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174 Equestrian Lane Lot 2t ` OPERATION PERMIT 1 • Davie County Health Department 210 Hospital Street Address: P.O. Box 848 City: Mocksville, NC 27028 State/Zip: Phone: 336-753-6780 Fax: 336-753-1680 r SINGLE FAMILY Applicant: Kristina Prysiaziuk Address: 174 Equestrian Way City: Mocksville State/Zip: NC/ 27028 Phone_#: (336) 940-2899 Address/Road #: 174 Equestrian Way Mocksville, NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 5 # of People: 4 *Water Supply: N/A *IP Issued by: 2244 - Daywalt, Andrew *CA Issued by: 2244 - Daywalt, Andrew Design Flow: 600 Soil Application Rate: 0.200 For Office Use Only *CDP File Number 122548-1 County ID Number: C4 -160 -AO -002 Evaluated For: EXPANSION ' Sq. ft. Property Owner: Kristina Prysiaziuk Address: 174 Equestrian Way City: Mocksville State/Zip: NC/ 27028 hone #: (336) 940-2899 Subdivision: Whip -O -Will Phase: NEW Lot: 2 Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: 148 ft. Inches O.C. Trench Spacing: _ lFeet Feet O.C. Inches Trench Width: - Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches Directions Hwy 601 N, to Cana Road turn right got to Whip -o -Will on left turn left into Development, Turn left on Equestrian, house at end *System Classification/Description: TYPE II B. CONY. SYSTEM WITH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS *Distribution Type: GRAVITY - PARALLEL (eq. d -box) *Pre -Treatment: N/A *System Type: INFILTRATOR QUICK 4 STANDARD Installer: randy miller Certification #: Page 1 of 3 *EHS: 2244 - Daywalt, Andrew Approval Status ® Approved ❑ Disapproved "CDP File Number 122548-1 Manufacturer: shoaf STB: Gallons: 1250 Date: 05/24/2013 "Filter Brand: N/A ST Marker: ❑ Yes ® No Reinforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ® No County File Number: C4 -160 -AO -002 Lat: Long: Installer: Certification #: •EHS: 2244 - Daywalt, Andrew Approval Status ® Approved ❑ Disapproved Pump Tank Manufacturer: Installer: PT: Certification #: Gallons: 'EHS: 9999 - Bonnie Lanier Date: Riser Sealed: ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min. 6 in.) Approval Status Reinforced Tank: 11 Yes ❑ No 1 Piece Tank: 11 Yes ❑ No E[OlApproved [I Disapproved Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Approval Status Approved fittings ❑ Yes ❑ No E[OlApproved ❑ Disapproved Pump Requirement Pump Type: Installer: Dosing Volume: Gal Certification #: Draw Down: Inches 'EHS: *Chain: N/A Valves Accessible: ❑ Yes ❑ No Flow Adjustment Valve: ❑ Yes ❑ No Approval Status Check -valve: ❑ Yes ❑ No PVC Unions: ❑ Yes ❑ No EOApproved El Disapproved Vent Hole: ❑ Yes ❑ No Anti -siphon Hole: ❑ Yes ❑ No Page 2 of 3 *CDP File Number 122548-1 tlectric tquipment NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ No *EHS: Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ No *Activation Method: Alarm Audible ❑ Yes ❑ No AlarmVisible ❑ Yes ❑ No *Operation Permit completed by: 2244 - Daywalt, Andrew Authorized State Agent: County File Number: C4 -160 -AO -002 Approval Status ❑ Approved ❑ Disapproved Date of Issue: 09/16/2013 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 II B. sewage septic system. Rule .1961 requires that a Type TYPE II B. 