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232 Goldman Ln (2)DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990004057 Tax PIN/EH #: 5747-40-4855 Billed To: Structural Designs LLC Subdivision Info: 2.52— Reference Name: Andy Beauchamp Location/Address: Goldman Road -27028 Proposed Facility: Residence Property Size: 9.25 Acres ATC Number: 4957 **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 Tank Date I 1 /,20 Tank Size 1l add Pump Tank Size System Installed By: %vwaq bvykn E.H. Specialist:&%n14 Qj'f Qu Date: DCHD 11/06 (Revised) L%v%s I Off" X11 SS CAiavnbe Zw `cul 4-6�ul 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 #: 990004057 Tax PIN/EH #: 5747-40-4855 Billed To: Structural Designs LLC Subdivision Info: Reference Name: Andy Beauchamp Location/Address: Goldman Road -27028 Proposed Facility: Residence Property Size: 9.25 Acres ATC Number: 4957 Site Type: MN' ew ❑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 chanee. Residential Specifications: # Bedrooms 2 # Bathrooms Z # People__L_ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size 0/, 7-5 k Type of Water Supply: ❑County/City Z�Vell ❑Community Well System Specifications: Design Wastewater Flow (GPD) Zy 0 Tank Size�(}Ot7 GAL. Pump Tank N A GAL. Id Trench Width Det 1Ro��is�Depth IZLinear Ft. 6cc,epted Systems -lav 2!7.,o h" use,! Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Teleahone # (336)751-8760. New well 10D' 4�brn (I Y"i a I YY1 i r ,(\-e. C1 V Environmental Health Specialist Date: 3 — ZU— 09 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 #: 990004057 Tax PIN/EH #: 5747-40-4855 Billed To: Structural Designs LLC Subdivision Info: Address: 854 Valley Road, Suite 200 Location/Address: Goldman Road -27028 City: Mocksvile Property Size: 9.25 Acres Reference Name: Andy Beauchamp 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: Wew. ❑Repair ❑Expansion Permit Valid for: a'5 Years ❑No Expiration Residential Specifications: # Bedrooms 2 # Bathrooms 2 # People I Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): ZVO Type of Water Supply: ❑County/City C9'O ell ❑Community Well As stated in 15A Ni%"AC 18A.1989(51 Site Modifications/Permit Conditions: excepted Systems ;nay also ba used Initial Repair Site Plan r Environmental Health Specialist ,,,ii -OA It LTAR 2"1 S 1 � INinp1. 5EY'nc C T n Date 3— 2Q— OBJ W OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street �oD9 Mocksville, NC 27028 ��`j� (336)751-8760/ Fax (336)751-8786 th App l ,`r pi uation/Improvement Permit ❑ Authorization To Construct(ATC) o ype of* pli y : (}Flew 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 � � - . il�;�( 7Z -;, *!!)1(2,5 Contact Person Billing Address =:�2 74/ �,� ��{ / Home Phone City/State/ZIl' /1i �I ��.�.c'.C''S i� c' Business Phone C= Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION City/State/Zip *Date House/Facility Corners 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 c /�rF7.�.:,!' Phone Number 15 - �l7;/ Owner's Address- %-. ;� !c,/,-/{ JC 5f /5e --?J / /: City/State/Zip Property Address 1, ' /_ City1�%-_!`�GT Lot Size 4-! &2 Tax PIN# .i /�{'?. 5S Subdivision Name(if applicable) Section/Lot# Directions To Site: (,r•�'��r. '��Z/: C`171F�� (' lJ1i�: i�t C�-sC it/fL, ... /� (c. r�j(�� C'�l /e—�� 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 CKo Does the site contain jurisdictional wetlands? ❑Yes "o Are there any easements or right-of-ways on the site? ❑Yes 2No Is the site subject to approval by another public agency? ❑Yes 9No Will wastewater other than domestic sewage be generated? ❑Yes BNo IF RESIDENCE FILL OUT THE BOX BELOW # People % # Bedrooms _- # Bathrooms_ Garden Tub/Whirlpool ❑Yes ONo Basement: ❑Yes Flo Basement Plumbing: ❑Yes V�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: offonventional ❑Accepted ❑Innovative ❑Alternative ❑Other. 