Loading...
370 Rabitt Farm Trail Lot 4Applicant: Breanna and Gregory Beaty Address: 370 Rabbit Farm Trail City: Advance State2ip: NC 27006 Phone #: Address/Road #: 370 Rabbit Farm Trail Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 'Water Supply: EXISTING WELL 'IP Issued by. 'CA issued by: 2140 - Nations, Robert `CDP File Number 139269-1 County ID Number: Evaluated For: REPAIR I\ Township: / Property Owner: Breanna and Gregory Beaty Address: 370 Rabbit Farm Trail City: Advance State2ip: NC 27006 Phone #: ierty Location & Site Information Subdivision: Rabbit Farm Phase: Lot: 4 Design Flow: 4 8 0 Soil Application Rate: 0 - 2 7 5 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 64 East left on Cornatzer Rd, 5 Miles or more, Rabbit Farm on Right "System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SaproliteSystem? QYes ©No 'Distribution Type: GRAVITY- SERIAL Pump Required? QYes &No 'Pre Treatment: Drain field 9 0 0 Sq. fl - .1 0 0 ft. ..100ft. OInches O.C. Feet O.C. Inches Feet inches Minimum Trench Depth: Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: McDaniel grading Certification #: 'EH S: 2140 - Nations, Robert Date: 0 7/ 1 5/ 2 0 1 4 Minimum Soil Cover. Inches Approval Status Maximum Trench Depth: Inches 0 Approved El Disapproved Maximum Soil Cover: Inches OPERATION PERMIT f r� Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Breanna and Gregory Beaty Address: 370 Rabbit Farm Trail City: Advance State2ip: NC 27006 Phone #: Address/Road #: 370 Rabbit Farm Trail Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 'Water Supply: EXISTING WELL 'IP Issued by. 'CA issued by: 2140 - Nations, Robert `CDP File Number 139269-1 County ID Number: Evaluated For: REPAIR I\ Township: / Property Owner: Breanna and Gregory Beaty Address: 370 Rabbit Farm Trail City: Advance State2ip: NC 27006 Phone #: ierty Location & Site Information Subdivision: Rabbit Farm Phase: Lot: 4 Design Flow: 4 8 0 Soil Application Rate: 0 - 2 7 5 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 64 East left on Cornatzer Rd, 5 Miles or more, Rabbit Farm on Right "System Classification/Description: TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SaproliteSystem? QYes ©No 'Distribution Type: GRAVITY- SERIAL Pump Required? QYes &No 'Pre Treatment: Drain field 9 0 0 Sq. fl - .1 0 0 ft. ..100ft. OInches O.C. Feet O.C. Inches Feet inches Minimum Trench Depth: Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: McDaniel grading Certification #: 'EH S: 2140 - Nations, Robert Date: 0 7/ 1 5/ 2 0 1 4 Minimum Soil Cover. Inches Approval Status Maximum Trench Depth: Inches 0 Approved El Disapproved Maximum Soil Cover: Inches CDP File Number 139269-1 Manufacturer. STB: Gallons: Septic Tank County ID Number:- Lat. Long: Installer: Date: / ❑ / Certification #: NO ❑ No *EHS: *Filter Brand: ST Marker: ❑ Yes ❑ NO Date: nforced Tank: ❑ Yes ❑ NO Approval Status ❑ Approved ❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No Pump Tank Manufacturer. PT: Gallons: Date: / Riser Sealed ❑ Yes RiserHeght: ❑ Yes einforced Tank: ❑ Yes 1 Piece Tank: ❑ Yes r5 ❑ No ❑ NO (Min.6 in.) ❑ NO ❑ No Su If Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ NO Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved pply Line Installer: Certification #: *EHS: Date: / / Approval Status ❑ Approved ❑ Disapproved / Pump Type: Installer: / 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 139269 - 1 