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480 Dulin Rd (2)DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street v Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990005135 Billed To: Jeremy Beauchamp Reference Name: Proposed Facility: Residence ATC Number: 4892 OPERATION PERMIT Tax PIN/EH #: 5850-53-9352.3 Subdivision Info: Location/Address: Dulin Road -27028 Property Size: 1.87 **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 d "—(Tank . Date ~ OTank Sized G Pump Tank Size --7Y System Installed By: / i h E.Y. Specialist: l / 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 #: 990005135 Tax PIN/EH #: 5850-53-9352.3 Billed To: Jeremy Beauchamp Subdivision Info: Reference Name: Location/Address: Dulin Road -27028 Proposed Facility: Residence Property Size: 1.87 ATC Number: 4892 Site Type: Y ew ❑Repair ❑Expansion **NOTE** This Authorization to Constrict (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 3 # Bathrooms3'5 # People .3 BasementRrl�asement plumbing2' Non:Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size �- ��d5 Type of Water Supply: C3i✓ounty/City ❑Well ❑Community Well Qd U System Specifications: Design Wastewater Flow (GPD)J %4') Tank Size �d=d GAL. Pump Tank GAL. Trench Width 3G t / Max. Trench Depth 3 , Rock DepthW, ''inear Ft. 3;)L7 O Site Modifications/Conditions/Other: o VAJEO 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. "S covk tocl- Q r� er S1 Environmental Health Specialist, n/'NT) i 1 /n i, (R evi ed) //-/�:�69 Davie bounty EnvironmentaF.Health= _- P O "Bog 848/210 Hospital Street l� Mocksville, NC 270281/ (336)7514760/ Fax (336)751=8786 �IO� q ( 1 IMPROVEMENT PERMIT 1 Account #: 990005135 Billed To: Jeremy Beauchamp - -- -- Address: 6108 Hampton Meadows Lane City: Clemmons Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5850-53-9352.3 Subdivision Info: Location/Address: Dulin Road -27028 Property Size: 1.87 **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An - -- - —Au orization-_ o--onstruct a -was ewa er system must e o me --om= is�o ' icf e prioi he --- �---- - con astewater system_orAhe-issuance-of a Mill ing_permlt(in_rnmplinnce with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site pjans, plat or the intended use change. Permit Type: 4!New ❑Repair ❑Expansion Permit Valid for: 25 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms3'� # People 3 BasementB'Basement plumbingB_�_ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 (co Type of Water Supply: PC5unty/City ❑Well ❑Community Well As stated in 15A NCAC 1.8A.1969(ra) Site Modifications/Permit Conditions: accP ted Systems may also be UG Site Plan 77. 4. 00` Environmental Health Specialist i.p.l 1-06 Flo 13 Site Plan 77. 4. 00` Environmental Health Specialist i.p.l 1-06 r • APPLI E EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health .O. Box 848/210 Hospital Street Mocksville, NC 27028 PVG 3 6)751-8760/ Fax (336)751-8786 Applicati For: Q r provement Permit ❑ Authorization To Construct(ATC) Elrloth Type of A lication: ° stem ❑Repair to Existing System, ❑Expansion/Modification of Existing System or Facility ***IMPORTA7'7 *** 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. J V—Ce-rgW 9,P_CUAdNC .w,4>- Contact Person Ap ee vttY U-PAuC" W16' Billing Address 610? a.ti &CLJOt�4s L. (U. Home Phone 3 �D J11 -IS -1-y— City/State/ZIP C I e mmor`t i19. C• a ? 