'Water Supply Type: ❑ County/City Water g<ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes PI 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 comers and locating and flagging or st�k;ng the hour/facility locavon, proposed well location and the location of any other amenities. s or owner's 5 � Date Sign given ❑Yes ❑No Revised 11/06 Site Revisit Charge signature Date(s): Client Notification Date: EHS: Account # DJ 7 Invoice # 64 GoMAPS - Davie County NC Public Access Davie County, 0 .01 E NC - GIS/Mapping System Click Here To Start Over Active Layer. ❑Use tf,ap Tips PARCELS (Map Tips Available) v+ - Page 1 of I Quick Search:(County ID or Owner Ni GaLo�� M. Addre http://maps.co. davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129... 3/4/2009 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation 37117_04955 APP.LICANT.,Il hLM ON Tax PIN/EH #: 5747-40Rc88ERTY INFORMATION Billed To: Structural Designs LLC Subdivision Info: Reference Name: Andy Beauchamp Location/Address: Goldman Road -27028 Proposed Facility: Residence Property Size: 9.25 Acres Date Evaluated: 13-9-69 Water Supply: On -Site Well I`/" Community Evaluation By: Auger Boring ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position T _F 'Ir Slope % 1016 HORIZON I DEPTH 150- 1 0- )D Texture group 5c,L S(,L 5 (,L Consistence F i i Structure Mineralogy S. S SDk/ HORIZON II DEPTH _ qq, 12 - o 1 yg Texture groupG C Consistence Structure 5 Yr 5 Mineralogy(' HORIZON III DEPTH _ Texture groupL Consistence rj Structure Mineralogy HORIZON IV DEPTH Texture group Consistence . Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION -LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: . Z"1 S REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 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) I TAR - I.nno_ti-rm Arrentnnra rate - onlhil vlft7 ■■■■ NEON MEMO OMEN NONE OMEN ■M■■ NONE NEON ■■■■ NONE ■OO■ Oman ■ i i i ■ ■ ■ moo■m■■ ■■■moon ■EMEME■ ■ME■■M■ ■MEMEM■ ■E■■EM■ ■om■om■ ■omo■o■ ■■■■■■■■■■■■■■■■■■■ ■■m■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■E■■■■■ ■■■■■■■■■■■■■■■■■■M ■■M■■■■■■M■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■ ■■■■■■ ■■MONS ■ i ■ ■ ■ ■ ■■■■■■ ■■■■■■■■NNONE ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■■■ ■■■■■■■■■■■■■■■■■mer■moi■■■■■ ■■■■Mmr�■■amt!■■■■■■■■■■■■■■■ ■■■■■■■mommo■■■i ■■■■■■■MEMEM■■■ ■■■■■■■u■■ommmol ■ ■M■MM■MMMMMM■ ■■■mMMM■MMM■■ ■■mMMMMM■■■mM ■M■■mMM■■m■m■ ■MMMMMMM■■M■■ ■■■mmM■MMMMM■ ■MMMM■MMMMMM■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■M■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■M■■■ ■■■■■■■M■■■■■ ■■■■■■■■■■■■■ ■■■■■■■M■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■M■■■■■■■■ ■■■■M■■■■■M■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■m■■■■■■■ ■■■■M■■■■■■M■ ■■■■■■■■■■■■■ ■■M■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■MM■■ m■■■■■■■_s■■■■ =on moms NEON ■■ MOON moms NONE ■o■■ OMEN NEON NEON ■■■■ ■o■■ NOME NEON MEMO moms ■■N■ moms GoMAPS - Davie County NC Public Access Page I of I Davie County, NC - GIS/Mapping System + Cbrk Nkm Ira Slat Chwr QMkk sawdk(COM*V ED or Owmw Nk P&twe twrEl use mw w5 PARCELS (Map, Tips Available) Adkhm AD 6).X 231? (142) http://maps.co.davie.nc.us/GoMaps/map/Index.cfm 3/19/2009