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165 Shaggy Bark Ln DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street . `•-� - � -`• Mocksvitle,NC 27028 ' (336)753-6780/Fax#(336)753-1680 � , REPAIR OPERATION PERMTT Acct�unt #: 990006002 ... . .• Tax_Pl�€/�H#: F600000124 ' _ . 8iilc�To: Nicole Ijames :........ �Suk�divisioii�info: . . . _ .. .., ,. _ ; i ;. Referer�ce Nar��e: REPAIR PERMIT David Purkey��: . . . :::.E�ocaiitznlAddr.e5s�.`165'Shaggy Bark Lane-27028:::� >:�.::f. .'. _.. Pro�o�gd F;��:i€iEy: Residential Repair � � ";; ��Pfb�erty�Six.e::= :.1�Ac = ; ` _ �TC�1etC��* �i@1�suance of this Operation PermiYshall indicate ibe-s�}��em 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 systern will function satisfactorily for any given period of time. . r �� ,,� System Type:_ �� S.T.Manufacturer �—Tank Date ��`6� Tenk Size Ffia�J/�•.� . Pump Tank Size__'�T Bedrooms�_ - 4 . System Installed By:� G�6N,'.�� ;-.� Installer#: I I � O . Date: I�a3—�.3 GPS Coordinate: . `; - G�.�fcra!� �r . � �5h� �� -� _-� � - �` � y . , � I =� . ��1 . 1 _ . ' c� Gh � � ,. ,Q, . . ) /�,• . � ' ��1 . \/ �\ `! ch g V�� . �, � , �. �,co` � co —,� ( . G , � �/V�� _ . , � � , Environmental Health Specialist: Date: /r(!"3��3 . � ' . ' DCHD I 1/06(Revised) / ' .�.�b,� DAVIE COUNTY ENVIRONMENTAL HEALTH • ' ' ` ' P.O.Box 848/210 Hospital Street Mocksville, NC 27028 . (336)753-6780/Fax#(3�6)753-1680 , AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTIOIY • Acco�nt #: 990006002 . � � � <;: '��x:P1NiEH#: F600000124 . Biile:d 7a: Nicole Ijames : ,. ; :��uE�divi�ia�t lnfo: . . . . R�fer�r�ce Nanie: REPAIR PERMIT David Purkey: � .: � ::�:Locat9oniAdi�r�ss :�•165 Shaggy,Back Lane,27028:� . . > Praposgd Fa�iEity: Residential Repair �t,�;�,� � w.<� :�;��Pro�rcr��&iz�:�,,�,1;Ac - : . , - -.: Site Type: �New J�;;Repair ❑Expansion ATC Nu�ber: 6017 ., . '�� . .� ... ,:�% , : ; ` , **NOTE**T'his Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Environmental Health Section prior to.issuance ofany 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 t : or the intended use change. Residential Specifications: #Bedroomsr�#Bathrooms �- #People S Basement�Basement plumbingG Non-Residential Specifications: FacilityType #People #Ssats � Square Footage(or Dimensions of Facility) � ' Lot Size�_ Type of Water Supply: DCounty/City �Well OCommunity Well System Specifcations: Design Wastewater Flow (GPD)��Tank SizeC��kS7-c�(�AL.Pump Tank / GAL. CJ Trench Width�(`� Max.•Trench Depth� Rock Depth�_ Linear Ft. 3�o a5d� Site Modifications/Conditions/Other: �� `� Contact the Davie County Environmental Iiefilth Section for final inspection of this system between ' 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. '��':��.. . - , f�L �.:,.:.,,� _t � i.;��:�,.�'..' . '. • . , / // . f � 4 � �, � � 1� � �'� �� N�� - /k �; � /�,rt`'� . _ � �� _ . �3�t' Environmental Health Specialist � Date: � 2�( DCHD 11/06(Revised) � , , .•. • DAVIE COUNTY ENVIItONMENTAL HEALTH . .� ..._ :� P.O.Box 848/210 Hospital.Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATIONPERMIT ��J ba� oO I� - - - Account #: 990004276 � Tax PIN/EH#: 5860-09-6631-1A � Billed To: Nicole ljames . Subdivision Info: Reference Name: David Purkey ` Location/Address: 626 A Howardtown Circle-27028 Proposed FaciGry: Residence • Property Size: 1 Acre � � ATC Number: 4661 I��(`�`J (�t��LL�• **NO�'E**The issuance of this Operarion 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. (,�a . - �� l�� '��s� � v� System Type:� S.T.Manufacturer�_ Tank Date � f -Pump Tank Siz-e� T (�,, ,[ � S stem Installed B : c � �E H S ialist: o U'��vD e: J �-�� Y Y P� 4 C� = r�-��rt( �V�G °,w �G« ��l ��r� .,.