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775 Dulin Rd (2)Account #: 989900063 Billed To: Larry McDaniel Reference Name: Proposed Facility: Building DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5850-700820-B Subdivision Info: Location/Address: 775 Dulin Road -27028 Property Size: 2.87 ATQVI,ff* 49i suance 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: -IVC- Q4 S.T. Manufacturer N6aF Tank Date S-11 Tank Size t ooa Pump Tank Size 6VA 11, o System Installed By: Zr• Q., VYMe E.H. Specialist: Date: 9 - 23-0 e z -Q7 n 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 M 989900063 Tax PIN/EH #: 5850-700820-B. Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: 775 Dulin Road -27028 Proposed Facility: Building Property Size: 2.87 ATC Number: 4907 Site Type: Mew ❑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 # Bathrooms # People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type 6!aAAV# People Z - 5— #Seats ,ov/A Square Footage(or Dimensions of Facility) ?=P 11 Lot Size 2.k7Ac. Type of Water Supply: .6ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) I.SG-O Tank Size GAL. Pump Tank IkIA GAL. Trench Width 3 G ,• Max. Trench Depth 31, Rock Depth N/� Linear Ft. Z Asp Site Modifications/Conditions/Other: Z S7% RlwutGw . � 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. C Environmental Health Specialist nrUTI 11InA (Reviv-.d) Btu} sr SIN- Date: q -2-Z'01-'- Im Account M 989900063 Billed To: Larry McDaniel Address: P.O. Box 577 City: Mocksville Reference Name: Proposed Facility: Building Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC .27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PLTN/EH M 5850-700820-B Subdivision Info: Location/Address: 775 Dulin Road -27028 Property Size: 2.87 **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: 01�ew ❑Repair ❑Expansion Permit Valid for: a 5 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People BasementO Basement plumbing❑ Non -Residential Specifications: Facility Type _Cnl_ SCi #PeopleZ-S # Seats N!,+ Square Footage(or Dimensions of Facility) 2a y jb Design F1ow(GPD):7;FA�1�1 Type of Water Supply: County/City ❑Well ❑Community Well Site Modifications/Permit ConditionSZe5s' 9 tA— S s Type LTAR Initial rwi Y I . Z Repair .7— Environmental Z Environmental Health Specialist — Date Q - Z Z -or APPLI �,. SITE EVALUATION/IMPROVEMENT PERMIT & ATC k0 Davie County Environmental Healtho Z � P.O. Box 848/210 Hospital Street �t e Mocksville, NC 27028 ` (336)751-8760/ Fax (336)751-8786 W A �tion For: f provement Permit 0 Authorization To Construct(ATC) both T I ` `iRPI'. " 1 ,t ", stem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility *** P NT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INF ATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed L i C. Contact Person e. Billing Address V- 61S t Home Phone - �t c City/State/ZIP fi! '" 9 j Business Phone,�,a_� Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 5/2VO f NOTE: A survey plat or site plan must accompany this application. Included: M Site Plan ❑Plat(to scale) (Permit is'valid'for 60 monthswi h site plan, no expiration with complete plat.) Owner's Name �� %1', e A.< 1 '' �l L`,r Phone Number Owner's Address City/State/Zip Property Addressf—_(i .. city Lot Size�, '`l /a - Tax PIN# �� _W) ,y 0 Subdivisi-on Name(f apXlicable)Section/Lot# Directions To Site: --7,/P- _:.I ; li, ,.J L If the answer to any of the following questions is "yes", supporting docume} tation must be attached. Are there any existing wastewater systems on the site? Ql'S�es ❑No Does the site contain jurisdictional wetlands? Dyes V60 Are there any easements or right-of-ways on the site? Dyes Pl0 Is the site subject to approval by another public agency? Dyes lfio Will wastewater other than domestic sewage be generated? ❑Yes 51f4o IF RESIDENCE FILL OUT THE BOX BELOW # People i - # Bedrooms _ # Bathrooms __ Garden Tub/Whirlpool L : _,No Basement: Dyes E'"No Basement Plumbing: Dyes f` IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness- Ga� ' 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:. ventional ❑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 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 Depwtrient to conduct necessary inspections to determine compliance with applicable. laws and rales. I understand that I am responsible for the proper identification and labeling of property lines and confers and locating and flagging or staking the house/factli location, Wroposcd well location and the location of any other amenities. 41, .�_—_ Site Revisit Chargeroperty erwner's legal representative signature. FDatc(s) Client Notifiration Date.:. Date--- Sign given LJYes ❑No Account # Revised 11/06 Invoice # r?' APPA&Q2MW#NB69=ffBDN Billed To: Larry McDaniel Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Tax PIN/EH #: 5850-MiWaTY INFORMATION Subdivision Info: 060 ~ 70 -Ontj Location/Address: 775 Dulin Road -27028 Property Size: 2.87 Date Evaluated: - " Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 4 5 6 7 Landscape position g..,•,,. Slope % HORIZON I DEPTHTexture grou &2— ConsistenceStructure (� MineralogyP 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 a U SITE CLASSIFICATION: Q LONG-TERM ACCEPTANCE RATE: EVALUATION BY: V-0)CI ,�) G&�� OTHER(S) PRESENT: A9 V REMARKS: V Q 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 1N'TSist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm }fit NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 rlat� 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 05/05 (Revised)