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126 Greene Court Lot 5DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax 4 (336)751-8786 OPERATION PERMIT Account #: 990004263 Tax PIN/EH #: 5841-06-2026 Billed To: Mark Campbell Subdivision Info: Pudding Ridge Lot # 5 Reference Name: Location/Address: Green Court -27028 Proposed Facility: Residence Property Size: 1.1 acres ATC Number: 4609 **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:�� T S.T. Manufacturer "- Tank Date' b Tank Size I WO Pump Tank Size —� t E.H. S f3 7 System Installed By: pec list: DCHD 11/06 (Revised) • 4 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street j Mocksville, NC 27028 I 0 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004263 Billed To: Mark Campbell Reference Name: Proposed Facility: Residence ATC Number: 4609 Tax PIN/EH #: 5841-06-2026 Subdivision Info: Pudding Ridge Lot # 5 Location/Address: Green Court -27028 Property Size: 1.1 acres Site Type: ❑New ❑Repair ❑Expansion **NOTE** This Aµthorization 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 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 III # Bathrooms # People BasementK Basement plumbing, Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size 0' 5 ezC-c Type of Water Supply: (County/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow (GPD) LI %O Tank Size1,66 GAL. Pump Tank WAGAL. Trench Width�� Max. Trench Depth Rock Depth l Linear Ft. S .33 - As stated in 35A NCAC 1i;'..AA96C 5 Site Modifications/Conditions/Other: �Mcd S s��s—n i;.i N ( ) y �i?�.: use Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-$7f0._ . , 1. K�fir 14 -le a �d8k3- 'actt-3 ` B`f' k3 a1� ,ter I.3 66 in �1 N u l (-Cd W u: Jot 6.2 I GY.r Sc ►t rc� � ;L Of Environmental Health Specialist C/`/�/ ate— Date: DCHD 11/06 (Revised) t' 1� _ t 'P ATA E EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health 2 200 P.O. Box 848/210 Hospital Street FE® Mocksville, NC 27028 (336)751-8760/ Fax (336)751=8786 E �� anrth"ENTALHEA�IN Applic tion For:ite;r'dluao rovement Permit Zuthorization To Construct(ATC) ❑ Both Type o A tion -New System ❑Repair to Existing System ❑Expansion/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 to be Billed JJgIf'' f < '7_C1119 jA C- C L Contact Person _PJA121` Billing Address _2- Q 1) ,FOX R tJA -1?9 Home Phone City/State/ZIP (; S�,llLt Nt'2- -2?U 2-A Business Phone 4 C� Name on Permit/ATC if Different than Above Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners FlaaRed WAP110 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) J Owner's Name ��J < 77 � �� ,? � �'// /,,/-0/gi!� eC'4 C Phone Number �/ �' � 7 O Owner's Address V.Cd -OX = U City/State/Zip /Yt U t' &Cl/; L C Property Address 146 C,: i�i"C3 iE � cI" $-'/' '�; ;;';�- ity_ Lot Size % . / , t. Tax PIN#J!"$41/-0 'Zpy(o Subdivision Name(if a plicable) T/U PPjA,1 L /' /1) Grp Section/Lot# 5 Directions To Site: •1' A/101)/-4 AI /)6&_ rAD Li' C"C%y 4,410.. 47— 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 RWo Does the site contain jurisdictional wetlands? ❑Yes kNo Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes,No Will wastewater othei than domestic sewage be generated? ❑YesAkNo IF RESIDENCE FILL OUT THE BOX BELOW # People 4— # Bedrooms 4 # Bathrooms 4 Garden Tub/WhirlpoolcflYes ❑No Basement:-R�lYes ❑No Basement Plumbing: ,ZYes ❑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) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:, (Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: Y'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 4�1,No If ves_ what tvne? 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 staking the house/facility location, proposed ell location and the location of any other amenities. Site Revisit Charge Property owner's or owner's legal representative signature - Z, Date Date(s): Client Notification Date: EHS: Sign given []Yes ❑No Account # 420 Revised 11/06 Invoice # `7w 1< ..,d.,....., � s .._ ` � "z ^ -... ` 9 NAME <_ /&'i e ADDRESS PROPOSED FACIILTY DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation .Co is DATE EVALUATED �/�54r PROPERTY SIZE '&ge' LOCATION OF SITE Water Supply: On -Site Well ✓ Community Public Evaluation By: Auger Boring Pit tip Cut FACTORS 1 2 3 4 Landscape position Sloe %. L HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH h �� Texture groupG Consistence r Structure / / Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY:�� LONG-TERM ACCEPTANCE RATE: REMARKS: '_� &- W.4,0 DCHD (01-901 OTHER(S) PRESENT: LEGEND Landscape 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 Texture S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt SICL-Silty +;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR-Very 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 Structure 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralogy 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 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 .......................................... ...................... .................................................................. ................................ ................................ ........................... ................... .................. ■..■■■......■■■.■..■■..■.■.■■■■■■■.■■■■■�■■■■■■�■�■■■■■■■■■■■\SISI■ ■...■■■.■■.■■■■■■■■■■■.■■■■...■■■■ ■■.■■MM■■MN■.M■■C■MMSISI■SISI■■..■ ■■■■■.■.■■■■■■.■■■■■.......■■.......■............■■. .■■■..... 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