__._ ._._ — " ► �,-,v1 : o�r � _ � � �b �� J� '�ro�n� �( � � �� 4�t . � -o � \ G� ,}�Cc C �- �„`"`- CJ � ' `, 't�` �� G �� „�;Q^° '" ��g j�,�o �o� O C �,� � I DCHD 11/06(Revised) ' (�b2 ' : � .. . . , . Pd . , .: .� , DAVIE COUNTY ENVIRONMENTAL HEALTH � / P.O.Box 848/210 Hospital Street `�`�1 Mocksville,NC 27028 '�j` (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004276 Tax PIN/EH #: 5860-09-6631-1A Billed To: Nicole Ijames Subdivision Info: Reference Name: David Purkey Location/Address: 626 A Howardtown Circle-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 4661 �� Site Type: C�1Vew ❑Repair ❑Expansion **NOTE**This Authorization to Conshuct(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 � #Bathrooms � #People�Basement� Basement plumbing0 Non-Residential Specif cations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �. �CI-L - Type of Water Supply: ❑County/City Ef Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) 3�eo Tank Size �d ovGAL.Pump Tank�GAL. Trench Width 3 G`� Max.Trench Depth �� Rock Depth �� Linear Ft. �_ �,� r �;v�T�.c.�acG D�� t{p•• Site Modifications/Conditions/Other: �rR �ta�ed in 15A NCf,C 18A � - — -- ->- - - . _ ys ems may.a s+� 4�► use _ _ __ _ — _ 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. , . ; � �_ "'�,r.L.�ei .Roa..d ._� � �w.4�� , a�� f I �o„a, � �o�.-�.�dtou-� � � c��. a� � o� �� -�-""t � �� `� � ` �� o �� o � .� �owS� � �� , i � . ��,��{-�.� D r�P �o r-�3 , w'..�, 3 Environmental Health Specialist • Date: � �� a� DCHD 11/06(Revised) ...- � .� p a . �. := � . � � . . . . . �� . PI��ATI��O ITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health � ENV;RONMEt�(fAIHEAl1N 'P.O.Box 848/210 Hospital Street DAYIE COU4tiY , Mocksville,NC 27028 _ (33�751-8760/Fax(33�751=8786 Application For: p Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) `� Both Type of Application:�JNew System ❑Repair to Existing System OExpansion/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 instructions. APPLICANT INFORMATION Name to be Billed t c� � S f{✓vl� " Contact Person / � �� (r�u.r.��- Billing Address D` c l ' � Home Phone �r��j'S -S�� S` City/State/ZIP M ��(C � ((� L !,2` Business Phone '��` b�� ( Name on PermidATC ifDifferent 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 ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name 1� i Gd( " � �s' Phone Number__�]q�-�,�,�� Owner's Address D 1'� � l I i r1c� City/State/Zip ��'jac�,U�l l�� _ �?D 2� Property Address ' � r�-r o�rl 'r�.�� City_�'�'�c.�LCS U 1 (��,�(� Lot Size � p-�E Tax PIN# S�f<o(�C�9 lo��3 l-�} Subdivision Name(if applicable) Section/Lot# Directions To Site:_ _�� E� -�-� � r,c�� i,s� �1 L;rL( , q � ;�. rn, �5 7.0�L /.