GICI:UII; GUUIUIrICUL County ID Number: NEMA4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification #: Box Adj. To Pump Tank ❑ Yes ❑ N o Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Status Alarm Audible El Yes ElNo El Approved 13 Disapproved Alarm Visible El Yes ElNO 2140 - Nations, Robert *Operation Permit completed by; Authorized State Agent: Date of Issue: 0 1 5 x 0 1 4 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 A. sewage septic system. Rule .1961 requires that a Type TYPE II A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator: NIA 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 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 entitywith a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system ownerand a management entity priorto the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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. ©Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 139269 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O. Box 848 County File Number: CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 0 Phone: 336-753-6780 Fax: 336-753-1680 0 6/ a 3/ 2 0 1 9 Applicant: Lake Norman Construction Address: City: State/Zip: NC Phone #: Address/Road #: 370 Rabbit Farm Trail Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: EXISTING WELL Property Owner: Brennan and Gregory beaty Address: 370 Rabbit Farm Trail City: Advance State/Zip: NC 27006 Phone #: Subdivision: Rabbit Farm M Phase: Lot: 4 Directions Hwy 64 East left on Cornatzer Rd, 5 Miles or more, Rabbit Farm on Right Page 1 of 3 Minimum Trench Depth: Inches \Site Classification: Provisionally suitable SaproliteSystem? OYes XNo Minimum Soil Cover: Inches Design Flow: 4 8 0 Maximum Trench Depth: Inches Soil Application Rate: 0 3 Maximum Soil Cover: Inches *System Classification/Description: *Distribution Type: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25°16 REDUCTION 1 -Piece: OYes O No Pump Required: O Yes (& No O May Be Required Nitrification Field 6 0 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 -Piece: OYes ONo Total Trench Length: 0 0 GPM --vs-- ft. TDH cC ft Trench Spacing:Olnches _ 9 O.C. (9 Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 0Inches _ ® Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 OII 0111 01V / Page 1 of 3 CDP File Number 139269 - 1 /'Repair Systen *Site Classification: Design Flow: Soil Application Rate: *System Classification/Description: *Proposed System: County ID Number: red:OYes ONO ONO. but has Available Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: ft. ❑ Open Pump System Sheet Trench Spacing: O Inches O. O Feet O.C. Trench Width:— Inches 8Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover: Inches Maximum Trench Depth: Inches Maximum Soil Cover: Inches *Distribution Type: Pump Required: OYes O No O May Be Required Pre -Treatment: O NSF OTS -1 OTS -11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R -mm 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. R m 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 130A336(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(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, Robert Date of Issue: 0 6 a 3 / a 0 1 4 Authorized State Agent: c� e,� Malfunction Log OYes Hand Drawing O Import 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 10 0 CDP File Number: 139269 - 1 County File Number: Date: 06/a3/a014 O Inch