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159 Grey Fox Trail•� DAVIE COUNTY ENVIRONMENTAL HEALTH i • P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005631 Tax PINIEH #: 170000008207 ;tl j6q Billed To: Mark Hutchins Subdivision'lnfo: Off Fork B -xbv Road Lot # 2 Reference Name: LocationiAddr •ss:Grey Fox Trail -27006 Proposed Facility: ResidencePeapert Size: 4TC: 5559 ATCmmjtLP#* TU Nuance 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 5 D Tank Date q 115 Tank SizeIWO Pump Tank Size NIA System Installed By: VDV5� NGAOC E.H. Specialist: &AM Date:Tl I g GPS Coordinate: DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION I� Account #: 990005631 Tax PIN; EH #: 170000008207` Billed To: Mark Hutchins Subdivision Info: Off Fork Bixby Road Lot # 2 Reference Name: LocationrAddress: Grey Fox Trail -27006 Proposed Facility: Residence Property Size: 2.8 Acres ATC Number: 5859 Site Type: XNNew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior tp 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 channe. Residential Specifications: # Bedrooms _-5# Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size d. Q[ Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)�� Tank Size 166C�GAL. Pump Tank )1A GAL. Trench Width ` ' .L, Max. Trench Depth ='rev` Rock Depth PJ 1; Linear Ft. C'X %p Site Modifications/Conditions/Other: d Vit►", st7'"t 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 # (33p6)751-8760. Environmental Health Specialist DCHD 11/06 (Revised) J r DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005631 'fax PIN!EH #: 170000008207 Billed To: Mark Hutchins Subdivision Info: Off Fork Bixby Road Lot # 2 Reference Name: LocationiAddress: Grey Fox Trail -27006 Proposed Facility: Residence Property Size: 2.8 Acres Site Type: RffNew ❑Repair ❑Expansion ATC Number: 5859 **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 chance. Residential Specifications: # Bedrooms__3 # Bathrooms 2 # People. Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 1�cc Type of Water Supply: County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) -?Tank Size IUOO GAL. Pump Tank AVk GAL. Trench Width � Max. Trench Depth ] C Rock Depth PIR Linear Ft. 190� ais _ Site Modifications/Conditions/Other: �VCF0� 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. 111—� . � Environmental Health,S DCHD 11/06 (Revised) Date: (91,,9426 Davie County Environmental Health Reference Name: Prop q -T4 .�ii�ij�ylh s imprResideovement 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: _VNew ❑Repair ❑Expansion Permit Valid for: 25 Years ❑No Expiration Residential Specifications: # Bedrooms -3 # Bathrooms_ # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design F1ow(GPD)&_y0 Type of Water Supply: &ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial S'v12MIXA-611 _ Repair $9 S Site Plan .J Environmental Health Specialist i.p. 11-06 Date C9/Z 'x1971 Del P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005631 Tax PIN/EH #: 170000008207 Billed To: Mark Hutchins Subdivision Info: Off Fork Bixby Road Lot # 2 Address: 5512 Oak Summit Court Location/Address: Grey Fox Trail -27006 City: Winston-Salem Property Size: 2.8 Acres Reference Name: Prop q -T4 .�ii�ij�ylh s imprResideovement 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: _VNew ❑Repair ❑Expansion Permit Valid for: 25 Years ❑No Expiration Residential Specifications: # Bedrooms -3 # Bathrooms_ # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design F1ow(GPD)&_y0 Type of Water Supply: &ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial S'v12MIXA-611 _ Repair $9 S Site Plan .J Environmental Health Specialist i.p. 11-06 Date C9/Z 'x1971 Del a • Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005631 Tax PIN/EH #: 5778-38-0039.01 Billed To: Mark Hutchins Subdivision Info: Address: 5512 Oak Summit Court Location/Address: Off Fork Bixby Road -27006 City: Winston-Salem Property Size: 2.8 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: JLNew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms3— # Bathrooms 2 # People � Basementid Basement plumbing❑ Non -Residential Specifications: Facility Type # People '# Seats Square Footage(or Dimensions of Facility) Design Flow(GPD)2 Type of Water Supply: Acounty/City ❑Well []CommunityWell Site Modifications/Permit Conditions: System Type LTAR Initial Repair ° A .2— Site Z Site Plan Environmental Health Specialist i.p.1 1-06 Date aJ7t2oll Y APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC F IV Davie County Environmental Health P.O. Box 848/210 Hospital Street JAN 2f4 ZQi i Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 (��O��Z Applit�i _ ite Evalution/Improvement Permit VAuthorization To Cons{ruct (ATC) ❑ Both Type of Application: ❑New 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 llllhggtt - lb A161 -4411z9 Name M A 4, IC y 7 CIA 1 1-4 5 Contact Person R 4 5 ,4? S 7'01 1` Address SSIZ OAK C5v rn Home Phone City/State/ZIP VJI S,q Lc Yl'I , N C Business Phone �3 36 ` 8 -44733; 771oS „ . II , Name on Per nit/ATC if Different than Above Mailing Address rN PROPERTY INFORMATION *Date House/Facility Corners Flagged_] - 7— NOTE: NOTE: A survey plat or site plan must accompany this application. Included: eSite Plan ❑Plat(to scale) (Permit is vA lid for 60 months with site plan, no expiration with complete plat.) Owner's Name g t4 ^L it —1o 4,3 Z 5 Phone Number33,e -g47- / Owner's Address &P f3 Cc Q 14 1 t -L City/State/Zip ArO�% tts C t -iR1 C Z 700 (p Property Address LocA?ti /J c>f-* T=c A 1C .&AiSy j'ZO City AO VIA&s C` , IAC. Lot Size Z , A, C --_ Tax PIN# 5-7-7'8'zB0 0 3 9 Subdivision Name(if applicable) oNA �✓, , ,' S Pko ,Section/Lot# L oT Z Directions To Site: S MtJ � `, s= �aYrt M-0 c. >r St/i LUE: 'T\JAr l 1`T 0-'4 To }=01k I< - 4 est( RID -Th �'<t3� t_1-/ctJ!�ooz> go. d?il�K'nZ )ZU (Doo ' N�tTH01= L1,&I-ZCtoo� A-0 If the answer to any of the following questions is `-`Yes",supporting documentation must be attached: ON "T At rZ t 1H 7 , Are there any existing wastewater systems on the site? _Yes &/No Does the site contain jurisdictional wetlands? _Yes jeNo Are there any easements or right-of-ways on the site? VYes No Is the site subject to approval by another public agency? /Yes No Will wastewater other than domestic sewage be venerated? Yes ✓No IF RESIDENCE FILL OUT THE BOX BELOW # People -3 # Bedrooms _�? # Bathrooms Garden Tub/Whirlpool ❑Yes V to Basement: V'fes ❑No Basement Plumbing: ❑Yes V3 o 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: MIConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: VCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? W 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 pernlit(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 r 2onsible for the proper identification and labeling of property lines and corners and locating fligging or staking house/faci location, proposed well location and the location of any other amenities. 4, ,Ci- ,(,L ✓ Site Revisit Charge Property owner's or owner' legal representative signature Date(s): Client Notification Date: Date EHS: PP E=DPP A t,l ZU'lI i Sign given L]Yes ❑No C) I Account # Revised 11/06 pyo__ _. _ Invoice # L-5 5/8" EIR Fnd 1" EIP Fnd OT 2 2.825 Acres -+-/— I Inciusive'of area in SR 1611 R/W & area in Proposed 50' Easement Proposed House Proposed Garage I Proposed LOT LOT 1 Septic Field N I }`t ! Area 3.76 Acres 4/ I� p _61.93' 140.29' Proposed--�►� Drive . . 1 v �O 0 114 1 E�seMen{ �\� qty - L-8 i I 1 NOTES: 1. Zoning: R/A & R-20 N( 2. Minimum Building Setback Lines: R/A: Front 40', Rear 30', Side '15' [ R-20: Front 30 Rear 30', Side 15' 3: Watershed Classification: WS-1V P THIS PLAT THIS PLAT V FIELD SUM / ry APPLICANT INFORMATION Account #: 990005631 Billed To: Mark Hutchins Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-38-0039.01 Subdivision Info: Location/Address: Off Fork Bixby Road -27006 Property Size: 2.8 Acres Date Evaluated: 4191� Water Supply: On -Site Well Community Evaluation By: Auger Boring ir' Pit Public Cut Landscape position HORIZON I DEPTH Wrap Texture grouR_ HORIZON 11 DEPTH Texture group Consistence Mineralogy 7 HORIZON III DEPTH Texture grou2 Consistence Mineralogy HORIZON IV DEPTH Texture group Consistence s��■��■� Mineralogy s��■�� SOIL WETNESS RESTRICTIVE HORIZON CLASSIFICATION «��■i SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: • 2S�if OTHER(S) PRESENT: TCJ/)P 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 YYgt 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) T TAT? - T n„nJa.