262 S Angell Rd a . '
• DAVIE COUNTY ENVIRONMENTAL HEALTH
, - ' P.O.Bax 848/210 Hospital Street
Mocksville,NC 27028
(336)'751-8760 F�#(336)751-8786
OPERATION PERMIT
Account #: 990004247 Tax PIN/EH#: 5840-21-8237
Billed To: Sarah Richards Subdivision Info:
Reference Name: Location/Address: South Angell Road-27028
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 4613
**NOTE�*The issuance of this Opera6on Permit shall indicate the system described on the ATC 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 sarisfactorily for any given period of
�e: �-F , ��
System Type:�!S.T.Manufacturer_�� Tank Date /�—13 Tank Size�
Pump Tank Size F
S em Installed B :�a.��&�e � �jG��-c�5 E.H. S �alist: °,h ✓'����odf Date: �`'� �� _� �
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DCHD 11/06(Revised) .
. .. : _ . ; .
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' � DAVIE COUNTY ENVIRONMENTAL HEALTH �,
�., -- '"' P.O.Box 848/210 Hospital Street '���,
� ` Mocksville,NC 27028 ��'
(336)751-8760 Fax#(336)751-8786 3
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004247 Tax PIN/EH#: 5840-21-8237
Billed To: Sarah Richards Subdivision Info:
Reference Name: Location/Address: South Angell Road-27028
Proposed Facility: Residence Property Size: 1 acre
ATC Number: 4613 /
Site Type: C�New ❑Repau ❑Expansion
**NOTE**This Authorization to Construct(ATC)MLJST 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 7— #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility) .
Lot Size /, Q�/`�c Type of Water Supply: C�County/City 0 Well ❑Community Well
System Specif cations: Design Wastewater Flow(GPD)3 4-d Tank Size f�,d dc GAL.Pump Tank�l1�GAL.
�i
Trench Width 3(�" Max.Trench Depth�ls Rock Depth� Linear Ft. Y 34
�'.s �tatr_d in 15A NC,4C �1�1.�.963{��
Site Modifications/Conditions/Other: ncCe�ied SvRt�r�� K�;� ,��Fg g�� _
Contact the Davie County Environmental Health Section for final inspection of this system between
� 8:30—9:30 -
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Environmental Health Specialist � __Date:,3
DCHD 11/06(Revised)
� •
� APPLI � E EVALUATION/IMPROVEMENT PERMIT & ATC
�, ` � vie County Environmental Health
D � .O.Box 848/210 Hospital Street
, 1 2 20�� Mocksville,NC 27028
FEB _ ( �751-8760/Fax(33�751=8786
Applicah n Fo ��l�I� ment Permit �Authorization To Construct(ATC) ❑ Both
Type of A plication. 8`�- m ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPO ANT***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 ` Contact Person ��C 4� ����� ' �;�,�. �
Billing Address � �e ' Home Phone '�E��—`i'�7� ��f(�'h
City/State/ZIP �(x,�SJ�1�e �G �-'7(,l�' Business Phone � � �'-C�j S�� q[�� S�l 5 �
. �
Name on PermidATC if Different than Above
Mailing Address ' City/State/Zip
9�
PROPERTY INFORMATION *Date House/Facility Corners Flagged -� �0�
NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale)
(Permit is valid for 60 mo hs with site plan no expiration with complete plat.)
Owner's Name � � � Phone Number a���D'1� -
Owner's Address / � ar�� City/State/Zip����s„�. ,(t C ��F 8'J�-oZ �S
Property Address $' � City_�Lla��;�T,�'//� �,�,(
Lot Size t a�,c,c.�- ax PIN GD 7 �1/�21 �Z3'7
Subdivision Name(if applicable) Section/Lot# �
Directions To Site: b � (��. �,-,� �� ,e, ,
! o � i ` 6'y� � �
If the answer to any of the following questions is"yes",supporting documentation ust be attached. t Qt✓�(
Are there any existing wastewater systems on the site? ❑Yes o�
Does the site contain jurisdictional wetlands? OYes o
Are there any easements or right-of-ways on the site? ❑Yes
Is the site subject to approval by another public agency? ❑Ye o
�'Vill wastewater othei than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms r` _ Garden Tub/Whirlpool ❑Yes o
- Basement:. ❑Yes No Basement Plumbing: OYes o
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 systemrequested:. �Conventional ❑Accepted ❑Innovative ❑Altemative �Other ���Q` SuS{trK
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 �No
If yes,what type?
This is to certify that the information provided on this application is true and conect to the best of my knowledge. I understand that
any pemut(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
roperty owner's or owner's legal representative signature
Date(s):
a'�—�� Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
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. ' � � DAVIE COUNTY HEALTH DEPARTMENT
� , Environmental Health Section
` Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004247 Tax PIN/EH#: 5840-21-8237
Billed To: Sarah Richards Subdivision Info:
Reference Name: � Location/Address: South Angell Road-27028
Proposed Facility: Residence Property Size: 1 acre Date Evaluated: �—�— ��
Water Supply: On-Site Well Community Public ��'
Evaluation By: Auger Boring -� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition ' L� S L
Slo %.
HORIZON I DEPTH p- � p --/5
Texture rou � J�- L.
Consistence -
Structure Y v „+
Mineralo • N. /•��.(/� /= cN
HORIZON II DEPTH � 7- 3v /s-y
Texture rou G
Consistence P /' ; .'r-
Structure .� ,S S
Mineralo ' � � / /' '
HORIZON III DEPTH --yg c Y -'
Texture rou �G ,-C�
Consistence • :r �
Structure S � E
Mineralo !r l. / � •
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS �
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE d�7 - cs d 7
SITE CLASSIFICATION: �`Ov • G�-��� - EVALUATION BY: � �a'
v
LONG-TERM ACCEPTANCE RATE: d'��� OTHER(S)PRESENT:
REMARKS:
, LEGEND
T, n s ape Positi n
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
T�ctur� .
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
.ONSTST�.N . .
MQi�t
VFR-Very friable FR-Friable_ FI-Firm VFI-Very firm EFI-Extremely firm
�
� NS-Non sticky SS-Slighdy sticky S-Sticky VS -Very Sticky �
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic -
�
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic •
MineraloQv
1:1,2:1,Mixed
LYQYs�T , �
Horizon depth-In inches .
Depth of fi11-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-gaUday/ft2 . DCHD OS/OS(Revised)
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• � • Davie County Environmental Health
P.O.Box$48/210 Hospital Street
� Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990004247 Tax PIN/EH #: 5840-21-8237
Billed To: Sarah Richards Subdivision Info:
Address: 609 Greenhill Road Location%Address: South Angell Road-27028
City: Mocksville Property Size: 1 acre
Reference Name:
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 Pcrmit is subject to
revocation if site plans,plat or the intended use change.
Pernut Type: Q�Iew �Repair. ❑Expansion Pemut Valid for: Years ❑No Expiration
Residential Specifications: #Bedrooms 3 #Bathrooms '� #People �/ Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 3(s0 Type of Water Supply: C�County/City OWell ❑Community Well
I'�s stated in 3.5A NCfiC 1uA.i5`£39(5)
Site Modifications/Pemut Conditions: �cCepted uY4te�s may al�,o be used
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Environmental Health Specialist Date_ � c _ �,
i.p.l l-06