162 Vogler Rd . �- * DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 990004434 Tax PIN/EH#: 5880-66-4516
Billed To: Leslie Ellis Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006
Proposed Facility: Residence Property Size: 178x180
ATC Number: 4757
**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 taken as a guarantee that the system will function satisfactorily for an�given period of
, time. �� �c.� � � � �
System Typ _ _- S.T.ManufacturerSha�Tank Date ( ` / Tank Size�G�
, Pump Tank S' e
stem Installed B • a�n-o E.H S eciali : �dN • � � �u�
Sy y. G r'�. . p st � Date.
1 (
� Q�
:
� �
,7
! t , � � ��G '� ,� 5
� � � � �
\ ,� '� , � __�_� y �-'`�
r� '
Sc.� � � �---
� _ �
4G ' ,,� �,
I
�
�
�
►
� — ,
4� � � ��
� G�
-- - --- -_ _ - --�_-
DCHD 11/06(Revised)
� . ��. DAVIE COUNTY ENVIRONMENTAL HEALTH .
' P.O.Box 848/210 Hospital Street 'j
Mocksville,NC 27028 `U ( � ��
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTE`VATER SYSTEM CONSTRUCTION
Account #: 990004434 Tax PIN/EH #: 5880-66-4516
Billed To: Leslie Ellis Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006
Proposed Facility: Residence Property Size: 178x180
ATC Number: 4757 Site Type: C�ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building pernut(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 Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) (.�.C�Tank Size ��Oc O GAL.Pump Tank�GAL.
« c� )� 1 r
Trench Width 3� Max.Trench Depth �� Rock Depth� Linear Ft. 'l�� �T
n�5 yv ��c�c..tc�r r:�
Site Modifications/Conditions/Other: l4s Stated in 25l� t`ca
. Q� � . y,tem� m�y �afsU bw zts.?;
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.
� ( I p
� 1 ti r y--4`��,, (2� ( n�9
( � �` �,��ti{�;5� �� � �. �F� F
�`f � a� �.- ��� 1� �°h
I x- �.
�, - - ,
��`" �� �4,�P�� �al
I � - — a ' � r� s
IY � I -------
� Q� �a �t �� �" o �
i�-� � l �
� f oN�
� � �► H I I �
�. a ��
,
� \� � �, �U�/w ��
(
O �_
,� (DU�
_�G O�----_-
�—
�,.e.�G+i f ��-e CI i
Environmental Health Specialist Date: -( � � � — d �
DCHD 11/06(Revised)
.
� '�
� TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
• '°'�, Davie County Environmental Health
� � P.O.Box 848/210 Hospital Street '
��`1 � � � Mocksville,NC 27028
3��� � ` ��\�, (336)751-8760/Fax(336)751-8786
���`Appl' .� �� aluation/Improvement Pertnit Authorization To Construct(ATC) Both
� b� ic ,�,,-,- ew ystem epa�r to Exsting System Expansion/Modification of Existing ys em or Facility
� �s O � POI�TAN7"'**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
��,*�•- c1 `? FORMATION IS PROVIDED. Refer to the INFORMATION BIJLLETIN for instructions.
.� , \ (
� ,�\ , ,,y
` " ' V • APPLICANT INFORMATION
p,,
\� Name to be Billed S � `> . Cntact Person �I�� �l I)•�
BillingAddress � \I �l P-1�' " Home Phane �i-�1,n �i. ?(— -ri.�
City/State/ZIP r � �a' "1! �t � K' Busness Phone 33 �SI— i�S
�--r—
Name on PermidATC if D�erent than Above
Mailing Address fity/State/Zip
t��1� PROPERTY INFORMATION *Date House/Facili Corners Fla ed �', `�7
NOTE: A survey plat or site plan must accompany this application Included: Site Plan Plat(to scale)
�� (PermR is valid for 60 onthswith site plan,no expQation with complete plat.) „7.�t- „
Owner's Name T � :Y-1-Y�,an Phae Number��V �-i�'
Owner's Address � . ? 7<: S '�� - aty/State/Zip �/ r �l (v ?� .
