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193 South Madera Drive Lot 21DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848%210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751--8786 ATC Number: 4537 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 VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. A Residential Specifications: # Bedrooms 7 # Bathrooms 3 # People VBasement❑ Basement plumbing ❑ Non=Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size /,PSY 3 `lid Type of Water Supply: R16ounty/City ❑ Well ❑ CommunityWell System Specifications: Design Wastewater Flow (GPD) 06 Tank Size MOO GAL. Pump Tank /Vi¢ GAL. Trench Width 34 Max. Trench Depth 31 -yo ` Rock Depth Nlk Linear Ft. 1/00 Site Modifications/Conditions/Other: ZS /U4e4-x' rltly - M-)- 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. 0 Environmental Health Specialist nrTTTI 11 /n 6 fR Pvi.cp.rll Date: AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990003524 Tax PIN/EH #: 5749-63-6067 Billed To: Greg Parrish Subdivision Info: McAllister Park Lot # 21 Reference Name: Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 105X300 ATC Number: 4537 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 VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. A Residential Specifications: # Bedrooms 7 # Bathrooms 3 # People VBasement❑ Basement plumbing ❑ Non=Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size /,PSY 3 `lid Type of Water Supply: R16ounty/City ❑ Well ❑ CommunityWell System Specifications: Design Wastewater Flow (GPD) 06 Tank Size MOO GAL. Pump Tank /Vi¢ GAL. Trench Width 34 Max. Trench Depth 31 -yo ` Rock Depth Nlk Linear Ft. 1/00 Site Modifications/Conditions/Other: ZS /U4e4-x' rltly - M-)- 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. 0 Environmental Health Specialist nrTTTI 11 /n 6 fR Pvi.cp.rll Date: Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990003524 Billed To: Greg Parrish Address: 1256 Peacehaven Road City: Clemmons Tax PIN/EH #: 5749-63-6067 Subdivision Info: McAllister Park Lot # 21 Location/Address: S. Madera Drive -27028 Property Size: 105X300 Reference Name: Proposed Facility: Residence **NOTE**This Improvement 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: flew ❑Repair ❑Expansion Permit Valid for: eTYears ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms 3 # People Basement❑ Bement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):I/JPd Type of Water Supply: 14 ounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: .�t.%,��, sy . /2J z) r 0 S stem Type LTAR Initial .3 Repair ziz- .13 J Environmental Health Specialist i.p. 11-06 I Date Account #: 990003524 Billed To: Greg Parrish Reference Name: Proposed Facility: Residence ATC Number: 4537 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT 1/ 03 Tax PIN/EH #: 5749-63-6067 Subdivision Info: McAllister Park Lot # 21 Location/Address: S. Madera Drive -27028 Property Size: 105X300 **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:l&Q1-t S.T. Manufacturer ShaaF Tank Date S -L`} Tank Size i ood Pump Tank Size Nlk System Installed By: 80a h V"lr ja E.H. Specialist: Date: Q DCHD 11/06 (Revised) �W F+• L W+�&4- IjGUJ rAA� APPLICATION FOR SITE EVALUATION/IAIPROVEAIENT PERAIIT E'gE Jj V Davie County Health Department U V �' EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street APR J Mocksville, NC 27028 3 2D�5 (336) 751-8760 ��RO NMENr ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE E INFORMATION IS PROVIDED. (Refer to the INFORMATION BULLETIN for instructions. S 1. Name to be Billed �L �-lu•= �l �l CContact Person Mailing Addreaa �& /,III I 1 LES y- �S 4— Home Phone 7 ' C>• -Z 7� y L:Jf1 4- 7 '7<d �7 � Y -y-q Cit /State/ZIP iiv;���"�'r'`a. ���'` �� Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. Syatem to Service:H,.o.,usse 11 Mobile Home ❑ Business ❑ Industry 11 Other S. Type system requested: 0 --conventional ❑ conventional modified ❑ innovative 6. If Residence: it People # Bedrooms � ,..,� �#Bathrooms � ODisiiwasher []Garbage Disposal E&fashing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Busineaa/Industry /other: verify type # People # Sinks # Commodes* # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: R--county/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes CI -x -o*' If yes, what type? ***IMPORTANT*** CLIENTS AIUST COAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BESUBM1rrrD by the client with TIIIS APPLICATION. Property Dimensions: A-5 ,C)� ' Tax Office PIN: IE Property Address: Road Namc (57/4;1j City/Zip If in a Subdivision provide information, as follows: Name: M° f}11 I S ' l P}r L Section: / Block: Lot: �L 1VRITE DIRECTIONS (from Mocksville) to PROPERTY: Date home corners flagged: `/- OS-' This is to certify that the information provided is correct to the best of my lutowledge. I understand fltat any perutil(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in tliis application is falsified or changed. I, also, understand that I aro responsible for all charges incurred front this application. 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 to conduct all testing procedures as necessary to determine the site suitability. DATE ' 13- OS 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). Site Revisit Charge Datc(s): Client Notification Date: Eki:S: Sign gfvcn_Z�L G%fil0a0�5 Account No. Revised DCIID (05/03 Invoice No. APPLICANT INFORMATION Account #: 989900035 t Billed To:. Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPAIZTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH M 5749-63-6844.21 Sytidivision Info: McAllister Park Lot # 21 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: c3 ct _ Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit I� Public Cut SITE CLASSIFICATION: ! S LONG-TERM ACCEPTANCE RATE: 0. EVALUATION BYE' OTHER(S) PRESENT: REMARKS: Zt 5 A)645C A flt t° NtL WX 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 1 is VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky f , NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure '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 DCI IID 05/99 (Revised) Slope % HORIZON I DEPTH ConsistenceFACTORS ■r.rs�.������■ HORIZON II DEPTH Texture group Consistence r��s���o��■�� �r:WMw4ain Texture group_ Consistence WA HORIZON IV DEPTH Consistence SOIL WETNESS am SAPROLITE SITE CLASSIFICATION: ! S LONG-TERM ACCEPTANCE RATE: 0. EVALUATION BYE' OTHER(S) PRESENT: REMARKS: Zt 5 A)645C A flt t° NtL WX 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 1 is VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky f , NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure '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 DCI IID 05/99 (Revised) :SS] s-u_v!,,)OsSV CINV c -,0= pm j�tstb;i�j G?.Dfl 10014S 'Ua-10 t, APPLICATION FOR SITE EVALUATIONAMPROVEME Davie County Health Department NOV - 1 2006 Environmental Health Section P.O. Box 848/210 Hospital Street LTH Mocksville, NC 27028 ��� DAVECOUNn (336)751-8760/ Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) oth ***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 Com.' e Contact Person C � Billing Address 2-�Z, Home Phone -71 -e City/State/ZIP L % C- Z Business Phone y, p`7 -4S Sim Name on Permit/ATC if Different than Above Address PROPERTY INFORMATION City/State/Zip NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete,plat.) Street Address City /1 rc�-S;� L4� Tax PIN# S% j - to 3 -Lo 76 Subdivision Name /L`!/�%CS,�r ✓-',� Section/Lot# Z / Lot Size / �. 4-,K,.e v Directions To Site: /S vr, S� L- / •Ca /Z, - ?'! ,r��J Date House/Facility Corners ,Flagged//- /- L�2 6 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 ELW6 Does the site contain jurisdictional wetlands? ❑Yes 223 o Are there any easements or right-of-ways on the site? ❑Yes CW% Is the site subject to approval by another public agency? ❑Yes1 Will wastewater othet than domestic sewage be generated? []Yes BNo IF RESIDENCE FILL OUT THE BOX BELOW # People 'f- # Bedrooms # Bathrooms Garden Tub/Whirlpool 2Yes ❑No Basement: ❑Yes Q-NbBasement Plumbing: ❑Yes CLIA 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: DConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: bounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in 2a1 J nd owned by 4 Site Revisit Charge lkro�certy o (er's or owner's legal representative signature Date Sign given ❑Yes ❑No Revised 2/06 Date(s): Client Notification Date: EHS: Account # Invoice #