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1509 Angell Rd � , ' y ♦ � ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990002026 Tax PIN/EH #: 5831-11-6603 Bilied To: Believers Sonship Tabernacle Subdivision Info: Reference Name: Location/Address: Angell Rd.-27028 Proposed Facility: Church Property Size: 6 acres ATC Number: 4751 **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. D��o System Type:�S.T.Manufacturer;��`tla� Tank Date ��� Tank Size �d G �Tank Size �p 6 c • C,r,r��. 'l�� �/ ,'"U� _�SyC� �f,�wg{�(t�p �U� N � a-� ,o:�s �7—� SystemInsta11edBy:JO-� J �Q�Ur� E.H. Specialist: �d�, aK�O Date: ` �vt Sd! �C^G� � ` �------ � � ����� � I `� - � I,� K (�' ��u'S � � ��pC �" �d t , �t w,�l -� ,�1 �� ��s��� ��s � � � �� l�� I I� ��-� � � 1 �� l �. II �f '� G G l � � c._. �� � — ,_- -- \_ '�t' _ _ — c «� ���``. `pO . � ��G� "� Io� Q1 S.� 1�� .��- ��5 C h ° � -- ¢' � a�C l� tl a.5 f �• `� - Cti � DCHD 11/06(Revised) , . . , ��� ' ' DAVIE COUNTY ENVIRONMENTAL HEALTH � A P.O.Box 848/210 Hospital Street I�ISCV� Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990002026 Tax PIN/EH#: 5831-11-6603 Billed To: Believers Sonship Tabernacle Subdivision Info: Reference Name: Location/Address: Angell Rd.-27028 Proposed Facility: Church Property Size: 6 acres ATC Number: 4751 Site Type�w ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MiJST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(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 FNE YEARS. This ATC is subject to revocation if site plans,plat � or the intended use change. Residential Specif cations: #Bedrooms . #Bathrooms #People Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type �� #People�#Seats Square Footage(or Dimensions of Facility) '7�j�� .�2 Lot Size Type of Water Supply:�ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size �AL.Pump Tank GAL. �/ �' �, �r / Trench Width� i�Trench Depth2���' Rock Depth �2 Linear Ft.� Site Modifications/Conditions/Other: '� � C � � LL�i�"'� 1 ' �r.l: "S!'Z=M- - ' FR�.M� /� ont t t e Davie County Environmental Health Section for final inspection of this system between ��=1���a� 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. � �`�x� 3��! � CJ � �'� � �y � " �2r�ai .�2��c., 1'l$' _ 1 L C��,� ��ox 14o Q , ��, �� � X.��� y S Q ��( t � /2 ,:.. �D� � �v O���fi� �� � � � r 1�. � ��' �.1.� �0�`�QQJ 'a'(s��1�`'�`�' _. G, L � 5HS �c� p-� �- � � � r �'' �' � � Environmental Health pecialist /. �-��.�1:�—� DCHD 11/06(Revised) � � � p'� Davie County Health Departrnent �O�s j� Environmental Health Section " � _ � � �� P.O. Box 848 . �1 ` ,- J 210 Hos ital Street �� ' (� .S„ P O U �'t Courier# : 09-40-06 �- Mocksville, NC 27028 Phone:(336)-751-8760 Fax:(336)-751-8786 AFFIDAVIT I �O e, S-�-a�rQ of_ Sa-c►�-�Q l.p,K���,T��d..l,�l do hereby Name Company certify that I am a licensed OSWW Contractor as defined by the North Carolina On-Site Wastewater Contractor and Inspector Board, and further certify that the septic tank and grease trap tank installed for 13elrutl,3 So�S�l,iv "j'ubuvv�a�l.e.., were installed by Facility �oc�n�N (.�y �� -�"-�'ncQ G-rad�c�nr, , a non licensed OSWW contractor, meets all ame rules that are applicable as stated in .1900 Rules(Sewage Treatment and Disposal Systems). Furthermore, by signing this affidavit, I assume all liability associated with the installation. Licensed OSWW Contractor Date �-�S-og � I certify that the following person(s)personally appeared before me this day, each acknowledging to me that he signed this document. Date /� 6�' � � Official Signature o Notary Official Seal i(: L,r4/(/I�-yrl Printed Name o Notary Public BONNIE M LANIER NOTARY PUBLIC DAVIE COUNTY,NC My Commission Expires: Zd I� . . . 