291 Stony Brook Trail Lot 39 s
Davie County Health Department
9�N'1s j� Environmental Health Section
4- P.O. Box 848 -
�, 210 Hospital Street
OZT �'S Courier# : 09-X10-06 }
Mocksville,NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Reconnection
Name: �(
Name: '
Phone Number y�y7 7-- � Home)
Mailing Address: (Work)
Email Address: y1 ema(Te a
Detailed Directions To Site: j,0r Al JZ2 J::S(}ireS 0&"-11
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P perty Address: $- %Dv ✓ll t A< )0'Xr P
Please Fill In The Following Information About The EX/ST/NG Facility: NoWrobk, _ I-DT 39
Name System Installed Under: g aW K/f 4'�'Ij}raolg Type Of Facility:AeA
Date System Installed(Month/Date/Year): '��01� Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any Known Problems? Yes o If Yes,Explain:
Please Fill In The Following Information About The NEWFacility:
Type Of Facility: -,r4 -s �1'• Number Of Bedrooms: Number of People
Pool Size: Garage Size:^3(2)c?D x/U Other:
Requested Date Requested:
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For Environmental Health Office Use Only
pprove Disapproved
Comments: A fill t /(j C
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order # Amount:$ Date:
Paid By: Received By:
Account#:_ g &of Invoice#:
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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
Account #: 990005053 OPERATION PE MITax PIN/EH#: 5820-33-9116
Billed To: BuiltRite Construction Subdivision Info: Northbrook Lot#39
Reference Name: Location/Address: Stoney Brook Trail-27028
Proposed Facility: Residence Property Size: 11.560
ATC Number: 4846
**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.
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System Type: / S.T.Manufacturer J/106f� Tank Date 'r/�i Tank Size ,
Pump Tank Size
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System Installed By: Q G E.H. Specialist: bks Dater
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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 #: 990005053 Tax PIN/EH#: 5820-33-9116
Billed:To: BuiltRite Construction I Subdivision Info: Northbrook Lot#39
Reference Name: Location/Address: Stoney Brook Trail-27028
Proposed Facility: Residence Property Size: 11.560
ATC Number: ;4846 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 3 #Bathrooms #People a Basement❑ Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size �. C�.C/�5 Type of Water Supply: Rr6ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) 36_ Tank Size J.e6V GAL. Pump Tank GAL.
Trench Width NO Max.Trench Depth 3,o Rock Depth /) Linear Ft. 7u
Site Modifications/Conditions/Other: Ag stated in.15A NCAC 18A. 969(5
un
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: 1
DCHD 11/06(Revised) `�r `p
FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
tv ASite Eva 'on/Improvement Permit Authorization To Construct(ATC) Both
Eta�� Eatio 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 ColA4y uc-�'0 to Contact Person rnte-i- t,ty
Billing Address t0 WWPS60110 h61V W' Home Phone 0 - to- / S `�-
City/State/ZIP 5+Qh5 Ville, hl G 2ffte 2 Business Phone c -
Name on Permit/ATC if Different than Above 0 5�
Mailing Address City/State/Zi
PROPERTY INFORMATION *Date House/Fac flity Comers Flagged
NOTE: A survey plat or site plan must accompamr this application. Included: Site Plan Plat(to scale)
(Permit is valid for 60 months with site lan,no expiration with complete plat.) yl Z'
Owner's Name Phone Number_y�3 (�-
Owner'sAddress f 07 0 GS City/State/Zip 0 Z7dZ
Property Address 2ql my Hyook Tkai L City
Lot Size // 5(00 Tax PIN# 203391/(0
Subdivision Narne(if applicable) v Section/Lot#- 13q
Directions To Site:
If the answer to any of the following questions is`yes",supporting documentatio must be attached.
