218 Beauchamp Rd Lot 3 OPERATION PERMIT or ice se ny
Davie County Health Department *CDP File Number 200429-1
7 210 Hospital Street 5870547679
P.O.Box 848 County ID Number:
°'=•�°' Mocksville NC 27028 Evaluated For,NEW,
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Dick Anderson Property owner. Adam and Emily Walker
Address: 225 Wing Haven Lane Address: 106 Irishman Place
City: Mocksville City: Advance
State2ip: NC 27028 State0p: NC 27006
Phone#: (336)998-2104 phone#: (336)391-0085
N—
ProperW Location & Site Information
Address/Road#: Subdivision Alan Mock Trust Phase: Lot: 3
Beauchamp Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East. Left on Comatzer Rd. left on
Beauchamp Rd. lot on right
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
*IP Issued by. *System ClassificationfDescription:
TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert
Saprolite System? OYes ONo
Design Flow: 3 6 0 *Distribution Type: GRAVITY-SERIAL. Pump Required?
OYes (j)No
Soil Application Rate: 0 a 5 *Pre Treatment:
- Drain field
Ntrification Field 1 4 4 0 S4-ft. *System Type: INFILTRATOROUICK4 STANDARD
("'No. Grain Lines 4 Installer:
Brian McDaniel
Total Trench Length: 3 6 0 ft. Certification#: 1118
Trench Spacing: — 9 Inches O.C.
& Feet O.C. *EH S: 2140-Nations.Robert
Trench Width: 3 Inches
Feet Date: 0 8 / .1 2 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 ApprovalyStatus'
Inches
" Maximum Trench Depth: 3 6 ® Approved L7, Disapproved
", Inches
Maximum Soil Cover. 2 4 Inches
CDP Fite Number 200429 - 1 County ID Number: 5870547679
Septic Tank
("'Manufacturer. Shoaf Lat.
STB: 760 Long: ,
Gallons: 1400
Installer. Brian McDaniel
Certification#; 1118
Date: 0 5 / 1 7 / .2 0 1 6
*EHS: 2140-Nations.Robert
*Filter Brand: POLYLOKPLA 22WiithPOAdapter
ST Marker. El Yes 1B No Date: 0 $ / a a / a 0 1 6
Reinforced Tank: ❑ Ye5 � NO � Appr»valStatus
1 Piece lank: ❑ Yes � No i® Approved❑ Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Appiovat Status
einforced Tank: ❑ Yes O No
D Approved❑ Dtsapprovetl
1 Piece Tank: ❑_Yes _ _ .❑ No ��.
Supply Line
Pipe Size: inch diameter Installer.
Pie Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated_❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO Approval Status
❑ Approved❑ Disapproved
Pump Requirerrignt
Pump Type: Installer.
Dosing Volume: Gal Certification#:
Draw Down: Inches *EHS:
*Chau:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NO `Approval Statu; '
PVC unions ❑ Yes ❑ No ❑ Approved❑ Dtsappfovetl
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole 0 Yes 0 No
CDP File Number 200429 - 1 County ID Number: 5870547679
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ❑ No Installer.
Bax 12 inches Above Grade ❑ Yes ❑ N o Certification#:
Box Box
Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status - g
Alarm Audible ❑ Yes ❑ No ❑ Approved❑ disapproved
Alarm Visible ❑ Yes ❑ No
2140-Nations,Robert
*Operation Permit completed by:
Authorized Stat gent: Date of Issue: 0 8 / a a / a 0 1 6
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE It A. sewage septic system.
Rule..1961 requires that a Type TYPE 11 A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System InspectioniMaintenance Frequency By Certified Operator
NIA
Reporting Frequency By Certified Operator. NIA
Rule.1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract.
