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120 Mohegan Trail r , . �� ZL,/ � 2 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Sh-eet Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005010 Tax PIN/EH #: 5754-23-3452 Bilied To: Andrew Fox Subdivision Info: Reference Name: Location/Address: Mohegan Drive-27028 Proposed Facility: Residence Property Size: 1.5 acres ATC Number: 4821 ` **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.190Q"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. SystemType:.I� 4� S.T:Manufacturer$�ou� Tank Date /o•/� Tank Size/a� Puinp Tank Size�tr/�' S?Y"1 Va System Installed By:� ��G�[� �A•( E.H. Speciahs Date: Z 'Z7�� r � \n o : ; �,�f �f . �x � ' J a � �= 0 T � � • .n , ` � s � , r � �y , o. o_ � ¢ � ° -o w � �= � � � �. 3 - , � �Z E,.. �rc� c�� - �� , $ � _Z�c1w.b�- ¢ ov � '{ CL v ;• � .ZI C . � � 9''�� ' °��- -Lv C�� o� � �. N _J. ' :; � w A�i l�w, 3 ' o „ ' Itc�,c.. c w6� � � ,,: c _ �n >. . o V' t,,,� te»J� dep�ti 30-� , .. , _,..rr ., ,,..�;,,. . „ r � DAVIE COtTNTY ENVIRONMENTAL HEALTH �a.� � P.O.Box 848/210 Hospital Street ,�` Mocksville,NC 27028 �`�' (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR�VASTEWATER SYSTEM CONSTRUCTION Account #: 990005010 Tax PIN/EH#: 5754-23-3452 Billed To: Andrew Fox Subdivision Info: Reference Name: ' Location/Address: Mohegan Drive-27028 Proposed Facility: Residence. Property Size: 1.5 acres ATC Number: 4821 Site Type: l�'New �Repair ❑Expansion *�NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernait(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systeins, Section.1900 Sewage Treahnent 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 3 #Bathrooms�#People 3 Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimension of Facility) 2.27-0't� Lot Size , �UG►'-i'�j Type of Water Supply: �ounty/City�11 ❑Cornmunity Well System Specifications: Design Wastewater Flow(GPD)��Tank Size ��p0 GAL.Pump Tank��L GAL. ,� ,, �� Y3 G. Trench Width�G Max.Trench Depth 3�i Rock Depth /_�_ Linear Ft. SiteModifications/Conditions/Other: �'�� stuted in �5l; �,�;o?� 1�i;.1��9�:a) ' . �4 �.'vµl:.. vyJtLlll:.: IIi:A� 4:JU UL 'J:iC. 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. l�-e \ y�w 5 yv�.� �w�.u-�,... o 4�� O �- 5'd �.�� r o w�- 5-t�O'� ��- �,�� 5 y��-�.�, � o- � ' �,e � �� '� �t � U. � ,� a�,r �. �� .� �- �- p . s o . � � ,��-� , � �o , � �' � � . � �.,�� , _ � � � �0 3 � p�,�� -�' S� 0 9 ' h , , � o o . � � � �0` rn i n !o N+. E�vironmental Health Specialist Date: � %� �!/ n!`ATl 1 1/(1F,(RPvieP�ll Davie County Environmental Health P.O.Box 848/210 Hospital Strcet Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990005010 Tax PIN/EH#: 5754-23-3452 Billed To: Andrew Fox Subdivision Info: Address: 504 FairField Road Location/Address: Mohegan Drive-27028 City: Mocksville Prope�ty Size: 1.5 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. Pernut Type: ew ❑Repair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms �— #People.� Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):��D � Type of Water Supply: ❑County/City 8'4Ge11 ❑Community Well Site Modifications/Pernut Conditions; �� t�:ied i� �."' ��`�''� 1�,'.'��'�':'� . . . �...�v..r.w.. ....lr_..,.... ......� �._ ... . . � . . . System T e LTAR Initial cc 1 �s Re air Q! e c -1- O�a.7 Site Plan 1 � (' ��i ` �� = p s � o o� � � � `�` °�` �O . T o � � `' � ��` � ` ��,d � 5 � h � — �-- � � �a� � 08 Environmental Health Specialist � -ate � -- l :_ii_n� .� ; C�a,l�� - �?ndrew a.7� ` �33G �Z' Z(��79 APPLICA ITE EVALUATION/IMPROVEMENT PERM & ATC � � � � Davie County Environmental Health P.O.Box 848/210 Hospital Street Q � 200a Mocksville,NC 27028 � JAN 2 $ _ (336)751-8760/Fax(336)751-8786 A 1 �n For: S' �/Im rov ent Permit ❑ Authorization To Construct ATC � Both PP Q �� P � ) Type f Ap ' �p�0��'�q}v; s epair to Existing System ❑Expansion/Modification of Existing System or Facility ***I T***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 � ' � Contact Person Billing Address ,�'O� �au�o( �� Home Phone 3G • G Z - G City/State/ZIP`�d e�v�Ct /t!C 2�Z� Business Phone �»j� • �30 • �i�DD Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged j Z�-�� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan OPlat(to scale) (Pernut is val' for 60 months with site.plan,no expiration with com lete plat.) Owner's Name �/o�,v ,Q•�►�c � !.�l�- L'��fuo%t � �� Phone Number Owner's Address /2� !Np/-FFC,� TiL' �- City/State/Zip �fde.CSv/t�t E- �/C Property Address �L10 ff�'G�-� 7yL � City ,¢�10C,rs�//[.t� Lot Size �,� Tax PIN# b7(/-Z��3�fS�oZ Subdivision Name(if applicable) Section/Lot# /�� Directions To Site: Grj/ S T�4,uJ ,�Z) o.