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988 Baileys Chapel Rd . . � . • • �� DAVIE COUNTY ENVIRONMENTAL HEALTH ��' P.O.Box 848/210 Hos ital Street � Mocksville NC 27028 \�\` , � (336)753-6780/Fax#(336)753-1680 REPAIR OPERATION PERMIT Accou�t �: 990004189 "��x�i�€.�EH#: 180000006802 �iElc�Ta: Stan Cotten . �uiatti�fi:,iort Ir�#c�: R�feE��E�ce.P�a��e�: REPAIR PERMIT LacationiAdc�E��ss: 988 Bailey Chapel-27006 Propc���c9 F��:i€i�y: Residential Repair � ��o�rer�y �iz�: 0:98 Acre t�TC N��'tb+��': 5909 � ,�, . , **NO ** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in com��ce 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. r � � / System Type:�S.T.Manufacturer Q 15 � Tank Date / Tank Size � .Pump Tank Size Bedrooms System Installed By: ,,�,(�.W�tQ, j��^h�S Inspector#: Date: ,c��Z GPS Coordinate: \��� .�� �y ��5 ,' / / 5� 3 � - - — — ^ ��'S1`nl — 'f � , ;^ 7� I�I� � – � � — — � " ,` i St��j,�')'" - _ t ----f- � , , ��� �, \ Environmental Health Specialist: Date: `7 ' DCHD 11/06(Revised) , . � DAVIE COUNTY ENVIRONMENTAL HEALTH • ' - . � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � (336)753-6780/Fax# (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRLJCTION � �ccou�t #: 990004189 "��x�I�€i�N�: 180000006802 �illc,s� �'a: Stan Cotten - 5����itri:.;�on Ir3��: ��fer�r�ce Rla�i�: REPAIR PERMIT Lac�iionlAd�3r�s�: 988 Bailey Chapel-27006 F�ro�c3sgc� F���;ility: Residential Repair - :: ��a��r�.� S�iz�::' 0.98 Acre Site Type: 1�1ew [�epair ❑Expansion ��T*�N����This A�uthorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to.issuance of anybuilding perrnit(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 #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Faeility Type #People #Seats � Square Footage(or Dimensions ofFacility) ' Lot Size •�� Type of Water Supply: C�County/City ❑Well ❑Community Well ���\ � System Specifications: Design Wastewater Flow (GPD)^��Y'�--Tank Size� AL.Pump Tank. . �GAL. �, �� �_ � Trench Width� Max. Trench Depth�6 Rock Depth�� Linear Ft.��% Site Modifications/Conditions/Other: ��a_L'` Contact the Davie County Environmental He�lth Section for final inspection of this system between . 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. ��v i c ^�t . � . ,I U"`��� .. � r r , r ` � - ._ �~ ^ ..r. i � � ! _ eXl��n��`'t-ES ,' � ' � _ / �` � . � - .';:, Environmental Health Specialist • Date:��� ��6 DCHD 1]/06 (Revised) w . ! • , DAVIE COUNTY ENVIItONMENTAL HEALTH � ' S ' ' P.O.Box 848/210 Hospital Street s ' Mocksville,NC 27028 (336)751-876Q Fax#(336)751-8786 OPERATION PERMIT Account #: 990004189 Tax PIN/EH #: 5788-09-1295 Bilied To: Stan Cotten Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27006 Proposed Facility: Residence Property Size: 26.90 Acres ATC Number: 4575 **NOTE**The issuance of this Operation Pernut 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. -- �Si��l� System Type:��S.T.Manufacturer Tank Date Tank SizeJ�CX� Pump Tank Size � • ��,•,�S 6��;��. �oa System Installed By: H. Speci ist: 1 I ------. ------ � � - ��1�� �} ��t7 Ct���. �,., ���5� ,�3�___L__I . � ,� ��'�� Z' , � ,�� ` ��,�,��s � �o� / �,������T�S � _-�� ��'C�a�Vtf�t2s �-a �.,�'.�, 1 �2�.., ��� � � DCHD 11/06(Revised) E .� • • � � , . r , . �, � � �lw 1� � c,,F �� —P.��� � , � �,Ja,�i-t.���` � ' . i R.�� r1 + � ` �� , � . ' . � navrE courrrY�rrv�or�n�rrrai.