1508 County Home Rd (2)�
� � DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
,Account �: 990005515
Bille�� io: Chad Fuller
R�fer�r�ce �la���: Chad Fuller
f�ro�t�s�c9 F��:i€ity: Residence
f�TC f��a�b�r: 5092
OPERATION PERMIT
�'�x �'i�I.��H #: 5728-61-2978
Su�t�i��i�ior� inffc�:
LocationrAddr�ss: County Home Road-27028
�'rt���r�y Siz�: 30 Ac
**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. Manufacture`��j64� Tank Datea � Tank Siz�d��
Pump Tank Size
E H ecialist: �te: Z ZL Zol< .
System Installed By:�1Gm�� eY� .. sp —��
(�d0 (,r.. �. C�tRw��2h5
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DCHD 11/06 (Revised)
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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
�ccc�u�t #: 990005515 "��x f�l�€%EH #: 5728-61-2978
8i!!c� ic.�: Chad Fuller Su�idi�fi�ior� Irif�:
f�efer�r�ce P�an7�: Chad Fuller LacationiAddr�ss: County Home Road-27028
F�rn�c3s�;c9 F,��,�iEity: Residence �'co��r�y Six.e: 30 Ac
f�T'C i�1u[t�b�3': 5092 Site Type: P1�Vew ❑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 chan�e. •
Residential Specitications: # Bedrooms� # Bathrooms �. �# People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size �� 4,C. Type of Water Supply: LK�ounty/City ❑Well ❑Community Well
��
System Specifications:. Design Wastewater Flow (GPD) �Q Tank Size� GAL. Pump Tank GAL.
' Trench Width �� Max. Trench Depth� Rock Depth� Linear Ft. �� GUO �
. / •� � � �/�,—
Site Modifications/Conditions/Other: /l(,�/� . �G�t, �QDT/l ,3�0 �� z`S�b �'""'-
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the dav of installation. Telephone #(336)751-8760.
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Environmental Health Specialist � �" Date:� z � �
DCHD 11/06 (Revised)
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Account #
Billed To
Address:
City
,
i Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
990005515 Tax PIN/EH #: 5728-61-2978
Chad Fuller Subdivision Info:
108-2 Friendship C�urt Location/Address: County Home Road-27028
Mocksville Property Size: 30 Ac
Reference Name: Chad Fuller
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: ❑New ❑Repair ❑Expansion Permit Valid for: @� 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: jZfCounty/City OWell ❑Community Well
�t� �,tt;tcti tn 15A NCAC la,�.�,� ;�j�y`
Site Modifications/Permit Conditions: �CCe�tc:d Systems m�y oirp �� �„_. .�°
Site Plan
0
Environmental Health Speciali
i.p. l l -06
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APPLICANT INFORMATION
Account #: 990005515
Billed To: Chad Fuller
R f�rence Name: Chad Fuller
Pro osed Facility: Residence
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DAVIE COUNTY HEALTH DEPARTMENT �
Environmental Health Section
Soil / Site Evaluation -
PROPERTY INFORMATION
Tax PiN/EH #: 5728-61-2978
Subdivision Info:
Location/Address: County Home Road-27028
Property Size: 30 Ac Date Evaluated: �%l/t ?�
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Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit � 1'�
FACTORS 1 2 3
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
HORIZON IV DEPTH
Texture group
Consis[ence
Structure
Mineralogy �-'"`°-
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE , -
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LONG-TERM ACCEPTANCE RATE ; ��"
SITE CLASSIFICATION;'�' � � S
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LONG-TERM ACCEPT�NCE RATE: -��
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REMARKS: '
Public
Cut
4 5 6 7
Z S'
EVALUATION BY:
OTHER(S) PRESENT:
LEGEND
i.�ndsca�e 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
T�xtur�
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
'. AN4IST N . ,
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VFR - Very friable FR - Friable FI - Firm VFI - Very �rm % EFI - Extremely firm
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NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
S r > >r
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
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Mineralo�v
1:1, 2:1, Mixed
LY��
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 soii colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
TTAR _ T.nnv-tPrm arrPntanrP ratP _ aal/�a��/ft7 T/�T7T hCll1G ir,__.:__��
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�Y
{� 1 ITE EVALUATION/IMPROVEMENT PERMIT & ATC
� Davie County Environmental Health
��� P.O. Box 848/210 Hospital Street
� 2��� � Mocksville, NC 27028
:' '` ti�A� 2
'� � (336)753-6780/ Fax (336)753-1680
, LN��TH
Appli�Cation� E�a �, �Si.tC� � al{�tio ovement Permit ❑ Authorization To Construct (ATC) � Both
Type f Application� ystem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
*� *IMPORTAN7*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFO MATION
Name � .. � �--
�
AddYess � � �--
City/St / IP /� f f
J � � Z d�/���c
Name on ermit/ATC if Different than
Mailin� Address
� ffr Contact Person CiL�� �-C.. !/�
— Home Phone — '% %
� OZ�usiness Phone �"_j 'j�S— $ g�,�
ii� ,
/State/Zip
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 �o
Does the site contain jurisdictional wetlands? Yes �o
Are there any easements or right-of-ways on the site? Yes l/I�o
Is the site subject to approval by another public agency? Yes ,�il�o
Will wastewater other than domestic sewage be generated? Yes�
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms
Basement: OYes,�10 Basement Plum ing: ❑Yes �No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Garden Tub/Whirlpool ❑Yes ❑No
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
� .,
Water Supply Type�County/City Water
❑Accepted ❑Innovative ❑Alternative ❑Other
❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this sysfem is intended to serve? ❑ Yes CJ( 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 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 les. nderstand at I a responsible for the proper identification and labeling of property lines and corners and
lo a a i 'n se �' location, proposed well location and the location of any other amenities.
roperty owner's or owner's legal representative signature
Site Revisit Charge
Date(s):
_�Z �- / b � Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No
Revised 11/06
Account #
Invoice #
J�/�j
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NCGS "JOYNER"
N: 780046.05'
�: 1524974.66'
�� � �S Highwoy 64
1 _ .