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 Total Time:(HH:MM) Page 3 of 3 S OPERATION PERMIT Davie County Health Department r -._ 210 Hospital Street \� *,; i \• P.O. Box 848 - trr Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Kristina Prysiaziuk Address: 174 Equestrian Way City: Mocksville State/Zip: NC 27028 Phone;r: (336) 940-2899 'CDP File Number 122548-1 C4.160•A0-002 County ID Plumber. Evaluated For: EXPANSION t To;rnship: / Property owner: Kristina Prysiaziuk Address: 174 Equestrian Way City.. Mocksville State.2ip: NC 27028 Phone::: (336) 940-2899 Property Location & Site Information Address/Road »: Subdivision: Whip -O -Will Phase: Lot: 2 174 Equestrian Way Mocksville NC 27028 Structure. SINGLE FAMILY r: of Bedrooms: 'y 151vir y C -A ZOA- of People: 4 'Water Supply: N.'A 'IP Issued by. 2244-Daywall. Andrew 'CA issued by: 22.4.4 - Daywalt. Andrew Design Flow: 6 0 0 Soil Application Rate: 0 2 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 601 N, to Cana Road turn right got to Whip -o -Will on left turn left into Development, Turn left on Equestrian, house at end 'System Classification/Description., TYPE 11 B. CONY. SYSTEM MTH 750 LINEAR FEET OF NITRIFICATION LINE OR LESS Saprolite System? OYes CINo 'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required? OYes Otto 'Pre -Treatment: Drain field Sq. ft. 1 4 8 n Oinches O.C. ()Feet O.C. Inches Feet inches Minimum Trench Depth: Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer randy muter Certification n: 'EH S: 2244 - Daywalt. Andrew Date: 0 9/ 1 6/ 2 0 1 3 Minimum Soil Cover. Inches Approval Status f:taximum Trench Depth: Inches ElApproved ElDisapproved Maximum Soil Cover: Inches CDP File Plumber 122,548 - 1 taanufacturer. shoaf STB: Gallons: Gallons: 1250 - Date: Date: 0 5/ 2 4/ 2 0 1 3 *Filter Brand: No Riser Height: ❑ Yes ❑ ST Marker: ❑ Yes ❑ No enforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Manufacturer. County ID Number: 01-1160-A0.002 Lat. Long.- Installer: ong: Installer: Certification 'EH S: 2244 - Dayr.va't. Andres Date: 0 9/ 1 6/ 2 0 1 3 Approval Status Q. Approved O Disapproved Pump Tank PT: Gallons: 1/ Dosing Volume: - Date: Gal Certification : Draw Down: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Fain. 6 in.) ,Reinforced Tank: ❑ Yes ❑ No 1 Piece Tank: ❑ Yes ❑ No Pipe Size: inch diameter Pipe Length: feet 'Schedule: Pressure Rated ❑ Yes ❑ No ,pproved fittings ❑ Yes ❑ No Installer- Certification nstaller Certification : *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply Line Installer: Certification *EHS: Date: Approval Status ❑ Approved ❑ Disapproved / Pump Type: Installer: 1/ Dosing Volume: - Gal Certification : Draw Down: Inches *EHS: *Chain. Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No • CDP File Number 122548 -1 NEIJA4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Sox Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes 'Activation Method: Alarm Audible Alarm Visible County ID Number: C4 -160-A0-002 Electric Equipment ❑ No Installer: ❑ No Certification;:: ❑ No ❑ No 'EMS: ❑ No Date: ❑ Yes ❑ No ❑ Yes ❑ No 224.1- D,yvial;. Andrew *Operation Permit completed by Authorized State Agent: Approval Status ❑ Approved ❑ Disapproved _J Date of Issue: 0 9/ 1 6/ 2 0 1 3 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 II S. sewage septic system. Rule .1961 requires that a Type TYPE II B,_,_i_ septic system meet the following criteria: f•linimurn Systern Review ByThe Local Health Department: NIA Management Entity: OWNER frlinimum System Inspection 11aintenance Frequency By Certified Operator: NA Reporting Frequency By Certified Operator: N!A Rule .1961 requires that a Type IV and V septic systems designed fora homerbusiness 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 prwate 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. GHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Activity Code: S-19 2Q.1 -OP issued NEW Type 11 Quick 4 Total Time.