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166 South Madera Drive Lot 12DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT 4w Account #: 990003524 Tax'PIN/EH #: 5749-63-4705.12 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 12 Reference Name: Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 0.54 Acres ' ATC Number: 4638 y- a 6� **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 1 I 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 Tank Date I ' Tank Size�7 Pump Tank Size 7�s/-07 System Installed B A'A M��Jl . DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street d Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 I6� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003524 Tax PIN/EH M 5749-63-4705.12 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 12 Reference Name: Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 0.54 Acres ATC Number: 4638 Site Type: IXew ❑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 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 3 # Bathrooms# People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply:�ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size 166033AL. Pump Tank I' GAL. Trench Width,31,,L Max. Trench Depth �� Rock Depth 12 " Linear Ft. gC01 Site Modificatio /Conditions/Other• -5 _01Z_tQ1 1bUT10,3X`--p ) 01 ©�_p -� (91 .)S� 1 �1�T NLL A-7 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)751-8760. '71 21' As stated in 15A NCAC ISA.1969(5� accepted Systems may c,Rsc be use Z�+ 15, 224' Environmental Health Specialist(�=aiDate: T)CHD 11/06 (Revised) 102-.' 233.5 sr- 214�Wlz I sC,vt D11IL"l-e SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health 2007 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 �ViRONh4ElIfAtNEAITH (336)751-8760/ Fax (336)751-8786 DAVIE COUM`l AlipUr.atiea-Fti"l-Site Eva ation/Improvement Permit C -Authorization To Construct(ATC) ❑ Both Cw Type of Application: QNSystem ❑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 4 Billing Address v? (> ere- City/State/ZIP KI?4 r v g: C-.-2 7 c Name on Permit/ATC if Different than Above Mailing Address Contact Person P r Home Phone '' :2 7/- Business Phone L1"' . 7- S �/ City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 1-y- 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.) Owner's Name Phone Number Owner's Address City/State/Zip Property Address Z /,V, s - City Lot Size , !;:c2 c ,,=e� Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: Lel f O�,t_//-S �3✓K --�%/' If the the answeranny of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes Dlo Does the site contain jurisdictional wetlands? ❑Yes LLW Are there any easements or right-of-ways on the site? []Yes ON -o' Is the site subject to approval by another public agency? ❑Yes DNo Will wastewater othei than domestic sewaee be Renerated? ❑Yes ONO–' IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms —S # Bathrooms Garden Tub/Whirlpool ZY-es--lnNo Basement: ❑Yes �—o Basement Plumbing: ❑Yes GlNe-- 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:. DQO–nventional ❑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 ❑ NO -- 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 s bmitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie Co Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am respmiple for the groper identification and labeling of property lines and corners and locating and flagging or staking th ouse/faci}' y lg ation, pr osed well location and the location of any other amenities. s 'or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: EHS: zqSign given ❑Yes ❑No Account # (�56 Revised 11/06 Invoice # 31 APPLICATION FOR SITE EVALUATION/IAIPROVEMENT PERtnn. p fI/�_Davie County Health Departmenti% V �'t Environmental Health Section P.O. Box 848/210 Hospital StreetMocksville, NC 27028 z005(336)751-8760 / ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE` -`R t� �'n INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed /"ems-lu•• zC ��/ L p �� Contact Person Mailing Address �[+ l,�i� ! E'_ �(' �S -i' Home Phone Z� - U •1 7 S- City/State/ZIP -;2-7/6'} Business Phone h16 -7 - 641 ..-<l 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 13"'iite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to Service: 2--H-0--use ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: Gg' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # le Peop ? # Bedrooms 3- - � # Bathrooms LJ Dishwasher ❑Garbage Disposal LBWashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes' # Showers # Urinals # Water Coolers IF FOODSERVICE: #i _Seats Estimated Water Usage (gallons per day) 8. Type of water supply: IEt' County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 0-M-0 If yes, what type? ***IMPORTANTP" CLIENTS r11UST COAIPL.ETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BE SUB.M17TED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: ## Property Address: RoadNamc 5/4: jJImo:(, City/Zip If in a Subdivision provide information, as follows: Name: /Vie 61I I S -k' � 7A -r L WRITE DIRECTIONS (frons Mocksville) to PROPERTY: Section: Block: Lot: f Date liome corners Ragged: This is to certify that the information provided is correct to the best of my knowledge. I understand tliat any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I ani responsible for all charges iacurrcil fruu: this application. I, hereby, give consent to the Authorized Representative of the Davie County I-Ieallli Departmcut to enter upon above described property located in Davic County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ' t3- D - SIGNATURE 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 VL Revised DCFID (05/03 IDatc(s): Site Revisit Charge Client Notification Date: EIIS: Account No. Invoice No. .� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900035 Billed To:' Richard Short Reference Name:. Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.12 Stjbdivision Info: McAllister Park Lot # 12 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: 4 2 0� Community. Evaluation By: Auger Boring Pit Public / Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH —Cr Texture groupL Consistence Frsssv Structure S Mineralogy"X HORIZON 11 DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH W Texture group "C -LA Consistence 5P Fr S Structure Mineralogy' HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE. lc)� OTHER(S) PRESENT: REMARKS: � OGI� ...�.. Xn' ►� ♦� P -L 3k —4:� &04CrL J 1 X- zt�o 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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE of VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS Non sticky SS - Slightly sticky S - Sticky VS -'Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic tr ct ure 'SC - 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 of t to n5/94 fRevisem