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entily prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shalt be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a cond lion of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 200429 - 1
Davie County Health Department CDP Filp Number:
210 Hospital Street 5870547679
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
ck
Drawing Drawing Type: Operation Permit Scale: ON Ack
p
El
i I F 7
l C 41
_�
CONSTRUCTION Forof�iceuse only
AUTHORIZATION 'CDP-File Number,:200429,-1
- �'- .Davie County Health Department County ID Number 5870547679
210 Hospital Street Evaluated For:
P.O.Box 848 Township:
Mocksville NO 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 3 / 1 0 / a 0 a 1
Applicant: Dick Anderson r
roperty Owner. Adam and Emily Walker
Address: 225 Wing Haven Lane ddress: 106 Irishman Place
City: Mocksville City: Advance
State2ip: NO 27028 State2ip: NO 27006
Phone#: (336)998-2104 Phone#: (336)391-0085
Property Location & Site Information
r. Advance
dress/Road#: Subdivision: Alan Mock Trust Phase: Lot: 3
eauchamp Road
NO 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East. Left on Comatzer Rd. left on Beauchamp
Rd. lot on right
#of Bedrooms: 3
#of People:
'Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
ssification: Provisionally Suitable Inches
System? Minimum Soil Cover. 1 a
y Oyes QNo Inches
low: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 - a 5 Maximum Soil Cover: a 4 Inches
"System Classif•Ication/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
"Proposed System: 25%REDUCTION 1-Piece: Q Yes a N o
Pump Required: QYes QNo QMay Be Required
Nitrification Field 1 4 4 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: QYes QNo
Total Trench Length: 3 6 0 ft GPM vs— ft. TDH
Trench Spacing: _ 9
Onches Feet O.C.O.C. Dosing Volume: Gallons
Trench Width: @Feet
Inches
3 Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI Oil 0111 OlV
Dona I of Z
CDP File Number 200429 - 1 County ID Number. 5870547679
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONO, but has Available Space
rDesign
system
Trench Spacing: 9 Q Inches O:C
ification: Provisionally Suitable Feet O.C.
Trench Width: Q Inches
w: 3 6 -- ,.___.3-, (7 Feet
Soil Application Rate: 0 a 5 Aggregate Depth: `
inches
Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE 11A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches
"Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 4 4 0 Sq.ft. Maximum Soil Cover. a 4 Inches
No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 6 0 ftPump Required: Oyes @No OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. jet
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for wastewater System Constriction shall bevalid for a person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be issued at the same time the Improvement Permit Issued(NCGS 130A-336(b)� If the installation has not been
completed during the period of validity of the Contraction Penult,the Information submitted In the application for a permit or Constriction
Authorization is found to have been incorrect,falsified ox changed,or the site is altered,tine permit or Construction Authorization shall become
invalid,and may be suspended or revoked(.1937(g)).Theperson owning or controlling the system shall be responsible for compliance
with the laws,rides,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? OYes ONo
Applicant/Legal Reps.Signature' Date:_
*Issued By: Date of Issue:2140-Nations,Robert 0 3 / 1 0 / a 0 1 6
.
Authorized State ° nt: Malfunction Log Oyes
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CDP File Ntftnber 200429 - 1 County ID Number: 5870547679
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ()No, but has Available Space
rDesign
System
Trench Spacing: 9 Q Inches O.C.
ification: Provisionally suitable — e Feet O.C.
Trench Width: Inches
w: 3 6 0 3 Feet
Soil Application Rate: s a 5 Aggregate Depth: inches
.� Minimum Trench Depth: a 4
*System Classification/Description: Inches
TYPE IIA.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover. 1 a Inches
'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches*
Maximum Soil Cover: a 4
Nitrification Field 1 4 4 0 Inches
3 Sq. ft.
No. Drain Lines *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 6 0 ft Pump Required: OYes ®No OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-II
'Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in.meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and maybe issued at the same time the Improvement Permit Issued(NCGS 130A-336(b)).If the Installation has not been
completed during the period of validity of the Construction Permit;the information submitted In the application for a permit or Construction
Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature: Date:.
*Issued By: 2140-Nations,Robert Date of Issue: . 0 3 / 1 0 / .1 0 1 6
Authorized State A nt: Malfunction Log OYes
®Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 200429 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 5870547679
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 3 1 1 0 / 0 1 6
Q Inch
OBloDrawing Drawing Type: Construction Authorization Scale: , ONIA = ft.
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CONSTRUCTION AUTHORIZATION
Davie County Health Department -
10 Hospital street 200429 - 1
CDP File Number:
P.O.Box$48 5870547679
rG/I Mocksviile NC 27028 County File Number:
Date: 0 3 / 1 0 / 2 0 1 6
Click below to Import an image from an external location: Drawing Type:Construction Authorization
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
TAP, Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: Siteluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: geywa System ❑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 H go Contact Person T"6
Address 2 A,S- W 10 k A Q r Home Phone 'hQ /
City/State/ZIP 440 C t;(4 V 1 L L k J2 C 2 7d.meq Business Phone - / 4, 9 - 2 7
Email-r l?A 10CJ2A t? YA/JOO, eo hn
Name on Permit/ATC if Different than Above
Mailing Address, City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit isv lid for 60 months with site plan,no expiration with complete plat.)
