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667 Daniel Rd� . . `. ' • . � DAVIE COUNTY ENVIRONMENTAI, HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 " (336)751-8760 F� # (336)751-8786 Account #: 990004153 Billed To: Jeffery Potts Reference Name: Proposed Facility: Residence ATC Number: 4551 OPERATION PERMIT � � Tax PIN/EH #: 5736-56-4891 � `� Subdivision Info: � Location/Address: Daniel Road-27028 � Property Size: 25 Acres a--� �� �5� **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., Secrion .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. � �p- -U System Type: .T. Manufacturer � J Tank Date �� -�� Tank Size �GO v Pump Tank Size �— System Installed By: ��•� tY� `�r t.,V��j E.H. Specialist: d� N�y ��Date: '��s �(,,� � n__ �_( �,.1 Cl 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 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004153 Billed To: Jeffery Potts Reference Name: Proposed Facility: Residence ATC Number: 4551 Tax PIN/EH #: 5736-56-4891 Subdivision Info: Location/Address: Daniel Road-27028 Property Size: 25 Acres Site Type:�w ❑Repair ❑Expansion **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 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 B # Bathrooms �# People �' Basement8'B�asement plumbing0 Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ��%''(�rLt� J Type of Water Supply: ❑County/City�ell ❑Community Well System Specifications: Design Wastewater Flow (GPD) �Tanlc Size j��GAL. Pump Tank GAL. 2, �� �� 4 Trench Width �:lD Max. Trench Depth � Rock Depth �� Linear Ft. � , _. ., .� _ Site Contact the Davie County Environme�Stal Health Section for final ins 8:30 — 9:30a.m. on the day of installation. Telephone # / 2�� w� n�`J Environmenta1l�Health � Y CHD 11/06 Revised) F���� ��� i of this system between 51-8760. g �� �� �,,,��,.'"`�' mG � !� �'dJ� v fl� u , p�- O �� � C/ � ���Vl��) 0 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.•Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004153 Tax PIN/EH #: 5736-56-4891 Billed To: Jeffery Potts Subdivision Info: �„�.� Reference Name: Location/Address: Daniel Road-27028 Proposed Facility: Residence Property Size: 25 Acres ATC Number: 4551 **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie Cowuty Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G. S. Ci�apter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type �� #People y#Bedrooms �_#Baths 3 B�sement w/Plumbing: ✓$asement/No Plumbing � Commercial Specification: FacilityT� #People #People/Shift #Seats Lot Size �-��Type Water Supply U�.1�TP( pesign Wastewater Flow (GPD) �Ll� Site: New � System Specifications: Tank Size �'^ GAL. Pump Tank ^ GAL. Trench Width �� Trench Depth �'�� �� Rock Depth Iz" Littear Ft. /�T other:_ A�..i��aii,.l� F`aw ✓.N�V� � 7 ��7"�2�a3flTi�nl ,��5 Required Site Modifications/Conditions: �N�S'r�1LL ���.17�, iCt_,"� l5��>� ���r�/�T Contact the Davie County Environmental Health Section for fin inspection of this system bettveen , 8:30 — 9:30a.m. on the dav of installation. Telenhone #(3361'751-8760. � J 2 1'�O1 �� � ! c�--,�� � N�%R�l+ � 0 Health DCHD 1�06 (Revised) o ��P ����� 1��0�� �R� � As st�te�i i� �.5A NCAC 18A �cc�pted Syst�ms rnay also ;�.�� i O 7���iv� ���Q �� �-� � � � �� R . ' ' ' APPLICA .+ � C���1 ..�,! "�' ,� �' � ',� �C��_ ��� . � � � � , � � � f � �z� � -.f�� � L.