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184 Cookson LnDAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-87G0 Account #: 990000720 Billed To: Stephen Cookson Reference Name: Stephen Cookson Proposed Facility: Business ATC Number: 2138 Tax PIN/EH #: 5708-66-2198 Subdivision Info: Location/Address: 1454 Godbey Road-27028 Property Size: 20 Acres AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �`� �C7''c�� `�j Date: �/�—�� CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemendOperation Permit 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 t en as a guarantee that the system will function satisfactorily for any given period oftime. `�� C)�u -�, i�rmP -' /�� ta� � y�r��e ��,,. �v✓�-s .%'�% ��i.. �! .��1 ��,7, s- r>a � � � d ��1, ��- . ftv �ra l ��vx ��5� Septic System Installed By: Environmental Health Specialist's Signature : DCHD OS/99 (Revised) � Date: �S ��'�i G ` - � � �/ ��99 �� , , • . � �-AP�I.ICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC (� �,� Davie County Health Department /� % `J .� '��.� Environmental Health Section (.�� // � e� v�' � r�i � �� ?�' P.O. Box 848 NEW PHONE NUMBER: �� '�i `�Mocksville, NC 27028 EFFECT!VE MARCH 22, 1998 � � � �� ` 704 634-8760 336 751-a760 / � �`� � ,�1 ( ) P � eG�%�aw '� �,l / � ^ y ,o ****IMPO TANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS A L��l �� THE REQUIRED INFORMATION IS PROVII?ED. � �� /7 �'�� %�/� 1. Name to be Billed ��" �� Gvl � o'O d' D� Contact Person �i �'F� n n 6't2 ��' �l� �i c,� LoD�dOv Mailing Address J yG� �� d�i �. Home Phone �� '" e� �� City/State/Zip /li o c-,� s✓� %/a .�G �7cr��' Business Phone s�, m C� 2. Name on PermidATC if Different than Above h Mailing Address City/State/Zip j� 3. Application For: [ Site Evaluation [] Improvement Permit & ATC [] Both �° 4. System to Serve: [] House [] Mobile Home [vJ Business [] Industry [ Other G'afil`' 4 9�.I' j 5. If Residence: # People # Bedrooms # Bathrooms [] Dishwasher [] Garbage Disposal [] Washing Machine [] Basement/Plumbing [] Basement/No Plumbing 6. If Business/Other: Specify type # People� #Sinks� # Commodes�� # Showers� # Urinals # Water Coolers '�r! '� �(%/� If Foodservice: # Seats Estimated Water Usage (gallons per day) , 7. Type of water supply: [] County/City [� Well [] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes � No If yes, what type? E Z THER fl PLAT OR S Z TE PUIN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***��`�� OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �� 7�'� �� WRITE DIRECTIONS (fmm Mocksville) TO PROPERTY: Tax Office PIN: # S%� - _� - �� ; ��ST � N � � "� �G � U £ (•Z . PropertyAddress: Road�ame /�%Sy oo1�j oy � �_T �d " l S� L� l-T � 5' City/Zip /►� �GKSV / ll� ;� o�D � E� IQl� � C� � P�ovT If in Subdivision provide information, as follows: � �/�iC /�- ES '� '% � 5�`�'' �S' � 1S� Name: � � / G-f-1 7� �J' / Dt' Section: Lot #: ; G 5n� �'I �i) < T h J�c-tr � f R t i►--� 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. t�,� �IGNAT Revised DCHD (06-96) THIS ARF.tI MttJ Ii& USEb �OR bRrttUZNG JOUR SZTE I'LttN: as ne�cessary to determine the site suitability. -�•� r� �'�� e� � i 2 a� �!N bl � n o � -� �;�_ �� : �-- --. � ,- �; . ._ _ ,;-f i - ��a.R. ,__ __- ' �.a,��; - � ' _� ,- � _ � _ ! � , � 1. 