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162 Underpass Rd (2) w ~ �. �� • ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005198 Tax PIN/EH#: 5880-31-1188 Billed To: Ken Burton Subdivision Info: Reference Name: Scott Smith Location/Address: Underpass Road-27006 Proposed Facility: Residence Property Size: 2.1/2 Acres ATC Number: 4928 **NOTE**The issuance of this Operation Pernut 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 take as a guarantee tha the system will function satisfactorily for any given period of time. �'� �C!�"/ �'�� --Q g O System Type: // S.T.Manufacturer_�..� Tank Date Tank Size�� Pump Tank Size -�10� ��'Iy,� , � System Installed By: � �'C"P � E.H.Specialist: ✓"W"'�'.%Uate: I �Z � � � � � � ,� Y.,..M� � . �,- � � �}� `l � _ � • I .k-. �.,. �_ � _ . i;. , 01 �� . h �� I^ i �, , � � o � �� > � d -� ' - �,s- � s ' -�` � �" t f � r ��!_'sZ�tN ;�a�"��:1 , /— --,.- —�—. .,� � �r � 0 � � DCHD 11/06(Revised) . . . ,.' ' ' DAVIE COUI�TTY ENVIRONMENTAL HEALTH �d, _Q P.O.Box 848/210 Hospital Street G�i� Mocksville,NC 27028 I II� (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR tiVASTE�VATER SYSTENI CONS7'RUCTION Account #: 990005198 Tax PIN/EH#: 5880-3.1-1188 . Billed To: Ken Burton Subdivision Info: Reference Name: Scott Smith , Location/Address: Underpass Road-27006 Proposed Facility: Residence Property Size: 2.1/2 Acres ATC Number: 4928 Site Type: ew ❑Repair ❑Expansion *�NOTE**This Authorization to Constnict(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 Treahnent and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,pl�t or the intended use ch�nge. Residential Specifications: #Bedrooms 3 #Bathrooms�#People �Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) LotSize �- � ac��`J Type of Water Supply: County/City ❑Well ❑Community Well � � System Specifications: Design Wastewater Flow(GPD) � �� Tank Size�GAL.Pump Tanl��GAL. � r, /' / � (,� Trench Width� Max.Trench Depth��o Rock Depth Linear Ft.`� SiteModif�cations/Conditions/Other. �j�[p �eG�u-c�1 bh. s !^�a. J �li � . -VJ��J . . e ^ ��`.��i"�7�I a{'��r��-r,�� -bn-tt�� Contachthe Davie County Environmental Health Sechon or�nal inspechon of this system between � � _ 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. � Y� tqj � ' I �) � � ��1 h ' e � -�� W�'�.-- _ �� $ � � �� Rt��,�,� � � ��,�� q p`C.;�c5��''� � � �� _ y�►"�� ,� a�( � ��j _ 5 �. p �1- � o e:�.c..�a•� ` �..._ �<<( �(`'��'' .�� Envuonmental Health Specialist Date: /�� D� �...rrr� .�inr /n"':__.7� . � ' . Davie County Environmental Health ' , • ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990002745 Tax PIN/EH #: 5880-31-1188 Billed To: Clayton Homes Subdivision Info: Address: 3866 N. Patterson Avenue Location/Address: Underpass Road-27006 City: Winston-Salem Property Size: 2 1/2 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. Permit Type: ew ❑Repair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specif cations: #Bedrooms � #Bathrooms�#People oL Basement❑ Basement plumbing❑ Non-Residential Specitications: Facility Type #People #Seats ' Square Footage(ar Dimensions of Facility) ' �- 2 . � Desig�Flow(GPD): J �QC� Type of Water Supply: �unty/City ❑Well OCommunity Well �.� �t��d in 1�A t�1��,C 1��-`,.i�u�,5) q Site Modifications/Pernut Conditions: �,�r��,,�� «�y,�,n� ,;��v �I_;;, b� a�s�� 7�� S stem T e LTAR � Initial y .r� c'�� r o, �:.� ��;;,r.. Re air 5 ,� � � a •- : . ..�. - _. _. -- ;;� Site Plan r� ;;.__ � � 7 , � I � , h 5r � a �," �- � � - _ � � � Y � s � � {'U.�r w�� a ti � ` �+ h ;I;a� S�,pt;c i _ �'` R� ,pa� r \� �;,�� 0. �ea 4 '' � � q�3 � Environmental Health Specialist Date l l -2 y�� i.p11-06 .