137 Elrica Lnn
I
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
• Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
OPERATION PERMIT
Account #: 990005397
Billed To: Integrity Builders
Reference Narne: Paul and Julie Snell
Proposed Facility: Residence
ATC Number: 5017 pwop
� 3� � l � 1\ cJcc- la.�►. �.
Tax PIN: EH #: 5811-80-5925
Subdivision Info:
LocationiAddress: Wagner Road -27028
Property Size: 4.302 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 syst will function satisfactorily for any given period of
time.
System Type: � S.T. Manufacturer Tank Date Tank Sized d
Pump Tank Size o6
W &js 9 Instal ed By: a/' ( u /s1�o K E.H. Specialist: ��w Date:
\ I
v
DCHD 11/06 (Re&gs _
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
**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 -3-57 # People / Basement Z asement plumbing? -
Non -Residential Specifications: Facility Type # People # Seats
//// Square Footage(or Dimensions of Facility)
Lot Size '1.Type of Water Supply: ❑County/City W<11 -0 Community Well
/d -Oa
System Specifications: Design Wastewater Flow (GPD) Tank Size GAL. Pump Tank GAL.
Trench Width 3 (e Max. Trench Depth Rock Depth Linear Ft.
Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1969(5)
accepted Systuniz, lilay U ::U % USI -0
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Spec
DCHD 11/06 (Revised)
—t
Date:
a1*5
r-,
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #:
990005397
Tax PIN.,EH #:
5811-80-5925
Billed To:
Integrity Builders
Subdivision Info:
Deference Name:
Paul and Julie Snell
LocationlAddress:
Wagner Road -27028
Proposed Facility:
Residence
Property Size:
4.302 Acres
ATC Number:
5017
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 -3-57 # People / Basement Z asement plumbing? -
Non -Residential Specifications: Facility Type # People # Seats
//// Square Footage(or Dimensions of Facility)
Lot Size '1.Type of Water Supply: ❑County/City W<11 -0 Community Well
/d -Oa
System Specifications: Design Wastewater Flow (GPD) Tank Size GAL. Pump Tank GAL.
Trench Width 3 (e Max. Trench Depth Rock Depth Linear Ft.
Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1969(5)
accepted Systuniz, lilay U ::U % USI -0
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
Environmental Health Spec
DCHD 11/06 (Revised)
—t
Date:
a1*5
r-,
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
�-- Davie>County Health Department
Environmental -Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC .27028 -
ov 1 6 2u09 (336)751-8760/ Fax (336)751=8786
Permit %Authorization To Construct(ATC) ❑ Both
!1MP&R77N7*** 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 =6+ k t Contact Person A-!1
Billing Address Home Phone - 5"
City/State/ZIP 13.,1T jLylC joTEQC_ 27 0b-(p_Business Phone - a 514
Name on Permit/ATC if Different than Above.
Address
City/State/Zip
PROPERTY TNFORMATTnN �Qu.\�n'e�� -704 '7 3 (
NOTE: A survey`plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Street Address City I/ or. ✓i lie Tax PIN# �gI ' �a
Subdivision Name A4 ift Section/Lot#4/4ta- / Lot Size O
Directions To Site: 141nv %nh) . /�F�-/ O.n73iGCCjv E. __!-%4" A
Date House/Facility Corners Flagged / n f 2a/ O`t
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 1&o
Does the site contain jurisdictional wetlands?
Dyes RNo
Are there any easements or right-of-ways on the site?
Dyes KNo
Is the site subject to approval by another public agency?
Dyes *io
Will wastewater othet than domestic sewage be generated?
Dyes X4110
IF RESIDENCE FILL OUT THE BOX BE OW
# People 0,__ # Bedrooms # Bathrooms_ Garden Tub/WhirlpoolXYes ❑No
Basement:XYes ❑No Basement Plum ing: 5Yes ❑No
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: Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water Pew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'N mo
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 understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections ta.Aetermine compliance with applicable laws and rules on the above described property located in
Davie County and owned by j _504-11
roperty owner's or owner's legal representative signature
— .3—; 20a
Date
Sign given Dyes ❑No
Revised 2/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account #
Invoice #
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GoMAPS - Davie County NC Public Access
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http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=41... 11/17/2009
} y
Davie County Environmental Health 7 f
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
Account #: 990005019
Billed To: Erik Lawhon
Address: 854 Valley Road
City: Mocksville
Reference Name:
Proposed Facility: Residence
V
1
IMPROVEMENT PEWPIN/EH #: 5811-80-5925.01
Subdivision Info:
Location/Address: Wagner Road -27028 .Siff l
Property Size: 9 Acres
**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: RNew ❑Repair ❑Expansion Permit Valid for: [35 Years ❑No Expiration
Residential Specifications: # Bedrooms3—# Bathrooms # People 'T Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):_ Type of Water Supply: 206—unty/City ❑ Well ❑ Community Well
Site Modifications/Permit Conditions:
Environmental Health Specialist
Date ��%— 0
r 4
"'APP 4A; �ITE EVALUATION/IMPROVEMENT PERMIT & ATC
N{ avie County Environmental Health
P.O. Box 848/210 Hospital Street
Q 208 Mocksville, NC 27028
F �e (336)751-8760/ Fax (336)751-8786
Appli Tion or: �t��li�'u3i fiprovement Permit ❑Authorization To Construct(ATC) ❑Both
Type o Applicati ystem 10 Repair to Existing System ❑Expansion/Modification of Existing System or Facility
'IMP RTANP" 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
SC R i L v.HI � oN
Contact Person
( e SL- (' -,
Billing Address
5 `1 V" n e
Home Phone
—5-3-6-
City/State/ZIP kA
C3c 1cs v, 0- ) tai!_ 3 76 L�'
Business Phone
"2C'
Name on Permit/ATC if Different than Above
Address
PROPERTY INFORMATION *Date House/Facility Corners Flagged .2 �/-
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name C.(Ac cj- ���,R ,(_( Phone Number
Owner's Address 1 I o City/State/Zip Z`102`-'
Property Address oCVS t, City
Lot Size d. `L p' ae, Tax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: 6.>t)1 rif'. n-, , D Q 0, -Pi
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,Edko
Does the site contain jurisdictional wetlands? ❑ Yes �No
Are there any easements or right-of-ways on the site? ❑Yes E2,No 59
� JO
Is the site subject to approval by another public agency? []Yes Flo
Will wastewater other than domestic sewage be generated? ❑Yes Zo
IF RESIDENCE FILL OUT THE BOX BELOW
Al
# People # Bedrooms_ # Bathrooms _ Garden Tub/Whirlpool ❑Yes CJKo
Basement: es No Basement Plumbing: ❑Yes ❑No
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: 'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water V<ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes !40
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 ealth Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I m risible f i` the. proper identification and labeling of property lines and corners and locating and flagging
or stak' o acili location, proposfd well location and the location of any other amenities.
