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106 Bramblewood Ln � j ; • t� ' DAVIE COUNTY ENVIRONMENTAL HEALTH t , P.O.Box 848/210 Hospital Street • Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Accr�unt #: 990000687 "��x�I�€,�EH#: 5823-33-9323-#2 BiElc� To: Cynthia Lyons Suf��ivia1011`1f1�0: �e:fer�r�ce P��n�e: LacatiortiAddr�ss: Bramblewood Lane-27028 F'ropc�sQc9 Fa�;i€ity: Residential - �co��rty Size: 18.18 Acres • a�TC Nu�tber: 5817 j; **NOTE** The issuance of tbis Oper�tion Permit shall indicate the system described on the ATC has been installed in compliance with Article l l.`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 � System Type: � S.T.Manufacturer�rlG��i�i� Tank Date� ��Tank Size�QD� Pump Tank Size /l�C7Q j2��� � Q���1 System Installed By: e f`�Q E.H. Specialist: � ate: /��l GPS Coordinate: .�c�P�,� (�lb'��� p��� � ��M � �b � `� sp(as�-- � 1 _ �� _ 3 � � ~Q � . �� b }'. I C � ' ! I � ' ^O J V \. ' - - _ � �`- ( �� � I + \ � � ,I `� �� �a\ � , _ . \ k DCHD 1 1/06 (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 CONSTRUCTION �cc�u�t #: 990000687 �"�x F�INiEH�: 5823-33-9323-#2 �ille;d Tc.�; Cynthia Lyons S���i�i,-ion Ir3fz�: R�fer�r�ce P�ar��e: E.ocationiAdr�r��s: Bramblewood Lane-27028 f�ropc�sec9 F;��:iliEy: Residential Pro��� �z�: �18 18�cres �C, 5g1, it��ype: ew epair ❑Expansion ���*�F��`�This����horization to Conshuct(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 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: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size ��i�. Type of Water Supply: ❑County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)���Tank Size1�GAL.Pump Tank�GAL. Trench Width� Max.Trench Depth�� Rock Depth� Linear Ft. U���� Site Modifications/Conditions/Other: �ZP��I.J[�� 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. �� ��� 2 � — �� a �� � ,� � �'�� ''� u-t1 �" � . � � � � :� � � � � � � � � � � � � .�. �,+ -a �Q , N �,,�,s��.� � .�, _ �� � � 1 (a��� �� Environmental Health Specialist ' Date: DCHD 11/06(Revised) 1, �, , , �1 �f.......��.�:� . . , ' --'• � + Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990000687 Tax PIN/EH#: 5823-33-9323-#2 Billed To: Cynthia Lyons Subdivision Info: Address: 108 Bramblewood Lane Location/Address: Bramblewood Lane-27028 City: Mocksville Property Size: 18.18 Acres Reference Name: , Proposed Facility: Residential **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. Permit Type: Lg.New ❑Repair ❑Expansion� w��Permit Valid for: I�S,S Years ❑No Expiration Residential Specifications: #Bedrooms_�#Bathrooms � #People�Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):_E� Type of Water Supply: f�County/City ❑Well ❑Community Well Site ModificationslPermit Conditions: S stem T e LTAR Initial � �d Re air y'v Q . `Z Site Plan � ��') 1 � L�-`` �� , � ���� _ �� ; � � ,� � �; � � � �� t� . h , �, �.`` � �`�� � '� . � Environmental Health Specialist Date ( ' i.p.I 1-06 , ,� , � . � � ,• � APPLICATION FOR SITE EVALUATION/IMPROVEMENT ��ZMIT & ATC Davie County Environmental Health �.:,���� P.O. Box 848/210 Hospital Street Mocksville,NC 27028 �uN Z � 2��� (336)753-6780/Fax(336)753-1680 �Y� Application Far: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Botti�—� Type of Application: ,�1ew 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 (33b �-ao�� Name lf�-�1iQ i� r'�.S ContactPerson�Q��pr, y4�pP_�, Address I O amble_�.mc� r Home Phone 33(v- �� - �►9�1 City/State/ZIP V�l������/���e��,�G �'"7 c�a�C Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Fla ed 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�33c_o>441��Cn ti 4�. Owner's Address_ "$��,r.