Scale: O Block O N/A 0 s� Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 139269 - 1 County File Number: Date: .0.6./ .2 3/ 2 0 14 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville NC 27028 (336)751-8760 �r&IvNAN � gr oiq ill ��0 ,�+A A��� T Account #: 990001911 Billed To: Lake Norman Constr. Reference Name: vroposea t-acmty: Kesiaence ATC Number: 2968 Tax PIN/EH #: 5870-41-6986.Lnc Subdivision Info: Rabbit Farm Sec 2 Lot # 4 Location/Address: Rabbit Farm Trail -27006 rrupeRy -,IZL: see 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 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE CONS N IS V ID FOR A PERIOD OF FIVE ARS. Environmental Health Specialist's Signatur : Date: 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 Artipfe 11 f G.�. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WA bet e �Va guarantee that the system will function satisfactorily for any given period of time. `D o U,\)ZS [ -j 02►- Septic System Installed By: -:===N,n Environmental Health Specialist's Signature DCHD 05/99 (Revised) MO Date: OZ- • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001911 Tax PIN/EH #: 5870-41-6986.Lnc Billed To: Lake Norman Constr. Subdivision Info: Rabbit Farm Sec 2 Lot # 4 Reference Name: Location/Address: Rabbit Farm Trail -27006 Proposed Facility: Residence Property Size: see map ATC Number: 2968 **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 t]5 E; #People �_ #Bedrooms T #Baths 3. S - Dishwasher: W/ Garbage Disposal: 11f Washing Machine: M/ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification:13tiFacility Type #People #People/Shift #Seats Industrial Waste: Lot Size � A0Type Water Supply � Design Wastewater Flow (GPD) 00 Site: New Repair ❑ System Specifications: Tank Size V20-0GAL. Pump Tank GAL. Trench Width C%- Rock Depth 12 Linear Ft. Q' Other: '� S'Ti✓+�Ji1o,�S � ��'1 dl.l� t_tc.9�S I D.G. ►u.,�1. i Required Site Modifications/Conditions: 4's"s-f ti x, 0-i ClBN I©c'Q, t� � FQ a+`^- l.O 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 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** ofZ) ZQ— Environmental Health Specialist's Signature: . Ijr.'st DCHD 05/99 (Revised) Date: 7/0 . FOR SITE EVALUATION/IMPROVBIENT PERAUT & ATC Davie County Health Department SEP E/Ivironmental Heaith Section .0. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONMENTALHEALTy (336) 751-8760 nevlc rnuerry Ed ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESSALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to' be Billed A, N v Co N 5 r *Contact Person0,;"ry Mailing Address a- 3 0 / d T / ( "'�'� �-�`" L Home Phone (7V V1) !!A� —.%04 City/State/ZIP yt0 eS 0 t �� -t %'�� � • 2 Business Phone 4DY 2. Name on Permit/ATC if Different than Above Mailing Address l,—�L„�2-` Z/yl�p1� lin/ City/State/Zip �1.lD�E'e$G!!x-Z`� ILI 3. Application For: ❑�Site Evaluation Improvement Permit/ATC Il Both 1T, 4. System to Service: go'use ❑ Mobile Home ❑ Business ❑ Industry I I Other 5. If Residence: # People # Bedrooms # Bathrooms3 ill, fTDishwasher e --Garbage Disposal Id Washing Machine CI Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City ❑ Well Il Community e. Do you anticipate additions or expansions of the facility this system is intended to serve? 11 Yes .WNo If yes, what type? ***1d1P0RTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPEItTY.INFORMA'I'ION REQUESTED BELOW. