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440 Jack Booe Rd• DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street o� Mocksville, NC 27028 ,A (336)753-6780 / Fax # (336)753-1680 ,�i OPERATION PERMIT Account #: 990003124 Tax PIN/EH 5813-50-3360 Billed To: Bennie Smith Subdivision info: Reference -Name: Location./Address: Jack Booe Road -27028 Proposed Facility: Residence Property Size: 24.7 Acres ATC Number: 5012 **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: l9 2 S.T. Manufacturer Tank Date 9 Tank Size. �G Pump Tank Size System Installed By: 10 %vr ru.QE.H. Specialist: ---� 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 Account #: 990003124 Tax PIN/EH #: 5813-50-3360 Billed To: Bennie Smith Subdivision info: Reference Name: Location/Address: Jack Booe Road -27028 Proposed Facility: Residence Property Size: 24.7 Acres //ac ✓'G` ATC Number: 5012 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 -3 # Bathrooms "A- # People Basement❑ Basement plumbingO Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimenzounty/City Facility) Lot Size 1 �aL'`_`�` Type of Water Supply: ❑ Well ❑ Community Well Gtcf-c � �,pd System Specifications: Design Wastewater Flow (GPD) 3� Tank Size_ GAL. Pump Tank)�AL. Trench Width G Max. Trench Depth 3G Rock Depth of Linear Ft. _Lr ✓� Site Modifications/Conditions/Other: As stated in 1 ystems may a -1 -so "W 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. 1 __ _"r C .5L �� pt I c�> t ` `o 9 f. 3 0y1d ark0-60 It, IDO - - %. r%114 J i I]- I J.0E Boa CL 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 #: 990003124 Tax PIN/EH #: 5813-50-3360 Billed To: Bennie Smith Subdivision Info: Address: 440 Jack Booe Road Location/Address: Jack Booe Road -27028 City: Mocksville Property Size: 24.7 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: ew ❑Repair ❑Expansion Permit Valid for: @f5 Years ❑No Expiration Residential Specifications: # Bedrooms .- # Bathrooms # People a Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Design Flow(GPD): (e Type of Water Supply: 21(50-unty/City ❑ Well ❑ Community Well As stated in 15A NCAC 18A.1969(5� Site Modifications/Permit Conditions: accepted Systems may also he usr-. System Type LTA Initial-;).,7-,;- Repair %.5 Re air c < I feer Site Plan S P �CeQ ck Or J�.J: a _ hl L9 l Environmental Health Specialist i.p. 11-06 APPLIC SITE EVALUATION/IMPROVEMENT PERMIT & ATC D Davie County Environmental Health " P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Ap €cafi ' For: ❑ $jt 5A ibn/Impro ment Permit ❑ Authorization To Construct(ATC) Zoth Typ of Alipl ,on0 �s Repair to Existing System ❑Expansion/Modification of Existing System or Facility *** T*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INF6R1\1ATIO9 IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATTON Name to be Billed d;F- 2). JW Contact Person Billing Address/ [ �' Home Phone - 5[.��; City/State/ZIP 0 O Business Phone q6y J- 3 i 3t j Name on Permit/ATC if Different than Above, Address PROPERTY INFORMATION *Date House/Facility Corners Fla-aized /0—/'0 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name i3,c1,y')� (� ��- �T7'S1 K ter, ,T . Phor ❑Plat(to scale) Number Owner's Address 124 City/State/Zip Property Address O .%Ac t-;aIE f Lot Size ,25L '/ .4t,- Tax PIN# c5V�340-5300 Subdivision Name(if applicable) Section/Lot# Directions To Site: &p A/ To j-,-4e-,g To / JatG 1J,a i/ 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? E�fes ❑No Does the site contain jurisdictional wetlands? ❑Yes -2No Are there any easements or right-of-ways on the site? ❑ Yes iTlo Is the site subject to approval by another public agency? ❑Yes eNo Will wastewater other than domestic sewage be generated? ❑Yes EMo IF RESIDENCE FILL OUT THE BOX BELOW # People - # Bedrooms -, # Bathrooms 2 Garden Tub/Whirlpool ❑Yes of,10 Basement: ❑Yes Bigo Basement Plumbing: ❑Yes 1;?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 consumption) FOODSERVICE ONLY: # Seats Type system requested:. 21:50nventional ❑Accepted ❑Innovative ❑Alternative ❑Other, Water Supply Type: wtounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Flo 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or sta ' g the house/faci ity location, proposed well location and the location of any other amenities. '� Site Revisit Charge Property owner's or owner's legal representative signature O. i ;�I A Date Date(s): Client Notification Date: EHS: Sign given El Yes ❑No Account # !i1T Revised 11/06 Invoice # Go1MAPS - Davie County NC' Public Access Davie County, NC - GIS/Mapping System u Click Here To Start Over Active Layer. ❑�' Use,hlap Tips { D PARCELS (Map Tips Available) Page 1 of 1 Quick Search: (County ID or Owner Ni M. Addre �layge� A�� per`-, w; �I 5ehd -Flvo2 ? 00(5 http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=412... 10/1/2009 . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION. Account #: 990003124 Tax PIN/EH #: 5813-50-3360 Billed To: Bennie Smith Subdivision Info: Reference Name: Location/Address: Jack Booe Road -27028 Proposed Facility: Residence Property Size: 24.7 Acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % HORIZON I DEPTH Texture group G S Consistence D/` e Structure Mineralogy 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:, EVALUATION BY: ( LONG-TERM ACCEPTANCE RATE: fes/ OTHER(S) PRESENT: W�C SIZi• !� 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 1YI41SI 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 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 1YQ.teT 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 - I.nno-term srrP.ntanrP rate - cmIlmail/ft') Tl/l7TT nC/AC in___:__.3%