368 Speer Rd ` ' DAVIE COUNTY ENVIRONIvIENTAL HEALTH
, � P.O.Bpx 848/210 Hospital Street
� Mocksville,NC 27028 3 �
(336)751-876Q Fax#(336)751-8786 z�
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OPERATION PERMIT L.d
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Account #: 990004204 Tax PIN/EH#: 57812-73-3967
Billed To: Chadwick Trivette Subdivision Info: .
Reference Name: Location/Address: Speer Road-27028
Proposed Facility: Residence Property Size: 5.1 acres
ATC Number: 4580
**NOTE�*The issuanoe of this Operation Permit shall indicate the system described on the ATC bas 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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DCHD 11/06(Revised)
DAV1E COUNTY ENVIRONMENTAL HEALTH
: �* P.O.Box 848/210 Hospital Street n�,r �
. Mocksville,NC 27028 Y ��'6
(336)751-8760 Fax#(336)751-8786 �i�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004204 Tax PIN/EH#: 57812-73-3967
Billed To: Chadwick Trivette Subdivision Info:
Reference Name: Location/Address: Speer Road-27028
Proposed Facility: Residence . Property Size: 5.1 acres
ATC Number: 4580
**NOTE**This AuthorIzation to ConstruCt(ATG7 MUST BE ISSUED by the Davie Cowaty Environmental
Health Section prior to issuance of any building permit(s),(in complianc�with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treaiment and Disposal Systems). THIS ALJTHORIZATION 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 Spccification:Building Type Sr+�,.,�#People �{ #Bedrooms � #Batbs 3•5
Basemeat w/Plumbing:_Basement/No Plumbing�,
Cominercial Specification:Facility�pe �#People #PeoplelShift #Seats
Lot Size Type Water Supply Design Wastewater Flow(GPD) Site:New Repair "
System Specifications:Tank Size �G��iAL.Pump Tank�GAL.Trench Width.3 Trench Depth.3G `�
Rock Depth (�" Linear F��
Other.
s s�ate ir �.� . .: a
. Required Site Modifications/Conditions: �cCe�.-�ted Syste+;�s rr�ay ai�a b� 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# 33 'I51-8760.
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Environmental Health Specialist Date: �— 3 D '�d� �
DCHD 11/06(Revised)
� �
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• APP R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� ' ((�� � � bavie County Environmental Health j_ �
D � " P.O.Box 848/210 Hospital Street ��� l�J� ��
, 3 ,��') ' Mocksville,NC 27028 � `. /��'�� �
�A� (336)751-8760/Fax(336)751-8786 `��-� _ ,3-0� �j_
'
plic ion F • � ���.��ation/I ovement Permit �Authorization To Construct(ATC) �Both.
T e o p���x�C� s em �Repair to Existing System ❑Expansion/Modification of Existing S stem or Facility
* ORTAN7***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 ��,�,� �� I✓,ik-"�C.
Billing Address 5 � o Home Phone 33(���t�r�--'71 a
City/State/ZIP ; D Business Phone 33 Lo-7�1`�O �x'T• !D l
Name on PermidATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged 1 Z D
NOTE: A survey plat or site plan must accornpany this application. Included: ❑ Site Plan 1�plat(to scale)
(Pernut is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name . :v� �. Phone Number .�.3�0� �oZ'7/0
Owner's Address S� � City/State/Zip lYlo ; 0
Property Address Y City (Y1�5�,"1�c,
Lot Size _,r","I acrcS Tax PIN# .5'�f� �7 3.3 q�7
Subdivision Name(if applicable) Section/Lot#
Directions To Site: �' �a � I..- �c.. v Go l. n�i C�S �v n r�c�h
�. �,� o .lo ; r�r f -1-. :I fc ,�/.
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? ❑Yes�No
Does the site contain jurisdictional wetlands? ❑Yes�''iNo
� Are there any easements or right-of-ways on the site? � ❑Yes No
Is the site subject to approval by another public agency? ❑Yes No
Will wastewater other than domestic sewage be generated? ❑Yes No
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms 3•5 Garden Tub/Whirlpool�'�Yes ❑No
Basement: ❑Yes No 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 DInnovative ❑Alternative ❑Other
:�
Water Supply Type:� County/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 applicarion is true and correct to the best of my Imowledge. 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 determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identificarion and labeling of property lines and corners and locating and flagging
or staking the ho e/facility locati n,proposed well location and the location of any other amenities.
Site Revisit Charge
Property owner's or er egal representative signature
� Date(s):
� 2 ��b Client Notification Date:
Date EHS:
Sign given ❑Yes �No Account# �� ���
Revised 11/06 Invoice#
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• • DAVIE COUNTY HEALTH DEPARTMENT
. ' Environmental Health Section
. � Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004204 Tax PIN/EH#: 57812-73-3967
Billed To: Chadwick Trivette Subdivision Info:
Reference Name: Location/Address: Speer Road-27028
Proposed Facility: Residence Property Size: 5.1 acres Date Evaluated: � '-� �—��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 . 2 3 4 5 6 � 7
Landsca e sition
Slo e % �.- -7 > > :
HORIZON I DEPTH
Texture grou G G -
Consistence
Structure S Bl�- r r K
Mineralo � t" ; 1
HORIZON II DEPTH -
Texture rou � -
Consistence - �
Structure K `d.
Mineralo � `
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou '
Consistence
Structure
Mineralo
SOIL WETNESS t
RESTRICTNE HORIZON
SAPROLITE
, CLASSIFICATION
LONG-TERM ACCEPTANCE RATE �."l�� � 0-`� U: �j `
SITE CLASSIFICATION: Qr�sii, � ����� EVALUATION BY: �r!� /v ��1�"L �
LONG-TERM ACCEPTANCE RATE: ����/ OTHER(S)PRESENT:
xENtAxKs: � r �' c� C P ` �� - �
- LEGEND
i, n s pe Position
R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
T�cLur.e, �
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 . ,
�QiSL
VFR-Very friable FR-Friable FI-Firm _ VFT-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
a�.tlll�,liL�
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv.
1:1,2:1,Mixed
LIo�
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 Environmental Health
P.O.Bos 848/210 Hospital Street
� � Mocksville,NC 27028
(336)751-8760/Faz(336)751-8786
IMPROVEMENT PERMIT
Account #: 990004204 Tax PIN/EH#: 57812-73-3967
Billed To: Chadwick Trivette Subdivision Info:
Address: 330 Speer Road Location/Address: Speer Road-27028
City: Mocksville Property Size: 5.1 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.
Pemut Type: Ci�1ew ❑Repair ❑Expansion Pernut Valid for: '�E�S Years ONo Expiration
Residential Specifications: #Bedrooms�#Bathrooms3_�#People y Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): y73 O Type of Water Supply: L�tL:ounty/City ❑Well ❑Community Well
Site Modifications/Pernut Conditions:
S stem T e LTAR
Initial P �� G.a � � ,
Re air �c . ec� G • 1 �
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Site Plan • ���
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Environmental Health Specialist Date � r 3�'" �?
i.p.l 1-06