�ti� t^i q h-�' ' If the answer to any f the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes C�o Does the site contain jurisdictional wetlands? ❑Yes � Are there any easements or right-of-ways on the site? �s ONo Is the site subject to approval by another public agency? ❑Yes �o Will wastewater othei than domestic sewage be generated? ❑Yes C�io IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms r� #Bathrooms ,�-- Garden Tub/Whirlpool �es ONo - Basement: �Yes G�iQo Basement Plumbing: OYes C�iQo 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:, C�onventional C�ccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water C�'I�iew 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 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 Department to conduct necessary inspections to deternune 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. t ' �/� � �v�'�'4i1 Site Revisit Charge Property owner's or o 's legal representative signature , Date(s): C b� Client Notification Date: Date EHS: Sign given ❑Yes ❑No I 7 j'1�� Account# '� Z Revised 11/06 �'V Invoice# -�I!`�� i� t '�-...� `' ' � . ' .�v��.v��ur��vi��vV � Vt11�J . � S 7�°4~��-� . . �,��:j J„� '--,_„� � C � �o _.__.,._.____' �— ✓ �'2�'^�-._�.��'$ fr�� Cor �o z �-�---...��_ -`u , r, _._� .�UQ Acr c + � s ^,-,-- Tar, Lat 10�.02 � ;v� � /rn Tax ;_ot t 06.Q2 . � - Tax tvlap F-6 o i -pro osed 3 ,Acce�° Eas�t^tnt `-'� N �' David Purke� �� F �o o, ��x ��,cp F-6 and wife � ^�./ (se� Ea ...., ` ti "cb;ei ��co David Purkey ��' r'� and v�ife r� Constance M. PurY.ey �' / �9�•�2� Canstcnce M. Furke ��9,4�, L�n� RB 551 � FG 7?5 iRs � --___L._.�_ tv 89°12'4Q"Fi' � tR5 RB 551 � PG 775 y �v �4g�5j„ ----------�--__ �. W �, �-,� � • I�S I4i f `�$ -_--_--Grc_ve!Drive----___ --- �'� - _' �'" --' '� - ----- ----� �-i`` �_�___.��_ e 4 � S 83a12'�-0"E ---------__ �----- __ _ � _ __ ___� - . ______,� !h'S E-------.__ '- � --,_ 'if-� __--' -----=ra�vP-`- �,I � 29�'t..24' �-� _ '� ``-----_- ____.�-3(�� _ _Ori��-�f�� f1p F�d r�� p �Q� � ' '' E-6`__`---- � -��1_ � 1S c`�oSF` � - „" �'X"r� r:-- �.4 ��"� \�\ o°'h 8 / q' e ,v` ,N � �O� LreS � r.°�j o Prcposed 30' Access Easement f 3 � ��X F�e�'�e� � _��— � N (5ee Easement Cali Table) � �`� • � o cn Tax Lot 106.Q2 �� , / S 85°�3 2�, _ �v tn . Tax l4ap F-6 ,F`.� y� ,� � 285.32' 3�1.42� Tofaf N 85�"',� vl R David Purkey o �' �. Tre'Cine IftS (245.50') 30'25 W and wife ,�e�`6 '� / -------�. (55.92�) Consfance M. Purkey �0cti; � // • v Tie (,�ne RS 55] � PG 775 90 ��' / '= IRS 644.97' =° ��" Contro! C � 8S'30 5"W / ,�,c q orner ;---._ __�„r. �/2" EfR Fnd (S 85 0f' 647, / Tcx Lot 100 a�'� NZEA IN �UESTION: GAP �t B 6„E �� " ----- bY witnass EIR � Tax Map=F=6:' . AREA IN QUESTION: GAP Point�g�nd O .O� / n/f J D :Pa{lard •' »� / and w�fe , � �� Mildred�8, Poflard . l 0 DB 64 �; PG 168 j Tax Lot 102 ' �� Tax Map �-6 � _ . n/f Laura Jo Robertson I DB 161 � PG 2�5 . - . ' 1 oning,Classi�cat�on f withm 2000' of:�site . , , � - _ . � � ';� . . ., . � � " � � 'C ='Face of Curb ' ' �• toc = eaok of-:curb `: � 'P - Pn�er Pole ' P - L,qht.Aole: H -Nan Hok';� N -.Chord Dictarroe ,:; - /Q --:Part nf�: . . � �� k "C{we) hereby understand that this plot is appvoved as exempt from tha B ,:'{�t.Baok'. Subdivislon Ordinance of ➢avid'County.::Thfs.is q iomfly subdiyision and B�- Retprd BooCc- ' is for tha eKclusive purpose of conveying':land among:famlty tf�embers G - Pa�qe , : , � . . B-�,�+th EJasir� r • within ifie.third degree of tineal ktnship, .These lots/tracts aNal(noY ba - S 5ewe�t,Ine; ,:. ' ` usad for the purpose;,of sale ar.building development, efther now orin'the A1 Woter'rllefer , . , . _ . . . . �...__ , .. . .. _. . .. , ., . _ ... . _ � i..._� �__... . ... .. . . . . .. . . . , , . ..,..:w,.. -,, .:.�,.�..-.-,��..� . .,__ . . ,_ . . i ° � L960 ,� - I � ` �Hb6'L) iw � . i, ; � ; ;� b008 w` � N' ' ' �V�OZ) �, � : � i � _ oQ _ _ , � � : �f --_ 680E � i i I - o�z � , ; _ - ��859 �'_� <<BZ� ; _ . a�' � �._._. _ __ � a. , ; -- i N i - a O .. ___._..