1854 Milling Rd DAVIE COUNTY ENVIRONMENTAL HEALTH
� � ' P.O.Box 848/2]0 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATiON PERMIT
,�c�r�u�t #; 990001883 • - , : T�x F�I�€.��H#: H60000002402
8illci� 7'a: Ken McDaniel . . Su�i�ii�iE�iori Ir��a:'
f��fer�r3ce (�an��: , '_ LacationrAd�r���: 1854 Milling Road-27028'
f�ropc�s�c9 F,�ci€ity: Residential .• . :, --:. , �ro��r�y Siz�: 12.132
��l'C E�umb�3: 5991 . . : �
**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 WAYbe taken as a guarantee that the system will function satisfactorily for any given period of
time. ' �
System Type;�_S.T. Manufacturer cS O Tank Date S�/Z Tank Size ova ,
� Pump Tank Size Bedrooms:_ 3 �-
System Installed By:,�. ( �,�„ba,Y►.��.1. Installer# Date:��� `"
GPS Coordinate:
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Environmental Health Specialist�%L�(Q t,����� Date:� �Q �
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
t�ccc�u�t #: 990001883 � , "��x F�l�€:EN�: H60000002402
f�ill�� To: Ken McDaniel �;uf�t�i�ri�iart 1r3�c�:
Re:fer�r�ce P��r��e:: _ _ :. Locationr4��r�ss: 1854 Milling Road-27028 . .
F'ropt���c9 F;��:iiity: Residential , �rr���rty Size: 12.132 , .
a�TC N��b�r: 5991 • . . �
Site Type: �Tew ❑Repair OExpansion
**NOTE** This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior tp 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�#Bathrooms0��' #People�Basement� Basement plumbing❑
Non-Residential Specifieations: Facility Type #people #Seats
' Square Footage(or Dimensions of Facility) ,
_ Lot Size � Q,(. Type of Water Supply:' ❑County/City �WeH ❑Community Well
System Specifications: Design Wastewater Flow(GPD)��Tank Size�G�Q GAL.Pump Tank � GAL.
Trench Width 3�p�� Max.Trench Depth' c� Rock Depth� Linear Ft.3�' ac�j�
Site Modifications/Conditions/Other: �Q�,(,1C17Q�'�
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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Environmental Health Specialist � Date: �S �I
. DCHD 11/06(Revised) � . �
A�'PLIC I OR SITE EVALUATION/IMI'ROVEMENT PERMIT & ATC
A'
� '� ' '=' � Davie County Environmental Health
�� P.O.Bog 848/210 Hospital Street
� O�T �i �� LO�i. Mocksville,NC 27028
��� , (336)753-6780/Fax(336)753-1680
Application For: ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New Svstem OReDair to Existin�System ❑Expansion/Modification of Existin�System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BiJLLETIN for instructions.
APPT.T('ANT TNF(�RMATT(1N
Name ��l_[V�L �J�►�,l/b�b�/�i - __ Contact Person_� ���{���
Address b W W� e\�- • Home Phone ;3� — q�[Q`�— /���
City/State/ZIP �M,dc V(, C bZ Business Phone�36�90 q—d g��
Email �}�,— cQ���".(� a ;.,�-1J�,�� .caN\_ _ ,
Name on PermidATC if D�erent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION � *Date House/Facility Corners Flagged
NOTE:_ A survey plat or site plan must accompany this application. Included: Site Plan lat to scale)
(Pernut is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name" 'S�l'�{���{ ���V�IOI�,� Phone Number
Owner's Address ZZZ� �� City/State/Zip C�-�Z.,/��C(,C Z7S(�
PropertyAddress j�S�} u-tNE . , city�G�rk�tUILGPT�
LotSize �Z.,�3Z �c�,�- TaxPIN#_ �7S�SSgQ� �(�(�U���02(Ed�
Subdivision Name(if applicable) Section/Lot# �
Directions To Site: `t". � 6 � I GR/�'� (,�( c M,
-CK k � �
If the answer to any o the following questions is"Yes",supportin documentation must be attached:
Are there any existing wastewater systems on the site? �es No
Does the site contain jurisdictional wetlands? _Yes �Io
Are there any easements or right-of-ways on the site? �'es No
Is the site subject to approval by another public agency? _Yes �/�10
Will wastewater other than domestic sewage be generated? Yes 1/100
TF RFS�T)F,NC;F,FTT,T,ni 1T TNF,RnX RFT,nW
#Peo le Z— ' #Bedrooms 3 #Bat�f ooms Z 2 Garden Tub/Whirl ool es ❑No
Basement: ❑Y� Basement Plumbing: ❑Yes �No p
TF.NAN-RFSTnF,NC.F..FTT T,niJT THF Q �iEI:OW
Type of FacilityBusiness /�/��� otal 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: [E'Conventional ❑Accepted ❑Innovative �Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑New Well [B'Existing Well ❑ Community ViFe�l
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �io
If yes,what type?
