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155 In & Out LnY DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account ##: 990000850 Tax PIN ##: 5880 -28 -4239 -LW Billed To; Lisa Williams Subdivision Info: Reference name: Rusty Williams LocationiAddress: In & Out Lane -27006 Proposed Facility: Residence Pftopeity_Size: 1 Acre AT -r: 5761 * � 13I * * 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 d Pump Tank Size System Installed By--I-� M,_ X e50 Y\ E.H. Specialist: Date: 7 GPS Coordinate: 1 �.e a . ' 1 -7 —1 r l..�l n a O M,271111 f DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)75376780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000850 Tax PINIEH #: 5880 -28 -4239 -LW Billed To: Lisa Williams Subdivision Info: Reference Name: Rusty Williams LocailoniAddress:. In & Out Lane -27006 Proposed Facility: Residence Property Size: 11Acre ATC Number: 5761 Site Type: Z ew ❑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 ot- the intended use chance. + Residential Specifications: # Bedrooms—15 # Bathrooms X # People 3 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats u Square Footage(or Dimensions of Facility) Lot Size 7 a Gfe Type of Water Supply: ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 3.4 y Tank Size ""GAL. Pump Tank AAGAL. Trench Width 'Max. Trench Depth 3 C& "Rock Depth I a t Linear Ft. 3 OCA Site Modifications/Conditions/Other: As stated in IFM accepted Systems may also be uSr± 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 � -e ✓' ��-e �dd.?.oHar %V L pf �r 01a • — , ,.�.eL 00, / Environmental Health Specialist6�' 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 #: 990000850 Tax PIN/EH #: 5880-28-4239 Billed To: Tim Williams Subdivision Info: Address: 219 James Road Location/Address: In & Out Lane -27006 City: Advance Property Size: 150x1020 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: ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration H� Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 &oeU Type of Water Supply: C]eounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1969(5) accepted ystems may also oe use System Type LTAR Initial of Repair �_ Site Plan 7�J � 40 p r I Environmental Health Specialist Date a i.p.11-06 /a 1-18 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC E G E I V E Davie County Environmental Health 2011 P.O. Box 848/210 Hospital Street MAR 1 5 Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: Site Evalujtion/Improvement Permit ❑ Authorization To Construct (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 Name �I�Q (1 I 9 i')') Contact Person S� t.('t 111 a ms Address Home Phone 3 $ ,. L/79zo City/State/ZIP ciuc n�Q , A}L► o�7pd(o Business Phone tallY S3& Name on Permit/ATC if Different than Above Mailing Address City/State/Zin PROPERTY INFORMATION *Date House/Facility Corners Flagged allrIll NOTE: A survey plat or site plan must accompany this application. Included: VSite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Li54 W i ll o qMS Phone Numbe(3 o 97$ fl37 Owner's Address. Jr�1Nd'Q j,�f L19N� City/State/7,ip Property Address Jf'6`/ y- ��{-N� City Lot Size Tax PIN# 6 gZ59 Subdivision Name(if a1��licab e Sec ' /Lot# Directions To Site: %7X� the answer,to any of the following questions is `•`Yes",supporting docun Are there any existing wastewater systems on the site? _Yes Does the site contain jurisdictional wetlands? / Are there any easements or right-of-ways on the site? _Yes Is the site subject to approval by another public agency? _Yes _Yes Will wastewater other than domestic sewage be generated? Yes 9 uLuat — a«aa. U. IF RESIDENCE FILL OUT THE BOX BELOW . # People_' eople#Bedrooms # Bathrooms Garden Tub/Whirlpool _s ❑No Basement: ❑Yes 11Ko Basement Plumbing: ❑Yes +; <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 reques ed:onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ZNo 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 pennit(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 detennine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and loco ' g and flagging or staking the house/ facility location, proposed well location and the location of any other amenities. -1� Site Revisit Charge 'operty owner's or owner's legal representative signature Date(s): -1-3 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # 1 CLDU� Revised 11/06 Invoice # i �Kt7�2 321 C 2 LIb 5�• D ey, p APPLICANT INFQRMATIO Account #: 990000850 Billed To. Tim Williams Reference Name: Proposed Facility: Residence DAVIE COUNTY. HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Property Size: Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit PROPERTY INFORMATION Tax PIN/EH #: 5880-28-4239 Subdivision Info: Location/Address: In & Out Lane -27006 150x1020 Date Evaluated: l Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group f C' e_ - Consistence Consistence S s P PSY 3 Structure 4 X9 SB.CK Mineralogy3� HORIZON II DEPTH t Texture group <C-6— Consistence 5 5R r3T Structure CA. 63he Ck MineralogyS" HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION fo3 LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �- REMARKS: EVALUATION BY: 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 VFR - Very friable FR - Friable Fl.- 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 Mineralog= 1:1, 2:1, Mixed .:, lY9ieS 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_tarm arrP.nfanrP rate - anlIdAu/ft) rllnTTTI ncunc