516 Merrells Lake Rd � DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
Account #: 990005097 OPERATION PER11��'� PIN/EH#: 5768-55-8791
Billed To: Shawn Brooks Subdivision Info:
Reference Name: Location/Address: Merrells Lake Road-27028 �
Proposed Facility: Residence Property Size: 10.8 Acres
ATC Number: 4875
**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. �O$
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System Type: ��_S.T.Manufacturer���`� Tank Date I Tank Size�
Pump Tank Size
S stem Installed B : ' (tf�l�� E.H. S ecialist: /�'/�Date: � � �7- �� �
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n('.HT� 11/nFi(Rr.vicPrll
• DAVIE COUNTY ENVIRONMENTAL HEALTH �� (,
' . . P.O.Box 848/210 Hospital Street ��b
Mocksville,NC 27028 n'�
(336)751-8760 Fax#(336)751-8786 � �
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005097 Tax PIN/EH #: 5768-55-8791
Billed To: Shawn Brooks Subdivision Info:
Reference Name: Location/Address: Merrells Lake Road-27028
Proposed Facility: Residence Property Size: 10.8 Acres
ATC Number: 4875 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�#Bathrooms�#People�Basement�sement plumbingC-1��
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size ' . � GtC�'.C�j Type of Water Supply: C3L�ounty/City ❑Well ❑Community Well
� System Specifications: Design Wastewater Flow(GPD) `O� Tank Size�GAL.Pump Tank/�GAL.
�� �� ? �� �. /
Trench Width�� Max.Trench Depth l� Rock Depth � � Linear Ft. ��
��
� Si e odifications/Conditions/Other: A�T� stated in 15i� NC��C 1��l�;1_���(5�
. U����'J�J��YIµTJ�i.a�f <al:s�.� i.�. �.i.r
� Contact the Davie County Environmental Health Section for final inspection of this system between
b 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist Date: � ` ��
DCHD 11/06(Revised)
• Davie County Environmental Health
, ' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990005097 Tax PIN/EH#: 5768-55-8791
Billed To: Shawn Brooks Subdivision Info:
Address: 115-16 Crown Chase Drive Location/Address: Merrells Lake Road-27028
City: Winston-Salem Property Size: 10.8 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
coristruction/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.
Pernut Type: C�1ew ❑Repair ❑Expansion Pemut Valid for: �'S�Years �No Expiration
Residential Specifications: #Bedrooms�#Bathrooms�#People � BasementC�asement plumbing�_
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): �GQ Type of Water Supply: 0'County/City �Well ❑Community Well
A�, stated in 15A NCAC 1�A.1��3(:�
Site Modifications/Pernut Conditions: �r.r.e t2�ci S�stems m�v �.Iso �e use�
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Environmental Health Specialist Date
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- � "� , SITE EVALUATION/IMPROVEMENT PERMIT&ATC
�`� � Davie County Environmental Health
� � � � � P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
� ,,�� ' {� (33�751-8760/Faz(33�751-8786
,�`1� App���F�r:O Site Evaluali pr4 ement Peimit Authorization To Construct(ATC� B��oth�
;�`�w� Type of Application: 5 R ir to Existing Syatem Expansion/Modification of Existing Systetn or Facility
" � � "''t�IIS TION CANNOT BEPROCESSED UNLESS ALL OF TIiE REQUIRED
� �.
INF ;tI VIDED. Refet to the INFORMATION BiJLLETIN for instructions.
LICANT INFORMATION
Name to be Billed ��c,u,.� �/o c(�' Contact Person S�a r,,,•, ��-u o k�
Billing Address l�—!� 4a��n e GG�a,ce 'r:v� Home Phone ? -1 2?1'
City/State/ZIP W:,,f-}w,�- Sc.(s.�. Nc z�t oc� Business Phone � .- -+Y� - c�yr �L�
Name on Permit/ATC ifDifj'erent than Above
Mailing Address City/State/Zip
PROPERTYINFOItMATION *Date House/Facili Corners Fla ed ����� �`���Q`� �/`�J�
N01'E: A survey plat or site plan must accompany this application. Included: Site Plan Plat(to acale)
(Permit is valid for 60 months with site lan,no iraGon with complete plat)
Owner's Name 5����✓r �- S'�Hp ��-��!✓' Phone Number��(-7�,a-�'r2�1'
Owner'sAddress /�S—/l� Gr+r,.�,u �'L+�.� O� City/State/Zip/�✓.wr�<-,-fo.l�.., rv� 2�/Lz!