��,� . � P.O.Box 848/210 Hospital Street • Mocksville,NC 2702$ 02/ d� (336)751-8760 F�x#(336}'�51-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONST�tUCTION Account #: 990004189 Tax PIN/EH#: 5788-09-1295 � Billed To: Stan Cotten Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27006 Proposed Facility: Residence Property Size: 26.90 Acres ATC Number: 4575 **NOTE**This AuthorIzation to Construct(ATC)MUST BE ISSUED by the Davie Cownty Environmental Health Section prior to issuance of any building pernut(s),(in complianc�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 PERI(JD FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specification:Building Type 1'tf�l�"� #Peaple � #Bedrooms �' #Batbs_,�,_ Basement w/Plumbing:T Basement/No Plumbing� Commercial Specificatian:Facility'I�pe #People #People/Shift #Seats Lot Size t`�x3ppType Water Supply x�j�Design Wastewater Flow(GPD��b Site:Ptew�Repair ,� �� System Specifications:Tank Size��GAL.Pump Tank_G,AL.Trench Width� Trench Depth� ^'��� Rock Depth ►�1 � Linear Ft. CD' Other: ���1'/�7 ��� 1���D:J Cv��l C:'�►/�'� '"T ��� ���d�� Required Site Modifications/Conditions: I J�S���-�['�.�2. �����D����L,L�%�, ��`��rL`� ContaCt the Davie County Environmental Health Scction for fin inspection of this system behveen /�cJ,�.`� 8:30—9:30am.on the da of installation. Tele hone#(336 751-8760. �� (�P. U„��4 f►Q►� �2�vE . � � � ��� � � � � � f � � � � � a � � � � z � � c� �, � � � � � � � � � — - ,� ._ 2 , �. N�i,,) �o . t.�,�� ^M��r ro� . Environmental Health Speciali Date: DCHD 11/06(Revised) � IA/ / �// / . r ^ , • i. ' ' /Yl►2.�b��� �/ l4�/0`I CC�� 6� o t/S�Gt.��.. � r t: � ,..,.�.r, � . � ' D� `�� �I SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health • ��� 1 �j 2��6 P•O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 ENVlRONMEfJTAL HFALTH �, / ' �E `���k�a� provement Permit ❑ Authorization To Construct(ATC) fIB'Both Type of Application:� I�'New 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. APPLICANT INFORMATION Name to be Billed ���+'� �_,t�"CC�i'� Contact Person �'cw�e o� ���"' �"`� Billing Address Z�I�� ���-�4►w��k �+' �i 5c�`7 Home Phone "3��- . �v s e�. �(`i I City/State/ZIP W;��}zw- �.l�.0 1�� �`�1 la� Business Phone S�:w.� Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: � Site Plan �'fat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name I�Y�r'L� i'Y��►�j Phone Number Owner's Address �7� �g�/�i�'(�iL�et��/� . City/State/Zip Property Address ' City �� Lot Size v��'•�'�(„�[�/'�S Tax PIN# �7�R—pFf.- tZ�S� Subdivision Name(if a licable) Section/Lot# Directions'T�J Site: ,� . ' (,fr � � /�' f S .VJ r � � -�'� �°LI� �.T /� ��-�C �/'e.i' ' � If the answer to any of he foll ing questions is"yes",supporting documentatio�us be attached. Are there any existing wastewater systems on the site? ❑Yes F7No Does the site contain jurisdictional wetlands? ❑Yes �'l�io � Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? ❑Yes�� Will wastewater other than domestic sewage be generated? ❑Yes�No IF RESIDENCE FILL OUT THE BOX BE OW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool es ❑No Basement: ❑Yes � o Basement Plumbing; ❑Yes � IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water L�sage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type:�unty/City Water ❑ New Well ❑Existing Well ❑ Community Well �,s.ri�y�-"' Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 