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1085 Williams Rd ` . . o DAVIE COUNTY ENVIRONMENTAL HEALTH � , P.O.Box 848/210 Hospital Street � �\�� ' Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 (�\ti .,` REPAIR OPERATION PERMIT Account #: 990002796 Tax PIN/EH#: 170000004501 Billed To: Melissa Long Subdivision Info: • Address: 1085 Williams Road LoptioNAddress: 1085 Williams Road-27028 City: Advance property Size: 6.206 Reference Name: Melissa Long Proposed Facility: Repair : **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:�_S.T.Manufacturer C' Ti� Tank Date_� Tank Size � Pump Tank Size_�! --�� System Installed By: ��l��p E.H.Specialist: Ir � (,l�(X,Date: ( �?�� � GPS Coordinate: ' l . � ���,y�_� � � �� �� . � , _ :o �; , � �,� � � .. . � � " '` � `•``• �, � ��/ � ~ � \ �� � ! � � 1 �� � ` '� . ` � :,. .. � : �, � \ � � � � -_ `� � �� � � , � � � � .� ` ,� � �i� \ � � �`�, . �`O��e� 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 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ,Ac�ount #: 990002796 r•�,r:,:;;.��..; ;� ,= '��x P`��lEH#: 170000004501 .. �illec�To: Melissa Long :��:i:::;: .`S�abdi�ri�on lnfac . Refer�E�ce Nan�e: Melissa Long �?:.:;:;, �:: P,..::€.�ca��r�lAddress; 1085 Williams�Rbad-27028 " , E'ropUs�;r! Facility: Repair ��r��-,.,� �,.:,� � ,��:: ,; ��e#�Siz�: 6.206 - ATC NuE'itb2� 5836 ,` ;�:� ;��'::�' =� Site Type: ❑New�Repair ❑Expansion **NOTE**This Authorization 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 AUTHORIZATION TO CONSTRUCT IS VAL�FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. � Residential Specifications: #Bedrooms�#Bathrooms #People i' Basement� Basement plurnbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size . �(, Type of Water Supply: C,1�ounty/City ❑Well ❑Community Well i � �y�� System Specifcations: Design Wastewater Flow(GPD)�� Tank Size � I� L.Pump Tank��%rJ�"J GAL. 1< << � 7 � Trench Width� Ma�c.Trench Depth� Rock Dept�,__��_ Linear Ft. �pp` � 1 � Site Modifications/Conditions/Other: ��,��R �� Contact the Davie County Environmental Health Section for final inspection of this system between 8:30— :30a.m.on the da of installation. Tele hone# 336 751-8760. . � �� !�-`'� I �� �' ��`� � ' ' , , �, , � , `,�`,� c , � • '� �; '\ \ �tb , , , � ' � � � � � � � ` � �� , , , � , �1�e � � ' �� �� �'� r � a� �I � �: l3` J' Environmental Health Specialist 1 ' Date: � � G�} � DCHD 11/06(Revised) . � . � • Davie County Health Department �Ps j� Environmental Health Section � ,.��, , �^ : � P.O. Box 848 �'� C� ~ � ,5,, 210 Hospit��l Street • � O U �'t Courier# : 09-40-06 "• '1911 Mocksville, NC 27028 Pl�one:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION Fax:(336)-753-1680 (Check One) Replacement Remodeling Reconnection Name: ��.�, � ���I��js G� I�,Q�Q Phone Number q�� - �J7�O (Home) MailingAddress: ��"�j_�����(,tMS �'�r (Work) ��\Q '�(S VI ���.���� Email Address: Detailed Directions To Site:_ �Q't E — �(''� �C'� ,U(�t�l��t 1'l� ^ �'(^� �[�l i 11 i�►^nS �� `�-h Q:r� `�� rn�1� � r1 ri�I�.f- Property Address: ��� W l I I i Ct rl�,5 ►�l�• � ..L�� C����o� ���(7� Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: ('� �p��, Type Of Facility: �I W Date System Installed(Month/Date/Year):�;�� Number Of Bedrooms: � Number Of People: � Is The Facility Currently Vacant? Yes No If Yes,For How Long? Any Known Problems? es ' No If Yes,Explain: �7CL-�e.�^ ��r�. ,p �.�e� �-y1�'�.