125 Cattle Way (2)DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753: 6780 / Fax # (336)753-1680
OPERATION PERMIT
Account #: 990005845 T�x �'ii�I.%EN #: 5757-64-0405
Bifle� To: William & Cylyndia Smith Su�itii�i�ian ir���: .. ,,
Re:�er�E�ce N�ni�: � LacatianrAd����ss: Cattle Way-27028
f�ro�c�sQi� F��:iEity: Residential �, ��o��riy�S�ix.�:: 4.016 Acres
a�TC Number: 5938
**NOTE** The issuance of this Operation 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 satisfactorily for any given period of
time. i ,�
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System Type: ''� ` S.T. Manufacturer ��'� Tank Date ✓ r� Tank Size F Q� d
Pump Tank Size Bedrooms:
� c56 Lt—S
System Installed By: � ,(..tr� Installer# Date: �"" i�— ��—
GPS Coordinate:
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Environmental Health Specialist
DCHD 11/06 (Revised)
Date: U � � � �•�
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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
Accr�ur�t #: 990005845 . "i�x F�I�€fEH #: 5757-64-0405
BiElc� TQ: William & Cylyndia Smith .'�� Su��i�i: iort Ir���: .
R�fer�r�ce N��ie: :� LacalianiAd+�E��s�: Cattle Way-27028
Propc�ssc9 F;�c:iiity: Residential � Pfc��er#y �iz�: 4.016 Acres
a'�i'C N�ar�tbe�: 5938
, Site Type: C�ew ❑Repair ❑Expansion
**NOTE** This Authorization to Consh-uct (ATC) MiJST 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. "
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Residential Specifications: # Bedrooms_� # Bathrooms� # People� Basement� Basement plumbing0
Non-Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size y� f Type of Water Supply: ❑County/City ,�Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) ��Tank Size IbDO GAL. Pump Tank � GAL.
�i /r .
Trench Width �_ Max. Trench Depth�(� Rock Depth� Linear Ft. �{�c��/�
Site Modifications/Conditions/Other: ��' �/��
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Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-8760.
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Environmental Health Specialist ' � Date:
Tlruri i � m� ruP�,;�P,��
. . - • Davie County Environmental Health
'�•� . P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax(336)753-1680
Account #: 990005845
Billed To: William & Cylyndia Smith
Address: 420 Frank Short Road
City: Mocksville
IMPROVEMENT PERMIT
Tax PIN/EH #:
Subdivision Info:
Location/Address:
Property Size:
5757-64-0405
Cattle Way-27028
4.016 Acres
Reference Name:
Propq��,��i�t,,ycj.,hR T�mpeovement 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: 6�,New ❑Repair ❑Expansion Permit Valid for: �45 Years ❑No Expiration
1`
Residential Specifications: # Bedrooms � # Bathrooms Z/'Z: # People Basement� Basement plumbing�
Non-Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):�� Type of Water Supply: ❑ County/City �Well `❑ Community Well
Site Modifications/Permit Conditions:
Environmental Health Specialist
i.p.l 1-06
w.. _ i I � •
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APPLICATIO OR SITE EVALUATION/IMPROVEMEI�IT PERMIT & ATC
� � � � � � Davie County Environmental Health
P.O. Box 848/210 Hospital Street
APR 0 4 2012 Mocksville, Nc Z�o2s
(336)753-6780/ Fax (336)753-1680
BY: -
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both
y Type of Application: � System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Naine �U i( � 1Cwv� 3 C ` d,' S,-E Contact Person �; l\�aw. 5 w«-�k
Address Z� rck�� 1�c,,r� 1�, Home Phone �3'3(0� qq& -iSZ (p
City/State/ZIP /hoc..ks'.,; \�e /�f �, 2�02$ Business Phone C33(o� `t8Z ,, 3(09 S'
Name on PermidATC if Different than Above.
Mailing Address
YKUY�KI Y 1NrUK1V1Al1UN �llate House/N'acilrty Corners N'la ed
NOTE: A survey plat or site plan must accoinpany this application. Included: ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan; no expiratiori with complete plat.)
Owner's Name wi \�c.�v�n � ; � Phone Number
Owner's Address L�Zd �rcwtl�. �11��l� �2 �, City/State/Zip_(1/�aL\CS v� ll e/v.�.
