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554 Children's Home Rd DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street • Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990003619 Tax PINIEH 5813-73-4677-WR Billed To: William Revels Subdivision Info: Reference Name: Location/Address: 554 Childrens Home Rd.-27028 Proposed Facility: Residence Property.Size: 21 Acres AT ,�IFbVp*- The7iisssuance 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. System Type: S.T.Manufacture��- Tank Dat Tank Tank Size Pump Tank Size System Installed By: E.H.Specialist: J)Y4406at-e:- %�'9`�L � GPS Co mate: I/ed W1 LaU 2,, — 6,s AL L 100' 7b , �C1ui+d DCHD 11/06(Revised) �y-� 1 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 Account #: 990003619 Tax PIN/EH#: 5813-73-4677-WR Billed To: William Revels Subdivision Info: Reference Name: Location/Address: 554 Childrens Home Rd.-27028 Proposed Facility: Residence = Property Size: 21 Acres - ATC Number: 5764 Site Type: Otew ❑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. 4 Residential Specifications: #Bedrooms 2 #Bathrooms 2 #People 2 Basement❑ Basement plumbing❑. Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size_ Type of Water Supply: ❑County/City ❑Well XCommunity Well System Specifications: Design Wastewater Flow(GPD)2Tank Size I(XX) GAL.Pump Tank IU GAL. Trench Width Max.Trench Depth J(D<< Rock Depth Linear Ft. � fop1 Site Modifications/Conditions/Other: �� a 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. { 3 3JC1�' Environmenta�Hea pecialist Date: DCHD 11/06(Revised) • 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 Account #: 990003619 Tax PIN/EH#: 5813-73-4677-WR Billed To: William Revels Subdivision Info: Reference Name: Location/Address: 554 Childrens Home Rd.-27028 Proposed Facility: Residence Properly Size: 21 Acres ATC Number: 5764 Site Type: VWew ❑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. nhf�gJA�nA -to A Z&Aoain Residential Specifications: #Bedrooms #Bathrooms #People2- Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) _Tank Size GAL.Pump Tank GAL. Trench Width Max.Trench Depth Rock Depth—A',i Linear Ft. 149 Site Modifications/Conditions/Other: As: stated in 15A NCAC 18A.19uC(5 �ccP�►�� e,��+,m� ,.;--,, ;,l,a b ontact 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. eAc,(^, 25% IUI, To nn. w, Environmental Health Specialist Date: < DCHD 11/06(Revised) Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990003619 Tax PIN/EH#: 5813-73-4677-WR Billed To: William Revels Subdivision Info: 'Address: 135 Leisure Lane Location/Address: 554 Childrens Home Rd.-27028 City: Mocksville Property Size: 21 Acres 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: F.j1.New ❑Repair ❑Expansion Permit Valid for: V5 Years ❑No Expiration Residential Specifications: #Bedrooms _#Bathrooms Z #People Z. 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 IXCommunityWell Az,, stated in 15A NCAC 18A.1869Z), Site Modifications/Permit Conditions: ar,.cPnted Systems may alon t,n h� S stem Type LTAR Initial h . Repair h Site Plan _ s Environmental Health Specialis Date i.p.11-06 APPLICAT OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �� Davie County Environmental Health P.O. Box 848/210 Hospital Street APR ZQ11 Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Applic1t% or: ❑ Site Evalujtion/Improvement Permit ❑ Authorization To Construct(ATC) t 1 Both Type of Application: ❑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 sz� Contact Person VN�,_ E\A NS Address J 3 S �Q= y t \.,.►� Home Phone City/State/ZIP /U C_ a`7b2� Business Phone �3�j(� (v X55--.2�i(e 5 Name on Permit/ATC if Different than Above � 1a t'- t Mailing Address City/State/Zip 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 site plan,no expiration with complete plat.) Owner's Name W\ \\ \ S?_ Phone Number '- Owner's Address v City/State/Zip0G 1cSo: k \,p ju r- Property Address S _�c1�'\a�eye N44:D v.P City "M�. =e ti C �- ?