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1800 Angell Rd • ' , � ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 I (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Accou�t �: 990005634 . .' "��x Pi�€r'EH#: 5821-73-5033 Biflc,� 7'c�: Hoyt Dorsett . Sut7t�i�ri�iar�;.lri��: �� er�r�ce �Ia��: . Lac�iianl�d�r�ss: Angell Rd.-27028 . , _ �ro t�st�c9 F��;i€ity: Residence � .,. , ... : ,. ;:., Pro��r�.y-Siz�:: 36.44 .. , �..; .. a�TC hlumb�r: 5735 . , **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed '� compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems," but sh be taken as a guarantee that the system will function satisfactorily for any given period of time. ^System Type: � � .T.Manufa rer ��a�Tank Date� —�� T�Size � � � G � � Pump Tank Size c �� `�j /� � ' �//� System Installed By:_��aN� E. . Specialist: ��/ Date. GPS Coordinate: 3 � d � �l 08� 5�� C O � • iuf �,,� � / ` � �� rq �� , ' � � g'1 �• / ��7 GY` . V� I � X 2-0° �-� �0� DCHD 11/06(Revised) , , � � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � (336)753-6780/Fax#(336)753�•1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Acc�►unt �: 990005634 . ;� "��x�i�iEH#: 5821-73-5033 _ BiEle� T�: Hoyt Dorsett • ;i :,` ,"Su�idi�i��ar�;Ir��: . }��fer�r�ce P�ar��: . :�� . . . �:; Lac�tionrAdc�r�ss: Angell Rd.-27028- . . F'rn�c��ec9 F,��;ility: Residence �:i °; ��er�y S�iz�: 36.44 , . , Site Type: Q3�w ❑Repair ❑Expansion h�TC �tu�'tb�3': 5735 ,.� ; ;.: � ,,_ , **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ • Non-Residential Specifications; Facility Type ✓r� #People #Seats� Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ounty/City ❑Well ❑Community Well U ,(�� System Specifications: Design Wastewater Flow(GPD)� �'ank Size '/a�GAL.Pump Tank�—�GAL. �r V 1 � Trench Width ��o Max.Trench Depth 3 G Rock Depth � �C Linear Ft: r f � �5 stat�J ir� 1�f� I�i,�1C �.�',.i�c:3�5� Site Modifications/Conditions/Other: ,,,, ., �� ,��.� � ,n�„ ��,� ►�r� {i��, �.s �t S� rn - Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone#(336 751-8760. . i 7' ��F � � � � 0 � � pro� - � �' .C�„; _., �` .s° . . P ' Rd '��: '�� (,�,p� �ia �1�, .e I s• . .+t,�� - - / � ��'�--- _ ..� _ � � �r�� ; � , , ( j 1 � I .�.: _ Environmental Health Specialist �:/� Date: �Q� � /I DCHD 11/06(Revised) 1 � ' � � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005634 Tax PIN/EH#: 5821-73-5033 Billed To: Hoyt Dorsett Subdivision Info: Address: 269 Riverbend Drive Location/Address: Angell Rd.-27028 City: Advance Property Size: 36.44 �� Reference Name: - Proposed Facility: Residence '` **NOTE**This Improvement Permit DOES NOT autharize 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: 0'New ❑Repair OExpansion Permit Valid for: f75 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms�#People Basement0 Basement plumbing� Non-Residential Specifications: Facility Type a/rl #People #Seats � Square Footage(or Dimensions of Facility) Design Flow(GPD): �da Type of Water Supply: �nty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: �`i� ��atecl i�t 1�A f��>C �8,��.1��;�{5} . � �v:. . �y�..,��. ec:y u...� ,.... .��,. � . S�stem T e LTAR Initial c .� Re air Site Plan ^ 1` 1 ` �,� ��j, �-r�G �q�.� ��a _ PP��X, f� 'F LiQQ ' . �_�+ � , � 76� /,�Q � d �tOo ` [ ' , �~ " �l , r ,4 � -- 1 � `� � - I' � _ .� ; I ��.� r _�, � --. , �\ �,� ��,eu �..,�� _.. Enviromm �tal Health Specialist �� Date ' (l� �/ i.p.i l-06 . � � � , / / � � \ ^� 1 f � ( � �� ," �� - � � � �� a . S� � � } . } APPLICATION FOR�SITE EVALUATION/IMPROVEMENT PERMIT & ATC �D�l, Davie County Environmental Health OI'� �� P P.O.Box 848/210 Hospital Street �� a Mocksville,NC 27028 � �.�� Q� Lo�� (336}751-8760/Fax(336)751-8786 �,,r Ap tion For: ua`fion/Improvement Permit ❑ Authorization To Construct(ATC) � Both Typ� pp icafion: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED 1NFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION /I '(Y,Ac�t�� "`'` Name to be Billed (� � Y ` !�S Qi r Contact Person l.`�;`to- b'�`��l Billing Address � ' v-P_.. r�. Q 'v-e� Home Phone 3 3 E'` 9 � 6 3 �� City/Sta�e/ZIP�,4��-�- X1'� �.r1(�(�,6 Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged ��{��%� �/�� NOTE: A survey plat or site plan must accornpany this application. Included: ❑ Site Plan ❑Plat(to scale) �?�f (Perxnit is v lid for 60 months with site plan,no expiration with complete plat.) Owner's Name c� , � �S Phone Number Owner's Address ��,� �,,,,{4\ L Q_�� City/State/Zip �ot(�s,,��P.T JvC=2']o,�� Property Address City Lot Size ��Q_��{�Tax PIN# ��—? �S �� Subdivision Name(if applicable) Section/Lot# Directions To Site: .,;� _ (�, \.,-� ��„ ..,,,� }, .rt -�,� .R..N., �..