106 Tulip Magnolia DrLot 3 r'
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERN�T —�
Account #: 989900093 Tax PIN/EH M 5880-50-1936
Billed To: Shelton Construction Services Subdivision Info: Lot#3
Reference Name: Location/A�--yc , 106 Tulip Magnolia Drive-27006
Proposed Facility: Residence Size: .78 Acres
ATC Number: 4841
**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:_S.T.ManufactureTank Date�� Tank Size )106�
Pump Tank Size
System Installed By: V74 K 11 y— E.H.Specialist: V1 2616&ate: IZ 3 b r
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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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 989900093 Tax PIN/EH#: 5880-50-1936
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#3
Reference Name: Location/Address: 106 Tulip Magnolia Drive-27006
Proposed Facility: Residenc6 Property Size: .78 Acres
ATC Number: 4841
Site Type: 4ew ❑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.
i
Residential Specifications: #Bedrooms _#Bathrooms 3') #People Basementg'�B-asement plumbingl!r—
Non=Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size G. 78�Gr1S . Type of Water Supply: 91:1ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)-34-6r Tank Size GAL.Pump Tank =GAL.
�r 1 r• '
Trench Width 3( rr Max.Trench Depth 3Rock Depth Linear Ft.y (v
As stated in 15A NCAC 18A.1909{S�
Site Modifications/Conditions/Other: gecepted gyztnmc malt nlsn he ut;�
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.
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Environmental Health Specialist Date:
DCHD 11106(Revised)
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mock§ville,NC 27028
.(336)751-8760/Fax(336)751-8786
Account #: 989900093 IMPROVEMENT PE#MIJBIN/EH#: 5880-50-1936
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#3
Address: 1257 Highway 64 West Location/Address: 106 Tulip Magnolia Drive-27006
City: Mocksville Property Size: .78 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: Y�ew ❑Repair ❑Expansion Permit Valid for: 2Years ❑No Expiration
Residential Specifications: #Bedrooms-3 #Bathrooms 3 #People_BasementE Basement plumbing
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
DesignFlow(GPD):� Type of Water Supply: County/City ❑Well ❑Community Well
s
tated in 15A NCAC 18A.1969(5)
Site Modifications/Permit Conditions.: accepted Systems may also be used
System Type LTAR
Initial
Repair A Cc 4-r 7
Site Plan W a v-c CK w e0-I
d U°
_y f
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9 � G
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Environmental Health Specialist Date_ /��rjo
:.11 11(,
�T ITE EVALUATION/IMPROVEMENT PERMIT & ATC
D Davie County Environmental Health
3 200a P.O.Box 848/210 Hospital Street
AQ� Mocksville,NC 27028
(336)751-8760/F7Auth
6)751-8786
Appli ation orQ1 i;-U` mprovement Permit orization To Construct(ATC) ❑ Both
Type f Applica ' ew 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 to be Billed <A, -11. Contact Person
Billing Address /-2-S-7 U% 4("J V (,-t W Home Phone
City/State/ZIP r'I o Vis, q r,1. Z:7 e Z. Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged 12,'& OS'
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name /k. G d,,,J- -j-;c _ Phone Number 7�y 5--
Owner's Address
--Owner'sAddress7y S l4-tvY (- `f kJ City/State/Zip /�►•�ks.:11� ,�✓_�. z-7oZ�
Property Address /0(o �.1; /✓1- ol:a City_l-dl.._,�
Lot Size .'7 ,- 5 ax PIN# 5-9 0 S U 1 7 7U
Subdivision Name(if applicable) ); Section/Lot#
Directions To Site: 60/ f.. �do/�, C _fG �� d - r✓i, !�- �J --, t L• o— ,�:s ��
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? oyes [ilii
Does the site contain jurisdictional wetlands? ❑Yes &NT-
Are there any easements or right-of-ways on the site? ❑Yes BNr
Is the site subject to approval by another public agency? ❑Yes CiNo
Will wastewater other than domestic sewage be generated? ❑Yes 2N6
'-
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms 3 #Bathrooms_� Garden Tub/Whirlpool Lames ❑No
Basement: QW-M ❑No Basement Plumbing: Er!?e-s ❑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; i ebnventional ❑Accepted-G Innovative ❑Alternative ❑Other
Water Supply Type: ZJ2
runty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes pNe---�
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
anv,pernut(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 oranged:.1.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 staking the house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Prop _ own s or owner's legal representative signature
Date(s):
3 Client Notification Date:
Date EHS:
Sign given []Yes ❑No Account#
�/\Revised 11/06 Invoice# --y —
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-•. '' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT.
Soil/Site Evaluation
APPLICANT'S NAME f✓I�A�Z el DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE 329 v
SUBDIVISION 1rj 0 ROAD NAME
Water Supply: On-Site Well Community / Public
Evaluation By: Auger Boring - Pit ✓ Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture groupf L �'� c
Consistence
Structure
Mineralogy
HORIZON II DEPTH y�f•' 0-
Texture rou C__Consistence
Structure 7!C r
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 -7
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: i OTHER(S)PRESENT: _to— /U6
REMARKS: -52e &4 ��l V C.
LE ND
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
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
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
Notes
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)
LTAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)