Site Revisit Charge
Property owner's r o r s leg repre nta 've signature
Date(s):
6 Client Notification Date:
Date EHS:
Sign given []Yes ❑No Account #�
Revised 11/06 Invoice #
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Avivii-. nr. ii,,/xxrphqitp/mnni7iPAX7Pr/lf;Pll7pr A In fn A n 17
SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
1 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
A�plication-F �H9�yw lu provement Permit ❑ Authorization To Construct(ATC) ❑ Both
T1 e of App`licatio�i 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 (f*,40 �� C
aegzt Contact Person
Billing Address 116 S�t,� ��'� R 7 Home Phone
City/State/ZIP /VC Z%dZS, Business Phone
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
*Date House/Facility Corners Fl
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan PKat(to scale)
(Permit is valid for 60 months with site plap, nQ expir4tion with complete plat.) .
Owner's Name KnLtgdgo(6t&vyeeJ Phone Number
Owner's Address /16 5LImT6e City/State/Zip �%f.1Gf�SG?Ll.�, AUL 2,70a
Property Address (t/RCity /�Q!,C✓s'fiGG,—r-
Lot Size 1£, AcrzC-5 Tax PIN# E?d 0000c5(),W 67911 '90 -5-W5
Subdivision Name(if pplicaljle) S ctiL t
Directi ns To Site: �D� N . 664;&04, ('�i re Q/V
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? Dyes W to
Does the site contain jurisdictional wetlands? Dyes [moo
Are there any easements or right-of-ways on the site? Dyes Quo
Is the site subject to approval by another public agency? Dyes 12'111
Will wastewater other than domestic sewave be venerated? Dyes G�'fvo
IF RESIDENCE FILL OUT THE BOX BELOW
# People 6- # Bedrooms # Bathrooms 3 Garden Tub/Whirlpool es ❑No
Basement: R' -Yes ❑No Basement Plumbing: a'l'es ❑No
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: ❑ County/City Water Rll ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes R<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 niles.
I understand th-aIrrrespon ' -tl pr4e identification and labeling of property lines and corners and locating and flagging
or sta ho- i�fdi i cation, oposed 11 location and the location of any other amenities.
Pro s or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given •,
❑Yes ❑No Account # �
Revised 11/06 Invoice # j
4
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002721 Tax PIN/EH #: 5811-80-5925
Billed To: Chad Correll Subdivision Info:
Reference Name: Location/Address: Wagner Road -27028
Proposed Facility: Residence Property Size: 18.2 Acres Date Evaluated: 'I-3n—
Water
l_3b"
Water Supply: On -Site Well / Community
Evaluation By: Auger Boring ✓ Pit
Public
Cut
FACTORS
1
2
3
4
5 6 7
Landscape position
L
Slope %
-
a
HORIZON I DEPTH
— G
C
0 14
Texture group
L
11,1,S
,S
C
Consistence
/
Structure
tJ�A
tc
Mineralogy
HORIZON II DEPTH—
y
Texturegroup
G
C
o-
Cl
Consistence
4
, .
Structure
'SA K
5 6 A 1k&
AbK154V
Y
Mineralogy
1 1
N'- C1
t f`
HORIZON III DEPTH
Texture groupG
Consistence
Structure
�E
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
-71,r
RESTRICTIVE HORIZON
SAPROLITE
`
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
p
G
-L-
6.
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY.
OTHERS) PRESENT: (bad Ca al /
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
Moist
VFR - Very friable FR - Friable FI - Firm VFI - 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 - 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
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)
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APPLI,CAN"F.Il11FQRlY1A�,IQ�1
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Billed To: Erik Lawhon
Reference Name:
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
Tax PIN/EH #: 581HWZ YM1NFORMATION
Subdivision Info: 681140,5117-5.01
Location/Address: Wagner Road -27028 el
Property Size: 9 Acres Date Evaluated:
Water Supply: On -Site Well Community
Evaluation By: Auger Boring LZ Pit
Public
FACTORS
1 2
3 4 5 6 7
Landscape position
(.
Slope %
HORIZON I DEPTHLie
^
Texture group'
�
G
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH
L —
Texture group
< •• C
Consistence
Structure
Mineralogy
C -
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
/_..-^
�•
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
j.
SITE CLASSIFICATION: EVALUATIONBY: �✓��llt �i7�_
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
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
Mineral=
1:1, 2:1, Mixed
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 (Re.vi-e.d)