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2478 Davie Academy RdATC Number: 4970 **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. Manufacturer Tank Date"'* Tank Size 110 oo Pump Tank Size System Installed By: ,f QLD C-iYUtea E.H. Specialist: 4AIADate: 31 Oil DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005256 Tax PIN/EH #: 5709-70-1155 Billed To: H & S Investment Properties, LLC Subdivision Info: Reference Name: Location/Address: Godbey Road -27028 Proposed Facility: Residence Property Size: .61 Ac. ATC Number: 4970 **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. Manufacturer Tank Date"'* Tank Size 110 oo Pump Tank Size System Installed By: ,f QLD C-iYUtea E.H. Specialist: 4AIADate: 31 Oil DCHD 11/06 (Revised) 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 #: 990005256 Tax PIN/EH #: 5709-70-1155 Billed To: H & S Investment Properties, LLC Subdivision Info: Reference Name: Location/Address: Godbey Road -27028 Proposed Facility: Residence Property Size: .61 Ac. k ATC Number: 4970 Site Type: ERNew ❑Repair ❑Expansion Pit **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 3 # Bathrooms 2 # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size . 6 1 k Type of Water Supply: C7County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size 1,000 GAL. Pump Tank 4A GAL. Trench Width AV Max. Trench Depth—ate Rock Depth i2" Linear Ft. q3&' As stbted in :15A NL'AC 18A.1989(5 Site Modifications/Conditions/Other: accepted Systems may also be used t,ontact ine iravie q,ounty r.nvtronmentat rneattn 3ecrton for tinat inspection of tnis system oetween 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. Environmental Health Specialist. DCHD 11/06 (Revised) Date: S' y-09 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account M 990005256 Billed To: H & S Investment Properties, LLC Address: 178 Holstein Lane City: Olin Tax PIN/EH #: 5709-70-1155 Subdivision Info: Location/Address: Godbey Road -27028 Property Size: .61 Ac. 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: Aew ❑Repair []Expansion Permit Valid for: 5?S Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms 2 # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats. Square Footage(or Dimensions of Facility) Design Flow(GPD): (00 Type of Water Supply: Di<ounty/City ❑Well ❑CommunityWell As ctated in 15A NCAG 18A.1969�5) Site Modifications/Permit Conditions: �rrp t� Systems :nay alnn ha un��i System Type LTAR Initial UC- • 215 Repair (t CPTFD.3 Site Plan Environmental Health Specialist i.p.11-06 ' 1 � 1 • l"y 1 a , INrnAL Q 1 SySTMM 1 2� � S 3 BIR- 2v 19 ��A a Date 5— Y-65 J . TE EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Applic tion For:'b9 Sjt6Juation/lmprovement Permit ❑ Authorization To Construct(ATC) tl Both Type o p 1p i�ati;i-�Lgew 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 ' S i;��' r1��i� P�'qlkriContactPerson /_ ►A Billing Address 1 $ Home Phone 'AQP/ -' y(o — 7 i� Q City/State/ZIP AO r0r& (an Business Phone inlq— d— 5207 Name on Permit/ATC if Different than Above .514THe/ Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 11'zo- NOTE: A survey plat or site plan must accompany this application. Included: "ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration vith complete plat.) Owner's Name �o�el� ��Il{l1'I'�i�Akee, hone Number Owner's Address City/State/Zip Property AddressCity o Lot Size Tax PIN# ,5709 -70 -1/55 - Subdivision Name(if applicable) Section/LX , ^/ ON j Diwctictns To Site: /,;Z/14 :S ,. OND �l t/re ASA;�f Lam' t If the answer t6 any of the following questions is "yds", supporting docuVe ation must be Attached. Are there any existing wastewater systems on the site? s ❑No Zv` Does the site contain jurisdictional wetlands? ❑Yes it < Are