This is to certify that the information provided on this application is irue 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 stakin e house/facility 1 ion,proposed well location and the location of any other amenities.
� Property owner s or o r's legal representative signature Site Re�tisit Charge
Date(s):
1�-/�'--lz Client Notification Date:
� Date � EHS:
,`;
,� �. n\' ` j
Sign given ❑Yes ❑No t` ,�`., �V Account# !�
Revised 11/06 � � Invoice# ��, S�r�O�
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Davie County Environmental Health
P.O.Box 848/210 Hospital Street
� ' Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
� IMPROVEMENT PERMIT
Account #: 990001883 Tax PIN/EH#: H60000002402
Billed To: Ken McDaniel Subdivision Info:
Address: 386 Howardtown Road Location/Address: 1854 Milling Road-27028
City: Mocksvilie Property Size: 12.132
Reference Name:
Propo����qt�Th����4nent 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: �[New ❑Repair ❑Expansion Permit Valid for: �15 Years ❑No Expiration ,
1
Residential Specifications: #Bedrooms�#Bathrooms�#People 2 Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type � #People #Seats
Square Footage(or Dimensions of Facility) ,
C—X�skn�
Design Flow(GPD): �(� Type of Water Supply: ❑County/City �Well Community Well �
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial :'�/e `
Re air �'�= � - 3
Site Plan
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Environmental Health Specialist � • Date 0 `�p7 �
i.p.11-06 / '
. . , , DAVIE COUNTY HEALTH DEPARTMENT �
� Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001883 Tax PIN/EH#: H60000002402
Billed To: Ken McDaniel Subdivision Info:
Reference Name: Location/Address: 1854 Milling Road-27028
Proposed Facility: Residential Property Size: 12.132 Date Evaluated: /O �3 /Z
�,��n�-
Water Supply: On-Site Well .k Community Public
Evaluation By: Auger Boring k Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition C
Slo % 2%p
HORIZON I DEPTH O� —2
Texture grou C L
Consistence I (�/%
Structure � ,�
Mineralo ;� `l
HORIZON II DEPTH 3 — �S �
Texture rou S
Consistence {_
Structure a g w 3 I<
Mineralo :I �I -1
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION I
LONG-TERM ACCEPTANCE RATE •3 ,
SITE CLASSIFICATION: �S EVALUATION BY: ���2P.L� �GY.I/uJOL�'
LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT:
REMARKS:
LEGEND
i,andscane 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- Sil[y clay C-Clay
CONSI T�.N E
a'IQ3S�
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
Mineraloev
1:1,2:1,Mixed
lY�.es
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-gaUday/ft2 DCHD OS/OS(Revised)
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ot ten�
O d nwe u,r pai N a e wrwy w�oG..c�ory,wa�e.u» - C L°�° t � SI7E
�.ca�eirac�on a��ina oorc.w.a court-oro«.a wrwy w on�. geot'ing RefrreflC
i � � �
exc.vtion.ee tb.a.+a„�do�or�ue�: RB 840 O PG 557 � , _��G da
° � �. TAa�t br�fer�+ati0a a�OtaWi!0 tl�i��rv�y�r y�dt Mwt i cm
wqM�1e e�n r dAa�ts ttr b�rt d n�t pro1�b�N t O t�
_,
ahitY p to Wa�piawt contoirrd in(o)t (d)a0a.+. �
tf1 � Soin Rd Ptkll'tp9
• ^O Lorw
'f`
. � GeOtgB R. StOne. PLS �
.. � , . � � Praf�sa' ol � ryor.L-3762 � - . � � � ' .
� vcinity Map (Not to Scote}
+ Site P1an for Proposed Lot 1 '
Du���ma � � ,
,�N CAR� PropertY Line foN n Cre�k � PROPE
RTY LINE CALL TABLE
i ow
s C ��
�,�oF�stp•.,�' _ _ os Loc � ��+�' t;r ��
�Q ti,�;'9 , , - - - - - _ _ _ _ ated on 9-21-20�2 of eek ' 0�°��� couRSE e�tir�c DISTANCE
SEAL - - - - - a` .