� Z�/ Lot Size Tax PIN#Sq 13 — 3-4Lo9-1 Subdivision Name(if applicable) Section/Lot# DiVion o Site: N ` KIX. 60 A If the answer td any of tie following questions is`•`Yes",supporting docume on must be attached: Are there any existing wastewater systems on the site? _Yes _',No Does the site contain jurisdictional wetlands? _Yes _� Are there any easements or right-of-ways on the site? _Yes �F� Is the site subject to approval by another public agency?, _Yes Will wastewater other than domestic sewage be generated? Yes '_ o IF RESIDENCE FILL OUT THE BOX BELOW #People Bedrooms _?Z_ #Bathrooms Garden Tub/Whirlpool ❑Yes Basement: 1,11"CS oro Basement Plumbing: ❑Yes 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well VExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [L 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 proper identification and labeling of property lines and corners and locating and flaging or stakin the hou /facility location,proposed well location and the location of any other amenities. Property owner's oro ner's legal representative signature Site Revisit Charge Date(s): ! j Client Notification Date: Date EHS: Sign given ❑Yes ONO Account# cPr9 Revised 11/06 Invoice# 1 .GoMaps GIS Page 1 of 6 7-3-g07 7 l n 0 X Ml L; 0 x v ti } r 55 YT k- 57-11 57,11 T � � 1oo, Sri r/ �S� s http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 4/4/2011 DAVIE COUNTY HEALTH DEPARTMENT ~ Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003619 Tax PIN/EH#: 5813-73-4677 Billed To: William Revels Subdivision Info: Reference Name: Location/Address: Childrens Home Rd.-270 8 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: G Water Supply: On-Site Well Community Public Evaluation By: Auger Boring OC Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 2 OA HORIZON I DEPTHd- Texture group � Consistence Structure r Mineralogy p. 5cp s&p HORIZON H DEPTH - _1-/ Texture groupC C Consistence PL Structure K �6 IL MineralogyG HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Q5 25 P5 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 5 EVALUATION BY: AJWJ;-� h0WOW LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND T, ndscapp 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 )Z'IQ1S>< 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 Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineral= 1:1,2:1,Mixed LY9St*.T 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) ITAR _I.nnv_term nrrpnfanrP rate_ anihiav/ft) TWITT"ncinc ■>Nis■■11/i■■�eii/■i■■i■e■/■■■s■■■t■■iiia■■■■iif�i■iN■e■■�i■■ei■�eii■e■ ts■■■■■■■■■■s■l■■t■■■■■■■■■■■■■t■■■■■■■■■ttt■e■t■e■■■■/■■te■ee■e■■ ■■■■■ii■1ri■It■■■i■iiiei■1•i■/■i■■■lei■i�■e■/t■■/■iei■■■■■■■■■■i■ee■■ ■see■■■■■■■■■■■■■■■■■■■e■■■■■■■t■■■■■■■■t■■■■■■■tt■■t■t■e■■■■■■■■■ ■■■■■■■■■■/■■■■■■l■■■■■■■■■■■t■l■■■■■■■■■e■t/■■l■■■■■■■■■t■■■till•■ ■■ei■■■■/l■l■/t/■let■■■■■■t■■■■■■t■■■■t■t■tt■■te■te■■lt■■■t■■■■■■■ ■tt■■t■■■■■il■■■t■■■■■■e■■■i■■■lest■e■eis�s■■■tl■ae■■t■■t■t■■■■lt■ ■■■e■e■■e■■■/■■■■■ee■/■e/■■/■e■■ �,■ter.�■it■■■■■e■■■■■■■■■■■■■■■■■■ ■■:CC��!!1i>•/■■■■■■t■■et■■■■■■ee■l■■■■■i■■il■■t■t■et/■■■■■■■■i■■■t■ ■/ee■e■■■■t■■■■■e■11■e■■//tie■■e■■■■■/■ee■■■■■■■■■■■■■■■■■■■■■■■■e■ tett■■■■■■t■■■■e■■It■■t■■■■■■■■■■■tti■■■■■e■■e/■■■■e■feet■e■■■l■e■■ ■■■■■■■■■■■■/■/■■■■■■■■■■■■■E:�■i■e■/e■■ane//■■■■■■■■■■■■■■■t■ts■t■■ Miiiiiiiiiiiiimiiiiiiiiil�' iiii� l�iiiiiil�iiiiiiil�ii■tiiiii1�11 ■■■i■■e■/■■e/■■■■■/■■/■/■■■■eleite■■■■■■e■■■e■■t■tttt■■■tt■t■t■■■■ ■eel■■■■e■■■■■■■■■■■■■■■e■■l�=:S.�`!!!!■■■■■■■■■■■■■t■■■■■■■■■■■i■ ■■■t■■■■Ct■1■■t■■tft■■i■■■■te■■■t■■■■■■e■■l■eti■■■■■i��5%■■i■■■■i■■ ■■■■■■■■■■�i��■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/Gid■■■■■■l■■■■l■ ■■■■tt■■■■■■■.-��■■tt■■elt■ri■i�■i�:!■w�;■rl�l�wtei■■■■■e■■■■■�.sl■■■es■i■■ ■■■■■■■■t■■t■■/tNi.��//■■/■ltii►,l!�1�1�.Q '��l�'■in��ili /■■■■i■e■��s/■e■t■■e■■e■■■ ■■■t■■t■■tllt■■■■■e■/e■//�._�•■■/t■■■tette■_=:�t■■■■■t■■■tt■tt■■■t■ ■■■■■■■■■■■■■■st■■■■■■■■■tl■■■■■■■■■■■ei■i/■■ee■/■ee■■■■■i■eette■■ ■■■■e■■■■tt■■tt■tt■t■■t■■e■■■■■■■t■■■t■t■■l■■t■■■■t■t■t■■■■■t■■■■■ ■■■■■■■■■■■■■■■■/■■■/■■■■■■■■/■■/■■■///i■/■■e■■■■■/■/e■■/■lie■■■■■