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302 Foster RdM DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005563 'fax PINfEH #: 5706-69-4349 Billed To: Don Brown Subdivision Into: Deference Name: LocationiAddress: 302 Foster Road -27028 Proposed Facility: Produce Stand Property Size: • - 39.5 Acres ATS* The74suance 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 560 Tank Date Tank'Size 1/D6 Pump Tank Size NIR' Q System Installed By: ltGnT int ti; 6 R E.H. Specialist::ZIOUA Date: GPS Coordinate: Job'c10WLj Z.ScIn � lel ti, i t ck DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH PJ(11( P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005563 Tax PINIEH #: 5706-69-4349 Billed To: Don Brown Subdivision Info: Reference Name: Location/Address: 302 Foster Road -27028 Proposed Facility: Produce Stand Property Size: 395 Acres ATC Number: 5745 Site Type: "ewRepair ❑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 / # People / Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type FEU f s111a # People_ # Seats Square Footage(or Dimensions of Facility) Lot Size 39 Type of Water Supply: ❑County/City Retl [Community Well Syste Specifications: Design Wastewater Flow (GPD) OU Tank Size // eAL. Pump Tank GAL. 0A 4 f, 2 �.le 1 Trench Width Max. Trench Depth /G Rock Depth �.2 Linear Ft. 3 �r Oq bt Site Modifications/Conditions/Other: •., � -:�� n ' 0 . on _ accepted S, Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Tele ho e # (336)751-8760. / - I .-I - 10 JAI IJ 1l" -Tomalc, jrttri (6"6 `e Environmental Health Specialist DCHD 11/06 (Revised) Date: /! r // . r Account #: 990005563 Billed To: Don Brown Address: 302 Foster Road City: Mocksville Reference Name: Proposed Facility: Produce Stand Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Tax PIN/EH #: 5706-69-4349 Subdivision Info: Location/Address: 302 Foster Road -27028 Property Size: 39.5 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: ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ (� ..oQ i o -%� pre Non -Residential Specifications: Facility Type i ('0&J C e #People #Sean Square Footage(or Dimensions of Facility) G �15'�j Design Flow(GPD): Type of Water Supply: ❑County/City EkWell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: accepted Systems may also he use Site Plan Initial f, 1? CA -rA (L+O 41eeh koaSrS 1� 1 LTAR a= Environmental Health Specialist i.p. 11-06 Date 3 _ 16 AP R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health v ems! 14bce- P.O. Box 848/210 Hospital Street O t Mocksville, NC 27028 �(� 1 (336)753-6780/ Fax 336)7-1680 p rc tion F x �valt mprovement Permit VAuth�.I)a�tion11To Construct (ATC) E Both pe o p$jiU� w System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ` * *bRTANT* * *THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 0 PDT It' 0 -NTT ThTPr)l? A4 0 TInXT 1L1 VL1 11\1 V1U�11111V1\ Name � �� W • ,/.3roa0N Contact Person Address 3nz Home Phone 3.36 - y9Z - S,Zlo3 City/State/ZIPfr�f�,;//� , /U� 2�pZ� Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip FKUYLK I Y 1N1' UKMA I IUN *Tllate House/Facility Comers N laeeed 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 Qin, Phone Number Owner's Address T City/State/Zip Property Address !!� L/L _ City_ Lot Size f; S- Tax PIN# ff,20p0000Do.-i- ` 70(0' Subdivision Name(if applicable) Section/Lot# Directions To Site: 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 —,b?6 Does the site contain jurisdictional wetlands? _--N'o Are there any easements or right-of-ways on the site? _Yes --No Is the site subject to approval by another public agency? _Yes moo, Will wastewater other than domestic sewage be generated? _Yes Yes IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes []No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Businessi1ro hce ,S�q��Q Total Square Footage of Building 8&_ # People # Sinks / # Cot(tmodes _�_ # Showers # Urinals Estimated Water Usage (gallons per day) S (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Aonventional Kccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well &xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? Y No 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 I o ting and flaggi or staking the house/facility location, proposed well location and the location of any other amenities. 0n- W. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: Date P P EHS: A AUG 1 3 2010 A J K r_ Sign given ❑Yes ❑No e vA Account # V J t[3 Revised 11/06 Invoice # � / %tq 6oMaps GIS r , Page I of 6 http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 8/18/2010 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005563 Billed To: Don Brown Reference Name: Proposed Facility: Produce Stand Property Size PROPERTY INFORMATION Tax PIN/EH #: 5706-69-4349 Subdivision Info: Location/Address: 302 Foster Road -27028 39.5 Acres Date Evaluated: a / W ter Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut '-1 FACTORS 1 2 CK 3 4 5 6 7 Landscape Rosition Slope % HORIZON I DEPTH oz Li Texture group(� Consistence Structure Mineralogyv HORIZON H 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 LONG-TERM ACCEPTANCE RATE .1 G SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: 2 2 REMARKS: LEGEND EVALUATION BY: A1% AW lc►✓til OTHER(S) PRESENT: tA�,. iC 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 . ,C ONSIST .N . . Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm M'd 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) i TAR - r lana -t- n--t—n .. __11A1 .1r.� — -'-- b North Carolina State Laboratory ofPubliclHealth w Department of Health and Human Services P. O. Box 28047 -- 306 N. Wilmington St. -- Raleigh, N. C. 2 61L Z010-8047 INORGANIC CHEMICAL ANALYSIS - PRIVATE WATER SYSTEM JF)AIfir (In iiti—, Name of System: Brown, Dennis Address: 435 Foster Rd Mocksville. NC County: DAVIE Report To: Davie Co. Health Dept. Post Office Box 848 Mocksville, NC 27028-0665 Courier: 09-40-06 Zip: 27028 ATTN: Robert Nations (336) 751-8760 Collected By: R NATIONS Date: 6/9/2009 Location of sampling point: Well Remarks: Permit # 0016, GPS N358 50.987/W80* 39.705 Source of Water: Source of Sample: Type of Sample: Type of Treatment: Type of Analysis Private Time: 11:45:00 AM Parameters Results Units Date Analyzed: Silver <0.05 mg/I 6/10/2009 Alkalinity as CaCO3 115 mg/I 6/10/2009 Arsenic <0.005 mg/I 6/10/2009 Barium <0.1 mg/I 6/10/2009 Calcium 27.5 mg/I 6/10/2009 Cadmium <0.001 mg/I 6/10/2009 Chloride IC 6 mg/I 6/10/2009 Chromium <0.01 mg/I 6/10/2009 Copper <0.05 mg/I 6/10/2009 Fluoride <0.20 mg/I 6/10/2009 Iron 0.14 mg/I 6/10/2009 Hardness as CaCO3 (Ca,Mg) 120 mg/I 6/10/2009 Mercury <0.0005 mg/I 6/10/2009 Ems' 1 i Magnesium 12.5 mg/I 6/10/2009 a 3 �zL?"FkSvA I Manganese <0.03 mg/I 6/10/2009' Sodium 9 mg/I 6/10/2009' Nitrite as N <0.10 mg/I 6/10/2009" Nitrate as N 1.18 mg/I 6/10/2009 i Lead <0.005 mg/I 6/10/2009 pH 7.9 Std. units 6/10/2009 ". Selenium <0.005 mg/I 6/10/2009 Sulfate 21 mg/I 6/10/2009 k;.- Zinc 0.17 mg/I 6/10/2009 Date Received: 6/10/2009 Report Date: 7/6/2009 Reported By: Today's Date: 7/6/2009 Ref: 8079 Login Batch: 060036 Sample Number: AB90622 North Carolina Division of Public Health Occupational and Environmental Epidemiology Branch, Epidemiology Section INORGANIC CHEMICAL ANALYSIS REPORT Private well water information and recommendations County: �'Vlt Name: �jVcw►, Sample Id Number: Location: Reviewer P/1- ANALYSIS REPORT Your well water was tested for 15 metals, plus nitrates, nitrites, and pH. The results were evaluated using the federal drinking wa€er standards. The pH is a measure of the acidity of the water. Drinking water may contain substances that can occur naturally in water or can be introduced into the water from man-made sources. (These recommendations are based on inorganic chemical analysis only.) TEST RESULTS AND USE RECOMMENDATIONS Your well water meets federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering. The following substance(s) exceeded federal drinking water standards. Your water can be used for drinking, cooking, washing, cleaning, bathing, and showering, but aesthetic problems such as bad taste, odor, staining of porcelain, etc. may occur. You may want to install a household water treatment system to address aesthetic problems. Barium I Cadmium Chromium Fluoride Iron Magnesium Manganese Selenium Silver Sodium Zinc pH The following substance(s) exceeded federal drinking water standards: We recommend that your well water not be used for drinking or cooking, unless you install a water treatment system to remove the circled substance(s). However, it may be used for washing, cleaning, bathing, and showering. Arsenic Barium Cadmium Chromium Copper Fluoride Lead Iron Ma nesium Manganese Mercury Nitrate/Nitrite I Selenium Silver Sodium Zinc p1l Re -sampling is recommended in months. Re -sample for lead and /or copper. Take a first draw, 5 minute, and 15 minute sample inside the house (preferably the kitchen) and if possible a first draw, 5 minute and a 15 minute sample at the well head to determine the source of the lead and/or copper. Contact your local health department for re -sampling assistance. OTHER CONSIDERATIONS Routine well water sampling for the above substances is recommended every two to three years. Sample your well water when there is a known problem or contamination in your area, after repairs or replacement of your well, or after a flooding event. Contact your local health department for sampling instructions. Contact your local health department for more Information or go to htta://www.eai.state.nc/eai/oii/hsfactsheet.htmI March 10, 2009