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260 Duke Whitaker Rd (2)DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990005067 OPERATION PER1Y�Iax PIN/EH #: 5801-80-0252 Billed To: Fred Hicks Subdivision Info: Reference Name: Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 22 acres ATC Number: 4856 **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 She Tank Date - Tank Size Pump Tank Size / . R,. a ((a ry N System Installed By: J/1"�N � V7 E.H. Specialist: D Y ate:l/ �C� v -0- LACC-\ 6 / Ile 1 '0 011. N,`G , 5 11106 fRPvicPdl 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 990005067 Tax PIN/EH #: 5801-80-0252 Billed To: Fred Hicks Subdivision Info: Reference Name: Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 22 acres ATC Number: 4856 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 13# Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats j Square Footage(or Dimensions of Facility) Lot Size 1 c Type of Water Supply: ❑County/City. OWell ❑Community Well System Specifications: Design Wastewater Flow (GPD) ,_(Tank Size /,Q11 GAL. Pump Tankxi��F "AL. r z Trench Width 34 �( Max. Trench Depth �' Rock Depth__j X Linear Ft. 66 As stated in 15A NCAC 18A.1969(5) Site Modifications/Conditions/Other: accepted Systems mov also be us^ Contact the Davie County Environmental Health Section for final inspection of this system 8;30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. • �c�'e`�` Gus D t"t, / A / x [� , Environmental Health Specialist. DCHD 11106 (Revised) H 00 \� LA A Y P Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990005067 Billed To: Fred Hicks Address: 260 Duke Whittaker Road City: Mocksville Reference Name: Proposed Facility: Residence IMPROVEMENT PERMIT Tax PIN/EH #: 5801-80-0252 Subdivision Info: Location/Address: Duke Whittaker Road -27028 Property Size: 22 acres **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An f 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: DKew ❑Repair ❑Expansion Permit Valid for: R<Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # PeopleA_ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) DesignFlow(GPD):� 'C' Type of Water Supply: ❑County/City B'�ell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: eccoored c.. . _ _ 7 J,U UV UbtU Site Plan X System. Type LTAR Initial -J7 5— Repair Re air O , Environmental Health Specialist i.p.l 1-06 Mob, . w,t 11 Date 1 AP SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street < Mocksville, NC 27028 (336)751=8760/ Fax (336)751=8786 App tion o • a tion/Improvement Permit ❑ Authorization To Construct(ATC) Ir �oth Type App ication: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMP9i_T4N7*** 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 Fk Contact Person F C -W A_ Billing Address she D t.,A W H,'r. fi- ��'a�r Home Phone 736- City/State/ZIP P7 OC{�S V 1'14F . Al, 4f • 20 �� Business Phone 33,6 Name on Permit/ATC if Different than Aboveil'i,� Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name 5"4i0! Phone Number Owner's Address WAV , City/State/Zip Property Address l;.)dl(,C T Ff' ci, City Lot Size Tax PIN# - 0Z Z Subdivision Name(if applicable) SectioV Directions To Site: 041111.i1,�/ 4x/ ei i�lQ.'7/tomN L the answer to any of the following questions is "yes", supporting documentatio must be attached. Are there any existing wastewater systems on the site? Dyes o Does the site contain jurisdictional wetlands? Dyes o Are there any easements or right-of-ways on the site? Dyes 9flo Is the site subject to approval by another public agency? Dyes Rfl; Will wastewater other than domestic sewage be Generated? Dyes @'No IF RESIDENCE FILL OUT THE BOX BELOW # People�� # Bedrooms # Bathrooms vZ Garden Tub/Whirlpool Dyes o Basement: ❑Yes L�N0 Basement Plumbing: Dyes 1940 IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks I # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:. 6�'Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well /Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R/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 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. _ 1 Site Revisit Charge Propertyowner's o o er's legal representative signature Date(s): J/ -Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account # Invoice # Db;e (N` abo �► GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County,'NC - GIS/Mapping System Click Here To Start Over Quick Search(County ID c Active Layer. ❑use Map Tips GIs PARCELS (Map Tips Available) *! Map Layers I Results I http://maps.co.davie.nc.usIGoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=412... 4/21/2008 APPL,QUR INEVNkN Billed To: Fred Hicks Reference Name: Proposed Facility:. Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Tax PIN/EH'#: 580INFORMATION Subdivision Info: Aga/"qo Dz6,7— Location/Address: Duke Whittaker Road -27028 Property Size: 22 acres Date Evaluated: —� On -Site Well Community Auger Boring Pit Public SITE CLASSIFICATION: 4W` n LONG-TERM ACCEPTANCE RATE: • r ! REMARKS: EVALUATION BY: >jV] �1`�-y-ubv►.� OTHERS) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope I 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 Ill • VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm �Y€.t 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 r)rWn nVnc in.,..:..,,all Mite HORIZON ►� r' i� I iii ---- -texture group Consistence Structure %-�®- Mineralogy M • • •Texture ili�1Y�s]—��® group MineralogyConsistence groupTexture Consistence HORIZON IV DEPTH groupTexture Consistence Mineralo • RESTRICTIVE HORIZON SAPROLITE CLASSIFICATIONrr��rs�o■■i■�� SITE CLASSIFICATION: 4W` n LONG-TERM ACCEPTANCE RATE: • r ! REMARKS: EVALUATION BY: >jV] �1`�-y-ubv►.� OTHERS) PRESENT: LEGEND Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC - Concave slope I 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 Ill • VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm �Y€.t 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 r)rWn nVnc in.,..:..,,all