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159 Stony Field Trail
. , . - ' ` ' DAVIE COLTNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Accau�t #: 990005541 Tax Plt�lEH#: 5759-02-8145 Billcs�Ta: Randy Ratledge Suk�divi�ior� info: Re�er�r�ce Na��e: LocaiioniAdc�r�ss: Milling Road-27028 f�rnpt�serl Fa�iEity: Residential Pro�s�rty Size: 1.64 Acre ^ f�TC Nu�ber: 5107 � �� ��GN J11 t ( I I r• y **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. , � � j� �� System Type: l%' .T.Manufacturer ,`���Tank Date �+ � Tank Size � �� Pump Tank Size / �— ,� �,p'�� 'L- `/�s/(� ���r( � System Installed By: / f► N`�-.`� { E.H.Srecialist: N` " Date: � GPS Coordinate: � ��a �j�, �f� / � F�G 3 �,a r � � c� �� ��� . ��� ��' a� . � �1 � . \� ' .i �. !`• U°r'� � -��7 c�` _� � �g�� � �� \�D J �� , - � � � c v— `� v ,� v s � �� � L a -� � � � � . DCHD 11/06(Revised) _ . � , � . • DAVIE COUNTY ENVIRONMENTAL HEALTH �� P.O.Box 848/210 Hospital Sfreet � � Mocksville,NC 27028 `� (336)753-6780/Fax#(336)753-.1680 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION t'�ccou�t #: 990005541 '��x F'INiEH#: 5759-02-8145 Billcd To: Randy Ratiedge Sufadivi�ior� info: R�fer�r�ce Nar�ie: Locat9aniAdc3r��s: Milling Road-27028 PropUs�i� ��cility: Residential F'ro�er#y Size: 1.64 Acre ��TC Nut71be3`: 5107 Site Type: f�1ew ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MIJST 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 Specilications: Facility Type " #People #Seats Square Footage(or Dimensions of Facility) - (. � 1 e� Lot Size aC�� Type of Water Supply: ❑County/City jdWell ❑Community Well System Specifications: Design Wastewater Flow(GPD)�0 Tank Size �1��GAL.Pump TanI��GAL. � Trench Width�(s , Ma�c.Trench Depth � t Rock Depth�� Linear Ft:3� � d"'� Site Modifications/Conditions/Other: �+� Stated in 15A NCAC 181�.1969(5j ��60 F��"�'`eY,o y� �rcceyic;u�psierrrs�Ta�aT� e uso 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. ��, _ 10��� - 0 � � N u�� � �t� � �a � r � �° � �` ��G ��,,,,r,, a z 7 . .".�"t .� a$�" �- -� �- . • ��v�� c; �'(�� �" � , Environmental Health Specialist _ Date: � �� ( � DCHD 11/06(Revised) • t � � Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005541 Tax PIN/EH#: 5759-02-8145 Billed To: Randy Ratledge Subdivision Info: Address: 159 Pete Foster Road Location/Address: Milling Road-27028 City: Mocksville Property Size: 1.64 Acre Reference Name: Proposed Facility: Residential **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. Permit Type: ew ❑Repair OExpansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms�#Bathrooms�#People 3 Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) � Design Flow(GPD):�y� Type of Water Supply: ❑County/City ell ❑Community Well Site Modifications/Permit Conditions: AS stated in 15A NCAC �8�•����1�� accep e S��r -- `�.� S stem T e LTAR Initial / Re air � /? Site Plan ��.-.( � , a�f \�` � c1 � � � `� ,u �� S e�� �D �'h � -��� - � y S�t� � `�` , �� , 6 �� W � � � � � g�^ �dQ / �. � � � � o�� � �` �,� � �a� �� ��Q �� Environmental Health Specialist Date �"— l y"-" �� i.p.11-06 5 ,g • '• . .. .�y._�j .. ' .�,,. � ' � ' . • ' . -• t� ,\� ``� ^ . . . ' � . F� �1�ICATIO + SITE EVALUATION/IMPROVEMENT �►.�i�� , � �'�� � ,,�,�� � Davie County Environmental Health A A ':t �� P.O.Box 848/210 Hos ital Street Jlll. (1 1 �d�n i �, - �� P �1 � `�1+`�: J��- Mocksville,NC 27028 I7 � � ' ��,�,Ht����N (336)753-6780/Fax(336)753-1680 BY� ' Q`� N���taMt��;;,a1� C Ap lication�or: e valu�tion/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both _ Ty of cation: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility *�*IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICAN'F INFORMATION Name �Q � Contact Person �U� 1���` � Add'ress � (— Home Phone -'"(5 - � City/State/ZIP YY�e,1GS u�,(,)� Business Phone��(� -�j q� --b��O Name on Permit/ATC ifDifferent than Above ��( � 3 3�— ��3— i g 3B" Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facilit Corners Fla ed /` �� �� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 month with site plan no expiration with complete plat.) Owner's Name - Phone Number -r( �`-��6 Owner's Address �S�'j -}Q ��(` City/State/Zip��C-S l�l, l �� t11 C a-7ba- Property Address/ � �� City � �( Lot Size � , (D4 0}�P 5 ax PIN# � � ��/ Subdivision Name(if applicable) Section/Lot# Directions To Site: � ��, ' � q �-.� - � ,e e� ��. �{� 1 �— c` S '�� c'r� the answer to ariy of the foll wing questions is"Yes",supporting documentation m t be attached: Are there any existing wastewater systems on the site? Yes x 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 7c I�lo � � Will wastewater other than domestic sewage be generated? Yes �No IF R�SIDENCE FILL OUT THE BOX BELOW #People #Bedrooms � #Bathrooms o'Z Garden Tub/Whirlpool ❑Yes '�To Basement: OYes �No Basement Plumbing: ❑Yes o 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 ❑Innovative ❑Alternative ❑Other Water Supply Type: 0 County/City Water C�'New Well ❑Existing Well 0 Community Well _ _ ._ _ _ _ _ ___ _ � ___.._..