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121 Waters Edge Trail Lot 10• DAVIE COUNTY ENVIRONMENTAL HEALTH • P.O. Box 848/210 Hospital Street • Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990004269 Billed To: James Frank Reference Name: Proposed Facility: Residence ATC Number: 4617 OPERATION PERMIT Tax PIN/EH #: Subdivision Info: Location/Address: Property Size: /2/U)442s t-6f�e- haw 5813-99-4644 Waters Edge Lot # 10 Bowman Road -27028 1.54 **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. Z— 11J _. p --r System Type: ��—*� S.T. Manufacturer r� O Tank Date Tank Size U� Pump Tank Size N 1& System Installed By: �uv► rn �m �� ��'-� E.H. Specialist: �0` 14OC�Zb 51)ate: Ci — 1 U v 6d(OoTpts c La s a V L DCHD 11/06 (Revised) )c �I`S l 45`f�LA3) bc) sem' � r DAVIE COUNTY ENVIRONMENTAL HEALTH P P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004269 Tax PIN/EH #: 5813-99-4644 Billed To: James Frank Subdivision Info: Waters Edge Lot # 10 Reference Name: Location/Address: Bowman Road -27028 Proposed Facility: Residence Property Size: 1.54 ATC Number: 4617 Site Type: ew ❑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 .3 # Bathrooms ;L # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size I. r Qc-or re, Type of Water Supply: ❑County/City 901(ll ❑Community Well System Specifications: Design Wastewater Flow (GPD) 3 GO Tank SizeIcX)GAL. Pump Tank A- GAL. Trench Width 3 io � � Max. Trench Depth 3 L " Rock Depth 11 Linear Ft. �{� t,� stated in 5, N �,� ^ . ""e kk Site Modifications/Conditions/Other: 1 A NCAC 18A.1.9a9(5) , �°�a-SySte y a -,o o use `ronx H_r • t �- qi rc et�q Contact the Davie County Environmental Health Section for final inspection of this system between �� u r r 8:30 — 9:30a.m. on the dav of installation. Telephone # (336)751-8760. r ,/ 7 �i'f7(G Yetu.4 44�lti�C5 � 3 30 p J FT � `�. 'Q�-c 4-4 Environmental Health S DCHD 11/06 (Revised) ?' , ' Date: J �eCL� a► -S 'APPLICATI SITE EVALUATION/IMPROVEMENT PERMIT & ATC Q� Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 \�O N���� (336)751-8760/ Fax (336)751-8786 Appli on or: � thi ion/Improvement Permit VAuthorization To Construct(ATC) oth ***IM ORTA THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFO ON IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. A PPT TC A MT TNRCIR M A TTCIN t� Name to be Billed .e s �(`� k Contact Person �YY�vvti� 15 vY1 Billing Address ? iv&Ic Home Phone City/State/ZIP Uct_r i 1C_ Business Phone Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with siteAlan, no expiration with complete plat.) Street Address PC W City (�l� e, C_ 14_.Sy i (I e- Tax PIN# 5813 l 0 q 6 c( Subdivision Name DJ&,�-e 0 Section/Lot#I,ot Size 1 . S�cr-cs Directions To Site: [ -ri ��rti«� G{ o Ov Date House/Facility Corners Flagged 3 —.3 --01 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 l No Does the site contain urisdictional wetlands? ❑Yes RINo Are there any asemesor right-of-ways on the site? kYes ❑No Is the site subject to approval by another public agency? Oyes)No Will wastewater othet than domestic sewage be generated? ❑ Yes ANo IF RESIDENCE FILL OUT THE BOX BELOW # People d # Bedrooms 3 # Bathrooms c;7,_ Garden Tub/Whirlpool ❑Yes ANo Basement: ❑Yes RNo Basement Plumbing: ❑Yes RNo 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: Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water y 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? Li 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 Davie County and owned by L L F.rr n 1; ro�a per's or owner's legalrepresentative signature 3 - Date Sign given ❑Yes ❑No Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # ` / Invoice # .ArcIMS Viewer Page 1 of 1 http://maps.co.davie.nc.us/website/mapviewer/MapFrame.htm 3/4/2007 .ArcIMS Viewer 5 -Pac�i %,• fc RCKTaysnoymvv- Cav�r,yc(C11942.2Y15 ® ���!A Page 1 of 1 http://maps.co.davie.nc.us/website/Mapviewer/MapFrame.ht n 3/4/2007 y' y APPUCATION FOR SITE EVAUTA 0 TI N/IMPROVEMENT PERMIT &ATC � Davie County Health Department MAY 2 3 Envimnmenta/Hea/th Sacbion P.O. Boz 848/210 Hospital Street a — 1-v e,e �"L e= ' Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ( L Contact PersonS,4,-'n L-/ Mailing Address ala N �/1� G/ lJ % f Hose Phon .z 0-.