317 Oak Grove Church Rd i . • , ' ,
� DAVIE COUNTY ENVIRONMENTAL HEALTH ;
- P.O.Box 848/210 Hospital Street �
Mocksville,NC 27028 �
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
�ccr�ur�t #: 990005617 "��x�'INiEH �: 5749-58-3088 Site 1
Billc,i� TQ: George Tucker ���i�i�iialOfl If3$�l; �/�
Re:fer�E�ce Na���: �L�ie,, I�r'UO�CS Lac�tioniAddE��ss• Oak Grove Church Road-27028
Prop��s$ii Fr��;i€i�y: Residence ��o��rty S�iz�: 21.5 Acres
e��TC �fu�b�3`: 5723
**NOTE**The issuance ofthis Operation Permit shall indicate the system described on the AT�has been installed
in compliance with Article 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and Disposal Systems,"
but shall in NO WA�be taken as a guarantee that the system will function satisfactorily for any given period of
time. �G
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System Type: � � S.T.Manufacturer S�Da Tank Date �G Tank Size �110 �
Pump Tank Siz�
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System Installed By: 1 ' e 1a��,e 5 E.H. Specialist: �'/' Date: 3 �o� 1 —' l (
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DCHD 11/06(Revised)
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- �� '" DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street n�
Mocksville,NC 27028 C ' `�
(336)753-6780/Fax#(336)753-1680 �\�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
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Accou�t #: 990005617 T�x F�1[�iEH #: 5749-58-3088 Site 1
Billc�Ta: George Tucker Su�a�fi�fi�iari lri��:
����r��E��� �����: j,�ui� �jtvc�GS Loc�tioni4d+�r�ss: Oak Grove Church Road-27028
f�rc��c�s�ii Fr��;i€ity: Residence �ra��riy 5�iz�: 21.5 Acres
a�TC Nu�'tber: 5723 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,Seciion.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 pians,plat
or the intended use change.
Residential Speeifications: #Bedrooms�_#Bathrooms�#People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size �. aL�'�5 Type of Water Supply: ounty/City ❑Well ❑Community Well
��� �d d
System Specifications: Design Wastewater Flow(GPD)��6 Tank Size�v"GAL.Pump Tank�GAL.
�r �� �. t
Trench Width 3 G Max.Trench Depthy�� Rock Depth ��- Linear Ft. ��
F�s stated in 1�a IVCAC �_�A.1�u�(5}
SiteModifications/Conditions/Other: ����,�be� cy�-te^��< <^ �s.� . ';� ;,�^�
a 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 6one# 336 751-8760.
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Environmental Health Specialist Date: �� "3d ���
DCHD 11/06(Revised) �
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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 O�
Account #: 990005603 Tax PIN/EH#: 5749-58-3088 Site 1
Billed To: Louie Brooks Subdivision Info:
Address: PO Box 290 Location/Address: Oak Grove Church Road-27028
City: Advance Property Size: 21.5 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
Atticle 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
. revocation if site plans,plat or the intended use change.
_._.._w______..____.___�_--- ----._....._._. _. ___,.��..�..__.___ ____.....___.._..__..._...._ ...._.__......
