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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� Jf OPERATION PERMIT L.d Z 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. o '� System'I�pe:� Q� S.T.Manufacturer S���t'f Tank Date 2✓�y Tank Size�� Pump Tank Siz �l�nNln.�-t�`�"�c ,�C'J\+v��"• � System Installed By: E.H. Specialist: �Date: `'`6��i���l� c----� �' -P� 2a0 ---- �.- � � �"Po�� � � I1 ���N�� ( ���-' I ��, � � � l ,� - � � ��� . � �s � °s s �l ' ' i�'�` � Iz 9 � oa. � 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. ��� � <�'� //��� � ' � � -��' ^�'� � � � � ` ���a`y s r►� v �� �b��r� "a � DEi � �� j ����� � � 1 � � ` � < < � � a d.p-O--O� -p-'T=\ — , __ _ � � . _ � - 3.�q ��s�a�� '�f CuC tl-t 5 6h CG.c'(p�,, � "_ �a�n� � (c,�w�L�k ,�,,,c,�1� b-� 5�wG 6�e� `�-'�`�P � � � P `�J . o�.... a5 S(10�� �� y� ��.C� � � � Environmental Health Specialist Date: �— 3 D '�d� � DCHD 11/06(Revised) � � � ♦ , • 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# ����— i . - .` — .. . .. _ ..... - - �1� , :i� ' , .- . .,. ,_. '_ , -. . f ..�� ��uW csos � O��lZL6 � � �H05'l) ` � 1i9�—' °' ZBuW �zo ���� � 9 L96E � ' �V8'L6) � o ' Z8 uW N � �, � � � I ` N ti L9� 0 , -=.- . .. . - .. '-. - ..�'(46S) 4 Zb ---- BIOC_— -_ . --� _ t�oz -- V � lbbL V ti - �g � N � N �5� ` ` .�-� (N7L'Q� Z£Z • • 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 . 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I I! g �' ��;�3�� ��- � � . - - - - �, �� ��oo n o 0 0 040��'3 L t{ `l� u a a a �mf a�= � 1�g � G � a a Cn �? D � �Y - � � . • 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 � �., Site Plan • ��� , � ` � 1 r , d� � S � � ' ��� � � � � � ..T� � � S � �� � � �^s�. �-L V r � � � � �- � � ` � _ � � �_ _ _ _ ��°� . _ � �- _ -�%�U.� � Q�, -- � � � ��'� � Environmental Health Specialist Date � r 3�'" �? i.p.l 1-06