550 Danner Rd � I
*' OPERATION PERMIT EEvaluated
ice use Only
+� Davie County Health Department Number 120966-1
�1 210 Hospital Street F400000006
�� ' P.O.Box 848 umber:
'I x;11 Mocksville NC 27028 or: NEW
Phone:336-753-6780 Fax:336-753-1680
I
Applicant: Thomas T. Gagnier Property owner: Thomas T. Gagnier
Address: 3556 Piedmont Rd. NE/Apt. Address: 3556 Piedmont Rd. NE/Apt.
•AA -
Cay: Atlanta Cay: Atlanta
State2ip: GA 30305 State2ip: GA 30305
Phone#: (813)523-1165 Phone#: (813)523-1165
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
550 Danner Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 601 N Turn right on Danner Rd. 1 mile property on
#of Bedrooms: 4 right at smail white house
#of People:
*Water Supply: NEW WELL
*IP Issued by. 2244-Daywalt,Andrew 'System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
'CA issued by: 2244-Daywalt,Andrew
SaproliteSystem7 QYes QNo
Design Flow:
"Distribution Type: GRAVITY-SERIAL Pump Required?
QYes (3)No
Soil Application Rate: - *Pre Treatment:
Drain field
N arification Field Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines 4 Installer: Jaime Barnes
Total Trench Length: 3 6 0 ft. Certification#:
Trench Spacing: — 9 Inches O.C.
Feet O.C. 'EH S: 2325-Mitchell,Brittany
Trench Width: 3 Inches
Feet Date:
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover. Inches Approval Status
Mamum Trench Depth: El Approved E3 Disapproved
MaxixiInches mum Soil Cover:
Inches
CDO File Number 120966 - 1 County ID Number: F400000006
"
Septic Tank '
Manufacturer. Shoat Lat. -
Long:
STB: -
Gallons:
1,000 Installer. Bames
Date: 0 6 / x 3 / x 0 1 3 Certification#:
'EHS: 2325-Mitchell,Brittany
'Filter Brand:
ST Marker: ❑ Yes ❑ No
Date:
Reinforced Tank: ❑ Yes ❑ NO Approval Status
1 Piece Tank: ❑ Yes ❑ No D Approved❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification#:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ NO (Min.6 in.) Approval Status
einforced Tank: ❑ Yes ❑ No 11Approved❑ Disapproved
1 Piece Tank: El Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
CPipe Length: feet Certification#:
'EHS:
'Schedule:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO Approval Status
❑ Approved❑ Disapproved
Pump e e
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches 'EHS:
'Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO Approval Status
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
,\,",Anti-siphon Hole ❑ Yes ❑ No
CD3;File Number 120966 - 1 County ID Number: F400000006
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO 'EHS:
Pump Manually Operable ❑ Yes ❑ No
'Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No
Approved❑ Disapproved
Alarm visible 1:1 Yes ElNO
2325-Mitchell,Brittany
'Operation Permit completed by:
Authorized State Agent: barak Date of Issue: 1 0 / 3 0 / 2 0 1 3
This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE II A. sewage septic system.
Rule .1961 requires that a Type TYPE II A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OWNER
Minimum System InspectionNaintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: N/A
Rule.1961 requires that a Type IV and V septic systems designed fora homelbusiness owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a homelbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity priorto the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity,unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Total Time:(HH:M61)
Activity Code: S-19 204-OP issued NEW Type 11 Quick 4 2 Hours 0 tr Inutes
OPERATION PERMIT
w Davie County Health Department CDP File Number: 120966 - 1
210 Hospital Street F400000006P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
OBloDrawing Drawing Type: Operation Permit Scale: ON/A-T-7
= ft.
N/
..............
j
_
:
i I I i I I I i
r I i I + I
lie lot:
L---
.............