+v. �.... ............ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■/■■■■■ ■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■/■■■/mama■■■11■■■/■■■■■■■■■■■■■ ■■■■■■■■■/■■■11■/mama■■/■/■■ ■■ ■■■■■■■■■■/■mil/■■■■■■■■■■/■ ■■ ■///////■/■/■11////■/■//■■/mama■ ■■o■■■■■eE■■■11■■E■m■■mom■■■■■■■■ ■■■■■N■N■■■moll■■oN■o'T,;'Io■■o■■o■ ■■■■■■■■■■■■o11MNon■o■moo■■■■■■■ iiil�iEMEMEMl41IMMEME MEMEME ME ■mama■■o■■mo■IINmoo■■■■■■■■■■■■■ ■ ■ ■ ■ ■■■■■■ ■■■■■■ ■■s■o■ MUNSON ■EME■■ ■o■Eo■ ■■N■■■ ■ENNEN ■■■■■■ mammas ■N■■■■ ■M■■■■ ■M■■m■ ■N■EN■ Emmons ■■NNE■ ■m■■E■ ■M■■M■ ■■NEE■ ■■M■M■ ■■■m■■ ■Em■■■ ■EE■M■ ■m■mE■ ■E■■■■ ■■■■■■ ■E■■■■ ■E■■■■E■■■■ ■■■■■NEEM■■ ■EIVEENVE■E■■ ■■immoli■m■■■ ■■mm■■II■■o■■ ■MMMMMH■■EE■ ■■■■■■A■■■■■ ■EEENUMME■E■ MEEMAN■■■■■■ ■EMMEM■■E■■■ ■MN■■■■■■■E■ ■E■Emm■EMME■ ■NEN■■■■■N■■ ■■E■■■M■■E■■ ■M■B■MM■MEME/M■ ■M■ ■■NM■■■MME■ ■NEEE■■o■EM■■■■■ ■MEmmm■NNMMMMMo■ ■■■mono■■NNE■■■■ ■N■MM■NM■ME■■M■■ iii ■N■ ■ N ;AROL INA Review Officer of Davie County, p or plat to which this certification tatutory requirements for recording. �r IUIREDD 13Y THE COUNTY PLANNING DEPARTMENT' 16 _ ring Director // �11 Date Tax Lot 78 A Tax Map 1-7 I n/f Deborah Jean Barney Jones DB 209 ® PG 66 Total 1/2" EIR Fnd 5 6 Control Corner 4.38'--J 15.00 0' Filed for registration at In Plat Book t 0 , Page .t�p M. Brent Shoat, Regi: Ing Fee Paid by DEPUTY 3/4" EIP Fnd I I �LO Tax Lot 1 Tax Map 1-8 n/f Ronald G. Jones & Sandra A. Jones DB 186 ® PG 127 I I _ l I 3/4" EIP Fnd T-6 Tax Lot 82.03 Tax Map 1-7 n/f Ronald G. Jones & Sandra A. Jones RB 320 0 PG 744 (Remainder) Grey Fox Trail 50' Access & Utility Easement 1" EIP Fnd i Address: 159 Grey Fox Trail IAdvance, N.C. 27006 ;1 LOT 4 31 n I Phase 2 o p 60 Revision 3 o n 2.820 Acres to 11CN J (Total Parcel Area) nl2.169 Acres +/— Exclusive of �o 1 Area in S.R. 1611 R/Wcb 1 & Grey Fox Trail Easement ib v iral nt 3 w tN� Come/ E IV f ' .71 ' ti77' �� ' d 2I 26 �t�e� foo Tax Lot 82.03 Tax Map 1-7 n/f Ronald G. Jones & Sandra A. Jones RB 320 0 PG 744 (Remainder) Grey Fox Trail 50' Access & Utility Easement 1" EIP Fnd . , v 4;)Pi83j46' CI 1A Tax Map: Address: Installer: EHS: Date: Operation Permit Inspection Checklist Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement to feet 2. Distance from system to well if applicable ✓ feet 3. Any other setback (.1950) requirements Supply line 1. Material supply line is constructed of P (r 2. Length of supply line (2' min.) (D%` 3. Amount of fall in supply line (1/8" per foot min)_ 4. Distance from ST/PT to the nitrification field/dist. device diameter Septic Tank/Pump Tank 1. Visually inspect top of tanks(s), interior & exterior walls, baffleand bottom 2. Any honeycombing or exposed rebar present? Circle : YES o O t/ 3. Visually inspect sanitary tee, lids, and air vent for proper installation and sealant 4. Tank Serial Numbers: STB 1u0 PT 5. ST Win 6" finished grade? Circle: (Mor NO 6. Date of manufacture: ST 61115 PT 7. Liquid capacity of tanl s ST 6pc-p PT 8. Effluent filter typed � I�j U o 9. Pipe penetration seal' present? Circle: 1ES) or NO 10. Riser(s) present? Circle: YES oiCR�) Riser Type 11. Pump Tank riser 6" above finished grade? Circle: YES or NO 12. Riser approved? Circle: YES or NO r'Iik inches feet Nitrification Field 1. Septic Tank outlet elevation S S`�, ) \1y r� 2. Trench Depth Readings (inches) n� 3. Number of Trenches Distance between trenches 4. Trench Width 3Lo" 5. Aggregate material type CH(,,mk PVS- and size 3 4 5 6 57 (Circle) 6. Aggregate Depth (inches) N I IA' 7. Nitrification lines installed on contour? Circle: YES or NO 8. Innovative system type 0I11', Installer certified for installation? Circle: YES or NO /9. N}P \ 2' earthen dam between ST (or d -box) and beginning of nitrification line? Circle: YES 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 N ({PC 1. Type Is the device watertight? Is it level? 2. Distance from Dist. device to trenches feet 3. Record elevations: Inlets Outlets