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1091 Baileys Chapel Rd . ' • ,' '' � � � �/ � ` DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Sh-eet 11��A Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT � Account #: 990003670 Tax PIN/EH#: 5789-02-7364 Bilied To: �I-Fer�4f+Hie�rns T�idc� 8ati�E� Subdivision Info: Reference Name: Todd Bailey Location/Address: Bailey Chapel-27006 Proposed Faciliry: Garage Property Size: 4.6 acres ATC Number: 4806 **NOTE**The issuance of this Operation Perxnit 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 satisfactorily for any given period of time. / ,[��/ �V �System Type: S.T.Manufacturer r`��Tank Date I I Tank Size� Pump Tank Size �lll��- �i �}a�{�Ow`� �� � �� g System Installed By: � E.H. Specialis4: �� Date: �- ��-- � �— I ,---/. � -�.., j � N � �a��-�- / :�� , , .�� I I � ���o� ��l �5� �'4 ' w �h �,5—, �f ` l ',,� / � � �`� ��`5� � ��y�- , q� / � / � � � � l �a� . � cG�r . �� � �, � T :; � �`� o�� � � � � � �, � � �4:;�'..,�-. . -. - . . . . . `' . . . ... . . , . :,� � � DAVIE CO[.TI�TTY ENVIRONMENTAL HEALTH P.O.Box 8481210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTENI CONSTRUCTION Account #: 990003870 Tax PIN/EH#: 5789-02-7364� Bllled To; �F�er�yrlA�f�knns Tocld F3Ai(e� Subdivision Info: Reference Name: Todd Bailey � Location/Address: Balley Chapel-27006 Proposed Facllity: Garege . Property Sizs: 4,6 acres ATC Number: 4806 Site T e: QNew ❑Re air ❑Ex ansion YP P P *�NOTE**This Authorization to Consmict(ATC)MUST BE ISSiJED by the Davie County Envirorunental Health Section prior to issuance of any building pemut(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treatrnent 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. Residential5pecifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage or D' ensions of Facility)��r�� � � . Lot Size `7r G � Type of Water Supply: B�ounty/City OWell OCoznmunity Well Q System Specifications: Design Wastewater Flow(GPD)��Tank Size�GAL.Pump Tank���AL. � �� u �` �j ` (� Trench Width �� I�(ax.�'r�nchDe��th .��' ck�e�,�th_0�" Linear Ft. �v � s s a eu in ;� �C �,��. �� ��_ Site Modifications/Conditions/Other: uccepted �y�tpm� may ;�Iso �� u�- .� 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. � �""__ �--�._,...` _ � . � � � �. � •... � (�- __ � � � � r \ ; I` � �' / , � � ;� � � � �` "'�`� � � '� ^ C � i� q ` � , - ` G ,� � s 3 h � � � "` , .\ /� , �� 1� 4 � �c ,�� ',y` �`� , , '\ r�� R�y��� � �G� .�� �� � \ � �r��� , p;� �.,. ..� � to, /�' -, ��� �� � �' � � __..- / ��� � / s� � � . `(,�t G���r� ��y,�\a'� �\�I �vironmental Health Specialist „�...� Date: � � � � U T,rur� i�m��RP.,;�P�11 � , , _� ,� LS 'APPLICATION FOR SITE EVALUATION/IMPROVEMEN � Davie County Environmental Health P.O.Box 848/210 FIospital Street ��� 2 '� 2��] Mocksville,NC 27028 _ (336)751-8760/Fax(336)751-8786 Q��IRO�MENTAL HEALhI DAVIE COUNTY Application For: p Site Evaluation/Improvement Permit ❑ Authorization To Construct( Type of Application: ew System ❑Repair to Existing System xpansion/Modification of Existing System or Facility r� ***IMPORTANT***THIS APPLICATI PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed _/ � �/ Contact Person �y �{� � r Billing Address ' Home Phone City/State/ZIP L Business Phone - Name on Permit/ATC ifDif erent han ove �-Q l,�� <,JC'� �� `'� Mailing Address �' C City/State/Zip / � l7 � PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernrit is val'd f9 r 60 months ith sit plan,no expiration with complete plat.) / Owner's Name / o G�� Phone N mber .