Properiy Address Cip
Lot Size�' T�PM#
Subdivision Name(if applicable) Setion/L,ot#
Directions To Site: i k;C% r�-r�;-� �F'1' !. : ',U ��' � ►� O . 1��=E i C'�I;�C f f(���—
i1'1 -1� `�`���fl • �� t�"Y.' O . �� ,� ���- _ (.$f��:i," ` s:�S� .��D � i1'�i i �'
If the answer to any of the following questbns is"yes",supporting documentati ust be attached. h � ��� �f ln �������n ,�
�{ ��� � 3r
Are there any existing wastewater systems on the site? Yes D✓' 1 � � C ' �S ��i���� �
»„
Does the site contain jurisdictional wetlands? Yes ����u�� �,n �;lj,�.
Are there�y easemen�or right-of-ways on the site? Yes Na •
Is the site subject to approval by another public agenc� Yes No
Will wastewater other than domeste sewage be generated? Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms � #Ba ms 'Z Garden Tub/Wh'vlpool Yes No
Basement: Yes o Basement Plumbing: Yes No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness TOaI Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Att�h documentadon of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: Conventional Accepted Innovative Altemati�e Other
Water Supply Type: ounty City Water New Well Existing Well Commun'ty 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 informatnn provided on this application is true and correct to the best of myknowledge. 1 understand
that any permit(s)or ATC(s)issued hereafter are subjed to suspension or revocation if the s¢e is altered,the intended use
changes,or if the informatbn submitted in this application is falsified or changed. I hereby grant rightof entry to the Authorized
Representafive of the Davie County Health Department b conduct necessary inspections to determine compliance with applicable
laws and rules. I understand fi�at I am responsble for the proper ident�ication and labeling of property lines and corners and
locatingand flagging or stakc�g the house/faality location,proposed we�location and the bcation of any other amenites.
� Site Revisit Charge
Property owner's r owner's legal representative signature
Date(s):
(� ClientNotification Date:
Date' EHS:
Signgiven Yes No Account# ��/��
Revised 11/06 Invoice# �1��,�JI/ /
� i .
�
�_. _
�
�o�� �e�-= arcu� �°12�� �, Ft•
� � ' � �
� � � � '� a�1'll'M,�'� � �
� � � : � .3
� `,�
� - � S ,
r q� ' � ' -- ,'� �� �
� � � : , .
�.. My pi�c����6 � , o
� � , 1 �; a"'
�' � �g- X�O' _ �'�_�, �'
� ;� �,)y,
��b�-1 � '��
� � - � , r
,-? ,
_ c� . - ' '
, ,
� s � �.
,.�.._.._-----�—��" � ,
' � ,
� � � .
, -� ,
� ,
�
�bq. l
�� ��
'IZ ��
� - �
�� ����� �
� �
�d• �
�
_ �
��
�
�� 1�
� �$ . So� IC�S�
�
. ___
_ _ ____ _ ______ _
, _ _
GoMA PS - Davie County NC Public Access Page 1 of 1 �i
Davie County, NC - GIS/Mapping System
Q�a�°t`�` �Cli�k Here To Start Ouer Quick �ae�arrh;(CaUnt3r ID c II
f + — �f�� �] �� 'rG'.
` � � � " � 1 � a1��] Act�ue L;��er: � Clse�^�a},� Trrrs �;I;
��.r U t{� L�.' #� � .;.•'' � ``�' PARCELS (.N1ap Tip�.Availak�le;ti �
'���� - hia� L,�yers � Re��3t� E
� ,�,�. ,.�.� ,�, ��_,��,�_ww,,; �:���.�����.�� ���,�
.,;
1 '
� � .' ��,�
�`�' �� '' r � i �li ;td�,^�tn�",
_ � ^'I��'�1����1������IH����i�I���V�����4����1 �I�q� '�� 'V
�! j� �� 1
' �� ����i�' � �L� �1��t�� 1 \�
�� �.( \ I
3 ^.Y� ld tAlb' �'�3 �t � , \\ �
�
� �� ��4� � �-4�d�d�� �� '� �'. \
� . 5�'7i�111 II IIfilY��71��A4 t��I��Nmi„@�f � �;d .��L'rL, ��,. . ,� I
��pp � - I �) N'x� �N� *
�`�:41�� h'�P . 1_��-✓ � �, It �
���' � , �� ��� p �� „- I
� ;
a;rw��� " �� �°� �a ��$'�i�, � a���W��i�t��. \
��aaP.�_� � e'. 1�, �y, �7 r v . ,v w,� 4 �.
