174 Timber Trails Lane Lot 13DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT
Account #: 990004487 Tax PIN/EH #: 5812-00-6100
Billed To: Wishon & Carter Builders Randy Trink Subdivision Info: Timber Trails Lot # 13
Reference Name: Location/Address: Timber Trails Lane -27028
Proposed Facility: Residenc(? Property Size: 5 Acres
ATC Number: 4817
**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,"
M shall in NO WAY j be taken as a guarantee that the system will function satisfactorily for any given period of
time. l v (µ
System Type:, S.T. Manufacturer Tank Dated Tank Size
Pump Tank size -&L
t�2
System Installed By: �Ju Date: gS
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 #: 990004487 Tax PIN/EH #: 5812-00-6100
Billed To: Wishon & Carter Builders Randy Trink Subdivision Info: Timber Trails Lot # 13
Reference Name: Location/Address: Timber Trails Lane -27028
Proposed Facility: ResidencO. Property Size: 5 Acres
ATC Number: 4817
Site Type: CR ew DRepair DExpansion
**NOTE** This Authorization to Constrict (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 # Bathrooms___3_ People )� BasementErasement plumbing 9'
Non=Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
LotS}ze a ar-e6 Type of Water Supply: B'County/City DWell OCommunity Well
System Specifications: Design Wastewater Flow (GPD) Y96 Tank Size�"0GAL. Pump Tank GAL.
Trench Width 4 j 1Max. Trench Depth .3G Rock Depth F)2 Linear Ft.
Site Modifications/Conditions/Other: A.s stated in 15 % rig. I",C
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.
C t'
W 136,
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rlivirronmental Health Specialist Date:_ . —
r,ri7rl 1 1104 (P P,A- )
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
.(336)751-8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account #: 990004487 Tax PIN/EH #: 5812-00-6100
Billed To: Wishon & Carter Builders Randy Trink Subdivision Info: Timber Trails Lot # 13
Address: PO Box 1719 Location/Address: Timber Trails Lane -27028
City: Yadkinville
Property Size: 5 Acres
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: Ylew ❑Repair ❑Expansion Permit Valid for: 6"Years ❑No Expiration
Residential Specifications: # Bedrooms # Bathrooms 3 # People a BasementRratBasement plumbingl�-'
Non -Residential Specifications: Facility Type# People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):q Type of Water Supply: t<ounty/City ❑Well ❑Community Well
/.s stntnd in 15,'11 I\'CAG 18A.1539(3)
Site Modifications/Permit Conditions:
System Type LTAR
Initial c 0,
Repair Cc
Site Plan
�r
y Y
4 y3
INS
of
�d
has �
Date
Environmental Health Specialist s� l —�U
APPLICATION FOR SITE EVALUATIONlIMPROVEMENT PERM C�
Da -,ie County Enviromnental Health
P.O. Bos 848/210 Hospital Street ,f
Mocks -v lle, NC 27028 J,QN 2 �i
(336)751-8760/ Fax (336)751-8786 Z
Application For: Site Evalua ' m ovement Permit Authorization To Construct(ATC) oth Q �OtJ /
Type of Application: ew S stem epair to Existing System Expansion/Modification of Existing ys or q�i� yTA
"•*IMPORTANT"• THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed W ' S �e" A"-# Cotr4y, Br.1d�CS Contact Person A,v� .( T -r t.
Billing Address grte /7v9 Home Phone (n79 --eo 3
CitviState'ZIP tic N.G. 270-C'.:a Business Phone 4Y63,105'09
Name on Pernit'ATC ifDi#j rent than
Mailing Address
D%NOTPROPERTY INFORMATION *Date House Facility Comers Flagged ) 12 L% /OR -
NOTE:
E: 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)
ORneI SName PA4felt .F HeetRnr-e Mi4,6c it Phone Number70' `137— J$1$
Owner's Address 165 ftiliv .oP. City/State/Zip Nqrj+,W,j AJ e, 216
Property Address / r7 If, Tm6erTama't s Litre- City /Kot:; t e
Lot Size 5 At"r, Tax PIN#
Subdivision Name(if applicable ) T, M h!4- Tr A t 1 i Section Lot= 13
Directions To Site: goat (took tto.a a et— A A +tn 77"«4- 'rep. i low LANe_
i,o4 1 3 aw rryt.;.
If the answer to any of the following questions is "yes", supporting documentalo ust 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
Is the site subject to approval by another public agency?
Yes
Will wastewater other than domestic sewage be generated?
Yes
IF RESIDENCE FILL OUT THE BOX BELOW
People r Bedrooms 4 = Bathrooms .3 Garden Tub'Whirlpwl e No
Basement: es_ No Basement Plumbing: es No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
T}pe of Facility Business Total Square Footage of Building = People
r Sinks -r Commodes - Showers T Urinals
Estimated Water Usage (gallons per dad-) (.attach documentation of sini lar facilit-y 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 ?!}king tliAi use/facility location, proposed well location and the location of any other amenities.
— Site Revisit Charge
Property owner' or owner's legal representative signature
Date(s):
e j '^ Client Notification Date:
Date EHS:
Sign given Yes No Account #
Revised 11/06 Invoice #
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLI MI*Eq§NW
Billed To: Wishon & Carter Builders Randy Trink
Reference Name:
Proposed Facility: Residency, Property y ize:
Water Supply: • On -Site Well
Community
Evaluation By: Auger Boring Pit
Tax PIN/EH #: 5812100111IFY INFORMATION
Subdivision Info: Timber Trails Lot # 13
Location/Address: Timber Trails Lane -27028 Q
5 Acres Date Evaluated: j -t f " QV
Public (�
Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
Slope %' ,
HORIZON I DEPTH
0 - q
—
Texture group
C,
Consistence
se "r
5 e 1 i
<4
Structure
I -b
� !4
MineralogyIn
j
HORIZON lI DEPTH
qA
Texture group
Consistencef
f
Structure
K
561<
Mineralogy
Q
5 F_yfo
HORIZON III DEPTH
Texture group
Consistence
��
t
Structure
'C
o
Mineralogy
HORIZON IV DEPTH
Texture groupr
Consistence
Structure
y t
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
5
LONG-TERM ACCEPTANCE RATE
d. I• 0
' y'
r
SITE CLASSIFICATION: J,
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
LEGEND
Landscape Position
R - Ridge S - Shoulders 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
11'Ioist
VFR - Very friable FR - Friable.. FI - Firm V)~I - 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
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
NateS
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 05/05 (Reviced)
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