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1179 Eatons Church Rd (2)r ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 OPERATION PERMIT Account #: 990000756 Billed To: Tabitha Alder Reference Name: Proposed Facility: Residence ATC Number: 4955 Tax PIN/EH #: 5822-42-1144 Subdivision Info: Location/Address: 1179 Eaton Church Road -27028 Property Size: 2 acres **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: Q� pD`"�j S.T. ManufacturerS b oa, Tank Date a -LI Tank Size I&D Pump Tank Size System Installed By:4� h] 1 )14A0t E.H. Specialis . Date: 1 1-0 1— I - l_ pp^�� 200' 1t.QDYI- . (\ti J KC 3" pvc, 40 +aJ t1L DCHD 11/06 (Revised) 1nleA-1n,-#1j d1ty. 5 e � 5`t V 2CS panels e. - 1 i nL it1nSk1ltd trn. 4 ST N/ in (", 55rb if eleaA oLj ins (ltcl S'-k-ench w;c(-1 DAVIE COUNTY ENVIRONMENTAL HEALTH Da, Oq P.O. Box 848/210 Hospital Street Mocksville, NC 27028 J (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000756 Tax PIN/EH #: 5822-42-1144 Billed To: Tabitha Alder Subdivision Info: Reference Name: Location/Address: 1179 Eaton Church Road -27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 4955 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 # Bathrooms 3 # People D- Basementel3asement plumbingff'-- Non -Residential Specifications: Facility Type # People . # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply:ounty/City ❑Well ❑Community Well tom` System Specifications: Design Wastewater Flow (GPD) �rbo Tank Size !CL. Pump Tank AL.� Trench Width 3(0 I1 "Max. Trench DepthAa Rock Depth Linear Ft. _3 Site Modifications/Conditions/Other: ns/Other: �t ,� �.eS -S . Contact the Davie County Environmental Health Section for final inspection of this syste betty n 8:30 — 9:30a.m. on the day of installa i . T le ho e # (336)751-8760. A a �.. abDct ,gyp ti 1► otu K3 "14 ZZ - 1 � 114 n l'C. eta �y `� C,��;,�,et �e� e�i a►� l gdr t QuG �57G acv �f �`�d PAY t��-e C c �� a 3 ``Gul k-eregoe6 , �� vy Environmental Health Specialist Date:41 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 IMPROVEMENT PERMIT Account M 990000756 Tax PIN/EH M 5822-42-1144 Billed To: Tabitha Alder Subdivision Info: Address: 1179 Eatons Church Road Location/Address: 1179 Eaton Church Road -27028 City: Mocksville Property Size: 2 acres 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: Zf4ew ❑Repair ❑Expansion Permit Valid for:Yeaarrs -❑No Expiration Residential Specifications: # Bedrooms 'i # Bathrooms - # People D—Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair Site Plan )1, r -e c� Environmental Health Specialist i„11_nA ® td 5�4-eµ. Date G —0 L GoMaps GIS Page 1 of 6 http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=47453&CFTOKEN=69718022 3/12/2009 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION 1119 �a�o�s Cht�lrrJH '� Water -Supply: On -Site Well