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262 S Angell Rd a . ' • DAVIE COUNTY ENVIRONMENTAL HEALTH , - ' P.O.Bax 848/210 Hospital Street Mocksville,NC 27028 (336)'751-8760 F�#(336)751-8786 OPERATION PERMIT Account #: 990004247 Tax PIN/EH#: 5840-21-8237 Billed To: Sarah Richards Subdivision Info: Reference Name: Location/Address: South Angell Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 4613 **NOTE�*The issuance of this Opera6on 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 sarisfactorily for any given period of �e: �-F , �� System Type:�!S.T.Manufacturer_�� Tank Date /�—13 Tank Size� Pump Tank Size F S em Installed B :�a.��&�e � �jG��-c�5 E.H. S �alist: °,h ✓'����odf Date: �`'� �� _� � 3'� Y P� 1 ����-�,°�,�c� . t �� ��" � a � � d ��7 1�� � t � �• � � .`� ,� 1 „_, ,Q� �, T a ( �� �,t��� , �0� .---- �. W O / / �hD ; �� �1� , �r� � ' �� DCHD 11/06(Revised) . . .. : _ . ; . -. . �_ _ ' � DAVIE COUNTY ENVIRONMENTAL HEALTH �, �., -- '"' P.O.Box 848/210 Hospital Street '���, � ` Mocksville,NC 27028 ��' (336)751-8760 Fax#(336)751-8786 3 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004247 Tax PIN/EH#: 5840-21-8237 Billed To: Sarah Richards Subdivision Info: Reference Name: Location/Address: South Angell Road-27028 Proposed Facility: Residence Property Size: 1 acre ATC Number: 4613 / Site Type: C�New ❑Repau ❑Expansion **NOTE**This Authorization to Construct(ATC)MLJST 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 7— #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) . Lot Size /, Q�/`�c Type of Water Supply: C�County/City 0 Well ❑Community Well System Specif cations: Design Wastewater Flow(GPD)3 4-d Tank Size f�,d dc GAL.Pump Tank�l1�GAL. �i Trench Width 3(�" Max.Trench Depth�ls Rock Depth� Linear Ft. Y 34 �'.s �tatr_d in 15A NC,4C �1�1.�.963{�� Site Modifications/Conditions/Other: ncCe�ied SvRt�r�� K�;� ,��Fg g�� _ Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30—9:30 - 9�''�� 1 1 1 �-�5�e 4��r.�'E-e � � o��p bo,�,�s � 1, �IY 1� ��l.�tG���i Ch ��Git�,�� Iw 1.;�,7tj W� CCJf�I 1'�Lt V' a`�' ` � 1 3�6 N o�' ��, �-�� 3 u« �..� �.�Pa�� . . � ,�o � �'`'� � I � yk:� d k'"�.�,�� ` 1�rK�. 1 + � w N�N � '� "�Ir I � 1�1� 1 � � Y I ( 0. � � ` 1 , o ► 1 1 ' v 0 Environmental Health Specialist � __Date:,3 DCHD 11/06(Revised) � • � APPLI � E EVALUATION/IMPROVEMENT PERMIT & ATC �, ` � vie County Environmental Health D � .O.Box 848/210 Hospital Street , 1 2 20�� Mocksville,NC 27028 FEB _ ( �751-8760/Fax(33�751=8786 Applicah n Fo ��l�I� ment Permit �Authorization To Construct(ATC) ❑ Both Type of A plication. 8`�- m ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPO ANT***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 ` Contact Person ��C 4� ����� ' �;�,�. � Billing Address � �e ' Home Phone '�E��—`i'�7� ��f(�'h City/State/ZIP �(x,�SJ�1�e �G �-'7(,l�' Business Phone � � �'-C�j S�� q[�� S�l 5 � . � Name on PermidATC if Different than Above Mailing Address ' City/State/Zip 9� PROPERTY INFORMATION *Date House/Facility Corners Flagged -� �0� NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Permit is valid for 60 mo hs with site plan no expiration with complete plat.) Owner's Name � � � Phone Number a���D'1� - Owner's Address / � ar�� City/State/Zip����s„�. ,(t C ��F 8'J�-oZ �S Property Address $' � City_�Lla��;�T,�'//� �,�,( Lot Size t a�,c,c.�- ax PIN GD 7 �1/�21 �Z3'7 Subdivision Name(if applicable) Section/Lot# � Directions To Site: b � (��. �,-,� �� ,e, , ! o � i ` 6'y� � � If the answer to any of the following questions is"yes",supporting documentation ust be attached. t Qt✓�( Are there any existing wastewater systems on the site? ❑Yes o� Does the site contain jurisdictional wetlands? OYes o Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Ye o �'Vill wastewater othei than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms r` _ Garden Tub/Whirlpool ❑Yes o - Basement:. ❑Yes No Basement Plumbing: OYes o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 systemrequested:. �Conventional ❑Accepted ❑Innovative ❑Altemative �Other ���Q` SuS{trK Water Supply 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 �No If yes,what type? This is to certify that the information provided on this application is true and conect to the best of my knowledge. I understand that any pemut(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 the house/facility location,proposed well location and the location of any other amenities. � Site Revisit Charge roperty owner's or owner's legal representative signature Date(s): a'�—�� Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# 1 ��a,�m;►�-c�.