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161 River Birch Ln • �j ' •' , . DAVIE COUNTY ENVIRONMENTAL HEALTH • ; P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 �%�� �� . OPERATION PERNIIT ` (p,I R' v�� Account #: 990001389 Tax PIN/EH#: 5880-36-4933.01 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupe Property Lot#� Reference Name: Location/Address: Jarvis Road-27006 �� Proposed Facility: Residence Property Size: 5 acres ATC Number: 4569 **NOTE**The issuance ofthis Operation Permit s�all indicate the system described on the ATC 1�as been installed in compliance with Article 11 of G.S.Chapter 130A,,Section.1900"Sewage Treatment and Disposal Systems," but sball in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. � 0 �"7 System Type: � S.T.Manufacturer �^�a� Tank Date�'��Tank Size G� Pump Tank Size � . � � /� System Installed By �^^� JV�d U�-e�- E.H. Specialist:_��� '���atse: `�C — � � �O� � \ � q� � 1 �� ��=�' �� � L loG _� �v-C �.+.., �� L —� \ '"-�; ' -� 1 C� � rfb �J� ; � _ -. \ \ d " 33�1� L� � � — N k i 5 � v �.�-P'� o � � i � � G X � �P.��..- �� ��u s-� � y� , � ��d� '� a � a6 ��i"�` - — , ; ��� �,� l�� l�Y�t,r (���. ��.e, �� � w-P(I �c�-��`° d00�' , . ��Y` ' �``�" �w`a� . . �'` �'� al ` `3°�• �o � � l6( '� � �� . � ��� _ 1 DCHD 11/06(Revised) ,, . _ , �...� _ ._ , - ,;�� _ .� navr�courrrY Exv�orm�rrr�.�ai,� �Q( • ' P.O.Box 848/210 Hospital Street , � Mocksville,NC 27028 �;Z(p d Z I (336)751-87b0 Fax#(336)751-87$6 AUTHORIZATION FOR WASTEWATER SYSTEM COI�ISTRUCTION Account #: 990001389 Tax PIN/EH#: 5880-36-4933.01 Billed To: Ron & Penny Stroupe Subdivision Info: Stroupe Property Lot#1 Reference Name: Location/Address: Jarvis Road-27006 - .Proposed Facility: Residence Properry Size: 5 acres ATC Number: 4569 **NOTE**This AuthorIzation to Construct(ATC'�MUST BE ISSI7ED by the Davie Coutrty Environmental Health Section prior to issuance of any building petmit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specification:�uilding Type '� �c #People � #Bedrooms 3 #Batbs �. 7 B�sement w/Plumbing:�Basement/No Plumbing„_ Commercial Specification:Facility'I�pe #People #People/ShiR #Seats Lot Size Type Water Supply Design Wastewater Flow(GPD) Site:New Repair System Specificarions:Tank Size ���GAL.Pump Tank_GAL.Trench Width 3��Trench Depth��-�G�� Rock Depth. Il�. Linear Ft. 4gQ Other. As st accepied Systems may atsn b� us$ Required Site Modifications/Condi6ons: Contaet 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# 33 751-8760. y aj � ��b�,�. 4Uo' , 1���6 � �- _._.9�'r�� __ _ { � , , 4 sa �-- � � - y� , , r� , , � . U �� / l � �Q Yj_ _ r'a.o. ? . � i ` _ ,}yx.�/ i 6 �_� ��Q�`' �ii� j ,�� ..�,`� i�- --�- ¢v �,�.,. N J . I �� � Co �cw r��L� �X�s��« Se�Oy�� `l��k '�� �CepvnoeQayp P��s-e�.�..c� ��4 w�b�k� g-`- �S`�k�� 't�-e�..e(�-e 5 o rn f vaG/'.P Y �a✓� �u-•" �'l d �-c e�-t�- (YG�n-- 3G"a��� N� �cv� S6tallcti ?'�4a. G /. Environmental Health Specialist Date: l""�G �G DCHD 11/06(Revised) r • Davie County Environmental Health . •• P.O.Boa 848/210 Hospital Street ` Mocksville,NC 27028 (336)751-8760/Fax(33�751=8786 IMPROVEMENT PERMIT Account #: 990001389 Tax PIN/EH#: 5880-36-4933.01 Billed To: Ron & Penny Stroupe Subdivi�ion Info: Stroupe Property Lot# 1 Address: PO Box 338 Location/Address: Jarvis Road-27006 City: Mocksville Property Size: 5 acres 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: C�Tew ❑Repair ❑Expansion Pernut Valid for: �Years ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms �•�#People � Basement� Basement plumbing0 Non-Residential Specifcations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3(�d Type of Water Supply: ❑County/City B'G�ell OCommunity Well As stated in 15A NCAC 18R.1S69(5� Site Modifications/Pernut Conditions: ;����{��gTsi�ts-nr^Qy�-cri�-;�w�'rs� S tem T e LTAR Initial ..tf" 6.al � Re air p.�'� Site Plan ���'� � , � y r �.CNGt..�....�t�C �b5 pfOf/cr� a � ( �,��„� ( � � � � , N V � -�. �?1 � � � � _ • ✓ � V.1 s j` � � _ h�� 1� r � 'ce-�u,,�a Environmental Health Specialist Date f"� �G "4 7 . i.p.l l-06 Page 1 of 1 . r' �-t..,, � �' � �. � !f, // I I ,� � r L . � ,��,, .' , � '�.