� If the answer to any of the following questions is"yes",supp rting documentation must be attached. Are there any existing wastewater systems on the site? �Yes L�io Does the site contain jurisdictional wetlands? ❑Yes Q� Are there any easements or right-of-ways on the site? ❑Yes I7kdo Is the site subject to approval by another public agency? ❑Yes 93Go . Will wastewater other than domestic sewage be generated? ❑Yes C�P� IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: OYes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness ST�'�C'i'1� ` ` � Total Square Footage of Building ..3 6 #People�_ , #Sinks�_ #Commodes�_ #Showers � #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY::#Seats Type systemrequested; [�Conventional ❑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 �3�0~ If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pernut(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 staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property er's or owner's egal representative signature Date(s): �. � Client Notification Date: Date EHS: � �� < ��►��QC�L Sign given ❑Yes ❑No �, � Revised 11/06 ��C 'y �'�'a Aceount# J��/ �,1 j � I� �� Invoice# -��L.�� ?.� a,��0�� ( ��r�� `�� /l . . ______. . . _ __ ___ _.. ... . . . Reports Page 1 of 1 , t . . Davie County, NC Tax Parcel Report � . � ? � �'': " 'ee��sp,'i�:A�•��a., F ��5`k?' .�� a T r ',w./ 66#�t • 7 ... �.�+'i�;^ ��' ... I I �'� .. .s, "�7 ,,�� .�� '� _ YAs..' . � . �' - . '�6i �.' . . � . � .. ... ... . 4 , ... '.t��i s��-q �� P:_� '<, � �` i '.� £ � � . _�� . r • , , . , i,.� ' s r� i'u . .. . �P S8r �;��t � � 8_ . ., �. . - . �Fx� � 4 . � . ,''_ . ,* �. , _ `+a".-`v _ z, t ,, <<��_.� ��'��,�� ,�j �� r -'� a ix � �;Y � i� _ t:_ +f ' '. �. [ � - r. I i r� . ,•t: r� _' `_ *' 1 3. � � ' J � � " `�`"'' �� - � ` - f "�,� ,�; { ' s . IiI �� ` j � .�� . . � ^°'� I ,. �r'r ;� ,i,"� y r'4 ��y ' � �� i � � ` ..� � � . � + %� 'i �' w' � � g� �, . �# � i �3 � ¢A'. � �l iik� . I � �'Jt j� . ��' . � C. , � , . . ' I ,�q�,r..� r. . � .�� i �; �. � .., .r., g� . �� i�, . . �i �. .�� i . { �' . r $ �� " �. . ' �� t � � � t ?.?� '' � � � �� '� �� ,''" � �, . `4� �� I :. � j, � � � � t � _. � .� ,. � -.� — ' - r � >�° �'z�C. � . I . �T ._ , � .-�� .F-. � I - . I „ - � - � � �� i . 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Users of this map are O�,��S Listed Owner#2: LUCAS BRIAN D � hereby notified that the aforementioned ', public primary information sources should Mailin Address 1: 1790 ANGELL ROAD ,I be consulted for verification of the Mailin Address 2: i information contained on this map.The Cit : MOCKSVILLE I County and mapping company assume no State: NC � legdl responsibility for the information �� contained on this map. Zi Code: 27028 , Legal Description: 35J59AC ANGELL ! Notes: ROAD , Acrea e: 34J4000000 � Deed Date: 020090217 Plat Bookk and Pa e: 00782�__� II Plat Pa e: I Buildin Value: 0 Outbuilding and Extra Features 66530 I Value: Land Value: 224310 otal Market Value: 290840 � otal Assessed Value: Z90840 _ �I `7 — I http:/hnaps.co.davie.nc.us/GoMaps/reports/report.ctin.CFID-106946&CFTOKEN=480927... 2/8/2011 , ---- --- -- -- - � . - • '� . _ � �� . � �� _ � � d �� ,� s � z�� P �� d �i Id :D �' W, a y ? ii w I �� v 1.L ` ^ �,Q) �6�� .� . .� Y . 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N.C. 27373(336� 76C-t873 �.�r. - DAVIE COUNTY.HEALTH DEPARTMENT � ' Environmental Health Section Soil/Site Evaluation ArrLicaiv�r nvFORMaTiorr PROPERTY INFORMATION Account #: 990005634 Tax PIN/EH #: 5821-73-5033 Billed To: Hoyt Dorsett Subdivision Info: Reference Name: Location/Address: Angell Rd.-27028 1 Proposed Facility: Residence Property Size: 36.44 Date Evaluated: d- ^'l ?irK' Water Supply: On-Site Well ommunity Public �— Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L Slope % HORIZON I DEPTH .� Texture grou G G Gonsistence � Structure Mineralo HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE � CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �l' ) EVALUATION BY: LONG-TERM ACCEPTANCE RATE: !/ • ✓ � OTHER(S)PRESENT: REMARKS: LEGEND T,andsca��;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 CONSIST�.N . . �Q1S� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Y� 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 Mineralo�v 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]and surface to soil colors with chroma 2 or]ess Classification-S(suitable),PS(provisionally suitable),U(unsuitable) � iTAR _I.nna_tF+rm ar�enfanra ratP_ aal/rla��/ft7 r�nTm nc�nc m__.c__��