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756 Fairfield RdI • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990005211 Billed To: Clayton Homes of Statesville Reference Name: Vinnie Proposed Facility: Residence ATC Number: 4959 OPERATION PERMIT Tax PIN/EH #: 5746-96-4208 Subdivision Info: Location/Address: Fairfield Road -27028 Property Size: .91 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 function satisfactorily for any given period of time. v p System Type: S.T. Manufacturer-_ —6W Tank Date Tank Size G d Pump Tank Size l oe -7�� System Installed By: gy5 �l E.H. Specialist: Date: ter ` R11- rd DCHD 11/06 (Revised) i 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 #: 990005211 Tax PIN/EH #: 5746-96-4208 Billed To: Clayton Homes of Statesville Subdivision Info: Reference Name: Vinnie Location/Address: Fairfield Road -27028 Proposed Facility: Residence Property Size: .91 Acre ATC Number: 4959 Site Type: ❑New ❑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 3 # Bathrooms 2 # People 3 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) �� • Lot Size (� . �l ( 2G f C h Type of Water Supply: ❑County/City Pr ell El Community Well System Specifications: Design Wastewater Flow (GPD)3 l 0 Tank Size gAL. Pump Tank GAL. Trench Width 3 Max. Trench Depth 3 Rock Depth l Linear Ft. 7,-3 stated in 16A ,5) Site Modifications/Conditions/Other: accepted Systems may s1so be us^dd Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telenhone # (336)751-8760. aaq to'V 7 Environmental Health Specialist, DCHD 11/06 (Revised) Date: 3 _.1 Q / 0 1h Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990005211 Billed To: Clayton Homes of Statesville Address: 2026 North Side Drive City: Statesville Reference Name: Vinnie Proposed Facility: Residence IMPROVEMENT PERMIT Tax PIN/EH #: 5746-96.1f208 Subdivision Info: Location/Address: Fairfield Road -27028 Property Size: .91 Acre **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 ❑Repair ❑Expansion Permit Valid for: Rr5 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms '��-#People--S 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 CommunityWell As stated in 15A NCAC 18;:.196:'311 Site Modifications/Permit Conditions: zocap*-d 1y.„tcmc alay b. System Type LTAR Initial L„ O• Repair -e w , ` 1n Site Plan aaI _Tn1-Y%0 ( J�o Y/C 1/ "I`7 11-ela i /' Environmental Health Specialist l Ilk 1 do Q Date 3 ,7 7 e / P ATIO 0�9 �d1Rca�\E�0 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 toaluation/Improvement Permit Q'Authorization To Construct(ATC) C�'13oth 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 on Permit/ATC if Different than Above Mailing Address CO i<. rSt'c U Ro Ile- r 336- G1 -'79 PROPERTY INFORMATION *Date House/Facili Corners Flagged;,, 6-d 1W. NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name PA4r 1 c -i R 1%j loye-r Phone Number Owner's Address 33tSAa-,.Jert 9w.J MnVog-A-' M City/State/Zip 2-795-6 _ Property Address ' r i e.� City WtoQlcs U, / Z'►v z8 Lot,Size , Ci 1 Tax PIN# 51q&tel -qWg Subdivision Name(if applicable) Section/Lot# Directions To Site: 601 o•v J A,r,Fejcl Food. .. aC - al If the answer to any of the following questi is "yes", supporting documentationmustmust be attached. Are there any existing wastewater systems on the site? []Yes LAN Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site? ❑Yes E Is the site subject to approval by another public agency? ❑Yes �, Will wastewater other than domestic sewage be generated? ❑Yes QNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrr ms Z Garden Tub/Whirlpool ❑Yes a110 -- p ❑Yes o Basement Plumbing: ❑Yes C3'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: @Conventional 3Accepted [#Llnnovative 4AItemative ❑Other ¢htc ft,p Water Supply Type: ❑ County/City Water Cy7New 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? C'No ')J'his 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 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 or staking the hose/facility to roposed well location and the location of any other amenities. Site Revisit Charge rope wne ' oro er's legal representative signature D 3-3-09 Date ate(s). Client Notification Date: EHS: Sign given ❑Yes ❑No Account # JZ/1 Revised 11/06 Invoice # to 957 Name to be Billed q 40d klovesT J; Ae-Contact Person V - nn:e-/��Y��n c. Billing Address 7-0z b 10or M S. Dr: oL Home Phone ?o4 - Qq t - S3a7 City/State/ZIP 54'A�c so . 