141 Sam Allens Way --•-., .
_, � DAVIE COUNTY ENVIRONMENTAL HEALTH (� 1O�
P.O.Box 848/210 Hospital Street � ,V\
Mocksville,NC 27028 1�`
� (336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Aecount �: 990003962 '�ax PI�€r'EH#: 5860-29-3926
Billc�Ta: Jerry Allen Su�adi�i�iorl Inf�:
Refer�r�ce N��ie: LocaiioniAddr�ss: Sam Allen's Way-27028
Propos�d Faci€ity: Residence Pca��r�y&ize: 2 Acres
�TC Nu�tber: 4405
**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.
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System Type: S.T.Manufacturer �r1da�Tank Date J- �`� Tank Size�G�
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Pump Tank Size
% �til�+�/ ��� �l-/d '" �9
' System Installed By: l�I �O E.H.Specialist: Date:
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DCHD 11/06(Revised)
�
� � � �` � DAVIE COUNTY ENVIRONMENTAL HEALTH
• � P.O:Box 848/210 Hospital Street
Mocksville,NC 27028
(33b)753-6780/Fax#(336)753-1680
' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003962 "�ax PI�t:EH#: 5860-29-3926
Bi[Icd To: Jerry Allen Suk�divi�iarz InfU:
R�fer�E�ce Nan�e: LocationiAddr�ss: Sam Allen's Way-27028
Prapossci Fa�ility: Residence �rapec�y&ize: 2 Acres
ATC Nu[t'3b�r: 4405 Site Type: C3New ❑Repair OExpansion
**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 FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change. �
Residential Specifications: #Bedrooms / #Bathrooms 1 #People�Basement❑ Basement plumbing❑
Non-Residential Specitications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
i
Lot Size . GrL�'�5 Type of Water Supply: �ty/City OWell ❑Community Well
System Specifications: Design Wastewater Flow(GPD)�Tank Size /��D�AL.Pump Tank�i"iri GAL.
. �� r �� 2
- Trench Width� Max.Trench Depth 3 G Rock Depth � a� Linear Ft.�.�� •
Site ModificationsLConditions/Other: As stated in 15A NCAC 18r1.1�fi3�'5)
�- -- -�-e--�c--u�@9
Contact the Davie County Environmental Health Section for final inspection of t6is system between
8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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'. Environmental Health Specialist Date: �G l�(� ���
DCHD 11/06(Revised) '
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�� APPLICATION FOR SITE EVALUATION/IMPROVEME E & ATC
Davie County Environmental Health �S n n�
� P.O.Box 848/210 Hospital5treet � i! �S
Mocksville,NC 27028
' (336)751-8760/Fax(336)751-8786 oCT � O
��
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Con t AT�'/Rpy�, oth 9
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modifi�ation o � F ility:,
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORI�IIATION`IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed J e�2-�� �L�� . Contact Person S'�-�� 1����r�
Bilfing Address „(�'S S�.,nn .�L�n�5 c,v I�y Home Phone 3'i 6 9 N o 57 S)
City/State/ZIP Moc-k� �t��c , rJG �-7�Zf�' BusinessPhone '33� �S! '1�cy
Name on PermidATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan OPlat(to scale)
(Pernut is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name ? zrz.iz,,.� /�LL�N Phone Number
Owner's Address •� !S� S w-rv� �+-�.c r�5 w�� City/State/Zip
Property Address f� I SK�m 1���S w A y City
Lot Size 1 � 6 q . Tax PIN# F(oc�oo0o t23
Subdivision Name(if applicable) Section/Lot#
Directioris To Site:
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�No
Does the site contain jurisdictional wetlands? OYes�To
Are there any easements or right-of-ways on the site? �I'es ❑No
Is the site subject to approval by another public agency? �Yes f�No
Will wastewater other than domestic sewage be generated? ❑Yes [t�To
`IF RESIDENCE FILL OUT THE BOX BELOW
#People _� #Bedrooms �_ #Bathrooms�_ Garden Tub/Whirlpool�'es ❑No
Basement: �Yes o Basement Plumbing: �Yes No .
IF NON-RESIDENCE FILL OUT THE BOX BELOW '
Type of Facility/Business Total Square Footage of Buildin� #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested:. ❑Conventional �Accepted �Innovative �Alternative �Other
Water Supply Type:�County/City Water ❑New Well ❑Existing Well 0 Community Well
Do you anticipate additions or expansions of.the facility this system is intended to serve? ❑ Yes �{]No
If yes,what type?
T'his is to certify that the information provided on this application is true and conect to the best of my knowledge. 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 informarion 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 corners and locating and flagging
� or staking the house/facility location,proposed well location and the location of any other amenities.
