ft. Certification #: 1018 Trench Spacing: — 9 Inches O.C. Feet O.C. *EFiS: 2140 -Nations, Robert Trench Width: 3 Inches Qj)Feet Date: 0 5/ a 8/ a 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches Approval Status Maximum Trench Depth: 3 6 Inches ED Approved 0 Disapproved Maximum Soil Cover: 2 4 Inches CDP File Number 187841 - 1 Manufacturer. Shoaf STB: 760 Gallons: 1000 County ID Number: N5-000-00-077-01 5eptiC TanK Lat. Date: 0 4/,2 1/.2 0 1 5 *Filter B rand: POLYLOK PL -122 With Pipe Adapter ST Marker: ❑ Yes El No einforced Tank: ❑ Yes 2 No 11_1 Piece Tank: ❑ Yes r*1 NO Manufacturer, Shoaf PT: 60 Gallons: 1000 Long: Installer: Jamie Bames Certification #: 1018 THS: 2140 -Nations, Robert 0 Date: 0 5/ 2 8 / 2 0 1 5 Approval Status E Approved ❑ Disapproved Puma Tank Date: 03 / a,2 /,2 0 15 RiserSealed S Yes ❑ No RiserHeight: 0 Yes ❑ NO (Min -6 in.) Reinforced Tank: ❑Yes No 0 NO 1 Piece Tank: 0 YeS ❑ No Installer Jamie Bames Certification #: 1018 THS: 2140 - Nations, Robert Date: 0 5/,2 8/ 2 0 1 5 Approval Status FE Approved ❑ Disapproved Supply Line Pipe Size: ,2 inch diameter Installer: Jamie Bames Pipe Length: 1 8 6 feet Certification #: 1018 *Schedule: 40 THS: 2140 - Nations, Robert Pressure Rated 2 Yes ❑ No Date: 0 5/,2 8/,2 0 1 5 Approved fittings ® Yes ❑ NO ApprovalStatus Cl Approved ❑, Disapproved Pump Type: Zoeler Installer: Jamie Barnes Dosing Volume: - Gal Certification #: 1018 Draw Down: Inches *Chain: ROPE Valves Accessible I] Yes ❑ No Flow Adjustment Valve Q Yes ❑ No Check -valve C7 Yes ❑ No PVC Unions (9 Yes ❑ No Vent Hole Q Yes ❑ NO Anti -siphon Hole p Yes ❑ NO *EH S: 2140 -Nations, Robert Date: 0 5/ a 8/ a 0 1 5 Approval Status C3 Approved ❑ Disapproved CDP File Number 187841 -1 County ID Number: NS -000 -00 -u77 -o1 NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No 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 ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by. Authorized State Agent: Owner/Applicant Signature: Date of Issue: 0 5/ a 8/ a 0 1 5 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 sewage septic system. Rule .1961 requires that a Type septic system meet the following criteria: Minimum System Review ByThe Local Health Department: Management Entity: Minimum System InspectioniMaintenance Frequency By Certified Operator: Reporting Frequency By Certified Operator: Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life ofthe 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 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 shalt 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. G)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** CONSTRUCTION AUTHORIZATION w Davie County Health Department _ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Joe Bailey Address: PO Box 965 City: Mocksville State/Zip: NC Phone #: (336) 978-6559 11 Address/Road #: 179 Nellwood Court Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC % For Office Use Only *CDP File Number 187841 -1 County ID Number: N5-000-00-077-01 Evaluated For: NEW Township: PERMIT VALID UNTIL: 0 1/ 1 5/ a 0 a 0 Property Owner: Joe Bailey Address: PO Box 965 City: Mocksville 27028 State/Zip: NC Phone #: (336) 978-6559 27028 Subdivision: McAllister Park The Oaks Phase: Lot: 1 Directions Hwy 158 right on Sain Road, right into Macallister Park turn right on Nellwood Ct to culdesac ecifi Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches \Site Saprolite System? OYes (& No 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: PUMP To GRAVITY TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons *Proposed System: 25% REDUCTION 1 -Piece: O Yes ® No Pump Required: ® Yes O No O May Be Required Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 5 1 -Piece: OYes ®No Total Trench Length: 4 3 6 GPM --vs— ft. TDH ft, Trench Spacing:Olnches — g O.C. (9 Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -11 OTS -II Septic Tank Installer Grade Level Required: 01011 O III 01V / Page 1 of 3 CDP File Number 187841 - 1 County ID Number: N5-000-00-077-01 Ir System Kequired:%U T e5 V Imo V Ivo, Dui nas /HVallame J Kepalr System *Site Classification: Provisionally Suitable Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 4 Total Trench Length: 4 3 6 ft. r ❑ Open