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
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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)
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EMMONSHEREMEMNONELIMEMEEMENI MEMONSON
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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