1400 Yadkin Valley Rd r _ _ ._._.__.__.. _.. _
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� DAVIE COUN�I,Y ENVIRONi�9EV�I'AL ITLf�I,�l f I
i P.O. T3or �48/2�10 3(ospital Street
Mocksville, NC 270?�
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Account #: 990000758 OP�;KATION PERi1�t.�� PIN/EH #: 5863-35-5150 II
Billed To: Ronnie Foster Subdivision Info: �
Reference Name: Location/Address: Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 7 Acres
ATC Number: 4839
**NOTE**The issuance of this Operation Permit st�all indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .7900"Sewage Treatment and Disposal Systeins,"
but shall in I�TO WAY be taken as a guarantee that the system will fimction satisfactorily for any given period of
time. �
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System Type:��_S.T.Mamtfacturer �hO C'� Tank Date� Tank Size_�, �1 CGG
Pump Tank Size �
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� System Installed By: �� ,!G'��:� ����z`` E.H�Specialist: �-�'��' Date: ��� �
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� • !'.0 F3o��-��/?1(i I-Iospitai St:ee: ����
vt�>c�:svi11�, NC 2702�
� r_��6)7�1-8760 Fax# (336)7�1-�786
1li'fHO121%;�'1�I0V� 1�0121V.�S'1'E�1'_1"1'F;R SYS't'FM CO'�STIZtiC'TIOi�
Account #: 990000758 Tax PIN/EH #: 5863-35-5150
i Billed To: Ronnie Foster Subdivision Info: �I
Reference Name: Location/Address: Yadkin Valley Road-27006
Proposed Facility: Residence Property Size: 7 Acres
ATC Number: 4839 I
�ite"I yp�: �i�ew i-:Repair l iEYpansion �
�*NO"I�E*� This Authorization to Constnict(ATC)ivfUST I3E ISSUED by tbe Davie County Lnvironmenta]
�Iealth Section prior to issuance oF any building permit(s), (in coinpliance with Article 11 of G.S. Chapter 130A ��
Wastewater Systems, Section .1)00 Sewage Treahnent and Disposal Systems). �i'HTS AIJ'1'HOIZIZA'I�10N TO
CONSTRUCT IS VALID POR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if sife plans, plat �
or the intencled use chan�e.
Residential Specifications: #Bedrooms �#Bathrooms__� �People � BasementfJ Basement plumbing�7 I
\ot�-Residential Specifications: Facility`I'ype_ _ #People__ #Seats__ �
Syuare Footage(or Diinensions of Facility)___ _
Lot Size_/ �C G1�7 '1'ype of Water Supply: GK;ounty/City �Well ❑Commutiity Well I
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System Specifications: Design Wastewater Flow(GPD) ��L' Tank Size � ��U GAL. Pump Tank��_GAL.
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rI'rench Width__7[�_ Max."1'rench Depth 3L• Rock Depth_ �:� _ Linear Ft. �_,�
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Si,e Modifications/Conditions%Other: ___ _ _.�� 3(t r��7(QIC�p�4��,a�
Contact the Davie County Environmental Health Secfion for final inspection of this system betrveen ��
8:30—9:30a.m. on the day of installation. Telephone# 336)751-8760.
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I;m�ironinental Health Spccialist—_ T)ate: —��
DCHD 11/OC(Revised)
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Davie County Environnicntal Hcaltli
P.O.13os S48/210 Hospital Street
Mocksville,NC 27028
(336)7�1-87fi0/ Fax(336)757-8786
Account #: 990000758 IMPROVF,MENT FEI���IN/EH #: 5863-35-5150
Billed To: Ronnie Foster Subdivision Info:
Address: 363 Harvest Way Location/Address: Yadkin Valley Road-27006
I City: Mocksville Property Size: 7 Acres
Reference Name:
Proposed Facility: Residence
**NO'1'L**This Improvement Permit DOES NOT authorize the constniction of a wastewater system. An
Atitlaorization To Construct a wastewater systern must be obtained from this office prior to the
construction/installation of a wastcwater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). Ttiis Improveme�it Permit is subject to
revocation if site plaiis,plat or the intended use change.
...._._.�._..._._.__.._..._. _..._�.4._..._____..,�._..._...�._..�......_........m.�.� ._..�.,..�._._,_....._.._..,
Permit Type: rew I 1Repair ❑Expansion Permit Valid foi: — Ycars�[-�No Expiration
Residential Specifications: #Bedroonls_�_ #Bathrooms j #People� Basement❑ Basement plumbing_:
Non-Residential Specifications: Facility Type #People _ # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):_�C �� Type of Water Supply: f�l�Ounty/City f7Well ❑Community Well
Site Modifications/Permit Conditions:
I System Type LTAR
Itutial � .�� 7 j
Repair �e� t <-e� . 7
Site Plan C/
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Lnvironmental Health Speciali t � .0 ���ate i
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�APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health '�
'��,'� � � P.O. Box 848/210 Hos ital Street
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��`x•.,'��,, , Mocksville, NC 27028
.
