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805 Cedar Creek Rd • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005234 Tax PIN/EH#: 5842-24-0041 Billed To: James Dobbins Subdivision Info: Reference Name:' Permit#3352 Expired Location/Address: 805 Cedar Creek Road-27028 Proposed Facility: Residence Property Size: 4.244 Acres ATC Number: 4951 **NOTE**The issuance of this Operation Permit shall indicate the system described on-thee ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal y b� but shall in NO WAY be taken as a guarantee that the system will function satisfac only for any n period of time. ��L .System Type: � S.T.Manufacturer Tank Date nk Size©J /� S Pump Tank Size t43 System Installed By: E.H.Specialist: u" D t —G Q - i G-t1t �K Y .e✓ yo t 71 �=--, S 3 1 DCHD 11/06(Revised) • 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 #: 990005234 Tax PIN/EH#: 5842-24-0041 Billed To: James Dobbins Subdivision Info: Reference Name: Permit#3352 Expired Location/Address: 805 Cedar Creek Road-27028 Proposed Facility: Residence Property Size: 4.244 Acres ATC Number: 4951 Site Type: ❑New ❑Repair ❑Expansion **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—3—, #Bathrooms3'S#People 3 BasementCOBasement plumbing❑ Non-Residential Specifications: Facility.Type #People #Seats Square Footage or Dimensions of Facility) Lot Size �•a14 q Type of Water Supply: ❑County/City 2<11 ❑Community Well System Specifications: Design Wastewater Flow(GPD) 160 Tank SizeGAL.Pump Tank GAL. [ Trench Width 3 G tf Max.Trench Depth '/ Rock Depth V.1f1 Linear Ft. &96 .r J Site Modifications/Conditions/Other: L �i o YL�'Y,�-(.tN F� e cl tray t on Cao n o-t be- r°Lkt�'1 cc c-c-� t o -1 •e �P-tti Ir 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#V336 751-8760. \kt VO 6-10 v5 N' - r AV Ae L207 /10 Environmental Health Specialist Date: DCHD 11/06(Revised) =� oto,► 't1�. �u��Gcicl Ir�� -h �--- TI, OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC - Davie County Environmental Health f3 2�� P.O.Box 848/210 Hospital Streetja yid r Mocksville,NC .27028 "1 (336)751-8760/Fax(336)751=8786 ApplicaltioiiPM&O Al HEAUK uatton/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both o pplication: ❑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 A &�Jjffc Contact PersonC=s 40 d�Wl' Billing Address Sob A o2 Home Phone 33 City/State/ZIP 9L-1141-,re ffi (-,/-c .2706) (. Business Phone Name on Permit/ATC if Different than Above f a,6i�f Mailing Address oC City/State/Zip 19011,o,4e tr, wc, 2,-.,o PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with si a plan,no expiration with complete plat.) Owner's Name 714- was d ' s Phone Number Owner's Address v 6 /9 J2v- City/State/Zip v /rc e Ky C Property Address C P ti c-R e-7.< City Lot Size Tax PIN# ALIZ-14-tm L/l Subdivision Name(if applicable) Section/Lot# Directions To Site: ,�,,,. cafe , C.Q d u(c. — 7?x cd -U,,-, )Ti t ll kL-,,4 `I// - 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 ❑No Does the site contain jurisdictional wetlands? ❑Yes []No Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes ❑No Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW #People 3 #Bedrooms _3 #Bathrooms 3.S Garden Tub/Whirlpool es ❑No Basement: B-Y-es ❑No Basement Plumbing: ❑Yes 2No IF NON-RESIDENCE 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 - E'g1ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [�- o 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 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 rules. I understand that I am responsible for the proVt identification and labeling of property lines and corners and locating and flagging or staking the house/facili ca to ro d well location and the location of any other amenities. 2 Site Revisit Charge Rxape�owner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# SZ 34 Revised 11/06 Invoice# f __ GoMAPS -Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System ClicIka Lay To St❑t eev Map j Ps 2oe) To Scak:: Go aha. F �y ,� ✓ - Quick Search:(County ID or Owner Name) GO 8 !p ❑ PARCELS Ma Tips Available v '. Map Layers Tools Help Links• Address/Name/Parcel Search I Results 8J5 J http://maps.co.davic.nc.us/GoMapa/map/Index.cf n?maimnapservice=gomaps&CFID=4129&CFTOKEN=61640881&ini[ializem... 