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I
I
CONSTRUCTION For Office Use Onlv '
AUTHORIZATION *CDP File Number 120966- 1
"A Davie County Health Department F400000006
,� •'"�''� tY P County ID Number:
4`t `., > 210 Hospital Street Evaluated For: NEW
.wP.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 0 1 0 0 0 6
Applicant: Thomas T. GagnierProperty Owner: Thomas T.Gagnier
Address: 3556 Piedmont Rd. NE/Apt.403 Address: 3556 Piedmont Rd. NE/Apt.403
City: Atlanta City: Atlanta
State/Zip: GA 30305 State/Zip: GA 30305
Phone#: �81523-1165 Phone#: (813)523-1165
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
550 Danner Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 601 N Turn right on Danner Rd. 1 mile property on right at
smail white house
#of Bedrooms: 4
#of People:
*Water Supply: NEW WELL
System Specifications
Minimum Trench Depth: 1 4
(Design
e Classification: Ps Inches
Minimum Soil Cover:
prolite System? O Yes (g No Inches
Flaw: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: a 7 5 Maximum Soil Cover: Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25%REDUCTION 1-Piece: O Yes 0 No
Pump Required: O Yes 0 No O May Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: 3 a 8 ft GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
— 9 Feet O.C. Dosing Volume: Gallons
Trench Width: 3 6 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre-Treatment: O NSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: O 1 O 11 0111 01V
Page 1 of 3
CDP File Number 120966 - 1 County ID Number: Fa0000000s
❑ Open Pump System Sheet
Repair System Required:®Yes ONO ONO, but has Available Space
rDesignFlow:
System
Trench Spacing: g Inches O.C.
fication: PS — Feet O.C.
Trench Width: j Inches
3 6 0 _ 3 6 Feet
Soil Application Rate: a 5 Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) a 4 Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: Inches
Maximum Soil Cover: 3 6
Nitrification Field Sq.ft. Inches
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 6 0 ft Pump Required: Oyes ®No O May Be Required
Pre-Treatment: O NSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A336(b)).If the Installation has not been
completed during the period of validity of the Construction Permit,the Information submitted In the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps.Signature Required? O Yes (&No
Applicant/Legal Reps.Signature* Date:
*Issued By: 2244-Daywalt,Andrew Date of Issue: 0 4 / 1 8 / a 0 1 3
Authorized State Agent: Malfunction Log OYes
®Hand Drawing O Import Drawing Total Time:(HH:MM)
**Site Plan/Drawing attached.**
Page 2 of 3 1 Hours 0 0 Minutes
S-8-CAS issued-new
.` CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 120966 - 1
210 Hospital Street F400000006
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 /,18 x 0 1 3
O Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
O N/A
11 e5
f "Y T
ab
bffG0nv\,er
Page 3 of 3
P1 P2
ti
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 120966 - 1
P.O.Box 848 F400000006
Mocksville NC 27028
County File Number:
Date: .0.4./ 18 / ,2 0 13
Click below to import an image from an external location: Drawing Type: Construction Authorization
Page 3 of 3
P1 P2
Page with Header and Menu Page 1 of 1
61 � __GroupTree� H 1 =!2 �CRYSTAL REPORTS';
Main Report
Construction Authorization For Office UseOnly
' .
Davie 'CDP F7e Numnber 120966-1
a I 210 Hospital Street County ID Number F400000006
1 11� P.O.BOX 848 Evaluated For. NEW
MOt*3V1lle.NC 27028 PERMIT VALID UNTIL:04118#2018
Phone:336-753-6780 Fax:336-753-1680
Applicant Thomas T.Gagner Property Owner: Thomas T.GaWm
Address: 3555 Piedmont Rd.NE I Apt.403 Address: 3556 P"Tiont Rd.NE I Apt.403
Ci!)r
Agents Atlanta
SWWZIp: GA 30305 Stateop: GA.30305
Phone is hums:(M3)523.1165 Phone/ (813)5231165
Property Location 3 Site Information
AddresslRoed is SW Danner Rd Mocksville,NC Subdivision: Phase: NEW Lot
27028
Struck". SINGLE FAMILY' Direction 601 N Ton night on Danner Rd.1 mile
property at right at small while house
i of Bedrooms: 4
i of People:
'Vlfaler&reply NEW WFJl
systern specifications f
Minimum Trench Depth 24 lunches rp]
She Classili alion: PS Mi i man Sod Cover, inches d'
Design Flow. 480 Mardrmm Trench Depth: 36 imdres
Soil Application Rate: 02750 Mabmrn son Cover: Inches
'Systern 'DishibutionType: Gmvffy-SERAL
TYPE it A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Septic Tarin: 1.000 Gallons
LESS)
'Proposed System 25%REDuanON I-Piscm.Dm EIN
Nitrification Field Sq.(L Pune Required: , Yes a No OMay Be Required
No.Drain lits Pump Tank Gallons
Total Trench Lemgtin: 436 1i 147ooe: Yes No
Trench Spacing-. g es achO.C. GPM_vs— IL TDH
X8 Feet O.C.