8, IQ — . ^ � � �' D�oP°S�D �aDPaS� p . .f . 1 1 , ��, ^ �{ w�' �3 ��a � i;�_I�.�,, k i �� d�� ` a� — / � �/�l/ I , r, ,. , � Q (�r, �, �i X/ a �I?� S � r. � c � _� l_ �� , . , /� �, t� ��t � .1� � ��.�� . C',��.�- s � (�6� � � � �� , v D � � � � �- �PR� � 0 5,= � � $�n,�r.,� �"A3,'as � � � � � �� S �6 �S �{�°" ��, ,. � � 5 � � � � � � � �.� u 0 �..� S� �1-� ► `` I � � �n� � �4✓ �fh., f=�--._ _ ,-�1� ��d ' � , � ' _ ,�, - �,�.�o� -- �___ , �- _ � \ � ,� _ � ��_ , . ._� � \� �` i�� . '�� 1�` �: • \.\ ' �/� � ~ �\ `: / � a\ c: DAVIE COUNTY HEALTH DEPARTMENT - � ' Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000720 Billed To: Steph�n Coakson Reference Name: Stephen Cookson Proposed Facility: Business ATC Number: 2138 ,� �-�� Tax PIN/EH #: 5708-66-2198 Subdivision Info: Location/Address: 1454 Godbey Road 27028 Property Size: 20 Acr�es **NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Deparhnent prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE TAIS PERNIIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People _� #Bedrooms #Baths �_ Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility T�� #People �#People/Shift #Seats Industrial Waste: � . Lot Size �� Type Water Supply _��/;e// Design Wastewater Flow (GPD) �`�i d Site: New ��Repair ❑ System Specifications: Tank Size� GAL. Pump Tank Other: Required Site Modifications/Conditions: / �/ GAL. Trench Width �_j� Rock Depth� Linear Ft.� F��J IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6" BELOW F'INISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Depaztment for finat inspection ofthis system between 8:30 a.m. to 9:30 a. . or 1:0 m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** �''�' �� L/�/lc n s'.� �j '(� P.l ' om �� p�'�f��<S' 7� � �U I.�a � � �CX �� %�D�'�Z J.�� l �`�� C �� LL c �� 5�;� ,� r � �� c �' �,,�,�D� � `�-`' i^c'c:�l Environmental Health Specialist's Signature: cG Date: �/�/ �j� DCHD OS/99 (Revised) , , r., rc �. G. � o. U I ,� N7��-40 W tEONARO A. GODBEY �� .� 272•62 0.8. tt3- 758 � I72- 433 �\\ � � � - � � ron toun d- � Q. . • � � -'w' itRt �• .. _' � • _ Y' - • S54�2T-45� or ,e. �. . .. \� � . -. _ .. 70� _ 12�-34' ��Totat 659.OQ SOO'-55 -35. . . . ' , � _ . po�nt � . _ . r : . � � � r30.52' �r°�np�a�4g8. 48 �ron touna- � iR� roca� _ . _ . . _ c . �. _ . � S 63'- 56 - 3O V�t . . . � � ; 243. 42� - . . .� � \ . . . . . . . c _ .QCR� . '� ..3 . `' �Ra��oo9 � S 58'-OT�-35��N . 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SoiUSite Evaluation APPLICANT'S NAME c-U�i�cf4 PROPOSED FACILITY � i` f SUBDIVISION Water Supply: On-Site Well � Community Evaluation By: Auger Boring Pit FACTORS Slope % HORIZON I DEPTH Texture group Consistence Structure HORIZON Texture �rc Structure HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Consistence Structure SOIL WETNESS SAPROLITE DATE EVALUATED �� PROPERTY SIZE �� J'�� ROAD NAME L�Dli � Public Cut � �0000�'� �0��---� ��_�---_ �ri�r�---� LONG-TERM ACCEPTANCE RATE � ,�/ �,�/ � , SITE CLASSIFICATION: fh-� L LONG-TERM ACCEPTANCE RATE: REMARKS: !