-. ......'y ��1f•1.1'.L'�lZt\ . �,,.,,�, �p ication For: "�,�Site��,v�l ion/Im SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Healtlz Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Pernut ❑ Authorization To Construct(ATC) � ^ �j � � . ��� � � �3� I�'�oth **'"il[%1PORTANT*** 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 �-F-Fv� � �, �� �f-S Contact Person Cj.E'� QU -ffs Billing Address I/ ro D�a; �/ �Q� L� Home Phone 3 3� - Z��{ - y�S6 City/State/ZIP __/l'I nc-�s v�ll��. �C 2 70 2 d� Business Phone 336 - 93i - 7/o5L Name on Permit/ATC if Different than Above �.Q, CL �.rr DQ � Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. ���,;�,,�. �Ybp�-�y> .(Pernut is v lid for 60 months with site plan, no expir tion with complete plat.) �, Street Address � �'R' S�YV �-Y�6� �� � -� $¢,q� �e.s �(Sa��ity ,o �sc� ` � Tax PIN# 5�3�,5� �8`� � SubdivisionName �lL� Section/Lot# �: —�3�'�LotSize �-ZSR.c:-,e� Directions To Site: `dD/ ,�o,,� .h, �� �'�,f- �r�. �'1 P_ C:c /� � uril� R�. �a i��`sGcf" o�, �...-� F��_ �o C %i�- �.� nt; �,�a ��Fz� � 1.y9� ` � ,..,��� / L� ..�i`.s� Id. � Date House/Facility Corners ,Flagged r v. 3� 2on � 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 f�'No Does the site contain jurisdictional wetlands? ❑Yes j�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 �o Will wastewater othet than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People � # Bedrooms � # Bathrooms 3 _ Basement: es ❑No Basement Plumbing: J�Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Garden es �No Type of FacilityBnsiness 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 Water Supply Type: [�County/City Water I,� 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? • ;�, i' This is to certify that the information provided on this application is hue and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, b� if the information submitted in this application is falsified or changed. I understand that I am responsible for all charges incurred •' from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Deparhnent to conduct necessary inspections to deternune com liance with applicable laws and rules on the above described property located in Davie County and owned by �- M�t�.�_����, �-1 , q` �, P er's or owner's legal representative signature y��Ob fo Date Sign given ❑Yes ❑lv'o Revised 2/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # Invoice # �,���Yy ea��p� �.��- �� ��;s'-"9..��� �. ���� S ,, ; +, ,, � '� `� ^�,�F+ x• �c-X C;ik7.E��1'' , - � � � �pooe �/! 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DAVIE COiJI�TY H�ALTH .DEPARTMENT � Environmental Health Section Soil / Site Evaluation � RO R I, aF RM I Tax PrN/EH #:` 5736-56-4891 - ;�;�-, � ;> Property Size Subdivision Info: #-.., Location/Address. ='Daniel'Road-27028, see map bate`Evaluated: Il Z�i O� .' 'Z�1Ia� . ' �� '.x ' Water Supply: On-Site Well Community . : i.: Evaluation By: Auger Boring •' ` Pit FACTORS 1 2 �� Landscape position I� L Slope % HORIZON I DEPTH Texture group Consistence .. Structure HORIZON II DEPT,�i Teztuie group . a Consistence • _��, • i "� Structure Mineralogy ''°��y HORIZON III DEPTH Texture group Consistence .� ,��lil �00�� �����0 ���'���-��� ; , � � : + � ��'�• : ��1�i'�����J� ��G��a��'��������'►��a� ������!�r'�r��'J_1� /L' a ' `� Gts�,i G.- %S �S 5�v c'`�� n'�' yc" 5— ¢D- L+_ /`�, S . � 20 — g.ua � �� E 5P . 0 JIIUGWIC �'� � [ t. • Z�K Mineralo �� j..�C/ HORIZON IV DEPTH ' ' .� �' 32- � Texture rou ��+< Consistence S ►J. ' Structure "� � Mineralo ' SOIL WETNESS "- 'L � �Z � Z � RESTRICTIVE HORIZON X � 2 30 � SAPROLITE �- '- - '� — � ' CLASSIFICATION ' V PJ �S�-f�c. �S ' LONG-TERM ACCEPTANCE RATE � • 3 �� .'z-� •3 PS' ; SITE CLASSIFICATION: EVALUATION BY. . LONG-TERM ACCEPTANCE RATE: �• �- OTHER(S) PRESENT: REMARKS: � � � �� C 2(� y + LEGEND L�ndscaoe 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�ctlug 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 ONSIST +.N . 