- OK�/ % 7 City/State/ZIP �Yh'IOi✓o1 ;Val � 7a/oZ 9 �nLness Phone �l l 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: Site Evaluation City/state/Zip ❑ Improvement Permit/ATC ❑ Both e. system to service: ❑ House Q-59bile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: /i People y # Bedrooms • Bathrooms —412 Ci'Dish.ashsr D-darbage Disposal Nashiag Machine ❑ Basement/Plumbing U Basement/No Plumbing 6. If Business/Industry/Other: specify type # Commodes / showers # Urinals # People # sinks t# Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of Water supply: ❑ County/City ell ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: � ' Tax Office PIN: Property Address: Road Name dUW`W &17 �e Cityizip�cc L4TUr /t'e '•�7�2-� If in a Subdivision provide information, as follows: Name:. Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: 6 /) / Al -,46 4unwe-2-� Za-/ 7 9 ",- Y/" Z�-z Date Property Flagged: -,5--c?/— G C'n 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 to conduct all testing procedures as necessary to determine the site suitability. DATE�� a? , a !"V SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing end proposed Dronerty lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: I EHS• Revised DCHD (07/99) Account No. /J Invoice No.� .N, - v�j < �'e������ � � �. 7�°� �iy.•aiy� �iyla('j.'a r r� t t x r �. t. • t�.H�' �+l�v'i 6� r �� ti. w e�� �k..4..G s� �f a -r: 4 * - •'} y t � �. 4i,�♦� v z ` tiid}.5.{S F }jx"�Qd '�.+ , t1 trrr s r r •iY .. � T7 y le A 00 1, ' `r lr�� s ,' } � '� goo• �I �" ; A\\ ,03/� , I I �F\ . \ •>� ( I I I S N eaao'tT w jr Otis 1 I. \ t 045.28 ACRES(t)MO t I 1 x cnso , xi FUTURE SECT/ON o• �wdwrr cA►isnwctaM n eetl'or w 27157 08 6'3 50' ,�... , �,2• `� , -+ \ / I-, , -.. _`� - �, �� .-= k PubVk VUiiiy Ealyd ,1 Nr A - A937 -2r .- r i 300.00' t - A7 oa• 4383 1 APPLICANT INFORMATION Account #: 990001199 Billed To: Ruth Spillman Reference Name: Ruth Spillman Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Property Size: PROPERTY INFORMATION Tax PIN/EH #: 5813-99-4502.11 Subdivision Info: Waters' Edge Lot # 161 Location/Address: Bowman Road -27028 1.55 Acres Date Evaluated: Community. Evaluation By: Auger Boring Pit 1� Public t/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: AZZ OTHER(S) PRESENT: 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 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) ■E■■ NEON NONE ■■■■ NOME iii ■■■M■■ ■■■ME■ ■EMEM■ ■EN■■■ ■MEMM■ ■EN■E■ ■MEMS■ ■■EM■■ ■MMM■■ ■■MEM■ ■■■■■■ ■■■■M■ ■■■S■■ ■■MMM■ ■■M■■■ ■■■■■■ NOME NEON ■ ■ ■ ■■■■■M■ ■MN■M■■ ■EM■ ■ NEON ■ ■MM■M■■ ■■EEM■■ ■M■■N■■ ■E■■M■■ ■E■■EM■ ■EMEM■■ ■■MM ■ ■■■■ ■ ■M■■■N■ ■EM■■E■ ■■EMM■M ■■■■■O■ ■M■■■E■ ■■■■■E■ ■■■■ ■ NEON ■ ■■■■■■■ MONSOON ■■ME■■■ no ME ■ ■M■MM■UMM■■M■U■ME■ ■■NNE■ ■■M■■■ ■E■■ ■■MME■■E■MEMMEM■EMM■ ■MEMS■M■■E■E■EMEM■■■ ■MEM■■EMME■■■■MEM■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■EMEM■■■■■EM■■ NONE ■EMEM■EM■MMEME■■M■■■ M■■N■■■■M■■■■■■■■■M■ ■■■■■■■■■■■■■■■■■■■■ ■M■MMM ■MMM■■ ■■■■■M ■M■■M■ ■M■■MM ■M■MM■ ■M■MM■ ■■MM■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ONE mom ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■M■■■■■■■■■■MEM■ ■■■■■■■■■■■■■■■■■■■■■■■■■