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2214 Sheffield Rd . . . ' , '' . DAVIE COUNTY ENVIRONMENTAL HEALTH ` P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT f'�cc��nt #: 990005252 T�x FIP�:EH�: 4890-79-4760 ,,Q �iiled Ta: Chris Lamb Sub�livisior� Ir3fo: �Z�L� s`/1e��%l � Ref�rer�c� Nan�e: Lacationiac3c3ress: Sheffield Rd.-27028 � Pro�c�sQci Fa�ifity: Residense Pco�ar#y Size: 4.346 Acres ATC �tuEnber: 4966 � �G�ZGn�-f �!3�?r2ad n�-s **NOTE**The issuance of this Operarion Pernut 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 . �e. � ,�� System Type: � S.T.Manufacturer�,��''��` Tank Date � Tank Size�0 O� I Pump Tank Size System Installed By: �� E.H.Specialist: ate: ��O v"� � 1�,W ��LLo-�-� � . �_. ��.��. � a��`� . �!' - �+�'^ . � , 4 . �� t + � I �� -r � � v � r..v '�r� I � � � v � , � r � ��s �� . �, � � d 3 � � �� , � � /J Lr.. � � � ��G- � I �� "{ ,��X , k��`��`� �� '�d � � DCHD 11/06(Revised) �� L� , r , . �. . -� .�' r_ � , . .. � � - - ��• . .. . .-... . • ~� � ��/�� V • `� . : . 1?A'V�C�UNT�EN'VL�L�NMENTA�.�'� �1� • P.O.Bo�848/210 Hospital S�eet � I Mocksville,NC 27028 ! (336)751-8760 Fa7r#(336)751•8786 � , , A,U'I'HOR�ATTON�'OR vVAS�'�WA��t SYST�M COIVSTRYJ'C'�ZON Account #: 990005252 7ax PIN/EH#: 4890-79-4760 Billed 70: Chris Lamb Subdivision Info: Referenc�Name: LoCation/Address: Sheffield F�d:27029 Praposed Facility: Residense , Property Size: 4.346 Acres • � 1 ' ATC Number: 4966 • Sicc Type: CC3'NNe�ov �Repair ❑�xpansion .• •'NOTE•'This Authorizatioa to Canstruct(AxC)MC)'ST B�ISStiIED by the Davie County Environmcnt�l, Hea�tla Section pxior to issuance of an�building permit(s),(in com�aiance witti Aracle]1 of G.S•C�sapter 130A Wastevvatcr S�stems,Section.1900 Sevvage'�'rea�ent and Disposal Systcros). 'T�S AYJ'T'HOYt7ZATION TO CONSTRCJGT TS VAL,�FOR A p�RI�D OF FFVE X�tS. 'X'�is t#x'C is suT�ject to revocation if site plsns,plat or the intended use cba�ge. Ytesidential Speeifications: #Bedrooms�#Batka�coonos,�#Peoplo Sase�ae;nt0 Basemtnt pinmbing0 Non Residemtial Spec�ifiiestionuc: �acility Type #People #Seats , Sqvare Footage(ar D'vmeasions of Faciliry)� ll.ot Size � ,3�-( (�Q��'r�pe of Water$upply; OCounty/Cit'y �Vtll �vmnv�ntity'Well 0 ��/� Syscetn Speci�iutions: Aesigu'GV'8suwater Flow(GPD) •Tank Size_ �D OAL.Puaip Tank 1vR, "JAL. Tr�w�a�n �G �`Maxc.Trench Dcpth3� ,+ RacJcDe�th /�,�/ Lincaz Ft� ' Site Modifications/Condiuons/Other. � �� A �� "�'`'�� cs�p4�d S�toms�r��t�o� Comiact the ria�vie County Environmea►ial�ealth Section for final ibspectioa of t}ais syat�m bei�veeb � 8:3D�9:30a.�m,on tLe da oi iustaII ' - ele ho�e# 33 751-$760. 4 ' • ��.� .� .�..� --��" ."._ � � �..� -�-- ..� ��-J'��,/�.�.� --�—' _ � � - `r r 1 � ��o�v� � � � t L � � � � �... � `'�� p(� " a 3 � � �-'�� ,� ( � r � . ` , 1�d3 Environmental Health Specialist �i��'.!! Date: �^ ��/ nc�d iio£�L9��N� . wds��s sooa � aa� i�r ; �� ay 29 09 '12:31 p Davie County En�ironmenta 3�6.7518786 p.1 . I�AV�E COUNtY ENVI�tOrMENTAL��LTH � " P.O.HOX 8�!$i21 O T�OSpital S�cst ro � r{� hiocks�vi_!c,NC 270Z8 ��` (33G)?51-8'6Q Fax�;330)751-378u AUTHpRIZAT70�1'FOR W_9,STEV6'a'rEx SXS'�'E]�i CONSTRUc[zon Account i�: 990005252 Tax PINlEH#: 4890-79-4760 • BilJed To: Chrls I..amb Subdivision Info: Reference Name; LocationlAddress: Sheffleld Rd.-27028 Proposed Facility: Residense P�openy Size: 4.346 Acres � ATG Number; 4966 5;t�TyFe: GNew nRtpa'v uExpansion "4'NOTE•'�Tb�is Au 'on to Con3M�ct(ATC)MUST BE]SSL"ED by tha Davie County�rn�u�nmenta] �lltallh Sectiotl prior i�su of any building po�mit(s),(ia complianct witfi Article i 1 af G.S.ChapEer 130A Wastcwatcz Syst,�a�s, octiQn_19 Sewage Trcatmcnt znd D'uposal Sysiems). THIS AUTI�OR1zATiON TO CONSTRC:CT TS V �R,�pERYOD OF FIVE Y�„P�RS. Thts ATC is snbfect to revocation if site paQ�os,plat or the intended use ang�.; '� RqidentialS�eci�ications: #�3edzooms �Ba•,hroorna �,People Basem�ntCBasementplucnbing� �l'on-Resideatial