�` '_��'. � �. Mr '
� k.
'�- �-t:::s`tic::-.
s� 'f...
p� ��'��� � ��., `� I
iq ���
d�s, ��'
Y(I)�
������������������� � �. I
a
� � �� ; � � � -� �
� r� �� ; �+w�. ' �� v�� �'��a 1� �s"A`- '�,
���� �� 1� $�U�� ��h����h��r� `'§� ����'P,*,.�}ae ""�,� ��( �, ��
ti �.s��� � ui,� ii ? � , ei � `;
. 5
��,�.' , I� .i ` � '° ���pF�aP� ��
�� 'i'� y� �� ��� I 9�) �q 4y �'
��
, 71��� _ �����..�.
� ������� �,. �� �n � �
�
�� �,���, ���� ,� �� � � �i
��,�� ,,, ,� i , es r:'
,
����� ��i�,��,�G , �
� � I
P[
� I�+�u ���..
, _.�(%� au�r�� r'�����u��
��,�- ����� � ,��� � �
o t�s.s r�
�
���
I
http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=�omaps&CFID=4129... 9/7/2007 I
GoMA.PS - Davie County NC Public Access Page 1 of 1
� Davie County, NC - GIS/Mapping System
���f
�• ;'° `� rt�, �� Cli�k Here T4 Start Ouer Quicl� S�earch:(Caunty ID c
�`" ` � � r} _ � J � `� �7J Actiue Lsyen �Use��Tap Tips GIS
n ...` � _
; ��tt �+� �; � � •� 0 �4 PARCELS (M�p Tips ASrailabl�} — ��ap Layers � Re�ult� �
�� ,���ti ��: � 4�
\
,.
� � �*� �' n � '\
�� � �.��� �,,�„ � "�:,� � ..y a> �\
� �. � � � �, _ �,� �� �
���; � �,$,'"�, �, �� ,.� `��� §�,� ;� •
r �
�y ,�- � r �.
��,„ ., � ,� . ,g�, y � ye, .
n,"' ,r^'F' ��4r am a . � �t cw'�iti"� � i ,��'Bs r rU � .
N.� tt ( .r.. 4 � '�I�'y'y�� .,p� �� 1 ����� s `�M1. .
ncA`� �.� 4'""��� �� �,, ..`p 1• # � �" �yp xx��'"i x.
.4
�p�� � � " ,r .��'a ' �l '�� ,�,ct�``�p,° �� y��-��� 1�,�.. ��'��:,
� �F�„ ���a'� «A . t'1�-�.�+��b,��'y�+ �'z�.�'"�,� a� ''�'+�� �e'f �.
°�". "'� \- �FC�_ 5i� �� "v,�
�±.��N�n� �1.7� ."'�.`� '"�" �a�'� "��."��y,�'�'` :�v���'`�`�.W�.�iMT.v.,
" pf.� "� �a`R.���' 'q.,t��{S+,.y��,. �. � 1� � �
�.-c� �t' ""�.y���1»�'� ..:s c
1
�� K .�. A � ;� 2`�k Y�'� �aii�.� �� �.' ��
+4
�' � A
�� �..�#. * ` i��� � �}fry�.� . ��� � �
^� .�.. ��`u� p�t� ....Y r Y 9� r TJN, � �'y'/�! -.3"��' �
� S .�.]
�3 � �, v�'d�p � �, y � � 4y f d I � 1 a
. �{' :.^� ��:��-+ �� !
� � "�+:U !v+ � ..� � k ��
�} ,A& � a. ���i� avA�
p* r.
,g. J .: �
@ `'� °' . � �d+� �� 4 �"` .u�
� ��� ,�` � � ; 5�� � � �<�_
. � , �
' �Ir�,� � �� y.�,�:� � .,�_ -
f�M �_�
�� ,�.
, F9
� '*� �.�-�-�'-';� �
� � � � ��� � �. ��� '�
,
.�y .K��,� � _ i< - ��r„� y;�;
� � � :.-. ,{ '.�" � . . ,�} I
.�..,�.� �� �'" „� �": � .e,,;���.{;�.
i � � ,. � � ,� �, �„ �� I
� . ,„,, K
��"� � � � �� { � ��: �.
