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189 Doby Rd• DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Sh�eet Mocksville, NC 27028 (336)751-87G0 Fax # (336)751-8786 Account #: 990005037 Billed To: Jason Dobson Reference Name: Proposed Facility: Residence ATC Number: 4837 OPERATION PER11�I� PIN/EH #: 4799-63-7803 Subdivision Info: Location/Address: Doby Road-28634 Property Size: 2.06 Acre **NOTE** The issuance of this Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treahnent 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. 1-. �4� �j�0�� 1 � ! System Type: 1 1 S.T. Manufacturer J Tank Date D Tank Size G'G� Pum Tank Size � .P � i �.'`J Gj�'� 1 .� � � "Q System Installed By ��.QY ��r�`" E:�I. Specialist: C� � �� Date: � � �,� �� 7 �� ,� L_ �� J� � � � ._._- � ..l�TTT 1 1 /llr /T ___'.. �\ �r��'fi a.i q'� 1 � c�` / -�, �--j-- �� oc� s �--��2��,�_,/` � -t- tG� (�-- ._.�- - . r DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O. Box 848/210 Hospita.l Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751, 8786 AUTHORIZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION Account #: 990005037 Tax PIN/EH #: 4799-63-7803 Billed.To: Jason Dobson Subdivision Info: Reference Name: Location/Address: Doby Road-28634 Proposed Facility: Residence Property Size: 2.06 Acre ATC Number: 4837 Site Type: � ❑Repair ❑Expansion **NOTE** This Authorization to Constnict (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pernut(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 J # Bathrooms� # People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size _(� L Ca c f,� . Type of Water Supply: OCounty/City C�ell ❑Community Well System Specifications: Design Wastewater Flow (GPD) ��Tank Size dC?� GAL. Pump Tank�trS�1— GAL. � �' ti � �� Trench Width '�G r Max. Trench Depth 3�O Rock Depth �� Linear Ft._ eL�S�_ �.J ::t�ied in 9.5ra N��"�C �£3,�.1��{�j SiteModifications/Conditions/Other: �,...��, �„_*_...__ _..: . =v y , „ _..0 ��'� ��Contact the Davie County Environmental Health Section for final inspection of this system between � Q� 8:30 — 9:30a.m, on the dav of installation. Telephone #(336)751-8760. \ � .. ��__ ��y ,s, �.� �s - - s5 � �{ �, � r c,� v�. � r� . �-�, �---� �. � L;�,,�,.� r � � .5-'r �h p k.'t� W� c�9 f_ "%-� as 5 Gw� t� . �— .�/-. _``/-... � / � S Environmental Health Specialist DCHD 11/06 (Revised) 16�� X �' ��« tlt� _ �� / � �=�� .�-- �u� � � � � �- ' � `'�' i" �. �-' .✓� � � �� G �l.��" i� r IM1 ,—. - .�—� �` / � �D i .�-- .f.. �� !` � /'h� �� N � G � -� �,PU,� Date: :p�J v � � A �'� Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990005037 Billed To: Jason Dobson Address: 170 Guilford Road City: Harmony Reference Name: Proposed Facility: Residence IMPROVEMENT PEF�I'�',IN/EH #: 4799-63-7803 Subdivision Info: Location/Address: Doby Road-28634 Property Size: 2.06 Acre **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Pemut Type: p�ew ❑Repair ❑Expansion Pernut Valid for: C�3"�'ears ❑No Expiration Residential Specifications: # Bedrooms� # Bathrooms �# People Basement0 Basement plumbing❑ Non-Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Design Flow(GPD): � v Site Modifications/Pernut Conditions: Type of Water Supply: �'Csounty/City ❑Well ❑Community Well Environmental Health Specialist Date LD � � �`n�.