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208 South Madera Drive Lot 171r Applicant: Address: CRY: State/Zip: CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 For Office Use Only *CDP Fite Number 138648-2 County ID Number: Evaluated For: EXPANSION � Township: MOCkSVIlle NC 27028 F'I=KMI I VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 9/ a 7/ a 0 a 1 Gerald Welborn FAddress: wner: Gerald Welbom 208 South Madera Drive 208 South Madera Drive Mocksville Mocksville NC 27028 NC 27028 Phone #: (336) 407-7530 phone #: (336) 407-7530 Property Location & Site Information Address/Road #: 208 S Madera Dr .Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Subdivision: McAllister Park Phase: Lot: 17 Directions Hwy •158 East right on Sain Road, McAllister Park on right stem Snecificati D-nnn 1 of Z Minimum Trench Depth: a 4 Inches \ Site Classification: ysuitable Provisionally Saprolite System? OYes Q7No Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: Septic Tank: Gallons *Proposed System: 1 -Piece: OYes ONo Pump Required: OYes ONo OMay Be Required Nitrification Field 4 3 6 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: OYes ONo Total Trench Length: 1 0 9 GPM—vs— ft. TDH ft. Trench Spacing: — 9 2 Inches O.C. Dosing Volume: _ Feet O.C. g Gallons Trench Width: 3 O 2Inches Feet _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 OII) OIV / D-nnn 1 of Z APPLICANT INFORMATION Account #: 989900035 Billed To: Richard Short Reference Name: Proposed Facility: Residence r DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.67 Subdivision Info: Richard Short Lot # 67 Location/Address: Sain Road -27028 I _ Property Size: 5 acres Date Evaluated: Community Evaluation By: Auger Boring Pit LM-15- FACTORS M-1 Public .1 Cut ••Consistence HORIZON I DEPTH Structure 11 DEPTH Consistence HORIZON III DEPTH Texture group Consistence HORIZON IV DEPTH Texture ConsistenceHORIZON ��s�■e���������MineralogySOIL WETNESS SITE CLASSIFICATION: EVALUATION BY:-�`TC'��At�� LONG-TERM ACCEPTANCE RATE: ."2 OTHER(S) PRESENT: REMARKS:—7 /1� Q"g-A ma?e'P� td's`^! � �XTZ COCK qG � _ LEGEND I andscape 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 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 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 DCHD 05/99 (Revised) CDP File Number 138648 - 2 County ID Number: ❑ Open Pump System Street Repair System Required:@Yes ONO ONo, but has Available Space *Site Classification: Provisionally Suitable Design Flow: 4 8 0 Soil Application Rate: 0 2 7 5 *System Classification/Description: TYPE III E. PPBPS GRAVITY DOSED SYSTEM *Proposed System: 50% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 6 Total Trench Length: a 9 0 ft. Trench Spacing: _ 8 V Inches 0. t O.C. Trench Width: 0 Inches a 0 Feet Aggregate Depth: inches Minimum Trench Depth: a 8 Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 4 a Inches Maximum Soil Cover: a 4 Inches *Distribution Type: PUMP TO GRAVITY Pump Required: OYes ONo OMay Be Required Pre Treatment: ONSF OTS -1 OTS -11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. 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)} If the Installation has not been completed during the period of validity ofthe 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(g)). 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 (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature Date: / *Issued By: 2140 - Nations, Robert Authorized State Agent: Date of Issue:. 0 9/ a 7/ a 0 1 6 Malfunction Log Oyes 01 -land Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 raving Drawing Type: Construction Authorization sa M CDP File Number: 138648 - 2 County File Number: Date: 0 9/ a 7/ a 0 1 6 Q Inch Scale: QBlock QN/A M—M CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 138648 - 2 County File Number: Date: .0 ,s l a7 l a 0 1 s Click below to Import an image from an external location: Drawing Type: Construction Authorization RECEIVED fil [L. W4e,(190[ 4ke,re, APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: tite tvaluationamprovement Fermit Type of Application: JNew System J Repair to Existing System 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 &P.raicl WQ-16dr'a Contact Person Gork.,, , �f�l6o�r ►'l Address %68 Sit k A4 4g Home Phone I J 1, - 4a'7 - 7 s Z 6 City/State/ZIP 146r kc" 1) A& , -2 -Z67 81 Business Phone 13 ,7 S i -!R 1 &4!7 Email Email: Name on nnit/ATC if Different than Above Mailing Address 20 1C S. City/State/Zip comers NOTE: A survey plat or site plan must accompany this application. Included: L Site Plan LPlat(to scale) (Pemtit is valid for 6f 1„` s with site plan, no expiration with complete plat.) Owner's Name orf e Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "Yes",supportin documentation must be attached: Are there any existing wastewater systems on the site? _Yes Does the site contain jurisdictional wetlands? _Yes _ Are there any easements or right-of-ways on the site? _Yes rMoo Is the site subject to approval by another public agency? _YesWill wastewater other than domestic sewage be generated? _Yes IF RESIDENCE FILL OUT THE BOX BELOW iK CV c r t"41,A 3 UJou-Qa I ke . 