152 Paw Paw Ln � . � i����
' DAVIE COUNTY ENVIRONMENTAL HEALTH �
' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 990004430 Tax PIN/EH #: 5755-90-3927
Biiled To: Patricia Ebright Subdivision Info:
Reference Name: Location/Address: Paw Paw Lane-27028
Proposed Facility: Residence Property Size: See map
ATC Number: 4760
**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 Treahnent 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 Q
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System Type: ,�-1-�✓ S.T.Manufacturer ��a� Tank Date �� Tank Size�
Pump Tank Size /D� �(7
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System Installel Zy: ,Q E.H. Specialist. Date: lP � � — � �
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DCHD 11/06(Revised)
. ,_,,,.....�.. DAVIE COLJNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
.
Mocksville,NC 27028 ��
(336)751-8760 Fax#(336)751-8786 �\�\
�
AUTHORIZATION FOR WASTE�VATER SYSTEM CONSTRUCTION
Account #: 990004430 Tax PIN/EH#: 5755-90-3927
Billed To: Patricia Ebright Subdivision Info:
Reference Name: Location/Address: Paw Paw Lane-27028
Proposed Facility: Residence Property Size: See map
ATC Number: 4760 ��✓'
Site Type: C3RVew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MLTST BE ISSUED by the Davie County Envirorunental
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 �1 #Bathrooms�#People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size f '��Lf'� 5 Type of Water Supply: CCounty/City C�'Well OCommunity Well
System Specifications: Design Wastewater Flow(GPD) ^1gV Tank Size ��ov°GAL.Pump Tank�AL.
� !,p�
Trench Width� Max.Trench Depth�(.D j Rock Depth /�.�� Linear Ft. J O
asn �q os�e �tew swals,(S paaciao��
Site Modifications/Conditions/Other: ���• . . ,,,� , . , �,,
Contact the Davie County Environmental Health Section for final inspection of this system between
:30—9:30a.m.on the da of inst llati n. Tele hone# 336 751-8760.
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Environmental Health Specialist Date: I ��� d 1
DCHD 11/06(Revised) •:d"
. , -
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMTT
Account #: 990004430 Tax PIN/EH #: 5755-90-3927
Billed To: Patricia Ebright Subdivision Info:
Address: 149 Paw Paw Lane Location/Address: Paw Paw Lane-27028
City: Mocksville
Property Size: See map
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: �'�Iew ❑Repair ❑Expansion Pernut Valid for: 5 Years ❑No Expiration
Residential Specifications: #Bedrooms ( #Bathrooms 3 #People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): ��v Type of Water Supply: ❑County/City OWell ❑Community Well
��s stat�d in 15/� NCr�C 1£3A.3968(�)
Site Modifications/Permit Conditions; arr����� �T��e���,����.,,�5a
S stem T e LTAR
Initial �.,,e c3� '7 ,
Re air �
Site Plan
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Environmental Health Specialist Date (.}� 7
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�F�I�A OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �/�`��
D �`' Davie County Environmental Health 1 /��
r � ��'� � P.O.Box 848/210 Hospital Street
i ,UL � Mocksvi11e,1vC 27028
� � (336)751-8760/Fax(336)751-8786
N�I�N �
Applicatird'�rl�i E, '�' uation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of ion: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTAN7***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 �K�r 1 C�UJ 1— �l ' �� Contact Person�C�����1�'�'Y� `� ��� � ��'
Billing Address 'v�J � i.+� --G�i L1L.� Home Phone � ��� - ` -L�}���—
City/State/ZIP � �� -e � � _� BusinessPhone�j ���• �Cii-�3�(-.�
Name on Permit/ATC if Different 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 ❑Plat(to scale)
(Pernut is valid for 60 months ith site plan,no expiration with complete plat.)
Owner's Name �i�� a�� �(;�.f���.�% Phone Number.
Owner's Address G`�.�J �u, City/State/Zip �oCJ'C�Ji � J (_ 1C�L S
Property Address �t t` City
Lot Size `�..<JCjleS Tax PIN#__.-1'j `7�5.�90, .��,2��
Subdivision Name(if applicable) _ Se tiQn/Lot# � )
Directions To ite: /tl !1`cJ
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If th answer to any of the following questions is"yes",suppo ing documentationj�ust be attached.