Permit Type: BIVew ❑Repair ❑Expansion Permit Valid for: 0'S"�ears ❑No Expiration
Residential Specifications: #Bedrooms � #Bathrooms � #People ) Basement❑ Basement plumbing❑
Non-Residentiat Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): � "1 � Type of Water Supply: �unty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: �s �taTed irt 15A f�CI�C 18;>.19��'y5 "
,�Y`!`Pt74f�f� �'vv tnrn+^ rn�-e�r �a���r�
S stem T e LTAR
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Environmental Health Specialist �':�iLG%liL� Date ��/ y` ��
i.p.l l-06
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� _ L�i�'�O � R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� � � � Davie County Environmental Health
� P.O. Box 848/210 Hospital Street
pE� � 4 201Q Mocksville,Nc Z�o2s
(336)753-6780/Fax (336)753-1680
�o�E�,� Fi �iF1';LTH
App icat�y�ti1C�'��r,'��,�,kte Ev :4 mprovement Permit Authorization To Construct(ATC) ❑ Both
Type of A t . New 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 l.�G -�/ Contact Person �Ov��.�%—�i
Add3•ess �Lt� tG� � Home Phone ��'—�Z�
City/State/ZIP K�c C Z Ud6 Business Phone ���—��S
Name on Pennit/ATC if Different than Above �DllIP� ��.C.�I�-�
Mailing Address City/StatelZip
PROPERTY INFORMATION *Date House/Facility Corners Flagged /-/�/D i/l �,�' �J
NOTE: A survey plat or site plan must accoinpany this application. Included: ❑ Site Plan ❑Plat(to s�ale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.) �� �fjZQ
Owner's Name��, ; � �ypak'� Phone Numbe
Owner's Address -y�,p �ax i2`�C7 City/State/Zip
Property Address �.�fCG�.r;vz �G,,,�.����( City
Lot Size Tax PIN#.�7� -Sc�-,3� _5i�� (
Subdivision Name(if applicable) Section/Lot# � � �'' �
Directions To Site: N t t�Y�- N
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 •�No
Does the site contain jurisdictional wetlands? Yes ,.�do
Are there any easements or right-of-ways on the site? Yes ,GNo
Is the site subject to approval by another public agency? Yes/�10 '
Will wastewater other than domestic sewage be generated? Yes �io
IF RESIDENCE FILL OUT THE BOX BELOW
#People Z #Bedrooms �- #Bathrooms�_ Garden Tub/Whirlpool ❑Yes B�a�
Basement: OYes �I4o Basement Plumbing: ❑Yes �I�o
IF NON-RESIDENCE FILL OUT THE BOX BELOW A'�
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: .B'Conventional ❑Accepted �Innovative ❑Alternative ❑Other
�Nater Supply Type: C'1'County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this sysfem is intended to serve? ❑ Yes f�No
If yes,what type?
Tliis 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 inforn�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 detennine compliance with applicable
laws and rules. 1 understand that I am responsible for the proper identification and labeling of property lines and cori�ers and
locatin and flagging or s king the house/facility location,proposed well location and the location of any other amenities.
"Site Revisit Charge
Prop y o ner's or owner's legal representative signature �
� Date(s): � � �
— Client Notification Pate: -`
�Le EHS:
Si�n given �lYes ❑No Account# � �Q�
Revised 11/06 Invoice#
.
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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 #: 990005603 Tax PIN/EH#: 5749-58-3088 Site 1
Billed To: Louie Brooks Subdivision Info:
Address: PO Box 290 Location/Address: Oak Grove Church Road-27028
City: Advance Property Size: 21.5 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.
Permit Type: ew ❑Repair ❑Expansion Permit Valid for: 0'S�ears ❑No Expiration
Residential Specifications: #Bedrooms � #Bathrooms �. #People ) Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): � -1 � Type of Water Supply: �unty/City ❑Well ❑Community Well
fi�s 5tated in 15A NC�iC �.$r>.19��j5
Site'Modifications/Permit Conditions: a,.�Q���a,},;�f��,g r��„ �l�,� k�� �����
S stem T e LTAR
Initial �G( w�.
O Re air cc t ��
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Site Plan
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Environmental Health Specialist ��j� Date �// y— ��
i.p.l l-06
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. � � .._ APPLICATI FOR SITE EVALUATION/IMPROVEMENT PERMIT& ATC
. ;i .� �';� � �� � 1� Ii.= ��� Davie County Environmentat Health \
f� , � P.O.Boa 848/2l0 Hospital Street ��1
� i Mocksville,NC 27028 � G
' �OV — � 2010 I�„� (336)753-6780/Fax(336)753-1680 _ I ��� �
U ) �
Application For: ❑S�te�val ation/Improvement Permit ❑Authorization To Construct(ATC) G?Both ���
Type of A lication• bNew ystem ❑Repair to Facisting System ❑Expansion/Modification of Existing System or Facility
Tn i n
ENVIR A`����r "i\�j�TANT""THIS PLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
VIDED. Refer to the INFORMATION BIJLLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed � . 4 ' l��j 1LL, Contact Person � �l?'(�
Billing Address . �� M1 Home Phone p
City/State/ZIP Business Phone
Name on PermibATC if D�erent than Above �rn'�
Mailing Address City/State/Zip
PROPERTY INFORMATION �b ,.(.�t �� *Date House/Facili Corners Fla ed
NOTE: A survey piat or site plan must accompany this application. Included:0 Site Plan ❑Plat(to scale)
(Permit is v id f r 60 months ith site plan,no expiration with complete plat.) J� /�
Owner's Name ' �l Pho Number ' ,`d �7 l!� Q:
Owner's Address _ City/State/Zip�;
Property A ess f�a � " ' City ! .;�
Lot Size , - � ax PIN# t
Subdivision Name(i a Jicable) Sec'on/Lot# r,
Du To Site: " " 'j , ;', �
$�� °� �;i� �/'.,
If the wer to any of the following questions is ,es",supporting documentation must be attached.