1 l C- IJL ZS 6 i 5 - Business Phone 76q- 0-7,5 - 2.5q7 Name on Permit/ATC if Different than Above Mailing Address CO i<. rSt'c U Ro Ile- r 336- G1 -'79 PROPERTY INFORMATION *Date House/Facili Corners Flagged;,, 6-d 1W. NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name PA4r 1 c -i R 1%j loye-r Phone Number Owner's Address 33tSAa-,.Jert 9w.J MnVog-A-' M City/State/Zip 2-795-6 _ Property Address ' r i e.� City WtoQlcs U, / Z'►v z8 Lot,Size , Ci 1 Tax PIN# 51q&tel -qWg Subdivision Name(if applicable) Section/Lot# Directions To Site: 601 o•v J A,r,Fejcl Food. .. aC - al If the answer to any of the following questi is "yes", supporting documentationmustmust be attached. Are there any existing wastewater systems on the site? []Yes LAN Does the site contain jurisdictional wetlands? ❑Yes Are there any easements or right-of-ways on the site? ❑Yes E Is the site subject to approval by another public agency? ❑Yes �, Will wastewater other than domestic sewage be generated? ❑Yes QNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrr ms Z Garden Tub/Whirlpool ❑Yes a110 -- p ❑Yes o Basement Plumbing: ❑Yes C3'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: @Conventional 3Accepted [#Llnnovative 4AItemative ❑Other ¢htc ft,p Water Supply Type: ❑ County/City Water Cy7New 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? C'No ')J'his 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 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 or staking the hose/facility to roposed well location and the location of any other amenities. Site Revisit Charge rope wne ' oro er's legal representative signature D 3-3-09 Date ate(s). Client Notification Date: EHS: Sign given ❑Yes ❑No Account # JZ/1 Revised 11/06 Invoice # to 957 xeports Davie County, NC Tax Parcel Report *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. Notes: Tuesday, 3/3/2009 Min rage i of i http://maps.co.davie.nc.usIGoMapslreportslreport.cfin?CFID=50491&CFTOKEN=89266712 3/3/2009 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation �1L•iK•1.1 � I s: a!%t%1•1•irr� � � � Billed To: Clayton Homes of Statesville Jr1�G-glv-4'L08 Tax PIN/EH #: 5746-gEQDBRTY INFORMATION Subdivision Info: Reference Name: Vinnie Location/Address: Fairfield Road -27028 Proposed Facility: Residence Property Size: 91 Acre Date Evaluated: Community Public Water Supply: On -Site Well Evaluation By: Auger Boring Pit FACTORS 1 2 3 4 5 6 7 Landscape position t --v Slope % HORIZON I DEPTH 0` _ - Texture group G Consistence FTI / Structure Mineralogy HORIZON II 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 ey 4-9 SITE CLASSIFICATION: i LONG-TERM ACCEPTANCE RATE: . . REMARKS: LEGEND 94M.s l�A N OTHER(S) PRESENT: han. n ds e Positio 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 YYCS , 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) I'T'AR - I.nnv-term arrPntgnre rate - anihinu ft) ncinc m__ ■M■MM■ME■ MMEMEMEEM ■■NEMS■E■ ■MNEME■■■ mommummom ■■■■■moss ■■N■M■NE■ EMNEEMEME MEMMOMMEN ■E■OMO■E■ MENOMONEE ■EMMEM■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■see■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■sE■■■■mos■■■■■■■■■■■■■■see■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■■momem ■■KU"Mm ■mnsomm ■o■m■■n ■■m■mrdr! ■■■■■NE ■ ■ENEEM■M■M■MEN■ ■M■■■EMEME■M■N■ ■■■MEMMEMM■MEN■ ■EM■NEME■EMEEM■ ■■■■■N■■N■■■■■■ ■■M■■N■■■■E■M■■ ■■■■■■■■EOE■■■■ ■■ONES■■■E■■■O■ ■NEEM■■MN■■■■E■ ■■■■■■■mom■■■■■ ■NNN■ME■■■■■■■■ ■mm■mm■mm■■■m■■ ■M■■■M■■■NM■■■■ ■N■■EEM■M■M■N■■ ■■■■■■■■■■E■■■■ ■■■■■N■■EN■■■■■ ■EE■NE■■■■■■■■■ ■■■■■■■■■■■■■■■ ■■■■NN■■■■E■E■■ ■■■■■■■■■■■■■■■ NEEM■■■M■■NE■■■ ■NEEM■■■■E■■■■E ■■MEM■■■■E■E■■■ ■N■■E■■E■E■E■N■ ■■N■■■■■■■■■■■■ ■■■■■■■N■■NE■■■ ■■■■■■■■N■■■■■■■ ■NE■E■E■■■■■e■■■ ■■■■M■■■EEE■■■E■ ■■■■E■E■■■■■EEE■ ■M■■■■EEE■■■■■■■ ■E■E■E■■■ME■■■M■ ■■EEE■EEE■■EOE■■ ■M■■■SEEN■■■EEE■ ■■E■■■■■■NONE■■■ ■■■■■■■N■E■■■■■■ ■■M■■■E■M■E■■■M■ ■■■E■E■E■E■E■■■■ ■■■E■■■E■■■■■ME■ ■E■e■■■E■■■■EEE■ ■■■E■■E■■■■E■E■■ ■■■■E■E■■E■E■■E■ ■E■■■MME■N■■■■■■ ■EE■■■■EEE■■■■■■