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311 Campground Rd. DAVIE COUNTY ENVIItONMENTAL HEALTH •„ . P.O. Bax 848/210 Hospital Street , : � ,� • Mocksville, NC 27028 . (336)751-8760 Fax # (336)751-8786 Account #: 989900199 Billed To: Robert Brodauf Reference Name: Proposed Facility: Residence OPERATION PERMIT ��J Tax PIN/EH #: 4797-41-4609.02 Subdivision Info: �� Location/Address: Campground Road-27028 Property Size: 1.88 � � ATC Number: 4594 **NOTE** The issuance of this Operation Pernut 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 gnarantee that the st m wiU function satisfactorily for any given period of time. �Y ��'�V �c��b �a �%— � System Type:_�,___�� S.T. Manufacturer T P l r Tank Date-� -� 4 6Tank Size �� d v Pump Tank Size System Installed By: � �� U �� � � �� � h E.H. Specialist: J cY�dok� ate: (1� � � � � � � + 3,�' � �,i �� , ---- ' 1�.� �, 3�Y��� 6 � d (� y. G°v DCHD 11/06 (Revised) 73 �3' D �� �'��. a�a1 -- �.�e r� � is`�i � �� — �� � 4�c..�S F � I.� v � � S�tiN�Puc, - ��� (i��5 `� � i�10� 5 Y. C�o�T � � �, ��rf�t�. , DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900199 Billed To: Robert Brodauf Reference Name: Proposed Facility: Residence ATC Number: 4594 Tax PIN/EH #: 4797-41-4609.02 Subdivision Info: Location/Address: Campground Road-27028 Property Size: 1.88 Site Type: �ew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MCJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treahnent 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 a# People � Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type .lxtrH # People �# Seats Square Footage(or Dimensions of Facility) /Soo S t- Lot Size l$'���.._ Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 34� Tank Size / o� GAL. Pump Tank �AL. < < Trench Width 3 i� � Max. Trench Depth 3� � Rock Depth I d�� Linear Ft. 4 3 G� �� stated fn 25.� NC�,C �.^:'�.i�f�(5� Site Modifications/Conditions/Other: �;abe��e� �1'�•','�,r �,-.., <<-� `- t�s<; Contact the Davie County Environmental Health 5ection for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-8760. i� _ / ._ � i � 1 � z I Q� �.�pUc sc� � �8 �r I _�o � -� rtust Itiov� ���t Ptv fivo-1 �7 � F� C QT 7' 4�� dr p�.�P ��u b.� ►�-�-�d.�d �3� y..r� O-��_�� — — � � � Environmental Health Specialist_ �7��r�1o!���/� Date: ����d 7 DCHD 11/06 (Revised) �ca , '''} P`�'I� FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � Davie County Environmental Health �p� 1 �� 20�� P.O. Box 848/210 Hospital Street 1 � Mocksville, NC 27028 �� �J� ��`� (336)751-8760/ Fax (336)75I=8786 � � �na�ca�A�H� - r�� �,1� _1�(0� � valuation/Improvement Permit CrYAuthorization To Construct(ATC) ❑ Both �� � , plication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility �� ***IMPORTANT*** 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 �,��,,;-� �,- ,��,,v� Contact Person `����,� Billing Address �a ;� ( :��„�, � � r-�,� � � "�Z �,�— Home Phone `70 � - . �' ��, --'�?j `� . ' City/State/ZIP �}r,,�•��� ; � lf• �'U , c: - ��C^ :� � Business Phone � � - ` i � Z - O � i � �'� Name on Permit/ATC if Different than Above Mailing Address ' Ci PROPERTY INFORMATION *Date House/Facilitv Corners Fl NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut.is valid for 60 months with site plan, no ex irat' with complete plat.) Owner's Name ' � , ��- .�- ! ��.,, Phone Number7�4 -�oZ-v� I� Owner's Address ��: z't�, -^.;, ,; A City/State/Zip S+: ��,�sv , l� N c'�. ��G .;Z� Property Address �3 � 1 C_'a,,,,. ,, f, ,�: �..� �'r.�. City S{z: l�s,.� : I�Cr 11�' .C'. Z.�.�, ,�.5' Lot Size 1s ''��L' ;�-� r(;�, . �' Tax PIN# ��y� �� 53- jw� Subdivision Name(if applicable) Section/Lot# _ � Directions To Site: '� ¢�, ��,► t . n a ,, , !