(H 14.t 11 M ) 0 1 Hours 0 0 ninuies OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 hlocksville NC 27028 Di"awing Drawing Type: Operation Permit CDP File Number: 122548 - 1 County File Number: c4-160-AO.002 Date: / Olnch Scale: OBlock ON/n • CONSTRUCTION Minimum Trench Depth: �\ Inches For office Use On►y AUTHORIZATION 'CDP File Number 122548.1 Iainimum Soil Cover. Davie County Health Department County ID P•Jumber:C4.1co.Ao-002 XI ., 1'.� i'r ` 210 Hospital Street Maximum Trench Depth: 3 6 Inches Evaluated For: EXPANSION P.O. Box 848 'System ClassificatioNDescription: Township: 'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Mocksville NC 27028 PERMIT VALID UNTIL: Septic Tank: 1 0 0 0 Phone: 336-753-6780 Fax: 336-753-1680 0 8/ 1 2 2 0 1 8 Applicant: Kristina Prysiaziuk Property owner: Kristina Prysiaziuk Address: 174 Equestrian Way Address: 174 Equestrian Way City: Mocksville City. Mocksville StatelZip: NC 27028 State/Zip: NC 27028 Phone :=: (336) 940-2899 Phone »: (336) 940-2899 Address/Road r:: Subdrvision: Whip -O -Will Phase: Lot: 2 174 Equestrian Way Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 N, to Cana Road turn right got to Whip -o- ill on left turn left into Development, Turn left on Equestrian, of Bedrooms: 5 ��. �lv-�n( �2 house at end of People: 4 'Water Supply: N'A System Specifications nage 1 of :S Minimum Trench Depth: �\ Inches "Site Classification: PS Iainimum Soil Cover. Saprolite System? OONo Inches Design Flow: 6 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 2 Maximum Soil Cover: Inches 'System ClassificatioNDescription: 'Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE III A. CONY SYSTEM > 480 GPD (EXCLUDING SFD) Septic Tank: 1 0 0 0 Gallons `Proposed System: 251'. REDUCTION 1 -Piece: OYes O N o Pump Required. OYes ONo Oh1ay Be Required Nitrification Field Sq. ft, Pump Tank: Gallons No. Drain Lines 1 -Piece: OYes ONo Total Trench Length: 1 5 0 GPI.1—vs-- ft. TDH ft. Trench Spacing: — 9 8Inches O.C. Feet Q.C. Dosing Volume: _ Gallons g Trench Width: C)Inches _ OFeet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI OII 0111 OIV nage 1 of :S CDP File IJumber 122548 - 1. Rer)air Svstem /KepaIr 5ystetl *Site Classification: Design Flom: Soil Application Rate: *System ClassificationIDescription: *Proposed System: Nitrification Field No. Drain Lines County ID Plumber: C: -160 -AO -002. 0 Open Pump System Sheet uired:(--)YeS ONO ONO, but has Available Space Total Trench Length: ft. Trench Spacing: 0 Inches O. –0 Feet O.C. Trench Width: 0 inches — O Feet Aggregate Depth: inches Mininwm Trench Depth: Inches i.!inimum Soil Cover. Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches Sq. ft. *Distribution Type: Pump Required: OYes ONo Of,tay 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 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 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? Oyes ONO Applicant"Legal Reps. Signature' __ — Date: - / *Issued By: 2244 - Daywal:. Andrev. Date of Issue: 0 8 % 1 2 / 2 0 1 3 Authorized State Agent: ��� � Malfunction Log OYes u+ndnta urdwrlry VllllPVlt urd+nrnty TotatTime:(HH.M1.1) **Site Plan/Drawing attached.