136 Stone Meadows Lane Lot 2 t
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.• DAVIE COi�NTY ENVIRONMENTAL HEALTH
. � ' ' ' • �� P.O.Box 848/210 Hospital Street '
. : Mocksville,NC 27028
. (336)753-6780/Fax#(336)753-1680 �
OPERATION PERMIT
ACCou�t #: 990002277 '��x Pi�.�'EH#: 5841-08-8737
- BiEled Ta: A-P Construction Co., Inc. S�E�ivis�on lnfo;
,
Referer�ce Name: Timothy&Sara Gardner Laca�aniAdt�rass: 136 Stone Meadows Lane-27028
Proposed Facifity: Residence Pra�r�y&ii�: 2.644 Acres
�TC Number: 5773
**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. � �
� �
' System Type:��/ S.T.Manufacture��� Tank Date � Tank Size��
Pump Tank Size �
S stem Installed B , �
Y y:���(�1(�S �.C�1(� E.H.Specialist: ate:����
� GPS Coordinate: -
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DCHD I 1/06(Revised)
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� � `�r � '` '' DAVIE COUNTY ENVIRONMENTAL HEALTH '
' ' ' . . � � "� ' � P.O.Box 848/210 Hospital Streef � �
� -'� Mocksville,NC 27028 �
. � ' - (336)753-6780/Fax#(336)753-1680 � ' , .
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
������ �: 990002277 , ������/�}�� 5841-08-8737 ,
��(�����; A-P Construction Co., Inc. §��j���j����� ����:
,
. ���������{���; Timothy&Sara Gardner ������j�l���§§. 136 Stone Meadows Lane-27028
' ��'�����E��'��j��,y; Residence � ����}�aj.�.�����: 2.644 Acres
� . �1�.�i�����'_ 5773 SiteType: f�New ORepair ❑Expansion
� **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.Ghapter 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 �z #People�Basement❑ Basement plumbing❑r;
;
- Non-Residential Spec�cations: Facility Type #People #Seats "���
Square Footage(or Dimensions of Facility) ,
Lot Size O .1�� Type of Water Supply: �County/City ❑Well �Community Well . .
System Specifications: _ Design Wastewater Flow(GPD) ��v Tank Size�U�U GAL.Pump.Tank GAL.
• Trench Width ���� Max.Trench Depth��, Rock Depth/Ura Linear Ft. aG�L� �`
�L=�p i�FC�,L�.C'�Icr�
Site Modifications/Conditions/Other: �
.s,
Contact the Davie County Environmental Health Section for final inspection of this system between
j
8:30—9:30a.m.o the a of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist � Date:
DCHD 11/06(Revised) � 2 1Z�C(
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,., 'APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
��E��/E Davie County Environmental Health
�.� P.O.Box 848/210 Hospital Street
APR � g 2�11 Mocksville,NC 27028
� � (336)753-6780/Fax(336)753-1680 ,
� , _-
Applicat�`Yori or: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both
Type of Application: ❑New System ORepair to Existing System ❑Expansion/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 �•Pl'or•���...r�iv.. ��.. �c, ContactPerson �,.r,aJy Z., d�,F�c�;uU�6C
Address y�g 5�.:��G.N_c. pfir�y !Sa Home Phone ?$� -��� - �S/� C�i�
City/State/ZIP G�Jci•�v�v-- rf/e . Z?Zi 3- � Business Phone ��Ln- �'�3 - 3 Zo�
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Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Eacilit Corners Fla ed Z�l /
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is v�lid for 60 months with site plan,no expiration with complete plat.)
