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124 East Chinaberry Court 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 #: 990004057 Tax PIN/EH #: 5747-31-4591 Billed, To: Structural Designs LLC Subdivision Info: South Arbor Lot# 13 ' Reference Name: Andy Beauchamp Location/Address: E. Chinaberry -27028 Proposed Facility: Residence Property Size: '1acre ATC Number:"' 4794 **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: MG 44 S.T. Manufacturer Tank Date t_� Tank Size t ODD Pump Tank Size System Installed By: Sjjjgn.0 ' E.H. Specialist: Date: J DCHD 11106 (Revised) J,'Nw SueL n zzet.. = irc). e- 6. 6. DAVIE COUNTY ENVIRONMENTAL HEALTH Pd. P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 al3�l� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION . Account #: 990004057 Tax PIN/EH #: 5747-31-4591 Billed. To: Structural Designs LLC Subdivision Info: South Arbor Lot # 13 - Reference Name: Andy Beauchamp Location/Address: E. Chinaberry -27028 Proposed Facility: Residence Property Size: lacre I,004519 ATC Number: 4794 Site Type: �Ti ew DRepair DExpansion **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. ResidentialSpecifications: #Bedrooms #Bathrooms#PeopleBasementOBasement plumbing❑ Non:Residential Specifications: Facility Type # People_ # Seats_ Square Footage(or Dimensions of Facility) Lot Size d Q Type of Water Supply: V—nsunty/City O Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)3( Size*gbAL. Pump TankGAL. X n Trench Width 3 �° Max. Trench Depth 36' Rock Depth Linear Ft. 3 �¢ As stated in 15aGGepA NCAC 18A.1969(5) Site Modifications/Conditions/Other: y tem may an t P u�c ` Contact the Davie County Envir mental Health Section for final inspection of this system between C`n• n k ce,, La. 8:30 — 9:30a.m. on t f installation. Telephone # (336)751-8760. (73' Ly-� I OCC k 3' 1A VX -PS � t t i i Environmental Health Specialist Date: DCHD 11/06 (Revised) APP R SITE EVALUATION/IMPROVEMENT PERMIT & ATC 1� U Davie County Environmental Health (�� P.O. Box 848/210 Hospital Street l 2p01 Mocksville, NC 27028 `�� (336)751-8760/ Fax (336)751-8786 pph tion tgel �tration/I rovement Permit Authorization To Construct(ATC) 0 Both e ofAp191fcatiori M em URepair to Existing System DExpansion/Modification of Existing System or Facility ***TMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed 9S<SYT - s Contact Person C/ 4u -/ CL Billing Address 5 i'W o� <f I�P Phone 3 - 3y5-- City/State/ZIP �/Ioc� sd f �a GCiI 27cge Business Phone cb Name on Permit/ATC if Different than Above Mailing Address City/State/Zip *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan OPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name ' �� • Phone Number /Yo Owner's Address 7 da /« u 20 u City/State/Zip 0-,, ApYZe wJe Z7o 2� PropertyAddress Ce / City, Lot Size Tax P# Subdivision Name(if applicable) �oz�, i eiz Section/Lot# Directions To Site: GD/ Srwfiel! � �� !2�,e, , 41, ori.4. f Qti Gt . Lo6tes, eZ�bA 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 �60 Does the site contain jurisdictional wetlands? DYes 1110 Are there any easements or right-of-ways on the site? 0 Yes Ao Is the site subject to approval by another public agency? OYes66 Will wastewater other than domestic sewaee be venerated? DYes o IF RESIDENCE FILL OUT THE BOX BELOW # People 7 2 # Bedrooms _ # Bathrooms ;2—' Garden Tub/Whirlpool DYes kKo Basement: [!Yes 25-6 Basement Plumbing: ❑Yes Edo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Btisiness 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; XrConventional OAccepted OInnovative DAlternative DOther Water Supply Type:24unty/City Water D New Well OExisting Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes If yes, what type? 15 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 DavieCounty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I underst rd that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or st 1 g�u a ho se/facilityJocation, proposed well location and the location of any other amenities. Site Revisit Charge rope owner's or owner's 1 a] representative signature Date(s): fv b Client Notification Date: Dae EHS: Sign given ❑Yes ONo Account # 405-7 Revised 11/06 Invoice # Mi �,,, LI APPLICATION FOR SITE EVALLIATIONAMPROVEMENTS G ° Davie County Health Department Y Environmental Health Section 7t P. O. Boz 665 I FEB 2 8 1996 U5vMocksville, NC 27028 u ul II UJ 1., Application/Permit Requested By T. Kyte Swicegood, agent {toA MA./MA-6. Kod Uloodwand 3U0" South .Maxn S-tAeet 704-634=1010 Mailing Address Home Phone MUCKSVILLE. N. C. 27028 Business Phone 704-634-2222 2r.Name on Permit if Different than Above Application for: 0 General Evaluation ❑ Septic Tank Installation Permit .,.`4.• System to Serve: TR House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown /3 2 -Wq%*L 5. If house, mobile home: SubdivisionSection - Lot # SOUTH' AR No. of People — No. of Bedrooms 3/4 'L No. of Bathrooms Dwelling Dimensions 1300 .6q. fieet +- 6. If business, industry, place of public assembly, other: Specify type No. of People Served i No. of Commodes N No. of Lavatories A No. of Sinks _ No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures, 7. Type of water supply: p Public ❑ Private 8, Property Dimensions See attached map Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ® Washing Machine. Q Dishwasher ❑ Garbage Disposal ❑ Yes Or ❑ Community 'NOTE: Improvements Permits shall be vaIIdd&baspmi=6akE0m= from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. PROPERTY INFORMATION REQUIRED: Tax Office PIN: '# ,571%?cZ2A PROPERTY ADDRESS, as follows: Road Name: South AAbbit City: MackhytXte N. C. SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. >,I This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. FebAuaAy 26, 1996 T.'Kyee Siv.Lcegood, agent {oA DATE r�ivr�run❑ "vd— and -n�(. t�(t i—woo - ' CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. EJ 2. 1 DO NOT OWN the property.. If you checked Box #2, the rest of this form MUST be completed by the ��owner ��o��r ��a��person authorized by the owner: I hereby give consent to the authorized represent ve ol� vie CQod' [UooWD aartment to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absor tion sewage treatment and disposal system. fT. jcy cego d UebjutaAy 26, '1996 j � DATE AT E ' DCHD(1t93) DAVIE COUNTY HEALTH DEPARTMENT 0_t Environmental, Health Section Soil/Site Evaluation NAME DATE EVALUATED ADDRESS S 1�M4 PROPERTY SI28 PROPOSED FACIILTY t7�j SQ LOCATION OF SITE pr Water Supply: On -Site Well Communi Public v Evaluation By:Cc��Auger Boring Pits Cut -R—Y7 FACTORS 1 2 1 1 4 Landscape position G Slope b I 0 HORIZON I DEPTH r Texture group C'. L Consistence F71 V S Structure g Mineralogy" l HORIZON II DEPTH fit` Zv Texture group Consistence Structure Mineralogy 1 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS S S S RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 'I SITE CLASSIFICATION: • 5 " LONG-TERM ACCEPTANVP RATE: REMARKS: DCHD (01-901 N;% EVALUATED BY:-i<ot�-� F#. OTHER(S) PRESENT: N�wQ LEGEND Landscape Position R -Ridge S7Shoulder 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 <;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay 1 Moist VFR- Ve.-y friable FR -Friable FI -Finn 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-Cranular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineraloey 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 - gar/day/ftz