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216 Pearl Ln . , � ' . � • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT f'�ecc�ur�t #: 990005211 T�x PfE�;�H#: 5802-46-3325-SP Billec� �� Cla ton Homes of Statesville SU�?L�3Y18EUtl If1�Q: R�fer€�E� e N�r��e: Susan Potts Lac�tiorli�lc�c�r�ss: Ben Anderson Road-27028 k�rnpc�sQd s��€ity: Residence �'ro��r�y Siz�: 5 Acres �TC Nutnb�r: 5006 **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. � Y YP � � � �._ Q 1- S stem T e: S.T.Manufacturer tr Tank Date Tank Size Pump Tank Size 1 �j„yi_�"N p � �i �j �� ..�; ��,�_ � -l -� _ System Installed By: I�� 'J�� E.H.Specialist: �� Date: � r L '7 ' ��C + , � Q�� j� � � q. \ :�, -r- �� „ � �,,; .- � � , I . ��.. �� ;� � �i �. . > i .��(' r �3Y' � 1 � � ' ( I Ty � / � ' �.. ...�... ... ...........�..�� Ci:�Q '� '"� �1 `(Gl l/� 't'a/l�t,��11 � �{�� ,�� . DCHD 11/06(Revised) t ' � � 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�cc�u�t #: 990005211 '�� Plf�i�N#: 5802-46-3325-SP 6ifle� Tc.�: Clayton Homes of Statesville �i��i�fiviyEUr� Iri�c�: R�f�;r�:r�c� P�ani�: Susan Potts Lac��ionl,�c�c�r��s: Ben Anderson Road-27028 F�ropc�:sPci F��;i€ity: Residence ��o��r�.y Siz�: 5 Acres �1'� NuE�tb�r: 5006 Site Type: ❑3�ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section priar 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�#Bathrooms�#People �asement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size !) Type of Water Supply: ❑County/City C�1WeIl -❑ommunity Well System Specifications: Design Wastewater Flow(GPD)�Tank Size�dGAL.Pump Tank��NAL. r. r< / < � Trench Width� Max.Trench Depth �G Rock Depth�Linear Ft. �'P� � Site Modifications/Conditions/Other: �5 5t�tt�:�d�)in 1,riA f�CAC 1�BA.1�J6�{5) a r��'~e-�Cc cy�l��5� �`!LL-'�'}7TE:U J�J�CCTTT,�'I�f7T�I'�, c�TJU v USv Contact the Davie County Environmental Health Section for£nal inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336)751-87 0. f �� n ��G � i aG �` y� 'CG �3� v� a�' �:��sy �-�.t�`� y , �' �� r�v �/�41� �v ln1-�� ' �� r � e� .- �� ` / � I�f ?f a'g�y/ � -� !�t F� /_jy 4 ; i / � Q r_ �� i�j /�� ' 4Sz-y��,� i-� �O L3�y� �� Environmental Health Specialist Date: Z �� 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 IMPROVEMENT PERMIT Account #: 990005211 Tax PIN/EH#: 5802-46-3325-SP Billed To: Clayton Homes of Statesville Subdivision Info: Address 2026 North Side Drive Location/Address: Ben Anderson Road-27028 City: Statesville Property Size: 5 Acres Reference Name: Susan Potts 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 changc. _._.____________�_.___.___..___� �� _. _.___._.__�._.__._..�..____..___....__.�_.._...�___..___..__._.._..__._:�._.�____� Permit Type: ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms�#Bathrooms �#People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) '`� �Qu> Design Flow(GPD): ✓�� Type of Water Supply: ❑County/City e'Well �Community Well Site Modifications/Permit Conditions: �� tated in 1,�iA I�CAC 18r�.196?(5) �s��E�Tem�-rrra� a":;u e use S stem T e LTAR Initial Re air Site Plan A ��c�� .L;- :� � � "��G ��' S � }�c e� �� ," 'p �Pcri P ("� � }��a � , , fe�\ . 3u c°v , r' � �" � / ' �r�,� �� '� o �-�(^ Fhti� �`- ! ��.�'�' �� B-� o ' -t- y � � Environmental Health Specialist Date — i.p.l l-06 . . . ► � - ----- • " � �'�� A�LI�A'�'I�T�R EVALUATION/IMPROVEMENT PERMIT&ATC ' ,';'��`�' D 'e County Environmental Health ��• 'i� O.Box 848/210 Hospital Street �. �. S�P ?_ � 2009 � Nio��ue,Nc Z�ozs � ( 36)753-6780/Fax(336)751-8786 � j � App1,�G3t14n.F.nr n SirP RY� ' rovem nt Permit ❑Authorization To Construct(ATC) ❑Both Type of.9�Spti�3t�qt��l`bTI1�e��4�m ❑Repa� to Existing System ❑Expansion/Modification of Existing System or Facility � � ��+11 r ;��1fdlY � � � � � � I APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BLJLLETIN for instructions. APPLICANT INFORMATION l�� l'�j��D Name to be Billed !A n! co Contact Ptrson �/,nn:c ,�(�F1�.a 9 0l Billing Address o� S•' Or Home,Phone —$"7 3—23�/� City/State/ZIP�g ft-s✓:! t . NG 2.�625 Business Phone Z— i -�a Name on PermiUA�'C if Diff rent than Abo e Su�F}!� '�D`f7.s , Mailing Addres City/State/Zip �pt,�SJ.% .