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591 Bear Creek Church Rd r . _ ' !. , �� . � � . _ ,' • , � c�L� LJ DAVIE COUNTY ENVIRONMENTAL HEALTH � �b - - ' P.O.Box 848/210 Hospital Street �I� � ' Mocksville,NC 27028 � ��" � . (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990005027 • Tax PIN/EH#: 5801-98-5438 Billed To: Greg Bacot Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility: Residence Property Size: 18.44 Ac ATC Number: 4965 �� **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. /j� �� — (��V System Type: �Y" S.T.Manufacturer ��Tank Date � Tank Size� d Pump Tank Size�, D � 5 System Installed By: ��- ��E.H.Specialis . � Date: 3 "�� d �p o �-�- a�,�r �,-„�.e.^�- �� , �r �G`c t/`�-. a tl�-!` � � � ,�� r� ��,rue��Q ` �rN:. /9 _ �1� �; . �� l P� � ' _ `� d � �� -°s�, �� ` S�t� �O� k/ ' � � S 16�,� y1�s `�� 3��,,�, -� �, u _ ��a' ? '� o �c�,��e. �G�.a� �' �� " \ � �ti �� ,, � � � DCHD 11/06(Revised) s�� i'' . 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 CONSTRUCTION Account #: 990005027 T�x FiIVl�H#: 5801-98-5438 Bil1c�To; Greg Bacot Subdi�isiort Irtfc�: Re:fereE�ce Na��e: LucaiianiAddress: Bear Creek Church Road-27028 Pr�posec9 Faci€ity: Residence Pfo�er#y Size: 18.44 Ac Site Type: C�New ❑Repair ❑Expansion ATC Number: 4965 **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 Treahnent 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�_#Bathrooms3�� #People �- Basement asement plumbing� � Non-Residential Specifications: Facility Type #People #Seats C� Square Footage(or Dimensions of Facility) ��ot Size I��_ Type of Water Supply: L(County/City ❑Well ❑Community Well ..� System Specifications: Design Wastewater Flow(GPD)�C7 Tank Size�GAL.Pump Tank�GAL. �, �, � ' �� Trench Width 3 G,� Max.Trench Depth 3� Rock Depth � �-- Linear Ft.� 33 '�' � Ay staied in 15A N�AC 18A.1969(� J Site Modifications/Conditions/Other: accepted Sv�tems ma�� a��-��;, �s^ �L l��- Contact the Davie County Environmental Health Section for final inspection of this system between h�a�`� 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. ) � �e o — ,-- �,.s�-��- ;,.- a �o�-��r�-e� P uc P � � EV L � ��J�.r wN�' j�r�fl � � s t{ _ �. --� P _JP -- , � �e,�/`� , (p�ss �l h 1 f _ S��" � 1 c_c_kd�-ef d 1.... �� l�d�ura � (� � � t � 1 ;\�._ � � .�p�fr ( ;I . �► �l cQ� � , ��; - �., a °� � � � � �� r —%��Q�� (,�5hrn _ — — - – � –�-��e� �._ --� _-- _.f � Environmental Health Specialist �i��%� Date: � '��J" . DCHD 11/06(Revised) _` . �� ' . ��...,, �i _:, . ' • • DAVIE COUNTY ENVIRONMENTAL HEALTH , • � P.O.Box 848/210 Hospital Street P�� . Mocksville,NC 27028 ,L�I Q9 . `. (336)751-8760 Fax#(336)751-8786 �� AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005027 Tax PIN/EH#: 5801-98-5438 Billed To: Greg Bacot Subdivision info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility: Residence �r Property Size: �.44 Ac Site Type: ew ❑Repair ❑Expansion ATC Number: 4965 � **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 v CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat � or the intended use change. I , Residential Specifications: #Bedrooms� #Bathroo��#People � Basement�asement plumbing� � Non-Residential Specifications: Facility Type #People #Seats ',,,,� � Square Footage(or Dimensions of Facility) � Lot Size .'� 1 Type of Water Supply: �unty/City OWell OCommunity Well � � System Specifications: Design Wastewater Flow(GPD)3�V Tank Size�GAL.Pump Tank GAL. � `� '` 3 3 .`.� Trench Width� Max.Trench Depth �� Rock Depth �� Linear Ft._� Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. � s � � U � � ` �' , � s ^ � V � / 1 � V '� . � � � `O I `' � d �\. 1 � ' 1 ' -.�. df S � ` � C � c` i I � � V �� y!