�c S��'�-� (`; ��r��, Please Fill In The Following Information About The NEW Facility: Type Of Facility: c 1��1��Q��►G�,e_ Number Of Bedrooms: � Number of People � Pool Size: Garage Size: Other: Requested By: ��t� �/�,�' Date Requested: �(�, �� � � (Signature) For Environmental Health Office Use Only Approved Disapproved omments: � Environmental Health Specialist " Date: ����p��Q// , *The signing of this form by the Environmental Health Staff i m no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ � Date: Paid By: Received By: � T�Account#: �I 7 (!' Invoice#: � �,. �.p .�] � r/� ��� � ��,C� � DAVIE COUNTY HEALTH DEPARTMENT �j�� � ��� �, Environmental Health Secdon �� ���y 1 � ^�d�3 PO Box 848%210 Hospital Street � , . ..,��. , �. co �ViRON�'nE`y�At r1 LT� Phone: (336)751-8760 p1V1EC0U�+ ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION 0 � Name: �c����,SC.l Lo na Phone Number: ���- ��G�t�� (Home) Mailing Address: 1 I�j � �, 1 ti� G Y7l 5 �({ _ (Work) A<i�,'��n c e; 1�_C . �o�� Detailed Directions To Site: L`i 1���i �l1� � i��r ���'�5 �[�. �o� t�'C�'Y1 I 1�f`��5 l�� 1�f� '�'[.lf Y1 ��P�-�- o fl Far I�Q�,tihv �cj.�b�s�cl� F"�rl� ��eD����r�c���� rn;l�s r.n (e,�-1- �n(;I1;�t,^r►� Qc� �-h�.� �'Z �r1 r�c;h}--. Property Address: ���''�� �+���Gt'Yt_S R('�. �- Please Fill In The Following Information About The Existing Dwelling: � �� � i Name System Installed Under: m Q.at LO r1Q Type Of Dwelling: ' Date System Installed(Month/Day/Year):�'�� � 5� Number Of Bedrooms:�_Number Of People:�! Is The Dwelling Currently Vacant? Yes f� No❑ If Yes, For How Long?�j�j'�-I15 � Any Known Problems?Yes❑ No C� If Yes, Explain: PIease FilI In The Following Information About The New Dwelling: , Type Of Dwelling: `i;����f,<I P� Number Of Bedrooms: Number Of People: � Rcquested By:� � Date Requested:� 10 _ (Signature) . � For Environmental Health Office Use Only A roved Disa roved ❑ PP PP Comments: Environmental Health Specialist �� Date � l�'�� "The si�nutg of this form by the Environmental Health Staff is in no way intended,nor should be taken as a �uarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time.- �3 3d � �4 Payment: Cash❑ Check' Mor�ey Order❑ # Amount: $ ��� Date: ���l,�–% Paid By: _�1 - :JC f���i Received By: t�L""��'�'— _ Account #: ��.-- � 7 � �'� Invoice #: - `P r� �J / ,. ��,�., __ �G , „ . . . . Yd .�.� ' �,���� h , ' ; -� � a � -" ` ,.'=� � ('' � DAVIE COUNTY HEALTH DEPARTMENT ' p-t �-� �� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `��p *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems .����=�'�'s"v�� Permit` Number Name_�[.[�L_���a'-'S'S�/�"���r��r�: ��"�/y'_ � Date ./ -/I� - ��.5� �� � g � C� ���/' r Location -�j `���/ ./`�-.c� .,��,�,/;�/� ';/ �' `�/ ��/��- r F/ �� /-�j /i� /lr;,f ,!��� ��' Subdivision Name Lot No. Sec. or Block Na Lot Size���'S� House Mobile Home �_ Business __ Industry No. Bedrooms �..�—.No. Baths �.__ No. in Family�_ Public Assembly Other Garbage Disposal YES � NO [�' Auto Dish Washer YES ❑ NO Q� S�cificati�s f�, Syst�m: „ �l'G'1iC�G: 1,�. �„/,1-��'��' Auto Wash Ma^hine YES �' NO ❑ • '�v Type Water Supply — ��1 ---- `-rU�� .�.��J,;,�� 'This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. ,.__..__�._. �` Improvements permit by _���L� *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by —1�� /��c,��l �� D � ' �----- �� � _.�..__..e,__..-- ! � ,.� _ _/ Certificate of Completion � .�`' fi Date � ���S 'The signing of this certificate shall indicate that the system described above has been installed in compliance with ' the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. , -„ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE IM�'�'•�>`'�.��;.