� flt1�lGs��lk.—� � ,; . , l,e 5 �w4 � �� , . �` � '�',c,hs�c-�S � ��� s S� �� . � � � � : 'i��� � 1 � � , ��� � ao She �` � Se.p��� � • � � Noc.esc � � ... � o �°—� �oo� a��`I-�` ' � �� � � � . � � q'F, ,� � � � . ��, � � . � 0 a � � � � � � j i .. ,._ w.� ":f•��;�;��•. ..- ' . .4Y�a.. ... � . � . ... .��.. . - ' _ . - `:��5 ���� ���'r��� � �/ ,�i ��� f����/� S�(,r � i .� � � � � , QO � , � , �� ��_ ;, � � : �� �� �� (21.50A) 8237 O � �� � ( - x ;. __ - PCCZ :;s;:��-'- CeB2 � "�.'k r ,,' - . � '�- .�.. .. �� � . . . - . . . . � � . � -., . . . - ., . . .. .. . . .. . . . .- � ,_. .�. _ _ .. - . .._. . . _ ... . . .. �� . .� . .. .q .� - . � . • , _ . _ - - --- _ __(1270). __ _ _. _ ' • - - __ _- ..- --.._ _.�-.��_�-,.;..� _. . ' � � DAVIE COUNTY HEALTH DEPARTMENT � , Environmental Health Section ` Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004247 Tax PIN/EH#: 5840-21-8237 Billed To: Sarah Richards Subdivision Info: Reference Name: � Location/Address: South Angell Road-27028 Proposed Facility: Residence Property Size: 1 acre Date Evaluated: �—�— �� Water Supply: On-Site Well Community Public ��' Evaluation By: Auger Boring -� Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition ' L� S L Slo %. HORIZON I DEPTH p- � p --/5 Texture rou � J�- L. Consistence - Structure Y v „+ Mineralo • N. /•��.(/� /= cN HORIZON II DEPTH � 7- 3v /s-y Texture rou G Consistence P /' ; .'r- Structure .� ,S S Mineralo ' � � / /' ' HORIZON III DEPTH --yg c Y -' Texture rou �G ,-C� Consistence • :r � Structure S � E Mineralo !r l. / � • HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS � RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE d�7 - cs d 7 SITE CLASSIFICATION: �`Ov • G�-��� - EVALUATION BY: � �a' v LONG-TERM ACCEPTANCE RATE: d'��� OTHER(S)PRESENT: REMARKS: , LEGEND T, n s ape Positi n 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�ctur� . 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 .ONSTST�.N . . MQi�t VFR-Very friable FR-Friable_ FI-Firm VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slighdy sticky S-Sticky VS -Very Sticky � NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic - � SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic • MineraloQv 1:1,2:1,Mixed LYQYs�T , � Horizon depth-In inches . Depth of fi11-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-gaUday/ft2 . 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■��■��■�■����■■■■�■��■����■�■���■���■��■������■�■��■����■■�������■ ■��■����������■���■■�■�■�■■����■��■■■���■�■■�■������■■�������■��■ ■��■�■■�■■�■��■■�■�■■���■����■�■ ■■�■�■�■���■�■■■�■��■■�■�����■�■ ■��■��■�����■��■�■�■■��������■�■�����■�■�■�■���■■■■■���■■■■��■���■ ■����■�■■�■�■��■�■�■���■��■�■■��■��■�■���■��■��■����■■���■■���■��■ ■����■�■�■■■■�■��■�■�■�■��■■����■■■■���■�■■■■■�����■�■■■�■■�■�■��■ ■����■����■�■�■��■�■■■�■■�■�■■��■�■■�■��■�■�e■�■�����■■■���■■o■��■ ■��■�■�■��■■■�■����■�■����■�■�■�■�������■■■�■�■■��■■��■��■�■o��■�■ ■■���■�■��■�■����■�■��■��■����■�■■�■■�■■����■■■■����■����������■�■ ■�■�■��■�■�■���■�■�■��■��■■■��■����■����■����■�����■����■����o��■ ■�■�■■�■�■�■�■�■■■�������■�■■■■■ ■■�����■����■����■������■■���e�■ ■■■�■■■■�■�■■■■■■�■���������■����■■������■�■���s�■■��■����■■�����■ ■■■�s�■■■���o■■■�■■����■����■��■��■�s■�■�■�■�■��■�■■�s�����■�����■ • � • Davie County Environmental Health P.O.Box$48/210 Hospital Street � Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004247 Tax PIN/EH #: 5840-21-8237 Billed To: Sarah Richards Subdivision Info: Address: 609 Greenhill Road Location%Address: South Angell Road-27028 City: Mocksville Property Size: 1 acre Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Pcrmit is subject to revocation if site plans,plat or the intended use change. Pernut Type: Q�Iew �Repair. ❑Expansion Pemut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms '� #People �/ Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3(s0 Type of Water Supply: C�County/City OWell ❑Community Well I'�s stated in 3.5A NCfiC 1uA.i5`£39(5) Site Modifications/Pemut Conditions: �cCepted uY4te�s may al�,o be used S stem T e LTAR Initial ` ,"a-Z S Re air � Y-� � 7 Site Plan ��0 ` 5��� � � , 1 � h� � a � �� � ' �` � h� � No�-s� �6 c ��o �� � k� � I I � - . � �� � ' Y �Y c ( � ' `� . � - 3I � a ; �` �' I � 0 - � �.�� Environmental Health Specialist Date_ � c _ �, i.p.l l-06