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1208 Cornatzer Rd DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Str(;!�,t — - Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account #: 990003972 Tax PIN/EH#: 5769-21-5016 Billed To: Delia Alvarado Subdivision Info`— Reference Name: -'Location/Address: 1208 Cornatzer Rd-27028 Proposed Facility: Bunk House Property Size: 111.8 acres ATC Number: 5084 **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. System Type: $ S.T.Manufacturers 9M Tank Date/ l Tank Size ko0 Pump Tank Size /Ups System Installed By; aqd U snylft kl tt. E.H.Specialist: ` ld e: * 20e0 06oCt— 0 DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH Vk XID i P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003972 Tax PINIEH#: 5769-21-5016 Billed To: Delia Alvarado Subdivision Info: Reference Name: Location/Address: 1208 Cornatzer Rd-27028 Proposed Facility: Bunk House Property Size: 111.8 acres ATC Number: 5084 Site Type: Clew ❑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 _#Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or:Dimensions of Facility) Lot Size a CSC Type of Water Supply: ❑County/City RWell ❑CommunityWell System Specifications: Design Wastewater Flow(GPD) Jank Size /000 GAL.Pump Tank /cc--6 GAL. Trench Width 3to Max. (Trench Depth_y(r Rock Depth Linear Ft.-3,"�O Site Modifications/Conditions/0ther:.K4Y'Q�'Vt��4Q& -:4'-)�� 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. Div?Woo 'r b S / 'FT Environmental Health Specialis Dater DCHD 11/06(Revised) �' Davie County Environmental Health P.O.Boz 848/210 Hospital Streit — Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990003972 Tax PIN/EH#: 5769-21-5016 Billed To: Delia Alvarado Subdivision Info: Address: 1208 Cornatzer Road Location/Address: 1208 Cornatzer Rd-27028 City: Mocksville Property Size: 111.8 acres Reference Name: Proposed Facility: Bunk House **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: LkNew ❑Repair ❑Expansion Permit Valid for: R5 Years ❑No Expiration Residential Specifications: #Bedrooms_2 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): DYO Type of Water Supply: ❑County/City R-Well ❑Community Well Site Modifications/Permit Conditions:-n�, System Type LTAR Initial Repair / Site Plan y(' PT 1�ri i�P Environmental Health Specialist Date_ W 211/' i.p.l 1-06 APPLICATION FOR SITE EVALUATIONAMPROVEME ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street pp� Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 RONMALN EENT ppV1E�� Application For:kite Evalujtion/lmprovement Permit authorization To Construct(A ) oth Type of Application: Wew System ❑Repair to Existing System ❑Expansion/Modification of xisting 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 7` G` V Y-a - o. Contact Person-_. ,Vm Address �Ae✓ k _ t Home Phone 3 ' City/State ZIP 1 Business Phone Name on Permit/ATC if Different than Above Mailing Address k. CL .�L 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 siteplan,no expiration with complete plat.) , , Cry Owner's Name' o 4 �.��tt �/ '1 Phone Nu ber\3��• Owner's Address, 0 G -" r2A City/State/Zip ( L Property Address .J City Lot Size UX , F:lq-<?s Tax PIN#4'�� — _sn►W.DA Subdivision Name(if applicable) ection/Lot# Directions To Site: r F L L- G:I e!X � D 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? Z'es No Does the site contain jurisdictional wetlands? _Yes VNo Are there any easements or right-of-ways on the site? ./No No Is the site subject to approval by another public agency? _Yes FIKO Will wastewater other than domestic sewage be generated? _Yes t/ o 1 IF RESIDENCE FILL OUT THE BOX BELOW POrd #People #Bedrooms k Pbo( #Bathrooms T Garden Tub irlpool ❑Yes No Basement:: ❑YesM'No Basement Plumbing: ❑Yes GdNo 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: Neonventional b ccepted ❑Innovative ❑Alternative ❑Other el Water Supply Type: ❑ County/City Water ❑ New Well (DExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'IN 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 proper identification and labeling of property lines and corners and /locatin and flagging or takin he house/facility location,proposed well location and the location of any other amenities. t �1 i t operty owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: e-Val 3q-7Z Sign given ❑Yes ❑No D Account# Revised 11/06 T # Iq TD Invoice# a SO4,F" "1330 CO '286 ,,29st 7244 7246 1 i 77• r 70 I i� lanwo&DoM Alvarado • 4WoAdbw 1137 Corrwtaar Road MockW" com Davi® SUft NC C4d@ 21928-7135 Cw*W Cuoibs Bank ' •• �•- _ � ------,gip, ••"' *r i . l i . r x 14 • - � 2i 1 .; MA 2z5iY� r. r -_ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION WCYS011e, AX_ a � Water Supply: On-Site Welly Community Public y Evaluation By: Auger Boring 11 Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% HORIZON I DEPTH - Texture group Consistence Structure r r Mineralogy HORIZON II DEPTH - Texture group Consistence Structure IL Mineralogy HORIZON III DEPTH -4 IK Texture group Consistence Structure - MineralogyQ HORIZON IV DEPTH Texture group Consistence Structure ' Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: S EVALUATION BY: —AA61101) h—a-AW" LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: 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 �l21S>< 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 Mineralogy 1:1,2:1,Mixed NQt� 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 05105(Revised)