8 l Dosirng Vekane: Gallons
Trench VVidOe - 36 Feet Grease Trap: Gallora
Aggregate Depth: inches Pre-Treahrrent L_�igF ❑TS4 nTS.11l
dc
SepTankInitak Grade Level Required: ❑ 11 11 01HLJ❑IV
Page 1 of 2
Help Files Copyright®2008 Custom Data Processing,Inc.All rights reserved. (odpnrptncversion2.0.7 6/132013 isd5.2.1 db=kyprodl)
https://portal.cdpehs.com/CDPNRPTNCNW REPORTS/ReportView.aspx?POPUP=Y&... 10/18/2013
CONSTRUCTION- For Office Use Only
AUTHORIZATION- — *CDP File Number 120966- 1
Davie County Health Department County ID Number: F400000006
f' 210 Hospital Street Evaluated For: NEW V
P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 / 0 1 / 0 0 0 6
Applicant: Thomas T.Gagnier r
roperty owner. Thomas T.Gagnier
Address: 3556 Piedmont Rd. NE 1 Apt.403 ddress: 3556 Piedmont Rd. NE/Apt.403
City: Atlanta CRY: Atlanta
State2ip: GA 30305 State2ip: GA 30305
Phone#: (813)523-1165 Phone:*: (813)523-1165
Property Location 8 Site Information
OMAddress/Road#: Subdivision: Phase: Lot:
550 Danner Rd
ocksville NC 27028 Directions
Structure: SINGLE FAMILY 601 N Tum right on Danner Rd. 1 mile property on right`at
smail white house
#of Bedrooms: 4
#of People:
'Water Supply: NEW WELL
System Specifications
Minimum Trench Depth: a 4
� Site Classification: Ps Minimum Soil Cover. Inches
Saprolite System? QYes QNo Inches
Design Flow: 10 Maximum Trench Depth: 3 6 Inches
14
Soil Application Rate: _ a 7 5 w Maximum Soil Cover: Inches
'System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 _ Gallons
*Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: OYes Q No OMay Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece:QYes ONo
Total Trench Length: ftGPM-vs- ft. TDH
Trench Spacing: - 9Inches O.C. Dosing Volume: _ Gallons
Feet O.C. g
Trench Width: Inches
_ 3 6 Inches
Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI OII 0111 OIV
Pagel of 3
CDP file Number 120966 - 1 t County ID Number: F400000006
❑ Open Pump System Sheet
Repair System Required:DYes ONo ONO, but has Available Space
rDesign' Flow:
ir System
Trench Spacing: Inches 0. .
lassification: PS — 9 = Feet O.C.
L, Trench Width; Inches
l�� _ 3 6 g Feet
1
Soil Application Rate: - a 5 Aggregate Depth: inches
Minimum Trench Depth:
'System Classification/Description: Inches
TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. a 4 Inches
'Proposed System: o Maximum Trench Depth:
Y 25/o REDUCTION Inches
Cover:Nilrification Field Maximum Soil 3 _ 6 Inches
Sq.ft.