Community Evaluation By: Auger Boring ✓ Pit PROPERTY INFORMATION Public Cut SITE CLASSIFICATION: , LONG-TERM ACCEPTANCE RATE: EVALUATION BY: — � - - -- kjkK -,t OTHER(S) PRESENT: REMARKS: 1 LEGEND I Landscape Posiion 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_ -i Silty loam CL -Clay loam SCL -,Sandy' clay loam SC -Sandy clay SIC - Siltyclay C -Clay - CONSISTENCE Moist VFR - Very friable FR - Friable FI -,Firm VE - 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 - Veryplastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky ' PL - Platy PR7 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 DCHD 05/05 (Reviced) Landscape position Texture group �►�■tor�r��.�a�r�e�� Consistence�11=F"SmWAWA ftjh i' HAM Structure "n =WKIMI HORIZON H DEPTH Texture group Consistence Mineralogy__ mpg HORIZON III DEPTH Texture - Mineralogy HORIZON IV DEPTH Texture group Consistence ����a���■����� Mineralogy SOIL WETNESS • • • CLASSIFICATION SITE CLASSIFICATION: , LONG-TERM ACCEPTANCE RATE: EVALUATION BY: — � - - -- kjkK -,t OTHER(S) PRESENT: REMARKS: 1 LEGEND I Landscape Posiion 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_ -i Silty loam CL -Clay loam SCL -,Sandy' clay loam SC -Sandy clay SIC - Siltyclay C -Clay - CONSISTENCE Moist VFR - Very friable FR - Friable FI -,Firm VE - 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 - Veryplastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky ' PL - Platy PR7 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 DCHD 05/05 (Reviced) ■tt/■■■■■■■■■■■■■■■■■■■■■■■■■■te ■■■/et■ecce/■■■■■■■e■tt■■teeet■e ■■■ae/tte■/■■■■/■■t■■■■e■■■■a■■■e■■/■/■■■/■■/t//■tt■/t■tt■■t■■■■■■ ■ttt■t■■tet■■■■■■■■■■■■■a■■■■■t/t■■■■/�■ttt■■/■■a■/■t■■■■■■■■■■■■■ ■■/■■■■t/■■■■et■■■■■■■■■■■■�,Y■ij■fit■■■■/■t■■■■■■■■■t/■■■■tt�a■■■■■ ■■■■■■■■■■■■■■■e■■■■■■■■��■■■■■■■ ■■■■■■11■■■■/■■■■/■■■/t■t■■■■■■■■■ ■■■■■■■■■■■■■■■i�■■■■■■■■��s■c�a■�i►iii■■■■■■��a■■■■■/t■■t■■■t■■■■■■■■■■■ ■■■■t■■e■tt■■■■��■■■■■■■■��■■■►�■■■uia■t■■■�i■■�:i7�t■/l�C�l■■tt■/�!1�■■■t■■ ■■■■■■■■■■■■■/■��■est■■■■�i/■■■■■■iii■■►�■��■�i■■��i��■■�r■�it/■■■t►�■i�t■■t■ ■■■■■■■■■■■■■■■�iia��■�ro■e��-••...��■■a■aa�i■tuuu■/■tr�tr�tt■t■�/..t■■■■■ ■■■■■■■■■■■■■■t�iera■��;,<!ri■■ti■■iiea■/■■■i���■■■■t■/a►e�■■■■r_•�u/■■■■t■■ ■■■/■■■■t■e■t■■eeetu/■■■■■e■■■■■�i■■��■�uit::::t■■//■■r!�■at■■■/■t■■■ ■■■■■■■■■■■■■■■■a■►■u■■■■■■■■■■■■■■■■■■iii■■■■■■■■■■■��r�eu■■■■■■■■■t■ ■■■■■■■■■tette//■■■■/■■■■■■t■■■■ae►:�/■■/■■■■■■■/a■■■■■/■■■■■■■■/■t■ Mammon Mammon mammon i EMNON iiiiiiiManamai IMMEM iiEmmons� ■■tt■■■■t■■■■■■■■■■/■■■s/r■■■�t■t■■■■e■t/e■e■■■■tt■■■/■e■■■e■/■■t■ ■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■/■■■t/■■■■ecce■■■■■e■■■■t■■■■■■■■■■eee■■■ee■es■■tee■te■■eteeee/t■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ata■■■/t■■■tt/■■/■tt/■sa■t■t/■ta■tt/t■t■/t/tt/t/atttat■■■t/■■ttt■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■tt■t■tte/ttt/■tt//t■e■eat//■■■�i■taat■tt■t/t■■ta■tt/■ttat■■■t■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section d x'1`1 FEg 2 3 2 PO Box 848/210 Hospital Street 0-� �r Mocksville, NC 27028 Phone: (336)751-8760 J/ LN�1RpP� E�OIiS�� ON-SITE WASTEWATECERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ Mailing Detailed Directions To } Numbers � 99- 606 / (Home) (Work) k /-/. Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under:—L, % Type Of Dwelling: #t' Z04/ Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People: Is The Dwelling Currently Vacant? Yes No ❑ If Yes,,, For How Long? ,, / f / Any Known Problems? Yes ❑ No If Yes, Explain: /V a W V�' &4I P16 04 t4,la 6l i�la��N� r4h h way Please Fill In The Following Information About The New Dwelling: Type Of DwellinghuSo Number Of Bedrooms: Number Of People: Requested By;�,� (Signature) C t For Environmental Health Office Use Only Requested: c::) Approved ❑L/Disapproved � Comments: S611 WaS tuh5tA%-VT lol,e d- , and +b'cr-e WaS r7oj rylo Lt ►h Environmental Health 3-12-0 I*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a I euarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount. $ Date: Paid By: Received By: Account #: 10 is Invoice #:. ".!�F'.{'iv'?.., �,•.jK. ': . _ 3.- 'I t'v' "- "r ".'ly �Tl 7 _. . ( �. .. .,. .. .. ,. v. ___A,. 4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section - • PO Box 848/210 Hospital Street Mocksville, NC 27028 ` Phone: (336)751-8760 V .E ON-SITE WASTEWATE CERTIFICATION FOR DWELLING (Check One) REPLACEMENT REMODELING ❑ RECONNECTION ❑ �'- 4 ii 1 / / 11��n (Home) Name: one Number~ Mailing Address: 7 9 (5:'G A <5 C- A VC/ (Work) Detailed Directions To Site: (� �' r (� ." O 1�_ C G f t l -/L N� ��22•�fZ-�/y� , Property Address: Please Fill In The Following Information About The~Existing Dwelling: Name System Installed Under: T " Of Dwelling: tl ��y,, s: N Date System lnAtalleil(Mo`nth/Day/Year): Number Of' roomumber Of People: Is The Dwelling Currently Vacant? Yes No ❑ 1f Yes;:For Hod Long7 i ,', / ry` air o i �fa- Y.f/fin/N9 Any Known Problems? Yes'O "No .,3 If Yes, Explain. ' � wW t p� I l(' % i r Please Fill In The Following Information About,The New Dwelling: - Type Of Dwelling:ge us r_ Number Of Bedrooms: Number Of People: C r, Xr Requested By:' Date Requested: (Signature) t. 1 `For Environmental Health Office Use Only Approved ❑ Disapproved Comments: sU'� wu, t;ir�c �kr��ile �1 ���►<I `+b1,4,( Ivo ,�0� rklo clk Gera a kl-P Ipcp '` ✓ r . ,fit } Environmental Health Specialist / i e`:' l`,. }Daae 3 / 2 ' O'c/ '" The signingof this form b the,Environmental Health Staff ' in no way intended, nbr'si�oulcl lie taken as a` ' t Y ; � ; ... Y , araritee extended or limited that the onsite wastewaters stem'will function ro rl Jfor an given period of time. � ( ) Y P Pe .r, Y bn Payment. Cash ❑ Check ❑ Money Order ❑ # Amount: $ Date: " ;: Paid By: /I Received By f ra Account #:6 �l. :.