1065 Wagner Rd �
. , � DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
, (336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
,Accnunt �: 990005876 '��x�l�€.�EH�: f3000000515
Billcd 'f'o: Freedom Homes Sia�r�i�ri;iar�,in��:; � ;
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R�fer�E�ce fVanie: �2or2e_..,IoN�s` LacationiAdc�r�ss: WagonerRoad- .
f'ro�c�s�c9 ���i(ity: Residence -J Pri���rty S�iz�: 2 Acres . �
ATC E�urnb�r: 5936 ,, .
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1�jY **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
$b in compiiance 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 S 0�'� Tank Date -3/ Tank Size »a0
Pump Tank Size -� Bedrooms: �
System Installed By:✓�� �Q(��Q'-� Installer# Date: l� /Z
GPS Coordinate:
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Environmental Health Specialist Date: � V'-
DCHD 11/06(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH ��
� � P.O.Box 848/210 Hospital Street �
Mocksville,NC 27028 �I �
(336)753-6780/Fax#(336)753-1680 rn � 1
REPAIR IMPROVEMENT PERMIT �'
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Accr���t #: 990005876 '��x�1�I.%�H#: f3000000515
BiEl�d To: Freedom Homes SuE�s�i�i�ior� irif�:
Refe►��E�ce N����: LacaiionrAddr�s�: Wagoner Road-
f�ropc�seii F,��:i€ity: Residence � ��c���r�.y Siz�: 2 Acres
wT� NU�v►�r $�3(G' Site Type:Repair O Expansion O
a��"�1��3fhis���uthorization 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 IP/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 plumbing❑
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)��Tank Size l�� GAL.Pump Tank_�GAL.
Trench Width�� Max.Trench Depth�� Rock Depth/�A Linear Ft.�
Site Modifications/Conditions/Other: p�~�o Q�'d G(���^t
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# 336 753-6780.
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Environmental Health Specialist Date:� (' 2
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 #: 990005876 Tax PIN/EH#: f3000000515
Billed To: Freedom Homes • Subdivision Info:
Address: 1124 Charlotte Hwy Location/Address: Wagoner Road-
City: Troutman
Property Size: 2 Acres
Reference Name:
Propo*�NOI�E*��ThRs�mp o ement 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: �iew ❑Repair ❑Expansion Permit Valid for: f�S Years ❑No Expiration,
Residential Specifications: #Bedrooms�#Bathrooms 2 #People �/ Basement0 Basement plumbing0
Non-Residential Specifications: Facility Type � #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): . •"'y� Type of Water Supply: �County/City ❑Well ❑Community Well �
Site Modifications/Permit Conditions:
S stem T e LTAR
Initial V v Q l�G � 3
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Site Plan
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Environmental Health Specialist � Date cs��/�
` i:p.11-06
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APPLICATION FOR SITE EVALUATION/IMI'ROVEMENT P ATC �
�►�� � Davie County Environmental Flealth ��A
� P' P.O.Bog 848/210 Hospital Street 'r��y � �� ,
� ''`u;' ; , ^�"'? A` Mocksville,NC 27028 � �
y�_ ,
� �� �D�� � (33�753-6780/Fax(336)753-1680 ��<
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Application For: te Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) �Both���y
Type of Application: �ew System ORepair to E�cisting System ❑Expansion/Modification of ExistinQ System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI�REQUIlZED
INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instructions.
APPT,TCANT TNFnRMATT(�N
Name L W ��� ��fGE�now� ,I-�Qytiti�.S Contact Person ��'I C �it/��L
Address 2 ' � v-�} c.�,w Home Phone '7fj�- J�Z8-']p/d
City/State/ZIP j��crf��� (��G 9_.�1 fo(� Business Phone 70 L-��'��(n!�,�
Email � C`La. o� vu ,C��1
Name on PermidATC if Different than Above ' 0��� �tiFcS
Mailing Address �38 �'�.v,o �o�£ l�oP City/State/Zip ,l�1/dlCr'r3�lGG L J�Jr
PROPERTY INFORMATION *Date House/Facility Corners Flagged /2 �2
NOTE: A survey plat or site plan must accompany this application. Included: [9�S"ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site lan,no expiration with comj'lete plat.)
Owner's Name "C�AP-C�Y �ON�� �l��A,�CL�1�'� ��t,�. �{E Phone Number 7�~�P����a3(`C
Owner's Address l�Q�/V�y��oCS� �,oc�p City/State/Zip�(9o�sSu«« w�, Zs��17
Property Address I�oT� Z tN v�e r (Za- City (Mvc�-scn I I c
Lot Size 2 -�d Tax PIN# U
Subdivision Name(if applicable) Section/Lot# 'Z_,
DirectionsToSite: SumM�+ �r� -}•�ih c�� o�n C'A���t�flt_- �hvnl?-�f ON ('oL•,�r � ,�i y�-o� (oQ l�n�f
15v1 C��a.�v �'l�vrc� Lc� a�► U,a 4 Nt� Cv f �s v.� I1�' LY�GG�'S -f,ra� /Q f��
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 t/No
Does the site contain jurisdictional wetlands7 _Yes ✓IQo
Are there any easements or right-of-ways on the site? Yes �To
Is the site subject to approval by another public agency? Yes ✓No
Will wastewater other than domestic sewage be generated? Yes �o
TF RF,�TnF,NC;�,F1T,T,nI JT THF,RnX RFT.nW
#People �_ #Bedrooms �_ #Bathrooms Z Garden Tub/Whirlpool B'1'es ❑No
Basement: ❑Yes C�'o Basement Plumbing: ❑Yes C�o
JF.NnN-RF,STDF,NCF,FTT,1„niJT THF RQX RF.I,nW
Type of FacilityBusiness 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: ❑Conventional ❑Accepted 1�I2�novative ❑Alternative ❑Other
Water Supply Type: �ounty/City Water ❑New Well ❑Eausting Well ❑ Community We�l
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C3�
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 responsible for the proper identification and labeling of property lines and corners and locating and flagging
or stak' g the house/facility location proposed well location and the location of any other amenities.
--�^�''`�� ��,�� Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
5'(l�'� z Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# � b 7� ��—
Revised 11/06 Invoice#
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� � ' � ' � ' � � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site,Evaluation �
APPLICANT INFORMATION ' PROPERTY INFORMATION
Account #: 990005876 l'ax PIN/EH #: f3000000515
Billed To: Freedom Homes Subdivision Info:
Reference Name: Location/Address: Wagoner Road-
Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: � �o �z
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e % G% � e 'o
HORIZON I DEPTH �
Texture rou C
Consistence �/
Structure y � �i�, f G
Mineralo /.'� � �.%
HORIZON II DEPTH .. O %3
Texture rou
Consistence U
Structure
Mineralo 1
HORIZON III DEPTH -�
Texture rou
Consistence
Structure R, ' G
Mineralo ` r�
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION �-r'
LONG-TERM ACCEPTANCE RATE • ?
SITE CLASSIFICATION: �/ EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT:
REMARKS:
' LEGEND
i.�ndscaoe 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
Tcxtur�
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
.oNsr�T .Nc .
MQist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely�rm
�Y.e.t
NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
a�YT11CtuI�
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev • •
1:1,2:1,Mixed
lYQi�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
Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance ra[e-gaUday/ft2 DCHD OS/OS(Revised)
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