977 Yadkinville Rd ' ; ,► � DAVIE COUNTY ENVIRONMENTAL HEALTH ��
. • ' P.O.Box 848/210 Hos ital Street
` Mocksville,NC 27028 �C3! �
(336)753-6780/Fax#(336)753-1680 � ,��`
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OPERATiON PERMiT �
Accour�t #: 990005407 � �'ax P��€.�EH#: H3040A0019
�illcd To: Davie County Farm Bureau Su�a�ivisian Info:
Re:fer�r�ce Na�ie: LocaiionrAddr�ss: 977 Yadkinville Road-27028
Pro�c�sQrf Fas:ility: Business Pro�spr�y Siz�: 1.5 Acres
ATC �turnb�r: 6027
**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:� C�'�Q�b S.T Manufacturer Tank Date� Tank Size OOC� ,
Pump Tank Siz� Bedrooms:
System Installed By: 1f� J (�c,CL�h�L Installer# Date: � a0/ .
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GPS Coordinate: ����Z��'3�
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Environmental Health Specialist (,C�Li Date: O
DCHD 11/06(Revised) �
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� ' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
' (336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Acc�ur�t #: 990005407 � �"ax Plf�i�H#: H3040A0019
Billcd To: Davie County Farm Bureau Suf�di�ri�ior� lnfo:
ReFerer�ce Nar��e: LocatiortrAd�r�ss: 977 Yadkinville Road-27028
Pro�ns�rJ F��ility: Business Prop�rt.y�ize: 1.5 Acres
t�T'C Numb�r: 6027 '
Site Type: ,pNew ❑Repair �Expansion
**NOTE** This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior tq 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 #People Basement0 Basement plumbing❑
Non-Residential Specifications: Facility Type ('�1�Q,. #People�#Seats
Square Footage(or Dimensions of Facility)
Lot Size ,� ��e-_ Type of Water Supply: �.County/City ❑Well ❑Community Well� , •
System Specifications: Design Wastewater Flow(GPD) I5� Tank Size 1�00 GAL.Pump Tank GAL.
Trench Width �,(�" Max.Trench Deptlk�('� Rock Depth et� Linear Ft. �$'� p
Site Modifications/Conditions/Other: �Q��(�j�,1/�
Contact the Davie County Environ n�tal Health Section for final inspection of this system between
a of installation. Tele hone# 336 751-8760.
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Environmental Health S eci ' Date:
D 11/06(Revised) q7� ��� .
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' ` , , ' '' Davie County Environmental Health
. ��
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 �i�o
(336)753-6780/Fax(336)753-1680 \��
IMPROVEMENT PERMIT
Account #: 990005407 Tax PIN/EH#: 5729-76-1983
Billed To: Davie County Farm Bureau Subdivision Info:
Address: P.O. Box 69 Location/Address: US Highway 601 N-27028
City: Mocksville Property Size: 188x280x121x
Reference Name:
Proposed Facility: Business
**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: ONew ❑Repair ❑Expansion Permit Valid for: ❑5 Years ❑No Expiration
Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type (��, �• �� #People (O #Seats
Square Footage(or Dimensions of Faeility)�
esi Flow GPD : �� Type of Water Supply: Cy"County/City ❑Well OCommunity Well
� � )� �
A� stated in 15A �ICAC 18.>.196�;5�
S te Modifications/Permit Conditions: acceptEd,SV�tems rnay alsc� be usc�
S stem T e LTAR
Initial �
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SitePlan�F-�` $� ����1 � '
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Environmental Health Specialist ✓ Date��a(� �
i.p.l 1-06
, ,
- �1�9 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ,
\� ��•J � Davie County Environmental Health ��*���� x
'�, �, , � P.O.Box 848/210 Hospital Street ,, '
�• . ,,i. � Mocksville, NC 27028 ��^:� C � �;-��
���j"�� (336)753-6780/ Fax 6)753-1680
�Y? �,`
Application For: o Site Evaluation/Improvement Permit Authorization To Construct(ATC) o Both
Type of Application: oNew System oRepair to Existing System oExpansion/Modification of Existing System or Facility
*"*lMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name: Davie Countv Farm Bureau.Inc. Contact Person John Fuller—Architect
Address:977 Yadkinville Rd. Address:68 Court�,200 Mocksville,NC 27028
. Mocksville. NC 27028 Business Phone•336-751-0400
Ema[il : johnna fullerarchitecture.com
, Name on Pennit/ATC if DiJferent than Above
Mailing Address: 977 Yadkinville.Road City/State/Zip: Mocksville.NC 27028
PROPERTY INFORMATION *Date House/Facili Comers Flagged-Yes
NOTE: A survey plat or site plan must accompany this a,pplication. Included:Site Plan(not to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.) - '
Owner's Name: Davie County Farm Bureau . Inc. Phone Number. 336-751-6207
Owner's Address:977 Yadkinville Road City/State/Zip:Mocksville,NC 27028
Property Address: City: Mocksville.NC 27028 -
Lot Size: 1.5 Acres Tax PIN# H3040A0019
Subdivision Name(if applicable) Section/Lot#
Directions To Site: The site is located on the north side of Ashley Brook Ln. at the corner of Hwy 601 and
•Ashlev Brooh Ln.
