126 Triple Creek Trailr
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
OPERATION PERMIT
Account #: 990005211 Tax PIN/EH #: 5759-59-4083
Billed To: Clayton Homes of Statesville Subdivision Info: t2(o Tripic
Reference Nanne: LocationiAddress: 22-2 HPpl@; Rvad 2 Q2Z
Proposed Facility: Resident Property Size: 1 Acre
ATC Number: 5119
**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 Tank Date Tank Size
Pump Tank Size
System Installed By: E.H. Specialist: te:
GPS Coordinate:
Q n I
i P03 PS i
v
.t C!
� ao
v /
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
F P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/Fax #(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005211 Tax PIN !EH #: 5759-59-4083
Billed To: Clayton Homes of Statesville Subdivision Info:
Reference Name: LocationiAddress: 239 Hepler Road -27028
Proposed Facility: Resident Property Size:: 1 Acre
Site Type: $New ❑Repair ❑Expansion
ATC Number: 5119
**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 # Bathrooms 2— # People 2 Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Lot Size 1 cu- Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) '24b Tank Sized GAL. Pump Tank 4 GAL.
Trench Width Max. Trench Depth Rock Depth Linear Ft.,� �Sw�
Site Modifications/Conditions/Other: L2�h
Contact the Davie County Environmental Health Section for final inspection of this system between
Environmental Health Specialist
DCHD 11/06 (Revised)
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
Account #: 990005211 Tax PIN/EH #: 5759-59-4083
Billed To: Clayton Homes of Statesville Subdivision Info:
Address: 2026 North Side Drive Location/Address: 239 Hepler Road -27028
City: Statesville Property Size: 1 Acre
Reference Name:
Proposed Facility: Resident
**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: -t.New ❑Repair ❑Expansion Permit Valid for: 93 Years ❑No Expiration
Residential Specifications: # Bedrooms_ # Bathrooms # People 2 Basement Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
11,, Square Footage(or Dimensions of Facility)
Design Flow(GPD): 2NQ Type of Water Supply: ❑County/City �_,'Well ❑Community Well
Site Modifications/Permit Conditions:
System Type I LTAR
Initial aM 1BId 1.9hon 1 -2-5-
Repair
2SRe air -cry.I . Z
Site Plan `
Environmental Health Specialist
i.p. 11-06
Date///2/20/0
R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
�Q P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 �I�3
(336)753-6780/ F:/Authorization
x (3 6)753-1680
A plicat it ' ugtion/Improvement Permit To Construct (ATC) ❑ Both
Type of Appltcat ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
** PORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
A PPT TC A MT TMPnP NA A TIONT
Name ( (4140eY
)k,- 11,
Contact Person
1/1 tA: C_
Address 7_b -z,!&
A4 -,-,k f, -A Q-;.
Home Phone
),94 - 5 yI - _172 c, -7
City/State/ZIP �i3T<SW4e
IJG Z06zr
Business Phone
?a+ --,-1S -zSg-7
Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zi
FKUFtt(1 Y 1NPUKMAl JUN fillate House/Facility Corners nagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Pen -nit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name ire, Phone Number 336 - &7q
Owner's Address City/State/Zip
Property Address 23`7 cp/a/ a
Lot Size I I Tax PIN# 5-755 - S"S - 5/o8.r
Subdivision Name(if applicable) Section/Lot#
Directions To Site: E,,,' 1 0,J � d f ON ��r7•'A/v.J �(,
00 Ib. 56kr,,) b'1V 4,J lo &1,1,) -( - 7µrd 51; / o&.,o&.,e geplcr
If the answer to any of the folloAng questions is "Yes",supporting documentatig must be attached:
Are there any existing wastewater systems on the site? _Yes _)CNo
Does the site contain jurisdictional wetlands? _Yes ,XNo
Are there any easements or right-of-ways on the site? _Yes )No
Is the site subject to approval by another public agency? _Yes T<`No
Will wastewater other than domestic sewage be generated? Yes )�JNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People Z # Bedrooms , # Bathrooms -2- Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ;q'No Basement Plumbing: ❑Yes ,KN6
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: OConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water ❑ New Well ' xisting Well 0 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 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 infonnation 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 m r sponsible for the proper identification and labeling of property lines and corners and
Iocatin a ing e 1 se/facility location, proposed well location and the location of any other amenities.