** 0 1 Hours 0 0 MinutesPage2of3 S-9 - CNS issued - expansion CONSTRUCTION AUTHORIZATION Davie County Health Department ' 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Di -awing Drawing Type: Construction Authorization CDP File Number: 122548 - 1 County File Number: c4•tso-A0.002 Date: 08/12/2013 Oinch Scale: . QBlock = ft. ONrA Panp 3 of 3 Davie County Health Department 4�) 1836 Ifi Environmental Health Section CEVA56 P.O. Box 848210 Hospital StreetI»Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 678 Fax: (336) - 751- 8786 -�'Op tvol)-SITE WASTEWATER CERTIFICATION FOR DWELLING 01pfr (Check One) Replacement Remodeling Reconnection �►55 Name: �� S ( a 33b J�) ZSPhone Number (Home) Mailing Andress: fr,— 7GG G ' 12 L (Work) 5"" • 1< tv • L - -L u -0 Email k f', sf r P f ✓1 lam`; 1 e- - V 0 V%^ Detailed Directions To Site: L u 1 f o e w We' R -tv r ^1 ri • ti 1ti �'('' 'L✓�+ �� b +^' /LT Vrtuft I&J'I W - v''w) /1. 1 Y,+� 1141 0>✓ G ve.olrlc-y I-Ov5c' -"„J e,.•� Property Address: �%� Li (.�eS- jaQ W qr, d r- •L - —I -7 y z8 &I jo D h©- Od 7— Please Please Fill In The Following Information About The EXISTING Facility: / �Z.7G%�VJ Name System Installed Under: �%�"/Vtr gril-:�Iije, -PfosLQ,ZAI WC Type Of Facility: l� Date System Installed (Month/Date/Year): 5-1q17000 Number Of Bedrooms:_�Number Of People:_ Is The Facility Currently Vacant? Ye No If Yes, For How Long? Any.Known Problems? Yes l No 1 If Yes, Explain: Please Fill In The Following Informati n About The NEW Facility: Type Of Facility:' i N e( -0 0 /'1I'1 Number Of Bedrooms:_/ Number of People_ . -Requested By: �'� ' Date Requested: J� (Signa e) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Paym t: Cash Check Money Order # Amount:$_ r-^ Paid � /<� Q0 Received By:_ Account #: o&� "�% Invoice #: Date: DAVIE COUNTY HEALTH DEPARTMENT ,.Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000696 Tax PIN/EH #: 5832-07-4847 Billed To: Sam.$ Kristina Prysiazniuk Subdivision Info: Whip -O -Will Lot # 2 Reference Name: Sam or Kristina Prysiazniuk Location/Address: Equestrian -27028 Proposed Facility: Residence Property Size: 6.274 Acres ATC Number: 2127 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G. S. Chapter 130A, Wastewater Sysiems, Section .1900 Sewa Treatment and Disposal Systems).. THIS AUTHORIZATION FOR WASTEWA ONS UCTI IS VALID FOR A PERIODa IVE YEARS. Environmental Health Specialist's Signature Date: �3 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit ',has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any I iven period of time. 0. V E Septic System Install Environmental Health Specialist's DCHD 05/99 (Revised) -TO e. -A.) I (:0-0 ,5T• lac LAD .,j Ir. oi. w 3:)) A ,v ,0, MI -OL -1 %01 W1 E��� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000696 Tax PIN/EH #: 5832-07-4847 Billed To: Sam & Kristina Prysiazniuk Subdivision Info: Whip -O -Will Lot # 2 Reference Name: Sam or Kristina Prysiazniuk Location/Address: Equestrian -27028 Proposed Facility: Residence Property Size: 6.274 Acres ATC Number: 2127 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewagp Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATY29ONST,4UCTIgf4 IS VALID FOR A PERIOD (PF FIVE YEARS. Environmental Health Specialist's CERTIFICATE OF COMPLETION Date: **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Install Y. Environmental Health Specialist's Signatu DCHD 05/99 (Revised) NEW DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000696 Billed To: Sam & Kristina Prysiazniuk Reference Name: Sam or Kristina Prysiazniuk Proposed Facility: Residence Tax PIN/EH #: 5832-07-4847 Subdivision Info: Whip -O -Will Lot # 2 Location/Address: Equestrian -27028 Property Size: 6.274 Acres OiW Vb r. 2127 **N'I✓*'Phis improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type Fk)tsE #People 3 #Bedrooms `'t #Baths . S - Dishwasher: El' Garbage Disposal: 0'- Washing Machine: Basement w/Plumbing: E Basement/No Plumbing: EI Commercial Specification: Facility Type #People #People/Shift #Se173� �' Wats Industrial Waste: Lot Size (D -210 ���� Type Water Supply ( Design Wastewater Flow (GPD) Site: New Repair System Specifications: Tank Size ICOO GAL. Pump Tank GAL. Trench Width 'Ra" Rock Depth e Linear Ft. SOO t Other: 17 XIS , �STAi� t`uJ+�S D•C.t,J. Required Site Modifications/Conditions: `tJSTDLt_ p,) CII QW 1�E2�" GOE[te!w^)L P.-) �e41�5 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 2,30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** `p� am -1 T TO N �N = Environmental Health DCHD 05/99 (Revised) Date: > OCA DAVIE COUNTY HEALTH DEPARTMENT M Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000696 Billed To: Sam & Kristina Prysiazniuk Reference Name: Sam or Kristina Prysiazniuk Proposed Facility: Residence Tax PIN/EH M 5832-07-4847 Subdivision Info: Whip -O -Will Lot # 2 Location/Address: Equestrian -27028 Property Size: 6.274 Acres ATC Number: 2127 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and' Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People_ #Bedrooms 4 #Baths �• Dishwasher: Garbage Disposal: 2r Washing Machine: Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size &ZL4A4Type Water Supply 6e�w Design Wastewater Flow (GPD) Site: New Repair ❑ r ''_ j'. System Specifications: Tank SizekO00GAL. Pump Tank GAL.' Trench Widt Rock Depth Linear Ft Other: 41 Ps-i2j6d"e ✓ 7-tNes AVNW00r5 C.T4n1Y- 4S Ro2 1WIM O Required Site Modifications/Conditions: A&01 dn11,117VI/9 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 "BELOW FINISHED GRADE. * * OTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a. :30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Sg Environmental Healt pe DCHD 05/99 (Revised) -Vg- i loves 1'°< % Date: ••, ; �� ` PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATV �I Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street2 6 1999 Mockaville, NC 27028 (336) 751-8760 kKNTAI HFALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Elam PLj---)Ja-zn;bK Contact Parson '= 1- cy- K� SiC1 n2 Mailing Address IQ 5 Stat bur � Y _ item phone - 33 LD --1 07 - o 9 O �pL( City/state/LSP CA-Lmfncns,. a, Business Phone a33 7 2. Name on Permit/DTC it Different than Above Mailing Address City/stag/sip 3. Zpplicaticn For. Site EvalY moon u Improvement Permit/ATC 0 Bo- h 4. system to service: V House ❑ Mobile Home 0 Business 0 Industry ❑ Other 5. If Residence: s People 3 i Bedrooms .4 • Bathrooms 3,12— 0 Dishwasher 0( Garbage Disposal i1 washing Machine Basement/Plumbing O Basement/No Plumbing 6. if Business/Industry/Other: specify type • People # sinks f Commodes # showers / Urinals t water Coolers IF FOODSERVICE: # Seats Estimated Rater Usage (gallons per day) 7. Type of water supply: J1 County/City ❑ Well 0 Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? 