5 6 "tl-1s I# Peoplees Plumbing: Bedrooms V 4 # Bathrooms?,, S Garden Tub/Whirlpool F. -Ws CNo m Baseent:OYo Basement =Yes [;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:�onventional JAccepted ulnnovative uAltemative LOther Water Supply Type: d6e g -Wee Do you anticipate additions or expansions of the facility this system is intended to serve? L 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 subrnined 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 stpking the house/facility 1pgi9n, proposed well location and the location of any other amenities. Site Revisit Charge Prop rty owner's or owners legal representative signature Date(s): Client Notification Date: Dat EHS: Sign given UYesONo Revised 11/06 Account # 130kO Invoice # ME Account #: 990004137 Billed To: Tycon Inc. Reference Name: Proposed Facility: Residence ATC Number: 4830 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 AOPERATION PEP241T ITax PIN/EH #: 5749-62-4785 Subdivision Info: McAllister Park Lot # 17 Location/Address: $-Madera Dr. -27208 Property Size: see map **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 Tank Datey Tank Size d o C) Pump Tank Size l i d U System Installed By: J /YI C�l/'t/` E. H. Specialist: a/vuUfol Date: !� S, Al a c`1 -'p"' 1jrr. ,. TTT 11 /Al' /n - JN w' t r DAVIE COUNTY ENVIRONMENTAL HEALTH Pd, P.O. Box 848/210 Hospital Street Mocksville, NC 27028 \v (336)751-8760 Fax # (336)751=8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004137 Tax PIN/EH M 5749-62-4785 Billed To: Tycon Inc. Subdivision Info: McAllister Park Lot # 17 Reference Name: Location/Address: %9.Madera Dr. -27208 Proposed Facility: Residence Property Size: see map ATC Number: 4830 Site Type: Rrltew ❑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: # Bedrooms3—# Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Q / Square Footage(or Dimensions of Facility) Lot Size . –1 �¢� 69C`{ 5 . Type of Water Supply: Bounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 3(LO Tank Sized GAL. Pump Tank lcoo GAL. Trench Width 3L " Max. Trench Depth � V Rock Depth Linear Ft. 3a 7 SiteModiftcations/Conditions/Other.` a.� 0AtUAk4l, 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)751-87j60. �yIV"`e a Y . �G �hfi b a AD L� L� Environmental Health Specialist.–_ JC7, :�%j Date: � 7 � J nriTTl 1 1 /(14 /P—;oars) e Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990004137 IMPROVEMENT PE%V�IN/EH #: 5749-62-4785 Billed To: Tycon Inc. Subdivision Info: McAllister Park Lot # 17 Address: P.O. Box 932 Location/Address: $.Madera Dr. -27208 City: Clemmons Property Size: see map 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. i Permit Type: RfTew ❑Repair ❑Expansion Permit Valid for: 95. Years ❑No Expiration Residential Specifications: # Bedrooms 3 # BathroomsL).# People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 ('C) Type of Water Supply: Zounty/City ❑ Well ❑ CommunityWell Site Modifications/Pernut Conditions.: _ Site Plan System Type LTAR Initial e ., a 7 Repair c a 'F Q . 9L17 57 0 FA Environmental Health Specialist Date :.11_N� .�-41 11 Q� 200a t'1 �yVtRO��;hECn�� � ',LTII ITE EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Appl ation For: D a uation/Improvement Permit /Authorization To Construct(ATC) ❑ Both Type pp ication: 2New 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 ivC Contact Person , c �� rc� kiACus Billing Address . Home Phone City/State/ZIP C Qtinr1 v 'l1G ,.l Business Phone ,33C� 3 y S -- 3 S / Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION . *Date House/Facility Corners Flagged cp la //0k NOTE: A survey plat or site plan must accompany this application (Permit is id for 60 month with site plan, no expiration Owner's Name r -- Owner's �' Co•U Owner's Address . Included: ,K Site Plan ❑Plat(to scale) with complete plat.) - Phone Number Citv/State/ZiD _ , .1 Property Address //tJ fit, /V1aCJr--an Ule • City f'It I qui 1 ] 1 Lot Size Tax PIN# Subdivision Name(if applicable) ' ✓ //ts to -ft / Section/Lot# Directio To Site: W.S. / DtN/a 3i* !'�/�i S Q / R / 0IU n 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 ❑No Does the site contain jurisdictional wetlands? ❑Yes ❑No Are there any easements or right-of-ways on the site? Z`Yes ❑No Is the site subject to approval by another public agency? ❑Yes ❑No Will wastewater other than domestic sewage be izenerated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _ 5 # Bathrooms %� Garden Tub/Whirlpool/Yes ❑No Basement: ❑Yes ^o Basement Plumbing: ❑Yes ,ANO IF NON -RESIDENCE FILL OUT THE BOX BELOW Typeof 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 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 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 tl�e use/fity location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature � Dat Sign given ❑Yes ❑No Revised 11/06 i e evisi arge Date(s): Client Notification Date: EHS: Account # ///37 Invoice # Nz