323 Cedar Grove Church Rd�
�
� DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
Account #: 990005118
Billed To: John Brown
Reference Name:
Proposed Facility: Residence
ATC Number: 4889
OPERATION PERMIT
Tax PIN/EH #: 5777-15-0467
Subdivision Info:
Location/Address: Cedar Grove Church Road-27028
Property Size: 1 Acre
**NOTE** The issuance of this Operation Pemut 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. � n/ (� � �(� () g
7
System Type: �� S.T. Manufacturer�� � Tank Date� Tank Size 1 C���
Puxnp Tank Size
System Installed By: � � � �� 1 `�'e E.H. Specialist: Date: � � �3 � (
�G� f
�'
�
1, I — �
� � —. �' K ; �'�..�
� �(a K� �
r
I
� d Le � r C Ceda� .�rou-e C.� I� �
DCHD 11/06 (Revised)
0
' DAVI� CO(INTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
�, � b
Q),�3\
b
AUTHORIZATION FOR �VASTE�VATER SYSTENI CONSTRUCTION
Account #: 990005118 Tax PIN/EH #: 5777-15-0467
Billed To: John Brown • Subdivision Info:
Reference Name: Location/Address: Cedar Grove Church Road-27028
Proposed Facility: Residence Property Size: 1 Acre
�
ATC Number: 4889
Site Type: �Pdew ❑Repair OExpansion
*#NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Envirorunental
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 chan�e.
Residential Specifications: # Bedrooms� # Bathrooms a # People � Basement❑ Basement plumbing❑
Non-Itesidential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size 1 G�!'� Type of Water Supply: CXCounty/City OWell OCommunity Well
System Specifications: Design Wastewater Flow (GPD) i[� Tank Size�O�AL. Pump Tank ��� GAL.
�� (� J ' � Q�
Trench Width �4 Max. Trench Depth�� Rock Depth� Linear Ft._�
As stoted in 15N NCAC 18A.19U?(5)
Sile Modifications/Conditions/Other: �ccepted Systems may also be usEd
Contact the Davie County Environmental Aealth Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-8760.
� ` . . _.._._.._
. �.
`° � �� I6o` x 3
��
�iivu•onmental Health Specialist
n/`ATl 1 1 /(1F, (R ovicarll
��s
ate:_ � —��
❑
�
' ' � Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)75,1-8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account #: 990005118 Tax PIN/EH #: 5777-15-0467
Billed To: John Brown Subdivision Info:
Address: 327 Cedar Grove Church Rd. ' Location/Address: Cedar Grove Church 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 Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: C�Tew ❑Repair ❑Expansion Permit Valid for: C�?'�Years ❑No Expiration
Residential Specifications: # Bedrooms �# Bathrooms_� # People � Basement� Basement plumbing❑
Non-Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): ��� Type of Water Supply: G}County/City ❑Well ❑Community Well
As �tated in 15�1 NCAC 1�A.1969(5)
Site Modifications/Permit Conditions: t��Cepted SyStems may �)so he usbd
i.p.l 1-06
. � , ..-�;' \
� ��
M , y ,�
/ �' (�i �LICATIO
��
o � 9 2��� �
`, ��� _ ;
�
__ �
p� Nc a�.�'�
��RON�'•�����,,�,�,�
� �av�� �
�
R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
� (336)751-8760/ Fax (336)751-8786
'I- Site aluation/Improvement Permit ❑ Authorization To Construct(ATC) '_ Both
tion. ew 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 o . O r-cJ /V Contact Person
Billing Address Q,r �ro ,. Home Phone �— Z 3— d
�ity/State/ZIP t�J,OGK�'U � `/��, ,-tt. C . Z � O � $' Business Phone 9� �f — �ZO :
Name on Permit/ATC if Different than Above
Mailin� Address
PROPERTY INFORMATION
City/State/Zip
*Date House/Facili
d ��—y (7�'
NOTE: A survey plat or site plan must accompany this application. Included: L�YSite Plan ❑Plat(to scale)
(Pernut is �v��id for 60 inonths with site plan, no e'f piration with complete plat.)
