3580 Hwy 158 . , . t
DAVIE COUNTY ENVIRONMENTAL HEALTH Q�,L'���
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Ac�ou�t �: 989900414 �'�x P�f�€.%EH#: 5851-80-6527.02
Billc,� T�: Tim Smith Su���i�i:.,ion ln��:
Re:f�reE�ce �I���e: Lac�tioniAddr�ss: Big Oak Lane-27028
F�rnpc�s�;c9 F���;ilit�: Residential ��op�rty S�i��;: �=�;�s (,9•3
a�T� t�u�b�3': 5094
**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.
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System Type: S.T.Manufacturer�� Tank Date�"� Tank Size�C�
Pump Tank Size
System Installed By:��e �(,�E.H. Specialist: ( lJ� """Date: b�O
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DCHD 11/06(Revised)
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•� , `;; �• DAVIE COUNTY ENVIRONMENTAL HEALTH � ��l�
P.O.Box 848/210 Hospital Street � 14
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
�c��u�t #: 989900414 "��x�1�€%EH#; 5851-80-6527.02
Bific� Tc.�: Tim Smith �ta��r�i�fi;,iori Ir3�z�:
R�fer�r�ce Pdar��e: � LocaiianiAd�r�ss: Big Oak Lane-27028
f'ropc�s�i9 F�ci€ity: Residential ��o��rty�iz�: �es (,�•3
��TC Nu�b�!3': 5094 Site Type: �1ew ❑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 l #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size -Z QC Type of Water Supply: �ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)�Q Tank Size OO GAL.Pump Tank�GAL.
Trench Width�(� Max.Trench Depth Rock Depth N/A Linear Ft.�S�
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Site Modifications/Conditions/Other: �1'�Q,RUn y��l „����.l�lv�
Contact the Davie County Environmental Health Section for linal inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist C 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 #: 989900414 Tax PIN/EH #: 5851-80-6527.02
Billed To: Tim Smith Subdivision Info:
Address: 137 Boger Road Location/Address: Big Oak Lane-27028
City: Mocksville Property Size: —�os�- (1,�
Reference Name:
Proposed Facility: Residential
**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: G�New ❑Repair ❑Expansion Permit Valid for: �S Years ❑No Expiration
Residential Specifications: #Bedrooms�_#Bathrooms #People Basement0 Basement plumbing❑
Non-Residential Speci�cations: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):� Type of Water Supply: �County/City OWell ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial O c5n .. 2
Re air �
Site Plan
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Environmental Health Specialist Date � Z��
i.p.]1-06
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`, � ITE EVALUATION/IMPROVEMENT PERMIT & ATC
i ,• � ��,%`'� ��1 .
• --�' t�. ,� '� avie County Environmental Health
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'�` , �, ,�,t��� P.O.Box 848/210 Hospital Street
� �\ • ►�, � Mocksville,NC 27028
� �` ��''�� :�.���'��' (336)753-6780/Fax(336)753-1680 ,
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Ap�li atio 6;��, �uat�ion/Improvement Permit �Authorization To Construct(ATC) .��oth
_ Typ o Applica -. ]�New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***I ORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
I�1FOR14�IATION'IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed � `
,'J�'7 �)� A � Contact Person ,/ .%�7 �i�^��iS�
Bil£iiig Address _ ��; �� 13�v���� f.�C� Home Phone �_�/��r�rCr < �yr ��
City/StaXe/ZIP j'Y�f,-,�,('s�,,�ffE /'�(: �_, Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Fla ged 3�✓��
NOT�: 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 . 7 a � Phone Niimber ��� ��'�CI•�]/7�
Owner's Address j � �► r;f�,��-i' ,�(" CitylState/Zip /�.�; .�t,7�>1�
Property A�dd ss ' ? � ' � c` City ����r�,,. : ,
Lot Si ,� ' � ��t- Tax P - �Q- f� t�
Subdi ' ion Name(if' plicable) �'�'"`"`�'� �o`f Section/Lot# J/ � �
Directions To �te: ,; ` s,�c '.=��- "- ' , '� `, � ,/. , s- ��
, � �_f�y � e ,� fa � ,�� � ,
If the answer to any of the following questions is"Yes",supporting documentation must be attac .
Are there any existing wastewater systems on the site? Yes �.�to
Does the site contain jurisdictional wet(ands? Yes �fNo
Are there any easements or right-of-ways on the site? Yes �No
Is the site subject to approval by another public agency? Yes �10 �
Will wastewater other than domestic sewage be generated? Yes��No
IF RESIDENCE FILL OUT THE BOX BELOW
#People � #Bedrooms �_ #Bathrooms `:r�. Garden Tub/Whirlpool ❑Yes t�IQo
Basement: ❑Yes C�4'o Basement Plumbing: ❑Yes ❑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 consu�nption)
POODSERVICE ONLY: # Seats
Type system requested: ❑Conventional ��t ccepted ❑Innovative CAltemative ❑Other
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Water Supply Type: ❑ County/City Water ;Z.�Iew Well nExisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this sysYem is intended to serve? ❑ Yes �o
If yes,what type?
Tliis is to certify that the information provided on this application is true and correct to the best of my knowled�e. I understand
tllat any perniit(s)or ATC(s)issuea nereatter are suhject to suspension or revocation if d�e site is altered,the intended use
changes,or if the infonnation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Re�iresentative of the Davie County Health Department to conduct necessary inspections to detennine compliance witll applicaUle
laws and rules. I understand that I am responsible far the proper identification and labeling of property lines and corners�ind
locating and fla �ng o ,stak' g the se/facility location,proposed�vell location and the location of any other amenities.
--�'^'''-'� �'�'�'�'���� Site Revisit Charge
Pro;�erty owner's or owner's legal representative signature
Date(s):
�� -,?�� ��' Client Notificatioil Date:__
Datc .�J"����V���� EHS:
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Sign given ❑Yes CINo � � ' Account# `"�` � ��
Revised 1 U06 gY . Invoice# � �
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' ,' ; ,� � ; DAVIE COUNTY HEALTH DEPARTMENT
w � Environmental Health Section
, �, . .
' Soil/Site Evaluation
APPLICANT INFORMATION R RT 'INF RM
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137 t�� er ��od� �3iqc�.� R����de,�z
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Water Supply: On-Site Well `� Community Public
Evaluation By: Auger Boring Pit � Cut
FACTORS 1 2 3 4 5 6 7
Landsca e position L L.
Slope% o a (,,., o
HORIZON I DEPTH
Texture grou C,L.
Consistence
Structure (i
Mineralo � �
HORIZON II DEPTH Q' 8— — 8
Texture rou C G
Consistence �/
Structure
Mineralo � (; �:; P
HORIZON III DEPTH —� -' —70
Texture rou i �
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS G " � M -
RESTRICTIVE HORIZON
SAPROLITE �aq.w.. Leq, �
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .
SITE CLASSIFICATION: �� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: . z OTHER(S)PRESENT: � ____
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LEGEND �3�ri
Y,�ndscape 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
CONCIST �.N .F.
NI41S�
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
, r> >r
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
�otes
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 s{�itable),U(unsuitable)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Revised)
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