Owner's Name �n[a� � � �►4aP�4- Q� ��E+2- Phone Number /fb�-�Z7'�/
Owner's Address�/D �-TbN�/L1�orx�s Lr�.�/� City/State/Zip
Property Address Sr�v� //lfE,tt�yt�,� L�q�+� City
Lot Size �,(�(CF �¢G Tax PIN# jg�����1$�
Subdivision Name(if applicable)� Section/Lot#
Directions To Site:f��� Z-�(o to G�"or.c� '�,,���,�,�� ( Irj�(E l�b�-a�,a �,r„�rY] s
PDu�t��Z, cx.� ��''g k�'
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 �/No �
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 �/�Io
IF R�SIDENC�FILL OUT THE BOX BELOW
#People '�, #Bedrooms � #Bathrooms 3 % Garden Tub/Whirlpool C�es ❑No
Basement: �Yes �No Basement Plumbing: DYes �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 OAccepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: C�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 B�o
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 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
loca 'i and fla i r st ing the house/facility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Pro rty owner's or owner's legal representative signature � •
_---- .. .. . Date(s):
� Z���,�� Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No . Account# �2��
Revised 11/06 Invoice# ��
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� '� �"�" • .���' Nti SITE EVALUATION/IMPROVEMENT PERMIT & ATC �� .
' j � "�� Davie County Environmental Health 1�1�`�
' G � � 2��� P.O.Box 848/210 Hospital Street " Q��
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. Mocksville,NC, 27028 �� ��,�
. �VyRp�V�pp�N�-jN_ (336)751-8760/Fax(336)751-8786 ��'�
Ap ication F • P ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) [�CBoth �
Typ pplication: �New System ORepair to Existing System ❑Expansion/Modification of Existing System or Facility
i '
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFOItMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed� � 2► l ti Contact Person M
Billing Address 0(� /� Home Phone 36 7?/ -��'
City/State/ZII' �,.,,����,/,�„ ,�L a7�tl'� BusinessPhone ,�(0 6 —�� 7 !�� �
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged a �b���
NOTE: A survey plat or site plan must accompany this application. Included: �J Site Plan OPlat(to scale �
(Permit is valid for 60 months with site plan,no expiration with complete1�lat.)
Owner's Name �2 �� .�`(_L_. �IV Phone Number '�(� � �3�.
O��rner's Address � � ` City/State/Zip�dG-�CSU�//� v- • c�-7vL S1
� Property Address ' % City �]i,ec._,���ti`��L-� /�� C , '
Lot Size Sq-�. +. Ta P # ��U /D�(7 Fj� D
Subdivision Name(if applicable) Section/Lot# �T��� /
Directions To Site: l� 57' K� �era-i ,./ L t�iT %�n..�' j� �_ �-t�cl
N: '�L ' ' ' s� � /_• `G� S2_ —� Ld! !Z S,�a�e � yr' �
f tlie,ans er to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �To
Does the site contain jurisdictional wetlands? ❑Yes [�to
Are there any easements or right-of-ways on the site? ❑Yes o
Is the site subject to approval by another public agency? ❑Yes�To
W�11 wastewater other tlian domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People �'{ / � � � #Bedrooms ����2�J�,{�Cy�#Bathrooms / o arden Tub/Whirlpool Yes ❑No
Basement: ❑Yes No Basement Plum i� ❑ es o
IR NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/F3usiness 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; f�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
-. ' ;
;��
. Water Supply Type:1�1,Cour}ty/City Water ❑New Well OExisting Weil ❑ Community Well
.
Do you anticipate additions or expansions of the facility this systeni 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 perxnit(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 Depariment 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 comers and locating and flagging
or staking the house/facility location,proposed well location and the location of any other amenities.
� ,. Gt�t�- ` .� ��J� / .
Site Revisit Charge
�operty owner' r owner's leg representative signature .
Date(s):
Client Notificatiori Date:
Uate _�{-�-' � �� EHS: — ---
1 � .J W
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Sign given OYes �No � �`���� Account# ��
Revised 11/06 � `�/ � � Invoice# ��'�
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� � • • DAVIE COUNTY HEALTH DEPARTMENT
� ' � � ' " � � Environmental Health Section
. ,� , , � .