5 wl� � , ,� . _ , : �. � , - CATI� �F' ITE EVALUATION/IMPROVEMENT PERMIT & ATC `, .,----, ��,,� �c, ,� .�F�`" avie County Environmental Health �'� '- � ���� ' P.O.Box 848/210 Hospital Street �' �, , �fn � Mocksville,NC 27028 ��, `�� �;�� (336)751-8760/Fa 336)751-8786 .F•� y - � `t �,�✓ \,�!;.,,A�`4�FS n:tl\ . Applic�tion tror:ED��{te�'��a� �on/Improvement Permit Authorization To Construct(ATC) ❑ Both Type o Applicat . ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTAN7***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 C' �U� ? VU' � �- 1 �/" ontact Person �`/2� �d���� Billing Address � � Home Phone Z City/State/ZIP ' 2 �i 7i (�� Business Phone Name on Permit/ATC ifDifferent than Above ��) /v1F_ Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged -� �'Q NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name ���J Phone Number Owner's Address City/State/Zip Property Addres City Lot Size___ �• C��'L� Tax PIN# f— —�v�'003 Subdivision Name(if applic ) � tion/Lo$# Direction To Si • f L � - 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 Q� Does the site contain jurisdictional wetlands? ❑Yes .��'!�o Are there any easements or right-of-ways on the site? ❑Yes-83�10 Is the site subject to approval by another public agency? ❑Yes�No Will wastewater other than domestic sewage be generated? ❑Yes l�No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE F� OUT HE BOX BELOW Type of FacilityBusiness 1�L� ' 1 Total Square Footage of Buildin X Z #People #Sinks � #Commodes_ � #Showers� #Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:. S"Conventional OAccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ounty/City Water ❑ 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? 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 pernut(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 deternune compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeliiig of property lines and corners and locating and flagging or s ng house/facili locatio ,proposed well location and the location of any other amenities. -��1 C'u�'�` Site Revisit Charge P per wne or owner's legal representative signahire Date(s): r� � _�� �j�, � Client Notification Date �� EHS: Date � Sign given OYes ❑No Account# ��2 ' Revised I1/06 Invoice# 2� _ I ; I _ j I a i i 1 ._�,..__...�a _.�.-s,�-;.�;,-#—_.._ ._--____-------- •---------.r IR� r lac:�d i:� �irn� o ,.f N !1"^-���3"'sr y2D.:R' TotrtT�.�.__..._-----_.._-.--�- -------'_' -- - � / .r�� .___.�---------`—" £39:�.'l4�. � f ' �` . :—�---_______--__--.-----�------ i � _`____'�. F rl �---�--___ S - J� __ _ _':� � !` j � . ' � � r ':+, �� � �r � i _ ;' � � � ; }' i �, � �...r.______�______ "�°�c7 �, � i i � '� �� (''--�--__ � � /I � -_ ` ; i � , . f � + � P� y- , 3 � Q � ���; ��O � { � l`_ .��v�,sA� + `� `� rr `/ � , ,� p �L1 i �u�f �� f ___._-� d��`� ;� ,�` ; ;� s s��ca•�a TC+x tl<��D �—�- ��.�—_. � . i '' � ; � 'Ys.o3 � Y � �. � r , + i � � �a a a=� r_ � , rfv � � � o---_� t�i .:r�' _� f , r�� it�. tl � �i � r �� � �.,' � � � � � � rr , i r ,{ � 1 f j• � � � � r �-�-�- —� � • i r �?{?C t=�:r�,i '�+ rL f �' t i� � <- i % , � ,� }� j � ,; ,� . '� r' f-------� c����o�•�;��� \'\ ' �f-�----- �;7.i 3' � , `, '/ � \ � :l �� � �� J ---`�--------------.____.____ c J � i ; �`(—�!�]! iu�/C'.:.:1 ri?� , ��i7.�;i' � , . � '�p � t t . - iRS { � � ' 617.5T' Tb#Ci �i r?�°57°�n:,� --------_— P�cI�Pt? ir3 l+r,R� ,p ! � �.___—_ --------•s•--;'.--,s,– `� �- i � � � �_" nJUP ':^ CL +�_ �,i�� 1 � �, % 1 � � .