Speci@cationc:��,Facili't,q Type #People �Seats Square Foorrge(or Dimeasions of�'ecility) ' Lot Size '�pe ofwatcr Supply: �County/Ciry CWell t7Community'DV'ell 1 Syctem SpeeiII¢xtions: Desig�s'W'ac�araur Flow(GPD) Y'ank Size GAL•.Pump'x'pnk GAL•. Trench Widch`T_ Max.Trench bepth Rock Depth Lineaz Ft. 1 , Sitc Modifications/Conditionsl0ther: i , Concact We Dsvie Couttt�►�nvironmSotal X�eslth Sectioh ior fin�l inspeetion af thfs systetn bccween • � $:30-9:30s.m.on the of tuatallation. Tele ltone# 33 751-8�6Q. , 5 , a 1 . ; �� . � . i ' �� ' � � � Eniironmental Fiealth Sy:ciali�t Date: �� d��6�:a�cs ��N wd��s —sooa �aa� i�r ; ;. � ' Davie County Environmental Health • • � P.O.Box 848/210 Hospital Street � , Mocksville,NC 27028 'v'��. (336)751-8760/Fax(336)751-8786 � IMPROVEMENT PERMIT • � � �i, Account #: 990005252 Tax PIN/EH#: 4890-79-4760 Billed To: Chris Lamb Subdivision Info: Address: 4226 NC HWY 174 S. Location/Address: Sheffield Rd.-27028 City: Asheboro Property Size: 4.346 Acres " Reference Name: Proposed Facility: Residense **NOTE**This Improvement Permit DOES NOT authorize the conshuction 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: ew ORepair ❑Expansion Pernut Valid for: 5 Years ❑No Expiration Residential Specitications: #Bedrooms � #Bathrooms�#People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) � Desiga Flow(GPD): (•3�� aU`�-�'S Type of Water Supply: OCounty/City ell OCommunity Well Site Modificarions/Permit Conditions: c c :ri3�Epi�� Sygt�ms may als��b� us� S stem T e LTAR Initial c c < -�c0 CS - '� Re air c c-� ec� �- ;. .��"_ _ `—' _ —_ _, _ — Or��ts.aF��` -_ _ � - — — � r — I ( . . 1 -� +a,` L_- �_ /I �� 9 Y � 1 � 5��'`� �� ea- s � � �-- Q C-Q u �'�,��4 � � -r� � ` � S � Environmental Health Specialist Date �/�3a � � i.p.l 1-06 � ; , . r . . . APPLICATION�FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 IIospital Street Mocksville,NC 27028 � (336)751-8760/Fax(336)751=8786 Application For: 0 Site Evaluation/Improvement Permit 0 Authorization To Construct(ATC) C�Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIItED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � � Name to be Billed � �S Lr� ,� Contact Person Billing Address � 2 Home Phone "7U • .��(p7�� City/State/ZIP p Business Phone �� A/„Z rlZ�(� 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: O Site Plan ❑Plat(to scale) (Pernut is vali for 60 mont s with site plan n expira ion ith complet plat.) Owner's Name �1/ ` LY P %sQ c�Phone Number Owner's Address W City/State/Zip �.Q'C�'`l// 'e Property Add ess � City Lot Size �, �c�� Tax PIN# � --�/7(�a Subdivision Name(if applicable) Section/Lot# Directions To Site: � If the answer to any of the following questions is"yes",supporting documentat�io ust be attached. Are there any existing wastewater systems on the site? DYes ❑No Does the site contain jurisdictional wetlands? ❑Yes � Are there any easements or right-of-ways on the site? ❑Yes B1�O � Is the site subject to approval by another public agency? ❑Yes ��' Will wastewater other than domestic sewage be generated? ❑Yes ONo �F RESIDENCE FILL OUT THE BOX BE OW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool OYes ❑No Basement: �Yes ❑No Basement Plum ing: ❑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 systemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ew 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 conect to the best of my knowledge. I understand that any pernrit(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 determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging ' or staking the house/facility location,proposed well location and the location of any other amenities. � � ,� ��?'/� �eu��/A�� ' � Site Revisit Charge . Property own r's or owner's legal representative signature �` �� , Date(s): Client Notification Date: Date EHS: �� Sign given ❑Yes �No ' • Account# � Revised 11/06 Invoice# _�n G3