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679 Greenhill Rd1 • 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 #:* 990005020 Tax PIN/EH #: 5728-41-8776 Billed To: Jason Green Subdivision Info: Reference Name: Location/Address: Green Hill Road -27028 Proposed Facility: Residence Property Size: 15.8 Acres ATC Number: 4826 Site Type: ❑New ❑Repair ❑Expansion **NOTE** This Authorization to Constrict (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 3 #BathroomsZ•r # People 3 BasementRll�asement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size / l• Type of Water Supply: ❑County/City Gell ❑Community Well System Specifications: Design Wastewater Flow (GPD) 340 Tank Size /00 GAL. Pump Tank IVIA GAL. Trench Width 3 6 h Max. Trench Depth 36 n Rock Depth WW Linear Ft. 3_2_ Site Modifications/Conditions/Other:��>�ri STst�+tci /r11 deli 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. ' i 70 �. oar Environmental Health Specialist 'run 1 1 MA (T? -';—I) - 7 ' S lo' w!t CJD F"' 1E l S' F*�- Date: 2 -21-0Y Account #: 990005020 Billed To: Jason Green Reference Name: Proposed Facility: Residence ATC Number: 4826 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5728-41-8776 Subdivision Info: Location/Address: Green Hill Road -27028 Property Size: 15.8 Acres **NOTE** The issuance of this Operation Pernut 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 be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type:. -�L S.T. Manufacturer 0� Tank Date / — Tank Size Pump Tank Size System Installed By: E.H. -voZ pnds -- 3ZV Ob r\c 9 A �. �OyiCZG .i v I 27' oy / ` ��°� FKoNT. Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 .(336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005020 Tax PIN/EH #: 5728-41-8776 Billed To: Jason Green Subdivision Info: Address: 1578 County Home Road Location/Address: Green Hill Road -27028 City: Mocksville Property Size: 15.8 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: Z<ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms —3 # Bathrooms -S # People Basementl7.$'asement plumbing' Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 (a Type of Water Supply: ❑County/City 0<11 ❑CommunityWell ,5 stated in 15A f�lCAC Site Modifications/Pemut Conditions; System Type_ LTAR Initial Repair -7 ie 6 Lb Oyu t NJ L"k 7o7/ z7 X Environmental Health Specialist Date -42,// Y ION SITE EVALUATION/IMPROVEMENT PERMI & A/fjC f, \ 1 ppa Davie County Environmental Healthy P P.O. Box 848/210 Hospital Street �l 1%Sd� bi-4/t, F� Mocksville, NC 27028 1, (336)751-8760/ Fax (336)751-8786 96�ti� av:i App l ation For: e valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type plication: (ew 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 ..l ,ti -,&y -� Contact Person J��1s✓ Billing Address 1579 Co. ,t//f�<,��r . rJ Home Phone City/State/ZIP 111,ks,.,,41e tt;,- tf �G ,; ? Business Pho ` O� - Uyt i? Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Fla�=d -Ol f 11W 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 .-1 sum �_-� F.� Phone Number Owner's Address ( l 7�? <'�,;,rJ f��� . ? _ City/State/Zip ,�'►4 !. <r� ,�,'//, Property Address (,, ick -,r(--. 11,~11 City Lot Size 1<,-(, ,.Tax PIN# - 1 - Subdivision Name(if applicable) Section/Lot# Directions,To Site: 4 0 +676'-d o F Cii"'1, "i.,n,; � 1 isf-� %�'�!�'IC ,� �✓ 41 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 (3No Does the site contain jurisdictional wetlands? Dyes Ao Are there any easements or right-of-ways on the site? ❑Yes ITNO Is the site subject to approval by another public agency? Dyes diNo Will wastewater other than domestic sewage be generated? Dyes C�<o IF RESIDENCE FILL OUT THE BOX BELOW # People- # Bedrooms # Bathrooms Garden Tub/Whirlpool Dyes W'No Basement: L ' o Basement Plumbing: Ayes ❑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 /New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes E4 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(sj 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 staking the house/facility location, proposed well location and the location of any other amenities. ' Site Revisit Charge Prop owner's or owner's legal representative signature Date(s)• a1-11-0 I _ Date Sign given ❑Yes ❑No Revised 11/06 Client Notification Date: EHS: Account # 507 Invoice # O !'3— PI) GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of 1 QPM t �rt�,Click Here To Start Over Quick Search: (County ID c V) till Active Layer. r Use Map Tips GIS typ f U N PARCELS (Map Tips Available) e) heap Layers i Results http://maps.co. davie.nc.usIGoMapslmap/Index.cfm?main-mapservice=gomaps&CFID=412... 