Are there any e�dsting wastewater systems on the site? ❑Yes�Io C �
Does the site contain jurisdictional weUands? ❑Yes f�(Vo J)� � �
Are there any easements or right-of-ways on the site? ❑Yes o
Is the site subject to approval by another public agency7 ❑Yes�o
Will wastewater other than domestic sewage be generated7 ❑Yes j�To
IF RESIDENCE FILL OUT Tf�BOX BELOW
#People #Bedrooms #Bathrooms Gazden Tub/Wh'ulpool ❑Yes o
Basement: ❑ es o BasementPlumbing: OYes o
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similaz facility water consumption)
FOODSERVICE ONLY: #�Seats
Type system requested: '6�Conventional ❑Accepted ❑Innovative ❑Altemative �Other
Water Supply Type:�County/City Water ❑New Well ❑Existing Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?O Yes �Io
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 aze subject to suspension or revocation ifthe 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
ws and es. I understand that I am responsible for the proper identification and labeling of property lines and comers and
lo ing a, fla ' ' g t e h use/f 'ity ocatio , osed well location and the location of any othe�amenities.
� Site Revisit Charge
ope o er s or owner's eg repr entativ ign
Date(s):
� � Client Not�cation Date:
Date EHS:
Sign given ❑Yes ONo Account# SGc3
Revised 11/06 Invoice# 7S0Z
,�j�P/l-3-Zaa ���
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GoMAPS - Davie County NC Public Access , �j
� WATERSHED_STRUCTURES
,�� - ! WATER_BODIES
a CQUNTY_BOUNDARY
PARCEL DIMENSldNS
�r '� o ADbRESS �
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STiREETS •
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` Friday,October 29 2010
***WARNING:THIS IS NOT A SURVEY!*** n � f � �
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded ��`re-.� � � G���t � :�i mt
dee ds,p lats,an d ot her pu b lic records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map. ��i��'Z - �,���(,��,��� ���,
O���
GoMAPS - Davie Count NC Public A �.
y ccess
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***WARNING: THIS 1S NOT A SURVEY!*** �� �� I
T11is map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded (���`,`;;�� .;� .� ��� `j;� ��
deeds, plats, and other public records and data. Users of this map are hereby notified that the afarementioned ublic
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" � � •- '� DAVIE COUNTY HEALTH DEPARTMENT
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. Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005603 Tax PIN/EH #: 5749-58-3088 Site 1
Billed To: Louie Brooks Subdivision Info:
Reference Name: Location/Address: Oak Grove Church Road-27028
Proposed Facility: Residence Property Size: 21.5 Acres Date Evaluated: // '"/��' .11�
Water Supply: On-Site Well Community Public �—'""
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 r 5 6 7
Landscape osition
Slope % � � O O .�
HORIZON I DEPTH � — _- p .�
Texture grou -5 L �
Consistence s
,
Structure
Mineralo -� .
HORIZON II DEPTH - � �p — —
Texture rou G(/ G -�� 5'��
Consistence - ';,c - ;f 5 3 'S
Structure ,`� ,�(� �( �
Mineralo � v �' -
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS / ` �
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S
LONG-TERM ACCEPTANCE RATE
( ���
SITE CLASSIFICATION: Q� EVALUATION BY: � i
yeu u.����..
LONG-TERM ACCEPTANCE RATE: � ` I OTHER(S)PRESENT: �_
REMARKS:
LEGEND
T,andscape Position
R-Ridge S -Shoulder L-Lineaz slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
T�utuT� �
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 .
�ON IS��F,NCF
Di�is�
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-Slighdy plastic P-Plastic VP-Very plastic
�trLctLre
SC-Single grain.. M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
1:1,2:1,Mixed
No s
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)
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