Owner's Name "T�o �► %. o c,�J/l,/ Phone Number 91 ��2�—���
Owner's Address �., w�,- ('r�o , City/State/Zip i21ocf4rJ�`��e �(%4'. 2 O;
Property Address �� �,�p�, , City c. u, � ��,
Lot Size f J�-Y� , Tax PIN# �� _. � � r
Subdivision Name(if a plicable) 6 Section/Lo # /�
Directions To Site: %� .��, o,,`, �, �,..� �, , z rn;l� � 1���:
If the answer to any of the following questions is "yes", supporting documentati�onf�'ust be attached.
Are there any existing wastewater systems on the site? ❑ Yes �'1Vo __
Does the site contain jurisdictional wetlands? ❑Yes ��f
Are there any easemenls or right-of-ways on the site? �Yes �1V
Is the site subject to approval by another public agency? ❑Yes �� �
Will wastewater other than domestic sewa�e be �enerated? ❑Yes QNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People � # Bedrooms _� # Bathro�ms � Garden Tub/Whirlpool ❑Yes
Basement: ❑Yes o Basement Plumbing: ❑Yes �
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 system requested: N1Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: (5"County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility tl�:s system is intended to serve? ❑ Yes N"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 pennit(s) or ATC(s) issued l�ereafter 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 �vith 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.
l
� Site Revisit Charge
Pr rty owner's or owner's legal representative signature '
J ` � ` �7-�
Date '
Date(s):
Client Notification Date:
EHS:
Sign given ❑Yes ❑No Account # �
Revised 11/06 -- Invoice # _ `�;, /' /� / j
7�
r ' • •
. •
� �.
. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION
Account #: 990005118
Billed To: John Brown
Reference Name:
Proposed Facility: Residence
PROPERTY INFORMATION
Tax PIN/EH #: 5777-15-0467
Subdivision info:
Location/Address: Cedar Grove Chu�ch Road-27028
Property Size: 1 Acre Date Evaluated: ( ��-�—d�
Water Supply: On-Site Well Community
Evaluation By: Auger Boring � Pit
FACTORS � 1 2 3
Texture groi
Consistence
Structure
HORIZON II DEPTH
Consistence
Structure
HORIZON III DEPTH
Texture group
Consistence
Structure
HORIZON IV
Texture group
Consistence
Structure
SOIL WETNESS
RESTRICTIVE HORIZON
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
�
SITE CLASSIFICATION: � S
LONG-TERM ACCEPTANCE RATE: � 3
REMARKS:
�
Public ,�_
Cut
5 6 7
EVALUATION BY: �C��2 /V��onS
OTHER(S) PRESENT: I�v1 �Yl y R1'�l�
LEGEND
i,andscape 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
•�► �►•
�IQ1S�
VFR - Very friable FR - Friable FI - Firm VFT - Very firm EFI - Extremely firm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very S[icky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
Slrustur�
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralo�v
1:1, 2:1, Mixed
L�iQt�S
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)
m
TTA D T ....... •..�.... ........_......... _...� __7 /J.,..IC.n . � �.��� .. � ... � .� . ..