I cra N 3p'''3o�E� _ 8� ronu 5, & wife, 13arbara G, Green � �
T e��e 678�- ,, ,Q pIN; 5�2851��9q � North Ref: DB 619 PG 599 m
Phicoll _ o
1 y � S _ � k
' m�SreA e enfed to fit ��� �y� � nC� 128 pG � � �
m�p- �
� o a SITE
� 1�on�{ 5, & wife, [3arbara G. Green —N°�2�'�s' ,s`7_ � a
'1 pIN; 5�2851��9� I + �` � � � County Home Road
� n13128 pG � i 4"oP
1 uP �
VICINITY MAP NTS
� � � Wood rad fence � rown I.ake, �YIC,
' g I encroaches 4.3'. -e� �
I �L,�c��. N?6.33� pIN; 5�28632�05
� o I � �� nC� 88 pG 2�0
� o � 9?0.
1 _ _ � �
�, � navid Wa�ne Anderson � — �—z
° � pIN: 5�28610�8� ,�•EIP AT STONE
� � n6 51� pG YOZ n, o�oo•oo-E
o I z se
�. 1 � � � ( 53.37) LP Proposed tiouse 9f"g�
N I N � � a°.
� m �
� � al .03' 123.33 �LT
m � 1r, � � �a� _
� o �
n- rn O � Q Ot��j��—
o ;o '�,� � 30.868 Acres o��;�' �----
fi � ,� �P Q`i��i \ '�'`'�`s
�: � ^ \ R *
� 1' � � �O `� �i l/------`_ -_ Culvert - ✓ �F
� ' �/ ' -�, �9
� � �� �� � �� ' � ������� �?).
1 11 � UP � o\ � \ ____-_ � �// \`����`��`
�
� �
� ,� o, :'� ��\`roposed ��;,;__--' �This portion not located by suniey. ���:�.
1 ` � � �` � Dr�veway �� �� �.�. Chain "gate"
N ,� � � �� �� � � /
1 � � 4 ^ ' ' �'/ \`�\� --- ` 1
� � _ �� �e�ay `�\�� , __. __ �
� i.',� , C,ca�e���� �, ,� -�__----^----' �
� � ,'_-- - ,
.V � � �O � --��' I d' Gravcl Driveway �a�`
' O ,� �� Gulvert ` \
.`.\
� � � � � '
.
i i �.`.
1 RRSPK �� . ���`.
ii � .
` ,� �i \3/4"EIP AT STONE
� h� �^ ' '� 1�own I.ake, Inc,
„
1 ��''�ry ` ' ;%� o��'c�, pIN: 5�28632�05
'/ .. , ;;;,�P . �°g� s n� 88pG210
RRSPK .5 EtP UP � �`ti
� �
s ���,9 744_44• ,�Q \Q `1 �!.
� �
2�2r��26'�s• � " , , ���ti°6� �� �h�k�Q ��
9$ , , s.2s• o E Q �
��.
?g9 ,�6A,. ��Ei� S � 1753.12333.35' ��4j� � ` 6'
��'IG' CO��G'��G' COt�O�"�IOt1 �9 5 Z 1$ � 05 05 126.85' � F.
pIN: 5�28�10963 tis �
� 141.45• �`
n(3105 pG 228 °'F� 11�e Coll ette Corporation �1 331.7g�
� pIN; 5�28�10963
n6 I05 pG 228 '"�'P
.\
.\
.\
NOTES: �
I . Tax Parcel Identification Number: 57286 I 2978
2. Deed Reference: DB 6 I 9 PG 599
3. Current deed's Exhibit A description contams errors cawsing a mathemat�cal misclosure of 475 feet. PrOpOSed HOUSe Loeation Plan for
4. I O' 6ravel drive is used by Town Lake, Inc. for access�o their property.
5. A grid coordinate was not established on the property because NCGS "405 JA5", the match for"JOYNER", has been destroyed. l.�h a d F u 11 e r
6. Raw traverse error of closure is I :40,I 94. Angular er�ror is 55 seconds in I 6 angles turned.
Town of Mocksville — Davie County
NORTH CAROLINA
LEGEND 120' 60' 0 120' 240' 360'
EIP F�(ISTING IRON PIPE
ESI EXISTING SOLID IRON
BOLT EXISTIN6 BOLT
ECM EXISTING CONCRETE MONUMENT SCALE DATE JOB � DRAWN
TBAR EXISTING IRON 'T' BAR WITH CAP SET BY GRADY TUTTEROW, PLS L-2527 P R E L I M I N A R Y P LA T ���_�20� 05�06�10 0060 JCA
RRSPK RAILROAD SPIKE SET
�� #5 REBARSET N OT FOR RECORDATI ON ,
NS NAIL SET
NCGS NORTIi CAROLI NA GEODETIC SURVEY C 0 N V E YA N C E S, 0 R S A L E S (�
RM/ RIGIIT-OF-WAY 1VS
PIN PARCEL IDENTIFICATION NUMBER
—_ —• —• —FENCE LAND SURVEYING
�o OVERIIEAD UTILITY Allen Geomatics. P.C. C-3191
^UP UTILITY POLE � �
LP LIGhT POI� PO Box 89, Advance, NC 27006
(336) 782-3796
www.Al IenGeomatics.com