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647 Godbey Rdr DAVIE COUNTY ENVIRONMENTAL HEALTH f, P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990004321 Billed To: Chevis Cuthrell Reference Name: Proposed Facility: Residence ATC Number: 4702 OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5718-47-2700 Godbey Road -27028 2.455 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 Typay"T S.T. Manufacturer 1�' Tank Date /G • Tank Size�GG Pump Tank Size System Installed By: 1I� �' E.H. Specialist: L�jd"L\Date: U —Vyr,- %W y, ok flame JfiJ0twu . f � . to G Y4,/ DCHD 11/06 (Revised)Z7 r 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 #: 990004321 Billed To:. Chevis Cuthrell Reference Name: Proposed Facility: Residence ATC Number: 4702 Tax PIN/EH #: 5718-47-2700 Subdivision Info: location/Address: Godbey Road -27028 Property Size: 5 Acres Site Type: Rllew ❑Repair ❑Expansion "NOTE" This Authorization to Construct (ATC) MUST BE. ISSUED by the Davie County Environmental Health Section prior to issuance of eny bcildirg pe=dt(e), (in cempliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCTIS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications; # $edroo=A_ # Bathrooms3• 5 #people, BasementO BasementplumbingF� Non -Residential Specifications: Facility Type # ?topic # Seats Square Footage(or Dimensions of Facility) Lot Size 15_AC-12� Type of Water Supply: CCounty/Cityxell t7Cotnrnunity Well System Specifications: Design Wastewater Flow (GPD) yank Size 1012cbAL. Pump Tank/SAL. Trench Widffi 3t- , ivlax. Trench Depth ;��' Rock Depth-/ 7-" Linear Ft. Site Modifications/Conditions/Other: _1 N S 1411.. D!J CCt�:MA Kra )CO RiciA Wa_J_ , 1L�-- Contact the Davie County Environmental Health Section for final inspection of this system between &.30 - 930a.m. on the day of installation. Telephone # (336)751.-8760. Environmental Health Specialist tt�lL?�'o�l��t1 o� [klV7t fi R007 L7 1e� • - Davie County Environmental Health ' P.O. Box 848/210 Hospital Street n Mocksville, NC 27028/ 2 V7 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account M 990004321 Tax PIN/EH #: 5718-47-2700 Billed To: Chevis Cuthrell Subdivision Info: 1Gy% Address: 697 Godbey Road Location/Address: Godbey Road -27028 City: Mocksville Property Size: 5 Acres Reference Name: Proposed Facility: Residence C�1 L **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: ?<New ❑Repair ❑Expansion Permit Valid for -X5 Years ❑No Expiration Residential Specifications: # Bedrooms I # Bathrooms 3• S--# People Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �� . Type of Water Supply: ❑County/City,,2<61 ❑CommunityWell Site Modifications/Permit Conditions: I)OLV\?WO&Eb Plan ]c System Type LTAR Initial GA!DIJV T1 . Z Repair I Ctrl V C—pJ-VOK f Environmental Health Specialist i.p.11-06 A A,'I SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health `ZdP.O. Box 848/210 Hospital Street g Mocksville, NC 27028 ' PQR (336)751-8760/ Fax (336)751-8786 Apicatior� r \ L wa on/Improvement Permit ❑ Authorization To Construct(ATC) oth Type f Applic iew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***I�ORTANT*** 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 C A e V I S C tk-t-µ ".LL- Contact Person 0-14 405 C UT A r -E cL Billing Address (L -,`i-7 Home Phone 33G -- yid - 51L17 City/State/ZIP Ll'�7C- kSJ I t_LE rJ L 7 0 a 6 Business Phone 33 G- ei $ - .31t I 1 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION I *Date House/Facility Corners FlaRved q-"77-0-7 NOTE: A survey plat or site plan must accompany this application. Included: N Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name F-A(Z L C-LcrN-P-eLt_ Phone Number3,?(,--1-J2 R -_C-I47 Owner's Address (p c17 Cin C y per. City/State/Zip 1yYbCr Sy i t_ L -. N( d -70-a? Property Address City Lot Size a, 115 JJ c. Tax PIN# fZ/-/�%-2706 Subdivision Name(if applicable) Section/Lot# Directions To Site: TU.PsI n►. 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,XNo Does the site contain jurisdictional wetlands? ❑YesXNo Are there any easements or right-of-ways on the site? XYes ❑No Is the site subject to approval by another public agency? ❑Yes`gNo Will wastewater other than domestic sewave be venerated? []Yes XNo IF RESIDENCE FILL OUT THE BOX BELOW AS # People _ 3 # Bedrooms 4 # Bathrooms 3. 5 Garden Tub/Whirlpool ❑Yes Mo Basement: AYes ❑No Basement Plumbing: XYes ❑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 ❑ New Well '%Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes X 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 t king the h /facili . location, proposed well location and the location of any other amenities. ' Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Gi"-' Q-] Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Z/ Revised 11/06 Invoice # lu 0 0� toolqns ©q9�"003 lo 4s • co o i, su 0 r, � � � ' � . `�,,��Wv ��1, � ,J �' �a�` � ��'��' c�5 �� A���� ,�' €�A � � Ci �a �a � � �� � �r� e�e .Vie; f�0��J �� Ar) 17, 05 )1 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section � Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990004321 Billed To: Chevis Cuthrell Reference Name: Proposed Facility: Residence Property Size Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5718-47-2700 Subdivision Info: Location/Address: Godbey Road -2702 2.455 Acres Date Evaluated: On -Site Well Vl/ Community Public Auger Boring Pit (4110-7 Cut FACTORS 1 2 3 5 6 7 Landscape position L i/ _ v C; Slope % 2c HORIZON I DEPTH v -/2 l� ©— v • 2 Texture group C Consistence 6_9 S SP I SSSS N TO Structure _' k_ Mineralogy S HORIZON II DEPTH 1Z-- "0 42—IL 10 — Z 1 Texture group Se -L4 Lf Consistence F,` S? Structure 55k• S Mineralogy 'T Sa HORIZON III DEPTH 16 _24 + l L_- 1 k4^ Texture group12,pCA4, 12 Consistence Structure Mineralogy HORIZON IV DEPTH Z Texture group C_+ Consistence Structure Mineralogyw SOIL WETNESS Z RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE I I I o • L SITE CLASSIFICATION: / o• Z LONG-TERM ACCEPTANCE RATE: 4 EVALUATION BY: J� OTHER(S) PRESENT: REMARKS: oe, Z!� A g 2 l f -T q ', aoC.,It(L? " —L(2;f d,J vOlai St 23 or Ur Orr rfwW Roc LEGEND 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 lYflres 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 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■SIG!■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■gni■■t■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■inn■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMNONMEMNONliMEMEME SUMMON MEMEMSMENNENEMMEMN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■��,ray■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■Il1111■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ X437 . .....6352 f . 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