Property Address rr� City fl9o[Crv.�//e
LotSize jl�. ac�-ei TazLPIN#_,s'?G�'SS�S79/
Subdivision Name(if applicable) Sec6on/Lot#
Directions To Site: (.✓ L e, /i'1 /rr!1' � K ,• r 5��,.i C�rr�
C�.,�/1f V, ��/� 'I'z�N.
If the anawer to any of the following questions is`�es",aupporting documentation must be atlached.
Are there any exiating wastewater syatema on the site? Yes
Does the site contain jurisdictional wetlands7 Yes
tlre there any easements or right-of-ways on the aite7 Yes��
Is the site subject to approval by another public agency7 Yes C"I�To�
Will wastewater other than domestic sewage be generated? Yes I�o
IF RESIDENCE FILL OUT THE BOX BII,OW ,
#People 2 #Bedrooms � #Bathrooms Garden Tub/Whirlpool� No
Basement: e No Basement Plumbing: e No
IF NON-RESIDENCE FILL OUT TT�BOX BII,OW
Type of Facilily/Business Total Square Footage of Building #People
#Sinks • #Commodes #Showers #Urinats
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested;'�[Conventional Accepted Icu►wative Altemative Other
✓�
Water Supply Typ . County/City W New Well Existing Well Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? Yea �
If yes,what type7
This ia to certify that the information provided on this application is ttue and coaect to the best of my lmowledge. I understand
that any perniit(s)or ATC(s)iasued he.reafter aze subject to auspension or revocafion if ihe site is altered,the intended use
changes,or if the infocmation submiUed in this application is fals�ed or clianged. I hereby gant right of entry to the Authorized
Representative of the Davie County Health Deparhnent to conduct neceasazy inapecGons to detemiine compliance with applicable
laws and cules. I understand that I a respons ble for the proper identification and labeling of property lines and corners and
loca�flagging or etaking use/facility location,proposed well location and the location of any other amenities.
Site Revisit Chazge
Property owna's or own 's 1 representative signature
Date(s):
� '-�a,r psi' Client Notification Date:
Date EHS:
Sign given es No Account# ��f
Revised 11/06 Invoice# ����/.?
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' . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation Jr7l�_55_g7`1�
APP,4,��,1NfI'#��VBA(�5�(9A�N Tax PIN/EH#: 5768����Ty INFORMATION
Bilied To: Shawn Brooks Subdivision Info:
Reference Name: Location/Address: Merrells Lake Road-27028
Proposed Facilify: Residence Property Size: 10.8 Acres Date Evaluated: _ /�� G�
Water Supply: � On-Site Well Community Public „/
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position �- - � .
Slope % � �
HORIZON I DEPTH � � �� - (�— '{
Texture grou G G �GL-
Consistence p �r � !,
Structure S 5 !c L
Mineralo � p ^
HORIZON II DEPTH � /� X
Texture rou • -
Consistence '
Structure
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure � .
Mineralo
SOIL WETNESS ��
RESTRICTIVE HORIZON + � �'
SAPROLITE
CLASSIFICATION S �j
LONG-TERM ACCEPTANCE RATE
, �
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: �� OTHER(S)PRESENT: --�������' Gl
REMARKS:
L�GEND
I,•�ndscape 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
Texturc " -
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
CONSISTF.NCE
��
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
1�Iineralo�v
1:1,2:1,Mixed
1YQtc�
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 DCHI��5/(15 �Revi�e�il