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107 Chandler Drive Lot 40DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 989900225 Tax PIN/EH #: 5749-64-0462.40 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 40 Reference Name: Location/Address: Chandler Drive -27028 Proposed Facility: Residence Property Size: See plat ATC Number: 4577 x1.12-1 1i 3 �2W4f-r- **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. 1 System Type:! S.T. Manufacturer Y 10 Q-� Tank Date —�() - aL Size j , O U Pump Tank Size 0 Installed By: E.H. Specialist: i Date: & —19-07 fp i OL DCHD 11/06 (Revised) i DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900225 Billed To: Jeff Ferguson Reference Name: Proposed Facility: Residence ATC Number: 4577 Tax PIN/EH M 5749-64-0462.40 Subdivision Info: McAllister Park Lot # 40 Location/Address: Chandler Drive -27028 Property Size: See plat **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 VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type #People #Bedrooms #Baths 3 Basement w/Plumbing: _ Basement/No Plumbing , Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size Type Water Suppl3CL LiiDesign Wastewater Flow (GPD) -;j:p Site: New Repair System Specifications: Tank Size CCO GAL, Pump Tank — GAL. Trench Width,:5(a Trench Depth -2+4 W X Rock Depth Linear Ft. e-%3C.o Other: Required Site Modifications/Conditions: Contact the Davie County Environmental 8:30 - 9:30a.m, on the day Environmental Health DCHD 11/06 (Revised) LL QrJ Health Section for final ' pection of this system between V 4 , r� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box' 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900225 Billed To: Jeff Ferguson Reference Name: Proposed Facility: Residence ATC Number: 4577 Tax PIN/EH #: 5749-64-0462.40 Subdivision Info: McAllister Park Lot # 40 Location/Address: Chandler Drive -27028 Property Size: See plat **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 VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type_ -1] #People #Bedrooms #Baths 3 Basement w/Plumbing: T Basement/No Plumbing — Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size Type Water SupplDesign Wastewater Flow (GPD) __2 Site: New Repair System Specifications: Tank Size I MD GAL. Pump Tank — GAL. Trench Width Trench Depth: - M Rock Depth Linear Ft.:c:0�� Other: Required Site Modifications/Conditions: 1LQMLL QJ C�t3WWOR. , Contact the Davie County Environmental Health Section for finali�sl 8:30 — 9:30a.m. on the day of installation. Telephone # Environmental Health a�— lwe t po' Sep, DCHD 11/06 (Revised) -nom r-rs mss' �— ' oA C 14o -s g, of this system between 4-8760. Tor �0 2/o DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST APPLICATION IP/ATC OSWW REPAIR VV0j- -jL Name Atia-daWalive- Telephone Number (1.5-q — 024 & Z Address lal(MaA!q16t- OP. Mailing Address (if different from above) Email Address: Subdivision Name RCM iS il, 4 I -/L Lot # qo Directions Date System Installed Name System Installed Under Type Facility Number Bedrooms Number People Served Type Water Supply Specific Problem Occurring 6,4 0,6 /1 Date Requested Info Taken By THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED FROM THIS APPLICATION. Signature of owner or Authorized Agent Initial Fee Date REHS n / Revisit Charge Date Reason Revised 2-2011 CONSTRUCTION _ AUTHORIZATION rte` Davie County Health Department ;,. ' ► 210 Hospital Street P.O. Box 848 Mocksville NC 27028 For Office Use Only \ `CDP File Number 175562-1. County ID Number: Evaluated For: REPAIR Township: J Phone: 336-753-6780 Fax: 336-753-1680 1 1/ a 5/ a 0 1 9 Applicant: Angela Wallace Property Owner. Angela Wallace Address: 107 Chandler Drive Address. 107 Chandler Drive CRY: Mocksville City: Mocksville State/Zip: NC 27028 State2ip: NC 27028 Phone 9:P hone #: Address/Road #: Subdivision: McAllister Park Phase: Lot: 40 107 Chandler Dr Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 right on Sain Rd. to McAllister Park # of Bedrooms: # of People: 'Water Supply: PUBLIC Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Saprolite System? QYes QNo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 5 Maximum Soil r. Cove2 4 Inches 'System Class ification/Description: 'Distribution Type: GRAVITY -SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 25% REDUCTION i -Piece: QYes ONo Pump Required: QYes ONo QMay Be Required N �rification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 -Piece: QYes ONo Total Trench Length:3 ft GPM—vs— ft. TDH .1 7Trench Spacing:9 (Inches O.C. Dosing Volume: _ Gallons _ QFeet O.C. g Trench Width: Inches 3 8Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O N SF OTS -1 OTS -11 / Septic Tank Installer Grade Level Required: 01 ()II 0111 OIV l Page 1 of 3 • CDP File Number 175562 - 1 Repair ,,Rel7air Systen "Site Classification: Design Flow: Soil Application Rate: 'System Classification/Description: Proposed System: Nitrification Field No. Drain Lines Total Trench Length: ft. County ID Number: ❑ Open Pump System Sheet :QYes ONo ONo, but has Available S Trench Spacing: Q Inches 0. _ ()Feet O.C. Trench Width: 0 Inches Feet Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Maximum Trench Depth: Inches Maximum Soil Cover: Sq. ft.' Inches 'Distribution Type: Pump Required: QYes ONo OMay Be Required Pre -Treatment: ONSF OTS -1 OTS -II "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. � 7 "Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. 