��1�2wZ�o L.,r. City/State/Zip��I�Sv,1,� � hY'. Property Address r-c�b � City��«,,,1 l�. Lot Size �g .�`� Tax PIN# "� 2 - � 3 3 Subdivision Name(if applicable) Section/Lot# Direetions To Site: �QO I - , O t'� �'l3� - � �� �(`c� h�n<< �c-��cf 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? fYes • No Does the site contain jurisdictional wetlands? Yes ✓ No Are there any easements or right-of-ways on the site? J Yes No �Ou3�r' ���e� Is the site subject to approval by another public agency? Yes ✓No Wi(1 wastewater other than domestic sewage be generated? Yes �/No IF RESIDENCE FILL OUT THE BOX BELOW #People �_ #Bedrooms �� #Bathrooms � Garden Tub/Whirlpool ❑Yes ,�No � . Basement: ❑Yes o Basement Plumbing: ❑Yes No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Buildin� #People # Sinks #Commodes # Showers # Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ❑Accepted OInnovative �Alternative ❑Other Water Supply Type: LR 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 � 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 arG 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 la rules. I understa hat I am responsible for the proper identification and labeling of property lines and corners and 1 cati nd flagging o s aki ouse/facility location,proposed well location and the location of any other amenities. Site Revisit Charge �Property wner's or owner's legal rcpresentative signature Date(s): � � � ' Client Notification Date: __ Dat • EHS: --- �l►L�`� . � C�� 1 S;gn given ❑Yes ❑No � ���"�� � , �D`� Account# D�d _ • Re��ised 11/06 �L � !.�s�3 "� � Invoice# -� * �� L S6 l S� .�'� �3�U �� � �, ��� �,► 1`�a5 �._,. 0 � � � � Go�lAPS - �av9e County �i Public Acce�s � j � — - � WA7ERSNED STRUCT11RE9 Q _ � WATER_CAD�S �•_:: � I ~ , i� ----._�____��y � � COt1KTY«BCM1NnAP.Y O - � ,:� ST�tEET3 � T -"'�� �yi�' RAILROAD CENTERl.NiE � � � �� . � PARCEi i O / CfiY_ltfldli5 � ; , -._,.,..__... :- ��.. t� ', �R1��BLEY.'07pLM.:. __:,::; a RERMiJ6ARUN � �/�yC�� - + �I � � CWLE�ME! . .:: i�r � s ( !�1` p� � , �rA��S��� �� -----� .J: � I a cwwe countflr � �� - ��; ri � � MOCFLVIUE �-y ! a . � ! ` ' � � � fiCCfiUll4Eb! ,__, �— � . 1' �c . . �= /' �` DAYIE � . ��' � - V � n �ar wn.,�r��.�a � / � `"�` f`� ;j � �� f.. I • �� , .� htonclay,June 27 2011 cv *i•WAI2NINC:THIS!SNOTASUR EYl�"' p This map is prepared for the inventory of tesil property found within this jurisdiclion,an is crompiled from recorded deeds,plats,and other pubiic � records and data.Users of this map arc hcreby�iotified that the afvrementioncd pubil prmary information soi�rees shouid be consulted for w veriscation of the info:matian containcd on Ihis map.l�he County und mappLig comp. y�ssume no Iegal respoiuibi3it,y for the infor,nation � � c�ntained un this map. _ � � � .mr � � . O�-.��1` t-`�n,��� �.�.51,�-�~' o � �� f _ . " C p C�/�+�\;►G �.-- �� �'�c� � -' - t� . t � e�c_��.� V � -----_.__�_......_._�.__, - -.._._.�__._.. ---.___.... . � � . �.� . ,.\ . . . . C7 �Ilt�[���. - 52X2�3 - � 3i�G �Q. f=T'. - 3 QEDF��QOVI - ��B�T6-[ �.^ '�� - TI-IIS f-IOME A�SO AVAILABLE lN 32' WIDTH MODEL � A ��f"1 SQ�:.° � TI-IIS H�ME AVAILAQLE AS A MODULAR 28' IVIODEL AND 32' M�D�,� .,. � . cTctie-i n.�,;F.�':T � f4Tln p�..np r�CT r---" —� i -------- ' o �} , o o � I I I t .' � ' � . = o�raiN� Roo� ; �: _ `�� E<iTCHEr� 9•1 x 12•9 ' i 11-9x12•9 1 @ATH2 BEDf�00(ti4 3 � � 9•5 x 12-9 ° . . � � � � o i 1 I I•,�ASTERBATH � `---------� HALL i / � r_______.__� � r-----------^-------- � I ' � � I � p ' � "---"L�rin;T�S UE�sli�.:l tQ�lEF.x'1C � . � 1 1 � . _ � ' 1 - • I i��lA5TER BED`RUOPiI � � LIVING ROt���t i 8EDR00(vl 2 � - td-0 x 1?