lf the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes ZC No
Does the site contain jurisdictional wedands? Yes 3�No
Are there any easements or right-of-ways on the site? Yes � No
Is the site subject to approval by another public agency? Yes x No
Will wastewater other than domestic sewage be generated? Yes �No
. IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool Yes No
Basemenr Yes No Basement Plumbing: Yes No
IF NON-RESIllENCE FILL OUT THE BOX BELOW -
Type of Facility/Business: Professional Office Total Square Footage of Building: 5,000 SF #People: 50 Max.
� , #Siaks: 3 #Commodes:7. #Showers:0 # Urinals: 0
Estimated Water Usage (gallons per day) 87.gallons (Attach documentation of similar facility�vater
consumption)See attached water bills—some are higher due to sticking toilet.
FOODSERVICE ONLY: #Seats: N/A
Type system requested: X Conventional _Accepted _Innovative _Alternative Other.
Water Supply Type: �. County/City Water _New Well _Existing Well _Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? _Yes- �C 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 penni[(s)or ATC(s)issued hereafter are subject to saspension or revocation if the site is altered,the intended use changes,
or if the infonnation submitted in this applic.�tion is falsiC:ed or changed. [hereby grant right of entry ro the Authorized
Representative of the Davie County Health Deuartrnent to conduct necessary inspections ro determine compliance with applicable
laws and rules. I understand that l am resrycnsible for.tlie proper identitication and labeling of property lines and corners and
loyatin�a flaggiry�or staking the house/facility location,propused�vell location and the location of any other amenities.
C L �-�-1� Site Revisit Charoe
Property owner's or o� r's le�al representative signature �
,/ Date(s):
J'��,� Client Notification Date:_
Date CHS:
Cc�� 1 Z�� 3d .
Sign given oYes oNo Account# J���
Revised I 1!O6 Invoice tl
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Pa�'�� �- �� �
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' , ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health '
P.0.Box 848/210 Hospital Street
'Mocksville,NC 27028
'(336)751-8760/Fax(336)751:8786
Application For. Site Evaluation/Im rovement Pe ' Authorization To Construct(ATC) Both
Type of Application: w ystem Repair to Existing System Expansion/Modification of Existing System or Facility
*'*IMPORTi1N7**'THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICAI�i,T INFORMATION
.,,""'- -
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.,�-- � a to` �� e �l° U. � � � (.(}!1P
.� � � i���,, eCY- Contact Person
„ � ��"' �il��ng A�ddres� . D Home Phone �7 — — rj
o� �`�, '� �� �y/Statel�iIF�1 Business Phone - (— 0 t��
� ^� , ��/ �
1 ! �` ' Namg on P'riniU C if Di,{J'erent than Above
' ': ', �C - �S Iv�ailing A�ress Ci /State/Zip
�, �� °;; rt
;.�.� a, �,
�h�,� .%a TY INF ATION *Date House/Facilit Corners Fla ed
� ���F � Q �:. plat or site plan must accompany this application. Included: Site Plan Plat(to scale)
�Y���"�'v��. ,���'` (Permit is,valid fo 60 mo ths ith sit plan,no expiration with complete plat.) 2� '/�
�`�+ Owner's Name C P h o n e N u m b r J J��`�'���
Owner's Address � City/State/Zi �� 7 =�
Property Addres D City /'YIaP�C51//j(-�
� Lot Size � X �! Tax PIN# T doj"j�1a,'��
_ Subdivision Name(if applicable) Section/Lot# +;L
Directions To$�t : r�I,19 �-
�Q.00IL L1V y p
If the answer to any of the following question is"yes",supporting documentatio must be attached. ,
Are there any existing wastewater systems on the site7 Yes o
Does fhe site contain jurisdictional wetlands? Yes o
Are there any easements or right-of-ways on the site? Yes o
' Is the site subject to approval by another public agency7 es o
Will wastewater other than domestic sewage be generated7 Yes
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathrooms Garden Tub/Whirlpool Yes No
Basement Yes No Basement Plumbing: Yes 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)�t�(Attach documentation ofsimilaz facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: omentiona�Accepted Innovative Alternative Other
Water Supply Type: ounty/City Wate New Well Existing Well Community Well
Do you anticipate additions or expansions of the facility this system is intended to serveT Yes No .
If yes,what type?
This is to certify that the information provided on this application is true and wrrect 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 falsi6ed 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 I am responsible for the proper identification and labeling of property lines and corners and
lo mg d flagg' or ta in he ou /f cility location,proposed well location and the location of any other amenities.
