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221 Timber Trails Lane Lot 4DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT 'Oea�?v I Account #: 990005206 Billed To: Clearwater Development, LLC Reference Name: Proposed Facility: Residence ATC Number: 4932 Tax PIN/EH #: 5812-00-1761 Subdivision Info: Timber Trails Lot # 4 Location/Address: Timber Trails -27028 Property Size: 5 Acres **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. aLfl System Type: S.T. Manufacturer Tank Date Tank Size 06 O Pump Tank Size �V System Installed By: 4 t E.H. Specialist: Date: a� DCHD 11/06 (Revised) f DAVIE COUNTY ENVIRONMENTAL HEALTH Q� P.O. Box 848/210 Hospital Street tiu� Mocksville, NC 27028 Is (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005206 Tax PIN/EH #: 5812-00-1761 Billed To: Clearwater Development, LLC Subdivision Info: Timber Trails Lot # 4 Reference Name: Location/Address: Timber Trails -27028 Proposed Facility: Residence Property Size: 5 Acres ATC Number: 4932 Site Type: Z'wDRepair 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. 2 i Residential Specifications: # Bedrooms 3 # Bathrooms ' S # People a— Basement2r Basement plumbing0----- Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) �U Lot Size Q 1'-e `J Type of Water Supply: ounty/City 0 Well D Community Well 0 System Specifications: Design Wastewater Flow (GPD) 3 Tank Size; GAL. Pump Tank I,O0; -GAL. Trench Width 3ce Max. Trench Depth 3 %", Rock Depth_ Linear Ft. l 5) 1969 Site Modifications/Conditions/Other: s stated in 15A NCAC 18A. ptod Syztoms =Y}�1� ._ 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. fLA , a� -Y 3' �%'I/uoo( Q�1 Environmental Health Specialist 3rPr \rU Date: /'�' _ 3 e-� —t -'-2g iu�r Type 4N`fH For ❑� 1- N2luation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility 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 ***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 Clearwoaic r Deuclopr,cn� , "C- Contact Person p1kgr• LQkeil Billing Address 110 t3ar0i Cgrolina Circle Home Phone RSI- STGS City/State/ZIP Moc ksuille. 1 Nc- 2x102.$ Business Phone (336) 909 - I STI Name on Permit/ATC if Different than Above -Jgmcs Cctn; el Lyncll Mailing Address 30$ A;Actw+l1J Circle City/State/Zip LexintJo, NL. rlc,Urrlcl Y 11NtU UVIA11U1N --)ate House/Nacnity corners 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 :TgM,es Do ml e l L y nc h Phone Number 336- 362 - 99 G4 Owner's Address 3019 Ric!5eMi 11 Circle. City/State/Zip LexinS4on Property Address 22.1 Tw+bcr —Tro 1s Sub City---!OGt4Stli it e. Lot Size 5 Acre z Tax PIN# &IZ- 00-/70( Subdivision Name(if applicable) "Timber, "Trail a Section/Lot# Directions To Site: Off of Bear Ck Church Rd 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? Dyes Brio Does the site contain jurisdictional wetlands? Dyes Belo Are there any easements or right-of-ways on the site? [I Yes B'llo Is the site subject to approval by another public agency? Dyes 2f4o Will wastewater other than domestic sewage be generated? ❑Yes 9f�o IF RESIDENCE FILL OUT THE BOX BELOW # People 2 # Bedrooms 3 # Bathrooms 193/% -Garden Tub/Whirl p of Kes ❑No Basement: V'Yes ❑No Basement Plumbing: irYes ❑No 3'/z, ;AL Bas"Cvl' 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 ❑Conventional ❑Accepted VInnovative ❑Alternative ❑Other --T4% lrat}or far) e� Water Supply Type: WCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes NlNo 