14 Yes 0 No If yes, what type? 'Rn; -5h baSuyy- l -t u -;*h f'Lh I***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED I BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: (D • 7� ��� �_.S Tax Office PIN: # 5 Property Address: Road Name E2 0 e- City/Zip ls'loe.}t---)d I �Le-- If in a Subdivision provide information, as follows: Name: Whip. 0 - W Section: Block: Lot: 2 - WRITE DIRECTIONS (from Mocksville) to PROPERTY: L+ 2 - Date Property Flagged: 7—.2 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed I, also, understand that I ane 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 S Iw'i;na PryS�azniUk to conduct all testing procedures as necessary to determine the site sultability. DATE 9-25-99 SIGNATURE n - THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): I Client Notifiestion Date: EAS: Revised DCHD (07/99) Account No. Invoice No. Jr% CnMy shat on FildClc: t4 I Co I `�� `J we surveyed the property shown on this plat; all of which was done under my supervision. s'p i9 6y United Umlted Engineering 6 Land Surveying, P.AI r LEGEND Er 'CaVV40 VFlom " — . rYYYf*-TT L40P AAF.Nr NOTER: \ . Tris WP CA tilkWM A►D ANY ACOOurANn10 OOa AEN I AA[ KV04011D TO M FV%II NM MAU D TIWON MD NO ALTDMPCeta CA US& QY r 4r40N PL CIED arHO e 4 PVXXTT[D L►11.ai1 Al rT/ CAM BY L4H 4AAON171C NORTH L -M L WW Q10� AND LAND MKON4Y A3, DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990000696 Billed To: Sam & Kristina Prysiazniuk Reference Name:,: Sam or Kristina Prysiazniuk ,1b,: Proposed FaciroResidence Property Size PROPERTY INFORMATION Tax PIN/EH #: 5832-07-4847 Subdivision Info: Whip -O -Will Lot # 2 Location/Address: Equestrian -27028 6.274 Acres Date Evaluated: Water Supply: On -Site Well Community, Evaluation By: Auger Boring Pit Public J Cut FACTORS 1 2 3 4 5 6 7 Landscape position L_ Slope % O 1 HORIZON I DEPTH L7 - t0 - (o C7`- n ` Texture group C_ Consistence 1'-r S S Structure C Mineralogy ('- > HORIZON II DEPTH (p - ' i 119 Texture grou C_ G Consistence F ' ` Structure 4 Mineralogy M,1 HORIZON III DEPTH 24 - Texture group SIR 11-:1<410 Consistence Structure Svc Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE Z SITE CLASSIFICATION: P's LONG-TERM ACCEPTANCE RATE: ► /i REMARKS: LEGEND Landscape Position J EVALUATION BY: OTHER(S) PRESENT: 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) ■■ ■■ ■■ No ME ME No ME ME ■■ i ■■N■ ■M■■ OMEN ■■ MEMO NONE so ■■ M■MM■■■ ■■■■MM■ ■■M■■M■ ■■■■■■■ ■■NOME■ ■■ME■■■ ■ ■ ■ MEMO■■■■E■■■■■■■■■ ■■■■■■■■■■■■■■E■■■ ■■■■■■■■■■■■■■■■■■ ■■E■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■M■ ■■■■■■■■■■N■U■■■■ ■■■■RI■■■■■■ ■■■■ ■ ■■■■M MEMOS ■M■■■ ■■■■■ MEN WHOM ■■■■■■ MEN ON ■■R■■■■E■M■■■M■■ on ■■■■■■■■■■■■■■■■■■■■ ■■■■i'■■■■■■■■■■■ no ■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■N■■■■■■■■■NOON ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ NOON■■■®■■■■■■■■■■■■■■■■■■ NOON■■■®■■■■■■■■■■■■■■■■■■ NOON■■■®■■■■■■■■■■■■■■■■■■ NOON■■■p■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■■■D■■■■■■■■■■■■■■■■■■ NOON■■■D■■■■■■■■■■■■■■■■■■ • , r���; LOT #29 v 5.006 , o sir LOT In #30 ca �� AC RES y—s . yNw AREA 5.044 ACRES o I �-► oa o t X `A� _ 85.00 \ 2 0(,-33,030 E 52 , 3q• `i 19.17 232. 0 W �N 5452.51 . g4' "560 E '� ✓w S 76.56 V N 325 081 N 69447.14 t \�\ s 22.28'51• E / 4p • S 06.33' 03' E 228.95 . i