' , , • Soil/Site Evaluation
APrLICANT INFORMA�ON �ROPERTY INFORMATION �
' ' Account #: 990004415 Tax PIN/EH#: 5841-08-7890.02 -
Billed To: Tim Gardner Mike Gardner � Subdivision Info:
. '� Reference Name: ` � Location/Address: Pudding Ridge R� 702
Proposed Facility:.. Residence Property Size: 5 Acres Date Evaluated: ��
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.!` Water Supply �� � ' On-Site Well Community Public �
i�.
��r Evaluation By: Auger Boring Pit �- � `� 2�� Cut
. ; �
FACTORS 1 2 3 5-- 6 7
Landsca e position (._
Slope%.- (o
, - HORIZON I`DEPTH ,- �^ �tJ � - �-1
Texture grou C G
� Consistence , r'� ,� � 5
Structure L C h�. 1�-�
Mineralo � �
HORIZON II DEPTH � p- � I ,, r� S '"�
Texture rou � �
Consistence ' ` 'V Y�V
Structure , �
Mineralo l,�v
HORIZON III DEPTH � .-
Texture rou � � - � c �x�,
Consistence: �-,r ,,1� SS
,. Structure � - �� . G�
Mineralo . -
,_ HORIZON IV DEPTH -7 .
' Texture rou L
Consistence '
Sttucture �
Mineralo � �
; SOIL WETNESS �2. � -- -� .-
RESTRICTIVE HORIZON — (�-L �'-3 D-3�
SAPROLITE ti
CLASSIFICATION ' �
LONG-TERM ACCEPTANCE RATE O• 6.� '
SITE CLASSIFICATION: � EVALUATION BY: �
, .�
LONG-TERM ACCEPTANCE RATE: �' +� OTHEI�S)PRESENT: �
_ _ • ; ,
REMARKS: ' �
, ; : LEGEND .
T,an 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
Texture . • -
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 �
CnNSISTENCE . "
NI�iSt .
. 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 � ,
Structure `
� SC-Single grain M-Massive . CR-Crumb GR-Granulaz ABK-Angular blocky ,
SBK-Subangular bloc�Cy PL-Platy PR-Prismatic
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,
MineraloQv �
1:1,2:1,Mixed, i '
. LI�S � � � � � �
Horizon depth=In inches .
Depth of fill-In inches i
Restrictive horizon-Thickness and inches from land surface •
Saprolite-S(suitable),L�(unsuitable) '
Soil wetness-Inches frotn land surface to free water or inches from land surface to soil colors with chroma 2 orless �
Classification-S(suitable),PS(provisionally suifab�le),U(unsuitable) r
LTAR=Long-term acceptance rate-gaUday/ft2 'DCHD OS/OS(Revised)
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, DAVIE COUNTY HEALTH DEPARTMENT
�' �� Environmental Health Section
PO Box 848/210 Hospital Street
� Mocksville, NC 27028
Phone: (336)751-8760 /Fax: (336)751-8786
September 10, 2007
Tim Gardner
6063 Willomere Circle
Winston-Salem,NC 27107
Re: Site Evaluation- ��� .
5 Acre Tract/Pudding Ridge Rd.
Tax PIN#: 5841087890
Dear Client(s):
As requested, a representative of this office visited the above site to perform a site
evaluation. Based on the fmdings of the evaluation, the site is classified unsuitable for
the installation of an onsite wastewater system for the proposed four-bedroom residence.
Therefore,the request for an Improvement Permit is denied.
However, further investigation of the site determined that the classification may
be changed to provisionally suitable by abiding by the following:
1. An easement for the repair of the onsite wastewater system to serve the
proposed residence on the evaluated lot must be established on the adjoining
parent tract of land. This easement shall be established along the south
property line,with dimensions of approximately 100 feet deep by 350 feet
long. This easement shall be surveyed and recorded with the Davie County
Register of Deeds.
Documentation of the easement must be provided prior to the issuance of an
Improvement Permit or a change of the unsuitable classification.