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 undcibtand 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, roposed well location and the location of any other amenities. l . A9o-- comirC460V - Site Revisit Charge Prolferty owner's or er's egal representative signature Date(s): 12 IR 10% Client Notification Date: Date EHS: Sign given Dyes ❑No Account # J �a Revised 11/06 Invoice # 11(a (� GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search: (County ID or Owner Ni Active Layer. R Use mf p Fips A. PARCELS (Map Tips Available) v' Adore http://maps.co. davie.nc.usIGoMapslmap/Index.cfm?maimnapservice=gomaps&CFID=41... 12/19/2008 R SITE EVALUATION/IMPROVEMENT PERMIT & ATC (c Davie County Health Department .bT Environmental Health Section 1 L P.O. Box 848/210 Hospital Street 1 Mocksville, NC 27028 v,�ONMESt (336)751-8760/ Fax (336)751-8786 pAV, Ol1N A licatio Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***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 ,..AAMC S 1�n N;e I ,. a( k Contact Person Billing Address P f�hx !E6 Home Phone 3Co 5C City/State/ZIPp ' /� fi %Y) �; c /Ui�- �-2 %p `J/ Business Phone 3',7C, S6 2 Z4 7,*-�;C :It Name on Permit/ATC if Different than Above. Mailing 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 ' %,'ale r (rz; ; I s Lv City 12Jr r_k: 5Li , '//e Tax PIN# 6912-0-17 Subdivision Name i ,:rn �2r TE= "/S Section/Lot# y Lot Size �"r-)A C Directions To Site: Date House/Facility Corners Flagged61�- / 3 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 ly<O Does the site contain jurisdictional wetlands? ❑Yes IAO Are there any easements or right-of-ways on the site? ❑Yes ef4o Is the site subject to approval by another public agency? ❑Yes E& Will wastewater other than domestic sewage be generated? ❑Yes [;(No TO TYU0TT VUT Tf' 1; 'UTT T 11T TT TTST; 'Q(1V T]T: T MIT 1L' 1 11111 LV/l LJ..iLV IY # People41 # Bedrooms J-/ '# Bathrooms � Garden Tub/Whirlpool es ONO Basement: es ONO Basement Plumbing: es ONO 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: I'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: WCounty/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? 5401' 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 enhy to the Authorized Representative of the Davie County Health Department to conduct necessary inspectio� to de��ermme omplianc with appl* able laws and rules on the above described property located in Davie Count0and owned b4 ' _ 1 me s Z ei N , c 17 Ltr+ V 17 1 424 Date Sign given Ves ONO Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # n� A/29!1999 21:26 396-679-5801 I•s `'I GATEWAY REALTY DEU C PAGE 02 111111111111 �rrrr��r�iir rrirr��r�� O M, ;j j ,r) s PAGE 02 111111111111 �rrrr��r�iir rrirr��r�� N 3x02 3� Bp' 6 429, fi 4q N 0 I i—Irc raj i"�i, / Pi Ts -42-,- E. Wb-EU' Toizi e / !s 4 ` 463.34` 194.64' 3Ca1.20' \ \ l 350 ?9' \ 24$_ 718t.US' S 47S. TRACT 5MO Aocrpa (dmd) T 2 17' 33'5' = 485.44 �� S.t�OO kips (dmd){�yp - - *kn — 148.82' / � /� ��• � 3 � �' �.�� es �trfr�) �� \� 6�A _ 8g Vk -2 ' 1.68 / _ 1515.0m.OACID$ (dmd) R 451.11'% r * . 36 8 - T X5.00° x i 5' -. 612'O� \ _ L 1 48.6 `•. ' /''._... a^•^"''..e®.... � 150_00' % �\ f .a� ri off' � �a�.O9' 8gfl id Y" "��^� '�' _. _�' >-,--'.'►+� 29�, t ,�, D 17�25 _ ( .�� lti'�y •-� ��c,.��i.-."�'► 3 Q,�a _°^�- - 1 S � m 484:18' \ A ✓ 14 r� i �A75.45 G ',; , r �4i'fli `. / = 45 28'4` \ (dmd) `� �o L i 490' �- •� . 