� �` �t! '� ;� � ; i 1 ;' j ' $ B i , i� � ,' /, _ 1� � � Q� � � 1 (Cri7[UN FOR SITE EVALUATION/lhIPIiOVChiENT PLR��117 S ATC T�� Davie County Heaith Department �' U O � �'� 2005 EnvironmentalHealtlr Section � �Q� P.O. Box 848/210 Hospi�al Street ' ���{ Mocksvillo, NC 27028 � � ��R����Q��� (336)751-II760 ' *** TANT*** TIiTS APPLICATION CANNOT BE PROCESS�D UNL�SS ALL TfiE RL'QUIR�D FORt•I1ITION IS PROVIDLD. 1Zefer to the TPTFORbi7�TI0N BULLETIN for innCructionn. 1. tlame to bc Dilled �L�67� DIt�3�j/� �j�J�^y�l.0 Contact Peraon ttailinc� Addrosn /���f�/i�-r{CS �~�' Ifomo Phone /7a -�7V� az 3�s-z�9z City/stata/ZIP f /' �l���t� , /�/�� ��Oa� IIu�inena Phono ���r �'7'�� ' 2. Namo on PermiL•/nTC ii Diffcrant tl�an Abovn 2dailing Addrons �- City/Stato/Zip 3. Applicatiori For: ���valuation ❑ Improvement PermiL-/ATC ❑ Dot;li1 . L C S S /9�r�,5�1 4. syacem �o sorvice: O IIouan - 2dobile Homo 0 IIuaine3a � Induatry ❑ OL-her C u l.. 5. Typn n�•ntem requo�tod: Conventional ' ❑ convantional modified ❑ innovaCivo pac�epted 6. Ti •Ro�' enca: It People �3� S Dedrooms 11 DaL-hrooinA i�ticaanhar ❑Carbago Di�po�al ❑19as2iing 2dachino ❑Da�ement/Plun�ing ❑Dauemant/2to Plwnbing 7. Zf Du�inonn/InduaL-iy /Othar: vcrify typo # People !! Sinku � II Commoctoa �i� B Showoris IF Urinaln ll 19aLar Coolora • Ir IOODS�RVIC�: �� Seatn �atimated Water U[rage (gailona per day) J��c�i�v ����- ��— 20�r IC� a. zypo ot �rator aupply: O County/City !�'Well ❑ Community 9. Do �ou anticipato addition� or cxpansions of t11c facility this systcul is intcndcd (o scrvc? ❑1'cs Li1-�2' If��cs,titi�l�at typc? ***IRII'OR7i1N?"'**CLILNTSt1lUSTCOAIPLE7'l:'T►IG ItEQUIItL•D PROPCRTY INI�ORA9A'I'lON ItLQULS'I'l:ll (31iLO1V. Tsitl�cr a PI.AT or SITC PLAN AfU.ST IIESUltl�fl7'7'F.n I»�U�c clic»t �vitli'I'IIIS APPT,ICATiON. .I'1'operE3�-�-}iu �� W �C P24 S WIi1T�D1I2GC7'lOn'S(1'rum 141ocksviUc)to I'1t01'LR'I'1':' �•r:,._orr,�� r�rr: i� v���I�l!•C�C�03 I'roperty Adclress: Road N:imc�77v�1c I�a ' � �' �N �r��- �c�. ��` D � � ��/� Clt�r•/t� �,,,` [� (� y�,,, CIIyIZIf) /�d'!TG¢ua�//LlL' CO�'hh. r""f�'�= !'�O/' cl v /�Y��''siY �DUO F%� If in a SuUdi��isiou provicic inforcnatio»,as follotivs; L1'h"'v� v N L• �`���� l�c� 'L��}r' Namc: �� c�773�3 ��h �� �I -�-os— Scclion: Bloclt: Lot: llatc liomc corncrs flaggcd: 'I'his is to cci•lil'y tl�at tlic inCoi•niatioti pi•ovidcd is coi•rcct to tlic bcst of iuy l:notivlcdgc. I undcrslacicl iliat any perc�ii((s) issucd I�crcaftcr are subjcct(o suspcnsioii or rcvocation,if thc sitc plans or intcndcd usc cl�:�u�c,or if tlic iuforivalion SUVI111UC(I 111 II11S 1I'1PIIC1(1011 1S I'lISlGC� OI'C11S11�C(I. I,al.so, u�trlcrslrurd tlrat I rtur resparsiLlc for al!clrnrb�es irrcru•rcrlfr��nt tlris applicaliv�r. I,l�crcby,givc consent to tl�c Autlia•izcd Rcprescntati��c of tlic Davic Counl}�IIcaltl�llcpartmcnt fo cntcr t�j�on abovc dcscribcd properly'IOC11C(I 171 DIIVIC COUII�)�at�d otiti•ticclby to conduct all (csling proccdures�s ncccss:�ry lo dctcrminc thc sitc suitabilit�. Dr�'1'I; f�— e�— D Sr` SIGNtI'I'URI; ✓Y TIIIS AI2LA 11IAY BL USLD I+OR DI�i�'�'ING YOUR Sl'TI's PLAN(Inciu 11 of tl�c follotiriug; Lxistiiig and proposccl property lincs ancl dimensions, structures, selbacics, and septic locations). � Sitc Iicvisit Cl�argc ' . Datc(s): : Cliciit Notificatioii Datc: �IIS: � , . �' �� Si n �ivcn � . o�lccoucit No. fi b � Revisccl llCIID (O5/03 Im�oicc Na. _ ��� Z . . ;� • • � � 0 h W � � , � � � w �j BE� � a � D.� - i � � �.� � � coucx � � �- JERRY I D.B. 371 , P�• 659 � � � � w q . W� � � .