8'� 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 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 Deparhnent to.conduct necessary inspections to determine compliance with applicable laws and rules. I understand t t I am respon ible for the proper identification and labeling of properiy lines and corners and locating and flagging or staki th ouse/ c�li ocation,proposed well location and the location of any other amenities. _ �. �� L/ Site Revisit Charge Pro�ier owner's or owner's legal representative signature Date(s): �Z 5 � Client Notification Date: � Date j EHS: '� Sign given ❑Yes� No l, � Account# �� Revised 11/06 �� Invoice# � �.� � Dec 27 06 02:51p Westbend Const. 3369403527 p. l ` ' � �, , J.Russe111Niison ' � � President � . '. . . � 6T�R'A�'y��'fF"�?!'^�T+^��� �1�F � :SSIi�! . .. � ' .. . . , � '�� 7 � .. 1 F� t.lSS �y� ��� _' � .. ' 1:;. iR+;^,' _S: . . � . � � � .. .;.•.. � � 151 Swpe Rd. � Westbcnd iew�sr�«e,N.c. 2�oza Coustructiou Corp. �one: 3369456811 Fax: 336945-9779 • Mobile:33681T-2212 Emaih westbend�triad.R.com � � ��� f 5e� �'�`'rz.� � � � � �� . 1�� a��� � � O N � . �a rn �T�.n. 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" , �: ' ' � ' • � DAVIE COUNTY HEALTH DEPARTMENT �• . � ' Environmental Health Section ' Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004189 Tax PIN/EH#: 5788-09-1295 Billed To: Stan Cotten Subdivision Info: Reference Name: � Location/Address: Bailey Chapel-27006 Proposed Facility: Residence Property Size: 26.90 Acres Date Evaluated: � f / 7 ��� 1 : 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 �. �,.'.. Slope % f� ' y HORIZON I DEPTH v - �" c? • t� —� Texture grou L�L L S�G�- C�-- Consistence ,�j$ Structure C�.L ' Mineralo Sv " HORIZON II DEYTH - 1� _ /� , / ; Texture rou 4= C Consistence ; � S � Structure l.�� C� Mineralo HORIZON III DEPTH I •y - 1 � I C�--�f Texture rou k �'c { '�, `"C �' �;,!7 CL f,� , ' Consistence - �; �'r P ; �C�S S Structure � S�'i< •;�` Mineralo rj.� O HORIZON IV DEPTH y Y � - � � U� Texture rou S 5� �n L.S � ���� >� r' Consistence �SS` Structure �IL Mineralo � SOIL WETNESS -� RESTRICTIVE HORIZON SAPROLITE �� CLASSIFICATION .s ' LONG-TERM ACCEPTANCE RATE O.�� p.'' O� .•�� SITE CLASSIFICATION: i � EVALUATION BY: �.� �-�-`��� � LONG-TERM ACCEPTANCE RATE: �'� OTHER(S)PRESENT: REMARKS: LEGEND i.�ndsca�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� - 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 ('ON IST .N . �'�415� VFR-Very friable FR-Friable FI-Firm VFI-Very�rm 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 �r, ,r SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 1:1,2:1,Mixed 1YQttgS 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 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■■�■��I�■■■■■�■■�■�■■���■■��■��■�����■�����Il■����■���■��■������■�■■ �� � � I : � - • Davie County Environmental Health , ' P.O.Box S48/210 Hospital Street � Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004189 Tax PIN/EH #: 5788-09-1295 Billed To: Stan Cotten Subdivision Info: Address: 2455 Northwick Drive Location/Address: Bailey Chapel-27006 City: Winston-Salem Property Size: 26.90 Acres 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 Permit is subject to revocation if site plans,plat or the intended use change. Pemut Type: ew ❑Repair OExpansion Pernut Valid for:, Years �No Expiration Residential Specifications: #Bedrooms � #Bathrooms 3 #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): LF� Type of Water Supply: �ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: S stem T e LTAR Initial C �� .