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386 Howardtown Circle (2)C Account #: 990001883 Billed To. Ken McDaniel Reference Name: Proposed Facility: Residence DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Tax PINIEH #: 5861-119866 Subdivision Info: LocationiAddress: Howard Town Circle -27028 Property Size: 0.966 Acres AT9*�*� A 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. f System Type: S.T. Manufacturer Tank Date Tank Size ]4(9 V Pump Tank Size / System Installed By -Er, Ew fw vtjp,( E.H. Specialist: �,,�� ate:. �( GPS Coordinate: I DCHD 11/06 (Revised) 01 cvj X/,qcv� 1 5 m(e— DAVIE COUNTY ENVIRONMENTAL HEALTH �O P.O. Box 848/210 Hospital Street Mocksville, NC .27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990001883 Tax PINIEH #: 5861-119866 Billed To: Ken McDaniel Subdivision Info: Reference Nance: LocationiAddress: Howard Town Circle -27028 Proposed Facility: Residence Property Size: 0.966 Acres ATC Number: 5767 Site Type: VNew ❑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: gCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 36 Tank Size /MQ GAL. Pump Tank GAL. M Trench Width � Max. Trench Depth_3� Rock Depth Linear Ft.lt 2 j% j Az. stated in 15A NCAC 18A.1960(5 Site Modifications/Conditions/Other: �nnnr� 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 Specialist Date: 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 IMPROVEMENT PERMIT Account #: 990001883 Tax PIN/EH #: 5861-119866 Billed To: Ken McDaniel Subdivision Info: Address: 386 Howardtown Road Location/Address: Howard Town Circle -27028 City: Mocksville Property Size: 0.966 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: 05New ❑Repair ❑Expansion Permit Valid for: N5 Years ❑No Expiration Residential Specifications: # Bedrooms-_ # Bathrooms # People Basement❑ Basement plumbing0 Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: XCounty/City ❑ Well ❑ Community Well Site Modifications/Permit Conditions: System Type LTAR Initial 2 Re air PAdWARPL Site Plan' R s 1 Environmental Health Specialist 04 i.p.l 1-06 Date KR tkma 161-JJY9 1 NMP E–t T --Ear w/cap Find c�Tax Lot 112.02 Tax Map F-6 Tie Line n/f Rodney A. Custer S 06 0 009 E C,4 and wife ! 0; Mieheala H. Custer DB 145 0 PG 610 DB 180 0 PG 335 t r Q �- %Ear w/cap Fnd RR SpTica Find S 87°54'18'E 380.65' i T gar w/cap Fnd qe -\� N �b�T LO t i i P rt of Tax Lot 112 S 04018'49'V °i .966 Acres +/— i 155.67' G,AcR G z 21-' 3 IRS: Control Comer i i "E 306.20' ` a7 IRS: Control Comer Rerfl6Ved--� -j LD Gcrc9s Lot Z ,r - Part of shed well House Tax Got 112 S 04°1849"W —� 100.18 ---- 0.748 Acres + — Gravel Drive- , J ;,Tete , / M ! J` Walk Porch. (a Z 1/2„ DR Fnd -��•�= �Q `- �Q crav�el or 154 3a6 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC APe p 4 • -..Davie CountyEnvironmental Health '..:::: ; :.:: `:..'....::..; •.. • R . �P.O,.Box848/ZIO;)ELospitalStreet.:``;:�;.':.,�:.;:.;'•:�;:.�.:..':.'. �`,f C�',; Mocksville*riC::27028;;:'.`;'::.':' i:'::':'. •. ':::' (336)753-6780/ Fal (336)751-8786. � : • •.' ` ' Application For: 0 Site Evaluation/Improvement Permit 0 Authorization To Construct(ATC) CYBoth ••Type of Application: Wew System 0Repair 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 Q Contact Person Billing Addressjt�1 Home Phone I -sl - `u° L City/State/ZIP MA_Kh F-; N,7,42 Business Phone XV- ya 9.-13X41. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip NOTE: A survey plat or site plan must accompany this application. Included: 2YSite Plan OPlat(to scale) (Permit is alid for 60 months with site plan, no expiration with complete plat.) Owner's Name L ihtV { J4Si_ Phone Number 144-4 Owner's Address 10, W 1l►y b1Rc l $ _ City/State/Zip ►)tUC�- Property Address City IrAdC Lot Size 6,16 Tax PIN# ;AT m Mhtr ¢-b Subdivision Name(if applicable) Section/Lot# Directions To Site: I L,N 1S EA3`T—R16lFC oil e iS iZYa -t- _ 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? 0Yes %Ko Does the site contain jurisdictional wetlands? Oyes 9 Qo Are there any easements or right-of-ways on the site? OYes S<o Is the site subject to approval by another public agency? Oyes Wo Will wastewater other than domestic sewage be generated? 