there any easements or right-of-ways on the site? ❑Yes 11,110, Is the site subject to approval by another public agency? ❑Yes vl'o Will wastewater other than domestic sewage be generated? ❑Yes P<oo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms _ Garden Tub/Whirlpool Wes []No Basement: ❑Yes o Basement Plumbing: ❑Yes [� o 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: BConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: Ii ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Ei; 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 locating and flagging or, st //g�� the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Y-Ao.01 Date Sign given ❑Yes ❑No Revised 11/06 Date(s): Client Notification Date: EHS: Account # 50&- Invoice # S6 1. Ffi a 36 �o� • , GoMA.PS - Davie County NC Public Access Davie County, NC - GIS/Mapping System ! Click Here To Start Over f,. Active Layer. (][ise Map 77ps 0 1 PARCELS (Map Tips Available) w zi 0� Page 1 of 1 Quick Search: (County ID or Owner Ni . Rp MI Addre http://maps.co.davic.nc.usIGoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=412... 4/20/2009 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section S '1/S1' 1 ' V; t E t APPLICANVNMU�z�v, SON �t,•c�trtr . — Billed To: H & S Investment Properties, LLC Reference Name: Proposed Facility: Residence Property Size: Water Supply: On -Site Well a vua ion — Qoq- 7a-1165~ Tax PIN/EH #: 5709-IMOIWRTY INFORMATION Subdivision Info: Location/Address: Godbey Road -27028 61 Ac. Date Evaluated: Jr- Ll'Qrl Community Evaluation By: Auger Boring ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L " Slope % HORIZON I DEPTH �Z Texture group(, Consistence Structure 5 5 Mineralogy 5 HORIZON II DEPTH m -42. In - - Z Texture group Q'451'�o( Consistence ; 5 Structure 5 5 5 MineralogyS - HORIZON III DEPTH - Texture groupC Consistence Structure j IL Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS -- RESTRICTIVE HORIZON -- SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND EVALUATION BY: 66 Obi l Vl".�n4 OTHERS) PRESENT: 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 CON IST ,NC . Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm )Yet 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) 1TAR - Irma -term a-rentnni-P rat,- - "IlAav/ft) T%f'TTTI nc1nc in___.__�� ■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■E■■ MEMO ■EM■O■ SEMEN■ ■ENNE■ ■MME■■ MONS■■ ■N■ ■ ONE ■ ■MMM■■ ■■NNE■ ■■MME■ ■M■■S■ ■■NNE■ ■■NN■■ ■■■ ■ ■N■�■ ■M■MM■ ■■■EOE■■■ ■■■■■■■E■ ■■NOM■■■■ ■E■■■E■■■ ■■■■■■■■■ ■OE■■■■E■ ■■■E■N■N■ ■■■E■■■■■ ■EEE■■■■■ ■■■N■■■■■ ■EEE■■M■■ ■■■■■■■■■ ■E■■■■■■■ ■■■■■EEE■ ■MME■■■■■ ■■EOE■■■■ ■EE■■■E■■ ■EM■■■■■■ ■■■■■■E■■ ■■■■EEE■■ ■■■E■N■E■ ■N■■■E■■■ ■E■■■■■■■ ■■EE■E■■■ ■■M■■■■■■ ■EEE■EEE■ ■E■■■■■■■ ■EOE■■■■■ ■■■■■EEE■ ■■■■NO■■■ ■EEE■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ ■ ■ i ■ ■ i ■ ■EMMEMM■ ■■MEM■M■ SOMME■■■ ■■■EM■E■ SOMME■E■ ■EMEMEM■ ■MMME■E■ ■■M■MME■ ■■M■MME■ ■E■■M■E■ ■■ME■■E■ ■■■■M■■■ ■■M■M■M■ ■■M■M■M■ ■■M■■MM■ ■■■OM■M■ ■■MMM■■■ ■■M■M■M■ ■E■■MM■■ ■■M■M■M■ ■E■■M■■■ ■■M■M■M■ ■■M■■ME■ ■■E■■■■■ ■■■■■■■■ ■■N■■■■■ ■■EOE■■■ ■■■■NNE■ ■EM■■■■■ ■EOE■■■■ ■■■■E■■■ ■M■■E■■■ ■■■■■■■■ ■■■E■■■■ ■■MMM■■■ ■N■■E■E■ ■■■■■■■■ ■■■■E■■■ ■■■■■■E■ NONSENSE ■■U■■E■ ■■ ■EE■ ■■EOE■E■ ■MEMO■■■ ■■■■N■■■ ■■■■E■■■ ■■■■E■■■ ■E■■E■■■ ■E■■EEE■ ■■■■■E■■ ■E■■E■■■ ■E■■E■■■ ■E■■E■■■ ■■■■EEE■ ■■■M■■■■ ■ME■■■■■ ■O■■■■■■ ■■E■EEE■ ■■N■■■■■ ■EEE■■■■ ■■E■■E■■ ■■■E■■E■ ■O■■■■■■ ■■■■EOE■ ■■■■EEE■ ■■■EOE■■ ■EEE■■E■ ■■E■■■E■ ■■■■EOE■ ■■E■E■E■ ■M■■■■E■ ■■E■■■N■ ■E■■E■E■ ■■MME■■■ ON No ■■■O■■■N■■ ■E■■E■■■■■ ■■■■■■■■■■ ■E■■E■E■E■ ■EO■■■■■■■ ■■■■■EOE■■ ■■■EOE■■■■ ■EOE■■■E■■ ■N■■N■■■E■ ■■■E■■■■E■ ■E■■E■■■■■ ■■■E■E■E■■ ■EE■■EEE■■ ■E■EEE■■■■ ■E■E■E■■E■ ■MNEME■■E■ ■EEE■N■■E■ ■■EOE■■■E■ ■■■■■■■■■■ ■■EOE■■■E■ ■E■E■E■E■■