` �; . + ., � • �O� TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC � Davie County Environmental Health � P.O.Boa 848/210 Hosp►tal Street Q � 1 `� �-�0� (33�51-8 0�/1Faa(336)751-8786 � �,�� Appli �Qt1or: Sit aluation/Lnprovement Permit ✓ Authorization To Construct(ATC') ✓ Both ��plica' . New System Repair to Existing System Expansion/Modification of Existing or Facility � 0`e,c,.�:`�� ~� F,r1��U;�� ' 1CfPORTAM"`""THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TIiE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instroctions. APPLICANT INFORMATION Name to be$iiled �C�irt'} �,•,�,.� Contact Person ��-$n„. Billing Address 3$v 4 � :r.. �v e � Home Phone_3�4''7�1 • !L.4'1 City/State/ZIP�,a, 5�;1.,� n�.� �-r�p s Business Phone Name on PernudATC if Di,�erent than Above ,J Mailing Address City/State/Zip �v c� nr.� - PROPERIY INFORMATION *Date House/Facili Comers Fia ed f!-! . NOTE: A survey plat or site plan must accompany this appGcation. Included: ite Pla Plat(to scale) (Permit' valid for 60 months with site plan,no expiration with complete plat.) • Owner's Name nn� �k � Phone Number O��ver's Address �2� �.ltrd.. City/ tate/Zip�on,e�. N.L Property Address City�,,,,,�,e� ,(� L._ Lot Size ��/�� ax PIN# O 1 Subdivision Name(if applicable) Secrion/Lot# ' Direction,{s�To Site: S F ^ S 4 c. (JX�.o�+�re�ss � c.en If the anstver to any of�llowing questions►s` es",supporting documentation must be attached. Are there any existing wastewater systems on the site? Yes Does the site contain jurisdictional wetlands? Yes Are there any easements or right-of-ways on the site? � , Is the site subject to approval by another public agency? Will wastewater other than domestic se�va e be enerated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms � #Ba�rqoms 2 Garden Tub/Whirlpool Yes No Basement: Yes No Basement Plumbing: Yes (DTd �'NON-RESIDENCE FILL OUT THE BOX BELOW , Type of FacilityBusiness Total Squ�re Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water,Usage(gallons per day) (Attach documentation of sunilar facility water consumption) FOODSERVICE`ONLY: #Seats Type system requested: Conventional Accepted Innovative Alternative Other Water Supply Type: oun / ' New Well Existing Well Community Well Do you antieipate additions or expansions of the facility this system is intended to serve? Yes No If yes,what type? This is to certify that the infom�ation provided on this application is true and coirect to the best of my knowledge. I understand that any pemiit(s)or ATC(s)issued hereafrer aze 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 1, Representative of the Davie County Health Deparlment to conduct necessary inspeetions to determine compliance with applicable laws and rules. I understand that I am responsible for the proper ident�cation and labe(ing 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. ��'� �+�w/i:-! L/�i� /n��.�_"✓•S�1'("`—� SiteRevisitCharge Pmperty owner's or owner's legal representative signature , Date(s): ��' 1�• O$ Client Notification Date: r '� Date '� EHS: � y j ` ,'Sign given Yes No Account# �/� � Revised I 1/06 Invoice# � � �� , ��mi�� . .�l�V t- �{ f��e�� 519� 4', r " '. 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Mi. ✓a/� %' ,�: �� _ �4!�`�'�. 4 '� �� . r r'� ADDRESS � �sg � '' ��:"�' j r�� / �� .�" � yf°�� ,�� , ' . �x` i;�, � � J '� ,, ,��`+ �*''� °" r DRIVES .i' �` �;�"y1►!-,_ �� ` �+�1�- I_ a; � �.�1� � �� ,, y � � . � sY ;{ ,.<F '�"�yd , , �►r��,� '�ks� STREETS �w .� � ` � ,: ,as , �_ �� y� ,� ^�, " � z.,'-�-;� 'ro•�� ' RAILROAD CENTERUNE ,,. � �,� � �,�� .�.;,,� _ ��. � — .