(336)751-8760/Fax(336)751-8786
Application For: Site Evaluation/Improvement Pernlit � I Authorizatiott To Construct(ATC) � '�� Both
Type of Applicati� =�New System �� �Repair to ExistinQ Systein IEx ansion/Moditication of Existin�S stem or Pacilit
� P � Y Y
***l�4PORTANT�`*�THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
�--
Namc to Ue Billed T� i -, E� ��, r E' �I��, �:, �c=�>� Contact Person �\l�:��-. ., ,'.. �. , f�,
Billing Address ��. � i-/cr�:>>_ .;, � �:'�:�r Home Phone `/�/ -�Z r; (.:;�
� Eity/State/ZIP ;'����-�: �,,,. /I,, �� ; _ �� j �t c_' � Business Phone `i�'; �- _; ;�=';_
� Name on Permit/ATC if Differerat than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *llate House/Facility Corners Flagged ,3� Ia -a�
NOTE: A st�ivey plat or site plan must accompany this application_ Included: '_1 Site Plat� ' IPlat(to scale)
(Perinit is valid for 60 rr�ntl�s with site plan, no expiration with complete plat.)
Owner's Name��>,�� � f���� �.� Phone Number �'S �� �
Ov�n�cr's Address Cit /State/li � ��� ���
l��l ►�: �L�1 �.�n_. i�.�.�._ _ �C?c�c�, )' I� �
Property Address City
Lot Size �/ ;-1, �- Tax PIN#SS�i .�S S/SU
Subdivision Name(if applicable) Section/Lot#
DIl'f.'Ct1017S TO Slte: �� e� ( *C �i �cC<n 4[.���� + <':.;�.t2^ [y�.itil ttu/�'-� �i���' I
�t, � . �i n-r i �t.; �4 h c�.� -� l f � � xsL�1 �n ��..-• �� �i
I�the answer to any of the followiug questions is"yes", supporting document�ation must be attached. �
Are there any existing wastewater systenzs on the site? � IYes ❑No �
Does tlle site contain jurisdictional wetlands? lYes I �No
Are there any eascments or right-of-ways on the site'? � 1 Yes ❑I�To
Is the site subject to approval by another public agency'? I IYes ❑No
Will wastewater other than domesric sewage be generated'? I !Yes ❑No
IF RF,SIDENCE FILL OUT THE BOX BELOW
#Pcople l� #Bedrooms � #Bathrooms _� Garden'I'ub/Whirlpool Yes 'No
Basement: Yes nNo I3asernent Plumbing: Yes `�No
IF NON-RESIDENCE FILL OUT THE BOX B�LOW
Type of Facility/Business Total Squarc Footage of Building _ #People �
# Sinks #Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of siinilar facility water consumption)
FOODSF,RVICE ONLY: # Seats
Ty�e system requested: i�Conventional �_lAccepted :��:Innovativc �. ;Alternative �� ��Other
Water Supply Type: �ii County/City Water C New Well ' �Existing Well Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve'? I � Yes IX No
If yes, what type? e,
This is to certify that the information provided on this application is true aild correct to the best of i��y knowledge. I understand that
any pern�it(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is alCered, the intended use changes, or if
the information submitted in this application is falsified or chaugcd. I hereby grant right of enh-y to the Authorized Represe»tative
of the Davie County Health Department to conduct necessary inspections to deternune compliauce with applicable laws and tules.