�/ /�'1diS�EG� Y7t. L G°T a�u �_5J 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? ❑Yes Ca3Qo Does the site contain jurisdictional wetlands? ❑Yes �3Vo Are there any easements or right-of-ways on the site? ❑Yes C�'No Is the site subject to approval by another public agency? ❑Yes C.�No Will wastewater other than domestic sewage be generated? ❑Yes G�No IF RESIDENCE FILL OUT THE BOX BELOW #People �g 3 #Bedrooms � #Bathrooms�_ arden T irlpool C�es ❑No Basement: ❑Yes Ca3Qo Basement Plumbing: ❑Yes C�r3Go 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:. �onventional ❑Accepted OInnovative ❑Alternative �Other Water Supply Type: B'Lounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Gl�b 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 any pemut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the infom�ation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deternune 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 location,propose3 well location and the location of any other amenities. Site Revisit Charge Pr perty owner's or own r's legal represertative signature Date(s): �•�Q � v g' Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �� Revised 11/06 Invoice# � s ��'� � ��/ �> �- . . __._. _.__ ___._.__._______� _ � . � � � � a�S, � � °'�a � � J �U i�.�-��F °(� -1} �� , � � � � ,�f�S( f '- j1 ; ; _ ; f,, �� _ ��, �� %J .� . xn�/ �� r'�.�� • � :, GQMAPS -Davie County NC Public Access Page 1 of 1 . Davie County, NC - GIS/Mapping System Q��r�' ,sm, Cii�k Here To Start Over Quitk Se�rch:{Caunty ID c � �+� �"-� �, J � � �� Actiue La er. � y r Use Map Tps Gis U t� , �� ', 0 �° PARCELS (Map Tips Available) - _ Map Layers � Re�ult� ( z" �� § — �,�1�93;# d��- — — — — �$ e, �t ��« N ., 0 4fl�J5� - - - - - � _� � T � � �g �� d� a�fl�� _ � � ^ �? �� — — -'310,�i� ¢�� ?� 1��1Y �x � �� _ ._ i �d� __ ,,..,��-.�.�,.....,.�. ,,_._..�, ___...,,... A� __�,_.._ � '.� ..�:. .--��-��t�E�AN�7 -,.�.._,.�. : 4123. Rl,�...,..,� �„ � + -�- ,._.. _ . ��_._,.�, �W�E I ;� —L I .- .� _ � _ ��4��y t �112fs�, �' ^ - - - - - _ �' �� e � i� t ._ �13�'i;� � ..� � �, ` s �,.�-�".�„.-:.--�^,,,�._ Ei` �� , 0 55ft �� http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 1/28/2008 G�MAPS - Davie County NC Public Access Page 1 of 1 �I Davie County, NC - GIS/Mapping System ��yv!`� Click Here To Start Quer QU�c1� Search:(County ID c �,,, + _ s,frr � �� \ � � �1��] A�tiue L�,•Qs- �!}se;'*tap Tps GIS I .- °tf ��„� �= �} ,� �' 0 "`'" PAF'��ELS �;n�1ap Tipt.�+iail;�blal � =��s-s � Resa�9t� � I ----. �� a � � -�� '"�- '�` � �6�� I� i�i� � �� ir g�,G� �� z�, �,�� s�� 5��°�� e � w b i�lai�� }�i� i i E .. �� i 4 .�ia : $ t �« * _ (y� ,a''��,t� rCy�4Pa i1� "�, � i I��g�b ?� '' �"� a �e+s r»: ��:�'�a a�'�,`�� aµ � ��'� � ' ��,ti tu 7 � ' ° h��l�,��i . �q �1 � �� . � p�� p' i§'. i 'I ii`� �� A ..A g G , F.i k �% � (t't��. NY{' �' �� &� F i '�`.�1 !`r. , �% ��)G �6 s�W ��tlNh .- � f �.s,�., C�. i .i.r . ��: . �"��-- � 5 �� .� �� 'k.��`t � I 4^. r. �,G' }-' � z i Pce.� �' 'II ��, MC3HEG;;�J TRL - > , _ _ _ _ � — — t— i -- � I � � 4 y L Y `Su I i — � — � I li � � � � I i �—_ I� http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 1/28/2008 �_ � ,, , •. . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLI ANT I Tax PIN/EH#: 57��Y INFORMATION Billed To: Andrew Fox Subdivision Info: �j7sy'�3�c3y6Z Reference Name: Location/Address: Mohegan Drive-27028 � �.,d, Proposed Facility: Residence Property Size: 1.5 acres Date Evaluated: �"� 1� ! Water Supply: • On-Site Well •� Community Public � Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape posi[ion L�- (� (�, . Slope % � �j 3 HORIZON I DEPTH � - � . Texture grou G � � G Consistence ;�— � Stzucture �' /� Mineralo " HORIZON II DEPTH Texture rou • � � Consistence Structure Mineralo HORIZON TII DEPTH Texture rou Consistence Structure Mineralo � HOR[ZON IV DEPTH Texture rou Consistence Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION � LONG-TERM ACCEPTANCE RATE . � "7 (�. � SITE CLASSIFICATION: � EVALUATION BY: � � /:r LONG-TERM ACCEPTANCE RATE: �. �� OTHER(S)PRESENT: REMARKS: LEGEND T,an s an�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 L5 -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 �ONSISTENGE Moist VFR-Very friable FR-Friable FT-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 Stru ture SC- Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK -Subangular blocky PL-Platy PR-Prismatic Mineralogv ' 1:1,2:1,Mixed Lyotes 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 wa[er 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/l15 (Reviser�l