��� Site Revisit Charge
Pr er's or owner's legal representative signature
Date(s):
�„R pc.4- 'd� Client Notification Date:
Date EHS:
Sign given OYes ❑No Account# �/ 6�
Revised 11/06 Invoice# �Io� , �
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� Filed for registrotion at o'clock _
V OFFICER'S CERTIFICATE
� 2009 and recorded
. Review officer of Davie County,
� that the map or plat to which this certification pIa{ gook , Page
xed meets all statutory requirements far recording.
Fling fee # paid. IA. BRENf SHOAF — DAVIE C
W OFFICER DATE
bY
DEPUiY-ASSISTM
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CHUCK RYAN FERRIS
D.B. 177, PG. 853
S 86•42'28' E __� existing
. 1 7 iron C41e> ,
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N JERRY LEE ALLEN
� T CT 2 . , D.B. 667, PG. 135
� AREA = 0.64 ACRE ^ � PIN #5860292956
P/0 PIN�5860199974 � ^ '
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TO BE CObIBINEO WITH PIN�k5860292956 � �
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EXISTING 25'F�R �ESCRIP7'�
�SEMENr� �N oF
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� LIL�IE JE,
OWNER --
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. - _ DAVIE COUNTY ENVIRONMENTAL HEALTH �� �
P.O.Box 848/210 Hospital Street IO
Mocksville,NC 27028 ��
, (336)751-8760 Fax#(336)751-8786 31
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003962 Tax PIN/EH#: 5860-29-3926
Billed To: Jerry Allen Subdivision Info:
Reference Name: Location/Address: Sam Allen's Way-27028
Proposed Facility: Residence Property Size: 2 Acres
ATC Numbe�: 4405 Site Type: ❑New ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Secrion 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.
IResidential Specifications: #Bedrooms� #Bathrooms�7#People L� Basement0 Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Q G�-cs Type of Water Supply: C�C;ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)��t�Tank Size ���GAL.Pump Tank��'`7�' AL.
i � �' ��
Trench Width3�� Max.Trench Depth� Rock Depth � � Linear Ft. 3�r
` � staied in 1SA N�CA�C 18A.19S8(5)
Site Modifications/Condirions/Other: �Pt�d �y�tems r��ay alro b� tt�t3d
Contact 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# 336 751-8760.
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Environmental Health Specialist Date: oC '-� � `�� '
DCHD 11/06(Revised)
' . •;' �. � , . DAVIE COUNTY HEALTH DEPARTMENT
• • ' , . Environmental Health Section
� �:';'` '� � �' P.O.Boa 848/Z10 Hospital Street (,,
• Mocksville,NC 27028 Qd'� ,� �Y
' 336 751-87G0 'V �
. � ) �,
� IMPROVEMENT/OPERATION PERMIT
Account #: 990003962 Tax PIN/EH#: 5860-29-3926
Billed To: Jerry Allen Subdivision Info:
Reference Name: Location/Address: Sam Allen's Way-27028
Proposed Facility: Residence Property Size: 2 Acres
**NOTE�*This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHOWZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
1
Residential Specification: Building Type #People� #Bedrooms�� #Baths��
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply� Design Wastewater Flow(GPD)� Site: New❑ Repair❑
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt��Rock Depth��Linear Ft�l'
Other:
As stated in 15A NCAC 18A.1969(5)
' Required Site Modifications/Conditions: accepted Systems maV also be used
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-87G0.****
�
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...� � � `�; .
Environmental Health Specialist's Signature: Date:� � �
DCHD OS/99(Revised)
. , . , ' ' , .
� .: , s • . , , DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
� P.O.Boz 848/210 Hospital Street
Mceksville,NC 27028
(336)751-8760
Account #: 990003962 Tax PIN/EH#: 5860-29-3926
Billed To: Jerry Allen Subdivision Info:
Reference Name: Location/Address: Sam Allen's Way-27028
Pro osed Facilit : Residence Pro e Size: 2 Acres
ATC Number: 4405
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
. the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CO STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
,�r �/
Environmental Health Specialist's Signature: /r,` Date: ��,G��
ar.r,ented SvStems may also�b� usP
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
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.
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Environmental Health Specialist's Signature: Date: �� �"/��'� �
DCHD OS/99(Revised)
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' ' '�..AP � FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
����1��� � � Davie County Health Department
� �'-��`� Environmental�Iealth Section
, ,�,' APR 2 8 2006 P.O. Box 848/210 Hospital Street
'`��' L ' Mocksville,NC 27028
�iv�RONM�pLHEp�1H . (336)751-8760/Fax(33�751-8786
oAv�Ecou�art
n or: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) �Both
***IMPORTANT***THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED
• INFORMATION IS PROVIDED. Refer to the INFOI2MATION BULLETIN for instructions.
APPLICANT INFORMATION �
Name to be Billed •� �w�.y F�t����J Contact Person �c�2�iz.y I�Lte�J
Billing Address l S S 5 r�m Rux,�', w��1 Home Phone `J`I o S�8?