`� l-1 S 32 48 53 E 324.59'
L-�162 , �4 ~ - �, o o , „
� -�5 ' - - � �
�''9 �.' ��,, � „� �L 6 _ - - �L���'` L-2 S 53°16'27"W 143.96'
O ',y ,,{Q�� I� � - - - - - _ - _ _ _ - - _ p' L-3 S 63°57'47"W 1 f 7.69'
� �(',t�,SUR;��Gj� �I � i � - - _ _ ' - - ` - _ - _ ' \�o` L-4 S 18°04'16"W 162.56'
` � r -r-. _ ao �� L-5 S 13°03'55"W 62.43'
ROQER \ � � -- _ _i� _ t'-1� ` - _ _ � 1 � L-6 S 17°22'S5"W 161.35'
� � � - - - - � � ° �-� s �2°�0�34��W 197.sv�
�
_ ��, , � , - - _ _ _ � � �-s s 8a°2z��s��w 24.i i�
��� l-9 S 88°02'OS"W 168.06'
� , L-10 S 68°00'01"W 12Q.55'
F ��� �►,at �, = 1 . 2o I . o � `��, LOT 1 �� - � - - - e , ,.
we swvayad the pr�oparty ahown on � `\ �\ ` �i L-18 � � '' - - L-11 S 67 46 13 W ta7.51
this plot: � y � N � Approximate Flood Hozard Boundary
� } L-12 S 70°01'S3"W 56.52'_
� o � `� � � 12.132 Acres +/- � F F F � for tht 100 Year (AE) Flood Zone �-13 N 56•22'28"Y�t 62.94'
N �, � � (Inc�us�ve cf area m SR �60o R/w) F F Referertee: FiRM Map � 3710575900J L-14 N Q6°42'25"W 71.39'
� I
. � � . � �\ �\ I pp�---�,___� Z Panef 5�59, Date 9-17-2008 L-t 6 N 14°19'33"E ?27.26'
� Or,,,, -� � ` i �4er;a`"_'`-� �
L-17 N 16"19'1 1"E 500.52'
�p �� � <� � �lfility (���--�---_.,`` L-18 N 81°45'24"E 93.56'
Ptat Reviaions: 10-t 1-12 p � \`� ` ti pp L-19 N 79°30'0�"E 252.60'
t. Revised Eoatem Property t.ine for � � `� � �, wT PROP i 1 L-2� N 68•54'14"E 1Q1.81' '
OSED HOUSE
Proposed lot 1 (Retsrenos CvNs L-1 thru L-8) � n � i L-2� N 60°OS'28"E �4.55'
� --._ , � r,�. LOCATiON � �
2. Rerrwved Livestodc Sred due to Removal r , � �f
o� Sl�ed by Property Owner on 14-11-12 � '�" 1 t � � � pSeptic Tank L�d ,
3. Revi�ed 30' Accts� Easement � N � �� � � � � i a70.4�+/-
` � —=-_�------------�
� o �t� � -� ---�------------ Milling R o ad
� a �'" 1 � � ° � ��--1-�689.9' NAVD 88 , ` TIE �►NE CAL.L tABLE
@ 1 COURS� BEARI!�,, QISTANCE
i
�o �D `� � +' a �o� �� � '�-, -' � ►s.� . 1 �oo
� �p � i 5 � +; Welloi � _ _; , \ \ < <�
:` � � h T-1 N 48°06'30"W 361.�9'
� ' 60' Public R/W
� N i ; �*� ��F , s � T-2 S 56°10'2S"E 56.38'
i ;� � - _ ef , ' . � \ /- e t Width 3,,, 255.46.
t ' ` 1 °"�=h F � , : 20 + Pavem n Z-3 S 50°30• r w
NOTES: ��1aa t3g.gg� -�R , , ` � �.� �'�°� \� �N � T-4 S 16°19,i 1�..N 32.96'
� S � o
• 1. Zoning: R/A �� � � l-7 7otol 1 � �` i - iRS �,��` ��\ , \
2. Mi�imum BuiWing Setbock L.inea: � � C=g � '-+ ' - -,`� �,\.� '�P�, 30' EASEMENT CA�L TAB�E
Front: 4Q'� ftecr. 30', Sitie: i 5' � � ' `
3. Wcterahed Clossif'�catlon: None � i :�� � ' " � ` . �� �
�� �..4 � � � � COURSE BcARING DISTANCE
4. No USGS or NCGS I�Aonumenta ' ' � � 'A � �! E-1 S 05°52'31 E 76.06
frnuid within Z000' 4f site • � �� . �, s ' �. .�; G � / �� ,
5. Ptopoaed Structur�s 5holl at o Minimum De ��, o� �,`� � �' � ♦ � E-2 S 15°43'S9"w 109.32'
ConBtruc#,�d at the �ub#ory Flood Protection ��• "� j ', � ' ��' a E-3 5 15°36'3?"W 99.90'
El�tafttorl (8FE piW 2 oot froeboor'd). The BfE � • �`�� 'l `�� p� `�� E-4 S 27°08'S9"W 47.32'
671.E}' NAV[� 88, ond.the Raq+�fatory Fh�od Protection \ . ��\� `�� �\ � f,�,��`o�o�' ?�� � /
, � � `� s
EMvotion i� 673.(3' WtYD 8$: Refsronce AAap �37105759QOJ. • � \ �, T e• t o.