�G!�/�' �1.!_�r�'h��° /D �� DCHD (01-90) .� , rJ EVALUATION BY: OTHER(S) / LL+'(TL+'fVllV �� ,�i��/%�i�'�i Landscape Position /7 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 M ist 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 - Subangulaz blocky PL - Platy PR - Prismatic Mineraloev 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 - gallday/ft2 ■ ■■��■�■��■��■ ■■■�■��■�■�■ ■��■■�■��■■■ ■��■�■��■■ ■�■��■■■��■ ■�■��■��■ ■��■■�■�■�■�■ ■■��■��■■�■�■ ■�■��■�■��■■■ ■�■��■■��■ ■�■■�■�■■■�■■ ■■■■■�■�■■�■■ ■■��■��■��■ ■■��■��■ ■��■■■■��■ ■�■�■■�■��■■ ■�■■�■■��■�■■ ■■■■�■��■ ■■■■■�■■��■ ■��■■�■■��■�■ ■■��■�■■■��■ ■�■�■■�■■■��■ ■�■��■■��■�■■ ■■■■■■ ■■��■■ ■�■�■■ ■�■��■ ■��■�■ ■��■■ ■��■■ ■■■■�■ ■��■�■ ■��■�■��■■■ ■�■■�■��■■�■ ■■�■��■■■�■ ■■��■��■ ■■�■��■■��■ ■��■��■��■ ■�■��■��■■■ ■��■�■■��■■■ ■��■�■■��■ ■��■��■��■■■ ■■��■��■�� ii■�■■�■�� ii ■■■■ ■■�■ ■��■ ■■■■ ■�■■ ■�■■ ■��■��■�■�■�■�■�■ ■�■t■■�■��■■��■■■■ ■�■■�■��■■■�■��■■ ■�■■��■�■��■■�■�■■ ■��■■■��■�■■�■�■■ ■��■��■��■■■��■ ■■��■��■��■■e■��■ ■�■��■��■�■��■■■■■ ■�■■�■■�■�■��■�■■ ■■■■■�■��■■■■��■ ■■�■��■��■�■■�■ ■■��■��■��■■�■�■�■ ■�■�■��■■■��■�■ ■ ■�■�■■ ■�■��■ ■■��■ ■��■�■ ■��■�■ ■��■�■ ■�■�■■ ■■��■ ■�■�■��■ ■�■ ■�■■ ■��■��■ ■��■��■ ■■��■r�■■ ■�■�■��■■ ■�■��■ ■�■■�■��■ ■��■■�■ ■�■ ■■�■ ■■��■�■■■ ■■��■■�■■ ■�■��■��■ ■■�■�■ ■■■��■ ■��■■ ■�■�■■ ■�■��■ ■■�■■■ ■■�■�■ ■■■��■ ■�■��■ iii ■�■ ■■��■ '■■��■ ■�■■��■ ■��■ ■■��■�■ ■■��■■ ■■■�■■■ ■��■■�■ ;�■■■�■ ■�■��■ ■■�■■■■ ■��■■■■ ■■��■■ ■��i ■�iii ■■�■ ■■�■ ■�■�■ ■�■�■ ■��■ ■��■■ ■��■■ ■�■�■ ■�■�■ ■■��■ ■■��■ ■�■�■ ■�■�■ ■�■■■ ■�■■■ ■�■■■ ■��■■ ■■��■ ■■��■��■ ■■��■■�■ ■■��■��■ ■��■��■ ■��■■■�■ ■■�■�■■�■ ■■■��■■■■ ■■��■■��■ ■�■■■��■■ ■�■■��■■ ■��■��■■ ■��■■��■ ■■�■■■��■ ■�■■�■��■ ■�■■■■■�■ ■��■■�■�■ ■■�■�■�■■ ■\�■��■�■■ ■��■��■ ■■�■��■■�■ ■��■��■■■ ■■��■��■■ ■�■■■■��■■ ■��■��■ ■��■�■■��■ ■■�■�■■■�■ ■■�■��■�■■ ■■■■■�1�■■■ ■■■�■\ I�11■ ■�■■�r��■ ■��■��■��■ ■■�■��■■■■ ■■�■■■�■��■�■�■�■�■■�■■■�■��■�■■�■■ ■�■■■��■■■��■�■�■��■■�■��■ ■�■�■�■�■■��■■■■ ■��■■■�■��■■■ ■�■��■��■�■��■��■��■�■��■�■■�■ ■��■■■��■■■�■��■�■�■��■■■�■��■ ■■�■�■��■�■■�■�■�■��■■��■��■��■�■ ■■��■■■��■�■�■■�■��■■��■��■ ■��■■■■■■�■■■■��■■�■�■�■�■■��■��■■ ■■ ■■ ■ri■��■ ��■■■�■ ��■�■ ■�i:�� ■��■■ ■��■■ ■■■■�■ ■■■��■ ■■■ ■■■ ■�■��■ ■��■■■ ■�■■■■ ■��■■■ ■�■�■■ ■■��■ ■■■�■_ ■■■�■ ■■■��■ ■��■�■ ■�■��■ ■■��■■ ■�■■■�■ ■�■■��■ ■��■�■ ■��■�■ ■■■�■�■ ■�■o■�■ ■■■■■■■ ■�■■�■■ ■�■■■�■ ■��■�■■ ■��■■�■ ■��■�■ ■■�■■■■ ■■■��■■ ■■��■■ ■�■��■■ ■��■■■■ �_� HEALTH DEPARTMENT RELEASE ,� ,,I ,�, Davie County Health Department , � - Environmental Health Section 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1680 Applicant: Frank Zecher Address: 3300 Beech Fern Drive City: Marietta State/Zip: GA �Phone # : Permit Valid Until: 05/27/2019 Property Owner: Frank Zecher Address: 3300 Beech Fern Drive City: Marietta State/Zip: GA / Phone #: Propertv Location & Site Information Address: Cookson Lane Subdivision: Phase: Road#: Mocksville NC 27028 Township: Lot: *Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 2 Directions:Hwy 64 West over I-40 lst left is Godbey Rd. go about 3 miles 1454 is on right. Cookson Lane *Water Supply: NEW WELL Type of business: Basement: � Yes �X No Total sq. Footage: No. Of Employees: *Proposed Improvement: � i *Release Conditions: Tie new structure into exiting system and maintain a 15 setback from basement foundation to any portion of the septic sytem. Ensure that foundation drains and gutter drains are routed away from septic system. **Site Plan/Drawing attached. ** Total Time: (HH:tMf) OHand Drawing OImport Drawing xours Minutes Activity Code: � HEALTH DEPARTMENT RELEASE ��1~ �, Davie County Health Department �1-' . Environmental Health Section 210 Hospital Street Mocksville, NC 27028 Phone:336-753-6780 Fax:336-753-1660 Permit Valid Until: 05/27/2019 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? � Yes � No Applicant/Legal Reps. Signature: *Date: *Issued By: Nations, Robert *Date of Issue: 05/28/2014 Authorized State Agent: **Site Plan/Drawing attached. ** xot8i Time: (HH:hIId) OHand Drawing OImport Drawing xours Minutes Activity Code: �� _ . . - - , �.�:�p� � 3� �io � - �to� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ,��i� Davie County Environmental Health �(`,� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 ' 9a�0' pplication For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of;Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name �" �Aiv�.� � Contact Person Address irl tr Home Phone 9[� �J (p � City/State/ZIP Business Phone �' Email � Name on PermiUATC if Different than ove Mailing Address PROPERTY INFORMATION /State/Z *Date House/Facility 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 Phone Number Owner's Address City/State/Zip Property Address 0� /1 („Q(NiU City , Lot Size Tax PIN# �' Subdivision Name(if applicable) Section/Lot# Directions To Site: Specify Problem Occurring: ^ � � � �� s r �� ` �.� % �'� /„G � S- j � U .�, .�, � . IF RESIDENCE FILL OUT THE BOX BELOW # People Z. # Bedrooms � # Bathrooms �_ Garden Tub/Whirlpool ❑Yes �10 Basement: �'es ❑No Basement Plumbing: �'es ❑No � ' 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: OConventional ❑Accepted ❑Innovative ❑Alternative �ther �r�� C��lS�S Water Supp(y Type: ❑ County/City Water �'New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�To 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 s. I understand that I am responsible for the proper identification and labeling of property lines and corners and locatin d flag ' o in e hou e/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Property owner's or o r's legal representative signature / �� Date(s): � � � � �j / � � Client Notification Date: Date � EHS: °�fis �� r� �Id�r Q�a�s � Sign given ❑Yes ❑No Account # � ,�� Revised 11/06 Invoice # _ • • ' . , �5 � C.ab,,, � ��r� �� sw �. J �, � � � � � IZ �,c r e; �- � � � � v