�e If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes C�1 Does the site contain jurisdictional wetlands? ❑Yes �f� Are there any easements or right-of-ways on the site? ❑Yes C�'No Is the site subject to approval by another public agency? ❑Yes C��1- Will wastewater other than domestic sewage be generated? ❑Yes C►3'No IF RESIDENCE FILL OUT THE BOX BELOW # People _� # Bedrooms _ 3 # Bathrooms „Z Garden Tub/Whirlpool - Basement: ❑Yes C�'No Basement Plumbing: ❑Yes C�'1�10 IF NON-RESIDENCE FILL OUT THE BOX BELOW �� es ❑No Type of FacilityBusiness t�,;r �, Total Square Footage of Building % 54��1 # People # Sinks � # Commodes �_ # Showers �_ # Urinals Estimated Water Usage (gallons per day) 3d ••' S`� (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Typesystemrequested:, ClConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well �xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Q No 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 deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of properiy 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 owner's or owner's 1 al representative signature ' Date(s): /4' Dat Sign given ❑Yes ❑No Revised 11/06 � IV a�� �e�m �� h �s ���� rarJ (�A-k���l�ec� Client Notification Date: EHS: Account # Qo C! Invoice # __�c�`�t _ l � ; �- E�'� " 1 L �Ri �F N' gp' 11' 3'�� �'Op� R� L 42 0 WELL W � � 280.06 Llti�� \ NcuSE � :� �__ : \ \ ,, 0�£f�� v / \ -o �;5� �, � • • 4, �7 PLACED IRON ( % ����` � � : ' .�! � 2' oRtivE F''" ' ��� G� 27.,A z12.52 ;� �Q�� �? '3 �h t f ; _. \� _ ' /� NEw . �--- -� _,. p��c� ,RON ��� - - � �. AREA = > . > 5_, 5 A C. � : PW aiN �y � a / � � (INCLUDES S.R. 7177 R/W) . IQ ' � � 'j�lCl \ � r \ f / '�, � ,o \ 1 / I ` F o 2$ � I,rn \ . � c y a' � ��' � 5. O o �'� // i, ` ` � .� �.�� o � � � ❑ui L `j . i � ��' \ A,� a _ ; �o. �� a ^ '` wE� -� 6 E . � . . p � - . . N -2A1� . �..•.� � .. `�1�1� � _ . . . � �.. - ` �;� .. � � �`T ._ ..,��-' • �� �' / � , . 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' v APPLICANT INFORMATIOI�I Account #: 989900199 Billed To: Robert Brodauf Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil / Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 4797-53-1208 Subdivision Info: Location/Address: Campground Road-27028 Property Size: 1.88 acres Date Evaluated: �'— �� �� Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit Public Cut LONG-TERM ACCEPTANCE RATE: �- �7 J__ REMARKS: EVALUATION BY: OTHER(S) PRESENT: LEGEND i.�ndscane 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 �IQiS� VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3�' 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 - Prisma[ic Mineralogv 1:1, 2:1, Mixed LY�t.C� 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 - gaUday/ft2 DCHD OS/OS (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 Account #: 989900199 Biiled To: Robert Brodauf Address: 302 Campground Road City: Statesville Reference Name: Proposed Facility: Residence IMPROVEMENT PERMIT Tax PIN/EH #: 4797-53-1208 Subdivision Info: Location/Address: Campground Road-27028 Property Size: 1.88 acres **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. Permit Type: Q3�ew ❑Repair ❑Expansion Pernut Valid for: k�5"�'ears ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms_� # People y Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type �Gvn # People_(_ # Seats Square Footage(or Dimensions of Facility) /�"DO S� Design Flow(GPD): (.Q O Type of Water Supply: ❑County/City B'Well ❑Community Well %E' S�ai�'.ii I;'7 �.�.�,� �iCi�iCi %i.�i.�. ti..�.`n.�1J� Site Modifications/Pernut Conditions: €�cCe�sted ��vatF;:�s r+ta�� al�� br� use Site � Initial Environmental Health Specialist i.p.l l -06 LTAR Date � "�'' � 7