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138 River Birch Ln , • � ' DAVIE COUNTY ENVIRONMENTAL HEALTH � '• '" P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 � ��� (336)751-8760 Fax#(336)751-8786 �`J -d� � �(��� � / Q� �us$e OPERATION PERMTT (�J `� Y 1 Ft'[7/1 Account #: ,990001389 Tax PIN/EH#: 54880-36-4933.04 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupe Property Lot#��� Reference Name: April Oalloway Location/Address: Jarvis Road-27006 Proposed Facility: Residence Property Size: 5 acres . ATC Number: 4691 **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. SystemType: � S.T.Manufacturer c51 kou� Tank Date����Tanlc Size �� o o�- Pump Tank Size System Installed By: ��c�v,1����-�:`1 5on5 E.H.Specialist: f.�b�lva f�,��, Date: l'��` �'� c3 ,��UI�(�Y�'1-.S C �--�` �-� � c�� /'u�s ,T � 3`�G� m c''` 4 35 � � oo�X , �- {�6 /� u. J'�w�`I l, �5�°"� t*�s` 3D � �� � ��o' / 'v-c� `rc Gt L c�, � ��—� / , S DCHD 11/06(Revised) �- ?,�d ��c.<--�a�,s kd � . � :; � . P�� � DAVIE COUNTY ENVIRONMENTAL HEALTH r /,rlO�/ P.O.Box 848/210 Hospital'Street �:Q��<< � �. Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990001389 Tax PIN/EH#: 54880-36-4933.04 Billed.To: Ron & Penny Stroupe � • � Subdivision Info: Stroupe Property Lot##� � Reference Naine: April Galloway ` Location/Address: Jarvis Road-27006 ' Proposed Facility: Residence Property Size: 5 acres ATC Number: 4691 / Site Type: EfNew ORepair OExpansion **NOTE**This Authorization to Construct(ATC)MLTST 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�•�#People � Basement8�asement plumbingB� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size ��a� �"�q C��e Type of Water Supply: ❑County/City C�'Well ❑Cornmunity Well System Specifications: Design Wastewater Flow(GPD) 3�0 Tank Size 1�b oo GAL.Pump Tank GAL. �;;, � Trench Width 3��� Max.Trench Depth 34/, Rock Depth �a`1r �Linear Ft. y�d Site Modifications%Conditions/Other: ti� stat�d in 15A NCAC 18A.1J69(5) � —Qeee�fed-�q stems-m�a�ats� e Contact the Davie County Environmental Healt�►'Section for final inspection of this system between " 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. • ' ��o.+o�� �.;�'14� � � J0�.21' " ' ' ��' . . ' 4Q . . �` � � � � _� L . 0, Q� �Q� ' -�c�jY��dL��Krs' ,�,� ` Q\� �o �y. ��J4�du �/ ' � L-1��� � � S,��ti� ` �� cj ro G�� ,eo'^`` �J¢ t�`'`�� �� - o��Q Q a,s h . � 1.,�.Jq l K a t.,�'1 �S' „F4,�1`' 4°''`�___.---� ��.c n1�'l�' �:i+' ��. �Qt`apo . 5..��1 t G fa n � +H�+-Sr - , , � j �j�2 /J I/'�9•». J/6� � N° �01 w �IRa w F��H�4 ��uv� _ _�=�.�d��t --t�4�-� _«----, ' � � �� �� �.n / Environmental Health Specialist ���:�'—"�� Date: �`�d� ---- . . .. _ .__ . .. � � � � ' Davie County Environmental Health . • ' P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751=8760/Fag(336)751-8786 IMPROVEMENT PERMIT Account #: 990001389 Tax PIN/EH#: 54880-36-4933.04 Billed To: Ron & Penny Stroupe � Subdivision Info: Stroupe Property Lot#4 Address: PO Box 338 Location/Address: Jarvis Road-27006 City: Mocksville Property Size: 5 acres Reference Name: April Calloway 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. Pemrit Type: ew �Repair OExpansion Pernut Valid for: 5 Years ❑No Expiration Residential Specifications: #Bedrooms � #Bathrooms a�#People�BasementC�J Basement plumbingQ� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):�� Type of Water Supply: ❑County/City C�Well ❑Community Well As stat�d in 15A NCAC 1f3A.%969(5� Site Mod�cations/Permit Conditions: �tcCe�ted Sy$�e��-�.����;, S stem T e LTAR Initial -F �•'...� Re air f O•3 Site Plan , �O�i � Y � - v p G'� ,�� ��f��' F'�Q �`� � ° � � � '(J`' � � 1` �o. ,/ � '3.0 � i d/'P� Y,,�'� fio . �"- � Jj ,P���t� ' 1 � t�5 �0 ���,� ,�� �o O� �.� Ot. s �`. G`f � � � O .f � Environmental Health Specialist �l r ate � ^� "�� � i.p.t 1-06 . .. , . '• �� {� � � � 11 ION SITE EVALUATION/IMPROVEMENT PERMIT & ATC D �, 9 2006 ��;� Davie County Environmental Health � NQ� � P.O.Box 848/210 Hospital Street �`.