Are there any existing wastewater systems on the site? ❑Yes C�N�
Does the site contain jurisdictional wetlands? ❑Yes [3�No
Are there any easements or right-of-ways on the site? ❑Yes C]�o
Is the site subject to approval by another public agency? ❑Yes C1��
Will wastewater other than domestic sewage be generated? ❑Yes O3Qo
IF RESIDEN -E FII,L OUT THE BOX LOW
#People #Bedrooms #Bathrooms � Garden Tub/Whirlpool es ONo
- Basement: es ❑No Basement Plumbing: +�P`es ONo
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 similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested; onventional ❑Accepted ❑Innovative ❑Alternative ❑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? ❑ 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 pernut(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 subnutted 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 detemune compliance with applicable laws and rules.
I under:;tar.3 that I am respcnsible for the proper identification and labeling of property lines and corners and locating and flagging
or 'ng the house/facility locationyp=o}��sed well location and the location of any other amenities.
� �, �
� Site Revisit Charge
Property owner's or owner's al representative signature
Date(s):_
''1 j �� Client Notification Date: �
Date
�� EHS:
Sign given ❑Yes ❑No Account# ��J6
Revised 11/06 Invoice# G�_3�
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. , DAVIE COUNTY HEALTH DEPARTMENT
, Environmental Health Section
' Soil/Site Evaluation
APPLICANT INFORMATION P�Z QP_ERTY INFORMATION
Accoun . Tax PIN/EH#: 5r5��=`35�
Billed To: Patricia Ebright Subdivision Info:
Reference Name: Location/Address: Paw Paw Lane-27028
�Proposed Facility: Residence Property Size: See map Date Evaluated: _ � � a�[ ` d�
Water Supply: • On-Site Well ✓ J Community Public '
Evaluation By: Auger Boring ..�� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position (..._
Slope % � '�-
HORIZON I DEPTH p •'-Cg
Texture grou � �'fi
Consistence �l ,�,�
Structure �' k 5
Mineralo -� D
HORIZON II DEPTH �
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 '�, („ k•
LONG-TERM ACCEPTANCE RATE .�7 p. ,
SITE CLASSIFICATION: �u �l'4b� EVALUATION BY: P ri�b J��'c�r�''� S
LONG-TERM ACCEPTANCE RATE: G•��� OTHER(S)PRESENT: l/V�4�� �l�e.� d 4 n rx wr,�
�
REMARKS:
LEGEND
J_.andsc�pe 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
C'ON�IST .N . .
M4iS�
VFR-Very friable FR-Friable FI-Firm VFT-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
Mineralo�v '
1:1,2:1,Mixed .
Notes
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 accep[ance rate-gal/day/ft2 DCHT�OS/(15 (Revi�eril
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� N �� `i� ��T 2 1. TOTAL TRACTS� 2
� , '�I F I��'11= 1.J�Q� //�i. � 2. TOTAL A�C.� 3.3i7 AC.
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� �• � ��� �
� ` • , �L � � 4. TRACT t HAS AN EXtSTING DWELLING .4ND SEPTIC
' �r SY'STE�I. TRA�CT 2 NAS iEEN EVALUATED Bl' THE
� ""_ �s ��` � i�C1lJNp TO��ETMSI��A�t�.E iOR��E�IC SYSTE�I.
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j ty �' S. THIS PROPERIY IS LOGATEp WITHW A WS-IV
� �. IMATERSH�p.
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� �Ill J� � \�� OWNER ------------------ DEVELOPER
I ������������ �•,�� �`��' A' � IAMWAII N. NlOADWAY
� ��•J,,'�N�O�••,� 's,' p(i"� ���S / 1 SZ �AW 'AW LANE
I :����+'' �i8� ��.`q, ;I gs I �; IIOCKfVILL[� N.C. 2702i
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: �_2�� ' : � " MOCKSVILLE TOWNSHIP
,G� s<.�� oe,� ; � DAVIE COUNTY, NORTH CAROLINA
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