129 Guinevere Ln (2)'= DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street 1
Mocksville, NC 27028
,., (336)753-6780 / Fax # (336)753-1680
OPERATION PERMIT
Account #:, 990003858
Tax PIN/EH #: 5745-18-0184
Billed To: William Link
Subdivision Info:
Reference Name:
LocationiAddress: Guinevere Lane -27028
Proposed Facility: Residential
Property Size: 3 Acres
ATC Number: 5810
**NOTE** The issuance of
this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 1
I 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. Manufacture "� 0 . Tank Date Tank Size
Pump Tank Size
System Installed By:
,f ,`ll
' SmE.H. Specialist: datz U date:
GPS Coordinate:
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 #: 990003858 Tax.PIN,EH #: 5745-18-0184
Billed To: William Link Subdivision Info:
Reference Name: Location/Address: Guinevere Lane -27028
Proposed Facility: Residential Properly Size: 3 Acres
ATC Number: 5810
Site Type: (RNew ❑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 2 #Bathrooms #People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size �CL�, Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 2:0—Tank SizeJCO GAL. Pump Tank GAL.
Trench Width t Max. Trench Depth FA Rock Depth Linear Ft. _-:3Z90 2v%
Site Modifications/Conditions/Other: Rdu' "- ki
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 – 9:30a.m. on the day of installation. Teleuhone # (336)751-8760.
Environmental Health Specialist
DCHD 11/06 (Revised)
0
• Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
IMPROVEMENT PERMIT
Account #: 990003858 Tax PIN/EH #: 5745-18-0184
Billed To: William Link Subdivision Info:
Address: 129 Guinevere Lane Location/Address: Guinevere Lane -27028
City: Mocksvile
Property Size: 3 Acres
Reference Name:
Proposed Facility: Residential
**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: Ulvew ❑Repair ❑Expansion Permit Valid for: 05 Years ❑No Expiration
Residential Specifications: # Bedrooms_ # Bathrooms # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD) :�jG L Type of Water Supply: County/City ❑ Well ❑Community Well
Site Modifications/Permit Conditions:
Site Plan
System Type LTAR
Initial Z
Repair `
Environmental Health Specialist
i.p. 11-06
Date
Account #:
Billed To:
Reference Name:
Proposed Facility:
Water Supply:
Evaluation By
- v
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
✓IATION>nFRTY INFORMATION
)3858 Tax PIN/EH #: 5745-t- I
m Link Subdivision Info:
Location/Address: Guinevere Lane -27028
lential Property Size: 3 Acres Date Evaluated:
On -Site Well Community Public
Auger Boring Pit_ Cut
SITE CLASSIFICATIO
EVALUATION BY:
LONG-TERM ACCEPTANCE
RATE: 2
OTHER(S) PRESENT:
Texture group
Consistence
r�r;�r�r��r�•�r�c�
Mineralogy
HORIZON H DEPTH W FEW=
It
Consistence
HORIZON IV DEPTH
RESTRICTIVE HORIZON
SITE CLASSIFICATIO
EVALUATION BY:
LONG-TERM ACCEPTANCE
RATE: 2
OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope V - 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 FIZ - Friable FI - Firm VFI - Very firm EFI -Extremely firm'
-'t
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
1:1, 2:1, Mixed
N
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(insuitable)
Soil wetness - Inches front 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)
T TAR - T.nna-term arrPnt�nrP ratr - valldav/ft? TInrir% nctnc m__-:__��
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APPLICATIO FOR SITE EVALUATION/IMPROVEMENT PERMIT
�' Davie County Environmental Health
�� P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
pU� (336)753-6780/ Fax (336)753-1680
Applica ite Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) 19 Both
Type of Application: 1ANew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
e-
L;,U lie
lo be
JA & ATC 1 /'a.
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE -REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name I,// i. g I ,gam 0?,4 V � , sJ(' ,T k Contact Person L✓n le, 4 ,x;A 3' �
Address Igg G uq0e_ye/V,P < /tJ Home Phone 33 4, 2 g� ;2 a
City/State/ZIP NL 2 h 02R Business Phone ,.�(p !9q0- ?39Z.
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged g13'
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan )Wlat(to scale)
(Permit is valid for 60 months with site plan; no expiration with complete plat.)
Owner's Name_ ltJ/L AiIqW2 OPiQY L I n.lt 3—le Phone Number S"j
Owner's Address /2 (, u1W,, /lope 4)t,' City/State/Zip
Property Address it /.- .ty
Lot Size 3 leoe-e S 5--7q5-- _ Tax PIN# ' C
Subdivision Name(if applicable) Section/Lot#
Directions To Site: (o a / S 76 X10 / S 6- ilz jve LP i2/ 1 A2 cpN e CI� 'liJ Z e
IDi s dry RI 9 N -t'
If the answer to any of the following questions is-"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes _X'No
Does the site contain jurisdictional wetlands? _Yes XNo
Are there any easements or right-of-ways on the site? _Yes ,(No
Is the site subject to approval by another public agency? _Yes )No
Will wastewater other than domestic sewage be aenerated? Yes V No
IF RESIDEN FILL OUT THE BOX BELOW
# People # Bedrooms 7, # Bathrooms Z• Garden Tub/Whirlpool ❑Yes ❑ o
Basement: ❑Yes o 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: I�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 pen-nit(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 detennine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
locat_i and flaggin or staking the house/facility location, proposed well location and the location of any other amenities.
Site Revisit Charge
Property owner's or ner's lega epresentative signature
Date(s):
a 0 / / Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account #
Revised 11/06 Invoice #
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 8/3/2011
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