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the dicnt with THIS APPLICATION. Property Dimensions: WRITE D1REC'I'IONS (from Mocksvillc) to PROPERTY: Tax Office PIN: # ��7 D - y/ - �98'l0 , �N yv=.s7- Ta �-a/ Property Address: Road Name City/Zip If in a Subdivision provide information, as follows: Name: �!�/✓ 7— 57,,,- 17- Section: Block: Lot: I/_ Date Property Flagged: 7— m — 0 l This is to certify that the information provided is correct to the best of my knowledge. 1 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. 1, also, understand that I ant responsible for all charges incurred ftom this application. 1, hereby, give consent to the Authorized Representative of the Davie County health Department to enter upon above described property located in Davic•County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE / /� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. _ y APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI f7 Davie County Health Department n �_ (; R Environmental Health Section �I P. O. Box 848 OCT 4 Mocksville, NC 27028 2 1997 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEMI? if ESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed��e/'1- o Contact Person SAyn� Mailing Address �.30 Seei-et5 IT /d1 G. l- Home Phone 70J - Pg,�' 1-50�. City/State/Zip A� /171'0 �.�, ����� Business Phone 2. Name on Permit/ATC if Different than Above 5A1W Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: Dishwasher Site Evaluation C --House ❑ Mobile Home # People City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms 0 -Garbage Disposal G -Washing Machine O'Basement/Plumbing 6. If Business/Other: Specify type # Commodes If Foodservice: 7. Type of water supply: # Showers # Urinals ❑ Both ❑ Other # Bathrooms ❑ Basement/No Plumbing # People # Sinks # Seats Estimated Water Usage (gallons per day) ❑ County/City (S Well # Water Coolers ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3�'No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: Ji- A-6!'6 S 1 WRITE DIRECTIONS (from 1 Tax Office PIN: # Mocksville) TO PROPERTY: 5870 - �� - � 9 ��O 1 Gy Property Address: Road Name �i6t hb; t>� A-V o ► 7 rx ; !! 1 q 1 ;y City/Zip X51 141.yNe e, AV. 4 7M Io 1 1 If in Subdivision provide information, as follows: 1 �i��0, l 1 Name: ' � �/4 r N'1 -1 Section: Lot #: 1 1 _ 1 A, 0 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 am 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 f0 h w /Y/ , �'Pij5 G -� d/to conduct all testing procedures as necessary to determine the site suitability. DATE " F? SIGNATURE Revised DCHD (06-96) \ !•1II1fr1. M .. Y,.... rlf� MfWAa�l—Gfaryil.f..—.. M,r..lr,rww l.lw.r•+I.r Ilii7'Miiw17 q:19 r fI.Rf1�f►O�fMlepOR►.7AI•. ...n.ar,elln. f. �•y riiwwioi ��----�_;r...i'Lr.l..+ll ulr.,nwrr.o•la ........r..,. �rIN11iL.�-_..Il�.n.+ ----ra-ai�r:,aus�aza��- ... - mo�.c/ rp .N 4'1 ..�... ,..a♦w�.r..1.r fw wri i. wn ewalr rw« ..wwrri..,.P,wM•+r,rrw,w l.�.+•.rrw• _.MYr1111SA.1... r.•.. ..+r l•.. .. I. •.N..r+4.f. ..___ .._.w -.. 1ti2iNYF.IH iL'ii18176ii E1.' '+ ..a (� 'Z s.1.N•s....�.�Iwa.ls � •II ,..•1. ... �rw.rnn «...r•. .««. .IP.+r-wi ..,1..Ilr. 1. 1•wiw1. r._--- w,. .,_..__..r,..•r�r.. :.. • •.�/a •.•N... _. .•.aL r.+......YIr��1.{ r.wrl y� /1`I i� �•�++r ..Y•rM Iwr+a w• N "-_ ♦I. G ..N .r++. rr. .•r _.. ......... r•.orr. - . _ .•+ee.l+.� nb .+ N qw. n..r1r�.1 ►rr.r.w r..l(� ter. •���R�•••• .w __. ✓,M..... __I __ .. rrr.r.r Lex 6•��,, rr•...err.. C .