-9 j 22•2 x 12-9 I t0-U x {�-9 � f � � I . 1 • 1 I - I - , I -= --'---------------------------' , , � � i i i � , . . � , � ' ' ' I' ,. • •• ;• ',�' • •� DAVIE COUNTY HEALTH DEPARTMENT y ' '� Environmental Health Section . � Soil/Site Evaluation APPLICANT I FORMATION �' INFORMATION Account #: 990i Tax PIN/EH#: 5823-s�'�� Billed To: Cy thia Lyons Subdivision Info: Reference Name: � Location/Address: Bramblewood Lane- 70 8 Proposed Facility: Re idential Properly Size: 18.18 Acres Date Evaluated: �_!_ �� Water Supply: On-Site Well Community Public X Evaluation By: Auger Boring Pit_X Cut FACTOI�S 1 2 3 4 5 6 7 Landscape position � Slope % � HORIZON I DEPTH Texture grou Consistence � S tructure � Mineralo � HORIZON II DEPTH Texture rou Consistence Structure Mineralo I HORIZON III DEPTH � Texture rou Consistence � Structure Mineralo HORIZON IV DEP'TH Texture rou Consistence Structure � Mineralo SOIL WETNESS RESTRICTIVE HORIZ N SAPROLITE CLASSIFICATION LONG-TERM ACCEPT CE RATE SITE CLASSIFICATIO : EVALUATION BY: .�� /' LONG-TERM ACCEPT CE RATE: -� OTHER(S)PRESENT: /��'I „`�P'P_ REMARKS: ` G LEGEND T,andsca�e Position . R-Ridge S -Should r L-Linear slope FS -Foot slope N-Nose slope � CC-Concave slope V-Convex slope T-Tenace FP-Flood plain H-Head slope Texture . S -Sand LS -Loam 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 ('nN�I�T+,N , �� 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 Struc.ture SC-Single grain M Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic � Mineraloev 1:1,2:1,Mixed lYotes Horizon depth-In inches ' Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(� nsuitable) Soil wetness-Inches fro 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) TTAR -T.nna-term arrant�nrP rata_ oaUAavlft7 Tll�TiT hGlAG m__.e__�� i � � �� . . ��- ; � �� ��,��,�� ���;��U�� . �����C��.�,�,� [��,sf�,� `� � � �;��� � r� �-Z�_ ���- ��;:� .G14 /�� ' � G; �\--��,Y� ����i�f,/ ���� ; 2 ` �� .,2�/ —� ` .�,�� ,�, ��/f� , � 9 �!�?��/'k y' 3 � � c�f�� -? � � �,�;� � ' '' _`_. - � �,1 ;;-: ;� �-�1� �'4i1 �f 4?. . �i �- . �,i ;, ii ;. ;; ;i :� �..��r_�,,�.,,..��.--..� � ��. .--y�; ��:_ _ .. �� {� , _ ;f ��,��� a!� o: )E�_,� � � ;� I I� ✓/ ,M c-> . i� \ _ � � . . . 1� p \ � P �� ^ I� ii 1; i' � Ir � � j! k i 3i � � 1 � t i� � i i !! � i� �k �_. _-..._ _ !i il �i i� �c 1j � , � ,. , � • a w.�c coucrt caznrr nuT nMs wa wwt otuvm ur+o�e w suvcnwsaw Q�' .. .. ..FROY AN ACRY�L SUFVEI'4AOE UNDER W SUPEIM90N.DEED DESCRIPIqN � RECORD�D M DEm BOOK(as noNd).PAGE(as notW)�te.:TM�T 1HE ERROR 1 MEREBf CERINY i1NT THE DANE COUMY MUL7M DEP�rtfyEM WS �2 OF CLO$URE AS GLCUUIED BY UTIIUDES AND DEPARTURES IS 1/10.000. � EVALW7ED T11E SUBOMSqN ENTI7LED CYNfNI�LYDNS WIlf7 7HAT 7HE BOUl0W45 NOT SUfNEYED ARE SIqWN AS BRq(D!UNES ROf7ED RESPECi TO CRRERu NID WNDfIIONS ESP&JSHED BY Sf�IE UW OR �� iRON INFORNA710N FOUND RI DEED 8001C(a�iated)PACE PROMIAG�iED TIIEREUNDER AND 711E SY1E 6 iWND 70 C9NPLY MiH SVCH ,��.��a��N��E�TM�.S.�-� �WIINARY PLAT CRRFRIA AND COIIDIIIONS IXCEPf AS FM1ND IN SUCH EVALW7qN.fOR ,��"` WI/NR$W WWD AND SEAL 1HIS�._DAY OF T20�''OR REC❑RDATI❑N �AT 7HE SND DEPMNEN7. $ � CONVEYANCES OR SALES �,��,TM��""�"w��o„w�„, ��� suo weomsror�rore rcaruv,�ov sEw�r,�auna � �� SUKVEIDR }S90 .� tt�c.�w. w� ca�r�n�oFrcv� �� 7FNT 5 PIAT IS OF A SURVEY OF AN pry ' � DtISfINC PARCEL Oft PAFtCQS OF IAND. / � � I / E/P SIfE ��~ � � ' ■ NOl N SC�LE ��� 0 / HOAABD�ROBIIiSON Q� � oa»o rc w� � /4G ``` ,� ' LEGEND �3p�p I EIP IXISTINC IRON PIN �/ �IMRp1NE 8p74'�'E IR�N S 8339'48'E 211.41'�. �BC R�'M R�-OF-WAY R/V / �NT �cs�i� —�o'GRnV ��— _=� �—__ `N���v I EIP EOGE OF PAVEMENT E/P � � � . � '—�� -�' �.53' A� E/G EDGE OF GRAVEl CM CONCRE/E MONUNEHT PP POWFR PoLE ER RN f o �'2�'u�R�DB � e4�S'� II.B.L YINIMUY BUILDING LINE ID Nnll ipS�. 