341 Little Egypt Rd , ; •
�-' DAVIE COUNTY ENVIRONMENTAL HEALTH
' �! P.O.Bpx 8481210 Hosgital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 990004326 Tax PIN/EH #: 5726-24-9200 �
Billed To: Jesse Bonds Subdivision Info:
Reference Name: Location/Address: Little Egypt Road-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 4655
**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 guararitee that the system will function satisfactorily for any given period of
time. � � � 'Q�
System Type: � S.T.Manufacturer�� Tanic Date � � � Tank Size D 4-d
Pump Tank Size �
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System Installed By: E.H.Specialist: �� Date:
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DCHD 11/06(Revised) -
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' � DAVIE COUNTY ENVIRONMENTAL HEALTH ��` O�
P.O.Box 848/210 Hospital Street ��[
Mocksville,NC 27028 �` �
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004326 Tax PIN/EH#: 5726-24-9200
Billed To: Jesse Bonds Subdivision Info:
Reference Name: Location/Address: Little Egypt Road-27028
Proposed Facility: Residence Property Size: 1 Acre
ATC Number: 4655
Site Type: �w ❑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 Cc c�� Type of Water Supply: F�ounty/City ❑Well OCommunity Well
System Specifications: Design Wastewater Flow(GPD�CQO Tank Size (�aoo GAL.Pump Tank��GAL.
Trench Width 3��� Max.Trench Depth 3���. Rock Depth ��• Linear Ft.�
As stated in 15A NCAC 18A.i9(i9(5� �
Site Modifications/Conditions/Other: ����.gf�$���s
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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5 �Environmental Health Specialist Date: Q
DCHD 11/06(Revised)
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� �'I SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� � Davie County Environmental Health
`�;���- P.O.Box 848/210 Hospital Street
��"'` \ Q 2��� Mocksville,NC 27028
`� �'M�\� AQR .2 . (336)751=8760/Fax(336)751-8786
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Ap licati ��� , ��u�1 ' mprovement Permit � Authorization To Construct(ATC) ❑ Both
Typ of Appli ati �� ew System ❑Repair to Existing System OExpansion/Modification of Existing System or Facility
*** PORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed ��� S'S-E • �o.���S Contact Person ��sS� ,�n��'
Billing Address 3�f 3 L.�� ;r�v�7` �'</• ' Home Phone 3 3�� �9z - /a�I23
City/State/ZIP_/9jGl/(Sv�%l,r . �!�� � 7c3q Business Phone__��(f - ZJ��7- y3S�'�
Name on PerniidATC if Different than Above � S��pJ
Mailing Address � - � City/State/Zip
. .. ::,.. ,. .- ; ;'��
PROPERTY INFORMATION *Date House/Facility Corners Flagged � Z� b7
NOTE: 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 c,��r�n��� ��/��y Phone Number ��� y`��'S�?S"
Owner's Address '`j�/l L��%T/� tfjy�T 1•? � City/State/Zip 11�C<�(S�il�r' , N-<' 27��
Property Address S��-t � City �
Lot Size___ J ,�qcr�. 4�Tax PIN# ��'�� �y q,2E�� �
Subdivision Name(if plicable) Section/Lot#
D'rec ion To S'te• / L (,l2 0/�/,
� .
f the answ r to any of t e following questions is` ,supporting documeritatio must be attached.
Are there any existing wasfewater systems on the site? OYes CC�I�o
Does the site contain jurisdictional wetlands? ❑Yes B�Q�o
Are there any easements or right-of-ways on the site? �Yes C�3�
Is the site subject to approval by another public agency? DYes Q fo
Will wastewater other than domestic sewage be generated? ❑Yes B�do
IF RESIDENCE FILL OUT THE BOX BELOW
#People ,� #Bedrooms 3 #Bathrooms Z Garden Tub/Whirlpool �es ❑No
- Basement: ❑Yes C�o Basement Plumbing: ❑Yes C�#a-
IF NON-RESIDENCE FILL OUT THE BOX BELOW �
Type of FacilityBusiness 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
Typesystemrequested:, �ventional ❑Accepted ❑Innovative ❑Alternative DOther
Water Supply Type: ❑ County/City Water C�ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �`o
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my lrnowledge. 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 Deparhnent 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 stakingzthe house/facility location, roposed well location and the location of any other amenities.
. ' ^ �' Site Revisit Charge
operty owner's or owner's legal representative signature
Date(s):
��d- C,� Client Notification Date:
Date EHS:
Sign given ❑Yes �No Account# . 3�
Revised 11/06 InvRice#
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�E EGYPT RD
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' ' ''�• DAVIE COUNTY HEALTH DEPARTMENT
� Environr�entai Heal#h�Section
Soil/Site Evaluation
APPLICANT INFORMATION . . , PROPERTY INFORMATION
Account #: 990004326 Tax PIN/EH#: 5726-24-9200
Billed To: Jesse Bonds Subdivision Infa
Reference Name: Location/Address: Little Egypt Road-27028
Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: �—J�;� �CJ �
Water Supply: On-Site Well '�/ Community Public
Evaluation By: Auger Boring �� Pit Cut
FACTORS 1 2 ' 3 4 5 ` 6 7 �
Landsca e sition L L='
Slope% ; _
HORIZON I DEPTH � �(
Texture rou � y, ,
Consistence - '
- Structure , _
Mineralo . � � .. , .'� _
HORIZON II DEPTH -- � _ �
Texture rou . , °
Consistence , _
� Structure _ '
Mineralo ►( `
.HORIZON III DEPTH t
Texture rou ` , p .
Consistence ; . _
Structure
Mineralo • , , , _
HORIZON IV DEPTH _ ,
Texture rou , . ; .
Consistence , - _ . . ,
;
Structure°
Mineralo 3 ;: . _
SOIL WETNESS
RESTRICTIVE HORIZON . ; �
' SAPROLITE ' ;
CLASSIFICATION + .
LONG-TERM ACCEPTANCE RATE ; � ;
SITE CLASSIFICATION: PI`a�� 51�-.��Ro,�.,p '` EVALUATION BY: d �2 �v�'�-�
LONG-TERM ACCEPTANCE RATE: � ; OTHER(S)PRESENT:
REMARKS: : _
: : _ .
' . ` LEGEND . ,
i, n sc e 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
T�xtu�� . , _
�, � . „_
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
CON4I4T�,NC , ,
�'I41S� ;
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
S r, ,r . _ �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky - - PL-Platy PR-Prismatic ` < `
Mineraloev _ .
1:1,2:1,Mixed . : ,
1Y,Qt�.� � ., , _
,
Horizon depth-In inches
Depth of fi11-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-gaUday/ft2 DCHD OS/OS(Revised)
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, � �
� � Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990004326 Tax PIN/EH#: 5726-24-9200
Billed To: Jesse Bonds Subdivision Info:
Address: 343 Little Egypt Road Location/Address: Little Egypt Road-27028
City: Mocksville Property Size: 1 Acre
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 Pernrit Valid for: C�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): Cccr Type of Water Supply: ❑County/City C�ell ❑Community Well
Site Modifications/Pernut Conditions: A5 stated in 15A NCAC 18A.19GS(5)
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Environmental Health Specialist Date �'�� Q�
i.p.l l-06