626B Howardtown Circle::. DAVIE COUN'T'Y ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital. Street
Mocksville, NC 27028
(336)751-8760 Fax # (336j!51-8786
OPERATION PERMIT
Account #: 990004102 Tax PIN/EH #: 5860-09-6631-2B
Billed To: David Purkey Subdivision Info:
Reference Name: Location/Address: 626 B Howardtown Circle -27028
Proposed Facility: Residence. Property Size: 1 Acre
ATC Number: 4662
**NO'T'E** 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. I o7
System Type: S.T. Manufacturer Tank Date 7— 3 Tank SizeOccr—>
Pump Tank Sized f A=
System Installed By: E.H. Specialist: u 4 tau S Date:
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DCHD 11/06 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital StreetI
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004102
Billed To: David Purkey
Reference Name:
Proposed Facility Residence
ATC Number: 4662
S.'
Tax PIN/EH M 5860-09-6631-26
Subdivision Info:
Location/Address: 626 B Howardtown Circle -27028
Property. Size: 1 Acre
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 3 # Bathrooms_ #People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size , d Q c r -e Type of Water Supply: ❑ County/City 2411 ❑ Community Well
System Specifications: Design Wastewater Flow (GPD) -moi Tank Size 0 GAL. Pump Tank d
4 -GAL.
Trench Width 3 6 Max. Trench Depth 3 rRock Depth a "Linear Ft. 3 06 i
Site Modifications/Conditions/Other: As stated in 15,E NCAC 18.4.1969(5)
aseepted-Systrsr,isplay so Ve use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 - 9:30a.m. on the day of installation. Telephone # (336)751-8760. ,
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DCHD 11/06 (Revised)
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EVALUATION/IMPROVEMENT PERMIT & ATC
vie County Environmental Health
MAR 9 2007 P.O. Box 848/210 Hospital Street
Mocksville, NC 27028`
ENYI,4oNMEP(1Al f1EAlIN (336)751=8760/ Fax (336)751-8786
VNE Coway
Application For: i ement Permit , ❑ Authorization To Construct(ATC) EV/Both
Type of Application: NfiewSystem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed _-Dt-✓) c- / ctr'1C.e. &d Contact Person G&YY -
Billing Address -_1166 im //1"14 1?, -j— Home Phone c1 Ci $ _ 5 3q S
City/State/ZIP 6rYla1,_ks , Ihl� G A70'-1�1 Business Phone
Name on Permit/ATC if Different than Above
Address
PROPERTY INFORMATION *Date House/Facility Corners Flaeaed 3 -
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months ith site plan, no expiration with complete plat.)
Owner's Name 7) Phone Number
Owner's Address IV I h, aq VA City/State/Zip
Property Address -City]o
Lot Size 1 ik C P I Tax PIN# 5'9 0O��i I -�
Subdivision Name(if applicable) Section/Lot#
Directions To Site: 15-'3 10 -i'ez�j f�P--,
If the answerlo any of the foll6wing questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes Gado
Does the site contain jurisdictional wetlands? ❑Yes UKo
Are there any easements or right-of-ways on the site? R<es ❑No
Is the site subject to approval by another public agency? ❑Yes DNo
Will wastewater othei than domestic sewage be generated? ❑Yes [iIN'o
IF RESIDENCE FILL OUT THE BOX BELOW
# People 3-- # Bedrooms 3 # Bathrooms _ Garden Tub/Whirlpool ❑Yes Rflo
Basement: ❑Y— ess R 10 Basement Plumbing: ❑Yes MNo
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:. 31(fonventional BPA*c'cepted ❑Innovative ❑Alternative ❑Other
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Water Supply Type: ❑ County/City Water VNew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes . Q 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 aking the ho facility location, proposed well location and the location of any other amenities.
'v� I Site Revisit Charge
Property owner's or owner's gal representative signature
Date(s):
3 q p 7 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account # z
Revised 11/06 Invoice #
Tax Lot 106.02
Tax Map F-6
David Purkey
and; wife
Constance. M. Purkey
RB 551 ® PG 775
S 85*3 51, 285.32'
T'ie Line'
oning
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ation
4�6
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IRS
X Nonmonumented Points
S 76��1,rL.
tr
Lot 2 268 22. ';n of Comer
1.000 Acres +/- 3
Tax Lot 106.02
�- Proposed 3 Acce Easement Tax Map F-fi
(See Easem all Tabte) cA David Purkey
291.92, N and wife 78 Te tin
N 89°12'40"W IRS RBn551 0 PG 775stanstance M. ey 9 44• N 76�-, W
Gra-vel Dnv-e - - - - - - - _ _—_- - ��
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S 829- 12�40'E 1RS _F_? -- ____ ` _`_ _#�_^^_ = = �_�e _F�„�PFnd
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4.24
Proposed 30' Access Easement X F
1.000 Cres j - co N (See Easement Call Table) ti3.'e
ro Tax Lot 106.02
CIV 40
301:42' Total N 85030'25('W(245.50')
(55.92')
W
Tax Map F-6
David Purkey
7COnt�rOICOmerl
eco
°REA
IN QUESTION: GAP
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f
RB 551'0 PG 775
Tax Map F-6
David Purkey
and wife
Constance M. Purkey
eco
Ti-=Une
644.97 N 8530'25"W
RB 551'0 PG 775
(S 8585_6„E 6 -- __
A to )
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b/2” EIR Fnd
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3/4" ElR Fnd
AREA IN -QUESTION:, GAP Point B
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Tax Lot 102
Tax Map F-6
n/f Laura Jo Robertson
DB 161 0 PG 245
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004102 Tax PIN/EH #: 5860-09-6631-2B
Billed To: David Purkey Subdivision Info:
Reference Name: Location/Address: 626 B Howardtown Circle -27028
Proposed Facility: Residence Property Size: 1 Acre Date Evaluated: ,� _ 3 --(:5
Water Supply: On -Site Well Community / Public
Evaluation By: Auger Boring t Pit Cut
FACTORS
1 2
3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
eei yAC
Consistence
ytl 11 4 Vyf-
Structure
C�
MineralogyI;
11 a:
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HORIZON II DEPTH
— O
Texture groupL
Ld k
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
LONG-TERM ACCEPTANCE RATE
ao 10. 4
10.
SITE CLASSIFICATION:
�iU.tti Sit c`u�i
LONG-TERM ACCEPTANCE RATE: d '
REMARKS:
EVALUATION BY: All o A Z, l G C�
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
CONSISTENCE
MQ1St
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
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)
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account M 990004102 Tax PIN/EH M 5860-09-6631-2B
Billed To: David Purkey ='' .Subdivision Info:
Address: 2103 Milling Road Location/Address: 626 B Howardtown Circle -27028
City: Mocksville Property Size: 1 Acre
Reference Name:
Propo,
,VSTOVThis i peovement 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: RKew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration
Residential Specifications: # Bedrooms 3 # Bathrooms a # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 4 O Type of Water Supply: ❑County/City V(Vell ❑Community Well
Site Modifications/Permit Conditions:
Site Plan
Environmental Health
i.p.11-06
S stem Type LTAR
Initial .e 0.q
Repair , c C 6. `f
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