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260 Duke Whitaker Rd (3)Account #: 990005836 Billed To: Russell Hicks Reference Name: Proposed Facility: Residence DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Taz PIN/EH #: F20000002102 Subdivision Info: Locationikddress: Duke Whittaker Road -27028 pcctperly Size:. 1540 kcres ATC Number: 5907 ; **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, 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. System Type:_ S.T. Manufacturer _ Tank Date_ Tank Size_I not) Pump Tank Size / Bedrooms: 2 - System System Installed By: y FkkAjQf Installer# Dater Z GPS Coordinate: DCHD 11/06 (Revised) y s � �� DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street ` \\` ' Mocksville, NC 27028 \ (336)753-6780 / Fax # (336)753-1680 1 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ,account #: 990005836 Tax PIN/EH #: F20000002102 Billed To: Russell Hicks Subdivision Info: Reference Name:: Location/Address: Duke Whittaker Road -27028 z�Z Proposed Facility: Residence Property Size: .IAcres Site Type: ❑New ❑Repair ❑Expansion ATC Number: 5907 **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 pC # Bathrooms o # People Basement Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size u_ Type of Water Supply: ❑County/City IW-W�eW ❑Community Well System Specifications: Design Wastewater Flow (GPD) Lab Tank Size GAL. Pump Tank % GAL. Trench Width Max. Trench Deptl&Q�_ Rock Depth Linear Ft. 2� c V Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8: — Telephone # (336)751-8760. Environmental Health S DCHD 11106 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005836 Tax PIN/EH #: F20000002102 Billed To: Russell Hicks Subdivision Info: Address: 288 Duke Whittaker Location/Address: Duke Whittaker Road -27028 biz City: Advance Property Size: 224f6Acres Reference Name: Prop%V&i is pcov went 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/iristallation 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: VNew ❑Repair ❑Expansion Permit Valid for: 21-5 Years ❑No Expiration Residential Specifications: # Bedrooms "2 # Bathrooms # People'Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People -# Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): ort d Type of Water Supply 4tCounty/City V Wele11�'-L Community Well Site Modifications/Permit Conditions: A�syAhat�`+e��d- +I�n� 15A NCTAC.{18A.ip98,.*9(5) 4G�i e7CC d�1i�J lrrar 6T`JY e_ us -1 Site Plan LTAR I Initial I z:i: /o v(nk r+rovi I . 3 1 Zr Environmental Health Specialist i.p. 11-06 i rIAIm l3��i r I P Date I - 111Z 2 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health E 'eek P.O. Box 848/210 Hospital Street MAR 5 2012 Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 A c�ltio - ite $valuation/Improvement Permit ❑Authorization To Construct (ATC) oth Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THEREQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMA'TIION Name S C? 1 ti 1 C S Contact Person j�Lki S e II �� i -c LS Address 0k i'-o.Ler Home Phone City/State/ZIP %►'l oc ks u i I le k- 2 7024 Business Phone 336- 62- 1171 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facility erners Flagged CE��S/�Z NOTE: A survey plat or site plan must accompany this application. Included: ate Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan; no expiration with complete plat.) Owner's Name ) dS Phone Number Owner's Address u i4q. City/State/Zip ,/1i1 pC ((,S ll, *11 e� o270t.5 Property Address City Lot Size 2 Tax PIN# F,7,W06O6Zl02 Subdivision Name(if applicable) Section/Lot# Directions To Site: _OBLtil Q/V ee Gt/1% ICer-O� If the answer to any of the following questions is•"Yes",supportin ocumentation must be attached: Are there any existing wastewater systems on the site? Yes ^Yes Does the site contain jurisdictional wetlands? `�No ^_Yes Are there any easements or right-of-ways on the site? _Z,�o Is the site subject to approval by another public agency? _No Will wastewater other than domestic sewage be generated? _Yes Yes No IF RESIDENg FILL OUT THE BOX BELOW ' # People &X # Bedrooms # Bathrooms Garden Tub/Whirlpool.,❑Yes G4e- Basement: ❑Yes QNoi o- Basement Plumbing: ❑Yes Mq_o�i IF NON -RESIDENCE 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: n onventional ❑Accepted ❑Innovative ❑Alternative- ❑Other Water Supply Type:- b County/City Water ❑ New Well fisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? \ This is to certify that the information provided on this application is true and correct to the best of my1nowledge. 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 that I am responsible for the proper identification and labeling of property lines and corners and locatin and fla ing_or, sta�Ki the house/facility location, proposed well location and the location of any other amenities. A. ' ' ' M ") Site Revisit Charge Prol5eo owner's or owner's legal representative signature _... Date(s): Client Notification Date: -bate EHS: Sign given ❑Yes ❑No " Account # �OJ Revised 11/06 J Invoice # au�� OV99 GOMAPS - Davie County NC Public Access W r� 00222f1 �e-Q 11 Thursday, March 15 2012 * * * WARNING: THIS IS NOT A SURVEY! * * This map is prepared for the inventory 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. WATERSHED—STRUCTURES is WATER BODIES COUNTY—BOUNDARY STREETS RAILROAD CENTERLINE PARCELS CITY—LIMITS BERMUDA RUN F1COOLEEMEE DAVIE COUNTY F-1 MOCKSVILLE laccountics DAVIE <a11 other+values> Thursday, March 15 2012 * * * WARNING: THIS IS NOT A SURVEY! * * This map is prepared for the inventory 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 DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005836 Tax PIN/EH #: F20000002102 Billed To: Russell Hicks Sybdivision Info: Reference Name: Location/Address: Duke Whittaker Road -27028 Proposed Facility: Residence Property Size: 22.156 Acres Date Evaluated: Water Supply: Evaluation By: On -Site Well Community Public Auger Boring it Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % o 0 HORIZON I DEPTH Texture group, Consistence 2' - Structure Structure Mineralogy% HORIZON H DEPTH Texture group Consistence Structure ' Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION - LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �J EVALUATION 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 C - Clay CONSISTENCE 1l�ist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Wit 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 1:1, 2:1, Mixed 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 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■ire■■■r�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■race■■■■■■■e■■■■■■■■■■■■■■■■ ■■■■tri■!�r�■r�■■■■■■■see■■■■■■■■■■■■■■■■■■■■■■■a■■■■■■■■■■■■■■■e■■e■■■■ CMEMNON :::::: :::::C :::::: do:::::::::::::::: ■■■■■ller■■■■■■■■Gi■!!■■e■■■■■■■■■■■■■■■■■i■■■■G:.!�e■■■■■e■■■■■■■■■■■■ ■■■s■■■■■■■■e■■■�■tfie■■■■■■■■■■■r��s��e■■■■tr■■■■■■■■■■■■■■■■e■■■■■■■■■ ■■■■■■■■■■■■■Y■■■C9■e■■■■lull!\■■ �ii�ri�wrr�r"'�li�iirililf�►7e■■,■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■Iii■■■■fG�\i■■■■■■■��L'■■li■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■i'\■e■■\�■■■■■■■.iw^::r^iiihi�i�iL'i7Y■�1■■■l�7■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ee■■r�rtnta.e■■■■■■■a■■■■e■eu■tr■■;�■■■■■■■■■e■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■C'...!' 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