�G 'Z'2o 5 D ` ntf .,�',+ , PROPERTY INFORMAT ON *Date House/Facili Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included:0 Site Plan ❑Plat(to scale) (Permit is valid for 60 onths th s)�t�plan,no irapo wi omplete plat.) Owner's Name S�.tSa� �i�d"T,$ / � Q. `Phone Number �0`'��''!2`,i —3 (�oO Owner's Address �L. � d ity/State/Zip • J: Property Address S D r�C r � City �S , � Lot Size_ �.U AL . Tax PIN# . ` Z Subdivision Name(if ap 1' able) ectio ot# �l Dire tions�o Site: 6S � L,� tr�� •.�� qt t'ZC� �-�"`T��'\� G+v S Gr I t e answer to any of the following questions is"yes",supporting documentatio ust be attached. Are there any existing wastewater systems on the site7 ❑Yes Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site7 ❑Yes Is the site subject to approval by another public agencyl ❑Yes Will wastewater other than domestic sewage be generated7 ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms _� #Bathr9e�is 'L._ Garden Tub/Whirlpool❑Yes o Basement:❑Yes o BasementPlumbing: ❑Yes ��o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Squaze Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) jAttach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats � i Z- � Type system requested: ❑Conventional ❑Accepted ❑Innovative OAltemative ❑Other �L�r►� _ Water Supply Type:0 County/City Water L�'New Well OExisting Well ❑Community Well � Do you anticipate additions or expansions of the facility this system is intended to serve7 0 Yes B'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 rul-e/s. I understand that I s'ble for the proper identification and labeling of property lines and comers and loca'n xQ �gi�� house/fa �ity location,proposed well location and the location of any other amenities. . %� rope owner's owner's legal represe ure, Site Revisit Charge Date(s): �'j"Z� �- L�r Client Notification Date: ' Date EHS: Sign given ❑Yes�No Account# L/21 1 Revised 11/06 Invoice# � ' ' • � - � , DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION �'ROPERTY INFORMATION Account #: 990005211 Tax PIN/EH#: 5802-46-3325-SP Billed To: Clayton Homes of Statesville Subdivision Info: Reference Name: Location/Address: Ben Anderson Road-27028 Proposed Facility: Residence Property Size: 5 Acres Date Evaluated: ��- a3 —d � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring '�' Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position � Slope % HORIZON I DEPTH — — —� Texture grou `�, ' G Consistence - i .• .� Structure $ �j �,� Mineralo —' ' 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 LONG-TERM ACCEPTANCE RATE U SITE CLASSIFICATION:_ �� EVALUATION BY: /ry �� C LONG-TERM ACCEPTANCE RATE: LJ � �� OTHER(S)PRESENT: •� �` �.S REMARKS: � � p LEGEND Q / j �� T,andsca e Position � � �l � R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope � � C�ncave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope �A ;C / •� /'O,� ��, ./ V �� 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 CnNSISTF.N . . �41S.L VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely�rm � NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic $�ructure � � SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed lYQtr� 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) TTAR -i.nna_tPrm arrentan�P ratP_ aal/Aav/fr� Tl�TiTl1C/!1G m__.:__�� . __ _ _ _ __ ___ __ ___ __ _____ _ ___ __ _ _ _ ____ _ __ __ __ _ _ ___ _ ____ _ .___ _ ___ � . _ ' z� -" - � � �---__ __ • , � . . _ � , , , � ' - . . - —- �.;:, . . � - _ , „ ,. , ~�� 'K. I ICI F IN EX� �� , , ; ' CERTIFICAT �� I H�Rtc�Y CEF <<;° PH H_ __ �.r I F� PROPERT'r SH � � � i - � SUBDIVISION J %,ND TIiA? I Ni WITH MY fRE� � 9UILDING SETf "] II � � Iv11�:H.�t� ��.;i_-� . � oar� F,�,i`�� 1 G J C' � �� r � , �arolin a N � - _ -----Courty I � Nctary Public of the Co ` L � d ------ .-_ _ � l-1 � �,, ackncrrledaed the execution of ' t/� ` _. . '�;;r;� :r .,�:a�, thjc �� _ � .� � - 'f ,�,� � �, � � �� I ��Y m; c �mmi-sion expires _ ��='��.3' -44n 2s, i Q; �Q.:` �' � �`J � �.� �— =� ' iy�f��IS10N P�AT '�I \ ` '� �_:a � :,,v;. � c i1,ATIQNS, V;ITH .5 �' „�� _ �F iN. F�,.1.4NNINGn BO.S '.`�j . d �n.. .. " � .. �J: �_.iSTCF' \IF ��C�.JS. IT ! � il/ � � ' _ . ' ., ':f'� i ,-� ? W .O r�� - . �. � �. . . .. „ I v�� i � ' (J� .•:;�;i ; . o� M � �I/r•� I 5.00 ACRt�.S . �,� aF �� ' , . i � - - � . . _ _ ._ . P.�7 3 � - �� - I /;.CJ4 � � . 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