No. Drain Lines 'Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 Pump Required: Oyes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-II
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
'Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall bevalld for a person equal to the period of validity of the Improvement Permit,not'
to exceed five years.and may be issued at the same time the Improvement Permit Issued(NCGS 130A-336(b)t.If the Installation has not been
completed during the period of wildity of the Construction Permit the Information submitted In theapplication fora permit or Construction
Authorization Is found to have been Incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location.Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
ApplicanULegal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature* Date:
'Issued By: 2244-Daywall.Andrew Date of Issue: 0 4 / 1 8 / a 0 1 3
Authorized State Agent: Malfunction Log OYes
_• Hand Drawing Olmport Drawing Total Time:(Fi1-1-11M)
**Site Plan/Drawing attached.**
Page 2 of 3 1 .Hours 0 0 1.11nutes
S-8-CKS issued-new
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 120966- 1
210 Hospital Street F4'0"000'P.O.Box 848
County File Number:
Mocksville NC 27028 Date: 0 4 / 18 / ;2 0 ~1 3
O inch
Drawing Drawing Type: Construction Authorization Scale: . OBlock
ON/A
�I'"i""��Nom^'
' I
E
apt- � - --1. i _;_
TU
I
1 _J
Pane 3 of 3
• IMPROVEMENT PERMIT For.offlceUse Only
`CDP File Number 120966-1
. 'n`• Davie County Health Department
210 Hospital Street
County ID Number:F400000006
-
. . P.O. Box 848 Evaluated For: NEW
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-16$0 PERff1T VALID UNTIL 411$J2018
'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
FAddress:
ant: Thomas T. Gagnier Property owner-. Thomas T. Gagnier
3556 Piedmont Rd. NE/Apt. Address: 3556 Piedmont Rd. NE/Apt.
Atlanta City: Atlanta
ip: GA 30305 State/Zip: GA 30305
#: (813)523-1165 Phone#: (813) 523-1165
Property Location & Site Information
rddress[Road#: Subdivision: Phase: Lot:
ner Rd
lle NC 27028 Directions
Structure: SINGLE FAMILY 601 N Turn right on Danner Rd. 1 mile property on
#of Bedrooms: 4 right at smail white house
#of People:
'Water Supply: NEW WELL
System S ecifications
F*SdIed"Classification:
ial System
Minimum Trench Depth: a 4 Inches
System? OYes ONo Maximum Trench Depth: 3 6
Inches
Design Flow: 3 6 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate: 1-Piece:
a 3 5 OYes QNo
Pump Required: OYes QNo OMay Be Required
`System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
`Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:0 Yes ONO ONo, but has Available Space
Repair System
`Site Classification: PS Minimum Trench Depth: a 4 Inches
Soil Application Rate: 2 5 Maximum Trench Depth: 3 6 Inches
O Pump Required: Yes • No May be
System Classification/Description: O O Y Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPO OR
LESS)
'Proposed System: 25%REDUCTION
Page 1 of 3
'CDP File Number 120966- 1 County ID Number. F400000006
:Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan The Improvement Permit shag be wild for 5years from dateof Issue with a site plan(means a drawing not necessarily drawnto
scale that shows the existing and proposed property lines with dimensions,the location of thefacility and appurtenances,the
(3 site forthe proposed wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shag be valid without explFatlon with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one Inch equals no morethan 60 feet,that includes:the specific location of the proposed facility
O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article This permit Is subject to revocation If the site plan,plat,or intended
use changes(NCGS 130A335(Q).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance;monitoring,
reporting,and repair(.1938(b)}
.ApplicantfLegal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps. Signature: Date: /
*Issued By: 2244-Daywalt,Andrew Date of Issue: 0 4 / 1 8 / a 0 1 3
Authorized State Agent: 1 OValid without Expiration?
O Create CA?
OHand Drawing 0Import Drawing
**Site Plan/Drawing attached.** Total Time:(H H-11 M)
Hours 3 0 Minutes
Page 2 of 3
Activitv Code: S4-IP'S issued:new,valid for 60 mos.
IMPROVEMItNT PERMIT 120966- 1 "
Davie County Health Department CDP File Number.
210 Hospital Street
County File Number: F400000006
P.O.Box 848
Mocksville NC 27028 Date:
Q inch
DrawinE QN/A Drawing Type: Improvement Permit Scale: . O
1-7
00
-4--_ _lam_ ___----♦_ .. _
- _ - -- - - =
� _
I �
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I 1
Page 3 of 3
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005653 Tax PIN/EH#: 5820-68-9073-Gagnier
Billed To: Thomas Gagnier Subdivision Info:
Address: 3556 Piedmont Road, NE;Apt 403 Location/Address: Danner Road-27028
City: Atlanta Property Size: 16+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.