� \ � �,. ��\\ � \../0 ; � ,�( . ,. \ �� / � + � \.1�/ � �/ r ��J �. � r� �:\�+�� '�P�?LIC,A�TION FOR ,�,_,� �� ` ,,�� / � `j�4�; ��-, ��0 �� p� EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Applicatio�r: Q Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) C�oth 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 THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed � G�� -\ �,��-Sj��Contact Person Billing Address __ 0�0 �-�,�� fc� Q� Home Phone �.Q�, - J�� -��, 1� Eity/State/ZIP _ ��, �{ �-� �� Business Phone ��%U�- qn� , y�'�� Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facilitv Corners Fla��ed o'1 �oZ;�( � D NOTE: A survey plat or site plan must accompany this application. Included: � Site Plan OPlat(to scale) � (Pernut is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name � �� '��Y1 Phone Number��-{ -�..�;Q �.�`��, Owner'sAddress � L v� �-�� \%_c:�1 City/State/Zip ��XC��!�,,�, �. �. �I.: `9t - ` Property Address 6 City Lot Size �, 0 6 Tax PIN# �-(�� fJ3 Subdivision Name(if ap �li,cable) Section/Lot# Directions To Site: �h-� ��" C-�� F��'�I Q�� '�� 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 BiGo Does the site contain jurisdictional wetlands? ❑Yes l�er' Are there any easements or right-of-ways on the site? ❑Yes 9�0 Is the site subject to approval by another public agency? ❑Yes [�33Qo Will wastewater other than domestic sewa�e be Qenerated? ❑Yes Qldo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms � # Bathrooms Basement: �s ❑No Basement Plumbing: �s ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Garden Tub/Whirlpool C��s ONo 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 Typesystemrequested: �nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water Gl-�tew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C,].3�0 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 pernut(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health 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 s in he house/facility location, proposed well location and the location of any other amenities. �'" Site Revisit Charge Property owner's or owner's legal representative signature r Date(s): ��-`a�� Q��J Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # �,3 Revised 11/06 Invoice # �� _ /— Exe N r • .,,,,.,,,.,.. ��'•u �w" .,,��n��.. .�.�• �r — �w � 1 h�nby cartify Uwt I am th� own�r d tM pnMrty shown ond dMc�ib�d h�ryon. which boat�d in tt� Cour�r of Dovi� ti�at 1 Mr�by ada�pt tt►iw pi�n d�ubdtviaion �ritl► my fr+M co�nsw►� Mld�Lt�d en�ier�wn buiidinq Mkbndc tin� afd d�dic� oM Mr+�1�b. all�yr. wa�. Paio� and otM�r WM a�nd �oMnwnt to publk or p�lva� uM w nabd. FurtF►�rtr►oh. I Fwsby d�t� dl �a�tOrY �sw�r or�d rralK �� t� Cowrky af Govi� , ,,,,� , .-�i ') � , , �/�� L%E'�c [37iL ,Fy'. Lc L��'!�%`.�--' ,�'f�-� �_c'_�:.c d c-" � f 1Mk1W1 N. CAYF'9ELL � �� ; �ic�' �z. �< <i�c,Lf:��,�'k. �� , . j ' � • ! ,. '��.. � '1' vF 11All.UW J. , � � o�c - I. te�.