� .., r+ 'fir' '° `�� ' f"Force #: 77 F ,�` v'. ''� I t ^, t DAV'IE COUNTY, HEALTH DEPARTMENT' t. a 1 y i .. r L',�­�I:r I-,',�.��,:.,�I�:,.­L,.��'`j,',�L t�:�,—�I.L.b�'1,:.�r,.,'�,�4"'-'l,�",­���,...�.rr,,:'.1'i:L,L�.L I,�I,,�:;,�r�"I"�.I,,r-,L,�L":I�-.A �.���:I�i'L,,'-ri,I�:­"L.,�r,�":I,.'/I�L—,—,,�,!�L'I�,'.. ,' ;[, `IMPROVEMENTS PERMIT.AND",CERTIFICATE OF COMPLETION `, ,r NOTE:Issued in Compliance With Article I I of G.S Chapter 130a it ry Sewage Sy ems. Permit Number , ,.r o f IL rL Name it �F'�rr� .�' �h� �f / ��f •�4 N= / S Date yy '�� �Cr G.',�ff+"'�L i I, 'f G'"�i•� ;? 1r�r „r1 u'"P i'� �' f+/�7, t e� fL=LUi ��d.,r.�>7^?" u'M�' f v f Location fr — -- - i i, - .. a i P; ec. or .' I �III : Subd"ision.Na�mo: ,., ^" Lot No S` Block No. - n �,C6; i e t r l�:T't. ,n r h V ': ,,,,,,,.r.'`"..' T­ 'li Lot:.Size "House Mobile Home - Business ' Speculation # 3 LL , No.,Bedrooms No. Baths - No: m Family Garbage Disposal YES ❑ NO` i„ ` i" ,t Speic ion #o,•Stem a` y�, c A'ufo DishWasher YES CSO"i ❑ �„6 Auto Wash Ma^Eine ,i YES NO ❑ �.,4,? / " ,` Type Water Supply _ ., I` 'Suis permit-Void if sewage system described below is not installed within 5 years from date of issue ":-'x III This permit is subject"to revocation if site plans or the intended use change. ;{ •ti, ft "r r 1''„ t t 4 ff u, .'i 6�� '�'�y i i .l %: i 'ryt t i Ni .i .s s t if d,� r IR1 .t }, r4 I r , � I A 1� r ” , r., ,, ,.rya. ,- , l� ,�ry :,rrt tir a, �E Pt 4+ . ' i " '�. tk; dy i ;.•Y tr r r•` " . ' + ` ..,, . v' y`t �v � q fi i ."_ a , T i � . Improvements permit by — "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 day of completicnk� I�phone Number 704=634 5985. r4u C! � r f Final Installation Dia ram S / em Installed by _ /t '` "�/ "t 9 - . {, oo { t a5 'r, I f %� 4 t- T p :, �-,,-L.,"1�LI...,�­��,,�.L,�",]­L.'��I LL,�,,1��r�,'�,��L,����"X�_I'-7,"�-�.-.�:,.,�L:",,�h,���,'-�I.�-I"-,",L,���,:,"I-,,-,,'�.I"'_..,I�,.-4���,-I�-��'-:1��:".�,�,,,r-,�_�,.,:�'7�'r!�,�,.�..z"z�,L:"-­�,L,�,�'��1,,L,'�I',"�,',�:�-'�"'r,.�"-'.L"eL.._­:'-,��''Ivr",.I�i�-�i_-.-�.;­.,,-l,,:,1'"",-�I�'"rC,,"��..IL,,�1::-,',.,I..,r-,�..;.II,'-�",.:,".','-�,,:�,�,,-:-r�'-',�-"'"..r�,�-.'I."I,�,,'I�,,I,-:,:,,,',.�,''1,-�,,:,,:�L,�,-,..�,'I-I.I'",',,:',�­.',,L.,L,_I'-,',.I�r-"�,�,',,.��,,,�L' r`, j,,T 1_ . ( M a x } ^' 1 t Yh, r^ r �1 kv 9 {:. I,! i ., { .ef 1 1 Y 1 ., _ I,l r u' i i ,. ra I (I r Certificate of Completion Date` a .'The signing of this certificate' shalt indicate that the system described ;aboJe hasibeen`installedin compliance.with L. I.IIr II iIr oa Iv foreanortniven naa sari fact �bwre femAlation, but shall m NO way be taken as a guarantee that the s stem will function " _' ._s.. -y