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114 Harness LnAccount #: 990005394 Billed To: James Staton Reference Name: Proposed Facility: Residence DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 OPERATION PERMIT Tax PINIEH # 574549-2531 Subdivision Info: LocalionlAddress: Harness Lane -27028 Properly Size: 6.11 Acres ATC Number: 5048 **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. Manufacturer 56t Tank Date G -G Tank Size Pump Tank Size System Installed By: J AM16 20911W E.H. Specialist—WillDate:10 r4 ew Q►.,,s� PUY x`"14 S iLX = e1- L " kit �►- Z' 27 C hOt' . 1 tl �: �o e,1�• . 10 Aq EiR NE?s c,r DCHD 11/06 (Revised) LA N O 00 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: 990005394 Tax PINIEH #: 574549-2531 Billed To: James Staton Subdivision Info: Reference Name: LocationfAddress: Harness Lane -27028 Proposed Facility: Residence Property Size: 6.11 Acres ATC Number: 5048 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�•.7 #People .2 Basement❑ Basement plumbing❑ # Bathrooms Non-Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ' l / Q L Type of Water Supply:ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)3 Tank Size GAL. Pump Tank GAL. f 4r Is Trench Width 3G Max. Trench Depth 3 G Rock Depth . I ,� Linear Ft. 4/34 4 As stated In 15A ICAC 18A.19&2i Site Modifications/Conditions/Other: ba L46 f. Contact the Davie County Environmental Health Section for final inspection of this system 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. II I.� DCHD 11/06 (Revised) Pr"I W9 Caepor l ,eci list LQ -0 t S 11� /i to) 4 Ce Date: �� Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005394 Billed To: James Staton Address: 114 Harness Lane City: Mocksville, Reference Name: Proposed Facility: Residence Tax PIN/EH #: 574549-2531 Subdivision Info: Location/Address: Harness Lane -27028 Property Size: 6.11 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: ❑New ❑Repair ❑Expansion Permit Valid for: F3 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathroomyalc# People_ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): (46 Type of Water Supply: KCounty/City ❑ Well ❑Community Well Site Modifications/Permit Conditions: A,- ,> acce t µEAtTN E EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 �tV1ROhMErt�A��, Applic tion For: ElSital ton/Improvement Permit ❑ Authorization To Construct (ATC) Both Type o ton: New System ❑Repair to Existing System ❑Expansion/Modification of Existin System or Facility 'IMPORTANT."* *IMPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. A PAT TO AVT TATT70T21k4 A TTnNT Name to be Billed -�>z� `�l t1 `Z'/f Contact Person JnM�5 ST7'-)TZ Billing Address //4/ A6q f2ry,54S L&l Home Phone Id- 5Z-Aj9 - fZ7o 6 City/State/ZIP Mpc- 5✓ict,--, A/G 07oZ8 Business Phone ' Name on Permit/ATC if Different than Above Mailing Address FROPER i x KNF uRMA 1 iulN Tllate House/Facility Corners Flaeaed I — -1 - f - W I " 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 Tme;s S�-A7-pd _ Phone Number 413-498-470 Owner's Address I ItL /4gQriESS Gnt __— City/State/Zip_14ocKSy/4�-E,Alc Z 7oze, Property Address 114 Pd:a( l&TS 1-0 __City Mioc(tS (/iccE Lot Size (,,,[I 4cK,6f Tax PIN# yqi-:75,3/ Subdivision Name(if applicable) _ Section/Lot# .Directions To Site: SouTu -Mc. 6.5 t r6 A(C5o i T. -m.1 Gc 2/o n,tIc.e - > a,o C<1f-r &J u AQV Esc L, -L _1 STZ o,- oa 21e.A-r- 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? ijYes —No Does the site contain jurisdictional wetlands? _Yes ;.-Wo 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 generated? Yes v No IF RESIDENCE FILL OUT THE BOX BELOW # People Z # Bedrooms 3 # Bathrooms 3 /2 Garden Tub/Whirlpool ❑Yes }No Basement: ❑Yes ANo Basement Plumbing: ❑Yes 'ANo 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:.County/City Water 5 New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes `l 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 la d rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and I o -ating ncl flagging or st in the hou /facility location, proposed well location and the location of any other amenities. — — Site Revisit Charge ope owner's or o ner's legal representative signature Date(s): lv_w10/D Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # � Revised 11/06 Invoice #� AI 14 6�Prle- W "IX rr C163 • -GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System QST l Click Here To Start Over el quick Search: Count ID or Owner Ni Active Layer. p fps y .... ❑Use t a t� ® PARCELS (Map Tips Available) Y•rJ Addre 7. /\1 24*'� J`724 1,2 <232' / http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=4129... 1/6/2010 APPLICANT INFORMATION Account #: 990005394 Billed To: James Staton Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 574549-2531 Subdivision Info: Location/Address: Harness Lane -27028 Property Size: 6.11 Acres Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 .2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH �( Texture group G Consistence f 3rd�y 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 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: elf REMARKS: EVALUATIONBY: OTHERS) PRESENT• -e G1 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 11/ � 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 1Y41eS 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-term grrP..ntgnre rate - oat/riau/ftp rw vir%ncinc in__.:__��