01 Business Phone (733(o) 9-7-•--q-7(43 X Name on Permit/ATC if Different than Above Mailing Address 00 9 M-Pj owS PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan lat(to scale) (Permit is Valid -for 60 months with site plan no expir ion w- h compI t plat.) Owner's Name - .ze e&w &tu teat,, 1 ;'m rok Owner's Address 19( a ,j 5 Property Address Lot Size Tax PIN# Subdivision Name(if applicable) Directions To Site: X3F Ut/1� 0(? - W69 Phone Number. C33 Q 7 t T - (S ( -5'- City/State/Zip Q Jpm tol5 (V, -70 ( ? City Section/Lot# rA If the answer to any of tlfe following questions is "yes", supportingdocumentation must be attached. Are there any existing wastewater systems on the site? ❑Yes Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site? ❑Yes NO Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _ # Bathrooms S Garden Tub/Whirlpool Oes ❑No Basement: 5fYes ❑No Basement Plumbing: 5?Yes ❑No 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: Pteonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: g7/County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additios or If yes, what type? e - of the facility this system is intended to serve? YYes ❑ No 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 permits) 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 locating and flagging o staki g the ho e/ cility location, proposed well location and the location of any other amenities. LU Site Revisit Charge rope o ier's oro er's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given DYes ❑No Account # :5436 Revised 11/06 Invoice # 1 I P.B. 8Lor PG. 32,3 PROPERTY OF RONNIE L, SMITH & NOW OR FORMERLY W NANCY JEANETTE SMITH JOHNNY LYNN SMITH 1 D.B. 166 PAGE 584 & m D.B. 102 PG. 495 �Q T �,I 212.27' ER13 0.HARTFORD: HARTFO INSIDE PSL LANE (30' PRIVATE EA ---__ - --___ - - / _ a N 4--45'-00' Lot Length ==430.71' 218,44' (SEE PLAT PppK 8 PAS ___ 323) SEMENT�`_Y E -` t07p.70' (Tofa! Boundory) 218.25' I Lot Length = 247.77' in PNS 29.51' O C ... 1.87 ACRES TOTAL o� O �\ �z'e` Via' 1.53 ACRES TOTAL _ COVERED i Qa 7,393 Sq. Ft. O^ PORCH a ,Z) 0.17 ACRES (D i / IN R/W wELL ►: , 9,246 Sq. Ft. GRAVEL DRIVE _ _ �- l- �, 0.21 ACRES % t 'KFRAME IN EASEMENT hh ), % STORAGE BUILDING iGS, ONE : lI I STORY METAL ,,,,.316.6,8' FRAME t N' BUILDING 30'. PRIVATE - ' ` ---- - _ ?°' BUILDING ' 46'Qi / (30' I ATE EAS�jIdEjNT _ PNS ' _ CAR ..:. 69 f E EASEMENT — PORTr.. I' / S' 7•_02'-48" Lot Len th 299.73' ) %p EIP 0.38' ��275.96' ! _'r 1009.42' (Total) �$ INSIDE P�! Lo '� _ _ �` :. v / 40.70' t Length = 317.06 _ IPS -- M / ' 243.84' NOW OR FORMERLY DELBERT BFNNcTT z� , PROPERTY OF RONNIE L. SMITH & r _ + ( NANCY JEANETTE SMITH �5' EIP (L) 0.91' INSIDE PA EA(L) 0.41' Lot Len th 392.22' 1 4 ER8 a,72' ARTFORD LANE (30' pF (13E • 5 IPS 212.27 Ord 25.03' Lot L INSIDE P/L �21'8.44' (SEE PLAT BopK g ength 430.71' PNS N 4'-45'-00' E -- 1070.70' (Total Boundary) Q� o ry N . � 7 A " S OTAL �i N ro �i N 1.87 ACRES TOTAL o s f o Z7, 9.246 Sq. Ft. /�,� ,:✓�:-Ff 0.21 ACRES h SR oo v� %.: > BUl IN EASEMENT � �: � Z PNS _ FRAME .01 BUILDING 392.63' � � "� � — --,_ _ 316,68' 30' PRIVATE — " _ _ PNS — IPS '`� (30' PRIVATEEASEMENT) MNT-�_ — EIP o 38' iv' ` ---- — 275,.9 . g 7._02.-48 Lot Len th 299.73' Oo INSIDE PA n W 1009.42' (Total) �• Lot Length = 317 "� 40.70' Ips 1 ? i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005135 Billed To: Jeremy Beauchamp Reference Name: Proposed Facility: Residence Property Size: Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5850-03-3352: Subdivision Info: Location/Address: Dulin Road -2702 1.87 Date Evaluated: On -Site Well I Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 O Landscape position L L LL r,, Slope % 3 HORIZON I DEPTH Texture group L Consistence Structure Mineralogy HORIZON H DEPTH 1 - r / —.XQ 19I L.ti Texture group "s C, 5 Consistence a. Structure Mineralogy Q 5J' 444 HORIZON III DEPTH Texture group�y. Consistence n Structure rr w Mineralogy HORIZON IV DEPTH Texture group Consistence Structure s Mineralogy SOIL WETNESS jq I r rr RESTRICTIVE HORIZON 'z6 1Aa ;2 b SAPROLITE / merit CLASSIFICATION P PS LONG-TERM ACCEPTANCE RATE , 3 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: d AW REMARKS: , EVALUATION BY- 1A, OTHER(S) PRESENT: ^ iopiq A 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 CONSIST .N Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm '3'I 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 Mineralogy 1:1, 2:1, Mixed Notes 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) T •re 73 r ..- -.--va___ir n _ — ..