If you have any questions, feel free to contact this office at 751-8760.
Sincerel � .
�
- ' Jeff Beauc amp, R.S.
Environmental Health Section
� Enc(s)
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' . • Davie County Environmental Health
� ' P.O.Box 848/210 Hospital Street
� Mocksville,NC 27028
Y (336)751-8760/Fax(336)751-8786
+ '
� IMPROVEMENT PERMIT
Account #: 990004415 Tax PIN/EH #: 5841-08-7890.OZ
Billed To: Tim Gardner Mike Gardner Subdivision Info: �
Address: 6063 Willowmere Creek Location/Address: Pudding Ridge Road-27028
City: Winston-Salem Property Size: 5 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:�i�Tew ❑Repair ❑Expansion Pernut Valid for:�'S Years ONo Expiration
Residential Specifications: #Bedrooms —T #Bathrooms � #People 2 Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): � Type of Water Supply:�'Crounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial /l� l� 'f D..�L a•�S
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Environmental Hea t pecia is a � ate
i.o.t 1-06
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' � � Tax Lot 52, Tax Map D-5 �
n/f Timothy Eaton Nerrs T;e Line
� DB 35 � PG 33 5 �30.16� W 1
. N 85°29'12"E S 84°20'26"E N 84r�2o�2s'"+�
q F d 247.80'
100.00' , ��, n � i _ _�_ _ _ 237.38�a�
�2� ,... ... � ,
1&1�4" EIP �, � �''^� PK-Nail Set � '.
6ent/Fnd •
48" �MP�� 28.02' �N,�fP —___ � �
✓ ,; — ---_'_-:— �
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I � r'^' ^ 1p•X��•SE \ � � 10' x 70' SE.� �.
� � � � re Line
� .�� Approximate Locetion of r�t � � N 03°46'09"EJ
8rarch/Wet Weather D�t�h N� � � �
� � � � 30.23°
- Lot 1 � QW � � � 1I
z � � � � � { 4
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. � 4t� � ►v Part of Tax Lot 4.01 0 � � � i ; '
i �° � Tax Map E-5 0� `D � � I
^; n� 2.358 Acres +/— � i �
v v' Inclusive of area i � �
n 5 w i t h i n S.R. 1 4 3 5 R i W � i � EXlsting
� � 10' Waterline
� � Easement . I
� ' Reference:
oiRS 359.56' rRs ��,a � PB 9 � PG �t 1
W N 85°00'14"W ��•� (
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m � � ��f � �;,N ��� � Tax Lot 4
W `D ; o � o �o� Tax Map E-5
� � �+ o Part of Tax Lot 4.01 W W �n, n/f Oebro L. Lakey I
� � o T a x M a p E—5 � a r v � � & J i l l C, B ro w n
o : � � I r2B 634 � PG 344
, � 2..644 Acres +/- - � i ,
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'ElR T;e���� Exlstl�g i i � �
� 60' Access & Utili Easement
S 6jo43. 1/2" E1R � i � �
89g 8�F Bent/Fnd Reference PB 8 �► PG 325 � �
� Reference P8 9 � PG 211 � i �
, , , Existing
� � 10' Water Line
� N 07°17'49"E ' ' Easement
100.02' ; ; Reference:
. � 374.56' i ;�� 2 PB � PG
/2„ EIR Fnd N 82°13'06"W � � �
Control Comer --- �/2" E/R Fnd � �
lm Control Corner � t"'10.�2' 175'98�
� 1�:� Existing (Reference PB 9 �, i , so.os�
Permonent Sewoge Syste Ea ement . �� ' � �
NMP �''�� i
Tie Line
---- NMP j � '�N 82°13'O6"W
' E-2 ` ""— 246.09' Total I
t, - -__. �15�
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Tax Lot 4.02 �� �� •
- a Tax Map E-5 `�
' n/f Debra L Lakey ��� �� �
� & Jill C. Brown � �
' RB 634 � PG 344
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