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455 Duard Reavis Rd• DAVIE COUNTY ENVIRONMENTAL HEALTH ILI ' �.NfY P.O. Box 848/210 Hospital Street 44 Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005628 Tax PIN/EH #: 5802-85-9415 & 5802-86-7889 Billed To: James Reavis Subdivision info: Reference Blame: LocationlAddress: Duard Reavis Road -27028 Proposed Facility: Residence Property Size: 1 Acre AT 4ffiqW* The issuance of this'Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11- of G. S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of 'System Type: S.T. Manufacturer : OQ Tank Date1Q Tank Size Pump Tank Size II System Installed By: Pbet5 &OaL E.H. Specialist: L bf A ate: S �l GPS Coordinate: aehC11/7 DCHD 11/06 (Revised) T DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street �� Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005628 Tax PIN: EH #. 5802-85-9415 & 5802-86-7889 �j \ Billed To: James Reavis Subdivision Info: Reference Name: LocationfAddress: Duard Reavis Road -27028 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 5770 Site Type: XNew ❑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. ;4 Residential Specifications: # Bedrooms # Bathrooms Z # People Z 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 Specifications: Design Wastewater Flow (GPD)-731I'ank Size /CWGAL. Pump Tank MGAL. Trench WidthM_ZEax. Trench Depth3 b Rock Depth�A Linear Ft. 3W 7 . Xi�stated in 15A NCAC 18A.18S9(.ri Z�i�'k VI Site Modifications/Conditions/Other: t CCPptP� &4r' ems b� use Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. t) C (210 Environmental Health Sp DCHD 11/06 (Revised) Date: 2vti Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005628 Tax PIN/EH #: 5802-85-9415 & 5802-86-7889 Billed To: James Reavis . Subdivision Info: Address: 455 Duard Reavis Road Location/Address: Duard Reavis Road -27028 City: Mocksville Property Size: 1 Acre 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: Wew ❑Repair ❑Expansion Permit Valid for: )U Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms .2— # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3%�� Type of Water Supply: ❑County/City XWell ❑Community Well Site Modifications/Permit Conditions: S stem Type LIAR Initial o Repair ° o ... on Ito' Site Plan to .t Environmental Health Specialist u Date- i.p. 11-06 atei.p.11=06 { &112 al�ore. o j�9 dioj 5, APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ,FIVE Davie County Environmental Health E P.O. Box 848/210 Hospital Street SAN 3 2011Mocksville, NC 27028 (336)753-6780/ Fax (336)753-168t , II AlMi'cat' _. i e valultion/Improvement Permit Authorization To Construct (ATC) ❑ Both J Type of Application: "ew 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 �A&jeC RPn J J S Contact Person e0a AdcYiess I 7 Home Phone �� (�, _ a - -7 7y3 r- City/State/ZIP (Y\n C V, < l-6 I 1�_ A), C, a -7 t) a P Business Phone Name on Per nit/ATC if Different than Above_ Mailinc Address i l---;- i /. YKUFhK1 Y 1NPUKMAI IUN fillate House/Facility Corners Flagged � NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is lid for 60 months with site plan, no expiration with complete plat.) Owner's Name 11 S Phone Number 31 Owner's Address- SS �Jr�l " {��cU; S City/State/Zip r Property Address 50, eyl City Lot Size y -.e Tax PIN# Ego& �5-, ofm- 001-96-1911 Subdivision Name(if applicable) Section/Lot# Directions To Site: (0ol jlar�k 4, J, Lr tlrc-1. kd. 141 n� -AN kc G If the answer to any of the following questions is `-`Yes",sup ( Are there any existing wastewater systems on the site? Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? Is the site subject to approval by another public agency? Will wastewater other than domestic sewage be generated? IF RESIDENCE FILL OUT THE BOX BELOW ting documentation must be attached: _Yes "No _Yes VNO _ _Yes No —Yes No Yes -No V People a # Bedrooms _3 # Bathrooms , Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes PNo Basement Plumbing: ❑Yes [ 1No IF NON-RF.SIDENC'F. FILL OT 1T THF BOX BFLOW 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 A Water Supply Type: ❑ County/City Water "ew Well ),Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U -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 pennit(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 detennine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and Iing and fl a ing or staking the house/facility location, proposed well location and the location of any other amenities. r;Ar-; 1 I -QDJv) Site RevisFPNAL N Property Aner's or owner's legal representative signature P P Date(s):. �A�, G��7 A _ Client Notification Ifte: �1AN 1 _ Dale �EHS: UD � �G�tiice� � eotSe Sign given ❑Yes ❑No q(09-30Atcount # Revised 11/06 Invoice 4 Go Maps GIS „1, 00158ft Page 1 of 6 http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 1/13/2011 ---------- socP v Q re P U a 10 -F4 . • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATI Account #: 990005628 Billed To: James Reavis Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5802-85-9415 & 5802-86-7889 Subdivision Info: Location/Address: Duard Reavis Road -27028 Property Size: 1 Acre Date Evaluated: dL Water Supply: On -Site Well Community Public Evaluation By: Auger Boring ,X Pit Cut Landscape position HORIZON I DEPTH NPX710� Texture group___ Consistence MineralogyHORIZON Il DEPTH l►::'�1'i rq. ' iii®®®® Texture . group Consistence Mineralogy Texture group Consistence -HORIZON IV DEPTH Texture prou—P Consistence Mineralogy SOIL WETNESSSAPROLITE CLASSIFICATION SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �0 REMARKS: EVALUATION BY: r(VII)VII&I 1 62' 17--l"Y.�/ - OTHER(S) PRESENT: VSs 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 C - Clay P CONSISTENCE Moist 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 SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralog 1:1, 2:1, Mixed Nate;: 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) i TAR - I.nna-term arnPntnnr#- rate - nallAav/ftp -T— ^11^1 �^ ■■■■/■■■■■/■■s■IMIM■■/■IM■■■IMIMIM■NIM■■IM■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■IM/■■/■■■IM■IM■■■■MI■NIM■s■IM■■■■■IM■■■■IM■IMIM■■■■■■IM■rwIMMI■■■■IMIM■■■ iOMINEE MEMNONMEMNONi�MwgAMl "e > liiiNIMMIN iiMIMUM iMEMNON i ■■■■■■■■■■■■■■■■■■■■■■■■■■■■IM■IM■=======�===�■■■■■■■■IM■IIIM■®ire■■■■■■■ ■/■IM■■■■IMe■■MIIM■■■■■MINIM■■■IN FUMIi■■■MEMO ■ ■/eIM■■IM■NIM■■■■e■■■■■■■■e■e■■■/■■■■ui■■■■■■e■■e■■■■IMIMse■■■■■IMe■■IMe■ ■■■■eel■■■s■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■IM■■■IM/■■■■■■■■o■■■IM■IM■■ ■■■■■■s■■■■■■■■■■e■■es■■■■■■■■see■■■■■■e■NIM■■■■■IM■e■■■■■■■■■e■■■■■