__ . . . �' .: > � ' �: ' .._____._ 1 ! � . . . -. . i . � ._ 'f� I . �e . . � /1; � 99Z8 4 � �` �H49'E) �' �a� � o o- . , :S � � l � �..,� �a' i _ , � i .,, � (E9S).. __ .. .. . . !"�� . . -'_------ '�_....^. . Z£Zl �-..- � __�: , ___��_.__� _,_.- .. ... -- 6 6 6L � — ` _ :. .< <. � _ ,,. �, . � � ;. . ; . , , ..�} :: \�''V , : Q S W j ;_ �Es� a .�� _ cvsEs> 8u� e � , Z�g - _— � ;-:.. _ � - < <e�� .---�._ _ , � du� �� __ ._ , ____ 1, _—`-- >""� �� 865 �5� -- ----__�.� rs�,�� cv�� s) � / ( _ ---.._;.� . I (� - �'�--- � , I _ , . .�. . .. _� � � .. N �+ ��• • DAVIE COUNTY HEALTH DEPARTMENT ' . . ' . • • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004276 Tax PIN/EH#: 5860-09-6631-1A - , Billed To: Nicole Ijames Subdivision Info: � - Reference Name: David Purkey Location/Address: 626 A Howardtown Circle-27028 Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: � �" �3'�7 Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring v Pit Cut FACTORS , 1 2 3 4 5 6 7 Landsca e sition Slo % • . ,. HORIZON I DEPTH -� t� G--I�- 0 - ( • Texture rou C L t- c� Consistence Structure r41' � (C ' Mineralo � �a , HORIZON II DEPTH - t 2.= Texture rou L� L Consistence N� ' Structure rR,v C + S h Mineralo �l * � HORIZON III DEPTH � 7 �-� Texture rou Lo.,� Consistence � r Strl1Ct112'0 ,-,�. • Mineralo 1 t�] f HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON - SAPROLITE ' ✓ CLASSIFICATION LONG-TERM ACCEPTANCE RATE U. .. . . . . . �D�7/,�'4.��{/`-� SITE CLASSIFICATION: "P( �L�' ��` 1 � � �'O EVALUATION BY: � �u LONG-TERM ACCEPTANCE RATE: V- � OTHER(S)PRESENT: �� `�v�� ' �`'� -y . .��- xEMARxs: .M 1�4��:� ��,.��,..,:..C��, �-' �Z+ - LEGEND i.andscape Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-F1ood plain H-Head slope . Tr�cf� � 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 ONSIST ,N . , N�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 . , t i ,r .; SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv _ 1:1,2:1,Mixed 1'Lot� . Horizon depth-In inches , Depth of fill-In inches Restrictive horizon-Thickness and inches from land,�urface ` Saprolite-S(suitable),U(unsuitable) Soil wetness-Inches from land surface tp 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) j` � � ', . . Davie County Environmental Health � . • . P.O.Box 848/210 Hospital Street , �� - �• Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 ' IMPROVEMENT PERMIT Account #: 990004276 Tax PIN/EH#: 5860-09-6631-1A Billed To: Nicole Ijames Subdivision Info: ; Address: 2103 Milling Road Location/Address: 626 A Howardtown Circle-27028 City: Mocksville Property Size: 1 Acre Reference Name: David Purkey Propo*edF i*it�r• R sidence NO�� 'I'his�mprovement 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. Pernut Type: ew ❑Repair ❑Expansion Pemut Valid for: 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): �. �i'��.� Type of Water Supply: ❑County/City UWell ❑Community Well � As stat�d in 15A NCAC 18A.1863(5) i Site Modifications/Pernut Conditions: ACCepted Systems may al�,o b� used '; S stem T e LTAR Inirial • R air • Site Plan ,� {�r-�Li�.�t-�-_—� �G �,�14. i �� Ela....�.��lou�'` t a� C��r c 1-Q . - _l _ _ f ,� , ._. •� - �-��t, 1 � i� �y�� f ru�fi ��l . ��r ,�i,G I � ,� R,�e �� 1° , ' �.y�a 5�ts�� _ 4' 6.' . .. �..�.•. � O'/ Environmental Health Specialist , Date f= �-�� i.p.i l-06 , .