� Y ` � ,� �.�'� `��T�—�` ��k:�'�,+»� - � ., �'� I�I PARCELS -� ,, � �, '�' �, "� '`�°` _ �: �� 2007Aerial_Photos � .;� � , � �.� a - - �y ,. � � p� a , . .. , ` � - �• -� ,;, "�r r ,: .� ~i. � �� ,.�,�'� CITY LIMITS ,;;�' '� --��yy- — �G.� . _„ ,� k ,_ � r _ i�+� �rt '� i '_t��.�,�r.bc,4,�i.�'a.>^� �`e�,:� r t�.` #".`�,� .a1�'. �' � �� .`- - � �,, � BERMUDARUN �' ""� � �`�.L'��'`+"`��•y,��` a� ::r � ? `�y� �„ yr8r;� f� �` lfr �;35 � � � :�3 �t�j � COOLEEMEE � J ��,��' .�� ;.,f ��` � �. , � . ,.N ,��;. �. �! ,:�,� ,.,- sy'`' 5 1 i l s •" Y �� y DAVIE COUNTY � QL ` {L: .. ....�. '��' . . 4 � . . •� ��t . . . �a:{' , �'rj�a�� . — •.� t _ . . . , r '� . � � �. �+ - . . .r . , . . :g,r. _ ... � « . ... �.:� . . T� �,.M:�� -�, .. - ,x.s - -.,�.,. . MOCKSVILLE � ' � _ � � M '�j :1 � ,, �;,. z �' ,�� , �.P �.,� ° " � .� — �� "'�' � � �� .. � �� a�� .R�� . ... + . " .� `* �° ": . s ^` e.:' � t<!�1 � 'I. . \ ' � A _� 1��, ,� ,�" }-4' s�r ,��^ s- �.�� . _ `, , — '�" � j .,��i � �. �� x � '' �� I '-:�. , X � $. � i s ��, ' . � x, :i:�tY g*.,`,.. �; . ' y F � . �� II ^ � ��, ...-. �.. �I .. :-�r�.,,� �..,�6 �'„ � �� ,r;�� I �`�.. � . � ti � . � ��'. � .+-i} � �.� , __._.. ...... .._. ..... _ +, � � I, .��- J . .'�1� _. . . ,� ,�.,. . . . . . ' � �... .. _� - , � ' 'h _._.. f > '� t , �'�;;;4` t I �� y • � 4 1 '�r "� .� �./J�� , �^ ..�` \.�4~'�y,�nr,".�t�'� ' l . . 4 � y � . .. � , �' r y .r s, s � , i++� .. � ' � `t ` � . �1 ��F ;� 1�r � . 3;,�' ti ti ^- �' . -a ! � s , , �,.,.� ` �,,�.� ��.. �� ''`�`,�:� , .�� ti �� Wednesday,November I? 2008 _ ;� _- ,� :�� :�� s .;�� " �I ti ti ' � �� ' 't� � . F :y {�,-` _.� 3 � •.� � � � ,a� �� : � t � � � #��I� �._ � �� "`j!� -,� ti� �ti �' '�� 1 '�`**WARNING: THIS IS '��O�f A SURVI:Y!":� ��his map is prepared for the inventory of real property lound�vithin this jurisdiction,and is compiled from recorded decds,plats,and other public records and data. Uscrs of this map are hereby notiGcd that thc aforementioned public primary infonnation sourccs should be consultcd for verilication of the information contained on this map. "I�he �� County and mapping company assume no legal responsibility for the intoi7nation contained on this map. ' . . r � . " . DAVIE COUNTY HEALTH DEPARTMENT i ' • ' Environmental Health Section � Soil/Site Evaluation . APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002745 Tax PIN/EH#: 5880-31-1188 Billed To: Clayton Homes Subdivision Info: Reference Name: Location/Address: Underpass Road-27006 � ,' �,�-� Proposed Facility: Residence Property Size: 2 1/2 Acres Date Evaluated: 7� � �!"'�� Water Supply: On-Site Well Community Public / Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Gi/ (/ Slope% HORIZON I DEPTH o 6- y O Q�- � Texture grou _ L Consistence 6� � Structure � ,F Mirieralo �,+� � HORIZON II DEPTH o - `/d Texture rou G Consistence Structure Mineralo � HORIZON III DEPTH Texture rou Consis[ence Structure Mineralo � HORIZON IV DEPTH � Texture rou � .� Consistence L Structure 1( Mineralo SOIL WETNESS �' RESTRICTIVE HORIZON ./' / SAPROLITE / / CLASSIFICATION LONG-TERMACCEPTANCE TE . 1' D. ' c�- SITE CLASSIFICATION: EVALUATION BY: J LONG-TERM ACCEPTANCE RATE: � J � v ��OTHER(S)PRESENT: REMARKS: LEGEND T,andsca,pe 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 CnN4IST�.N . . �� VFR-Very friable FR-Friable FI-Firm VFI-Very fir�n EFI-Extremely firm �Ye� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic $�r� ,r . ' SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky . - SBK-Subangular blocky PL-Platy PR-Prismatic � Mineraloev 1:1,2:1,Mixed Ot S 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)