267 Pearl Ln , �. DAVIE COUNTY ENVIRONMENTAL HEALTH ��1�
P.O.Box 848/210 Hospital Str��t — - � �
Mocksville,NC 27028 � '
(336)753-6780/Fa�# (336)753-1680 ,
, OPERATION PERMIT
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,Acc���t #: 990005453 '��x P1�€r'�H#: 5802-46-2239
Bill�:� "f�: Scott Levesque �u�adi�i4,iart lr3��: z�P� .f��I �n�'-
R�fee�r�ce €�ar��e: Lac�tioniAdr�r�ss: ad-27028
f�ropc�s�:c� F���:ility: Residential P�n��c�.y 5�i��: G.e'�Acres %'
a�T� Nurnber: 5071
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**NOTE** The issuance ofthis 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 (� � ank Date ��d�Tank Size G��
Pump Tank Size �(Yu1�
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System Installed By: •�c,', /,�,� � E.H. Specialist• t �' ,�te: 2��6
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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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Accnu�t #: 990005453 �"�x�I�I.%EH#: 5802-46-2239
�ifle� To: Scott Levesque 5u��i�fisian 1r3��:
Refer�E�ce Na��e:: LacaiionrAdi�e��s: Ben Anderson Road-27028
Pro�c�s�rl F;���iEity: Residential Pro�zr�y Size: 7 Acres
f,TC t�u�'tb�r: 5071 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 � #Bathrooms ( #People 3 Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(ar Dimensions of Facility)
Lot Size ��� - Type of Water Supply: ❑County/City '�Vell ❑Community Well
System Specifications: Design Wastewater Flow(GPD)��i�v Tank Size�aC'X'AL.Pump Tank�GAL.
. Trench Width�_ Max.Trench Depth�(� Rock Depth rCl/ff Linear Ft. 200
Site Modifications/Conditions/Other: �� C` Di'I, � �'j(Q.l'L�,
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#t 336 751-8760.
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Environmental Health Specialis WVI Date:�����
DCHD 11/06(Revised)
� ' � , Davie County Environmental Health
P.O.Box 848/210�Iospital StreFt — -
Mocksviile,NC 27028 �
(336)753-6780/Fax(336)753-1680
IMPROVEMENT 1'EI2MIT
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Account #: 990005453 Tax PIN/EH#: 5802-46-2239
Billed To: Scott Levesque Subdivision Info:
Address: 135 Palm Street Location/Address: Ben Anderson Road-27028
City: Inglis
Property Size: 7 Acres �'
Reference Name:
Proposed Facility: Residential
**NOTE**This Improvement Permit DOES NOT authorize the constructiorl 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: �New ❑Repair ❑Expansion Permit Valid for: r2 5 Years ❑No Expiration
Residential Specifications: #Bedrooms�#Bathrooms � #People '1 Basement0 Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): ���p Type of Water Supply: ❑County/City (1�We11 ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial 7 ` o �3
Re air `b H
Site Plan
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Environmental Health Specialist Date-����`-�-�
i.p.11-06
GoMAPS - Davie County NC Public Access
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***WARNING:THIS IS NOT A SURVEY!*** Tuesday,Apri13 2012
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public 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.