2 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe Issued at the same time the Improvement Permit issued (NCGS 130A-336(b)j If the installation has not been completed during the period of validity of the Construction Permit, the Information submitted In the application for a permit or Construction Authorization is found to have been incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become invalid, and maybe suspended or revoked (.1937(8)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting and repair (1936(b)). Applicant/Legal Reps. Signature Required? Oyes I,ONO Applicant/Legal Reps. Signature: _ Date: 'Issued By: 2140 -Nations, Robert Date of Issue:. 1 1/ a 5/ a 0 1 4 Authorized State Agent: L_.�/�a Malfunction Log QYes 01 -land Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 i �w a COMMON AREA I (total) S88°01'40"E 11.7.93'----� 69.83' 48.10' 40 a. O 4 o ! 39 ��yy m O 23.6' O W a.. N 48.95' c O ui O I O z 27.0' O I r, X16.02' N A2.3' 6.0' O a PROPOSED HOUSE 2.3' (n I Oi I LOCATION 16.02' 0 0 I 48.9T- 0 ' - O N 12.0' 11.0' ' o 11.2' r' 1ss' 1 � 1 � j�(Il,z✓ � w O. �00. PRELIMINARY FOR REVIEW C N88°00 00"W 95.00' 40 CHANDLER DRIVE GRAPHIC SCALI (50' PUBLIC R PER P / /W FOR REVIEWL JEF A PROPOSED SUBDM! TAX MAP TM MOC TAX BLOCK TAX LOT No. 40 MAP C g—r Z/O APPLICATION FOR SITE EVALUATION/I&IPROVEAIENT PERNIIT Ely CS Davie County Health Department' Environmental Health Section P.O. Box 848/210 Hospital Street APR 7 Mocksville, NC 27028 3 .005 (336) 751-8760 4VViR0NMT ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROOVVSIDED. Refertothe INFORMATION BULLETIN for instructions. 1. Name to be Billed //L Contact Person i� �� L Mailing Address 6 45? Home Phone City/State/ZIP Lj, �'��'+`� ,, le — %/d 5 Business Phone '` 6 %' � C/ -9-C/ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 1 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service:H,ousse ❑ Mobile Home ❑ Business [3 Industry ❑ Other S. Type system requested: 111' Conventi�o7nal E3 conventional modified F-1innovative 6. If Residence: # People r # Bedrooms ,.,,,� �, � , � - � #Bathrooms BDistiwasher ❑Garbage Disposal LBWashing Machine ❑Basement/Plumbing ❑Dasemont/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals ll Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Type of water supply: IH'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-N- If yes, what type? ***Il1fPORTAN7'*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitl►er a PLAT or SITE PLAN AIUST BE SUBAt1TfED by the client will► THIS APPLICATION. Property Dimensions: 5 n 11c4ee Tax Office PIN: fl Property Address: Road Name '5t4 1,11 City/Zip If in a Subdivision provide information, as follows: Nantc: Section: Block: Lot: WRITE DIRECTIONS (frau Mocksville) to PROPERTY: �-- �, ► n � � r- �, moi_ -�-� � /°l �- � �- Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand tl►at any pci-mil(s) issued hereafter are subject to suspension or revocation,'if tl►e site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that 1 aur responsible for all clrages incurred front this application. I, hereby, give consent to the Authorized Representative of the Davie County I-Iealll► Deparl►nent to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. - - ' DATE �.3 �f SIGNATURE'- •�I `ter' TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign given Site Revisit Charge Datc(s): Client Notification Date: EIIS: Account No. Revised DCI -ID (05103 Invoice No. TII R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health Jars 2 2007 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Ew1pvm4EtJAL HEALTH _ (336)751-8760/ Fax (336)751-8786 DI'VT U)"INI Y �- Application For: Q D Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both Type of Application: $ew 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 e le Contact Person _ e Billing Address 6� YoAHome Phone City/State/ZIP Business Phone _3 36 - 0,/3 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: 9,Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's NameE? Phone Number Owner's Address City/State/Zip Property Address Lot Size T Subdivision Name(if applicable) Directions To Site: /,�-Q, 4, 5,,,,— Y&Z ection/Lot# 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 [qo Does the site contain jurisdictional wetlands? []Yes UKo Are there any easements or right-of-ways on the site? ❑Yes []No Is the site subject to approval by another public agency? ❑Yes [V6 Will wastewater other than domestic sewage be generated? ❑Yes QXo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _3 # Bathrooms 3 Garden Tub/Whirlpool Ryes ❑No Basement: ❑Yes C� o Basement Plumbing: ❑Yes [;Io 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; eConventional ❑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 B- 0 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 staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Pro71 owner' oro s legal representative signature Date(s): Z—Ll' Q z Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Q[�2 Revised 11/06 Invoice #