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321 Hilton RdY DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990001211 'fax PINIEH #: 5862-04-2900 Billed `1'o: Randy Grubb Subdivision Info. Reference Name: Hope House LocationiAddress: 321 Hilton Road -27006 Proposed Facility: Hope House Properly Size: ATC Number: 5093 **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 Tank Size /000 Pump Tank Size�f System Installed By: TS/�/��� E.H. Specialist: j \ DCHD 11/06 (Revised) 5- '7 '7 ZEE Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990001211 Tax PIN/EH #: 5862-04-2900 Billed To: Randy Grubb Subdivision Info: Address: 130 Kent Lane Location/Address: 321 Hilton Road -27006 City: Mocksville Property Size: Reference Name: Hope House Proposed Facility: Hope House **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: Mew ❑Repair ❑Expansion Permit Valid for: k5. Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):A06 Type of Water Supply: (County/City ❑ Well ❑CommunityWell Site Modifications/Permit Conditions: Environmental Health Specialist Lp.11-06 DateC�' 2(�l ` 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 #: 990001211 "fax PIIS/>=H #: 5862-04-2900 Billed To: Randy Grubb Subdivision Info: Reference Narne: Hope House Location/Address: 321 Hilton Road -27006 Proposed Facility: Hope House Property Size: ATC Number: 5093 Site Type: ❑New ❑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 change. Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: IOCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)`%/g�a Tank Size I&J52 GAL. Pump Tank GAL. Trench Width 19CMax. Trench Depth Rock Depth A�WLinear Ft. 300 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. Telephone # (336)751-8760. Environmental Health Specialistok4g AkA A,wl !i(ii— Date: 6 DCHD 11/06 (Revised) }V.2 2010 . Pbom: (336) - 7.5 - 6780 / County Health Department onmental Health Secdon P.O. Box 848 210 Hospital Street Cowier # : 09-40-06 Mocksville, NC 27028 ax: (336) - 753.1 �! ON-SXTE WASTEWATER CERTIFICA'T'ION FO&WI's G (Check One) Replacement Remodeling Reconnection Name: f ✓c.[7� Phone Number 336 J1' fO " Z�zq l tae) Mailing Address: 0 c , 3 9?9 - 7� ?91 �) moakccl,411e- Al. Ct Please Fill In The Following Information About The EXISTING Facility-+TP4 PIN 5<6(D Z 0 q Z9 00 Name System Installed Under: V -ig2 Type Of Facility: v5 Date System Installed (Month/Date/Year): Number Of Bedrooms: "•, _? _Number Of People: 7 Is The Facility Currently Vacaut7 0No If Yes, For How bong? A/--� Any Known Problems? Yes No If Yes, Explain: Please 1FiQ In The Following Information About The NEW Facility: Type Of Facility: A " Number Of Bedrooms: � _,Number of People_ Requested By:-&d� ,s Date Requested: 3„ Z q- 2 d / U For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: 1-111,110 /1O 01 *The signing of this form by the Environmerital Health Staf is in noway intended, nor should betaken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order 4 Amount:$ —Date: Paid By: . Received By: Accountt!:GiX� // Z // Invoke #: _ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: ❑ Site valujtion/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of Application: 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. ADM Tr A ATT TATUOTJ AA A TTOXT Name Address a U City/State/ZIP oc e - Name on Permit/ATC if Different than Above Mailing Address Contact Person✓ Home Phone i Business Phone YKUYLK 1 Y I NP UKMA HU1N � Date House/N acllrtv Corners rlaesed NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid or 60 mont w' h site plan, no expiration with complete plat.) Owner's Name 0.S 4 cG& Phone Number Owner's Address , h City/State/Zip 61_Z& r 1 Z Ta 2 ism Property Address S'cu,— City Lot Size Tax PIN# Subdivision Name(if applicable) Section/tO Directions To,Site: Mx//<3;r 7,�,.� /1177-,, Ai ",77,2 Z"Iel U-M� a �- If the answer to any of the fol owing questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes - No Does the site contain jurisdictional wetlands? _Yes ZNo Are there any easements or right-of-ways on the site? _Yes Xo Is the site subject to approval by another public agency? _Yes /�to Will wastewater other than domestic sewage be generated? Yes No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms_ # Bathrooms _ Garden Tub/Whirlpool ❑Yes Imo Basement: DYes � Basement Plumbing: ❑Yes BX—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: ❑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. O 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 les. I nder hat I am responsible for the proper identification and labeling of property lines and corners and locati and fla m r mg the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge roperty owner's or owner's legal representative signature Date(s): L— Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # _ y/Z// Revised 11/06 Invoice # ``%v ' V DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION �s 130 1CQ,4 wb&-S UV If ,)c a76a& Water Supply: Evaluation By: On -Site Well Community / Auger Boring Pit PROPERTY INFORMATION l Sr, 66�e Public Cut FACTORS 1 3 4 5 6 7 Landscape position L Sloe %o b HORIZON I DEPTH Texture group Consistence Structure Mineralogyd 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 SITE CLASSIFICATION: �S EVALUATION BY: ii,tal4L LONG-TERM ACCEPTANCE RATE: 3 OTHER(S) PRESENT: IQIY REMARKS:MOKI I dip 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 loamSCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C Clay CONSISTENCE list VFR - Very friable FR Friable FI - Firm VFI = Very firm EFI - Extremely firm 33'et NS - Non sticky SS - Slightly sticky S - Sticky VS -Very Sticky . NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic aStructure 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 LLOteS 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)