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175 McCullough Rd Lot 4 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990002315 Tax PIN/EH#: 5747-00-2532.04 Billed To: James Larry McDaniel Subdivision Info: Rebecca Acres Lot#4 Reference Name: Location/Address: McCullough Road-27028 Proposed Facility: Residence Property Size: .690 Acres ATC Number: 4958 **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 NWAY be tpken as a guarantee that the system will function satisfactorily for any given period of time. W6kW System Type: S.T.ManufactureTank Date � Tank Size Pump Tank Size / System Installed By: V�5 ` S E.H.Specialist: V Date:7f( 0 °G. e �-�--- l L C�uc u f c (7 to �- L� �.o 20 DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street ko Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 3 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION V Account #: 990002315 Tax PIN/EH#: 5747-00-2532.04 Billed To: James Larry McDaniel Subdivision Info: Rebecca Acres Lot#4 Reference Name: Location/Address: McCullough Road-27028 Proposed Facility: Residence Property Size: .690 Acres ATC Number: 4958 Site Type: R<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 3 #Bathrooms of #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size . (D-qo Type of Water Supply: ❑County/City 21rei­1 ❑Community Well System Specifications: Design Wastewater Flow(GPD) 3 W Tank Size // GAL.Pump Tank Ac- TrenchG AL. Width3b tr Max.Trench Depth 3(P Rock Depths l Linear Ft. Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1969(5 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. 10 fl 6� i a g s� �v s' s.� S Environmental Health Specialist Dater- X4-0 ? 0 DCHD 11/06(Revised) -r EVALUATION/IMPROVEMENT PERMIT &ATC a 'e County.Environmental Health' O.Box 848/210 Hospital Street Mocksville,NC 27028 6)751-8760/Fax 3 l App ' a to Evaluation/Im rovement Permit Authorization To Construct(ATC) Both Type of A cation: New System Re air to xistm �nn/ty�nr�ifi atinn of F.' in System or Facility YP Ph Y P g stem g Y Y **IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1 APPLICANT INFORMATION Name to be Billed 1, ��.z y VV C-,4�IA7,y, k l Contact Person Si9s� --Z Billing Address Home Phone.? ?� 3 j' City/State/5tlp.vl. ge BusinessPhone 23L' 11 Name o i'Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 3 r q U NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name tiT�cMr.y 1,..1.00"C '�aD,q,.�. Phone Number 331. zS b �9 S3 .Owner's Address ;5 8- , / = A c.JCity/State/Zip L I-�...'��%�,,� A.I. 7 9 Propert .y Address i . A .C, ;tCity Lpt Size .�' 41Y 6 . A L Tax PIN# 7,-r-I D v S' 3G Subdivision Na ' .,. me(if applicable) r: G..��.��.a ��7 c/��tSection/Lot# Directions To,Site: "'... ..i' If the answer to any of the following questions is"yes",supporting documentati ust be attached. Are there any existing wastewater systems on the site? Yes Does the site contain jurisdictional wetlands? Yes Are 3here any easements or right-of-ways on the site? Ye o Is the site subject to approval by another public agency? No ��'� Will wastewater other than domestic sewage be generated? Yes:-E2 IRRESIDENCE FILL OUT THE BOX BELOW y' #People` #Bedrooms _� #Bathrooms Garden Tub/Whirlpool Yes o Basement?' es' o Basement Plumbing: Yes o W IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building k#':]?eople #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facilitywater consumption) FOODSERVICE ONLY: #Seats l ylsetsystein requested: Conventional Accepted Innovative Alternative Other Water Supply Type. �ou�nty/CityWater NewW,ell Existing Well Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Yes oNo If yes,what type? ` This is to certify that the information provided on this application is true and correct to the best of my .` lI understand that any'permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is alterstrt,ended use changes,or if the information submitted in this application is falsified or changed. I hereby grant'iight o entry'to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detemliifie compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and 1 locating and flagging or staking the house/facilit ation,proposed well location and the location of any other amenities. Site Revisit Charge operty owner's oro n is legal representative signature ' Date(s): Client Notification Date: Date EHS: Sign given Yes No Account# 23 I Revised 11/06 Invoice# i i Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990002315 IMPROVEMENT PTL i1V/EH M 5747-00-2532.04 Billed To: James Larry McDaniel Subdivision Info: Rebecca Acres Lot#4 Address: 585 Giles Road Location/Address: McCullough Road-27028 City: Lexington, Property Size: 0.6g0Acres 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 collstruction/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: PKew ❑Repair ❑Expansion Permit Valid for: 5 Years ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3(t� Type of Water Supply: l;<�ounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: Mn aq osle few swals�tS poldaooc �� �d! paleis sem System Type LTAR Initial cc '� ed a- Re air 0�c ID X7 Site Plan �4r Nr b �,�,�a,✓ 3n .