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212 Todd RdAccount #: 990004085 Billed To: Anthony Ward Reference Name: Proposed Facility: Residence ATC Number: 4652 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital. Street Mocksville, NC 27628 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: 5788-44-7095 Todd Road -27006 2 Acres **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. Manufacturer Sal Q Tank Date r I- 1 Tank Size_/�� Pump Tank Siz Specialist:Zm/,4�C! It ate: -//—&1—Z 1—v 7 System Installed By:� E.H. DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004085 Tax PIN/EH #: 5788-44-7095 Billed To: Anthony Ward Reference Name: Proposed Facility: Residence ATC Number: 4652 Subdivision Info: Location/Address: Todd Road -27006 Property Size: 2 Acres Site Type: ❑New ❑Repair ❑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. 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 /I # Bathrooms q # People Basement Basement plumbing Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size D. Ctc - Type of Water Supply: C>-6unty/City ❑ Well ❑ Community Well System Specifications: Design Wastewater Flow (GPD) YC6 Tank Sized GAL. Pump Tank/t�AL. // it Trench Width , ip Max. Trench Depth 3 Rock Depth Linear Ft. 5 .3 3 �s (ate, in 1S�lCk` Site Modifications/Conditions/Other: ke Yd ao�'''r��'`(' t '"i` "` ` �C�. k• is r, Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. Q Environmental Health Specialist. DCHD 11/06 (Revised) / D / Date: If—,I 7 -e:77 r. + . APP I t A" T' SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department toL p�G �T 2006 Environmental Health Section �J y, P.O. Box 848/210 Hospital Street �IVIROt�IECOUZ � L� Mocksville, NC 27028 pp Ate Fax (336)751-8786 App ication For: C� Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANT"`** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION s Name to be Billed A1/,c,� �, <rl Contact Person I o- �� I, Billing Address 2-i%Z e'z Home Phone 356- '76C1 *12 City/State/ZIP AIC Z,'7103 Business Phone -6.3(- - -Y&S- 335* Name on Permit/ATC if Different than Mailing Address PROPERTY INFORMATION City/State/Zip NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address '► C4 elf City Atiu�,nce Tax PIN# Subdivision Name Section/Lot# Lot Sizes Directions To Site: C.ci SOL,Fti 3„.'lis �Ssf rh./ , �, �1 � {res Lr�:., ��T�% -t,Y• Date House/Facility Corners Flagged z 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? Dyes 51'No Does the site contain jurisdictional wetlands? ❑Yeso Are there any easements or right-of-ways on the site? R'Yes 9 o Sli r V e `'%► n" Is the site subject to approval by another public agency? Dyes 20 J Will wastewater other than domestic sewage be generated? Dyes ENO IF RESIDENCE FILL OUT THE BOX BELOW # People 3 # Bedrooms # Bathrooms i— Garden Tub/Whirlpool ❑Yes ONo Basement: ❑Yes IZNo Basement Plumbing: Dyes [-?No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: dCoun(y/city Water ❑ New Well ❑Existing Well ❑ Community Well y Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes P 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by j}1 n t i P 1'Ct- Word Property owner's or owner's legal representative signature 5 "-LI •a4 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given ❑Yes ONO Account # Revised 2/06 1� TUv, ee !1 `� Invoice # t%��n �Q ate. � ..-.,. �,_!, �' � � .. :}. �. f � �p�p:: rix .. ,�.. _°*' i � " ���,�,�. 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""w:. :�� .. . . , .. .� � �� _� APPLICANT INFORMATION Account #: 990004085 Billed To: Anthony Ward Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health,S.ection Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5788-44-7095 Subdivision Info: Location/Address: Todd Road -27006 Property Size: 2 Acres Date Evaluated:"'�r�� Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % b z HORIZON I DEPTH Texture group Consistence Structure / (/ Mineralogy / - HORIZON 11 DEPTH Texture group Consistence �r f Structure Mineralogy HORIZON III DEPTH Texture group 0 by Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE i CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: S REMARKS: LEGEND EVALUATION BY: /76:74 OTHER(S) PRESENT - Landscape Position 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 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 CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm M1 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 - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes 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 - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■I.fir■■■■■■■■■■■■■■■■�■■VGA■■�!�i1■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■I■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/lit■■■■■■■■■■■■■1\■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■�i�■■■iii■■■■ ■■■■I\■■GCS■■■■■■■■■!I■■■■■■■■■■■■ ■■■■■■■■■�■■■■■■■■��■■■■■■■■■■■_■■_■■■■■I■\\■Lir■■■■■■■■■/I■■■■■■■■■■■■■ EMMONSHEREMEMNONELIMEMEEMENI MEMONSON ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Improvement Permit September 8, 2006 Mr. Anthony C. Ward 2812 S. Stratford Road Winston-Salem, NC 27103 Re: Todd Road Tax PIN# 5788447095 Dear Mr. Ward 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 or the intended use change. System To Serve: d Wastewater Design Flow(GPD): f �� Valid: Z!�_Years ❑No Expiration System Type: ❑Conventional /Accepted ❑Innovative ❑Alternative ❑Other. As stated in 15A NCAC 18A.1969(5 Site Modifications/Permit Conditions: /1 y4 P accepted -Systems may also hp use i.p.letter 7/06