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194 Edwards Rdf ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital. Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990004311 Billed To: Jordan Cline Reference Name: Proposed Facility: Residence ATC Number: 4656 OPERATION PERMIT Tax PIN/EH #: 4890-86-6057 Subdivision Info: Location/Address: 194 Edwards Road -28634 Property Size: 1 acre **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 fimction satisfactorily for any given period of time. System Type: S.T. Manufacturer Tank Pump Tank Size System Installed By:--'��� �C'�K j=•H. y �QA4, q -ND v� sr Poe" CO- Ito Tank SizeUa 00 DCHD 11/06 (Revised) �w�� Air DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 l (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004311 Tax PIN/EH #: 4890-86-6057 Billed To: Jordan Cline Subdivision Info: Reference Name: Location/Address: 194 Edwards Road -28634 Proposed Facility: Residence Property Size: 1 acre ATC Number: 4656 Site Type�-e<ew ❑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. Residential Specifications: # Bedrooms. # Bathrooms= 1S# People Basement❑ Basement plumbing❑ 4 Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size LACE Type of Water Supply: ❑County/City ell ❑Community Well System Specifications: Design Wastewater Flow (GPD) �ank Size iOL Pump Tank GAL. Trench Width � Max. Trench Depth Rock.Dgepth 1 Z Linear Ft. 3� Site Modificati s/ ngtions/Other: �' 171 ZsM� li'J S �iSTgLL D C.'W ' QAC Contact the J)avR Environmental Health Section or final inspection of this system between 8:30 9:30a.m. day of installation.' Telephone # (336)751-8760. i -~ L-"� roJlh i 0 DCHD 11/06 (Revised) ;o x40 As stated In.3.5A NCAC 18A.1960(5) accepted Systems .rnay afso bo use ` _ t1` l 1 `• ApR � i a OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax.(336)751-8786 u provement Permit ❑ Authorization To Construct(ATC) S l oth System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility V`MI_MPORTAN7.*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruEtions. APPLICANT INFORMATION ,ri Name to be Billed V l n e Contact Person Billing Address / 0 Home Phone cg3&7 City/State/ZIP Business Phone 1 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: kSite Plan ❑Plat(to scale) (Permit is val' 60 onths with* plan yo.expiration with complete plat.) — Owner's Name - Phone Number Owner's Address e City/State/Zip Property A dress_ Lot Size Subdivision Name(if Tax PIN#. If the answer to any.of the following questions is "yes", supporting documentatiod mush be attalhed. Are there any existing wastewater systems on the site? ❑ Yes Ego Does the site contain jurisdictional wetlands? . ❑Yes Rlqo J Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW # People OR # Bedrooms # Bathrooms Garden Tub/Whirlpool []Yes o Basement: ❑Yes UTO� Basement Plumbing: ❑Yes EX6' 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:, Xonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water Vdew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes cl-wo 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 pernmit(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 fines and comers and locating and flagging or sta 'ng the hous /facility location, proposed well location and the location of any other amenities. Site Revisit Charge Pro r er's or owner's legal representative signature Date(s): Z2,-,2- Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # 4da Revised 11/06 Invoice # /nn 25 t 7S-4 c s Map Output Page 1 of 1 http://maps.co.davie.nc.us/servlet/com.esri.esrimap.Esrimap?ServiceName=davie&ClientVersion=3.1&Form=True&Encode=False 4/3/2007 Davie County GIS Online f Legend Selected Features City Limi lines, -r BMUUQARtJN f,1 COOLEEIrEE 578 — X76 f.f UOCKSVI LE Streets 57 /Y NTERSTATERAMP 1s A/ PRNATE A/ PUEL3C % RESTAREA property Dimensi©ns property Lines f✓ Streams C1�,` D9 275 16 469 NI /' ! p3 459 $ RP-K:.TP;-'W&Vr-S-' k41, http://maps.co.davie.nc.us/servlet/com.esri.esrimap.Esrimap?ServiceName=davie&ClientVersion=3.1&Form=True&Encode=False 4/3/2007 CD cp j f LICANT INFORMATION Account #: 990004311 Billed To: Jordan Cline Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 4890-86-6057 Subdivision Info: Location/Address: 194 Edwards R -286 4 Property Size: 1 acre Date Evaluated: co 010 On -Site Well / Community Auger Boring / Pit Public Cut ff • • •Landscape position HORIZON I DEPTH Texture group Consistence Texture group Consistence Texture group EMMA FW4 M, M11111111111111111 Consistence HORIZON IV DEPTH Texture group Consistence SOIL WETNESS CLASSIFICATION SITE CLASSIFICATION: PS EVALUATION BY C3LaI.—P a6 LONG-TERM ACCEPTANCE RATE: c� •3 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 Moist VFR - Very friable FR - Friable FI Firm VFI - Very firm EFI - Extremely firm 3Y'et ^ NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky i NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic P aStructure 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 LYOtcS - 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) LIAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■lei■� 37■■■■■■■■■■■■I■►.J■■■■■■■■■■■■■■11■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■111■■■■■■■■■■■■■■nlll■■■■■■■■■■■■■■■■11■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■�i■■�iiin�n■■■111■■■■■■■■■■■■■■■■11■■■■■■■■ ■■■■■■■■■■■■■■■■■■■RRA■■■I■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■I■■■■■■■■ ■■■■■■■■■■■■■D!!/.■■�� ��!cel■■■■■■■■■■■■■■■II■■■■■■■■■■■■■■■■■I■■■■■■■■ ■■■■I■■■■■■I■■ ■■■■■■ �■■■■■■�■■■■■■■■■■■■�■■■■■■ ■■■■■■ ■■■■■■ I■ME MEN ■■Amey ....�.�� ' ■�i■���----------- ■■■■■L'1�■■�■■!!i'=�!j:�ll■■■■■■■■■■■■■ �1%11D1■Cis■■■■■■■■■■11►D■■■■■■■11■■■■■■■ ■■■■■■:'..■■■■■■■■■■■■■■■■■iih.11■11I,,�I�JIt1D■■1r�.1►1■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Environmental Health P.O. Box 848/210 Hospital Street ^ Mocksville, NC 27028 (336)751-8760/ Fag (336)751-8786 IMPROVEMENT PERMIT Account #: 990004311 Tax PIN/EH #: 4890-86-6057 Billed To: Jordan Cline Subdivision Info: Address: 194 Edwards Road Location/Address: 194 Edwards Road -28634 City: Harmony 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: /New DRepair ❑Expansion Permit Valid for: ;a' Years ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms 2 # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply:,❑County/City�ell ❑CommunityWell Site Modifications/Permit Conditions: System Type LTAR Initial ! o --15E Repair J4 -3