� `7`C�►� ` %J, All Environmental Health Specialist Date _ �- �� ':�D d f CATS+ OR SITE EVALUATION/IMPROVEMENT PERMIT..,& ATC ; - �✓ Davie County Environmental Health '�\.- 1 ►�QO P.O.Box 848/210 Hospital Street Mocksville,NC 27028 �lytG; (336)751-8760/Fax(336)751-8786 50Ap at( tigl' to E aluation/Im rovement Permit Authorization To Construct(ATC) Both Type of A cation: New System Repair to xtsttng System Expansion/Modification of Existing System or Facility **IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. .f= APPLICANT INFORMATION 'Name to be Billed—JHwriZ 1t k,144,/ Contact Person Billing Address �!FES G,'/,cjr ,Qcj Home Phone City/State/ZIP k ,C,-ae c. A 7:2 usiness Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 'PROPERTY INFORMATION *Date"House/Facilit Corners Flagged NOTE: A survey plat or site plan must accompany this application. . Included: Site Plan Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name 2.,if-4 Phone Number 336 zS d t}9S3 .Owner's Address ,�,5G.. / =s /�,c� City/State/Zip t r Sc, „Q j;ci AJ.< ;17 Property Address City Lot Size. d-7 b 14 G Tax PIN 7G/ D v •3 G Subdivision Name(if applicable) cR 1Z Section/Lot# Directions To_Site: If the answer to any of the following questions is"yes",supporting documentati ust 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? Ye _ )60 -. Is the site subject to approval by another public agency? No �/�"`�' ,, �Zo Will wastewater other than domestic sewage be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People t4 #Bedrooms _ #Bathrooms_ Garden Tub/Whirlpool Yes o Basement:: es' o Basement Plumbing: Yes o 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 (yp systein requested: <Conyentional Accepted Innovative Alternative Other aterl Supply Typed (ounty/City Water New-V�ell Existing Well Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Yes CNo If yes,what type? A This is to� ify that the information provided on this application is true and correct to the best of m 5. T understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is alte tat titded use P,4,* changes,or if the information submitted in this application is falsified or changed I hereby grant'(igTif o .e'n to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deterafifie compliance with applicable ` laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facilitation,proposed well location and the location of any other amenities. kn Site Revisit Charge operty owner's oro n is legal representative signature ' Date(s): Client Notification Date: Date EHS Sign given Yes No Account# Revised 11/06 Invoice# i, s r. - DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 990002315 Tax PIN/EH#: 5747-00-2532.U4 Billed To: James Larry McDaniel Subdivision Info: Rebecca Acres Lot#4 Reference Name: Location/Address: McCullough Road-24028 Proposed Facility: Residence Property Size: 0.690 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.position Slope% HORIZON I DEPTH Texture group Consistence StructureMV . 4 Mineralogy � HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group . ' Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROUTE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: '� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: r OTHER(S)PRESENT: REMARKS: LEGEND Lnndscane 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 CONSTSTENCE 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 Mineral= 1:1,2:1,Mixed lYQles 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) TTA T) T ...... r..—.... ...................__a., __i 1A 1r.11 � ... ..-..._ .� .. Iz ru. io/ I PG. 97 . Planning Director Date 0Jj / . McCULLOUCH 1 / FORMERLY OLD SALISBURI t` ,, N.C.S.R. 1135 PAVED R/W IS MAINTENANCE AS PER EXISTING II 18" RCP N 40.16 19 E-�- 848.28 IPs a OUL — t 115.78' 6NTROL IPs 115.79 1 IP 1 118.15' EXISTING \17.65' S WM r )�DRIVE CORNER _ SHARED DRIVE PP Et AIL (TYP) 1 .;� 1SEE DETAIL (TY ) I _ _ 30' MBL —�� { 30' MBL I - I 30'�IBL I \ ( 30MBL 057 AC. ('0.833 IAC.I z ��"` r, ,' I__ I X0.690 AC I 01 V,0 �'. t�,8I I ` PITo J I PIT En u+ 1 I�N v: O N 41 L PIT (n q I u `} 1 ! _ w 4. PIT EJ I i A �,I rn � m O w CM PIT l i IW 37 �I W �I b, j IW �; I PIT r ' I o I I W PIT I I I I� PIT I I ` O I cn l ' I I m I I I PIT 11 1 P�l� 1 �30'� MBL— —J,t (_ — 30' MBL, — � } 4) Ips 95.02' IPS 32.86' (FOUNoj E 84.83' S 41'40'00"W IPS IPI / 0 j ti •� t 1 I _ I(ON PIP 1 7�f} \ \BILLY JOE\BR( D.B. 115 PG. 6 O � � t IPS (% 6 1721) tiry5 \ MAP ANO. 1 OF THE (7 DR. R.P. ANDERSON PR0P1 \ P.B. 9 PG. 97 \ \ ROBERT SZABOCSAN\ \ D.B. 185 PC. 455 \ `, I hereby certify that\khe Davie County Health Depart nt has evaluated the S \ \ REBECCA ACRES \ with respect to criteria and conditions established-by state law or promulgate is found to comply with such criteria and conditions EXCEPT as found in suc of this evaluation. and for limitations, see the written report on file at the De IMPORTANT NOTICE: THIS CERTIFICATION DOES NOT CONSTITUTE A PERMIT OR \� APPROVAL OF INDIVIDUAL LOTS IN THE SUBDIVISION FOR INSTALLATION OF SEWA FACILITIES.