� i ��Ibtid m� _.__._�.�...�,..H�,.:.�...,..�,-�:.,,� . _.:-.r:,.._..-_..�-ti.,�-- .. ..,... �.s..,...,�,.s--.�..,,�.,�.--�«.�,_.._�.,�. .,r.___,. : �: c? ..�_ __ _ —•�%iY.f�y_Y �' � %_ - � ��,� o � , , 1 �� _ r � :-- _ � a ,, ___ . , . ,.—� , ��a `J __�,. �._ _-----._ .� , ,,� �. c �� ' ' � .,��? � �� S ' .. - �, l ��. _��/"�1/ y �� . `' � ; o�� ,� s �� % � .; �� . GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System O �9s F . � �' � � '� � �°t� �'� f� �, � '� � � 0 ��_ Click Here To Start Over Acti�� Layer. � Use Map �ps PARCELS (Map Tips Available} - Page 1 of 1 , 2oom To S�cale: � y , Quick Search:�(Gounty ID ar Owner Name� � _. _ .�_�___- . GIS D�t Horrp Paqo_ � Caritacts � Deoartment � Ii�f Map Layers � Results ( Address%NamejPar�ei Search � Toois http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129&CFTOKEN=61640881 &initializem... 3/4/2008 GoMAPS - Davie County NC Public Access Page 1 of 1� c Davie County, NC - GIS/Mapping System r Cs �'':;� �l.t� . - -T. f : :-`�,.�`�� `� � � ��t ��' U t+"' � � � ,+'' 0 �", Ce�a2 � i?O $ Y:: RU �� : 0�2�9ft Cli�k Here To Start dver Active Layer, � Use �nta,� �p� PARCELS �,Map Tips F�vailable) - zc�om io 8�cale: � �uick Search:�C�ount}� iD or Oti�aner Name) tiIS D��t Harrp Gaq� � rcint�ts � Devartrr�nt � Inf Map Layers � itesults � AddressfNam�fP,�rcel Seareh � Tool� http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129&CFTOKEN=61640881 &initializem... 3/4/2008 , • APPL�(�'ce�3r'�t I�FC�3lDQf�T�'N Biiled To: Jason Dobson Reference Name: Proposed Facility:. Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section � Soil / Site Evaluation Tax PIN/EH #: 479��Y INFORMATION Subdivision Info: Location/Address: Doby Road-28634 Property Size: 2.06 Acre Date Evaluated: ��^ [� � Water Supply: ' On-Site Well Community Evaluation By: Auger Boring Pit FAC'I'ORS 1 2 3 Landscape nosition fi �� Slope % ' HORIZON I DEPTH Texture group Consistence S tructure , HORIZON II Texture grouF Consistence Structure HORIZON III DEPTH Texture group Consistence Structure HORIZON IV DEPTH Texture group Consistence Structure � Mineralogy SOIL WETNESS RESTRTCTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � SITE CL.ASSIFICATION: � LONG-TERM ACCEPTANCE RATE: L%• �` ? S�- 0 rl` 4 � Public Cut S I b EVALUATION BY: _ OTHER(S) PRESENT: / 7 , REMARKS: �.�,� -�'�-r 's�4' f '' �+ L�GEND � I,�n s .ane 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 - Silry clay C- Clay CONSISTENCE 1�Qis.� VFR - Very friable FR - Friable FI - Firm VFI - Very finn EFI - Extremely firm � NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic � r, ,r SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic MineraloQv � 1:1, 2:1, Mixed LYQtc� 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 ru-un n�inc in....:.,,,,,� / . � • ' Account #: 990005037 Billed To: Jason Dobson Reference Name: Proposed Facility: Well ATC Number: 0005 Davie County Environmental Health P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (33�751-8786 WELL PERMIT Tax PIN/EH #: 4799-64-3039 Subdivision Info: . Location/Address: 189 Doby Road-278634 Property Size: 2.060 Acre Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. �_ Permit Typ�: New � Repair ❑ � � � ~l --�ropese�-�Vel�-�eexdon-Bi�gfa�t—f �`-� . � r 1 1 � i �., (w J,�`�� ,0. � �v � � �,�"' �� ,� �I �`°�i�c � � 5 i 1 i � �� ` �� 1 0 �U v �� ' S � �� v �� l ❑ � �, � � � �a �� `�-� �� , � , /< � � � �w Comments: W-e � l �, �'} ,�,j.