—^�Site Revisit Charge
Pr erty caner' r owner's lega sentative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # 2 /'
Revised 11/06 Invoice #
<'`.k- ZV77
i
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
Account #: 990005211
Billed To: Clayton Homes of Statesville
Reference Name:
Proposed Facility: Resident Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5759-59-4083
Subdivision Info:
Location/Address: 239 Hepler Road -27028
1 Acre Date Evaluated: // &
Water Supply: On -Site Well /f Community
Evaluation By: Auger Boring I/ Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
7/6
Gr
HORIZON I DEPTH
-'1_10
Texture group
Consistence
Structure
Mineralogy
/ '
HORIZON H DEPTH
-2
- L
Texture group
e
G
Consistence
Structure
[
Mineralogy;
1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
. 25
5
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: • 2�
REMARKS:
EVALUATION BY: Aua'&) AWG
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 .
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
A
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
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)
T TAR - T nna_tPrm arrArfnnnn .gym 1! ../C� 1 — ---
■
■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■
■11■\CN■
■■1LI■fN■
■*1117111■
■■►1■111■
■lkq■!■■
MONS■■
■N►J■■
■■mmN■
■■MONS
■
■■■O■
■IMUIIE
■IIRRIP.1
■MEAM
■■Oil■
■mmo■
SENSE
■EE■■
SEEMS
■■11■\",
NOMINEE
NOMINEE
NOMINEE
Mom■■■ ■■■mm■m■■
SIMMONS■■■■■■■■■
■E■■N■■N■■■■■■■■■
■■■■■■■E■■■■■■■■■
■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■
■■■■■■■E■■■■■■■■■
■■■■■■n■■■■■■■■■
■■MONS mons■■■■■
■
■
■
■
■
■
■
■
CV
0
'itfl�
r
z
CD 'R OF AFORESAID
I WHICH THIS CERTIFICATION
ccc
•_j ENTS FOR RECORDING.
U
i
LL
CURTIS W. EUBANKS
12.0/666.
I
EIP. l.'2" R 8AR
_ 178.13'
S 86001'12"E'-483.12'
(TOTAL)
o
b
CD
f
304.99'
0
•- SEIBACK ..INES. '
L
I
O ;
0.69 ACRE
w'EL_ CASING
r--TANI:
RESIDUAL LOT
-
'�
10
1.31 ACRES
CD
CD
CD
'
SPARK
C-iGLENN
v
i
o
�k
v c"475/905
CD
N
y
O
-_-� _ p -,'� -
-V0.
"._
co
:ae—
•
�;.�..-
� — P __—•�►.. P --
r�:'�.�.,:..��=;;�.:.� �.::.
—,, ._.._,-�
'
'P �-----'-
...- s�,�;�..
p _ _._- — P _—q
EX. 25' ACCESS NT
(769/E
00
EIP 1 5/81,+ PIPE�._`--
�.:;...r.,
-
(CONTROL CORNER)
�C
n.l.ti.:.:.�•. •. •'••�+ :..�
t`
j
125.50'
.......
R '--N 86°01'30"W
141P 2" PIPE IS 1.21'
. . ............ :....' :.::'....' -...
....
506.50'T
(OTAL
SOLITN OF PRUPERTT LINE
J
EIR 1/2" RESAR
CV
0
'itfl�
r
z
CD 'R OF AFORESAID
I WHICH THIS CERTIFICATION
ccc
•_j ENTS FOR RECORDING.
U
i
LL
CURTIS W. EUBANKS
12.0/666.
0
0
N
9
a:
m
2
Lo
0
CD
0
v
0
SE18,4CK HNES --
178.13'
I io 11
0.69 ACR
o u�
M
j o �
z N
'•I _•.r-4• .v_ ts,aa 4•a; ••w;•Fi �-P �: '..tet -P 'syr.+��•'��P-...-
i pa_
000 DID 1 5/8•' PIPE 181.13'
;CONTROL CCRNE:R)
CD
r--
CD
•
0
cn
i
:R OF AFORESAID
} I WHICH THIS CERTIFICATION
ENTS FOR RECORDING.
0LL-
-`—
S 86001'12"E -►463.12'
304.99'
-wrL_ CASING RESIDUAL LOT
-TAN'; 1.31 ACRES
GLENN SPARK
475/905
to0
N
I 1 •
_�- �? 25' ACCESS EASEMENT
` 125 ... ..... - ��1+7rs;�,:..•..-�.
50' �,. .
�. ....
'-EIP 2•' PIPE IS 1.21N
86`01'30"W 506.50'(TOTAL)
SOUTH OF PROPERTY LINE EIR 1/2" REBAR
CURTIS W. EUBANKS
12.0/666. -