� Re air L. .3 Sita P an ��'v— ��D• L I N!� � Q�� C - . .. �, � �h ��r � O � � � � � � � � .� Z �� r �� i � � � � � .A --� t � � � , 2e�' �� �� Environmental Health Specialist %� Date i.p.11-06 r � �� �� 02/96/2012 .13:12 . 3369241766 KARL STIMPSON BLDRS PAGE 01/04 , �� . � . • _ _ . . �� � _ . �. � f , ��Cl-S ` �C i�1�► �e,V• S.F. r v� ���� �,.�h,ern (,um�le- •` v �� g 0�' �'�1�� 'e Couuty Health DepartYnent �� �� p. FE � �q � a Ftivxzo�zxneaital Health�Se�Cto�� R� ,,�- : r.c�. t;<�x xa� , . �'�� � �, ��"� lIQ H�spit;il Strcct �: D U�'C ��u Couricr# :(K)-�(�U(a �- "7 Mac.•{:xviJle.NC; `�7018 19ttmc:(.'kl(il—ii3-fii8i) F:�s:(:f�C)—i:ii�tfiAp Orr-S�'x'�wA8"x'EWATER CERT1FrCA,�'�ON (Check Onc) Replaceme�• R�e��g Reconneetion �wi�L.�r/R+�,snN d�s• : Name:�[,_,��� ,,���i/ �a/J�Phonc Number���� _ (Home) Mailing Addcess: � ���. � �T/�r�++��= (�lib'brtc�w/�i� a.�.C+C /1/ . �J'-fj.0.6 ' �� • 1+��3' �'(�'all Wl�e.n..- �n p,. ,,,e� �r.el�--�v'�`� -/�-(_ _ �', � Detailcd Directions To Sioe: �r/� �'rirVfi �i� �J✓ ���.�1s ���' ,�.},77 fi/��tS�' O� .�Ei'T �ma►� � n i.�re�.t� �Cc�r 1 S�-�-m n s�-�.�Ic�.�-5 , �e n� Pcoperty Addn�ss� � A/ �. !Lf -�- �O � �� �1� Plesse Fill ta Thc Following informat;�n About The EX�iSTINC�'Acility: Nam�Systcm installed lJnder:��/�1/ ��Allr �4TT�i✓ Type Of F'acility: ..��N E �i�j�.�. �S` Date System instailed(Month/f)ate/Yeat):�w,�T����ber Qf Bedrooms;�� Numbor Of People:�� I�The Faciliry Currently Vacant? Yes � If Yes.For tiow t,ong? ,,,_. _ Any Known Pcoblemc? Ye�� tfYcs.Explain: . Plea.re Fill In The Following InformAdon About The NEW Facility: ,� �-P to/Z ���' �. �f'��`' Type Of Facility: �/�1 l�/�NA�.. �[fJ�1'y�l, Numbe�Of Bedroomc��„�Number of People � P�ol Siu: Tar�ge SiZe:_. , Othcr: � Requested By . Dats Requested: 2 � / _ .�, ($ignatur — For Environmental Heald�Office Use Only Approd ` Disapprm�ed Commcnts: f nvironmentat Health Specialist Date: �/ "�Thc signin�af this fann by the Environmental HEaith S is in nv way intended,nor should be tak�n as a�uarantee (extcndcd or limited)that the on-site wastewater system will function properly for any glven periad of time. Paymcnt: Cesl Check Money Order # _ �,,., Amou�rt:S Daze: - �. Paid By: Received 8y:__ Account#: �� �O ��. invoice#: � I�d l 1 m Ctii ) C��.�.C��L Se,c �-���l�� �-�y . - - � • �, ' •' , , DAVIE COUNTY ENVIItONIvI�NTAI.HEALTH " ' '��� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-876Q Fax#(336)751-8786 OPERATION PERMIT Account #: 990004189 Tax PIN/EH #: 5788-09-1295 Billed To: Stan Cotten Subdivision Info: Reference Name: Location/Address: Bailey Chapel-27006 Proposed Facility: Residence Property Size: 26.90 Acres ATC Number: 4575 **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 saUisfactorily for any given period of time. System Type:�S.T.Manufachuer `��"��� Tank Date Tank Size�t�C�C..� Pump Tank Size , � . : System Installed By: �-�`'�"�`� ���I� �E.H. Speci ist: � 1 I lv� __._-_-.-_�� _---. .�— � l ����� � 5�a ��� : � , ���� ,�;� ._._.I.._._.I , 1� �� ���fi L� � :��. . :�e�a f��S -_, �a,.,,... ./��� / �`'�e���1�y�r�� � � • z��� �....� a��f�i2� ,�_._ 1"�:.��. � ���;.. � (lr 1� DCHD 11/06(Revised)