Pumo Svstem Sheet Trench Spacing: 90 Inches O. — ® Feet O.C. Trench Width: 3 Inches — Feet Aggregate Depth: inches Minimum Trench Depth: .1 4 Inches Minimum Soil Cover: 1 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *Distribution Type: PUMP TO GRAVITY Pump Required: ®Yes O No O May Be Required Pre -Treatment: O NSF OTS -I OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema m 9 750 *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. Characters Remaining 2000 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 may be issued at the same time 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 may be 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? O Yes ONO Applicant/Legal Reps. Signature? Date: *Issued By: 2140 - Nations, R ert Date of Issue: 0 -•1. / 1 6 / a 0 1 5 Authorized State Agent: Malfunction Log OYes ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 ...Page 3 of 3 __. P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P O Box 848 CDP File Number: 187841 - 1 ' Mocksville NC 27028 County File Number: N5-000-00-077-01 Date: AL / 16/. 0 15 Click below to import an image from an external location: Drawing Type: Construction Authorization Page Page 3 of P1 P2 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health pA� 1 P.O. Boz 848/210 Hospital Street ✓` Mocksrille, NC 27028 Date� (336)753-6780/ Fax (336) 753-1680 i 11�un For: ❑ Site Evaluation/Improvement Permit Authorization To Conshuct(ATC) ❑ Both Type ot'Application: )(New System ❑Repair to Existing System ❑Expansion/Moditication of Existing System or Facility •• •IMPORTAN7"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed -B Contact Person J0 P— 6-11ey Billing Address _ _ Home Phone City/State/ZIP Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip *Date P PROPERTY INFORMATION House/Facility Cornets Fla ed NOTE: A survey plat or site plan must accompany this application Included:t7 Site Plan ❑Plat(to scale) (Permit is valid for 60 months wi site pl . o expiration with complet plat.) 236 9/18 6� Owner's Name Phone Number - Owner's Address AddressCity City/State/Zip a �Property 8 Lot Size T P # r• e -"*e a , Subdivision Name(if applicable) r Section/LoO ot, Directions To Site: ' 6 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? Does the site contain jurisdictional wetlands? ❑ Yes ywo Dyes Wo �6-600-b6-07 ..Q Are there any easements or tight -of -ways on the site? ❑Yes yNo Is the site subject to approval by another public agency? ❑ Yes)lo Will wastewater other titan domestic sewage be generated? ❑Yes Flo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes Mo Basement: ❑Yes KNo Basement Plumbing: ❑Yes ,M4o 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑ New Well Misting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes KNo 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 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 and rules. I understand that am responsible for the proper identification and labeling of property lines and comers and I0& and g ' house/facility location, posed well location and the location of any other amenities. i perty owner's or owner's 1 repretative tore Site Revisit Charge ner Date(s): yC Client Notification Date: Date EHS: Sign given ❑ Yes ❑No Account # Revised 11/06 Invoice # -- I Lot.. --•.,,.,_ ..,,� -20x2 1.1,5 I CO N pati t.".' 179 351 r Neliwood Drive Court way 60x61ft 1 .sem J-ot # 1 The Oaks of McAllister Park i ------------ 1' i Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004186 Tax PIN/EH #: 5749-53-8619.01 Billed To: Cool Spring Builders, Inc. Subdivision Info: The Oaks at McAllister Park Lot # 01 Address: PO Box 2040 Location/Address: Sain Road -27028 City: Advance . Property Size: see map Reference Name: Michael Moorefield Proposed Facility: • Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: Xew ❑Repair ❑Expansion Permit Valid for: 05 Years Expiration Residential Specifications: # Bedrooms �'i j # Bathrooms �-S # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 0&-L Type of Water Supply,.�a&unty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: I' K (4--Qo) a) Site Plan fj t-, . System Type LTAR Initial 0,1 L O • Z J Repair 19. ZiJ-- • L` N . a Z`8LZ In Environmental Health Specialist i.p.11-06