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836 Fork Bixby RdM DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Sheet Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990004142 Billed To: Ronald Jones Reference Name: Z51 -iii Lan,) i nj Proposed Facility: Residence ATC Number: 4822 OPERATION PERMIT Tax PIN/EH #: 5778-27-5890 Subdivision Info: Location/Address: Fork Bixby Road -27006 Property Size: 0.912 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 tak as a guarantee that the syste will function satisfactorily for any given period of time. q !' —(J System Type S.T. Manufacture 1$ v Tank Date Tank Size Pump Tank Size 1 12 ., E.H. p System Installed By: -,t PAC���-�1 ecialist: �� Date:' - 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 990004142 Tax PIN/EH M 5778 -27 -5890 - Billed To: Ronald Jones Subdivision Info: Reference Name: .tLW;1V LI°1NN1 NJ Location/Address: Fork Bixby Road -27006 Proposed Facility: Residence Property Size: 0.912 Acre ATC Number: 4822 Site Type: B'New ❑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 # Bathrooms .2- # People Basement❑ Basement plumbing❑ Non=Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size L9 aCri - Type of Water Supply: R6ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 3 �O Tank Size /6015GAL. Pump Tank _&/,L4�AL. Trench Width -?6 Max. Trench Depth3 6 Roc7k Depth .Z Linear Ft. ' .3 6 AS stated in 15A NGAC 1 Ll,) A 90) Site Modifications/Conditions/Other: r^ecepted Svstcros may also be JaL �G�,Eo tact the Dp4e County Environmental Health Section for final inspection of this system between d "% HAW R30 - 93da.m. on the day of installation. . a► al 1 o``� D- 175 - SL 7S L S. in ENvironmental Health Specialist ,r'U n 1 1 /n4 Ml—i—l) ;2 -11-e 9 ` Davie County Environmental Health P.O. Box'848/210 Hospital Street Mocksville, NC 27028 .(336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004142 Tax PIN/EH #: 5778-27-5890 Billed To: Ronald Jones Subdivision Info: Address: 168 Cedar Hill Lane Location/Address: Fork Bixby Road -27006 City: Advance Property Size: 0.912 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: &f,1ew ❑Repair ❑Expansion Permit Valid for: Q5 Years ❑No Expiration Residential Specifications: # Bedrooms_ # Bathrooms off— # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 (g0 Type of Water Supply: [?/County/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: As stated CPC ln� , rq n -):J j ;-.!Sc) be o;;Z, J Environmental Health Specialist_ 1_11JV 6711 c . P 4 TE EVALUATION/IMPROVEMENT PERMIT & ATC, avie County Environmental Health 3 Q 20�a P.O. Box 848/210 Hospital Street Mocksville, NC 27028756 ea 3 36 - MEtS�F�-'.tiEj�,1N (336)751-8760/ Fax (336)751-8786 Ety�11 "ii COUI,iY Applic tion For: uation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type o ation:iew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed c 6 U, Contact Person Billing Addressit C LL Home Phone 3� E % r%ao City/State/ZIP )'f S, ' 500 Business Phone 3 (v CIO 2 //Y/.3 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facility Corners Flaaaed /—M-0 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 1519 /'n Phone Number Owner's Address City/State/Zip Property AddressD _ % City Lot Size �, �Z- 414I�-GS Tax PIN# S'7 '7 7S_ 8 % D Subdivision Name(if applicable) _Section/Lot# , To Site: If the Answer td any of the folldwing questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes ITNo Does the site contain jurisdictional wetlands? []Yes [�No Are there any easements or right-of-ways on the site? []Yes 2No Is the site subject to approval by another public agency? []Yes [No Will wastewater other than domestic sewage be generated? ❑Yes 21�o IF RESIDENCE FILL OUT THE BOX BELOW M # People # Bedrooms :-?