__. .....: .......___ ___..__. .__..._. _.. _ ._. __ .... _, , _ ._._ .. _ _ , Do you anticipate additions or expansions of the facility this sysfem is intended to serve? 0 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 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 co`mpliance with applicable la and rules. understa d that I am responsible for the proper identification and labeling of property lines and corners and c ing�nd a ' r s king the house/facility location,proposed well location and the location of any other amenities. �wv� Site Revisit Charge Prope owner's or ow r's legal representative signature Date(s): �i d� � Q �� Client Notification Date: Date �� • EHS: �. � Sign given OYes ❑No �`� Account# ���� �� Revised 11/06 ,����/ Invqice# 73(D _ b , , CtolyI�APS -Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System O�'ssi�fi '"+ '_' .� r `U"� � � � � � Click Here To Start Over Quick Search:(Cnunty ID or Ot��ner N� �,QU• .�; � `�'�. %.» Active Layer. _�Llser�tap_�ps --- r�. 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T'. _ . „ _ - x ..-�-� s�-_.;- s � ,-.:�..., i�. � , -,^ ' .3, ` —� i' � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005541 Tax PIN/EH#: 5759-02-8145 Billed To: Randy Ratledge Subdivision (nfo: Reference Name: Location/Address: Milling Road-27028 l Proposed Facility: Residential Property Size: 1.64 Acre Date Evaluated: �'���dd/d 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% HORIZON I DEPTH �- � �1� ? .! Texture rou G Consistence Structure ,(� Mineralo /� .== � HORIZON II DEPTH � d .� Texture rou $'G-b � s Consistence � Ci S'� k Structure ,� 9� (c C Mineralo � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou . Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZO,N SAPROLITE ` CLASSIFICATION g ' LONG-TERM ACCEPTANCE RATE C SITE CLASSIFICATION: EVALUATION BY:�� ��� LONG-TERM ACCEPTANCE RATE: ��' � 1�• �` ✓ OTHER(S)PRESENT: —����-_ REMARKS: LEGEND i.andscane Pocition R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope; Texturg . 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 CONSISTENCE NIQiSY 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 f SP-Slightly plastic P-Plastic VP-Very plastic �tTll�ilTg 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 LYQteS . 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) ■��■���■■��■���■�����■����■�■���■■�■��������■���������■�■■����!I�■■ ■■■�0��■����0������■■■��■��■�■�■�■■�o�■�■��■�■■�■��%�■�����I����■ ■����■����■��■����■�■�■e■��■�es■ ■�■�■�����o�■■■!!�������7�I►i�%���■ ■�■�■��■���■��■�■�■���■■����.�■■■S■�■�■�■■■��■��■�\►���l11�■V�L�II��■ ■■■�■�����������■�■����■�■��■�■���■�■���■�■������■�%��I7IiJV■��'I��■ ■��■■�■■e�■■■■0■■����■�■��■�■�■■�����■■■0\■���■■■■II�I�/I�■����U■��■ ■■�■��■��■���������■�■����■������■�■�■��!■■����■�/������■�■���■■�■ ■■�■�■�����■■��■�■���■■■■�■��������■�������■���■�II�Y�■■��■����■■�■ 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' ,,._...---� � Davie County Environmental Health P.O.Box 848/210 Hospital Street �{. Mocksville,NC 27028 . � i�p (336)753 6780/Fax(336)753-1680 �I2 WELL PERMIT ��� � -?j,3� ' � �cct�ur�t #: 990005541 "��x�i�€iEH#: 5759-02-8145-well �iflecJ 70: Randy Ratledge Suf�t�ivi�ion info: Refer�r�ce Nan��: LocationiAddr�ss: Milling Road-27028 F�ropc�s�d F'��ci(ity: Residental Well F'rop�rty Size: 1.64 Acres . � �'� 5�o n y JY�; 1�7'r, ATC t�umber: 0059 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this � well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any facdcircur}�stances upon which this permit was issued. - ..........1._...^...�.�.._._...��,_,�....�.._.....,.._.._ �....�_�...._._�._�...�...�... ,....v.. _.._..._...._,».....�.._..._........-..._-...�,_...,..�....��._.«�.._ Permit Type: New [� Repair ❑ Abandonment ❑ Proposed Well Location Diagram � ' Certificate of Completion Diagram a,c�' ' ,. ..r . .. \ �� -` � . r S t��� c ` i . � � . �c �;G � . '� � r.�� S P, � � �� I� � C � � ; �sa � � �-� ) �- - . . � -- , ��.� � G�� �r �o� � � �' ,�,p� � \. \v� . r.`� 1' � _ � a � w , � o�'�+ y �ilo ��Ye ' 1 Qo' �w�� . � � '� � . 3 ' .... c.j . . t°� � '� A��,�- �� � . ( ti 1���,,41�,�d� _� � � R Comments: ��.�� � II►'1.1�5� �-Q � �d Driller: `S � �! ' �' � 'J� +U� � ��C � � u�- Certification#: . i ' 1 ,�n e1 ,P Grout Inspected: d-7' �U (V l� Well Head Inspected: �j� � �� � �� GPS Coordi ates:IJ 3 5 �a-�� W ' °� � EHS: � ' Date: r '—� EHS: Date:�ll`��� W.P.7-08