Site Revisit Charge
Pr ert wn r's or owner's legal representative signature
O Date(s):
Client Notification Date:
Date EHS:
Sign given Yes No �� wa . Account#, �����/_L_
. Revised 11/06 , � 4�� Invoice# /'_/{_i
J/lUl
� � . .
. � •, � , • ' '� DAVIE COUNTY HEALTH DEPARTMENT
� � , � Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005407 Tax PIN/EH #: 5729-76-1983
Billed To: Davie County Farm Bureau Subdivision Info:
Reference Name: Location/Address: US Highway 601 N-27028
Proposed Facility: Business Property Size: 188x280x121x Date Evaluated: �� — �-y l CI �
Water Supply: On-Site Well Community Public ��
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape osition L,
Slope % v• f o
HORIZON I DEPTH ,�' _ �_ � (
Texture grou G.
Consistence �' R � U /'
Structure � ( c ��,
Mineralo � , .,�
HORIZON II DEPTH - t � " � !
Texture rou
Consistence ? ' �
Structure ✓
Mineralo �f. i n
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE r� �
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 6 .Z /: �. a� Z
SITE CLASSIFICATION: EVALUATION BY: � l�<
,
,I� r� i
LONG-TERM ACCEPTANCE RATE: v � °� OTHER(S)PRESENT: ' l '- � � ��
REMARKS:
LEGEND
i.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
T.exLnr� •
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 '
CONSISTENCF.
l�ist
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-Slighdy plastic P-Plastic VP-Very plastic
Str�ct�re
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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
Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable)
TTAR _T.nna-term a�rrntan�r ratP_ oal/�iav/ft� r�nriT nc�nc m__.:__��
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GoMAPS - Davie County NC Public Access
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. '� Thursday,December 3 2009
- ***WARNING:THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
• primary information sources should be consulted for verification of the infortnation contained on this map.The
- County and mapping company assume no legal responsibility for the information contained on this map.
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�� - �1�� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
�. '� Davie County Environmental Health ������ '�"
, ,,,-�,, �
, � , � ; �,,, };;� � P.O. Box 848/210 Hospital Street �,I , „
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� Mocksville, NC 27028
� . i*�;,"�� (336)753-6780/ Fax 6)753-1680 _
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" Application For: o Site Evaluation/Improvement Permit Authorization To Construct(ATC) o Both
Type of Application: oNew System oRepair to Existing System oExpansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name: Davie Countv Farm Bureau, Inc. Contact Person John Fuller— Architect
Address: 977 Yadkinville Rd. Address: 68 Court Sq, 200 Mocksville, NC 27028
Mocksville, NC 27028 Business Phone: 336-751-0400
Email : �john(a�fullerarchitecture.com
Name on Permit/ATC if Differerzt than Above
Mailing Address: 977 Yadkinville, Road City/State/Zip : Mocksville. NC 27028
PROPERTY INFORMATION *Date House/Facility Corners Flagged- Yes
NOTE: A survey plat or site plan must accompany this application. Included: Site Plan(not to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name: Davie County Farm Bureau , Inc. Phone Number: 336-751-6207
Owner's Address: 977 Yadkinville Road City/State/Zip: Mocksville, NC 27028
Property Address: City: Mocksville, NC 27028
Lot Size: 1.5 Acres Tax PIN# H3040A0019
Subdivision Name(if applicable) Section/Lot# .
Directions To Site: The site is located on the north side of Ashley Brook Ln. at the corner of Hwv 601 and
Ashlev Brook Ln.
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? _Yes X No
Does the site contain jurisdictional wetlands? Yes X No
Are there any easements or right-of-ways on the site? Yes X No .
Is the site subject to approval by another public agency? _Yes X No
Will wastewater other than domestic sewage be generated? Yes X No
. IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool Yes No
Basement: Yes No Basement Plumbing: Yes No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business: Professional.Off.ce Total Square Footage of Buildin�: 5 000 SF # People: 50 Max.
# Sinks: 3 # Commodes: 2 # Showers: 0 # Urinals: 0
Estimated Water Usage (gallons per day) 87 gallons (Attach documentation of similar facility water
consumption) See attached water bills — some are higher due to sticking toilet.
FOODSERVICE ONLY: # Seats: N/A
Type system requested: X Conventional _Accepted _Innovative _Alternative _Other:
Water Supply Type: X County/City Water _New Well _Existing Well _Community Well �
Do you anticipate additions or expansions of the facility this system is intended to serve? _Yes X 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 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 I am responsibte for the proper identification and labeling of property lines and corners and
lo�atit� a flaggiryg or staking the house/facility location,proposed well location and the location of any other amenities.
� �'���"`� Site Revisit Charge
Property owner's or o r's legal representative signature
Date(s):
�� 'J�"�3 Client Notification Date:
Date EHS:
Sign given oYes oNo Account# ��v r
Revised I 1/06 Invoice#
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