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No.i �V1S10'� n�s n�E wr oF � .ioit il 1�2 wF.ST YAIN .S�ET- sca.E�i• - 60' 113134 °�'ES TH�I[llSVII1E N.C. '27980 AIU RE��N PUT BOOK ,PAGE DRAVN HY�TA DATFi ��1�AS'VIfIF� �3.98� 4T2-9408 SURVEYED HYLC.TA oeioai2ou ��PNP. u.erswr s�m.r.r�asrcrs av ocros �ZGTON� (938) 243-7429 fAlllTri DAVIE TAX SU 5823 - 33 - 7506 �����, IIII�iSTON-.SAIEII�(538� 788-070$ T�VNSMP CURKSVIU.E STATE�NC � 10/04/2011 14:41 3364925104 ABEE'S GR�DING AO . • � � ��� � � � 10 P�3�� � . • . ���R OO�a WRP/MyAV�R�d W wkf O�rM N�M�w�a�CpOyM' � � • ' N��hOiWtO�aM�tl� �wYYOQ�•� 6�1�T COO� �� • /OrlC7�O Y��CO��i��i�M[0�� • fMn Ns M0�111Mlyd Nc oaN�s�q��ub r1n�D I�Yno wqOp000 nO 7R W�A 191M�0 C0�/u�1111 � � ��PI�=Al1/O M OLW bOK(M MY/�Fli(�UMId\1W CMI�M/Y�mp101{RI�►K R1M M A�:P MMMIIP��OI � n4 r�r qY NITMta M�a�oric[Mf��J,�/�J'0 �s wDM� 1i/�� • ht�,f Ac W IP�MI�CA4 �i� A1K'i►W IMIO MID?PLL 1Mi�1M_ONY 0/ ,y�d��.�t M �MI�M . � w . 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F �t . �. �I . � � . � s r � � i � . . . � . i i ���f � � . � �,*a�-� . � .. .. • r . . { � � i �d��.�, I � , o ' • "��" ' �,.d� ' .• � M�pw�°•y • ,_�,.j-- i_/�,/ �na omca�ar.ws ave+.aonrr ' M i�wZyyV��q Wpr��pe}�u��e w�w M an�nri�s wnw wf���riu1c11► � �rea I : �f64=:4��3r.�.i� • lJ� ' r a • r r ' r, � ipp anqa � • CYNTfQA LYONS °'�` � •.. ' �«w�.se.eoe erR nua� ��_� � a 11�/� �YADI 8'� , • vuvt�ar� DwG. Nvr a�u vc�� Mr a��.»�+ , '!'f�1f�8Y0�i9 If�C. 878Q0 SCAtb Y�i0' 1l�t7� pp�pp r t `C .�w[ �7 • 7iRV[Mm�'1lG TA 0!/DIV2W7 �K� � Y��}AN.�OIi10�P RiO� ' • , �QrDx� ���43�� R� — ��611�i��l�6��06�070A �If�l dML. U�A������ wl1rR fpylfbpA qI1�Plqit tT11TD NC . , • • _- _ —_ ���s�"'__"_. __�« �—+-��+� ' . � ., '� • . . � � . . ' . . . . • '�i • DAVIE COUNTY ENVIRONMENTAL HEALTH 4 • ' " f " P.O.Box 848/210 Hospital Street , � � J Mocksville,NC 27028 (336)753-6780/FaY#(336)753-1680 ' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �c�t�ut�t �#: 990000687 T�x F'I�fiEH#: 5823-33-7506-NEW Bille�T�: Cynthia Lyons S�f��ivi�iart Inf�: ' f�efer�E�ce P�a��e: New Permit Issued LocaiioniAd�r�s�: Bramblewood Lane-27028 f�rn�c�s�ec9 F���:ility: Residential . T��r��r�r�.y Size: 1 Acre Site Type: ❑New ❑Repair ❑Expansion a�TC t�umber: 5784 **NOTE**This Authorization to Construct(ATG)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 Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site ptans,plat on the intended use change. ^ Residential Specifications: #Bedrooms #Bathrooms � #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats � Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: �County/City ❑Well ❑Community Well System Specitications: Design Wastewater Flow(GPD) Tank Size GAL.Pump Tank GAL. � 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. � , I , Environmental Health Specialist • • D�te: DCHD 11/06(Revised) .: ` � . . l��vis�� �7 , �. � 3 j�11 - . � • • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County �nvironmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax (336)753-1680 Application For: ❑ Site Evalu�tion/Improvement Permit ❑ Authorization To Construct(ATC) Both Type of Application:`�Ie�v System ❑Repair to Existing System ❑Expansion/Modification of Existing Sy tem or Facility `� ***IMPORTAN7*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION '3sb- y�Z-ZoB� Name ��A[T{-�( /k ��(S� �,l{�J�f J Contact Person��-��J1� ��-``.