Permit Type: 31 ew ❑Repair ❑Expansion Permit Valid for: ears ❑No Expiration
Residential Specifications: #Bedrooms #Bathrooms 3 #People Basement9115a'sement plumbingl3'
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): Type of Water Supply: ❑County/City ell ❑Community Well
As stated in 15A NCAC 18,3.1969(5)
Site Modifications/Permit Conditions: accepted Systems may also be used
System Type LTAR
Initial c }{C� G• �'�
�te 11n
µ
s t•�� •H r�
M
` l �e
�a
Environ ental ealth Specialist Date-,,&�N
i.p.11-06 .
APPLICATION FOR SITE EVALUATIONM"ROVEMENT PERMIT& �►
Davie Cdrint-Env1 nrnentdHealth •
.� � . : • P.O:Doz$d8;IZ10.HospitatSrreet M,t•
Mocksville,NC 27028 Ali
`U (336)753.6780/Faz(336)753-1680 4 107!
Application For:V 8104lushw lmptovemert permit 0 Authorization To Construct(ATC) 0 Botb
Type of Application: ew System DRepair to Faristing System 011vaudon/Modiflcation of adsting System or Facility
•f*/MPORTitNTo THIS APPLICATION CANNOT BBPMC ED UNLESS ALL OF THB REQUIRED
v INFORMAITON IS PROVIDED.Refer to the INFORMATION BULLETIN for instructions.
4 APPLICANT'INFORMATION
m Name to be Billed ' Contact Person /
Billing Address Bone Phone
ata Business Phone .•
Name on Pem2WATC ifL rant thaaAbove N A
Address Ci 1S
` PROPERTYINFORMATEON aDstagnLrfFacM Comers ed
V NOTE: A survey plat or site plan must accompany this application. Included:0 Site Plan OPligto scale)
(Permit' for 60 m with ' plan,no caphition with complete plat) /e
---1 Owner's Name Phoma Num ! D
Owner's Address tyrstat�ip
. t/) Property Address qty
Q� Lot Sim T PIN#
SubdivislonName( liable .
O fi Directions To Site l
If the answer of the fallowing qt---- '--
saq> doemn ' must, atte / /
Are there stay existing wastowater systems on the site? OYes llh /
those any easements or light-of x�ys on the site? OYes
Is rho site subject to approval by another public agatcy'1 rjYcs
Will wastewater other than domestic be gerersted7 DYas o
IF RESIDENCE FILL OUT THE BOX BBL w
#People #Bedrooms A Bathrooms fades Tn1ANYirlleol oyes o
Basement: Yes ❑No BasementPjMW. Lyes 0No
IF NON-RESIDENCE FELL.OUT THE BOX BELOW
Type of FaciiityBusirmw Total Square Footage ofBualdinp #People
#Sims #Commodes #Showers #Urinals
E stu hated Water Usage(gallons per day) {Attach documentation of aitnilar facility water consumption)
FOODSERVICE ONLY. #Seats
Type systam requested;% omvendwnl. MccepW Olnnovative aAlternative 00ther Al
Water supply Type:0Couoty/CilyWater V<Mwell Olhdstingwell oCommtadtYwell
Do you anticipate addirioaa or of the facility this system is intended to servo?0 Yes No
If yes,what"?
This MD certify that the irdwroa tion provided on this application is to and correct to the best ofmy knowledge I understand
that any permits)or ATC(s)issued hereafter aro subject to suspension or revocation if tho site is altered,the iotemded use
changes,or if t e information submitted in this application is falsifud or changed I hanby grant right of enay b the Authorized
Repress ve of the Davie County Health Deportment to conduct.necessary impections to dotero"compliancowith applicable
laws andrU1 etstand that I am res ons)ble p pmpar Wenallcation and labeling of properly lines and corners and
e/ArC s oration,propnud well location and the location of mry other amenities.
Properly mune's or 'a t ve sigaahae Site Revisit Charge
Date(#-
Client Notification Date-
EHS,
Sign giver OYes DNo , Account#
Revised 11/06 Cblr� Invoice# eS/lyl/
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Rad 290.00' c o
wr ❑I4yfWM Review Officer'.Certificate
STALE OF NORTH CAROLINA
OR TCOUNW OF DANE
+ 1 1Tract One e N L Revises lot o/
�° Tnct Four 16.000 gCre9 & toA.county.certify loot 1. may a mal
to which lob certify th t is alfised mob al
jstatutory r•qufrem•nb la recoding.