"��a��.:� ^��.� ,r��"� �� •r � ''"� ,�.,.� ��'��'�'� a ���a�"� '� �t b„ ,
aw��+� ' "�#'� a,���.�'�` r� ,','b^s�. ��3� r�""� ��d .
-�fi� �'�"�- i
,�,yP�" R.- � , d ` I 4 ' II�
t. �:' �„` �.' � � g. �i a ,e s �pp � - �
, � '�'� �:.«��¢,��� � "x:' ' ' S+r�`. ,��! .`a�„�a�4�Q � �
� �'.,� a�r�".s'� ��--+,. t+�.- �� ,� '-,�.�m ��v
. _
.,�`.� ��" ..,�'' +� p a . z+,�,+�.'d�""`f., ,�,�'sw
�., . "�, ,:-���� �
�� .
� ��,;`� """�� �by.�a .�,:,. �?`e,.,t a.
'y'i� �,�'..����-I �� p.� I .��^. .� � . � �°.�'k" `��� �,,�p� � a^�'�. '�"' ;a: `y; a�w
� � .:� .� i wia
.�°��15`T' � a; Y7''��•.�,: a
�..�.¢ �,�.Yac°,:� � ...�.
I
i
http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129... 9/7/2007
' DAVIE COUNTY HEALTH DEPARTMENT
,
�. � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION .P�Q�ER'�7C INFORMATION
Accoun . Tax PIN/EH#: 5ssv��
Billed To: Leslie Ellis Subdivision Info:
Reference Name: Location/Address: Vogler Road-27006
Proposed Facility: Residence Property Size: 178x180 Date Evaluated: �' � Ct ' O�
Water Supply: � On-Site Well Community Public �
Evaluation By: Auger Boring Pit Cut ,
FACTORS 1 2 3 4 5 6 7
Landscape position L... L. •
Slope % �
HORIZON I DEPTH � 0 � �K
Texture grou � �G �G.
Consistence i f�
S tructure � ,`„ k Y `a � x�
Mineralo 5'�
HORIZON II DEPTH
Texture rou • -
Consistence
Structure
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure �
Mineralo
SOIL WETNESS ,��
RESTRICTIVE HORIZON �^
SAPROLITE ��
CLASSIFICATION u,fa
LONG-TERM ACCEPTANCE RATE , 8. 'Z 6• '�
SITE CLASSIFICATION: �.J�+�t�dl]�� EVALUATION BY: �o b !v a7�o r�5
LONG-TERM ACCEPTANCE RATE: ���-�-�' OTHER(S)PRESENT:
REMARKS:
LEGEND
i,an�dc�ne 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
T�xtsu'g
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
CONSISTF,N . .
D�4iS�
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 SP- Slightly plastic P-Plastic VP-Very plastic
StrLctLre
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
ineraloev '
1:1,2:1,Mixed .
Notes
Horizon depth-In inches
Depth of fill -In inches
Res[ric[ive 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 DCHI��5/ll5 fRevi�P.�l
.
Davie County Environmental Health
P.O.Box 848/210 Hospital Sfreet
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990004434 Tax PIN/EH#: 5880-66-4516
Billed To: Leslie Ellis Subdivision Info:
Address: 164 Vogler Road Location/Address: Vogler Road-27006
City: Advance, Property Size: 178x180
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.
Pemut Type: ew ORepair ❑Expansion Permit Valid for: 5 Years �No Expiration
Residential Specifications: #Bedrooms�_#Bathrooms�#People�Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):��i� Type of Water Supply: �County/City ❑Well ❑Community Well
�'�� statcd in 15F� NCi,C 18A.2.969(5)
Site Modifications/Permit Conditions: uccepied Systems riaM al�n h� used
S stem T e LTAR
Initial � � �. ' a
Re air � O •a-Z
Site Plan �, r
� � �
,1 `
> � �J�� �,� �
J � � ,
�
� -- � _
� '�"Y G h �
` �� /o'�-1—�
`��—�
�;,,,-�=, �� s,..����� 5Y s��,t.--
� ` �r � �.
.�, �U ,;
Environmental Health Specialist + Date �'[ ��� —Q�
:.ii_n