�— � \� , _ _ _____ _ S`83•_� E'""--"S 83'S9'2 � 117.13 �._105,6F R/R splke M ` i n � rond existing � �ror \ � . J _ I �� o � 1 � � � �1 � r., ��,,•lS \ \ � B �-�.s VEYED .BY� ,.w A1 � S 'S AR' � � 6.000 ACRES �rJG C0. ` Tv ATED p SUR I ,2 001 �NSH �' TABERNACLE � =�� FOR BELIEVERS � \ Y N ` , r .�0 � � . ~ �� \ i 1 3 S'NiITH \ f p�. 305 � E-144 � � ` \ �� ��� . � ��� , \ �� ��� � \ � \ \ � \ \ � � . � � ��2� • • ,} , . So x3 ,f`J �� �� � . �� . �� �'� ;� � �Sp y�,,F �� �� � ��� � ��� . / �. �� k�; ' ' DAVIE COUNTY HEALTH DEPARTMENT ` - Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002026 Tax PIN/EH#: 5831-11-6603 Billed To: Believers Sonship Tabernacle Subdivision Info: Reference Name: Location/Address: Angell Rd.-27028 � Proposed Facility: Church Property Size: 6 acres Date Evaluated: �� 7 � � Water Supply: On-Site Well -� Community Public Evaluation By: Auger Boring �/ Pit Cut , ::___.FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e% Z� 3 Zc Z'� HORIZON I DEPTH o- �-�2� �-/� Texture grou L C G Consistence � � ; S :VS 1/ � Structure c 3 ►w A3r1< Mineralo p.�,.�s yw�,� HORIZON II DEPTH .3Z •2 Texture rou C�. ScL C G�t C � Consistence SS�P ;VS Structure �� �'� � Mineralo I;•k lt ' HORIZON III DEPTH ,�ky 3Z- 2 Z$-3 lP Texture rou (st.- �. s:u.) k k�- S�. Consistence F+' Fi' ' F�-5 Structure Mineralo �► HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS y"3�S �/n RESTRICTIVE HORIZON SAPROLITE � CLASSIFICATION fS ��S V S LONG-TERM ACCEPTANCE RATE D.?� l� SITE CLASSIFICATION: � EVALUATION BY: ���� �*�N LONG-TERM ACCEPTANCE RATE: �.Z OTHER(S)PRESENT: REMARKS: LEGEND i.�ndscape 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 T�ttlug 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 .ON4IST .NC . a'IQ1SY VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S r' ,r SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 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', ,*t�b e��*..`�s'���4� �k����,a,y;� ,� �m, ,.*�vy�;�; � ;�+ � � k , d,�'� " ����"f. �d� ` a� � �� �`, � ,�`a��� :� �a�r r, r c I � �r3 �fi �� � � �a�m ��9���,�"�,h'- '� �'&��,��'"� y ��y }� �y, � !b�� . x , I � �'�` � �1 �' i `&,, .�i. � ,� ° sa,.M $ ������#� ,��i '�� :� ' '� 's� i ��; t � - �'*"���' � ''&;::�k��# .�" , ; �; s �,;�s4 ,��.�',�a�' � ���6g. '� �� s I ` ° �- � ; rx ,. ���( � � , x .g'°�`_,..�.��w. �ti �. w1Y..' Y... ,_.ad3'a..vc :�M"„�Wcf...�.-x'�Y.�A`.���i��.�.a. __ . ��e _ .F ''� � _r;cauY fi F _ {� '"dd^� j� �jJ�"'p+� '.3� � >. . I�I ' , , f. . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 / F�: (336)751-8786 November 15, 2005 Believers Sonship Tabernacle Attn: Jerry Couch 135 Potters Lane Mocksville,NC 27028 Re: Site Evaluation- 6 Acre Tract/Angell Rd. Tax PIN#: 5831116603 Dear Client(s): As requested, a representative from this office visited the above site November 10, 2005 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. Facility location, size and other design criteria may necessitate the use of an alternative or innovative system. System design will be determined at the time an Improvement Permit/Authorization to Construct is applied for and issued. Before a representative of this office will revisit the site to issue an Improvement Permit/Authorization to Construct, the appropriate application must be completed and submitted to this office. The location of the facility the system is to serve must be staked off. If you have any questions, feel free to contact this office at 751-8760. Sincerely, Jeff G. Beauchamp,R.S. Environmental Health Section Enc(s) ` �► • � � . . � :�� �C�3 3 e P�� ---� �_ ------_._, �I ; 3�,,)3 �y ` ___ �._��) � � ---. .___���53 � _ ��� , � _ _ .� � ____ ._ � -- - -_____ � ���