20.000 Acres
5bad p
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\ Dale
r dverf+br Jv OwVhy 1 1`Q a'diM el3lond
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c99orG7H in m c� Aa9d. NO PLANNING DEPARTMENT APPROVAL REWIRED.
77 RL 582088705'1
In ' vo BSB rG 642
2 1 PLANNING DIRECTOR
East 981.19' _�y
Manz! so
g0 East 1297.74' $
S 8Y '02'E
a a3 39
11YY-�e` L JEFFREY C.ADEN -certify lhb pbt seas
Slonon Ase aC«my wpaM nal(deed Wsaipibn coreea kyi eodei
•• f.(IItIQ `adr n@claoh 9hd- ed�one Wawnat e from hionnotbn found b
n y 1 N -evePH�Baeulal 1 10000+:that that
thisthe
plal was precision
in
milts by s 7geT}1 �• wrnrG551 accordance eith G.S.47-30 ae amended:that regarding
Q G5.1]-3IXf)(11)d,Nb wx.sy b an ncapt.to the
p�L d.1mitan of subdivision.
1W „3
Tract Two tallness my Wglnal signature,registration nanber
�' and sea this 7U day of March,2011.
M 4870579958 &� Tact Three 17.815 Aare
w Lo 917P4809 22.875 Acres °
L912BP4N500 �
PROFESSIONAL LAND SURVEYOR L-3910
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b44 1 OF w.5,k lsed
L14 // �� 19
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V.asw t y�•� 411 Rrr
FM T;5.6" "' R coxa PRELIMINARY PLAT
W=" NOT FOR RECORDATION,
5 57011♦
5s5 CONVEYANCES,OR.SALES
LEGENDp G `t 7513TAN 4y og 291.71 19TA/1g
eaxss 6•arhg Drlanes
Or exallw IRON rre GO 525/G'.o9 115.
rr WI y 2 7307 N OS2329 58.09
cm Dm71NG IRON REDAR s 872'50 Labev-fisdtd. N 173522 W 50.45
uY O03TNG AXLE 1' , ret M2061600 3'OS O2 W 2 A9
FANG CO3 WANGLE IRON G' DIM 1 I�q [9525M50 4 N 1't724 w 2.
TSAR o=Tlw IRON T BAR IT q9 J112 W 17. Donald Joe Danner
Mw OQ97111re ETON[ t91'131 N P 9 31 W N.1
rr rO w MOIL Ou D oll - s bZA I e.P rN,yd. I NN•23 05 w 4
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cr MDG!Or PAVCAr A 81 5 810866 575 Us N 1-4152 w to3.t0 Clarksville Township Davie County
hW RIGHT.O WAY4'4 S W 19.14 NORTH CARDUNA
LTA► CORRI1GATm METAL PIrE
19§11`15.581 Lto N 5So724 w 93.23 150' 75' 0 150' 300' 450'
11 N 5544 14 W 4.95
rIN FARC&vew MCATION NUMEOC 1 1N 54'57 25 W 97.15
TT TCl?t101Y rmC3TAL t N M5'12"IN 170.20
-,x- BAum.wta MCI! DAME COUNTY REGISTER OF DEEDS L14 N 872638 w 137.ss SCALE DATE doe/ DRAWN
.O. OV6a1G1D IIDI1fY PLAT REGISTRATION u5 x e60619 145.47 05 W.181'-150' 04/11/11 0202 JCA/MCF
��A< CERTIFICATE OF OWNERSHIP AND DEDICATION LT. s§.6'3443 50.45
• FILED FOR REGISTRATION AT O'CLOCK _M. I hereby certify that 1 om the owner of the property le s SRI4 52.12
NOTE5: - described hereon,waNn is located h Ue subd--' L19 S 762924 E 51.12
THIS, THE DAY OF _ 2011, AND jurisdiction of Davis County oma that 1 hereby adaal L20 1 5 W51'29" 57.12-
1.Ta read ldasAubon Nunken 5620669073 RECORDED IN PLAT BOOK _ PAGE _ this suDdMslun plan with my fres consent.establish ('1
2.DeedRelononrn,Pont o/DD IMFG469 minimum bolding setback lines and dedicate al 1lJS
.,
S.1h1e1N=1K"Am Bunte(road.).dleye,walks,pa,ks and other°ilea OW1NERt
4,rrapety a not Ioc.W weden a 5PacW rlopd Healed M. BRENT SHOAF, REGISTER OF DEEDS
and n..menls to public or ornate use one noted. Donald Jos Danner t A e u S V x V F Y l N 5
Aviv d per rEMA road Ines-Rada Map �FILING FEE PAID. $.11 Tamworth Rd
(37105U=kl-otrPal d•tad 3apta,bar 17,2006) Asheboro,NC 27023
Allen Geomatics,P.C. C-3191
s.3ubpa popaty salad,RA BY. PO Box(33 Advance, NC 27006
