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243 Gibson Way1 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street — ,�11, Mocksville, NC 27028 -75 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Accnunt 990000979 Tax PINI WH #: 5745-51-6640 Billed To: Camp Manna Ministries Subdivision info: Reference Name: LocationiAddress: Gibson Way -27028 Proposed Facility: Activity Building Property Size: ATC Number: 5054 **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. System Type: S.T. ManufacturerS4-C14 - Tank Date_ _ Tank Size�0- Pump Tank Size�/� S stem Installed B 1 Y Y�.��/.�i'/L /jjrU�'�• E.H. Specialist: te: Z.S 20/0 r jqC IeSbud I6 Chp'""bf �s 59di�d � l L DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000979 Billed To: Camp Manna Ministries Reference Name: Proposed Facility: Activity Building ATC Number: 5054 Tax PIN: EH #, 5745-51-6640 Subdivision Info: Location/Address: Gibson Way -27028 Property Size: Site Type: aNew ❑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 # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type & - j?ln # People # Seats q Square Footage(or Dimensions of Facility) % Lot Size -1 �G��S Type of Water Supply: ❑County/City El ell ❑Community Well System Specifications: Design Wastewater Flow (GPD) Ud Tank Size OZ4AL. Pump Tank AGAL. � 2 tr ``ir � Trench Width Max. Trench Depth J � Rock Depth d Linear Ft. Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1960'191 accepted Systems may also be user', Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the-da--y­of installation. Telephone # (336)751-8760. Environmental Health Speciali DCHD 11/06 (Revised) 'n �� beg To 4 mat Date: :3 r Davie County Environmental Health P.O. Box 848/210 Hospital Street — Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990000979 Tax PIN/EH #: 5745-51-6640 Billed To: Camp Manna Ministries Subdivision Info: Address: 243 Gibson Way Location/Address: Gibson Way -27028 City: Mocksville Property Size: iti Reference Name: Proposed Facility: Activity Building **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 ifsite lans, plat or the intended use change. _..._ ---------- _____._._._.._,..._____....___-._._-...___._._.._..__.....__._._._.-. _ Permit Type: ew ❑Repair ❑Expansion Permit Valid for: M Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type C— �0�►n # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: ❑County/City Edell ❑Community Well Site Modifications/Permit Conditions: Site Plan Gi System T e LTAR Initial C / 5 40W Environmental Health Specialist i.p.11-06 kntp CA ate ate �> 17 � use %S1i Q SLe �-� C/v AIJ SP�i-I�/ ic •t . r ' LT I TE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ✓ c c e `L 2 N ( 36)753-6780/Fax(336)753-1680 licatio For: ❑ Si date `t, Impr ent Permit ❑ Authorization To Construct (ATC) ❑ Both ype of Applic �} st Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPOR AN HIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED FO N IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed A'Iskii4i IV ` `f3''t$ontact Person iIG�'Z Bilffng Address ' 4 r t L'' Home Phone City/State/ZIP ilu c .0' Business Phone 1 -7-6 �J Q Name on Permit/ATC if if erVqt than Above eo`I Mailing Address City/State/Zip PROPERTY INFORMATION *Da . ieHouse/Facility Comers Flagged IU 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 Phone Number Owner's Address t City/State/Zip Property Address City Lot Size Tax PIN#5-7115-51-0-46 Subdivision Name(if applicable) SectionA�gt# e , If the answer to any of the following questions is "Yes",supporting docutuantation must be attached: Are there any existing wastewater systems on the site? Yes _No . Does the site contain jurisdictional wetlands? _Yes Are there any easements or right-of-ways on the site? _Yes — Is the site subject'to approval by another public agency? _Yes No Will wastewater other than domestic sewage be generated? Yes �IVo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No =06WE_► WIL11010* 14O11[6111JIIIIICI C OZ:SS-1Q1011i71 Type of Facility/BusinessMeVA a o ifs9otal Square Footage of Building # People # Sinks L- # Commodes 1 4 4 Showers "Z-- # 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 E'Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? 14 -0 ---- 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 infgst n submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representati f theCounty Health Department to conduct necessary inspections to determine compliance with applicable laws and es unthat a sponsible for the proper identification and labeling of property lines and corners and local' d flaggin1g . e t se/facility location, proposed well location and the location of any other amenities. �,.. / Site Revisit Charge Proper owner's or owner's legal representative signature Date(s): if Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # r-. s� 'GoMAPS - Davie County NC Public Access Page I of I Oo343ft N5000000 4 24.515 AC FF PINE RIDGE C http://maps.co.davie.nc.usIGoMapslmapllndex.cfm?mainmapservice=gomaps&CFID=412... 