1?�isi 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 Mineralo�v 1:1, 2:1, Mixed LY�� . � ; � Horizon depth - In inches Depth of fill - In inches f 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 DCHD OS/OS (Revised) ' APPLICANT INFORMATION Account #: 990004153 Billed To: Jeffery Potts Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Envtronmental Health Section Soil/Site Evaluation � PROPERTY INFORMATION Tax PIN/EH #: 5736-56-4891 � Subdivision Info: Location/Address: Daniel Road-27028 Property Size: 25 Acres Date Evaluated: I � ��P Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut � �� FACTORS 1 2 3 4 5 r 6 7 Landsca e osition 1_. �, L L. Slo e% 3` 52a S� Co7.a HORIZON I DEPTH � i �^ S O^ I'2 `'1'� p'' 10 p^l D� Texture grou GL L � ' � Cl_ G7._. Consistence ' {' '� '. V� � ` ; �.S �-; V V (--c' SS S( Structure � •v�_ � 31� �-1Z Mineralo j' S i.: � �'�.,"Xl HORIZON II DEPTH -] � �-� I 2- Z � d-� �" Z� ^ 2 Texture rou /� L Gt �- $ C- � Consistence , V �/ � � ; �� � S t Structure �- �t _Il t3 Mineralo /U1s }�n► �'Q �f1� +� �w=� HORIZON III DEPTH 3'`F��S 2 r S �.�� � - Z Texture rou 5���� { L � LS �� o � Consistence �` N ' � ►� • .3 Structure /v� W� Mineralo -L HORIZON IV DEPTH ' Texture rou Consistence Structure Mineralo SOIL WETNESS '7' 33 i�—f> �-!Z� 1� -- Z lu - �" 2y-4- 2 RESTRICTIVE HORIZON � � v D 2 2Z D SAPROLITE S -5 S — "' S CLASSIFICATION l�S P j � ) �S LONG-TERM ACCEPTANCE RATE . Z p. Z O• Z- SITE CLASSIFICATION: EVALUATION BY: ,- -]-i-� �'�.-E`�-�-�--1 LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: LEGEND i,an s e 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 Ts�ztturg . 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 ONSI�T .N . . �415� 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 - C3r�,nulaz ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic \� Mineralo�v 1:1, 2:1, Mixed LY�t� 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 - gaUday/ft2 DCHD OS/OS (Revised) ' ` � '� - � � � , �, iI _ r � J ,� ..� - , � � ` � _ 4 �� � ° a5 i ' � � L� \ ; ` � ;� � 1X �f^ `, v�'' � J ;� ;� , �, i . ' � �'d - � ; .. �, .-,• � �' Z � , \ y�. J MT , .- � a„ �� ; � ; � � C< < �N,,� � ' � . - -� _ _ �----�-�" " , � ` ,� �:= �._.._._ -�---- . - -.- ..... _ - , £ - __ _ -- ._ .__. j ,� ':� . .,i � � � ; , � �, �L �i � . .,l£" .'�� 1�� �-,'irT . ;f. . . . ' � , �.. ` . '] � 0 . Davie County Environmental Health ' P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (33�751-8760/ Faa (33�751-8786 IlVIl'ROVEMENT PERMIT . Account #: 990004153 Tax PIN/EH #: 5736-56-4891 Billed To: Jeffery Potts Subdivision Info: Address: 1150 Daniel Road Location/Address: Daniel Road-27028 City: Mocksville Property Size: 25 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 systern must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building pernut(in compliance with Article 11 of G.S. Chapter 130A, Wastawater Systems). This Improvement Permit is subject to revocation if site plans, plaf or the intended use change. ,-, Permit Type: ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms� # Bathrooms�, # People� Basement0'�asement plumbingE3� Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): (Gx�v Type of Water Supply: �ounty/City 0 Well 0 Community Well Site Modifications/Pemut Conditions: 6—j �� �—��y � � � �J ��� ���� i � Environmental Health Specialist a ,' �, .� ..•`� � - '\ � . . , . , . ,� � �J l�.. �7r � � � I ��''�'�, �� � �� `` 3l � �e�,3 `�. �� �� . {b s�.___.-----. '^ .-' �� �`�, .V G�'�v � � � . ;