— # Bathrooms Garden Tub/Whirlpool ❑Yes ❑ Basement: ❑Yes ❑No Basement Plumbing: ❑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:. ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ZCounty/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? ❑ 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 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 house/facility location, proposed well location and the location of any other amenities. rl-,LA1 l Site Revisit Charge Property owner's or owner egal representative signature Date Date(s): Client Notification Date: EHS: Sign given ❑Yes ❑No Account # 4114 Revised 11/06 Invoice # Is RONNIE JONES CONSTRUCTION, INC. Custom Homes & Remodeling 185 Livengood Rd. Advance, NC 27006 1 Ll �v�v I f\J Jf-77 Lo 1 -TA 1111 Phone (336) 998-7206 (336) 909-1193 . GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of 1 O aV��` Click Here To Start Over Quick Search: (County ID c 01U14-11 ;±) �") � f Q ) A� Active Layer. r ' Use Map Tips GIS `jv 0 D PARCELS (Map Tips Available) Map Layers I Results I http://maps.co.davie.nc.usIGoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=4129... 2/l/2008 GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of 1 <3 fl lce Click Here To Start Over Quick Search: (County ID c Active Layer. F Us. Map Tips GIs °U tk'% C' Q ❑ PARCELS (Map Tips Available) Map Layers ( Results ( http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainrnapservice=gomaps&CFID=4129... 2/1/2008 GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of 1 Out �rh, Click Here To Start Over Quick Search:(County ID c Active Layer. r Use Map Tips GIS tIooPQ �, PARCELS (Map Tips Available) Map Layers ( Results http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=4129... 2/l/2008 APPLIQ44l QJ+iA),ATI2pj Billed To: Ronald Jones Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Tax PIN/EH #: 57 IMY INFORMATION Subdivision Info: Location/Address: Fork Bixby Road -27006 Property Size: 0.912 Acre Date Evaluated: 9�.— I ( D On -Site Well Community Auger Boring__ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L . Slope % HORIZON I DEPTH_ ' Texture groupL Consistence -.9t r pff Structure C , '5N4 6 14 Mineralogy ' 5 G_ ) E:v 1P HORIZON 11 DEPTH Texture group [— Consistence •v Structure Mineralogy' HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON � SAPROLITE CLASSIFICATION SIA, 16d LONG-TERM ACCEPTANCE RATE &, .:41' SITE CLASSIFICATION: A;j u_ T* LONG-TERM ACCEPTANCE RATE: -7 REMARKS: EVALUATION BY: rr) , OTHER(S) PRESENT: 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 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 MineraloQv 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/05 (RevisP.d) Feb 12 08 12:36p davie county envhealth 336 751 8786 p•2 FIU - A AFP, '�c V $ U ealdi DeparLrrlent 1836 EI.1 Health , ectiol7 ,�:. 