2/12/2008 GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search:{County ID c Active Layer. P Use. Map Tips GIs L K D PARCELS (Map Tips Availae) _. bl_ Map Layers I Results I GREENE FLOYD E 1� 3300000038 .___ / ' 6D8_o'� {913 09 m 629 � � N 662Z 667* �t i {i 7 —A 1 6923 yr+, o y. d �o� V, T1 9 -s 73)+1441 45209 349 � I.:16_' a 732' 0 t� ;d' 'ti, .a ✓ ��733 °Du, 1658 ( � � -1i T.-. MORRIS RO+ Z ..... 0 144ft 155£s 152+1 r + 1b37 15784 1593 1 2141DSH, 1084 123j 1 1334 1 f �1 45,p 151 http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?maimnapservice=gomaps&CFID=412... 2/12/2008 GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of 1 yr O 3. _ Click Here To Start Over Quick Search:{County ID c + Ai rr, - ` r Active Layer. r U., 11ap Tres FIs Q � D a*, PARCELS (Map Tips Available) U Map Layers l Results j http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?maintnapservice=gomaps&CFID=412... 2/12/2008 r� A P P L NT.Il?IFQR0 6 ffd6?N Billed To: Jason Green Reference Name: Proposed Facility: Residence Water Supply: 1. Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Tax PIN/EH #: 5721WOY INFORMATION Subdivision Info: ,57Zf-g1-97A, Location/Address: Green Hill Road -27028 Property Size: 15.8 Acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cu SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: . EVALUATION BY: i ,-) 1Y 1 )\ja [o Cell 6 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 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 Mineral= 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 (Revised) Landscape position slope % ����---- HORIZON I DEPTH Texture group Consistence rr,��ac������a■�� HORIZON H DEPTH Consistence Structure HORIZON III DEPTH Texture group__ Consistence _HOMZON IV DEPTH Texture group Consistence ��r������■���i SOILWETNESSRESTRICTIVE HORIZON SAPROLITE CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: . EVALUATION BY: i ,-) 1Y 1 )\ja [o Cell 6 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 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 Mineral= 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 - 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Operation Permit Inspection Checklist Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement 15/ feet 2. Distance from system to well if applicable 1150' feet 3. Any other setback (.1950) requirements Supply line 1. Material supply line is constructed of 2. Length of supply line (2' min.) 3. Amount of fall m' supply line (1/8" per foot min)_ 4. Distance fronST pT to the nitrification field/dist. r� diameter 3 inches Septic Tank/Pump Tank 1. Visually inspect top of tanks(s), interior & exterior walls, baffle nd bottom 2. Any honeycombing or exposed rebar present? Circle : YES oNO 3. Visually inspect sanitary tee, lids, and air vent for proper installat and sealant y 4. Tank Serial Numbers: STB (� p a K (5 PT t4 5. ST Win 6" finished grade? Circle: YE or NO 6. Date of manufacture: ST 3 / 15 PT A 7. Liquid capacity of tanks ST 0 PT ►� 8. Effluent filter type be 9. Pipe penetration seal rese t? Cir • YES or NO 10. Riser(s) present? Circle: YES o No er Typ 11. Pump Tank riser 6" above finishe de? Circle: YES or NO 12. Riser approved? Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation feet 2. Trench Depth Readings (inches) (o`, 3. Number of Trenches .> Distance between trenches q` (a' 4. Trench Width :56 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth (inches) 7. Nitrification lines installed on contour? Circle: YES or NO 8. Innovative system type Instal certified for installation? CYES or NO 9. 2' earthen dam between ST (or d -box) and beginning of nitrification line? Circl • YE or NO 10. Stepdowns a. 2' undisturbed earthen dam(s) Circle: YES or NO b. Proper rise over stepdowns? Circle: YES or NO c. Solid pipe used? Solid, Corrugated or other? d. Elevation of each stepdown e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO Distribution Devices 1. Type .D -Boy- Is the device watertight?Is it level? 2. Distance from Dist. device to trenches 31 1 (_a , feet 3. Record elevations: Inlets Outlets