1797 Davie Academy Rd DAVIE COUNTY ENVIRONMENTAL HEALTH I
. X01
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
Account #: 990002450 OPERATION PERTDaaxIT PIN/EH#: 5707-69-6139
Billed To: D.H. truction Subdivision Info:
Reference Name: ce u'" Location/Address: 1797 Davie Academy Road-27028
Proposed Facility: Guest House Property Size: 54 Acres
ATC Number: 4859
**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:%aG QA S.T.Manufacturer.S oa F Tank Date(,- Tank Size 1 tl"
Pump Tank Size N/61
System Installed By: MK ,I to twJ E.H.Specialist: Date: 16'3
Zs�—500 Fro w•
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751=8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 990002450 Tax PIN/EH M 5707-69-6139
Billed To: D.H. Lakey Construction Subdivision Info:
Reference Name: Zo—e TW2t I Location/Address: 1797 Davie Academy Road-27028
Proposed Facility: Guest House Property Size: 54 Acres
ATC Number: 4859
Site Type: ❑New ❑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 7— #Bathrooms #People Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City Gell ❑Community Well
System Specifications: Design Wastewater Flow(GPD) 0 Tank Sized GAL.Pump Tank 14GAL.
ft
Trench Width 36� Max.Trench Depth 34 Rock Depth 0, Linear Ft. 276
As stated in 15A NCAC 18A.19690
Site Modifications/Conditions/Other: accoptsd Systems may-elso
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Tee hone#(336)751-8760.
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5vironmental Health SpeciaKt Date: 5 4a
nruT1 111114 fRP.,;�P.11
• Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990002450 Tax PIN/EH#: 5707-69-6139
Billed To: D.H. Lakey Construction Subdivision Info:
Address: 166 Horseshoe Trail Location/Address: 1797 Davie Academy Road-27028
City: Mocksville Property Size: 54 Acres
Reference Name:
Proposed Facility: Guest 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: P<ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration
Residential Specifications: #Bedrooms Ilk #Bathrooms#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
nn
Design Flow(GPD): d� Q Type of Water Supply: ❑County/City 3'6ell ❑Community Well
Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1969(
ucceptedSys ems may also be use
System Tyee LTAR
Initial cc - e 0. a-75
Re airc ct'
Site Plan _
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11 T
Environmental Health Specialist Date
i.p.l l-O6
APPLICATION FOR SITE EVALUATION/IMPROV 15=
Davie County Environmental Hea 11APR 2 4200$
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786 ENVIRONMENTAL HEALTH
DAVIE COU111Y
Application For: Deite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ oth
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 to be Billed r{, Lp4l OV c -I1�i Contact Person �Zsoue
Billing Address Home Phone e -
City/State/ZIP /n,n <-c(t k( , AJ,C , a,7(),gy Business Phone ne,-- - 40 9 - 6,4 P,
Name on Permit/ATC if Di erent than Above
Mailing Address /179 7 fir- City/State/Zip M u ` w.e - -74 e
PROPERTY INFORMATION *Date House/Facility Corners Flagged • Zoe
NOTE: A survey plat or site plan must accompany this application. Included:l019ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name --76tr `f"n t i e Phone Number 17'7
Owner's Address 119r) :_,I d r /�Jc�cJ�y�,/ �c� . City/State/Zip P0o4e,r
Property Address j?c5 City_p adcs t, ,�(��•�
Lot Size *e _ Tax PIN# v - 13 c7-
Subdivision Name(if applicable) ISection/Lot#
Directions To Site: 14&JV X1,4 4- - —r7-
=- 4o -
TZ2- /'7 /040,
If the answer to any of the following ques ions is"yes", porting docume lation must be attached.
Are there any existing wastewater systems on the site? EI'Yes ❑Nosic ff 7"G a10,-VO/'7
Does the site contain jurisdictional wetlands? ❑Yes Ifio
Are there any easements or right-of-ways on the site? ❑Yes Bfto
Is the site subject to approval by another public agency? ❑Yes Blf�o
Will wastewater other than domestic sewage be generated? ❑Yes Biqo
IF RESIDENCE FILL OUT THE BOX BELOW &64
[#
eople - �2' #Bedrooms _ #Bathrooms ( Garden Tub/Whirlpool ❑Yes &�No
❑Yes P-No Basement Plumbing: ❑Yes PN10
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facili Business ` r' 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 systemrequested:. [Conventional ❑Accepted OInnovative ❑Alternative ❑Other
Water Supply Type: fyCounty/City Water ❑New Well CI'Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 91110
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 pem-dt(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 thisapplication 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 flagging
or staking the house/facility location,proposed well location and the location of any other amenities.
, Site Revisit Charge
Property o er's or owner's legalfepresentative signature
Date(s):
D Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# -;N0
Revised 11/06 Invoice#
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AUTHORIZATION,NO: 0 6 5 8 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee ---- P.O.Box 848
Name: r .. - ' `� ' ��''� MocksvilIe,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property: Section: Lot:
AUTHORIZATION FOR
WASTEWATER �)", '+ r
SYSTEM CONSTRUCTION Tax Office FIN:#. �� - !
Road Name: jbA V1 0- t'
r
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
L., ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
1��7 IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMEE rAL HEAL SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE A/ ;#BEDROOMS BATHS #OCCUPANTSGARBAG&DISPOSAL.Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZES TYPE WATER SUPPLY A�// DESIGN WASTEWATER FLOW(GPD) I NEW SITE L- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE �L, 'A GAL. PUMP TANK GAL. TRENCH WIDTH l ROCK DEPTH/7 LINEAR FT. +3
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
l�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)6348760.
OPERATION PERMIT
SYSTEM INSTALLED BY: `''►�
fa1�sL s-t- 1 oN DATL:
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AUTHORIZATION NO.QG v OPERATION PERMIT BY: DATE: 7
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 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.
DCHD 05/96(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
_APPLMAdtltMINFOMM051 diN_ Tax PIN/EH#: 570rX9X95TX INFORMATION
Billed To: D.H. Lakey Construction Subdivision Info:
Reference Name: Location/Address: 1797 Davie Academy Road-27028
Proposed Facility.... Guest House Property Size: 54 Acres Date Evaluated: l
Water Supply: On-Site Well Z Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope % `
HORIZON I DEPTH — (]—
Texture groupCL
Consistencex Jig
Structure K
Mineralogy ,E
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 0
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
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
list •
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
pct'
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
Notes
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 nr•url nvnc rn.,..:—AN