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�- ` AP �LICATION FOR � EVALUATION/IMPROVEMENT PERMIT & ATC . IISI�
��f� } ���A� � � 2�1D `� ie County Environmental Health �
`� � .O.Box 848/210 Hospital Street
�------;,;,iti;��,;�,i�;F�+TH � Mocksville,NC 27028
. . � EN�:i;„ -
r;..�','.��ir,',:-,Y 36)753-6780/Fax(336)753-1680
Application For: ❑ Site Evalu�tion/Improvement Permit ❑ Authorization To Construct(ATC) �Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
*i*IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT TNFORMATION
Name +i� � L�? V�� � '�- ContactPerson c.�< <�_� �lLG�.�C���-�
AdcYress I 3 j 7�l rti S f Home Phone �� ;,L ;�-;��� � C'�7 �
City/State/ZIP ��n�; (; � �1�r,�a ��f��/ Business Phone `/`� 7 .5/�J
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facilit Corners Fla ed � — v
NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale)
(Pennit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name `�c�c� �r' ti'j �l: � Phone Number
Owner'sAddress 3�'� ^��� ���'�''j�,�'� City/State/Zip�1�l'i(.K�j V; �
Property Address City
Lot Size �� ��. Tax PIN# a -
Subdivision Name(if applicable) Section/Lot# , ,�J
Directions To Site: �L�� � (_� ,���" ( "�J� ` C��v('e��'1 (`1. �� ` � (�� F-11��'�(�SU�h
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 o
Are there any easements or right-of-ways on the site? Yes o
Is the site subject to approval by another public agency? Yes �o '
Will wastewater other than domestic sewage be generated? Yes o
IF RESIDENCE FILL OUT THE BOX BELOW ,
#People �� #Bedrooms �_ #Bath 6oms Garden Tub/Whirlpool ❑Yes o
Basement: ❑Yes [[id'NNo Basement Plumbing: ❑Yes �o
IF NON-RESIDENC� FILL OUT THE BOX BELOW -
Type of Facility/Business a�'1�L= Total Square Footage of Building ��� —]��'� #People 7
# 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 Supply Type: ❑ County/City Water zi�Necw Well ; xisting Well ❑ Community Well �. �QS f�
s.- �
,
, ,,
; _ ., __ _ _
Do you anticipate additions or expansions of the facility this sysfem is intended to serve? ❑ Yes �No /�
If yes,what type? ��"�•��
__ . _ r-�
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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 aitered,the intended use
changes,or if the i:fcrmation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the D�vie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rtiles. I undef"stand that I a�n responsible for the proper identification and labeling of property lines and corners and
locating anc} g�n�,bt�taking the house/facility location,proposed well location and the location of any other amenities.
�1-��`�/"''� .-'�'��-'' Site Revisit Charge
Property owner s or o�ner s legal representative signature .
Date(s):
I'1�� � � �(i�� Client Notification Date:
Date EF�S:
Sign given ❑Yes ❑No Account# �1�J
Revised 11/06 Invoice# ��7�'�
GoMAPS - Davie County NC Public Access Page 1 of 1
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http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 3/15/2010
.. - _`,
• . DAVIE COUNTY HEALTH DEPARTMENT
..
' Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005453 Tax PINlEH#: 5802-46-2239
Billed To: Scott Levesque Subdivision Info:
Reference Name: Location/Address: Ben Anderson Road-27028
Proposed Facility: Residential Property Size: 7 Acres Date Evaluated: ��[���
�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape osition (,
Slope % D
HORIZON I DEPTH .
Texture grou S(,
Consistence
S tructure r
Mineralo
HORIZON II DEPTH ..�/
Texture rou
Consistence
Structure
Mineralo .
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEP"I'H
Texture rou
Consistence
S tructure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE , , $
SITE CLASSIFICATION: � S EVALUATION BY: ����)��iJ(/
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: �(}( ��IJQ�O�(.�
REMARKS:
LEGEND
i.andscape Position ,
R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose siope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Tgxiut�
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
.nN�I�TF.N . .
��
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-Slightiy plastic P-Plastic VP-Very plastic
StrnctLre
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
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 water or inches from land surface to soil colors with chroma 2 or less
Classifica[ion-S(suitable),PS(provisionally suitable),U(unsuitable)
TTAR -T.nna-trrm arrentanrP ratP_ aat/�av/ft� r�nrm nc�nc m__.:__��
�- Was bn���1�k '►�n s�5�er -
�_ .6 ,•. rax �.of � �` 1
7ox Map D-2 ��Y� - �GIV�• ��uV•S� lU(.(�1��Y1 \S
, ' R.H. Boger ��JCS
and wife ,�
Pearlie Mae Boger G(�,//���(�I�(��� Ul/��e� �
D8 82 � PG 94
DB 91 � PG 901
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/r P�E - ����s �''� Proposed Property Line = Center Line
� /� I' ��R_. of Proposed 50'Access Easement
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� � Part of T�`� Lofi�9 , -��, `o``
N S 7.070 Acres i-�- � � 1 ;/ ` ` \ P
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'•-� Center Line of Proposed 50'Access Easement \
Reference Survey by Kenneth L. Foster&Associates, PA �7—Point
Job No.: 2694-07.0' 2 E1R
25�25'� Dated: 2-05-2002 1&1�.� Line � m Pon
IS'9 07 6 W f�d ��5� �/Fnd fR..
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gA6• byg.23� Tre Line I
N O1°48'03"E
55.62'
I IP
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Fnd 26.2��
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Part of Tax Lot 1 �
Tax Map D-2 I
D8 82 O PG 94
08 91 � PG 9p 1
Ref: Survey by Kenneth L. Foster &Associates, FA
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