- Adcti•ess +OS `�Yri'���41lZ?c�� �... Home Phone '3 3�, �(1-f v- (o)G�l-(� City/State/ZIP �nC(�SVI L I_�C_ l�C c�"7(�o1a Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORIVIATION *Date House/Facility Corners Flag ed s.3d�// NOTE: A survey plat or site plan must acco�npany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernlit is va d for 60 months with site plan,no expiration with complete plat.) Owner's Name �'��In.i� L�v�s� L`(���5 Phone Number Owner'sAddress�p� t3�M�i�� t,jpOt� L,/}N�Z City/State/Zip ��1LSv��t1�Z ML 2.� oZ�S Property Address-�3p ��ti•Z c n ���� City �./�pLILsV��t�Z N L Lot Size��C� Tax PIN# �23- �j- J�Q(o Subdivision Name(if applicab e) Sectio /Lot# �n / Directions To Site: �Q� �. jq� �{ QD l c�q�rl, c�uJd DN Kf�'�"i7�� 7 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 �[No Does the site contain jurisdictional wetlands? Yes �No Are there any easements or right-of-ways on the site? Yes No Is the site subject to approval by another public agency? Yes �/No ' Will wastewater other than domestic sewage be generated? Yes �J No IF R�SIDENCE FILL OUT THE BOX BELOW # People �T #Bedrooms �_ #Bathrooms�_ Garden Tub/Whirlpool ❑Yes 1No Basement: OYes C�10 Basement Plumbing: ❑Yes L�10 IF NON-RESID�NCE 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: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other �Nater Supply Type: �Cotu�ty/City Water 0 New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this sysfem is intended to serve? ❑ Yes i No If yes,what type? Tilis is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any pennit(s)or ATC(s)issued hereafter are subject to suspension or revccation if d�e sitc 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 deterniine compliance with applicable la �s and rules. I u erstand that�I am responsible for the proper identification and labeling of property lines and corners a�id l in an flaggi g or staking �h house/ ciliry location,proposed well location and the location of any other amenities. �� � " Site Revisit Charge Prop rty wner's r owner' legal epr sentative signature Date(s): �_ �7— � � ClientNotiticationDate: Date EHS: Si�n given C]Yes L�No Account# V 10�1 _ Revised 1 1/O(i Invoice# � . � �j s`�r�� S�ecQ. r i poah(� VvreQ.� �6 1C 5.:�. �'t��Oi tx �1�� �Yc�mh�v�o� L►� . GoMaps GIS Page 1 of 6 . r. , 414. J %' r � DR[:MSG;P[ LPJ , O f �f�� p' � + �; �r 1 � U'����.' � � '�. _.", cf,I �f' r�.[� � rt f.�.,�� 'J I '�Q�'-\��y �i'''11 p— ;y _--I f�r --���C�. ' �,� I �� �--- ;.�;� � �__�� L �� � , `�`�,r f,,'`~�� J ' J � —��r' �• . i ,:..�3 f.' ff'••'/x � - ---���I f,� � � 11 �.�`� f�,���' l�' ,1`1 _ _ � � 1 � }J r `� — I f� -��`��,� I �.1�, '� �� I ! �' 1 1`��; � "!"�� 1 l ti ~ � ,���r� � �+ . � � � I , J � 5 iy �';�r.`;, 1 L I I —�.B R�;h1 E L E�,vo 0 0"i ra— ---- �{' � 1 ,•' S� � I i R r + � I � �I ,��..�f� �'f'ft,,5 i _.} r Y I I I � � r �. � I � I � � :f±�� I� + � a! �� I --� I -''-;� a� I � � �, ( � � + � I I � , ;;:, ,� � � I �---� I � ' ) � f + ----�-- I ,+, ( I - . � ' � � -��,�nrt � , I i � i � ( � http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 6/2/2011 ❑ �n��c�. - ��x2� - � 3�� s�. r--r. - 3 ac��oonn - z���;r�-e - _ TI--IIS I-IOME ALS� AVA{LABLE IN 32' W1DTH MODEL � � .��f"i SQ. 1={: Tf-IIS H�ME AVAILAQLE AS A MODULA(� 28' MODEL AND 32' MODEL .,. �.TFi:r,.i o•vSF.P-T ' �Sffi , P*.TI^ p�-.np r,p7 � r----- —� 1 ------- � o nv a o I ' ' � � = . �, , � . — �-; DINING R00(v1 i , �'� K{TCHEN 9-1 x 12•9 ' � l{-9x12-9 f gA7H2 4Ea�00i�� 3 � � J-s x 1 z-9 � . . . � o , o , , , I�J�ASTER BATH O `—`-------, HALL i �� Oo "' i ��,_------1 . � �_____'__�_�_��__��__ ' , . � I � � � { '---�—_'Ori14Ti: C'E�i:�..Li CC�JEE7.