� i bG � i � ` , t �/ � J�j H . GK +'t _ i' �u n I.T �,�„ y ti G/( 5.�1Q 1u ru ��S EHS: W.P. 7-08 Date: 'J of Completion Diagram <� ( }� f �, � + ( � '_ � �. w� �( � ( �, � � 5 ` _ \ �,� r�� f Driller: � e K� u u ��l Certification #: Grout Inspected: —��/ "� � �t/ i� Well Head Inspected: �j � 1. 6 �. GPS Coordinates: L '- � � � �`% p` �HS: � �J ,J�/ r�.� i nv�� Date: � • L. Q v"' � �1 !i� 1 �� o � c.�.� 01� W ��7z- � a T ��sf� APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Ca�� w`°�", $�m'�/� ***IMPORTAN7'�** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name to be Billed �O,G 1 ��1 Contact Person Billing Address $� �'C),1 Q c1 Home Phone '�O�- Syln - a$'a,�"j City/State/ZIP NC�xrr�r� N<- 3 Business Phone -1� —�pa— �1qaC� Name on Permit if Different than bove Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Piat (to scale) Owner's Name J G � Phone Number �O�—a -��'�'��c Owner's Address \"1C7 �4 Ui 1-�'OC�d City/State/Zip �-�i�('�� p_�C. �Y`J,9� Property Address \ City �\� Lot Size 'I..OGC� �C�/eS Tax PIN# � Subdivision Name(if applicable) Section/Lot# Directions To Site: � f�l.c/� T�� a'� qo! ' 7�• /.�unsii G+iL I� /iL1 s�, �hv -%�Lt�/� DEVELOPMENT INFORMATION Permit Type: New Well ✓� Well Repair Well Abandonment Other (specify) Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. e Date 7/1/08 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # �� Invoice # D i � / { b _ ��_. ,� � � � t � / \ \ � � � / D.& 529.P C. 371 1 M� e.rtly Mat I�n er enr d tlr orao�p Mnw� om Ca anr swveN ti.en. .�+a� bme.e Y� uu Cou�d .e OaN. 1M I �w�lf' �� tliY CM M w►s+r4 �IM �7' fn� �wrR �Mw aMltw d OnM Oa�'. ..�w,w �r�... s� ..w.� ti.. .�e e.s�s. a.a..e� � nae .�v « v�a r.Na ar e.nn�n �n ••� r� •�e aM .r. aw ..w�rnc r e� r r �rw. a.ma� war�+� �« ��a pAay r r nebL Ivtlrmww 1 MbY adoab a r�Y ... w.�e. �.. d w�«�b w oa* /j/ �.� 1��'� •ua iil .'li::�,, ��/ %�./✓Q2 ��- an a ci �atr� n. arieni i r�<.v wh % �� a � u /1n i •'xGcw v,r��"� 1111NY��—l� ^ .�xa�- z.oso lc. �IILIIY 9. CAYPBdLI. Trusts• D.B. SE9, PC. 37f FAYIIY SIB�ON�40N �) �,..�, �.r. �.�pwM �,� �. �3ieEAMm��O� d DaM� CawO'. fiY 1� � I�eN wlA4a �d r mr w.�wY. pve.. �ce�..�� w.�e�q e.�+r �e.• .mrn u. rora rq• ar r�.r u�++n �r a./saee. r�r ��ee r Y..a �. w w.w.. w..i. ..w�a .ar m. . ■ w rww. �d rar Ne.. r.�+r �.�a.� .va� w�e..�Pi.d .�r. e��°« ,aa'�a' m °Y�Y °'°" .y ��v�� o.nns � j��d1f ad,�flo� b�y ird bnb wr�M� '_r y __'w..w.�.-nra.u.ew� 'Ib1r ..d�r� Sh^'�� lat/•_� �tl 'aN� � i MaM NlatlarA4 y � � w/i_..�a �, ioy .w w�. �aw�++v s � �� I J `�C � "f . `. IIIlLlAdf B. CA3fPBSLL, 7'n�atae � '� D.B. 6Y9. PC. 3yf 1�"' �� `,,�, _�—. -_'� � � � �� `�� if `'�.� MtM M usi�'[Nf"-----�-...v-- �` AS Oi �WI-IY-IWR �l \ �� rt �� i I I 1 1 1 I I I MNM��Mrrw,� .�"Q.SH ��(i�+ �?�,��.�� . 