� �p `� �� a i '/ � ;. � �i � � � � � _ —, ._ _____ �"'� , d � a� �n�' t —------ ___�--- -'"' �, � ''� �o Environmental Health Specialist �i%� Date: ��rQ� DCHD 11/06(Revised) • , ' ��!4- � ' �; � (� �'� N FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC :v � Davie County Environmental Health � ; D � n. � P.O.Box 848/210 Hospital Street 2 ��y Mocksville,NC 27028 Ap� 2 ; (336)751-8760I Fax(336)751-8786, ' Site Eval ation/Improvement Permit uthorization To Construct(ATC , Both ,�vtR��u �cation: ystem Repair to Existing System xpxns� ��cat�on of Ex�stmg System or Facility IMPORTANT"**THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed L.4 rC CJ�GO� Contact Person ��e'-� Billing Address D Q d�C �o�� Home Phone_ 3�0— � �o� � City/State/ZIP f L'W i 5 V� 1L � �7 O L 3 Business Phone Name on PermibATC if D�erent than Above � Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: rte Plat(to scale) (Permit is valid for 60 mo ths with site plan,no expiration with complete plat.) �� S.�/_G D Owner's Name C7 IY� ��GOT Phone Number3 �/ Owner'sAddress PO !o City/State/Zi LGaJIS✓i/ e NC 3 D PropertyAddress r Cftt(L C ✓Lh �Ci��y � 5✓� lt Lot Size 1�l�t /4-L Tax PIN# 5B D�—SB—St38 Subdivision Name(if applicable) Section/Lot# Directions To Site: �IO N�Ge o L 16 N Cl? �u� �ea.� �^�e1L cvz h � 'e v,,�n/ �.r. !e if the answer to any of the following qu stions�s"yes",supporting documentatio must be attached. Are there any existing wastewater systems on the site? Yes � Does the site contain jurisdictional wetlands? Yes No Are there any easements or right-of-ways on thc site? Ycs N Is the site subject to approval by another public agcncy? Yes Will wastewater other than domestic sewage be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 3 #Bathrooms • Garden b/Whirlpool e No Basement: Ye No Basement Plumbing: es No 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 system requested: onventional Accepted Innovative Altemative Other Water Supply Type: unty/City Water New Well Existing Well Communiry 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 correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter aze subject to suspension or revocation if thc 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 Counry Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand tha I am responsible for the proper identification and labeling of property lines and comers and locating a flagging or st ' th house/f ility location,proposed well location and the location of any other amenities. Site Revisit Charge Property owner' r owner's lega!representative signature Date(s): (� l' Client Notification Date: D te EHS: Sign given Yes No Account# Revised 11/06 Invoice# \ � �� t�� b , � l �� u� U 7 Y,T �'n�e � �,-0 �Sa� �� t � \o � � � � f � � � �� v ��. � b� Pz � �� a�t;S �'�!n�� 1I � . - nD �� aY1 � � �� ` a� �� . • . - .i _� - , �� • • a+--�-o N D -�� ,S}�� '-�� d � � • . .► . . .i . , � � � . � � . . . �� .� - � d- . . Davie County Environmental Health � ) _ P.O.Boz 848%210 Hospital Street , � I a Y Mocksville,NC 27028 � (336)751-8760/Fax(336)751-8786 Account #: 990005027 IMPROVEMENT PEl��',IN/EH#: 5801-98-5438 Billed To: Greg Bacot Subdivision Info: Address: PO Box 625 Location/Address: Bear Creek Church Road-27028 City: Lewisville _ Properry Size: 18.44 Ac 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 Tmprovement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: ��Repair. ❑Expansion Permit Valid for: H��ears ❑No Expiration Residential Specifications: #Bedrooms 7 #Bathrooms3•� #People �Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �� Type of Water Supply: Q�ounty/City O Well O Community Well �4s stated in 15A NCAC 18A.1989(a) Site Modifications/Permit Conditions: aQ��p J�,m�� u •� • S stem T e LTAR , Initial c � Re air .r . �1 . Site Plan / � . �',��-�s�( �� r°`" c.�� Y - Sf�� f" !'�T`d'�� , A v� . I��Parr� � � a°M. ��,� `e ��J�`o� � ' a� . _ . . f�0 �G y �� (�(r � �_ _____�-- �.r `:, ; :��`/ �_/ S � _ /— b \„ ,�a �,� � � �o ` Environmental Health Specialist ,c��?i� Date 3— ��l`� :.,,�,� / .��,Q;� f f��.�-,��, r .(��, l r�t� � 3�2 - C� 3s8 � h� w�� M��-� �. � S�-� . � , . - � - • . � �-' . APPLICATION� ITE EVALUATION/IMPROVEMENT PERMIT & ATC � �� , � �;� ��. avie County Environmental Health ,�j `1, � .