�lE � . - � I I � . I � I - � . � 1 ti�IASTER BEDRUOG�I � LIVIPJG R00��1 � BEDROOIvI 2 � td•0 x 1Z-9 j ?2•2 x 12.g I IU-D x I�•9 I � I � I . ! I I . � - I -= --=--------------------------' GoMAPS� - Davie County NC Public Access - � � WA7ERSHED STRUCTURES _ � € �%. "- - �`` � ; � �����_ WATER_BODIES �`� � � £� �� � I a CCSUNTY�BdUMDARY �a�' � PARCEL_DIMEMSIOMS �. '''� • � s ADQRESS r -��, � � �i DRNES � Z�� ,., '�? STREETS I N � �' ' ,�x`'` RAILROAD_CENTERLIME ` XY � � PARCELS ~� ,c CITY LiMITS Q �, ti +'+ � M� -� 19L�� � BERMUDA RUN � ,�477 � CflOLEEMEE � QAV1E COUMTY 8Y � � � MOCKSVILtE �=��7Lti1� �� _ 2 � � � � � � � K � �� , �. ���a ,�. 2�a. �, T � • 0 o53ft � Monday, May 30 2011 ***WARNING:THIS IS NOT A SURVEY!*** This map is prepared for the inventoty of real property found within this jurisdiction,and is compiled from recorded deeds,plats, and other public records and data.Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map.The County and mapping company assume no legal responsibility for the information contained on this map. • DAVIE COUNTY HEALTH DEPARTMEN'f P� •/G�9q • �� ► Environmental Health Section • . � . P.O.Boa 848/210 Hospital Street , Mocksville;NC 27028 (33G)751-87G0 IMPROVEMENT/OPERATION PERMIT Account #: 990000687 Tax PIN/EH#: 5823-33-7506 Biiled To: Cynthia Lyons Subdivision Info: Reference Name: Cynthia Lyons Location/Address: Bramblewood Lane-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2128 **NOTE** This Improvement/Operation Pecmit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department 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 LS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type M -�01�t #People Z #Bedrooms�_ #Baths Z Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: ❑ BasementlNo Plumbing: � Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0 Lot Size , `�K� Type Water Supply��^� Design Wastewater Flow(GPD�(� Site: New�Repair❑ System Specifications: Tank Size ���('AL. Pump Tank GAL. Trench Widt��� Rock Depth 12� Linear Ft�O�� Other: Z �'1���T1o..� ��� , (IJ`'�TDJ.�� L.i►S�cS �,O.0 . Required Site Modifications/Conditions: _�1S��/�.�,j� Q� Cp�Ti�L�Q� ��1 �[j ��- f� (,,-1 n�� IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW FINiSHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C)751-87G0.**** � �'J� x�CO���Z�� � ��o' . $ ' � � , tso �� , �? � Z � � 0 a� Envi �' ntal Health Specialist's Signature: ate: � 9 DCHD OS/99(Revised) � � • � , DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Health Section y P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (33G}751-87G0 Account #: 990000687 Tax PIN/EH#: 5823-33-7506 Billed To: Cynthia Lyons Subdivision Info: Reference Name: Cynthia Lyons Location/Address: Bramblewood Lane-27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2128 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE**This Authorization for Wastewater System Construction MLTST 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 CO TION IS V ID FOR A PERIOD OF IVE YEARS. Environmental Health Specialist's Signatur : �� Date: � �i �� CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article i l 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. Septic System Installed By: Environmental Health SpecialisYs Signature: Date: DCHD OS/99(Revised) �(]` �i/���� . �'� APPLICATION FOR SITE e:►ALUATION/IMPROV�fENT PERMIT&ATC D � � � � � � �� • Davle Cou�ty Health Depa�t:n�nt /�i� ���•� ��5� Environm.enta/Hea/ifi S�Yio.n JUL 2 0 1999 ���� P.O. Box 848/210 Ho�pit.E.i Street Mocksnille, NC 27€f28 (336)751-8760 Et�VIRDAVIE COUNTNIl�LTH ; ***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED � INFORMATiON IS PROVIDED. Refer to the INFOkMATION BULLETIN for instructions. 