� Donad,Ise Danner oats (336)782-3796
-AlenGeomatics.com
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005653 Tax PIN/EH#: 5820-68-9073-Gagnier
Billed To: Thomas Gagnier Subdivision Info:
Reference Name: Location/Address: Danner Road-27028 J� �,/
Proposed Facility: Residence Property Size: 16+Acres Date Evaluated: 3
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 1— Z
Slope% . 41 e
HORIZON I DEPTH 'YO _ (P
Texture group G C C
Consistence
Structure. 4t4 K
MineralogyF
HORIZON R DEPTH – p.1
Texture group C.f: G
Consistence SS `
Structure k
Mineralogy5
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralo So,
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE 0 .).-T4j a26,
SITE CLASSIFICATION: VALUATION BY:
LONG-TERM ACCEPTANCE RATE: 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-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 4 C-Clay-
CQNSISTENCF
a'I41St
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 ��(� A
SBK-Subangular blocky PL-Platy PR.-Prismatic
lid
Mineral=
1:1,2:1,Mixed
lYQt� [' ✓ D
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)
TTAR -T.nriv-term nnr•entnnop rntP- anilli9V/ft7 T/•TiT nClAG m__.c__a
J
APPLICATION FOR SITE EVALUATION/IMPROVEMENTP ' TC
Davie County Environmental Health
i ®� -
P.O.Boz 848/210 Hospital Street /J,�R
I Il i/t ka ���d _ P '
Mocksville,NC 27028
Ph (336)753-6780/Fax(33 3-1680
Application For: ❑ Site Evaluation/Improvement Permit uthorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TILE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION.BULLETIN for instructions.
APPT,TC;ANT TNFORMATTON
Name Contact Person:,,�,. �ayyY-
Address ` -) Ckdar CVeZV- tk Home Phone
City/State/ZIP 4(- vit?-V Business Phone
Email-crc-\\-Av®Q�lckwrrer cr�r�6�s.Cor+n _
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged 3-1 5..1
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
Owner's Address P;edmq4 Rd rJk City/State/Zip 941an4a 66 3036- 7oo?
Property Address D"Yur Kit City Ilk
Lot Size 1 to A c. Tax PIN# LO�7 3
Subdivision Name(if applicable) . Section/Lot#
Directions To Site: 6 0 TO 2)anyu, Sd �c rasa ton+ Vivuuur(1 �w> �Gv41 Ot�� ��t(S TN Fran
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 LNo
Are there any easements or right-of-ways on the site? _Yes _�LNo
Is the site subject to approval by another public agency? —Yes ,/_No
Will wastewater other than domestic sewage be generated? _L-Yes No
TF RF,SIDENCE FTT T.OI Pi'THE BOX BELOW
#People Z #Bedrooms 3 #Bathrooms 33 Garden Tub/Whirlpool ❑Yes RNo
Basement: Yes ❑No Basement Plumbing: ❑Yes NNo
TF ETON-RF,SIMNCE FII_I:,OUT THE BOX BFd.,.0W
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: XConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
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 i 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 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 tht I am responsible for the proper identification and labeling of property lines and comers and locating and flagging
r staking the h e acility location,proposed well location and the location of any other amenities.
^' Site Revisit Charge
P erty owner's or owner's legal representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
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