�� Mocksville,NC 27028 �Nv1�c�M���U�� ' (33�751-8760/Fax(336 751-8786 �� ��iy/a�] App'cati . Site�'aluation/Improvement Permit Q Authonzat5on To Construct(ATC) ❑ Both Type of Application: L�INew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTAN7***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 � Contact Person � /'� D2 0 Billing Address iD Home Phone —p � City/State/ZIP Q Business Phone — Z. Name on Permit/ATC if Dif erent than Above ��I ���`lQ�Q- Mailing Address City/State/Zip ✓! G Z PROPERTY INFORMATION *Date House/Facility Corners Flagged � d7 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is v�ali for 60 months with site plan no expiration with complete plat.) Owner's Name „� ' � G Phone Number , Owner's Address City/Sta e�ip � _ Property Address � D City (J E �t��-.36'�C� •�[` Lot Size �3. �Ca?.�S Tax PIN# � / � C���@Wp /ll�uJr�7�p / Subdivision Name(if applicable) Section/Lot# y / Directions To Site: - V . g0 S If the answer to any of the following questions is"yes",supporting documentation must be attached. n r„„� ���1 Are there any existing wastewater systems on the site? ❑Yes L9'1Q�o �l'W / Does the site contain jurisdictional wetlands? ❑Yes L93Qo Are there any easements or right-of-ways on the site? ❑Yes B�Qo Is the site subject to approval by another public agency? ❑Yes C+}�do Will wastewater other than domestic sewage be generated? ❑Yes L�'I�o IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms #Bathrooms o?• Garden Tub/Whirlpool �Yes o - Basement•. 'es ❑No Basement Plumbing: fl'�'es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 systemrequested: �onventional OAccepted ❑Innovative �Alternative ❑Other Water Supply Type: ❑ County/City Water Q"New Well OExisting Well ❑ Community Wel( Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes f5'�to If yes,what type? � This is to certify that the information provided on this application is riue and correct to the best of my knowledge. I understand that any pemut(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 Deparhnent to conduct necessary inspections to deternune compliance with applicable laws and rules. I under�tand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or sta in the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Pr perty owner's r owner's lega representative signature Date(s): !`�z�O/ Client Notification Date: ��. Date EHS: . � Sign given ❑Yes ❑No Account# /�� _ Revised 11/06 Invoice# _6� c_ � ,: . � ` �« ';4 i ti � 1 + ±�.♦ ` ,� ' J` , .� " � { �� � t .: W z � � � s '� ; : � �.,s + '(�+ � �, �� � � �i �'b ft,� � 1 � '' � � L♦ l N � If3�, ���� � O �f ie� 6 J c.yr i 5'.�. � a � r.` �' �+,.,7� � �j��' y\ y �al ;�, d ,, ,t . 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I l � � .� T� � , 'rr x,�,,. k� �' I . . . . � - rV� � � � / , „ .-�-.� ' , � DAVIE COUNTY HEALTH DEPARTMENT � , . � Environmental Health Section - . � Soil/Site Evaluation �PPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001389 Tax PIN/EH#: 54880-36-4933.04 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupe Property Lot#4 Reference Name: Location/Address: Jarvis Road-27006 Proposed Facility: Residence Prope�ty Size: 5 acres Date Evaluated: � 3�� � � Water Su 1 : On-Site Well ✓ Communit Public PP Y Y Evaluation By: Auger Boring J Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo % („ - HORIZON I DEPTH i - � Texture rou G G c . Consistence ' , ,y� Structure Mineralo ,t t � HORIZON II DEPTH -' ,� 1= Texture u ,' L 'LL Consistence �� - Structure 5 K 5 �uu � Mineralo 1r % (�` - HORIZON III DEPTH Texture mu � Consistence � Structure Mineralo HORIZON IV DEP'TH Texture rou Consistence � Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE O.� •� .3 SITE CLASSIFICATION:_�w }�o��,G- EVALUATION BY:_. _ ��b ./U a� � v'1 � LONG-TERM ACCEPTANCE RATE: G•� OTHER(S)PRESENT: - � REMARKS: . LEGEND . . . T,an s pe Position R-Ridge S-Shoulder L-Linear slope . FS-Foot slope N-Nose slope � ; CC-Concave slope CV-Convex slope ; T-Tenace FP-Flood plain H-Head slope � Textute ' 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 . . .ON4IST .N . . . . M4ISi 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 - Struct�g � SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev 1:1,2:1,Mixed � . 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