� I undeistand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or s� g the house/facility cation,proposed well location aiid the location of any other amenities. �
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��� i� � ��- Site Rcvisit Cl�arge
roperty owner's or owner's legal representative signature I
� Da�e(s):
_��j'� � "�' Cliciit Notification Date: _ __
Date E�IS:
Sign givcn Yes ❑No Account t� I � �
Reviscd 11/O6 Invoice# � � I
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�t����'s 77ft � , �r' � �, i,
*WARNING: THIS IS NOT A SURVEY!* WLdCIeSd�jy, ?_/?._0/2008 Parcel Number� --
This map is prepared for the inventory of Number. 5863355150
real property found within this Ky�����
jurisdiction, and is compiled frorn ccount Number: 000082514545
recorded deeds, plats, and other public C, `�;- '�� RIDDLE]ERRY WF
records and data. Users of this map are QU �.t Listed Owner #1: R
hereby notified that the aforementioned
Listed Owner #2:
public prirnary infarmation sources should 1366 YADKIN VAL
be consulted for verification of the Mailing Address 1:�ROAD
information contained on this map. The ,
County and mapping company assume no Mailin Address 2:
leyal responsibility for the information Cit : DVANCE
contained on this map. State: NC
Notes: Zi Code: 27006
Legal Description: 7.00 AC YADKIN
i
VALLEY RD
Acrea e: 7.43000000
Deed Date: 020000307
Deed Bookand Pa e: 003280150
Plat Book:
Plat Pa e: �—
Buildin Value: 0
Outbuilding and Extra Features �
Value:
Land Value: 95100
otal M<�rket Value: 95100
http://maps.co.davie.nc.us/GoMaps/reports/report.cfm?CFID=4363&CPTOKEN=84588107 2/20/2008
GoMAPS - Davie County NC Public Access Page 1 of 1
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• . ' i
. • • ' DAVIE COUNTY HEAI TI-f DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPI PC�d�'�'tI�:F�B.�OQ��I Tax PIN/EH #: 586B1�$6�Y INFORMATION
Billed To: Ronnie Foster Subdivision Info: �'s!�<.�_:��`�f�j��
Reference Name: Location/Address: Yadkin Valley Road-27006 ��
Proposed Facility: Residence Property Size: 7 Acres Date Evaluated: �=���' �,
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Watcr Supply: On-Site Well Community _ !'ublic � II
Evaluation I3y: Auger Boring_ Pit _ Cu[ _
FACTORS 1 2 3 4 5 6 7
Landscape positio�l (,,_ �- �.---- �
Slope % f � r
HOR17.ON I DEP'1'H �_ : ' C% — L;
Tcxttuc grou ' � �. �+ —
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Consis[ence ;,;i ;� ,;/ �
Sfructure �' �� � 1�� �� �
Mineralo� ! _ n � -�, , �� ' I
]iORI"/.ON iI DEl'TH
�I�GXCUI'C �I'OL]. ' .
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SII'UCLll["C
MIIICI':1�04!}�
NOR110N ili DEPTI��
Texturc �rou�
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Consistcnce �
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Structure
Miueralo* ��
l101t►'T.ON IV llEI'TH
� Te�turc �rou �
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Consistencc
I� Structure
Miner�ilo� � I
SOII_,VVETNESS ..—��
KES'I'RICTIVI?HORI"1-ON ��"
� SAPROLITE
�� CI.ASSIFICAI'ION � ` �
LONG-TERM ACCEP'TANCE RATE . � ` — ) i '
` ) ^ f i
SI`l'E CLASSIFICATION:_ `� J EVALUAT[ON BY: ���f1 ..�I/����f[;�1 � _
' _ .
LONG-'1'�;RM ACCTP`I'ANCE IZATF_: �' ��-� O'I'H�R(S) PRESENT: �O�'1 f"�s F �(�����
I
RLMARKS:
-- -- LEGEND -- --- —
L�t1d��pe P��sitiori �
R - ltidgc; S - Shoulder L- Lincar slope FS - Foot slope N - Nose slopc
CC - Cuncave slope CV -Convex slope T-T'errace HP- }�lood plain I-I - Head slope
Ts�stllrs�
S - Saucl LS - Loamy sand SL- Sandy loam L- Loarn SI- Silt
SICI_,- Silty clay loam S1L- Silty loanl CL- Clay loam SCL-Sandy clay loam
SC - Sandy clay SIC - 5ilty clay C - Clay
S;S2I�,�1STt�:NCL
1,1�
VI�R -Vcry friable FK - Friable FI - Firm VFI - Very f�irrri EFI-Extremcly firm
�YsI
NS - Non sticky SS - Sligh[ly sticky S - Sticky VS -Very Sticky
NP- Non plastic SY- Slightly plastic P-Plastic VP- Very plastic
Strustu►•e
SC - Singlc grain M - Massivc CR- Crumb GR- Granular Af3K -Angular blocky
SBK - Subangular blocky Pl,- Platy PR - Prismltic
�'Iincr.�l�ig��
1:1,2:]. Mixcd
\c�tc�
Hurizon cicE�th - ln inches
Depth ��f fill - ln inches
Rcstrictive horixon -Thickness and inches from land surface
Saprolitc - S(sui�able),U(unsuitable)
Soil wetness - Inches from land surfacc to free water or inches from l�nd surfacc to soil colors with cl7roma 2 or less
Classification - S(suitable),PS(provisionally suitabfe),U(unsuitable)
LTAR - Long-term acceptance ratc- gal/day/ft2 r�rUr�n�inc iv,...:....a�
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