City/State/ZIP �'V�o c_I�S�'�u.P � +�C 'a1 o Z-�S Business Phone H 77 �"t-( `1
Name on PermidATC if Different than Above •
Mailing Address City/State/Zip � �
PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Street Address �55 Spm �}t�.c,�5 w�y City :.��c(c5v;w� Tax P1N# ���D aq 3� ��,
Subdivision Name Section/Lot# Lot Size
Direetions To Site: �ti�,,n ,r,�cCi�Sv:�t-e �1tt4.w_ �T�S43 �ASi- �0 F-levsa£�}cw,v c:;�c.Lc 1aC�o�.-{-
1 ,/1'l�d..e t7o;,J��l i-1cwA�2D�c�.J�'� G��cl.c gArn �t,��r•sS i,•�ra�f ' S orJ �hc i��-�
Date House/Facility Comers Flagged__ �-Z�'Q�a
If the answer to any of the following questions is"yes",supporting documeniation must be attached.
Are there any existing wastewater systems on the site? 7�es �o Z lieies ���eae��u��/yr �
Does the site contain jurisdictional wetlands? ❑Yes (�i4"o .
Are there any easements or right-of-ways on the site? � ❑No
Is the site subject to approval by another public agency? ❑Yes C�I�
Will wastewater other than domestic sewage be generated? ❑Yes p�
IF RESIDENCE FILL OUT THE BOX BELOW
#People �f #Bedrooms 3 #Bathrooms 2 ��Z. Garden Tub/Whirlpool ❑Yes C�10
_ _ Basement: ❑Yes o Basement Plumbing: ❑Yes �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 system requested: �Conventional ❑Accepted ❑Innovative OAltemative ❑Other
Water Supply Type:f�Gounty/City Water �New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �'No
If yes,what type?
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 understan�l that I am responsible for al!charges incz�rred
fi�om tliis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health llepartmcnt to �
conduct necessary inspections to deternune compliance with applicable laws and rules on the above described property located in
Davie County and owned by Cc e�" i�-��dN �
.
lJv�^��� �'
Site Revisit Charge
�, P erty o ner's or owner's legal representative signature
�— Date(s): `
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Date EHS:
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Sign given ❑Yes ONo Account# � V!Z
Revised 2/06 �j �p -� �Invoice# �J�
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�. . DAVIE COUNTY HEALTH DEPARTMENT
',, • �' •' Environmental Heaith Section
� Soil/Site Evaluation
APPLICANT INFORMATION �'ROPERTY INFORMATION
Account #: 990003962 Tax PIN/EH#: 5860-29-3926
Billed To: JerryAllen Subdivision Info:
Reference Name: Location/Address: Sam Allen's Way-27 28
Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: � �
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Water Supply: On-Site Well Community Public �/
Evaluation By: Auger Boring Pit Cut `
FACTORS 1 2 4 5 6 7
Landsca e osition L, �
Slope % ��
HORIZON I DEPTH �- �� �-
Texture rou ,[,
Consistence /T' /`�
. Structure �
Mineralo ,•
HORIZON II DEPTH � /� �i
Texture rou
Consistence l
Structure S .L
Mineralo / l
HORIZON III DEPTH • '' ti � �
Texture rou !J i
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
. Structure
Mineralo '
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFTCATION
LONG-TERM ACCEPTANCE RATE , c ?
SITE CLASSIFICATION: O� EVALUATION BY:
LONG-TERM ACCEPTANCE RATE:_`� OTHER(S)PRESENT:
xEEM�txs• ��} �`�0�o.y JUa �/'a vr S .�L— �� --Cj `�
LEGEND
T.�nd�a�e 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
Tgxtni� . .
S -Sand LS-Loamy sand SL-Sandy loam L-I:oam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
('ONSTSTF.NCE
�41SL
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firtn
3�'e.t
NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S r� �r
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
MineraloQv
1:1,2:1,Mixed
��
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)
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Davie County Health Department
Environmental Health Section
' P.O.Box 848/210 Hospital Street '
' Mocksville,NC 27028
(336);751-8760/Fax(336) 751-8786
May 17,2006
Mr. Jerry Allen
155 Sam Allen's Way
Mocksville,NC 27028
Re: Sam Allens Way
Tax Pin#: 5860-29-3926
Dear Mr. Allen,
As requested, a representative from this office visited the above site May 11, 2006 to
perform a site evaluation. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed,the site was found to be provisionally
suitable for the installation of an on-site sewage disposal system.
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 or the intended use change.
Improvement Permit
System To Serve: � T�rn� Wastewater Design Flow: 3�b
System Type: C�Conventional ❑Accepted OInnovative ❑Alternative ❑Other
System Location: /5s ��r�vr p11eNs w� �PQ2 Valid: �ars ❑No Expiration
Site Modifications/Permit Conditions:
�a��t��/��• — l� D�
Environmental Health Specialist ate
ps-i.p.letter 2/06