2/22/2010 Davie County, NC - GIS/Mapping System ;;V/ , Nick Here To Start Over QtjWe �w,-,.rch: (County ID or Ovj ner Ni • Active Layer Huse.'fa'D -Frps l� lw PARCELS (Map Tips Available) r-ICDANIELHELEr j - s Oo343ft N5000000 4 24.515 AC FF PINE RIDGE C http://maps.co.davie.nc.usIGoMapslmapllndex.cfm?mainmapservice=gomaps&CFID=412... 2/22/2010 M �,. Davie County Health Department Environmental Health Section P.O. sox 848 210 Hospital Street C? Courier #: 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name:—Phone Number /l �� Id� (Home) Mailing Address: !W 5�v 4 3'i�4Vq (Work) OvillieAlb-/ie 2 dZ� Detailed Directions To Site: Pjib'50A)W-1-1 erty Address: w A s 7�A V s Rd) Please Fill In The Following TIiformation Aout The /EXISTIN,GFFacility: : �%Y1 Name System Installed UnderW � I�°� '�TliA112i%�/e Type Of Facility: Date System Installed (Month/Date/Year): 00 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW FacilityfUQs Type Of Facility: Number of People �`� Requested By: o '� ' l Date Requested: 7"Z'2-10 For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way 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 Money Order # Amount:$ Paid By: Received By: Account #: Invoice #: Date: Account #: 990000979 DAME COUNTY HEALTH DEPARTMENT _ Environmental Health See1ion P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Billed To: Camp Manna Ministries Reference Name: Stan Riddle Proposed Facility: Rec. Facility ATC Number: 2338 Tax PIN/EH #: 5745-51-6640.01 Subdivision Info: Location/Address: Pine Ridge Road -27028 01 Property Size: 42 Acres '4 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATE O STRUCTION IS VALID FO?p PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: AZA - A/ Date: , :�V ',&) CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit 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. /60 l= Septic System Installed By: Environmental Health Specialist's Signature: ��� �' L=am - Date: e-x�2 0 DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT - ' • - Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990000979 Billed To: Camp Manna Ministries Reference Name: Proposed Facility: Activity Building Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5745-51-6640 Subdivision Info: Location/Address: Gibson Way -27028 Property Size: 3q%,OM5 Date Evaluated:�'— On-Site Well Community Auger Boring �_ Pit Public Cut SITE CLASSIFICATION: i LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: epil AjQ _"W'S 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 CONSIST ,N - . )Y141St 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 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 rJotes 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) TTAR - T.nna-ti>.rrn gvrf-ntnnrP rate - oa1/ri%v/ft7 T\r-•TTTI ncinc /Tl__.:__J\ _-Landscape position _��Wq��WAM HORIZON I DEPTH Texture group Consistence i,fd7���� Structure IR MineralogyTexturegroup _Co Mineral .:HORIZON ��«Jf����� III DEPTH Texture groupi Consistence Mineralogy HORIZON IV DEPTH Texture group M MAMO Consistence MineraIogy- SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION SITE CLASSIFICATION: i LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY: epil AjQ _"W'S 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 CONSIST ,N - . )Y141St 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 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 rJotes 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) TTAR - T.nna-ti>.rrn gvrf-ntnnrP rate - oa1/ri%v/ft7 T\r-•TTTI ncinc /Tl__.:__J\ ■MOMM■■E■■■■■■ ■M■E■E■E■EM■E■ ■M■ME■■M■M■■M■ ■MMM■MMM■M■■I■ :iiiiiiiiiiiiin ■■■■■■Ona■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■ ■■■■■■■RME■■ ■■■■■■■W:i■■ ■ ■ i ■■■■■■■■■■ ■ ■ ■MM■MMUMM■■ ■MME■■ ■■M■ ■M■M■■M■■M■■ ■MMM■■MMM■M■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■ MEMO■■■■■ ■E■■■EEE■ ■E■■E■E■■ ■E■■E■■■■ ■■O■■M■■■ ■■■■■amo■_ ■EEE■■UMM ■E■E■EWEN ■■ iii ■S■ ONE mom MEN ■ ■ ■■■■■■■■■■►R■ ■EMEM■ ■■MONS ■ONSO■ ■■ ■M■ ■■■■■■■■■■■■■►�■■■■►�■■■■■■■■■■ ■o■■■■■■■■■■■■■■■■■■►�■■■■■►�■�i■■ci ■■■■■O■■■92 ■M■M■MEMENE ■■■■■■■■■Nu ■■■■■■ ■■ ■■■■■■■■■■■ ■■MEMO■■■■■ ■■■E■■■■E■■ ■■ME■■■M■■■ ■■■■■O■■■■■ ■■Oo■O■u■■■ pommo0bm■■■ ...c:r■■E■■ SOON MEMO ONE MEN ■■■W■ME■■WNUMMME■ ■MMM■MM■■NMAMM■■■ ■■■■■■■■■WUMM■■■■ ■■■■■■■M■■"MM■■■■ ■M■■w■■■■■WEAMM■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■ ■ I - -.- 6heN ec -Pob S-IzsI rz- N, es 7o -rct, a47 c AC4,tu'llf-S Octvi,,R,s-t