3/3/2009 �r DAVIE COUNTY HEALTH DEPARTMENT � `. Environmental Health Section r P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT ` Account M 990002457 Tax PIN/EH M 5842-14-3650CD Billed To: Chris Dobbins Subdivision Info: $0T Reference Name: Location/Address: 841 Cedar Creek Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3352 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type /7 #People J/ #Bedrooms Q?' #Baths Dishwasher: JV Garbage Disposal: ❑ Washing Machine:e Basement w/Plumbing:R*`� Basement/No Plumbing: 171 Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply 111el Design Wastewater Flow(GPD) Site: New)e Repair System Specifications: Tank Size/,,��} GAL. Pump Tank GAL. Trench Widt �Rock Depth Linear Ft. Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection ofthi§ system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 in.on the day of insta Telephone#is(336)751-8760.**** 1 i h , man y+� Environmental Health Specialist's Signature: / Date: DCHD 05/99(Revised) 6rmilE�Dfej ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990002457 Tax PIN/EH#: 5842-14-3650CD Billed To: Chris Dobbins Subdivision Info: &15� .Reference Name: Location/Address: 541"?,'edar Creek Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 3352 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER COJNSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: T f�'� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AT Davie County Health Department C� Q 1 Environmwta/Hea/th Section P.O. Box 848/210 Hospital StreetJfi� Mocksville, NC 27028 Q �) (336)751-876.0 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. Rifer to the INFORMATION BULLETIN for instructions. E; 1. Name to be Billed 1 t 5 D D bh i n,s Contact Person Uri n 'bd b iz Mailing Address 5oto &A-mare �:Nd Home Phone 99 O 6 5 3 J �Cv City/State/ZIP -A d y e'e ,/' v a`oo�p Business Phone 14— l -3 40 R 2. Name on Permit/ATC if Different than Above 0 / a s .res Mailing Address City/State/zip IK�l / J?-.,. 3. Application For: EV9ite Evaluation Improvement Permit/ATC CI Both 4. system to service: UAfouse ❑.!Mobile Home ❑ Business Q❑ Industry 0 Other 5. If Residence: # People `fes # Bedrooms J # Bathrooms IN'Dishwasher II Garbage Disposal IL)Tashing Machine 14-11a�sement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # .People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water _Usage (gallons per day) 7. Type of water supply: ❑ County/City W�lell ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes &W If yes,what type? ***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBhIITTED by the client with THIS APPLICATION. pr Dimension : WRITE DIRECTIONS(from A9ocksvillc)to I'1201'tsli"1'1': Tax Office PI # 594J14-3(650C- HA"/C 53 40 Firm or�fo n R�- --urn Property Address: Road Name gYl War(./ !' IV-4 nr,�dG t - City/zip Ole /V e.)70-V r,G&4- on Q.2t_,( - Go a.DWX If in a Subdivision provide information,as follows:- ` 1 �Q — niz Is d n 'he. Name: Section: Block: Lot:�— Date Property Flagged: 3- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or changed. I,also,understand that I ant responsible for all charges incurred from this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by _ to conduct all testing procedures as necessary to determine the site suitability. f DAT[; q � SIGNATURE V THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and l roposed property*lines and dimensions, structures, setbacks, and septic locations). GAS—u,�— Site Revisit Charge PQr" Kv3Datc(s): Client Notification Date: CHS: v Account No. Re ised DCHD(07/99) Invoice No. of 8 — 836 812 tiRpy r 841 612, W40 1+1av1 4 741 6126 1136 06 47 Axa i �r a-ai lazs6, vuo sole � aae1 e5o .' noem' 2z7 4 5 - �IN Ale V DAVIE COUNTY HEALTH DEPARTMENT > - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002457 Tax PIN/EH#: 5845-14-3650 Billed To: Chris Dobbins Subdivision Info: Reference Name: Location/Address: 841 Cedar Creek Road-270/28 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well I Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1. Sloe% IT HORIZON I DEPTH 66. y Texture grouS Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence l Structure Mineralo l HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: L� LONG-TERM ACCEPTANCE RATE:_ THER(S)PRESENT: REMARKS. � Eire/z �� U� Awl. ✓G� LEGEND Landscape 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 CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet 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 Mineralogy 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 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 DCHD 05/99(Revised)