�co- ��' ' Owner's Address ' City/State/Zip L � Property Address City A � Lot Size Tax PIN# '� - C7 (o Subdivision Name(if applicable) �//� Section/Lo # Directions To Site: � If the answer to any of the following questions is"yes",supporting documeptation must be attached. Are there any existing wastewater systems on the site? C�Yes ON Does the site contain jurisdictional wetlands? ❑Yes � Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes � ' Will wastewater 6ther than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ONo Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL UT THE BOX BELOW � Type of FacilityBusiness Total Square Footage of Building J #People #Sinks� #Commodes __ #Showers� #Urinals ' Estimate ater Usage(gallons per day) (Attaeh ocumentation of similar acility water consumption) FOODSERVICE ONLY: #Seats � � Typesystemrequested:. C�onventional ccepted ❑Innovative ❑Alternative ❑Other i Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansioris of the facility this system is intended to serve? ❑ Yes CXNo 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 Ghanged. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labelirig 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. Pro rty owner's or owner's legal re entative signature Site Revisit Charge Date(s): -a�'� Client Notification Date: Date EHS: Si n iven ❑Yes ❑No � � g� �61� Account# � �evised 11/06 �� Invoice# _/� � . � , ,z,o H800000042 \ ' � H80000003601 ` \ H8000000420'� /� a.so n ,lr�'�� 7364 � � ' H80000004301 l.3+ �t�i3�i 0 � ��� � ,� H80000004101 H80000004102 H80000004103 �,��j (1.35A) H8 QQ�,E o�2708 ��4777 0 7739 �'�` ���;�: o1'i 4'T . 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DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section � Soil/Site Evaluation APPL I F � Tax PIN/EH #: 57�B�1Q��Y INFORMATION Billed To: Harry Williams Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27006 Proposed Facility: Garage Property Size: 4.6 acres Date Evaluated: L— ��G� Water Supply: • On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L [� . Slope % � HORIZON I DEPTH _ � .— Texture grou �''L L V Consistence � ' Structure C-lraf ^�vu:•� �r«:,n Mineralo �r S '' HORIZON II DEPTH � — _c.( � — y� Texture rou � - � �� Consistence Structure 1L k j` Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo � HOR�ZON IV DEPTH Texture rou Consistence Structure � Mineralo SOIL WETNESS /- RESTRICTIVE HORIZON ,/' �/ SAPROLITE .�—" / / CLASSIFICATION ,• (�: LONG-TERM ACCEPTANCE RATE � , C�. 3 � ._ `J� !� �t 1 v,.L S SITE CLASSIFICATION: �✓ EVALUATION BY: LONG-TERM ACCEPTANCE RATE: v` � OTHER(S)PRESENT: VL�i-C ` REMARKS: LEGEND i,an s �e 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 Testure S -Sand LS -Loamy sand SL-Sandy loam L-Loam SI-Sil[ SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC- Sandy clay SIC- Silty clay C-Clay CONSIST .N .E l�is.t� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm YY�� 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 MineraloQv � � " 1:1,2:1,Mixed lyotes 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 wa[er 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 DCHT�OS/(1S (Revi�P.�l � , � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT l Account #: 990003670 Tax PIN/EH #: 5789-02-7364 8 Billed To: Harry Williams � Subdivision Info: Address: 972 Hartman Road Location/Address: Bailey Chapel-27006 City: Lexington Property Size: 4.6 acres Reference Name: Proposed Facility: Garage � **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. � Pemut Type: ew ❑Repair ❑Expansion Pernut Valid for: Years ❑No Expiration � � Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ UQ Non-Residential Specifications: Facility Type �_�'�'-� #People #Seats .� Square Footage(or Dimensions of Facility)��,p� G r (� ,l / Design Flow(GPD): "l v Type of Water Supply: ❑County/City ell ❑Community Well A� stated in 15ra NCAC 1�A.1969(a) I Site Modifications/Permit Conditions: �.ecept�d Svstems m:>v �lso be usEd � S stem T e LTAR Initial 1� -f-<c .+ Re air C c. � • Site Plan � __ � _\ � _ �` �� � . � � _ � � _._�\ . ► p/ � � �.�lpur`� � � ��� �j , ,- h � I �� �� (� ����l �� � �� � � �h �•t � y � .:\ 1�,j �� 3� ��i '�Q r t �, J s �. � � -�t�` \ � � . �` ��� J �� -�=�, � � � � 1 �i.�'�"�) � �— I� � � ��.ay� Environmental Health Specialist Date � q ^ � i.n.l 1-06