� , � :� P.O.Box 848/210`Hospital Street Dti' �-, ; Mocksville,NC 27028 ,�� -��a � � (336)751=8760/Fax(33�751-8786 '+,` �,� Appli ion For: Site��- `altiati�p;�t✓Improve ent Permit q Authorization To Construct(ATC) ❑ Both Type App�ication;^C9New115'}rste epair to Existing System ❑Expansion/Modification of Existing System or Facility ***I DRTANT***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 CafC� ��(,D� Contact Person �G�►^'►-� Billing Address Pb (�1C (n Z� Home Phone 33(�-�j � S-C!ll7 v City/State/ZIP Lt,�3 J � Ic. fV � �.7 D L,3 Business Phone 3 3(�- 9�� Ll�� Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged � - -�-av9 NOTE: A survey plat or site plan must accompany this application. Included: ite Plan at(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name S`-�-CJ L•'� (n��h �-t lS Phone Number_o�6�"�2�'��9� Owner's Address 3 14 0 S ur�� ec.{-{�e,,/j y w 0. City/State/Zip ,3 i � Z c� �'3'l a Property Address do �;c4r Cr�cc.lL 2oa City /�U��CSVi L� Lot Size ($, +-{� A�-L Tax PIN# �8't� / q �' S`f 3 S Subdivision Name(if applicable) Section/Lot# — Directions To Site: }�wu !�o! n/��.G� � L;6�/�ar C1t��h 2��1 , L��f-� /,;P�IC��c�L �'1'i H,✓L�'t Qva G�. � �PirN N�a/ bna✓ Crct lC. �73�-CltcvrL If the answer to any of the following quesrions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes C�o Does the site contain jurisdictional wetlands? ❑Yes C�id'o Are there any easements or right-of-ways on the site? ❑Yes C�o Is the site subject to approval by another public agency? OYes C�"o Will wastewater other than domestic sewage be generated? ❑Yes Ct�o IF RESIDENCE FILL OUT THE BOX BELOW #People vZ #Bedrooms #Bathrooms 3� v Garden Tub/Whirlpool [�Yes �No Basement: es ❑No Basement Plumbing: f�Yes ❑No 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 system requested:. LK(;onye��onal [�Accepted ❑Innovative ❑Alternative ❑Other !Co Water Supply Type: C3"County/City Water ❑New Well OExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes fi�fi(o 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 perniit(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 labeling of property lines and corners and locating and flagging or staking the house/fa ' 'ty 1 cation�propose well location and the location of any other amenities. � �� Site Revisit Charge Pro rty wne or owner' lega'representa rve si re . � Date(s): � Client Notification Date: Date EHS: Sign given ❑Yes ONo Account# r�z� Revised 11/06 Invoice# � - � T , (o��d� � f�evised— ?�09 � �� , , j . • • . - �, . • DAVIE COUNTY HEALTH DEPARTMENT • ' . Environmental Health Section � Soil/Site Evaluation APPL�A �I�,F�� Tax PIN/EH#: 58��INFORMATION � Billed To; Greg Bacot Subdivision Info: Reference Name: Location/Address: Bear Creek Church Road-27028 Proposed Facility:. Residence Property Size: 18.44 Ac Date Evaluated: ��d tJ Water Supply: ' On-Site Well Community Public . Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition � . Slope % � . HORIZON I DEPTH � .._ '� � Texture grou � G Consistence ��. Structure L ,(G Mineralo � HORIZON II DEPTH � — -� Texture rou � � ,.$'I-C '� Consistence _ � rr �- `, Structure � krt- ` 5' " Mineralo �' HORIZON TII DEPTH Texture rou ` Consistence � Structure � Mineralo � � HOR�ZON IV DEPT'H " � C� Texture rou Q fj 0 Consistence � Struccure � �" Mineralo SOIL WETNESS RESTRIGTIVE HORIZON SAPROLITE � CLASSIFICATION LONG-TERM ACCEPTANCE RATE , � SITE CLASSIFICATION: Y • - 7 . . EVALUATION BY: �� ;�l�',�S LONG-TERM ACCEPTANCE RATE: �' �'� OTHER(S)PRESENT: REMARKS: LEGEND I,an s aRe 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 clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CON�ISTENCE 1�ist 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 'Structure . SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic MineraloQv ' 1:1,2:1,Mixed . ��Ie� Horizon depth-In inches Depth of fill-In inches , Restrictive horizon-Thickness and inches from land surface . 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