� PanM 5755. Uate: 9-17-20Q8. -n �'s `;;\\ �,�T ?. � ,�\ ti
- \ ____ _ , °l°, .'�' �
�"� - ��`--__'=��...
\ �� GG h� �4 `�----'� - �'`'�'.x�,-�� _ , � �,/
\ Approximate Flaoti Nazord Boundary ��5 .�'L, E_3�'1--�; _ _ '- _ ♦ w
� for the 100 Year (,�4E) Fiood Zone � E-2'` E.t ^ �� � �
Corner S)rmboi Tabie Reference: FtRM Map � 3'I10575900J ~ � �Q4 \� `Ep
Panel 5759, Date �-17-2008 f�'
X N1NP O C/L +/- of Creek C/L 30' Access �� '�/�y `
dc Utility Eosement �'
� e PlMP O C/L of 30' Eoserne�t (15' each side of C/L)
See Eosement Col! Tabte �,�
. ` �/
Tvx �ot 24.02
Tcx Map H-6
` n/f Sydnry Seymour
f>B 840 O Pg 557
R/�M - Right-uf-Wpy � FC - Focs of Cu� tR@!�)OI�1dBf� ca Site Plan
EIP - ErcKtin4 ��+ � BoC - Back of Curb � �Or.
EiR - E�cistirty Iro� ttebor PP - Power Pob t
P - Post LP - Lqht Pols 1 �
� - ����.��,t �, - �� �. ��° Sydn,ey Seym,o�.�r
iRS- kon Reba 5s1 CH - Ctwrd pitto�ce
P/l �- Ptope+tY Lin� P/0 - Port ot
� - Cor+crete P�pe � P8 - Plat 9oolc _.
• , C1�AP -Coen�qet�A Metd P'�e R8 - Record Book I _.�_�.
LOT t
t�_coer�,qatad Pbst;c �e r� - � Part of Tax �ot 24.02
-F- 100 Ys�F7ood @oundorY C@ ^ Cotch B�in
-o- overh�oe uiilities -5- Se.�r line ' 7ax MUp H-6
-X- Fence YYM - Mtoter Meter I PIN 5759455904
F�d -Fow►e wv - woter voas Record Book 84J O �'ege 557
n/f -:Nor w FormerlY 8� - 8encn Nark
w�' - Nonmonwn.i+tw Poi�+t feu - ten,p..ory�ge�cn t�rt, LOT 1 Acroage: 12.'32 Acres +/-
CL - �entK.tins RRS - RA�l Rood ! (lnciusive of orea ;n SR 1600 R/W)
E� - Edqe of Pa.timent CN- GoW� 7�Pedestoi � 1 Area Computations by Coordinate Geometry
TP - TNephon� PWestd El8 -'ENeWe Tronatormer 8ox
-W-wdte�tiM CO - Sa�itary S�.pson Out SCALE TOWNSHIP �UN1Y STATF DATE
�iS CC 1/2" RebOr Co�trol Corntr -..--_`_
OMnef: "'�� � 1" = 120' Shodti Grove Gavi� Nor!r: �;roi� �,:; �- :�-201 Z
Sydney Seyrnour ��
� t 20 0 �2a 240 3so 32�o� r�o�� o� 1`�' ` i S�a Sto n e La n d S u rv ey i n g C o m��r�y �� No.
. COIY. N.C. 27518 RS.PH 8ualnesa Flrm Certificote Number: C-1704 ,�iG RS
,:;.
G�H�e, se�.F — FE� ��: � ��'Q� RoDertEStone. PLS 1-3162 MAP AtO,
,�; �; .. _RS
GRS �Ancwvv ; V , . �
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