The URL can be used to link to this page

691 Cedar Grove Church Rd0 � DAVIE COUNTY ENVIRONMENTAL H�ALTH � P.O. Box �48/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990002335 Billed,To: David Jones Reference Name: Proposed Facility: Residence ATC Number: 4798 OPERATION PERIYIIT Tax PIN/EH #: 5767-72-3528 . Subdivision Info: 27d2� Location/Address: Cedar Grove Church Road-�7-086— Property Size: 17.8 Acres *�`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 guarantee that the system will function satisfactorily for any given period of time. (� � �_ �� System Type: �' S.T. Manufacturer��U a�nk Date Tank Size ��O'C/ Pump Tank Size_ ��. � �S � {, Q System Installed By: jAV� �`�u ��E.H. Specialist: OZ� ' 1� �te: /_/�� C' pCHD 11/O6 (Revised) �Ic'_ 1.��_` / F , DAVIE COUNTY ENVIRONMENTAL HEALTH �� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTE`VATER SYSTEM CONSTRUCTION Account #: 990002335 Billed To: David Jones Reference Name: Proposed Facility: Residence ATC Number: 4798 Tax PIN/EH #: 5767-72-3528 Subdivision Info: Z7o� Location/Address: Cedar Grove Church Road-2�()96— Property Size: 17.8 Acres Site Type: ew ❑Repair ❑Expansion *�NOTE** This Authorization to Constnict (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 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� # People � Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) � i. �S 7c�r Lot Size Type of Water Supply: B'�ounty/City OWell ❑Community Well System Specifications: Design Wastewater Flow (GPD) a�� Tank Size ffU��GAL. Pump Tan1cN/�GAL. �� c� dl �� f Trench Width 3�1 Max. Trench Depth �� Rock Depth�� Linear Ft. �i5 stated in 15Ei ��CF,C 1�3A.'! 95�J- j�) Site Modifications/Conditions/Other. �,ccepted Systems ma�d �Es� �� usc,a Contact the Davie County Environmental Health Section for �nal inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone #(336)751-8760. � � � _ � \� ��c` �. � Envirorunental Health Specialist. DCHD 11/06 (Revised) �� . d�-� 5 �� , ,� A �� -�,�-, � � , � C a5o \ � �_._/� ��i0 � � , 1 r � � ��'p�t'� � � � � _ �— — Date: � �— � � � r a ? , ♦ Y Y •� . � . of SITE EVALUATION/IMPROVEMENT PERMIT & ATC _�`'' ,_=--�'" �\ � j Davie County Environmental Health v� P•O. Box 848/210 Iiospital Street ��, - 5 �401 Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 — �•��a�F�t�EA�TN � ii �oi�� ,;��t�' mprovement Permit ❑ Authorization To Construct(ATC) l�oth p l�ieri:�IINew 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 _� ��j j�,v ,,� J o rti' �� Contact Person Billing Address ► � � UJ � .;; }—.,z-,.. � 'V",'J �� '�]] N , Home Phone �3 . �� City/State/ZIP CI �a ,nn tY� Q►-� r /✓. C t� �/ �_Business Phone Name on PermidATC if Different than Above Q� Mailing Address City/State/Zip " PROPERTY INFORMATION *Date House/Facility Corners Flagged �� -0% NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name �Q�p Phone Number Owner's Address City/St e/�i Property Address / �� City - : e Lot Size /'J. �Q ��/".�S Tax PIN# b%lo% �Z-352F� Subdivision Name(if app icable)�_ Se tio�'�rot# � Directions To Site: /�� A�'� //�/an/ ' /7N A P� (�5'!dl/p . � ,�i' .� the answe�to any of the follo`wing 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'�fNo IF RESIDENCE FILL OUT THE BOX BELOW # People ) # Bedrooms oL. # Bathrooms.�_ Garden Tub/Whirlpool ❑Yes �No Basement: ❑Yes �No Basement Plumbing: �Yes �No 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 Typesystemrequested:, f�onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Weil �,Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �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 Deparhnent to conduct necessary inspections to detern�ine compliance with applicabie 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/facil'ty location, proposed well location and the location of any other amenities. � \ Site Revisit Charge Property owner's or owner's egal representative signature Date(s): � � —s — (j Z Client Notification Date: Date EHS: .., Sign given ❑Yes ONo Account # Revised 11/06 Invoice # GoMAPS - Davie County NC Public Access � � �. . . .:; i Davie County, NC - GIS/Mapping System Page 1 of 1 a$�!� Click Her�e To Start Over QUicl� aearch:{Caunt3r ID c �• �+�a �„� � �'�''f `; � s�!� a�� ` Uu Active Lager. r ff�e r'7aR TPS GIS �pU't�� '� �' •,�''� �� PARGELS {Map Tips Available} ' Map LaXers � t�e�ult� � � http://maps. co. davie.nc.us/GoMaps/map/Index. cfm?mainmapservice=gomaps&CFID=412... 12/5/2007 • .. . ' ' � . �. �� a� � � � ' DAVIE COUNTY HEALTH DEPARTMENT • • r • Environmental Health�Section ' Soil / Site Evaluation APPLICANT INFORMATION �� PR PE�jTY INFORMATION ccoun . Tax PIN/EH #: 576�3b Billed To: David Jones Subdivision Info: '�,�Z� Reference Name: LocatioNAddress: Cedar Grove Church Road �666 Proposed Facility: Residence Property Size: 17.8 Acres Date Evaluated: 1 1-1 �-- r�"7 �� '.. . . Water Supply: • On-Site Well ✓ •= - Community � Public � Evaluation By: Auger Boring � Pit Cut �, FACTORS 1 2 3 4 5 6 7 Slope % � HORIZON I DEPTH �r �- Texture erouo �� S tructure � HORIZON II DEPTH '� - � Texture Qroup � - � G Consistence �' .�'�;r'v ..��; ;',✓ Structure � v <i u,� S �F [=t,. Mineralo p S HORIZON III DEPTH -Texture rou '' f'` " ' � ' Consistence Structure IUZ��:i Texture rou Consistence ' S tructure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION '� �'�' LONG-TERM ACCEPTANCE RATE � �„� Q• 17 SITE CLASSIFICATION: �l [.l i 1!� ��- EVALUATION BY: a 6 Cl G'� LONG-TERM ACCEPTANCE RATE: • OTHER(S) PRESENT: �N �� r� "d � �5 REMARKS : L�GEND I,andscane 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 - Sil[ SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C- Clay ("ONSISTENCE Mois VFR - Very friable FR - Friable FT - 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 StrLctLre 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 , Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface . � Saprolite - S(sui[able), 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 DCHI� �5/(15 (Revices�l Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990002335 Bilied To: David Jones Address: 124 Western Villa Drive City: Clemmons Reference Name: Proposed Facility: Residence � c � C C < � � � C IMPROVEMENT PERMIT Tax PIN/EH #: 5767-72-3528 Subdivision Info: �� Location/Address: Cedar Grove Church Road-��988 Property Size: 17.8 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. Pemut Type: ew ❑Repair �Expansion Permit Valid for: Years ONo Expiration Residential Specifications: # Bedrooms .,C # Bathrooms d— # People o� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Design Flow(GPD): �� Type of Water Supply: B"County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: A� st3ted in 15i: NCA� 1E3:1.��9(5� cu��.v +�•Ii—:iv•�T.'Ri'�TTur-'E.SSvr Ci.�.. Environmental Health Specialist Date � a"��?'�� i.o.l l -06 .