` . ". - — . 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T-a a�nr+o�e tx.n e��� r.a..�..ne rn» • r-� s envarr e�.rr . . • ,�, �Q � � �� v ICATI F ITE EVALUATION/IMPROVEMENT PERMIT & ATC ' O '' 2 9 2� avie County Environmental Health �` ��� P.O.Box 848/210 Hospital Street 0��`E�p���j� Mocksville,NC 27028 FSLv�R�p��E���N (33�751-8760/Fax(33�751-8786 Applic ' or: Site�'aluation/Improvement Permit ❑ Authorization To Construct(ATC) oth Type of Application: 11New System ❑Repair to Existing System ❑Expansion/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 instrucrions. APPLICANT INFORMATION Name to be Billed � Contact Person� �� O� o Billing Address Home Phone - City/State/ZIP ' Business Phone - - Name on PernudATC if Different than Above ,��/y1E Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this applicarion. Included: ❑ Site Plan ❑Plat(to scale) (Pern2it is vali for 60 months with site pla no expuation with complete plat.) Owner's Name .� � G' Phone Number Owner's Address City/Sta e/ ip � Property Address � City � Lot Size . Tax PIN# �' / r�'�� � , Subdivision Name(if applicable) Section/Lot# � • Directions To Site: - � � '$O S a Q . 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? OYes t93�o Does the site contain jurisdictional wetlands? ❑Yes L53Qo � Are there any easements or right-of-ways on the site? ❑Yes�1Qo Is the site subject to approval by another public agency? ❑Yes C+}�do -._._. . . . Will wastewater other than domestic sewage be generated? OYes [93�0 IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms #Bathrooms o?• Garden Tub/Whirlpool ❑Yes o Basement: � 'es ONo Basement Plumbing: g'�'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: L9�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water Q'New Well ❑Existing Well ❑ Communiry Well Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes L9'�10 If yes,what type? " "This is to certify that the information provided on this application is true and correct to the best of myknowledge. I understand that any pernut(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 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 ' the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Pr erty owner's r owner's lega representative signature Date(s): r`�LS1�0/ Client Notification Date: ��. Date EHS: Sign given ❑Yes ❑No Account# �/s2Q1— Revised 11/06 Invoice# 0o'+M t . . _ . ., r� .-z ��r ��m aro �� rn. �• � � t .. c�- � � � , � � 4� : lac�' � S"# i i�y r.. a � . s �l � �f � � M '. 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(1.60A) Y� ., u53 's�_,Y �. ) �' _�� , , eaao a W T: . _, ..�� A �. r.� 4� 1 „5 _ ,� _. - - - ' ,� 159 16� a,5 � r � I �< �,� � � .M;:j � ` . �.a,�, � � ^ . � /m �„6 w �<y� p � � • a m�a ': �� � � , , � '� x DAVIE COUNTY HEALTH DEPARTMENT ' � Environmental Health Section ' ' � Soil/Site Evaluation APPLICANT INFORMATION PROPERTY IP�IFORMATION Account #: 990001389 Tax PIN/EH#: 5880-36-4933.01 Billed To: Ron &Penny Stroupe Subdivision Info: Stroupe Property Lot# 1 Reference Name: Location/Address: Jarvis Road-27006 Proposed Facility: Residence Property Size: 5 acres Date Evaluated: / — � "v r Water Supply: On-Site Well �' Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition L-�. L G Slo e% - HORIZON I DEPTH �v �/ �J-� - Texture grou ' L c L G L Consistence D Structure ,E f� " ` /e , Mineralo / :! !:� � ' HORIZON II DEPTH 8�y 1-y - ' Texture rou G F� G 5 Consistence S- ' Structure " Sbk Mineralo /; / /: / HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �'r�rJ • SU f�G�n�(� EVALUATION BY:���1r /���'G LONG-TERM ACCEPTANCE RATE: �•�h OTHER(S)PRESENT: /�r: r�G"�ai/i'd� 5����-r�.r!' . �' REMARKS: LEGEND . ��' i, n s ape 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 Tsxt�re, � 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 . . NI�1SL 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 ,�Il1Ct11I� , . 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 � lY� . _ , 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) LTAR-Long-term acceptance rate-gaUday/ft2 . DCHD OS/OS(Revised)