���ti�d+ t ' f • Davie County Health Department � + �� Environmental Health Section O��' � � ��`�`'} l� P. O. Box 665 Mocksville, NC 27028 -�------ ------ � , � `7���G1�-5�� ,� 1. Application/Permit Requested By 1�. �O �� �SS F�� �--0 �1Q����� L Mailing Address d3�M�Ii�n �� � Home Phone �d - � 1 v I�kS1/i � �(�_, �.0 . c�-7('��� Business Phone G�����o�'� �� 2. Name on Permit if Different than Above �`���ss���2�� 3. Application for: �General Evaluation �eptic Tank Installation Permit 4. System to Serve: ❑ House C��fobile Home p Place of Public Assembiy p Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ BasemenUPlumbing No. of People � ❑ BasemenUNo Plumbing No. of Bedrooms Ga'Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: C�Y('ublic �D�gDd,,o�.`�-� p Private ❑ Community �J�f 0 8. Property Dimensions � / / �« Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes [.�Vo If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: �b ��i i es e a s� o n l��I -�-u r r, � C'�►rl �O f k l7 i X�y C C hurc l-� �2 c 1. 0 3 m � Ie 5 I S+l lar d �c�.� e�1 r�oc,d o�, I �e-�--l-V�� �I l �'c�.m �d- -�i�r5� -�V�o S O�'Y Y�J h i�e- h o c_.t s�e o n '�� ►� �G In f , L�i��tic�-� CL-� �2.�-a.-�y o��-c� �� B`�-� �� C,Qic.Cl�- �:U/�/�`�2� b� - � ��v ! �,%Z�I.�.�:�„`-- 8��-2.. � � ��� � ' This is to certify that the information provided is correct to the best of my knowl dge, and I understand I am responsible for all charges incurred from this application. ' �alac� Iq� ATE IGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPEFiTY MUST CHECK ONE: ❑ 1. I OWN the property. � I DO NOT OWN the property. If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by �c.l n►'1 i P�. L o r,a to conduct all testing procedures as necessary to determine said site's suitabili or a ground absorption sewage treatment and disposal system. _ � a ac� q - ` ` �, DA E ' .. _ SIGNATURE DCHD(1�93) � � �^ � : - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME � DATE EVALUATED �o� ���� ADDRESS PROPERTY SIZE ��I��OJ'G �� PROPOSED FACIILTY //�� �(�,�27+P LOCATION OF SITE l/1//��ii�r l/Z!/ Water Supply: On-Site Well Community Public `� Evaluation By: AugerBoring �/ Pit Cut FACTORS 1 2 3 4 Landsca e osition L ,L Slo e 7. — — — HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH � � f 3 � Texture rou � C` Consistence � Structure /c � l Mineralo /.'/ /,' HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASS.LFICATION LO�IG-TERM ACCEPTANCE RATE , ,:� SITE CLASSIFICATION: � EVALUATED BY: � /C�/� LDNG-TERM ACCEPTANCE RATE: � � OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge 5-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 �ICL-Silty <;lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-V��y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structnre �C-SYr.gle grain M-Massive CR-Crumb GR-Granular ABK-AnBular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mi neralo�y 1:1, 2:1. Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil w etness - Inches from land surface to free wate� 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 DCHD(01-901 ■���\�������������������������������������������������i��■ i1�t.7�■ ■�����■■����■■��■����■������������■�/�����������■�����������■�■��■ ■�����■�■��■�■�■■�■������������■ ■��■��r■������\���■�■■��0��l��■■ ■�■��������■�■�����������■������������������■■�����������������■■ ■��������■����������■■��■�����������������������������■�������■��� ■�■���■������■��■�����\��������������■��������������■������������■ ■���������������������■����■�������������������/������������������ ■����E■■��■��■�����������������������������/■�■����■■■■����������■ ■■�����■��■■���■■■���������������■������■������■��������■■■�����■ ■�����■�����������■���������������■������������������■��A■�■������ ■�■�������������������■��������������������������■��������������■ ■���������������/��������������� �������//����������������������� ■����������■������r������������■�/�■■���������������■�����■�■���■■ ■�����������������������■�� ■������������������ ■����������������■ ■�i������������■���������������������/�������� �������� ■����/���■ ■����������■������������■���������������� ��■■ ■ ■ ��■�������■ ■■ ■■����■������■������������������������������■ �������■���������■ ■��������/�������������������������������������������������������■ ■���■\����■�������������■���\������������������■�\��������■�■��■ ■���■��■����■����■■��■���■���■� ■�����������■��������■����i����■ ■�■����■■���������������������������■��■■�������������������■����� ■��■������■����■�������0�������������������■��������������■■■�■��■ ■������������■�����\��■����■�������■���■���������■ ■���� ■������� ■��■����������������������■���■�■����������������■��\��������■��� ■�■������t■�■����������s■i�������■ ■■���������������■����■■���� ■ ■��������������■������������������■����������■�u�■����������■ ■�� iiiiiiiiiiiiiiiiii�iiiiii�i�iiiii�iiiiiiiiii=ii�iiiiiiii�i��i�=�iii ■��������t������������a������������N��������������� ������■���� ■���������������������n�����������������������������_���������■�� ■■�■■�����■�������■�������■■��������■�������■����■ M��■�������■ ■ .......................■..................■......■C..........■.... .................................................■......■■■..■...■ .................................................■.......■.......■ ■��������������������u�����������������������■�����������������■ ■�■���\i���_�������������������■ ������������U���������������■�■ �����������������\,�����������■�■��������\����� ■������������■■�■ ■��■����������������I����������������r����■�7��������������������� ��������������%����11������%�������t�������%rA�u�%�������%�������/ ■��������������■���II���N■��������■����� �������n������■�\���■���� ■������������������11���������������������������� ��������������� ������e��i�r�w��n�i■�������i�■������■���i������� �����■����■����i ■�������i■��i��i��;i������i�����■���■�����������������■��������������■�■ ■�������r�����r�►�����������������������������i�=■ ��u��iiiii�ii�iiii�i ■�����ll I�Y���/I������11��������\����■���� ■������llt�■���Yn�■■■11���������■■��������.. �■� ��������������� iiiiii�'�,:��iiii i�i��i=ii�iiii��iii=i:C��'� ��:C:C�:::C:� ■����■�i�lli������■�■������������������ a��rlJ� � ��r����u������� ■��■���i������■�������■���������������� i=ii� iiiue�iii�ii i ■����������������ui��■���������������� ■■��■�■���������■��i���■����������■� �����n� ■ �������C■����� ::::::::::::�:�::;:::::::::�:::�_:�:�.. �. .■.��■■■..■....� ■����■■���■���.�-■i���■�������■���■ ���'�i� ■ H������ ............�................... _.....� . :��C:: :�:::::. :::::::%::�::�:_:::::::�:::::�:::::�:"� =:C::::::::::::■ .....�. 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BOX 665 . MOCKSVILLE,N.C. 27028 PHONE:(704)834�5985 December 29, 1994 Jeffrey & Melissa Long 2s5 M�dison Rd. Macksville, NC 270�8 Re: Site Evaluation/Williams Rd. Dear Mr. & Mrs. Long: As r,equested, a representative from this office visited the aforementioned site on December �9, 1994. Based ��pon the information pr,ovided on the application for site evaluation and after� the evaluation was completed, the site was found to be provisionally suitable for the installation of an on—site sewage disposal systen. If you have any questions, please feel fr•ee to contact this office. 5incerely, : �������� . Robert B. Hal l, Jr�. , R.S. Environmental Health Section RH/wd