Are there any existing wastewater systems on the site? Yeg
Does the site contain jurisdictional wetlands? Yes
Are there any easements or right-of-ways on the site? Y
Is the site subject to approval by another public agency? Yes o
Will wastewater other than domestic sewage be generated? Ye o
IF RESIDENCE FILL OUT THE BOX BELOW
#People 2 #Bedrooms 3 #Bathrooms Z. Garden Tub/Whirlpoo Yes No
Basement: Yes No Basement Plumbing: Yes 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: Conventional Accepted Innovative Alternative Other
Water SupplyT e: County/City Water New Well Existing Well Community Well
c
Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No
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 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 Department to conduct necessary inspections to determine compliance with applicable
laws and hiles. I understand that I am responsible for the proper identification and labeling of property lines and comers and
locating flagging or stak' g the house/facility location,proposed well location and the location of any other amenities.
Property wne's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given Yes No Account# _
Revised 11/06 Invoice# _����
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
.(336)751-8760/Fax(336)751-8786
Account #: 990005053 IMPROVEMENT PENIN/EH#: 5820-33-9116
Billed To: BuiltRite Construction Subdivision Info: Northbrook Lot#39
Address: 1420 Wilesboro Hwy. Location/Address: Stoney Brook Trail-27028
City: Statesville Property Size: 11.560
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a was 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: e ew ❑Repair ❑Expansion Permit Valid for: R<Years ❑No Expiration
Residential Specifications: #Bedrooms�5_#Bathrooms Z #People ) Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):3 te.0 Type of Water Supply: B't aunty/City ❑Well ❑Community Well
As stated in 15A NCAC 18A.1969(5)
Site Modifications/Permit Conditions: accepted Systems may also bp tBE
SystemType LTAR
Initial A cc-'CA-0.A,1A-0. A, 17y-
Repair
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Environmental Health Specialist Date
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G. GREGORY 1 1
'9• 185 ` D.B. OBBY 0, M0� 1 GLEN FOSTERII' ®UST
i 76 Pg. 522 1 D.B. ER PHILLIPS i
'4029'16• E —..� 1 89 Pg. 117 1 D.B. 196 Pg. 52.3 /
449.86 1 D.B. 172 Pg. $93 /
786.26 oj
P WILLIAM MUNDAY
,JI D.B. 181 Pg. 463
LOB 6 Pg. 74
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-- — LOT #39 r
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Li (11.650 AC.)
PRIVATE ROAD --- l
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• LOT #40 N
a (s.s,s Ac.) I DEREK L. NOR CENTER OF EASEME
a
D.B. 182 P NORMAN
a g. 58 LINE BEARING DISTAD
oz P.B. 6 Pg. 74 L1 N W15'00' W 270.1
LOT 5` L2 N 8515'00; W 296.:
L3 N 851500 W 200.(
! .0 L4 S 82'43'50" W 36.:
L5 S 50'53'47" w 153.t
L36 L6 S 50 53 47M W 82.t
N 63'11'41• w _ L7 S 33'22 28 W 48.1
':. . C r - 209.03 —" _ L8 S 01'51'45' E 206.5
y.---•' ��� .�.. .j:- „j 30 "' ''. / L9 S 01'5145» E 295.1
L22@ �'� // j L10 S 42'5'02" E 154.5
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r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APP LWc iFtINFQA61MiA.9M Tax PIN/EH#: 582$ INFORMATION
Billed To: BuiltRite Construction Subdivision Info: Northbrook Lot#39
Reference Name: Location/Address: Stoney Brook Trail-27028_ f
Proposed Facility:. jResidence Property Size: 11.560 Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2'. 3 4 5 6 7
Landsca e position
Slope % 4
HORIZON I DEPTH W$ — L
Texture groupC 2 L
Consistence t r / Dv
Structure
Mineralogy [ -
HORIZON II DEPTH q ,
Texture group. r '�, 'Consistence
Stricture
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
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: d`� yd
r.
REMARKS I
LEGEND
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
3Y'
NS-Non sticky SS.-Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
Str nct r
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
Horizon depth-In inches
Depth of fill -In inches
'—Restrictive horizon-Thickness and inches from land surface
Sapr'ol,ite-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-tern acceptance rate-gal/day/ft2