■���■■����■��■■���■�■�■■��������■������■■ ■■�������■■■����■�■■■�■�■■�������������■■
■�������■��■■■�■����■��■■�����■�■■����������■■��■�■■■■�����■■���■��������■�■��■��■■
■■��■■�■■���■■■���■■■■��■����■■■■■����■��■���■�■■��■�■������■����■�■��■■��������■■■■
■■�■■■����■�■■������■���■■■�■�■■■■■�����■��■■■■���■■��������■�■�a����■■■������■�■■�■
■��■■■■�■�■■■■�����■���■■■■��■■■■�■��■��■�■■■■����f��■����I�■�■�■■���■�■�■■■������■�■■
■■��■���■��■■■���■�■��■■■■�■■■��■■■�■��■■��■■■■���!�������I�����■�■�����■■■■�■����■�■■
■��■■��■�■���■■■���■�■■�■■�■����■■�■■��■����■■■■/■��■■���I����■������■■��■�■����■���■
■�■�����■�■■��■■■���■■��■■��■����������■���■��■������■�■�I■■��■�����■■■��■�■■���■■��■
■■��■■�■������������■■��■�������■�����■■■ ■��■����■�■���I�■�����■�■■■��■■���■■■■■��■
■��■������■��■�■���■■■■�������■■������■■��i■������i■■�■�■������■��■�■■■�������■��e���■
■■��■■■���■���■������■�■■��■����■����■����■���■■t�i■���■■���■�■■����■■��■�����■■■■■��■
■��■■���■���■■■■���■��■■��■��■��■�■���■��■���■����i■■■����i��■■�■��■■■■��■������■■■��■
■�������■■��■�■■����o��■■■■����■�■■��■��■■�■�■����i■■�����i�■■■■���■����������■��■���■
■������■■�������■���������■���■�■■■■���■■�■������n■■�����i�■■■��■������■�������■■�■�■
■��■���■�■■�■■■��■�������■��■■��■�■���������■■■��n��������■■■■�■��������������������■
■■����■■■■■■■■■���■����■�■■■■■■��■■■�■��■�■■�■����i��■■���t��■■����■�■���■��������■��■
■■�����■■��■�■����■■■�■�■���■■■■�■�■■���■ ■■■��■�i■■�■���i■■■�■■■■■■���■�������■�■��■
■������■����■����■�■���■■■��■��■■■�A���■��ii��������:���■■��■■��■��■�■■�■�■��■��������■
■��■■��■�■��■�■��■■�������■■����■■��■�■■��■■■■■���I�\ir■■■11�������■�■■■����■■■�■�■���■
■■�����■■■■■■�■�����■�■���■�■■■���■■■�������■�����If�ii��l�����������■■���■����■�■■■■■
■�■����■■�■■�■��■��■����■�\�■�■��■���■■��■�■■■��■�I���■��'�■�����■���■���■■■������■�■■
■������������■■■■■���■�����■����■���■�■■■��■■■■���'�■0�■�������0■■�■■����■■�����■��■■
■���■■��■�■���■�■■�■■■��■■���5����■���■��■�■■�����■����■�����■■���■����■■�■��■����■■
■���■�������■�■����■�■��■����■���■��■����■�■�������%n■��;���■�■�����■���■���■■■�����■
■�■������������■�����■������■■■■■��■��■������■�■A����■�I��v����■■�■■■����������■���■
■■��■����■�����■�■■������■��■■��������===���������i�■���/I�����■■�■���■���■�■��■�■�■�■
■�■�������■���■■■�■����������������■���.�r�r.;��������■i��a�������■■����■������■■■�■���■■■■
■��■�■��■�■t��■�������■���������������u�����.�...����a���i■■■■■���������■�■��������■■■
■����■■■�■������■■�����■�����■■■�...==::��s��iiiiiiu�.■������■■����■�������■��■����■■■
■■■■■����■■■��■�■���.■■■■■.�■����ii����������������u�►�■i���■■��■�■■�������■■��■��■��■
■■�������■■���■��r�■■���■��■�������■.�ic�����i�■■�■�■�i��:����■■■■��■����■■�■■■�■������■�■
■■��������■■�����r�����■s��■■��■■��������■�i������t�uc��������������������■■�����■��■�■
ii�iiiiiii�iiiii i�iiiiii�iiiiii�iiiiiiii«iiiiii�i�iiiii�iiiiiii�iiiiii�iiiiii�i
■�■■■�������■■■�r������■■■■■■������■�����■iii���■�■��i�Fr�■■�■■��s�■�����■■�■�������■■■■�■
■���■����■��■■■�������►�■�■■■�����������■�■�m■■�����■i,�����i��■■����■■�■������������■■■�■