0Yes Geo IF RESIDENCE FILL OUT THE BOX BELOW 41W11 &—fl—a. Abgal 6.1 # People 3 # Bedrooms # Bathrooms Z Garden Tub/Whirlpool es ONO Basement:: OYesBasement Plumbing: Oyes 11140 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 ofsimilar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: ' onventional DAccepted Olmtovativc OAltemative 00ther Water Supply Type: //Eounty/City Water 0 New Well DExisting Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? -e Yes 0 No If yes, what type? CA910 \ 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 lite 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 staking the house/facility locati , proposed well location and the location of any other amenities. f�Site Revisit Charge Property owner's or owner legal representative signature / Date(s): • , `( Client Notification Date: Date EHS: Sign given OYes ONO Account # 0Revised 11/06 Invoice # E-3 t m% opma rim . NUP E-2 T—bar w/cap Fnd N Tax Lot 112.02 C 't Tax Map F-6 Tie Line �- n/f Rodney A. Custer and wife S 062009 E o j iA Michealo H. Custer N DB 145 ® PG 610 io DB 180 ® PG 335 3� o T—Bor w/cap Fnd RR Spike Find 9.99' S 87°54'18'E 300.657 1 T -Bar w/cap Find1 N '+' N btu , 52 } sg Lot 1 P rt of Tax Lot 112 S 04918'49"W °t ?' .966 Acres +/- 1 155.67' r7 0 3La� 3 z IRS: Control Comer S 81 °37' 15"E 308.20' 'rs IRS: Control Comer RemoYed Lot 2 'O Part of snea i well House Tax Lot 112 S 04°18'49"W - H.. 100.18 C---- 0.748 Acres + - Grovel Drive--• I Concrete l / o ! 1, Walk Porch t/2" IIR Fnd z-/ ---- QD— ctuv��el Drt� __.-__ — -- 37 7S 1 sa San • ; DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990001883 Billed To: Ken McDaniel Reference Name: . Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5861-119866 Subdivision Info: Location/Address: Howard Town Circl -')7 028 Property Size: 0.966 Acres Date Evaluated: � �f Water Supply: On -Site Well Community Evaluation By: Auger. Boring Pit Public Cut -LancNcape position HORIZON I DEPTH Texture group Consistence Mineralogy HORIZON H DEPTH Texture 9,roup— Consistence HORIZON III DEPTH Texture group Consistence HORIZON IV DEPTH Texture group • RESTRICTIVE HOREZ—ONSAPROLITECLASSIFICATIONWE ARTIESIZENNIM SITE CLASSIFICATION: S LONG-TERM ACCEPTANCE RATE: • 22S - REMARKS: 2S -REMARKS: lAegdr 1� EVALUATION B OTHER(S) PRESENT: LEGEND la rwv 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 1124.1811 VFR - Very friable FR - Friable F1- 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 Mineralov 1:1, 2:1, Mixed lYQtgS . 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) ITAR - Lnna_term arrrntanrr rate - aal/rlati/ft) "fly TTI ncinc rn__.:__�� 2 Ems S■■SME■a■Mmamm■a■mM■m■■■■■M■■■■■■■■■i`!lrTRi';ti.�■'T,�/I�i ,n Mom■■■■■■■■■■■■■■■■■■■■■■■■■t■■■ ■■■■■■t■%i■■■I■■M�CI�i�����CCCCCCCC ■■■■■■■■■■■■■■■■■■■■■■■M■■■■E■E■1�■■■■■■■■■■■■■■■■■tM■■■■■■■■■■■■■ ■■■■■■■■■■aaM■■■■■■■ma■■■■maamE■MM■■■■■■■■■■■■■■■ ■■■■ ■■■■MM■E■MMM■MEEEMm■■a■■m■■M■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■M■ ONE ■■■■■■■■■Samoa MEN■■■aMm■mM■■MMES■■■■MEa so RENEE ■■Maa■■■■■■■■■■■■■■■■■■■■■■■■■■■■M■■■■MEMO MEN a ONE■■■■■■■■ma■■■■■■■NEWSMEN aaa■■■■■■■■■a■■Ma■■■M■■maMOm■O■■E■■■■■■ NNE■■■■■■■■■■■O■■■■11■■■■■■■■�■■■ ���� MEMEME ���■E■■E■■■■■■■■ME■M■■■EMEM■ 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mom■MEM■MMS■a■■■■m:■■ME■■■■■E■M■ ■■E■oEMEEMMM■EMMOMESa■■■M■MIMMM■ NNW m■meet■■MMOO■■■■M■MMtt■■OMaMME■MO■EMl MAN m■■■mom tetmSMEMMOt■OE■■ mom■ma■■■■MS■Mo■MM■EM■■■O■E■MME■■■■E■■MO■■■■EME■t■■MEM■E■ESOMSNONE • Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990001883 Tax PIN/EH #: 5861-119866 Billed To: Ken McDaniel Subdivision Info: Address: 386 Howardtown Road Location/Address: Howard Town Circle -27028 City: Mocksville Property Size: 0.966 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: ❑New ❑Repair ❑Expansion Permit Valid for: 05Years ❑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): Site Modifications/Permit Conditions: Site Plan Type of Water Supply: ❑ County/City ❑ Well ❑ CommunityWell System Type LTAR Initial Repair Environmental Health Specialist Date. i.p. 11-06 1.-