426�Z7 s :09y�,yp��,a;! nt�;,�++� N�Nin l O�aA� l. TuRwe�. owEh 1Ad t!i Mol .a Oraw� �qr Rry wq�MMa� bem � aebd �ev / mae� �ndr �qwrWen er[ noe�a�C Y� leak � YW� M�) dlrr 1/nt 1M ee�nee�4� rol v'�i'tl � � Aa.w Ilom Monrotlan faM In H. Pop� yqt 1M M4 d/sYM Y Wnla� � 1. +'� • aU�ot tl�U 0� � f��Da'� ti eaoerdanw �Rh C.S �w � .��ew. Nar � on¢� dpwerw � w.ro.r N ai �� A�r • r (s.s �r I �.aw+aa� wne.. gK- q PG� 2q�- F,.a ,� ..� .� �55 •� �. FF.BfZIJA[�Y 12. �ooe .b.y,.��,.a r r+ot sar �_. bw c�� - �r.t:,rr a esd -e►eo �w�w 1 '� � Y1GllVl17 MA I �\ 1 � � � � / � �� IIlLLLlN ✓. CAEfPBBLL � � �` D.B. 343,\C 69f i / ; �` j / � / � 1 � � � i � i � � �� i � 1 JOYCl DOBSON �II2lSldN SUZW1Vd DOB: ; D.B. *85, PQ 519 . ; '�i , � �� =�� NL10 _ — _�M � 0�. 465. � � ; �� , � �10 5'0. �� 1 i i IIILLIAAf .7. CdYPBBLL 1 y J. �P49b� 11 � D.B. 4g3, PC. 822 i wTD B��1, Pr^' ; 1 I IIIILGY J. CdAfPBBLL D.B. J59, pG. 600 ��TE �EI 1C CISE1LMf AND E%IST�MG 1�' F/SEYEM M71 MOT BE A INMm Rd1�WM' •T 7NR 71YF. AS YF/t BINR CM�uBERS. DANE cowtr oteclavv[�rt scn�cs. fie-�-sooe w w+�a.� iea� n n� t tMs vrtavcxxrc inaTm wmw m[ ws-� ��IO�r �� MATEFS�KD APEI �cwnr nN..m ama x n�n[ e no owFunie a eu�nn+c au n�s srtc ws ov rce-�-zooe. �� q PLAT MAP: i�ILLIAM H. CAMPBELL, Trustee OWNER —_--------� DEVELOPER YMIUTAH Il CAYtBELL t�t� r. r[voRw. kwr wu�uorcr, N.c. seex CAUHAN TOWNSHIP DAVIE COUNTY, NORTH CAROLINA n�rs: r�rr-xe-xooe TAY YAP REF.: H-1. P/o � surr�vm er: TUiTEROIf SURVSYING CO3[PANY 707 NDKIM S�LISBURY SIItEET MOdCSHLLE. MC 2702a (1}6) 751-3816 f' � f 00' SUO 30 0 100 200 300 SCALE iN �EET rxa w�uc� toorto wWc: aawma nuusoa .r-oos cwe[u�-n �wsa � � �----s--� . . , .. , • . DAVIE COUI�TTY ENVIRONMENTAL HEALTH P.O. Box 348/210 Hospita,l Street Mocksville, NC 27023 (336)751-8760 Fax # (336)751; 8786 AUTHORIZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION Account #: 990005037 Tax PIN/EH #: 4799-63-7803 Billed.To: Jason Dobson Subdivision Info: Reference Name: Location/Address: Doby Road-28634 . Proposed Facility: Residence- Property Size: 2.06 Acre ATC Number: 4837 Site Type: � ❑Repair ❑Expansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building perrnit(s), (in compliance with A.rticle 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) LotSize _C� �= C�c �.� Type ofWater Supply: ❑County/City C�Jell ❑Community Well System Specitications: Design Wastewater Flow (GPD) ��Tank Size ddG� GAL. Pump Tank��GAL. t �� ti� Trench Width �[�r Max. Trench Depth 3�' Rock Depth �� Linear Ft.�� , �+s �t�#ed in 3.�t9 NCt,C 1�3�.:i��(a� Site Modifications/Conditions/Other: ��,��r�,� �uv,., .•.�,_ , ..,4 i.�� . �,+y �� 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. ^ �� : ( �%' 1 C�� `� X � ` '�v�t�c e�i� � `-`. __ ��,�y . �5' ��4. , ►�.�, r. ?S- � � � � � �- �wtt� � � �,� � �� (u.r,�� .,5-t�� a �.rt- �v� w3 � �b-� ��5 5 G �r;� � Envuonmental Health Specialis DCHD 11/06 (Revised) _ f�d�`� /� ' � �� ` �— J� ct d�: v� , -�.--!' ..�^ % � � -- p �'►�- i- �, , � � � F. '�.-� , �. � +�` ,----- - �,h� ---... �. �-� �`" ��' -- _ ,--,... __---- ..-�-_ ...�-�� / f l � L� ��'' �P,,�r�Q� Date: � � --��' �