1. Nams to bo Hillad �� ^ •�. J Contact Porson V�� P� l�lailing Addreas b l ew L 8ome Phone 3�� -1`t� b L-1 T City/State/ZiP 1 A ►(�(�SV(�1� , IV(' � t��lQ Suainass Phono ���p / l(�� "l �� 2. Nama oa Pormit/ATC if Differeat thari Above Mailing Addroea City/Stats/Zip s. i�,ppiication For: ❑ Site Enaluation ❑ Impronement Permit/ATC oth a. syst� to sen►ico: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other s. if Residence: � People � 8 Bedrooms � # Bathrooms v� ❑ Diahwaehez O GarY�ago Diapoeal �Washing Machine ❑ Hasement/Plumbing ❑ Sasament/No Flumbinq 6. If Sueinoee/Iaduatsy/Other: Specify type # People # Sisilca A Commodes � Shoxera # Urinale � Water Coolere IF FOODSERVICE: # S@ats Estint8ted WAter Usage (gallons per day) �. Type of water supply: l� County/City ❑ Well ❑ Community e. Do you antic's�ate adciitions or eapansions of the facility this system is intended to serve? ❑Yes ' L�No If yes,what type? _ ***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION TitEftiJESTED I BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by t6e client with THIS APPLICATIOI�. Property Dimensions: �",/�G! � WRITE DIRECTIONS(from Mocksville)to PROPERTY: Tax OtTice PdN: # s�'� 3— ��- 7���, ���/� �C�/.� /p u1s/ ��f� P!�operty Address: Road Name��y/��/�(dfaDC�' h�. GU �� �! �� -' �G� ��S�" � c;ryiz;p ./�o�`l �I�'� ��02�' Gf�,-��u���.� �'�l'u���. If in a Subdivision provide information,as follows: �/�G�1 ��«�� �� Gr�1����. Name: / �/t� JP� !j�'1�U d,:�� /�'O?/�`'C . Sectio�: Block: Lot: Date Property Flagged: ������ ,�'his is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issa�:�hereafter aee subject to sus�ension or revocaHon,if the site plans or intended use change,or if the iuformalloa submitted in this applicatio!�is falsified or chaaged I,also,understand that i am responslble for all charges incurred from thls application. I,hereby,gsve consent tm�1�e Authorized Repces�:±ative of the Davie County Health Department to enter upon abov�described property located in Davie County and owned by to coaduct all testing prceedures as necessary to determine the site suitabi DATE� 1- oCD- -'I� SIGNATURE THIS AREA MAY BE USED FOR DRAWIIVG YOU�€.SITE PLAN( nclude ll of the following: E�sti d proposed property lines and dimensions, structures, setbacks, and septic loca Site Revisit Charge Date(s): � � (::lient Notifica:Ion Date: IEHS• � L � ,..,, / . ...�,..ount No. �O ;'s,:E�vised DC�(07/99)�pp �c� Iuvoice No. J�U _ �`. �� 7� � � � . � � s �� .__ ' ��:�-y.�j�� . �... ._ � �. �� .� �� +r,��.��?,. .*'�. . N .:�. J. �, � �� ,� ,,y�� ,�.��� . � � :�+�`'�ir�+►•`���l'�~;t�,f�R'�� ,,de1n �� �•� �.�+ � ,yp :�+ w `. 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Community Public ----""� Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition L L Slo e% 37 HORIZON I DEPTH -1 ��- � Texture rou G G Consistence Fi � Structure Df�Y iL Mineralo I i�'7 M� HORIZON II DEPTH �3 � - Texture rou L� Consistence Structure Agl� IL Mineralo �1 7 Urf� HORIZON III DEPTH 3�,+ + Texture rou �c � Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION PS t��j LONG-TERM ACCEPTANCE RATE O.2 SITE CLASSIFICATION: 1 — EVALUATION BY: ��'� ,r�v�t����� LONG-TERM ACCEPTANCE RATE: Y�•� OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace 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 Moist 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-Subangular blocky PL-Platy PR-Prismatic Mineralo¢v 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-gal/day/ft2 DCHD