36� t9' --�` / =551.89' 438.06' ,� y S.00O �s (drasi) i a TRACTS a TRAAT 9--k } B A14 C h &EEK 1e1lrGr, C � a 5.t ,+; �uaYea (csa nQ p o ij � � • �\ , / � o � r� N+ `� TRACT 5. o Acres (dmd) { o is 5.0C?0 Acr (dmd) .5 TRACT 12 �t� HUr2C �.5 it � �\ • � � � `� �� ! i !� � `~�� 841 464 `\ p \;• uo ':.}4, (5 64.21 39':4.r4' �I 32.40 LiB.I[P 2x1~�O' 2711. Iig t W (9627 TRACT 9A MdB MnB2 761 (48.8 �) TRACT io (4.88A) 8824 • 1 DAVIE COUNTY HEALTH DEPARTMENT 3 4 5 6 7 Environmental Health Section L L Soil/Site Evaluation Sloe % APPLICANT INFORMATION 2v PROPERTY INFORMATION Account : 99000 031 Tax PIN/EH #: 81 - - 5812-00-1761 Billed To: 'Billed James Lynch Subdivision Info: Timber Trails Lot # 4 Reference Name: Loeation/Address: Timber Trails Drive -270 8 Proposed Facility: Residence Property Size: 5 Acres Date Evaluated: 7 oto Water Supply: On -Site Well Community Public Evaluation By: Auger Boring ✓ Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L L L_ Sloe % 2v 1520 HORIZON I DEPTH 0-1,4- O O- O- Texture group - 5 i CL Si GL- Consistence -r SSSP Structure S Mineralogy A t, HORIZON II DEPTH 12 '2,Z. Io- Ztr7 - Texture group G; C. sc, sic_ 5• C, Consistence RI -Z' �Zsv Structure `.• k :5>5t 3 V - Mineralogy r HORIZON III DEPTH - 4 1� - 44 - t, - 4-4 Texture grou '.0—+Sq0' f C -A Consistence SO 1fr ; 'j p StructureAISIC A3 MineralogyS.> 5 HORIZON IV DEPTH 2. Texture groupS Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION Is V5 P S LONG-TERM ACCEPTANCE RATE 7> j 0 • 45 O.?,S-- SITE CLASSIFICATION: 1 S EVALUATION BY: LONG-TERM ACCEPTANCE RATE: Q. I", OTHER(S) PRESENT: REMARKS: 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 is 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 VI' - 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 nr'rto os/99 Revitocll r Davie County Health Department Environmental Health Section' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Improvement Permit James Daniel Lynch PO Box 562 Pilot Mountain, NC 27041 Re: Timber Trails Lot #4 Tax PIN# 5812001761 Dear Client(s): 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 or the intended use change. System To Serve: 1 � Wastewater Design Flow(GPD)Ab-0 Valid: Years ❑No Expiration System To Serve% System Type: ❑Conventional .P�Accepted ❑Innovative ❑Altern ' e ❑Other ' Site Mo ica ion ermit�onditions: ztf` I'Or� � 4 h"UJT 1�-dm' )N6 Site Plan 'Ru -P IQ .ate.=A L -T -A(2 i.p.letter 7/06 Date Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection � Name: 1�5 i nn �- '� I.J 1 1, � Phone Number �' ` 1 `(Z ? y 2 1 Home) Mailing Address: 7 r> • r -57 L- ( 4. " ( i Work) if l c'c 1c 1" l (� N C Email Address: rd 1 r-, 0 (f or J Detailed Directions To Site: f4t,1 r ��G 1 { L e ! n !.- ,.+ n { i�<'(• ` r> L(,14 Property Address: �_ ' i ; .� =e r -r-r { S Ln it I , L Please Fill In The Following Information About The XISTING Facility: Name System Installed Under 140 GE{) (/ Date System Installed (Month/Date/Year): =- A (� / Number Of Bedrooms:_2 _Number Of People: Is The Facility Currently Vacant? Yes /No`s If Yes, For How Long? Any Known Problems? Yes � 0 If Yes,, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: ` 1 r V, y' �� Number.Of Bedrooms: { 10, Number of People r r Pool Size: -,) 14 Garage Size: N = Other: Requested By: ,-� V > - %%' Z Date Requested: > L' I hi (Signature) For Environmental Health Office Use Only Appro�ed Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account #: 3 InvoicE #: 9/20 7 0 !�� l r l q Lf t l� �C� •