■■�����■�■■■■■�I/��►�Jfil:�l��■■������■■■■�■�III■����■�■lir►c��l■�■■■�����■��������■�����■■�■
■����■■�■■��■■�I�■�����■��■■�������■�■■�■�I11���■�■��I�Gl��i■�■�■■����■��■■�������������■
■�������■■���■��■■���■�■��■■���■�■■����■�III■■�������I��Y\11�����■���������■�■■�■�■�����■
■■■�■����■■�■■�I����■���■■��■■■■��l��l�■■���III■�■�����I:f�!�11�����■�■������■■■■�����■����■
■�����■��■��■�IJ��■��■■■■■■■■■����1li�■���■��������I��■■11■��■����■�■���■■■■■■�■�■■■■�■
■�■�■■�����■■■I��■���■■■��■����■\����:=��� ■������I■�■■�t■�■■�■■�■�■�0���■■■■■■��■■■�■
■������■����■�■�����■■����=�ii��■��■■■������■��■��1��1��1��■■������■����■�■■■���■■■■�■
■�■■��■��■��■iiiiiiii���■■�����■■■�■�■■�■�����■�\■�i��l�■I1���■������■����■■■■■�����■■�■
■■��■■■������������■��■���■����■�■�■�■����,\■■��■��I����■II��■■�■���■■����■■■■������■■�■
■�■���■■������■■���■��■■■■■■���■��■�����■�Il����■��I���■�I��■■���■��■������■�■����■■■�■
■■■■�������������■■���■■■�■■�����■���■����11�■■����I��.�■�I������■��������■■■���■����■�■
■�■�■■��■�■����■■������■��■■���������■��■��1�����■��►�'i\�LI■■■�■■��■■■����■�■������■■■�■
■■■�■�■�■����■��■��■�■�■�■■�������������■ '■■■�■�■1�@!i�%���■■����■■■���■■�■��■■��■■■�■
■■■■■��■����■■■���■■■�■■�■■■��■������■����■�■■���i7�1`��■■■�����■�■���■■■■���■������■
■��■�������■■���■����■�■�■■�����■��■�■��■■�,��������■���■■■����■���■■�■����■����■���■
■���������■■���■�■■����■■■�\�■������■���■��I�������■■��■■��■�����■■��������■■�■■■�■�■
■��■��■����■�����■■����■�■������■■■���■�■■�I���■■■�■��■������■����■����■�■�■���■■■■■■
■■■����■■�■�����■■�■��■���■����������■■■■�■I���■■������!�■■��■��■����■■�■�■■��■■�■■■■
■��■��■����■■■■�■�����■■�■■��■����■��■��■�■������■■::�(%►]�����■�■�■■����■��■■�����■��■
■����■����■■��■���■���■■■����■���■���■������■■��■�Ea�rL=l1��������■����■�■■����■■■■�■
■■���■■■�■�����■■■■���■■■������■���■�■■�■ ■��■������l�il■■��������■�■�■■�■■�■������■
■�����■■�����/�■�■������■■���■�■��������■����������■�■■�■��■�■�■�■�■��■■■�■■■��■��■
■����■��■��■���■■■■�����■■�■�����������■■��►\������■���■■��■������■■■�■■����■■■■■���■
■�■�■��������■�■�■■�����■�������■����■�■■■��1�����■����■■■■■■■����■■■����■■�■■■�����■
■��r��■������■�■■��■���■■��■����■����■�■���������■��������■�����■■■����■■��■■������■
■�����������■■��■■�����■■■�����■���■�■�■��■�■�■�������■����■��■��■�����■■■�■■���■��■
■����■■��������■�■�����■■���■���■�����■■������■�����■�■■�������■■■���■��■�■■�■�����■
■��■�■■�������■■�����■����■����■■���■■��■���■����■����������■�����■�����■■�■■�����■■
■��������������■■■■��\���������■��������■_ ■���������������■���������■�■■■�■�������■
���������■����■■�\����■■■����■■■�����■����■■���������■■��■■�■■■■■■���■■■■�����■��■■
�; .
310)
-
120
L co
� �y
`� 1.110A
�88 1604 �
�
i72
K70000005101
oJ`� -
� ��
� �nj � �
��
6M ��,� K700000073 �5��
�
� � G` 1/
1 ,C� �'`Sc
0
1.040A
� N� 7357
�
� �0 A
8467 /
, - 67
�:�e�oc�:,�7�. ,
�s �'
� 2
3
� �
�� K700000075 ��`� �
�
�
N
1.815A
� 8010
�
�
2.049A
0235
4
254
�, 2.049A
N
� i�iQ� G:
,
0
N
�
�
N
•
••
�
�
103
O
�
J70000010306
K700000053