►w,r�r�.. �i •--------}�r�F-:ir-i�.ir a.vn .•�..w ann. e.nwl •o.+�m...+ rtT— .t+.fwl +...+•I.w. 1.-.sa. r.raw to ?' B 7 G = I Iwl ....a •wllry r..l 1 M...) w •.. r+.: I.�•f 1.• rr. r . Ir w...+ r W I 1 Iw .w 0"Im SM mom "uO ar.r 'S 2 I .......all •.+.`.: . �.w+a IYI PI, f .f wMl.l•Iw •I.. Irl fr.. •w...l• ax EDO- •1 .Ilr .�1i.M..., rlw•..11 •r.. wlw� wii� �. r.rnr r+. .,wr . F I .. 'r..Plr �wlw1. �P.ua .• b.Teu Or I..f 1.•t TSV •MI 6-e av ft— t � -GN..a'- GNac'- -L.N K.� -•.1SK�- -S.1[..C�- -iN K�� �(arla�!M.: -4.erd- � -S.'•e ►cl-I -S.Ob.C•- �I -77. r•u awM 111 .•/ � e lri iN [�. auwav�uc e• / C r P 6-• a••'•- ex 6N -J.rr u. w....N.L" I Il.e.yq I _�•.... u. uar6.d- � lu•.`u•. s�•4- /r ,• \ � `/� - LOG•RifOU .'Mir I•i.M� .u.e, 1. •r. ..i.Mr .le.It.aN _.w. a J W.u..+l eJ f.aa•.s / J •W OIMO. I t \ •l`'s I'll +ii -7� � . r L - C47J1' t.� CY' �-' [• • E1.' iai •.rJN'.la t �/ • ., Lex 6•��,, 24 AC¢eS�"-� ...4rRM In \ 11 to ?' B 7 G = I Iwl ....a •wllry r..l 1 M...) w •.. r+.: I.�•f 1.• rr. r . Ir w...+ r W I 1 Iw .w �- 'S 2 I .......all •.+.`.: . �.w+a IYI PI, f .f wMl.l•Iw •I.. Irl fr.. •w...l• pAVll Csu r+vr U.G. •1 .Ilr .�1i.M..., rlw•..11 •r.. wlw� wii� �. r.rnr r+. .,wr . F I .. 'r..Plr �wlw1. �P.ua .• b.Teu Or I..f 1.•t TSV •MI 6-e s....r.a».- '+1 t � -GN..a'- GNac'- -L.N K.� -•.1SK�- -S.1[..C�- -iN K�� �(arla�!M.: -4.erd- � -S.'•e ►cl-I -S.Ob.C•- �I -77. r•u awM 111 .•/ � e lri iN [�. auwav�uc e• u tiTsu 7y�•N, u G f1ie1 r P / a tl I 11 I J W.u..+l eJ f.aa•.s / J •W OIMO. I t MD..r..a• v... ...w �����_1 /• rY�•�; 7 r /r • ZT..+ - - - - - - - - - - - - - - - - - - - r � 'RA881T FAft/TIMO-ILIvr 1 I Yi 1 ' • 13 14 15 IC. 1-1 18 19 SO +' 21 ±' 22 23 • _7 .•..•• �I -7 ••.tl-�- T -Or1 /.al/' -�.TAI.�j• -•.seflal- -f.i•K.-. �{.N K.� �i.NIN.-.. .(hllG�� �(.aeC�- -i... •.C•� -[.e K' -1. 14 K•. \ r L - C47J1' t.� CY' �-' [• • E1.' iai •.rJN'.la t �/ • ., Lex 6•��,, 24 AC¢eS�"-� ...4rRM i i \Ap91T Fp m%A, P"Okse LI — I Iwl ....a •wllry r..l 1 M...) w •.. r+.: I.�•f 1.• rr. r . Ir w...+ r W I 1 Iw .w g.+efrr 6f.d+/ -TbwN WP .• �.w+a IYI PI, f .f wMl.l•Iw •I.. Irl fr.. •w...l• pAVll Csu r+vr U.G. •1 .Ilr .�1i.M..., rlw•..11 •r.. wlw� wii� �. r.rnr r+. .,wr . F I .. 'r..Plr �wlw1. �P.ua .• b.Teu Or I..f 1.•t TSV •MI 6-e .. 1 rwu•e tv 5— N. 4�•..., .l.L P �. 4, rC M ` -z�� ` 5//�/,�� t.�. lei- PC Yi .•/ � e lri iN [�. auwav�uc e• u tiTsu 7y�•N, u G f1ie1 DAVIE COUNTY HEALTH DEPARTMENT �— Environmental Health Section SECTION LOT —!K Soil/Site .Evaluation APPLICANT'S NAME PROPOSED FACILIL&I-OT %'SUBDIVISION J� � Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit DATE EVALUATED PROPERTY SIZE ROAD NAME Awrr Q�L Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH p _ 2 % o- ' Texture groupC C Consistence <- - Structure k Mineralogy HORIZON II DEPTH — / - L `7 '� 2 Texture group Consistence - Structure Mineralogy1 HORIZON III DEPTH -1 2 -414- 4fTexture Texture rou C Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION 95 LONG-TERM ACCEPTANCE RATE 0. 