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210 Hillcrest Dr.�,. DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 :Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax # (336)753-1680 OPERATION PERMIT Account : 990005948 '::.Tax PIN,EH #: F80000005 Billed TO: Edward Bruebaker "Subdivision:Info* a Reference Name:- , , .::Location/Address: Hillcrest Drive -27006 Proposed Facility: Residential r ,, + -= ;;; Prnperty Size: 1.58 Ac ' ATC Number: 5982 **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.{1(z"t�:T. Manufacturer1 Tank Date—� Tank Sizeb - Pump Tank Size Bedrooms. System Installed By: 12041 WIFLCn Installer# Date: ZC� GPS Coordinate: Environmental Health 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 #: 990005948 Billed To: Edward Bruebaker. Reference Name:' Proposed Facility: Residential Tax Pllriil H F800000054 - ;: SubdiVisiorl'.Info: � .;ssLocationiAddress: Hillcrest Drive -27006 Ptoperty:Sizo: 1.58 Ac ATC Number:. 5982 Site Type: GdNew ❑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 FORA PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: # Bedrooms_ # Bathrooms 2 # People J� Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ) 5$ 0"_ Type of Water Supply: IZCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) 3AQ_Tank Size 1w* GAL. Pump Tank GAL. Trench Width Qu Max. Trench Depthr_J � Rock Depth Linear Ft.t1foo, 0)s5ro Site Modifications/Conditions/Other: '�i1Q�fj� [Ji �Q _/HCl ��9n Contact the Davie County Environmental Health Section for final inspection of this system between �N(Joid&# 91,12. 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: ONew ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration Residential Specifications: # Bedrooms_ # Bathrooms Z # People 5� Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility. Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: ®County/City OWell ❑Community Well Site Modifications/Permit Conditions: S stem Type LTAR Initial QS`% RfAac6n 7-2 5 Repair ° pry Environmental Health Specialist i.p.l 1-06 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680, r IMPROVEMENT PERMIT Account #: 990005948 Tax PIN/EH M. F800000054 r Billed To: Edward Bruebaker Subdivision Info: Address: 219 Hillcrest Dr. Location/Address: Hillcrest Drive -27006 City: Advance Property Size: 1.58 Ac 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: ONew ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration Residential Specifications: # Bedrooms_ # Bathrooms Z # People 5� Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility. Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: ®County/City OWell ❑Community Well Site Modifications/Permit Conditions: S stem Type LTAR Initial QS`% RfAac6n 7-2 5 Repair ° pry Environmental Health Specialist i.p.l 1-06 C APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 19 2012 � , ApplicaWnn'� or: 0 Site Ev atio €gprovement Permit ❑ Authorization To Construct (ATC) oth Type ofcation: ys em PRepair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPI JC;ANT INFORMATION NameContact Person Address 2 / g /2/.1-4. Home Phone City/State/ZIP /yG �27ao6 Business Phone y�13�j6rJ� Email * 0,,eAgW�l��,Y"o0, <foly Name on PermiVATC if Different than Above Mailing Address 2/? City/State/Zip IU c 2 q v a PROPERTY INFORMATION *Date House/Facility Comers NOTE:. A survey plat or site plan must accompany this application. Included: VSite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name' e1)1Ng�'17 g 644 . Phone Number Owner's Address2 /� �L[ 4c"4T � City/State/Zip O(/,Q/(/ <'� WC Property Address Lot Size Subdivision Name(if applicable Directions To Site: Tax PIN# Section/Lot# 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 L4 -o 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? C-�o. Will wastewater other than domestic sewage be generated? —Yes Yes TF RF,STDF,NC;F, FIT J, OT TT THE BOX RFT,OW IF NON-RF,STDFNC E FTT.L OUT THE BOXBFTOW 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: BIS' nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 9.1 unty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 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 corners and locating and flagging or stak' g the hou /facility location, po d well location and the location of any other amenities. _ Propeer's oro�wii s legal representative signature , Site Revisit Charge L� Date(s): Z) Client Notification Date: DaW EHS: Sign given ❑Yes ❑NoAccount #C/ Revised 11/06 � Invoice # ZGcf �Z�}Z ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005948 Billed To: Edward Bruebaker Reference Name: Proposed Facility: Residential Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: F800000055 Subdivision Info: Location/Address: Hillcrest Drive -27006 Property Size: 1.58 Ac Date Evaluated: q 2 On -Site Well Community Auger Boring_ Pit Public X Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % d/ Al HORIZON I DEPTH .g &_ Texture groupSL Consistence R Structure Mineralogy HORIZON II DEPTH Texture group` Consistence Structure Mineralogy(. HORIZON III DEPTH , qz Texture group Consistence �,tl Structure *"4 Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION P5 LONG-TERM ACCEPTANCE RATE' •'Z A15 SITE CLASSIFICATION: ►PS EVALUATION BY 4 LONG-TERM ACCEPTANCE RATE: .225 Lr OTHER(S) PRESENT: REMARKS: 2 ^ ` I it✓ ftm, a h (u& Qr 3ro'r in kZ IfW C A, /ATL. Z.Y" LEGgD 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 ON4IST .NC , 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 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 NQts� 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 05105 (Revised) m /YX7g Flo N-7- III T R Mc F� i Z3?