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110 S Benson Lane Lot 3DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990003401 Tax PIN/EH #: 5746-48-2346.001E Billed To: Ken Durham Construction Subdivision Info: Twin Cedars Lot # 3 Reference Name: Location/Address: Walt Wilson Road -27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 4600 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article I 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 Pump Tank Size ZJ System Installed By: 4t1W 1' 4UJOK E.H. l uTtt,1 Q-�-� Q icy -'I DCHD 11/06 (Revised) i p 220► -3'3 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 #: 990003401 Billed To: Ken Durham Construction Reference Name: Proposed Facility: Residence ATC Number: 4600 Tax PIN/EH #: 5746-48-2346.001E Subdivision Info: Twin Cedars Lot # 3 Location/Address: Walt Wilson Road -27028 Property Size: 1 acre 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. Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size -1'&C9C Type of Water Supply: .t 6unty/City El Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) ank SizeIAL. Pump Tank GAL. TrenchWidth O' Max. Trench Depth s Rock Depth �2Z Linear Ft. 3 71 Site Modification / V onditions/Other: t C>r- Ca>—'a (Q D `r F+P L4 _) c Contact the Davie County Environmental Health Section for final inspection of this system between SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street F E B 1 6 2007 Mocksville, NC 27028 (336)751-8760/=ion 1-8786 pplicatioF)'o%jA',r �T �gRi�atioIm rovement Permit To Construct(ATC) ❑ Both erri 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 ' eh \ D(A vin. c t vyA Contact Person c Billing Address 0 o .t, Li 0 '1— Home Phone Zg`- f Q 4 g City/State/ZIP Al C Wc ( Business Phone C1 9 O a a C� �- Name on Permit/ATC if Different than Above, Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with sitelan, no expiration with complete plat.) Owner's Name P 'du (�,.,�,4, Phone Number Owner's Address f City/State/Zip Property Address City Lot Size ,. e-- Tax PIN# 57 Y6 Y 2-3--Lf-4, Subdivision Name(if applicable) Section/Lot# Directions To Site: 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 ❑N Does the site contain jurisdictional wetlands? ❑Yes P<o Are there any easements or right-of-ways on the site? PKes ❑No Is the site subject to approval by another public agency? ❑Yes pP4`6- Will wastewater othei than domestic sewaee be Generated? ❑Yes ®ado IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms _ 2 Garden Tub/Whirlpool es ❑No Basement: ❑Yes IeTo Basement Plumbing: ❑Yes aXo- 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:, D<�&nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: PeKounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes L?<o 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 the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge r perry owner's or owner's legal representative signature Date Sign given ❑Yes ❑No Revised 11/06 qww apoC, Date(s): Client Notification Date: EHS: Account # 46Q Invoice # SEC QP iW(? Y CEDARS ;(Page -2 of.2) _ t ;4.4(i :P M. - and,. recorded on March 23, 2400, i*t F i� Ptah Book 7 Pages . I17. 118 it 1 , 1 W 2 ,\ 28 123 I U i fCq � 1 1 + � \�Baa. ���.COMMON AREAS 1� 2 �� K " GREEN A�sO• r J31.21. pvth 1 r y COKMOL COO"" le � 1 A;jy THOMAS H. PRICE D.B. 126 Pg. 487 '0"t22 '0 1 70' S�(T ^ 7 (DAM ACl+J[j » � ! ✓\SEmENTCTYI j c / "' 3 � 6 GREEK t Q ' "0. u1!i1TY EASEMENT ' Ir 3%..4 20 22 �33� 1' �S• ` �/ �p 23 6b73 210 21 `t/ I r. ` ♦♦9 (0.74 AC1l3 (0.a AM le t• !-ASE1+EtiT(TYP) ti 6s. \ � h J 2S. S• APPi:CAMN FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC !� Davie County Health Deparhnent .. Environmental MMIM SmWon RR M 2 P.O. Box 848/210 Hospital Street np L5 U R Mocksville, NC 27028 U 1336)751-8760 AF1017M ***ZWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS THE.,.AEQUIRED.___ INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN fa init 1IE11LTN .2. Name to be Billed /tz, C Contact Person'U'��Q�1GtJ 5JI'y�L't(/rJL� !!ailing Address New Phone City/State/tip D Business Phone ¢7 2,- J V lv 7. Names on Permit/ATC Mailing Address Different than Above City/State/Zip 3. Application For: .�p�Site Evaluation 0 Improvement Permit/ATC 0 Both 4. system to service: / \� House 0 Mobile Home 0 Business ❑ Industry 0 Other a. Iff ms Residence: # People L # Bedrooms 3 # BathrooZ— of Dishwasher Q Garbage Disposal 94ashing Machine 0 Basement/Plumbing 0 Basement/No plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # showers # Urinals # Fater Coolers IF FOODSERVICE: # Seats Estimated Nater Usage tgaiions per day) 7. Type of water supply: 9 County/City 0 well a. no you anticipate additions or expansions of the facility this system Is intended to serve? If yes, what type? 0 Community 0 Yes 0 No ***IMPDRTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 3 a 'D00 Tax Office PIN: # Property Address: Road Name �U�Cr" w'%GS��' P'6 City/Zip llv4D«Salla` /v"( - WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Name: Section: Z Block: Lot: 3 Date Property Flagged: W 143191 This Is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) 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 am responsible for all charges incurred from 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 M Ll twicce to conduct al esting procedures as necessary to determine the site sultabilih. DATE t'�2T lt�•l �� / /� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN cl all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. 3 Invoice No. 5 8ff I 't; DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION ---A Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit -q $16 SECTION 2 LOT X 3 DATE EVALUATED 17,101 PROPERTY SIZE U x Z'�__ ► �,� X LZ3 ROAD NAME Public -� Cut FACTORS 1 2r3� 4 5 6 7 Landscape position L L - Slope % c20 HORIZON I DEPTH Z o - Texture group Consistence F i Structure CL G MineralogyIrl i HORIZON II DEPTH ho -2,-14e - LV Texture group C Consistence 5 Structure c Mineralogy'l HORIZON III DEPTH Texture group + Consistence Structure te- Mineralogy- HORIZON IV DEPTH Texture group Consistence F Sn Structure 1 L Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE p,33 - n c�c -ILL? 2y -32 n SITE CLASSIFICATION: �$ 7O/'0 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: C4.,4, -JT i REMARKS: b,24jj.14 &L QOA i) 'C.&Sb-r&' v6t,�-�-.� , Gt3►�. tl l rJ L`v 01 "T P .S.- DCHD (01-90) 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 Moist 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 �4 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 ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■■■■■■■■Err■■■■■■■i�■■■■■■■■■■■■■■■■■■ ■ENNWAMM ■■■mumm ■■EWMEN ■■■■■■■ ■■■■■■■ ■■■M■■■ ■■■ ■■ MEN no ■■■■■■■ ■MM■■■■ ■■■■■■■ no ii MR ME i ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■M■■■■■M■■ ■■■■■■■M■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■M■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■■■■■■1U1■■■M■ ■■■■■■ MESON ■■E■OM■■■■■■■ ■EM■■■■M■■■■■ ■E■■MEME■■EM■ ■EM■■M■■■■■E■ ■M■■■■EEM■■■■ ■M■■EM■■M■EM■ ■E■■MMO■■■■■■ ■■■EMM■■■■■■■ ■■EME■■■M■ME■ ■■■MMO■■E■■E■ ■■MME■■■■M■■■ ■ ■■■ ■ ■ ■ ■ ■