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129 West Chinaberry Court Lot 19DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital. Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT !% L410 4"9 rl� Account #: 990004057 Tax PIN/EH #: 5747-21-6541 ' / Billed To: Structural Designs LLC Subdivision Info: South Arbor Lot# 19 Reference Name: Location/Address: W. Chinaberry Court -27028 Proposed Facility:. Residence. Property Size: 1.1 Acre ATC Number: 4665 **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: S.T. Manufacturer°` Tank Date' (� Tank Size Pump Tank Size System Installed By: E.H. Speci e: JuO (cam% 1 QSG-�►�n�s q' 15 DCHD 11106 (Revised) rIZ • r :; ]''_.,,� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street 51-876 iFa # ( 27028 \ (336)751-8760 Fax #(336)751-8786 \\ AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION) Account #: 990004057 Tax PIN/EH #: 5747-21-6541 Billed To: Structural Designs LLC Subdivision Info: South Arbor Lot # 19 Reference Name: Location/Address: W. Chinaberry Court -27028 Proposed Facility: Residence Property Size: 1.1 Acre ATC Number: 4665 . Site Type.,Z<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 # Bathrooms 2 # People_ BasementO Basement plumbing❑ Non -Residential Specifications: Facility Type # People_ # Seats_ I Square, Footage(or Dimensions of Facility) Lot Size Type of Water Supply: Xouuty/City ❑Well ❑Community Well • y' y, I System Specifications: Design Wastewater Flow (GPD) �Od Tank Size' iCMGAL. Pump Tank _ GAL. Trench Widthnn nnJO Max. Trench Depth S5 RockDepth -A Linear Ftp �� SiteMlo�dific tions/Conditions/O er: 1 tL 1rajiN" - I<L , KON/ Acp WOE 1 -we Contact the D vie County Environmental Health Section for final inspection of this system between ,. . �if.1' 8:3 = 9:30a.m. on the da of installation. Telephone # (336)751-8760. ZS . Tjr ej p � � h /� 4� Environmental Health Specialist ate: DCHD 11/06 (Revised) r' D i p I�T SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street O AeR ro 20� MocksviIle, NC 27028 aH (336)751-8760/ Fax (336)751-8786 n ZP�HFA � A licat t ion/Improvement Permit 0 Authorization To Construct(ATC) Ath T of Appc ew System ❑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. APPT.TCANT TNFORMATTON Name to be Billed GLC Contact Person t Billing Address 5 200 Home Phone -S - O City/State/ZIP YRe C Z-70 Business Phone Name on Permit/ATC if Different than Mailing Address PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: WISite Plan OPlat(to scale) (Permit is valid for 60 m nths with site plan, no expiration with complete plat.) Owner's Name 17 Phone Number_Z Owner's AddressataCi"ty/State/Zip u' Property Address CT.. City Lot Size /.I a -e 2s Tax PIN Subdivision Name(if applicable) Section/Lot# / Q/ Directions To Site: /_t71 S .iza2) If the'answer to any of the following quegt(ons is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes W'&o Does the site contain jurisdictional wetlands? []Yes 21Io Are there. any easements or right-of-ways on the site? ❑Yes ErNo Is the site subject to approval by another public agency? ❑Yes Z7 To Will wastewater other than domestic sewage be generated? OYes Z"No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms 2 Garden Tub/Whirlpool es ONo Basement: OYes 5No Basement Plumbing: ❑Yes 0'No IIa C1030Oki *yu)pie to) Doa IR11818JOIago0-10040-30 COWAN 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; pConventional CAccepted []Innovative OAltemative ❑Other .. Water Supply Type: %county/City Water 0 New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes !A'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 staking t house/facility location ' roposed well location and the location of any other amenities. Site Revisit Charge operty o is or owner's legal re sentative signature Date(s): Client Notification Date: l D le.. EHS: Sign given ❑Yes ONo Account # q Revised 11/06 Invoice # 057 --- - -- -------------------------- nmm r r i APPLICATION FOR SITE EVALUATION/IMPROVEMENTS _ C, ° Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, NC 27028 FEB 2.8 1996 1. Application/Permit Requested By T KNXQ Swicegood agent AAA MiL /fts Rod WoodwaAd Mailing Address 300 South Main St)teet Home Phone 704-634-1010 MUCKSVILLE. N. C. 27028 Business Phone 704-634-2222 2, Name on Permit if. Different than Above 3; ,Application for: (A General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: • {x7 House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry . ❑ Other ❑ Unknown /g 2 5. If house, mobile home: Subdivision 5ftlTifSection Lot # No. of People 3/4 No. of Bedrooms 'L No. of Bathrooms Dwelling Dimensions 7300 sq. yeet +- 6. If business, industry, place of public assembly, other: Specify type No. of People Served N No. of Commodes 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: ® Public O Private 8: Property DimensionsSee attached map Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? it „ems ,.,Heb �„neo ❑ Basement/Plumbing ❑ Basement/No Plumbing ® Washing Machine Q Dishwasher ❑ Garbage Disposal ❑ Yes ❑YN0 ❑ Community 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFORMATION REQUIRED: -122 Tax Office PIN: If -5 V PROPERTY ADDRESS, as follows: Road Name: South AnbbA City: tifocuyit.Ce.. N. C. SUPA11T A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. ;,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. IebAucrAy 26, 1996 T.'KyZe�Staceegood, agent goA DATE -- --- woodwatri CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. I:J 2. 1 DO NOT OWN the property.. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized represent ive of.th pa vie�D un y Heal D artment to enter upon above described ;property located in Davie County and owned by an hyc3• Ko� fUoa� to,conduct all testing procedures as necessary to determine said site's suitability for a ground absor tion sewage treatment and disposal system. T. y cego d I-ebxuaAy 26, 1996 C- •� DATE 14ATOE DCHD (1193) J DAVIE COUNTY HEALTH DEPARTMENT % Environmental Health Section Soil/Site Evaluation q NAME �' �DATE EVALUATED ADDRESS J ®`s\`� PROPERTY SIZE 302X -D-13 PROPOSED FACIILTY `�'� cs\ LOCATION OF SITE li 4o - cl-� Water Supply: On -Site Well Community Public - Evaluation ByC''tL Auger Boring Pits V Cut U d7 FACTORS I 12 3 4 Landscape position S 3' L Slope 7, HORIZON I DEPTH - Texture group G Consistence Structure 113 S Mineralogy A HORIZON II DEPTH Texture groupS Consistence S. - ' S Structure 1 Mineralogy 1'. 5 HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH. Texture group Consistence Structure Mineralogy SOIL WETNESS S SS RESTRICTIVE HORIZON — - SAPROLITE — CLASSIFICATION -777_ LONG-TERM ACCEPTANCE RATE , p . SITE CLASSIFICATION: •S- EVALUATED BY: LONG-TER ACCEP ANCE RATE: OTHER(S) PRESENT: � d N2 REMARKS: ��/ -�+°` 0.ar�- �.-,I,-tzir i - 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 <.lay 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 firth Wet NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic Structure 3C -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 (01-901