12. e4 SITE CLASSIFICATION: F5 EVALUATION BY: _S�FF Vir4c9�-1�'`ti� LONG-TERM ACCEPTANCE RATE: O, OTHER(S) PRESENT: REMARKS:__ - DCHD (01.90) 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 Fl - Firm VFI - Very firm EFI - Extremely firm Wet NS - Non sticky SS - Slightly sticky S - Sticky VS Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 ■ i iii iii OEM MEN ONE ■■M■MM■ ■■■NEEM ■M■■M■■ ■■M■■■■ ■■■■■■■ ■EME■M■ ■■M■■■■ ■■MEM■■ ■■M■■■■ ■■MNEME ■EMEMEMMEM■■ ■M■■ME■EMME■ ■E■UM■■■M■■ ■■■ ■■■■M■■ ■■■M■■■■■M■■ ■■■E■M■■■M■■ ■■MMMM■■EME■ ■■EM■■■■■■■■ ■MMMM■■M■■■■ ■■M■■■■E■E■■ ■■■ ■■■■■■■ ■■■ ■■NEEM■ ■■■■■■■■IMM■■ ■■■MMM■■MMM■ ■■■MM■■EMM■■ ■■■■■■■■■O■■ ■M■M■■■MMM■■ ■EM■■■M■■M■■ ■■■ ■MEMO■■ ■■■ ■■M■M■■ ■■■■■M■■■M■■ ■■■MEM■■■■■■ ■■■M■■■■■M■■ ■■ME■■■■■M■■ ■M■■■■■M■O■■ ■■■■E■■M■O■■ ■MME■■■ ■■M■■■■ ■MNEME■ ■■MM■M■ MEMO■■■ ME no ME ■■ ME ME i ■ ■E■■■■ ■M■■■■ ■E■■■■ ■■■■■■■ME■■M■■ ■■■■■■■■■■■■■■ ■E■M■■■■MM■■M■ ■■■■■■■■■■■■■■ ■■■MMM■sot■■■■ ■M■MMMMMMM■MM■ ■■■■■■M■M■■MM■ ■■■M■■■■■■■M■■ ■MMMM■MM■■MM■■ ■M■■■■■■M■■■M■ ■■■M■■■M■■M■M■ ■■■s■■■■■■■■■■ Davie County Health Department and Come Health agency Environmenta(Health Section P.O. BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 October 30, 1997 Greg Beaty - 930 Secrest Hill Dr. Monroe, NC 28110 Re: Site Evaluation Rabbit Farm II/Lot 4 Tax PIN: #5870-41-6986 Dear Client(s): As requested, a representative from this office visited the aforementioned site on October 29, 1997, Based upon the information provided on the application for site evaluation and after the evaluatiorr- was completed, the site was found to -be provisionally suitable for the installation of an on—site sewage disposal system. If you have any questions, please feel free to contact this office. L Sincerely, A ,J .' / 2 Jeff'8eaucha"mp, R. S. ' U Environmental Health Specialist JB/wd '' Enclosure(s) VO ' A ., APPLICATION FOR SITE EVALUATIONAMPROVEMENT 1"' Davie County Health Department flet Environmental Health Section It P. O. Box 848 Mocksville, NC 27028 ii (704) 634-8760 I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THERE_ QUIRED INFORMATION IS PROVIDED, p Name to be Billed w -� Contact Person> V �� C Mailing Address ,21.% C�O� I^► �r'S �/ Home Phone & City/State/Zip W'5, V L �2 2&9 9 Y Business Phone 2. Name on Permit/ATC if Different than Above I Mailing Address r City/State/Zip 3. Application For: Cl' --Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: U'—House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ❑'Dishwasher ❑--Giibage Disposal ❑–Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: ❑ County/City a Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Or ---No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: /e J -e -S 1 WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # `7 - - % Property Address: Road Namer� r I V ►� .5 1 1 4-sz� p it i ), tL City/Zip %JJ1/z7 illef ,17 : t-15 L If in Subdivision provide information, as follows: 1 � 1 Name: .1 Section: Lot #: 1 1 I 1 This is to certify that the information provided is convect 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 am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie CountyHealthHealt/h Department to enter upon above described property located in Davie County �1 and owned by To /I /P/r-6 5 E 1 L/;�C to conduct all testing procedures as necessary to determine the site suitability. DATE��t� i� SIGNATURE`r�u: Revised DCHD (06-96) mmuw d b In.wa u..ls Otr.O.ria FltW.!t•D°Ir TMr'^-'r ---'--'- rwt.�w.r• ..r ___ r Ow%fffwRer7MMwOlrrom OIIOOME/MIOIM.7. I. IY..tac w•Ih ,. ... ants .r�.w+110•w�fi r.IYrwe�r/w•Irrrww• rr.r.__ L•7�A_._—__. pw "-,Ial )1.••. t. Iyr.IN.t r b CY.A rrewr.tr+►/ i.B OIR'+i NIIYNIi. $iiti'1ia�a p �/A wrw.�.�.w ianl fw wu waw uwW .w w..Iwna.taww w.w e.wf.wwrt�wlwe <...Q61ALK�.-._.•rs..x.+ rr1Y. •I.wN .rw•r N trs+.1Y ti C(ililGi� NWD I/OI I ` ` •r. •i Z _ cm"pw~ .91 .w••1. W w W MY. f Iw Mw tN b >rwt r . _ _� .,.... IT _ ._ _... ti ti W • /w� Y rlw.