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346 Fulton Rdt Ao gg- DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street d I Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990005078 OPERATION PERAfg PIN/EH #: 5777-58-6947 0 Billed To: Richard "Dean" Ball Subdivision Info: t"( Reference Name: \ Location/Address: Fulton Road -27006 Q r f Proposed Facility: Residence Property Size: 6.344 Acres '[ ATC Number: 4861 **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 an given period of time. —( i j i9 System Type:17�� S.T. Manufacturer Tank Date rilc Size rumpSize . Op� I2 alled By: Q • E.H. S ialis, Date: God V� l� h 1 U y 5C4 �a v n(.1 -TT) 11106 rRevicPrll 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 #: 990005078 Billed To: Richard "Dean" Ball Reference Name: Proposed Facility: Residence ATC Number: 4861 Tax PIN/EH #: 5777-58-6947 Subdivision Info: Location/Address: Fulton Road -27006 Property Size: 6.344 Acres 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--4-- Bathrooms # People 4 Basemente"Basement plumbing?' - Non -Residential Specifications: Facility Type # People # Seats L/ Square Footage(or Dimensions of Facility) Lot Size r �1 Q c. -,c 5 Type of Water Supply: ounty/City ❑ Well ❑ Community Well ativ 11so System Specifications: Design Wastewater Flow (GPD) &06 Tank Size GAL. Pump Tank L — GAL. (, #1 / l Trench Width 3 G Max. Trench Depth a-1 f f-'- Rock Depthj Linear Ft. cj T ��R�y�tctin 15A NC>C � �/icic c r u+, Site Modifications/Conditions/Other: ;+nd c,,.-+nm�; m= 8:30, 9:30a.m. on the -Y (5—) /OSS ' X3' ��r\ bp a t Reciucf% C?1411 40&5-e > bG �DU1 Health Section for final inspection of this system betwee�] of installation. Telephone # (336)751-8760. 1"/ d� 0 Coil C qG c3� Yl't / Environmental Health Specialist s�=i'�u-� Date: DCHD 11/06 (Revised) 411 A Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005078 Billed To: Richard "Dean" Ball Address: 156 McDaniel Road City: Advance Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5777-58-6947 Subdivision Info: Location/Address: Fulton Road -27006 Property Size: 6.344 Acres **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: ❑llTew ❑Repair ❑Expansion Permit Valid for: Cf5 Years ❑No Expiration Residential Specifications: # Bedrooms ---5—# Bathrooms # People_ Basement❑ -$asement plumbing4`' Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of FaciZounty/City ity) Design Flow(GPD): 60 Type of Water Supply: ❑Well ❑Community Well Site Modifications/Permit Conditions: enf-!nted4 s 'ne tl ' Site Plan LTAR Initial 119.3 1 Repair r -1 ifr=� ' ct a+ E'11. fof P,z-Y �lIle te �0 �G41` R-4 0 Tuj ie c&,c Environmental Health Specialist. i.p.11-06 Date qLf OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC / Davie County Environmental Health P.O. Box 848/210 Hospital Street +t ' 1 Z� Mocksville, NC 27028 '. (336)751-8760/ Fax (336)751-8786 i Application For rovement Permit Authorization To Construct(ATC) Both a Type o et#ti ew m Repair to Existing System Expansion/Modification of Existing or Facility " THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED ON IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed'I; L Igtj eQ J�q (I Contact Person rb2Q4 Ila Billing Address 1 (p m C �a t ; e ( Home Phone 3. to q q City/State/ZIP � �{�,� �t� ��'� App , Business Phone 3 3 (e rj rf (g Name on Pemtit/ATC ifDii erent than Above Mailing Address City/State/Zip PROPERTY INFORMATION 'Date House/Facili ers Flagged NOTE: A survey plat or site plan must accompany this application. Included: Qitc Plan Plat(to scale) (Permit is valid for 60 m the with site plan, no expiration with complete p Owner'sName�j �juyn i 1 nnA Phone Number' Owner's Address of -33 el'%re-le., L ✓WOW J City/State/Zip S-} Sy111P Property Address AArmagen City All "re— Lot Size Ev.3 ad ve e, Tax PIN# 5`j_'11 9047 Subdivision Name(if applicable) Section/Lot# L4-4 10 Directions To Site: 4b -At PY i 1- I RD . 41v i t 14inly iY)ca Qb l If the answer to any of the following 4iiestions is ` yes , supporting documentation must be attached. Are there any existing wastewater systems on the site? Yes 0 Does the site contain jurisdictional wetlands?4e , y Are there any easements or right-of-ways on the site? Yea No. Q�`��1 n9 Polder- I i rtG K�ITf Is the site subject to approval by another public agency? es Will wastewater other than domestic sewage be generated? Yes IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms r Bathrooms r Garden Tub/Whirlpool Yes No Basement: Y s No Basement Plumbing: Ye No IIto ► to) �aR**110] ie IQA01rf11Li11116VIIMOi}i ]a11i1VIA 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: 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 No 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 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 comers and locating and flagging or staling the house/facility location, proposed well location and the location of any other amenities. t lit_ .' L r n fi n �- vw Site Revisit Charge Property owner)or owner's legal representative s' nature/�C) Date(s): fj '� ^ V a Client Notification Date: Date EHS: Sign given Yes No Account # Revised 11/06 Invoice # 1" evel t�e +so Nc Hwy 801 s AyTroX. Ac fle s : G 3 0 - Z v C •� Gw�a e GCItq ��ve �s' x ��•1� Qa— j fax 1 #�14 -�.,,� ; tic -!ems -�-1. •Ne �GS� mc►-.5-�- ��vr�.�i�C� � �-i�v,5e C� �.ra�-ac�e O*fAq w'. I Iwo �k ti 9 rfogy) `ti�1> II I �. �� (962) �/ i ��ipN� yon e� `11 $may �� - a r,�� J y6� to ',�-, ,lel r 11 �� Q .. J 1501 �. - '.:. ` �o iZfl �^J- � _ DAVIE COUNTY HEALTH DEPARTMENT w Environmental Health Section Soil/ Site Evaluation APPLICANT I FORM NIIW ItU INFORMATION amount , Tax PIN/EH #: 577 - Billed To: Richard "Dean" Ball Subdivision Info: Reference Name: Location/Address: Fulton Road-27� f 5`6Proposed Facility:. Residence Property Size: 6.344 Acres Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring -00� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position (r Slope % HORIZON I DEPTH V -- Texture group�j G' (� C Consistence 5 A, I le Structure r -P Pie q yam - Mineralogy HORIZON II DEPTH 0- 17 1� Texture group Consistence /t Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ACE LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: f LONG-TERM ACCEPTANCE RATE: L.fu LEGEND EVALUATION BY: OTHER(S) PRESENT: Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope CC�C� Texture 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 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 Mineralogy 1:1, 2:1, Mixed LIQts� 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 (Revi.-ed) ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ OF ■■■■■■■■■■■■ ■■■■■■■■■■■■ Nn■■■■■■■■■■ ■■WR■■■■■■■■ ■ NONE ■EE■