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288 Pudding Ridge Rd�q • DAVIE COUNTY ENVIRONMENTAL HEALTH Z. P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005207 Tax PIN/EH #: 5841-49-1423 Billed To: Larry Umberger Subdivision Info: Reference Name: 57heknc,0 b pa Location/Address: 288 Pudding Ridge Road -27028 Proposed Facility: Residence Property Size: See Site Plan ATC Number: 4941 **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 ction satisfactorily for any given period of time. f) ) System Type: S.T. Manufacturer ' `� I iik Date Tank Size X Pump Tank Size System Installed By: R -o"00 0 c tbjX :.cel E.H. Specialisty� ate: 4i✓'Lr�^ DCHD 11/06 (Revised) W • - 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 #: 990005207 Tax PIN/EH #: 5841-49-1423 Billed To: Larry Umberger Subdivision Info: Reference Name: Location/Address: 288 Pudding Ridge Road -27028 Proposed Facility: Residence Property Size: See Site Plan ATC Number: 4941 Site Type: 2New ❑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 '15-# Bathrooms 3 # People I BasementP-B-asement plumbinga— Non-Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size l , QGi�e- Type of Water Supply: ❑County/City (ill ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size /� GAL. Purpp Tank GAL. tr Trench Width Max. Trench Depth 3 (r Rock Depth !.YALinear Ft. -750. 1 Site Modifications/Conditions/Other: ��y tated in 1:`,A N -CAC 1$,�.1� "!,'30 � 1� c�ecae'f 1 UN 7­7­R:a sj 6V 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. IX 3 �a �- to k u s -p— ary .e.� �fi LV A � o Environmental Health Specialist P/?- Date: 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 IMPROVEMENT PERMIT Account #: 990005207 Tax PIN/EH #: 5841-49-1423 Billed To: Larry Umberger Subdivision Info: Address: 288 Pudding Ridge Rd. Location/Address: 288 Pudding Ridge Road -27028 City: Mocksville Property Size: See Site Plan 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: ❑qqew ❑Repair ❑Expansion Permit Valid for: 11-5 Years ❑No Expiration Residential Specifications: # Bedrooms 5 # Bathrooms —3 # People Basement E1 asement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_ &V Type of Water Supply: ❑County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: Az: atated�in iai NcAc t8;,,1c95 (5� lsira���7},.Yt..,T �ra`,2p ia7.Tlid�7l:.C. System Type LTAR Initial i.p.11-06 • e ' •APPLICAT ON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �. N� Davie County Environmental Health O� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 O�C 1 (336)751-8760/ Fax (336)751-8786 C�. A t; Si aluation/Improvement Permit Authorization To Construct(ATC) oth V �F�t)pI5,1 New System Repair to Existing System Expansion/Modification of Existing System or Facility * MPORTANT* ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION --� t—" Name to be Billed Lary J . tArA CXR dN' Contaaecson kav r aV KArLn Um1 Billing Addresszsry 'K t Home Phone G —'Yf8'—Y 4W City/State/ZIP Btsiness Phone Name on Permit/ATC if Different than Above Mailing Address Ci /State/Zip PROPERTY INFORMATION *Date House/FacilityComers Fla ed 12-;V-09 NOTE: A survey plat or site plan must accompany this application. Included.Site Plan Plat(to scale) ` O (Permit is valiq for 60 months w it p an, no expiration with complete plat.) Owner's Name L -At ri T, UY1/11J e -r— Phone him er 7 / A Owner's Address u iH Cty/St�at�e/Zip V% AIC- 2?dam Property Address C6y MOCLs L[ Lot Size 8 6tO Jal PIN# O� Subdivision Name(if applicable) ectdn/Lot# j Directions To Site: T --L1 n LX /'7 eL . wt i -f 5 Pu iH� L . lei%- 4Y1 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 Does the site contain jurisdictional wetlands? Yes Are there any easements or right-of-ways on the site? Yes Is the site subject to approval by another public agency? Yes OD Will wastewater other than domestic sewage be generated? Yes W IF RESIDENCE FILL OUT THE BOX BEL # People 1' e # Bedrooms # Bathrooms Garden ub/Whirlpool Yes Basement No Basement Plumbing: X19) No T'L r,,,SSi ft 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: onventional Accepted Innovative Alternative Other Water Supply Type: County/City Water ew Well Existing Well Community Well Do you anticipate additions or expansions of the facility this Sys te is 'mended to serve? Yes If yes, what type?917 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and lova m and fl ing or staking the houselfacility location, proposed well location and the location ofany other amenities. X—I Site Revisit Charge Property owner's o is legal repres to ive signature Date(s): D Client Notification Date: Date EHS: Sign given YesNo Account# 5 Revised 11/06 Invoice # �2� 6 L� APPLICANT INFORMATION Account #: 990005207 Billed To: Larry Umberger Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5841-49-1423 Subdivision Info: Location/Address: 288 Pudding Ridge Road -27028 Property Size: See Site Plan Date Evaluated: _/76)_ "--7— On -Site Well ZZ,�ommunity Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH _ / 0—/(.- p — Texture group C, G C "5p Consistence U -P ;C - Structure A A A5 Mineralogy S'5 LV2 HORIZON II DEPTH O 4 - Texture group C%5 -.W Consistence ' Structure MineralogyF HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS / RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O. SITE CLASSIFICATION: e5 LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY:. /I� V ✓��12��_ OTHER(S) PRESENT: LEGEND 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm .�I.trt' 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 N D10 Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprohte - 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 acceptance rate - gal/day/ft2 DCHD 05/05 (Revised) ■E■■'i■ ■mEromm ■moms■ ■■■■I■■ ■■m■Il■ ■■E■IN■ ■■m■Il■ ■M■■ NONE ■E/■ moss ■E■■ ■ IMM■■■/////■/■■■/■\1■■■/■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■E■E■11 MUMMER ■ENNEII ■ENNEN MUMMER ■■■m■11 ■ENN■N ■■NN■N ■EMENNI ■■NSEll ■ENN■■ ■E■NEN ■ONME■ ■■NNE■ ■ ■ ■ ■ ■ ■ENE■ ■ENE■ SENSE ■ 0 ■■MONS ■■■M■■ ONE ■mss■■■ ■MON■■ ■■■ ■■ CNiaii■ ■Nmmmo■ ■m■mm■■ ■MOMME■ ■ENMEM■ ■ENEME■ ■M■NEE■ ■MMENE■ ■MEMS■■ ■■■mo■■ ■EMEME■ ■■E■■E■ ■■M■■N■ ■■■mm■■ ■■MEN■■ ■M■MEN■ ■EMENM■ ■ JN A l, �'t' tt le T; T�ll " 01 �?-- - - -, , ­ . _7 — I �1 x jr; 'L di�i x 11.14. 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