OS/99(Revised) � � , � ■��������■■■�■����■���■■�■��■�■��■�■■��■■��■■��������■���o�■��■ ■���■■�■■■■����■��■��■�■����■�����■■■■��■■�■■■����■������������■ iiiiiiiiiiiiiiiiiiiiiiiiiiiiii�iiiiiiiiiiiiiiiiiiiiiiiii■�r■ii�ii ■��������■��■■■�����■■■■■■■���■�■�������■�������e�����■����■■ ■■ 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Box 848/210 Hospitai Street Courier #09-40-Ofi Mocksville, NC 27028 Phone #: (336)753-G780 June 23,2011 Ms. Cynthia Lyons 108 Bramblewood Lane Mocksville,NC 27028 Re: Bramblewood Lane T�PIN: 5823-33-7506 Dear Ms.Lyons As requested,Andrew Daywalt,Environmental Health Specialist with this office and Kevin Neil,Regional Soil Scientist on June 20,2011 evaluated the above-referenced properly at the site designated on the platlsite plan that accompanied your improvement permit application. According to your application the site is to serve a {DESCRIPTION,ex: 3 bedroom,residence} with a design wastewater flow of {360 GALS.} gallons per day. The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code,Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative Code,Rules.1940 through.1948,the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore,your request for an improvement permit is DENIED. A copy of the site evaluation is enclosed. The site is unsuitable based on the following: • .1943 Soil Depth • .1941 Soil Characteristics These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However,this office has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above,the property is currently classified UNSUITABLE,and an improvement permit shalt not be issued for this site in accordance with Rule .1948(c). However,the site classified as UNSUITABLE may be reclassified as PROVIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. " You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor with this office. You may also request an informal review by the N.C. Department of Environment and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, � Environmental Health Section. You also have a right to a formal appeal of this decision. To pursue a formal appeal,you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center,Raleigh,N.C. 27699-6714. To get a copy of a petition form,you may write the Office of Administrative Hearings or call the office at(919)431-3000 or from the OAH web site at www.deh.enr.state.ne.us. The petition for a contested case hearing must be filed in accordance with the provision ofNorth Carolina General Statutes 130A-24 and 150-B-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g)provides that your hearing would be held in the county where your property is located. ------- Please�ote:-If�ou-wish-to-pursue-a-formal-appeal,-you-must-file the petition-form-with-the--— Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is {DATE}. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. ♦ • � f If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law(N.C.General Statute 150B-23)to send a copy of your petition to the North Carolina Departrnent of Environtnent and Natural Resources. Send the copy to: Office of General Counsel,N.C.Department of Environment and Natural Resources, 1601 Mail Service Center,Raleigh,N.C.27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel,NCDENR. Please call or write this office if you have any questions or need any additional assistance,as follows: Telephone number: (336)753-6780 Davie County Health Department Environmental Health Section P.O.Box 848 Mocksville,NC 27028 Sincerely, Gy/�- ��/T (` wl � .J Andrew Daywalt Environmental Health Specialist Enclosure(s): Soil-Site Report Rule .1941 and 1943 AD/bl