Property Address .(1��.�1 e t,� ,o��, City (�,��Sv ��� e
Lot Size y, b 14 �t Tax PIN# 5 � 5� C� UDUD 5"
Subdivision Name(if applicable) Section/Lot#<
Directions To Site: 1'7��,,,,16� H2�. �e-�� o� ..,4"►.�� SL���- 12.�t�+ o K cafl,-l�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 �e�
�,poes the site contain jurisdictional wetlands? �Yes ,.�e—
Are there�any easements or right-of-ways on the site? Ycs �'
Isthe site subje�t to approval by another public ager.cy? Yes .�o
Will wastewater other than domestic sewage be generated? Yes t,Akf'
IF RESIDENCE FILL OUT THE BOX BE�OW
# People �( # Bedrooms � � # Bathrooms ZYz Garden Tub/Whirlpool �❑No
Basement•.—C `es �No Basement Plumbing: � �No l�,;�e,�. l S:„��-
IF NON-R�SIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 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 system requested: onventional �Accepted ❑Innovative ❑Alternative- ❑Other
Water Supply Type: ❑ County/City Water ew Well ❑Existing Well ❑ Community Well
_ _ _.. _
Do you anticipate additions or expansions of the facility this system is intended to serve? � ❑ No
If yes, what type? � p${a. � ca� :��o�.� �-�cs, �Q� � S� vt1� ( 5�4-e�
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 permit(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 rul s. I understand that I a respo ' or the proper identification and labeling of property lines and corners and
locat� ' g Qr stakin se/f 'lity tion, proposed well location and the location of any other amenities.
Property owner's or own r's legal re s tive sig e Site Revisit Charge
Date(s):
/Z Client Notification Date:
Da e EHS:
Sign given ❑Yes ❑No
Revised 11/06
Account # � 1� 7�
Invoice # � 4i�
����I2 �d- �fi��
GoMAPS - Davie County NC Public Access
� ***WARNING: THIS IS NOT A SURVEY!***
This map is prepared for the inventory of reaI property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
� primary information sources should be consulted for verification of the information contained on this map. The
:_ County and mapping company assume no legal responsibility for the information contained on this map.
� WATERSHED STRUCTURES
WATER_BODIES
� C�UNTY_BOUNDARY
STFtEETS
�' RAtLROAD_CENTERLINE
� PARCELS
CfTY_LIMITS
� BER6!UDA RUN
� COOLEEhSEE
� DAVIE COUNTY
ah40CK5VILLE
• nccountics
DAVIE
� <all other values>
Monday, Apri�2012
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' L. JONES
97, PG 143
5757649313
ntw
IRON
IRON
� C3
WILLIAM K. SMITH
D. B. 212 PG. 588
PIN # 5757640405
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.�.—�
tTIE�
CATfLE WAY
�.,...�..... -... �...�..�.R
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AREA= 4.016 AC.
TO BE RECOMBINED W.tTH
�405
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wEw 67.69
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F---
EI�ITFa r..- �.--
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CONTROL
CORNER EXISTING
IRON
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� � ti�°�;"° KEITH L. JONES
^�' S��°� D.B. 197 PG. 143
PIN #.5757649313
NE}y
IRON
.
CONTROL •
CORNER
HVI
Fled for registi
Plat Book
Filing fee � paid
KEITH L. JONES
D. B. 384, PC 104
PIN # 5757646592
CATTLE WAY
•EXISTING 30' EA$EMENT
SEE D.B. 384, pG. 104
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NOTES:
1. TOTAL TRAC
2. TOTAL AG.=
3. NO NCGS C
4.TOBEAR
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section , ,,�
Soil / Site Evaluation
'APPLICANT INFORMATION � PROPERTY INFORMATION
Account #: 990005845
Billed To: William & Cylyndia Smith
Reference Name:
Proposed Facility: Residential
a
Property Size
Tax PIN/EH #: 5757-64-0405 �
Subdivision Info:
Location/Address: Cattle Way-2702 / ,��/
4.016 Acres Date Evaluated: � ! �.�°�` �`
Water Supply: On-Site Well '�v'� Community
Evaluation By: Auger Boring ' i.� Pit
�
FACTORS 1 2 3
` Slope %
�HORIZON I DEPTH
Texture group
Consistence
$itUCiUIC
Mineralogy
� HORIZON II DEPTH
2
4
,�
Public
Cut
5 6 7
��`°�'t� �"�' y.� � � k,�.
"e',��,.;' °,7s{ �`�- `:r;:' rzf';� ,
, �.,. : �. }'` :r 7.fti � � �
. .�
� �f'^ �',�. �. ,. ,..��� rF � �:` ��1;..
} . . �� ��,.:�5 rf ��, W 6 -� �i,�'� �'4.'�Ru. �� � _.^y • �,�„�.a
Consislein�e v"1 H�`� �'r �;.�=a a{ p f j, ,
d
Structure t.i^.i«<r�I �,.> �"i° -� .* r, a;~; f`� r z tr+�"�.i7r..' :���`� -
Mineralo � ► . � ' ` � - " ` �
HORIZON III DEPTH -
Texture rou �
Consistence
Structure
Mineralo
HORIZON IV DEPTH i
Texture rou
Consistence �
Structure - , "�,- "
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON �
SAPROLITE
CLASSIFICATION •,''.S� S �' :Y �
LONG-TERM ACCEPTANCE RATE f . 5 . 2
. SITE CLASSIFICATION: � EVALUATION BY: ��'."!�'a"�•��c�',{� ���-,/'�
LONG-TERM ACCEPTANCE RATE: •� OTHER(S) PRESENT: �
REMARKS:
LEGEND
�.�ndsca,pe 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
T�xturg
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
ONSIST ,N .
�415�
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
Structurg
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
IYQ�e&
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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