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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 � � � r��� � System Installed By: E.H.Specialist: �� Date: ` --� � � �7`v �-e � \ � Q�,Q� � � x � � � �� � I � � o�� l �; �S�`� � rv.o�-�-��.✓� �� 4_ � °`"`ci t h � — � � �. �� I ti� � ` �p . p ` � (o � DCHD 11/06(Revised) - � : -- • ' � 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. . .� -1- cD �-� l�c� 4Q�.. C� �c� ��� ,7� ��� . �� � _ _ i�� � .J"� -e�, �3� ` ' 4 c Ms'`` --�,. � �, ���� -� 5 �.� . '13��.� � a� g` �� ( �s� o� �s'� � �, �� � _3�__ , � � �`y `���a�� �`� �� ��6 5� �` , � � , 3a� (i� � De�k � ��) � �;0� �,n�5 �tleu`�aa� 6�' /� J C3, j kQ`L�`n e S /`t t c p'E c d t � � Q� c -�F�a a S� r�d �nu .�,� � s�srt 1 t 5 �Environmental Health Specialist Date: Q DCHD 11/06(Revised) ' , ��` , � -. :� � � �'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 � : ��p,1.SN 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# � , ���. a N,i( w°��' � U�� / O� �,,� da fc � �� �� r �� a �d �+�� ��� �' � � � a �10� �5 � . , v � _� �,� � i � u, l��o��- � � b 9 4� � � o � g o; _____.____.___._._---=� a u,-f.__.t,�co_��_ , �/' � ��� - -----�_.__,.--- .�,rt� . N� vi� d�i a l ti, �-� ��,.�a �o�� � fi �fifi-� .. � �. r � . , � � _ . >�� ;�..—� ;�� �� �� ,` � � ���� � �. .X � �� .�. � - � t , �`�-'., ' � a.� � ���� � � ' � �' 357 y7i � � � � 79p``a� , _ �t, � p�85 _ �. `�o = ��"`�,, � �'� �.,. �. � ` � F :< .�" � � � � � � 79�< `,ir78 ; ;� �� /� : �' i --�Ae` ,.�.�T r 3�M JJJ t � �. � �� � � \^^��..�'Z��. �'� f•- . � . ��. � � � � -' , � . � � �. r � � . C hA ` 4 � � � �� � �� �. � . . � � � .�� _ ��� }ja..��FP � � f�� � . � � � . : � \;.�� - t �� � M� � . � �� ., . �... r .. . ' ./ � . � � �,0.97,� G a D � � (11.48� � , � o � � ���.n'�.�_� 3223 � � � ���� 9200 (i2.39A) �- � � i �y '�a`•,�^t'1�r.i 2 �� . . � , . � � �� � . �. � �. � �� . «: .,. �� � :�„ / ... .. � , . � . n � _ . .� _ .. �. . . �� � : � � � 4193 � �� _ � � �, � ; � _,`� � � ` F � � � � � "� �; � � �� ' � � � � �ti - � ;� - �_;� GnB2 . �; �E EGYPT RD � � 475 524 720 '. � � � ; 2657 . . _,��t "5.�..s��.a, W sr ii�,. ,v,3 z :�, _ �, � �i �� �e:�-�.`:. ,_. . �. � . � . - __ .__ _ _ . ' —_ 1 ' ' ''�• 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) ■�■�■■�■���■■��■�■�����■■■■�■��■\��■■�����■■����■��■���■�■e�r►\��/i ■■���o���■■■�■■■�����■■■■■�■�■���■�■�■�■�■�■e■■■■�■������::-:�e::�r�r�wl ■■�■s■■�!■■!�■�es��s■�■■s■�■e�■■ ■■�0.._-,=iinii�.■■oo!■�si��o�]'��L�i�[��: ■■��■■■■����■�■����■■�■■■■■S■0■o!=�i�l�06iiii/�I,%I��■�����a���`�f i�r���� ■■�■■���■■■�■���■�■��■■■��!�i�1ill/I��l���w�l1lPi.J■L�`�:i�i�:i�����■�i■��e�%��■fi ■■■��■��■■��■�■■0■■�!�i�0�■�■�i�`iL'J�l.!���%I-�■����n..��■��■■�■�■■�/��/■ ■■�■■■�����■■�!��i�■■�■�■■��I��='�Gi��ri■�1�■��■�■��vi■■�s���e��■�dse�■ ■�■��■���■■���■■■�_■_=c::::�■�■■■■■■�o�■■����■�■�au■■■■����■■■e■e�■■ ■�■�o�����■■�■�■■��■����■���■■�■��.•����■��■■�■�����■����■��e■■�■�■■ ■■■■■■■��■�■■■����i�e■�s���■■e■�■�i�c�se�■■�.■a�■o�■�e�■�■■����■��■ 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■����■��������■�■■�e■■■■■�■���■■�■■a■s�■e�■��v■�■�s■�o■�■�so��■��■ , � � � � 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) r �--5y��rs��'��� � ;,o _� use S stem T e LTAR Initial G. '�S Re air -� O.a- Site Plan �„r'/�/Q E� 1- nd '•--� �O Ra+���c�r �� - "� . •I � (� i ��I <<� ��� � � I , - �9 �g� b .�� --- �� I,,, � �� � .Dcck ��,o• �-�;a� S-e P�6 c sc,���.�w ��,/� Ge i( �'(,e�l ►� `� 7 Environmental Health Specialist Date �'�� Q� i.p.l l-06