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429 Potts RdDAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005233 Tax PIN/EH #: 58800271776 Billed To: Mark Beverly Subdivision Info: 4X -7 Reference Name: Location/Address: 427 Potts Road -27006 i - Proposed Facility: Rsidence Property Size: 3.9 Acres 4 3 ATC Number: 4956 t� 7& **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," (e 3 but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of _ time. /Yd0 System Type. S.T. Manufacturer h" e Tank Date Tank Size / doo Pump Tank Size .I— rv�WA Y'C System Installed By:T!x 07 10 U- E.H. Spec'alist: lax Date: a�/ DCHD 11/06 (Revised) 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 #: 990005233 Billed To: Mark Beverly Reference Name: Proposed Facility: Rsidence ATC Number: 4956 Tax PIN/EH #: 58800271776 Subdivision Info: Location/Address: 427 Potts Road -27006 Property Size: 3.9 Acres Site Type: 15 ew ❑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--lasementgog�as'ement plumbingif!' Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: 2County/City ❑Well ❑Community Well � t rovj 00 d System Specifications: Design Wastewater Flow (GPD) Tank Size_V_ D GAL. Pump Ta4V AL. 9 tr Trench Width ' Max. Trench Depth Rock Depth near Ft. t.c___� Site Modifications/Conditions/Other: 0��4/ )=6t4,.,Clevyl 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. R0& 0,(, k -A 1 t� ¢,3 stated in 15A tivAC 18A.1969(5 �k_trm4 r��ri o1w ba u5 :c Environmental Health DCHD 11/06 (Revised) Date: 3 r N o y Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990005233 Billed To: Mark Beverly Address: 427 POTTS ROAD City: Advance Reference Name: Proposed Facility: Rsidence IMPROVEMENT PERMIT Tax PIN/EH #: 58800271776 Subdivision Info: Location/Address: 427 Potts Road -27006 Property Size: 3.9 Acres **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: ❑'New ❑Repair ❑Expansion Permit Valid for: F5 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms q #People_5_ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats /L Square Footage(or Dimensions of Facility) Design Flow(GPD): /Y Type of Water Supply: County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: As ctated in 15A NCAC 18A,lcat:Z(5} i.'.� (mptcd Sytons �iicr,�a�Tt=,5�: IIS'' Site Plan S 9C System Type LTAR Initial 0.3 Re airO FYW Environmental Health Specialist ,,,>>_nr, r 4 1� y3 a6 :3 bo -Date 3 "'� �( C/ From:VF CORPORATION 336 424 3642 03/04/2009 10:55 #096 P.001/003 LICATT X00 EVALUATION/IMPROVEMENT PERMIT & ATC O U" Davi County Environmental Health �►�� P. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 plication Fo . Siler uation/Improvement Permit ❑ Authorization To Construct(ATC) 0 Both T e of Applies ' . DSNew System DRepair to Existing System OExpansion/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 _M[ef� f;i�eia �� oL-. Contact Person Plla ,4- or". cz4 Ije iJnr/tir Billing Address LL -1 P„ 4k P -,,J, Home Phone (3-30 70 /— Quo 45- 1 City/State/ZIP _/Ac. L)n nee TALC -A-DO (o Business Phone Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION *iTatnHouselFaciIitvCo .FIaeeed r NOTE: A survey plat or site plan must accompany this application. Included: J5 Site Plan OPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name LUCA4 AhPeL Phone Number 7-(-`t9 CFS Owner's Address _ /( (fin City/State/Zip �}�i V(t t�1C•pT J�)C . 27 l n �c Property Address <f'te 7 `?ot City M un nc e_ Lot Size 5, 9S Ar Tax PIN#_ 588w7177b Subdivision Name(if applicable) Section/Lot# Directions To Site: J -,Io F61 S, .-{n 'p� 151 a+ fid) 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? DYes JRNo Does the site contain jurisdictional wetlands? DYes ®No Are there any easements or right-of-ways on the site? DYes ®No Is the site subject to approval by another public agency? ❑Yes ®No Will wastewater other than domestic sewage be generated? Dyes It 0 IF RESIDENCE FILL OUT THE BOX BELOW # People J— # Bedrooms _ # Bathrooms Garden Tub/Whirlpool R' es DNo Basement: RYes ❑No Basement Plumbing: VVcs ❑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: P3Conventional ❑Accepted []Innovative DAlternative ❑Other Water Supply Type: kf County/City Water D New Well DExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes If yes, what type? X No 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 tyles. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or stakingthe house/facility location, proposed well location and the location of any other amenities. :0 -- � Q /! Site Revisit Charge Property owner's or owner' egal rescntative signature Date(s): !i2 G a? Client Notification Date: Dat EHS: Sign given DYes []No Account # `:� Z '33 Revised 11/06 Invoice #�6 XV:-- 6t -Pale gou90 aul;� pt 0A Al � , F�om:VF CORPORATION 336 424 3642 03/04/2009 10:55 #098 P.002/003 6 1p Ar L y 1 APPoICA T INMNON Billed To: Mark Beverly Reference Name: Proposed Facility: Rsidence Water Supply: Evaluation By: HORIZON II DEPTH Texture arouD HORIZON IV DEPTH Texture group wilatualugy [�l1TT \TITTATT (�C� On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Tax PIN/EH #: 58800rMFIRTY INFORMATION Subdivision Info: Ppotts Location/Address: Road -27006 Property Size: 3.9 Acres Date Evaluated: Community Auger Boring Pit 1LLiU 11\Lt.11 Y l.i 11V1�1L.•V1T l.Lt1J J 1r1JL %_t111 V 1 V SITE CLASSIFICATION: `T 5 LONG-TERM ACCEPTANCE RATE: 0.3 REMARKS: LEGEND Public / EVALUATION BY: OTHER(S) PRESENT: J 1PU'e?y' jLy 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 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 Mineralogy 1:1, 2:1, Mixed Notes \C. 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) ITAR - I.nna-term arrentanne rate - aal/dav/ft7 t-%nTrn neine