+r+w.rf \Iw t. I.wt•N. wr.. >•.rt.__..ww.r w.rw.wrwrw.wf wrM .r.Yr.+r.7.�t,w.ra .rrw w . erww _ 11 10 9 B _ tG.ItO•!t p.1\t\Doi" 17M. nfYjy�7•ePr•�Y.°�w•n ... h "_ w/ f` .. �..Ir W. ,GY� wrn.t. Iww•Y r•r4 t. w••r•..o..r Z { -G.. n<•--4.ee..c'- r•1•«nrr..M -6.ji •i•- -S.if..<>_ -A.s .s•- ^ieY..•� _i.ow.-'- I -5.�4 ►c•_I-�.s/-..c•- *I -7. 7L •. <. ` .w7 w.1//A`(G.J IIwN L( 'j ♦ ___.___Si M� �aLiiYlf dA11r Y1t1Wl •OIIM wtnfw.101.t-I.fSl.n. « ifw.l..1 ttieYr.r•'..' I.: Ij4a 7./e.In. MY...�.. +r D.Me..as MaM \f fta•DG.. � fla.) I - [ \ a,- CA#O OAIM'. KK r Ir V- SIX Ase FAUM T%ZAIL � C l CCe I I � Let �, G-• a...a- � x 6-• � -J..w w. W.r..7'�•l I 14L.yA � -Je� r. W. rl.ew/- _rGl.0 ...4 • I�t.M� 11l.4�bM >.M. lG, b. YI � w.f�.�- ,V �� 24a•,.4t� Ib1.740 /` \ /� ,.,`• - LeaM•7i�^MP• r>•••. i •�Z. c�rc� •�' 7 �e \tl 11 10 9 B ie �' e• ► r Z { -G.. n<•--4.ee..c'- -4.er .ac•- -6.ji •i•- -S.if..<>_ -A.s .s•- ^ieY..•� _i.ow.-'- I -5.�4 ►c•_I-�.s/-..c•- *I -7. 7L •. <. ` .w7 D.Me..as MaM \f fta•DG.. � fla.) I - [ \ a,- Ir V- Ase FAUM T%ZAIL � C l � I 13 14 IS Ir✓ 17 r 18 19 20 +' ZI 22 2 3 24 ZS + \-7-sact-� -t. rt.ac\��� �e.T.ae•^j• _1.7•♦<l� -1.7R NC•• -S.e .K•- -f.G4 AC•r-•sdAG•- ^tj.IK•- -•j O.K•� -S.Su• 1 _s.z4.�._ , I ` t47J t 1i L1� wi ' �tfa�•e ...... IS 1. 24 S `f •' .s.�'r a x: ea Wt a,a •M v «>,umtcttta� —" RAO�IT r AQM, RASE II -- .6 r _ w�S�M 'a C,q '°rl_ err •n Isa►> �• I1� Ilw)yyWw.•4iwtN �•wr1r4 W t1IwI•MI••. $>4NtTI GaW! iuWNN.\O Y•�M.n Iw •( pMl•I.lw .la O la:l fm •ew••G\. DAy1G Ceu rTY� K_C_ ��- : ft' •IIM •�l I•re W .Nlwt. >II rs... wl.Y wrn. N .un .r......w r..u. .+,A. _ L _ ........ ., «.,�.,.':' �.'S"�'ir•. •.....w Sw 1 C:. •r�• M r.t .w. 1� •� •w,.S�'"S r .n ` a �.v a•e i.:u `.I.p.:.`. '• ►. re/TON O. mart 1.>a H \N. �wy b» OG 4q µ w . . r . ... "" ... '.,�«�� w. YAL. O w -A. .42. sa w C ,^ �_ �:�:: • ,. ,_ ._ ��";:.. 1.1.11 i �^ ... ...�.� . �^.� rt _ •�� �••�• .,•�Zw..w _ of .lW.� S//GIS �.�._ 1•.�0 1„� + G�2...1Ca1 Cu NaV.•.0 U. •S_.r•.r /Y'1 L / •r >+•.> ♦ .• •.aa. r • WfN LTG•! t,t.tM, 4 G- t7�0) • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY lrT SUBDIVISION Water Supply: Evaluation By: On -Site Well 1/ Community Auger Boring �/ Pit DATE EVALUATED /Z-7 _/?7 PROPERTY SIZE /�� 14/d ROAD NAME Gam` gal X %moi Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH b �� Texture group Consistence r Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: /4� LONG-TERM ACCEPTANCE RATE - REMARKS: DCHD (01-90) 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 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 ■■■■■■■N■iii■■■M■■■■■M■■■■■■■■M■■■■■■■■■■■■■M■■■■/■■i■!■■ ■■■■■■■■■■■■■■■■■■N■■■■■■■■■■■■■■■ilii■■■■■■■■■■■■■■■■■M■ ■■■■■■MM■M■■N■■■/ill■■■■■■■MMM■■■■ill■■■■■■■■iii■■■iii■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ ■■NEEM■■■■■ ■■■M■■■EM■■ ■■MMM■MMM■■ ■EME■EEEME■ ■■M■■M■■N■■ ■■NEN■■MME■ ■■M■M■M■M■■ ■■N■NM■■M■■ ■MEEMEMMEN■ ■■■M■■■■■■■ ■M■M■M■MM■■ ■■■■■■M■■■■ ■■■■M■■EE■■ ■MMMM■MNMM■ ■■N■■M■■■■■ ■■M■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Heafth Department ancCHome Heafth Agency Environwnta(Heafth Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-40-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 January 10, 1997 Burt Yokley 817 Cool Springs Rd. Winston-Salem, PJC 27107 Re: Site Evaluation/Rabbit Farm II -Lot 4 Tax Office PIN: #5870-41-6986 Dear Mr. Yokley: As requested, a representative from this office visited -the aforementioned site on January 3, 1997. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. r Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosures) JUL-1b-101 Uv;015 HM tXUL-U51VE IND IMeUKT5 704 882 4654 r" Davie County Heafth Department and Home Heafth Agency Environmenta(Heafth Section PO laox i!411 1 2 1 0 Howe m. Smia CauFa6R 009 4.OG MoCXSVILLE, N.C• M26 PMNL: (704) 634.8760 October 199'7 =car 6e,t•r .Y; 1."I :.t'C:t`2:l Re: Site f=%.aluatio'r1 rte1~r.;t Farm ll/Lot 4 Az UEar C,Je•nt•tsi: As req eStap, P repreeentAti ee from tr+iA office vitite:l the Based jpcin +.t:e ►nf.:rmation j.roviapd, Ctrl tree .j.p iI atio�l it.•.' jG■� Av:.'LUc!zS.'ri and ;•iter` t) eVcliUa oil WaS CO'IClleLe%, Lr.0 -iCE' Wrls *:'.:r!-4 t0 ttt' stot..ili:io for the ii►i;.tal ',atinr of e:-1 l•r,-.:t4 sei!age disf'Gsal systes. if y %s r•6VA uestion_, please feei `rep to contaiA this office. Sincerely, - - -1 jreff �E—cav_•h0(1pI P. a. U t!Ivl: oi1:SEr,t,,1 Health .iB/wd i nc.losure ti5i APR -2-2002 05:43P FROM: TO:13367518786 P:1/1 H f'h-10Y-10X NY : MJ rl'1 C^; -L -UJ 1 v C Ar -IM • /9r YR . O . -- --- -- ..• .�� 3 JuT &aohmo-/7 /,Jn"L� Cow# -74,�, 67(, 3- 1-53 f lD 00 �S- Lr)LDM M J .y . -7W-6P&3- 133 t &Wf r(JAI-n, rd. Ad VO -06C I /�X- w. M- M M m m r r W N 0 N q1' 7.0/ 54911 l ZivE C . X8037 . p Temporary Certification Form LD M en Fztow L.P. 65 [ndugtrisi Park Road 091" TN 38060 Phone: 977-3684294 no o wase w. rDrdaw sysim'w wot. 8 This Certifies That 9 of � tin completed the necessary training on the paper installation of the E#kw Fm pmduct in aceoedaocc with state rules and regulations as issued by the govcraing agency• Dz m _.._•_�_r �..... _ ._ ...._ .. m Davie County Health Department. V P1836j� Environmental Health Section �^ P.O. Box 848 Lon , �„ 210 Hospital Street Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: M(au Irt, Phone Number ' �� 710111 (Home) Mailing Address: l'-;�b ( M&J // I wd CIP , . 33�- 761— M9 t (Work) Z—�IJZ- ( Email Address: f wit , akk Detailed Directions To Site: flwyl 6 � , L. SFT oil 998 17 104 Property Address: -?� 20 IT M-1' 1' d ly\ G Please Fill In The Following Information About The EXISTING Facility: '' // Name System Installed Under: t71�F-- G Type Of Facility: \ '/g �Lr Date System Installed (Month/Date/Year): ZyJD Z Number Of BedroomsA _Number Of People: Is The Facility Currently Vacant? Yes (No If Yes, For How Long? Any Known Problems? Yes( No If Yes, Explain: C. Please Fill In The Following InformationAboutThe NEW Facility: Type Of Facility: C}l �� / }�D��+1 f�� L Number Of Bedrooms: 0 Number of People 0 Pool Size: 3 �' Garage Size: �0 �- �( �E, Other: UJ Or Requested By: F -- Date Requested: 3- Zea ' Z - (Signature) (Signature) " - For Environmental Health Office Use Only �ADedDisapproved Comments: Environmental Health Specialist % ,.�,�� � ,�f(.L,y �,�,, t,�( (r'C� �, Date: *The signing of this form by the Environmental Health Sta 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. Payment: Cash h ck oney Ord r # / U5 / Amount:$ / UU, Paid By: Received By: Account #: '� �3 Invoice #: I, y._li:YiifS'""1�1 FiP 'RA'F'li'"fat#Ed IN " i4CGdRf7ANC:E W17H G.S. 47-30, AS AMENDED. WI ESS MY HAND AND SEAL THIS _Z� DlY OF A.D. 2002. ����AROLINJ �� _— - --_ •"""'QQ"".q ; PROFESSION LAND SUR OR at I' s9 4R REGISTRATION NUMBER °'wuumon tn`r M 0 0 to N Aoo_ 7316/� SRM �RA+L /i�UtFIJcE � �1