4 LENVIRONMENTALEHEWflt1jBox 848 ' • ti DA\ IE COUN C� ,S„ pit�d Street 0Courier ## : 09-40-06 luj Mocksville, NC 27028 Phone: (336) - 751- 8760 Fax: (836) -751 - 8786 ON-SITE M ASTEWATER CERTIFICATI-DN FOR DWELLING (Check One) Replacement 0 Remodeling; 2"' Reconnection 0 Name: }�PE(j��°�G i _ Phone Plumber (fie) Mailing Address: z55_97 G 141W4 (Work) Detailed Directions To Site: 'Acr �6 I s. L 071 � � ���� rf� ✓ :By PIN -.�'7' 5Tri u Property Address: �(�C/�liJ 7f7;Q7111'7✓Gif Please Fill In The. Following b9orma Ilion About The EXISTING Facility: Name System Installed Under: �"1'Vl t� E lV1 V1'21 ✓1 _Type Of Facility: Q Date System Installed (Month/Datc/Year):_ ZOO Number 0! Bedrooms: Number Of People:-- Is eople:- Is The Facility Currently Vacant? YesD a 12( If Yes, For How i.ong?_ Any Known Problems? Yes ❑ No `U' If Yes, Explain: Please Fill In The Following Informa•:lon About The NEW Facility:(t, k c G1,•ru,, 01 a Hz{ (Alt cl 5%�' Type Of Facility: e_ Nwnbm or-B—M-00-M. Number of People 51ncu kdV b e Requested By: C=Dudd J4 Date Requested: �/� %1 U �L} ,or Enviromnental Health Office Use Only Approved V Disapproved ❑ Environmental Health Specialist Date: ` *The signing of this form by the Environmental Health Staff is in no wavy intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check Mev Orc.er El# Amoi bate: Paid By: cl}} Received By. z V Account #: • .2/7-S7 _ Invoice #:__'74 L 2___ r - _ N 15'20'48" W CC ---_IR S 15' 22' 43" E IR --�---- IR 50.01' 89.7,3 I TIE 1 17/82.03 RONALD G. JONES SANDRA A. JONES DB 389 PG 175 ZONED R-20 17/103 RONALD G. JONES SANDRA A. JONES DB 389 PG 174 ZONED R-20 0 60 120 SCALE: 1"=60' - _ - 60' R/W N CARq �9�Ji� SEAL - L-3513 - �� tiNfC I " G 11RI J.- 18' Hy I SHADY GROVE COUNTY: 17/104 1 I W LLj W JUSTIN M. LANNING I BRITTNEY L. CROTTS 198.001.GE SURVEY BY: DB 749 PG 193 3 DATE: I ZONED R-20 . h� r� J. LANNING DATE: 4/18/08 CO 11o.51' I 2 }W Ir } I I h' r` 17/96 w HERBERT G. BURTON I VELMA S. BURTON ,n w DB 607 PG 922 N ZONED R-20 O IW � n Q � I Q 11 Z � 0 1" EIP BENT •�` • � Hy SHADY GROVE COUNTY: I W LLj W STATE: NORTH CAROLINA PROJ. NO.: 198.001.GE SURVEY BY: J. LANNING DATE: 4/16/08 DRAWN BY: J. LANNING DATE: 4/18/08 11o.51' S 21' 13' 4" E }W N } I j O M Ip N ` w1 I L_.__..._._...,n ...... 30' BUILDING r to SETBACK LINE W 48.09' U I j W .� 52' w� (° iozto Ln I i9 y 34' N mQ 52' mal u')6,3' C', En 2' !NI LO 2� 0.792 ACRES AREA BY COORD. ; I 22.7' 30' BUILDING . . SETBACK LINE._..__. u')_.. I� 10'x70' SIGHT rn LO j EASEMENT d (I 5' NEGATIVE ACCESS ).07' � — _- --_— — — — — — — — — — 10' 19" W 171.31' N 18'35' 10" W -�f- Q ROAD 20' ASPHALT FORK' BDWY R.O. S.R. 1611 SURVEY FOR: JUSTIN M. LANNING & BRITTNEY L. CROTT'S 836 FORK ' BIXBY RD ADVANCE, NC 27006 S.VBDIVISION LOT--Z- DEED BOOK 749 PG. 193 GREY ENGINEERING, INC. Civil Design and Surveying P.O. Box 9 Mocksville, N.C. 27028 greyengineering.com (336)751-2110 EX. BE TIE ROD W/ R CDEF. NAIL 1/2- EIR 1 TOWNSHIP: SHADY GROVE COUNTY: DAVIE STATE: NORTH CAROLINA PROJ. NO.: 198.001.GE SURVEY BY: J. LANNING DATE: 4/16/08 DRAWN BY: J. LANNING DATE: 4/18/08 WHITE PVC TRIM ON PECK w 14'-0° EXISTING RESIDENCE w WHITE VII W/ BL.9 31 ^�I nl_OII �I�O�I �tJ 1V41-OII GENERO 5/4xh AZEK DECKING, i WHITE PVC PERIMETER WHITE WEATHERWISE YIN, PICKETS TO Er QUILT F