Owner's Name f lri►'11L�1 GC lC�e� Phone Number 336 3e1 /—4OFss
Owner's Address City/State/Zi-PADPAAE AJC ,z 2&
Property Address City
Lot Size Tax P #�S("J /9,s't A!7 (o 7 Al Ct
Subdivision Name(if applicable)'9fY90Cft,4PtP RD Section/Low 3
Directions To Site: y0 To £ro/ 5 z XT an-) Co,1/ktfnze5R / A T13�f1UG4,4AIP
- 3 U .! 6-t' o N A T
Specify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
rPeople � #Bedrooms Z - #Bathrooms .2 2 Garden Tub/Whirlpool es ❑No
sement: ❑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: 2Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: 2'(;ounty/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additio r exp i ns o the f cility this s ste is in ended to se e? ,3fes
If yes,what type? D v
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 p6les. I underA9dthat I am responsible for the proper identification and labeling of property lines and corners and
locatinVaA flaggin king the house/facility location,proposed well location and the location of any other amenities.
Prop owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Z Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
bU�Z9
Revised 11/06 Invoice# u
'DiG�� �ND�tz5a�7 CONST
4 !
s
PpO�
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S8. 10
Flu ' A/V\ P
' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
Account #: 989900339 ORIZATION FOR WASTEWATER Taz P f CONSTRUCTION -03
Billed To: Distinctive Properties of the Traid Subdivision Info: Alan Mock Trust Lot#3
Reference Name: Location/Address: Beauchamp Rd-27006
Proposed Facility: Residence Property Size: 2.235 Acres
ATC Number: 4925
Site Type: ONew ❑Repair OExpansion
**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 L4 #People BasementO Basement plumbing❑
Non=Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size c7,935 Type of Water Supply: ❑County/City OWell OCommunity Well
System Specifications: Design Wastewater Flow(GPD) D�Tank Size GAL.Pump Tank GAL.
Trench Width Max.Trench Depth 36Rock Deptht�,/A Linear Ft.
SiteModificat}ons Conditions/Other: 1 • �e iA(AI.0n • n -4 Q
0-" W'�' p )r_07e-v
ontact the Davie Count Enviro mental Health 96tionlfor final inspection of this system between
8:30—9:30a.m.on the day of ins allation. Telephone#(336)751-8760.
`DPa�Ewgy
D
W 0I 5
d
wuonmental Health Specialist Date: I
..—T. . .gni
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account M 989900339 Tax PIN/EH M 5870-65-2977-03
Billed To: Distinctive Properties of the Traid Subdivision Info: Alan Mock Trust Lot#
Reference Name: Location/Address: Beauchamp Rd-27006
Proposed Facility: Residence Property Size: 2.235 Acres
ATC Number: 4925
**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 Tank Date Tank Size
Pump Tank Size
System Installed By: E.H.Specialist: Date:
DCHD 11/06(Revised)
AP `K R SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
Qa P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751=8760/Fax(336)751-8786
A licat'on , ation/Improvement Permit ❑ Authorization To Construct(ATC) 0 Both
T e of PPI ti V ew System ❑Repair to Existing System OExpansion/Modifrcation of Existing System or Facility
*** RTANT***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 Contact Person% 1'11), A112?/;)
Billing Addres Home Phone.:3�J� <<J—
City/State/ZIP/ Business Phone ' �3q R4/��
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged - -
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 %�ii i,�-};dam/, Phone Number
Owner's Address City/State/Zip
Property Address City
Lot Size Tax PIN#
Subdivision Name(if applicable) Secro
t#
Directions To Site: /C
If the answer to any of the following questions is"yes",supporting documentation ust be attached.
Are there any existing wastewater systems on the site? ❑Yes ❑��
Does the site contain jurisdictional wetlands? ❑Yes 22��
1
Are there any easements or right-of-ways on the site? ❑Yes
Is the site subject to approval b another public agency? ❑Yes C�No
J PP Y P
Will wastewater other than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms #Bathr000 Garden Tub/Whirlpool.ANO
Basement: ❑Yes til o Basement Plumbing: ❑Yes , o
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: Convent' real ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: County/City Water 0 New Well ❑Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes o
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 unde that I responsible for the proper identification and labeling of property lines and corners and locating and flagging
or akin the facility location,proposed well location and the location of any other amenities.
� � Site Revisit Charge
rope owner's or owne ' ega representati signature
Date(s):
Client Notification Date:
to EHS:
Sign given ❑Yes ❑No Account# g OQ 3139
Revised 11/06 Invoice#
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑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 P1411t.At l�' it i"+1�� i4 f'� �ontact Person Q!� Y
Billing Address A J 0 LL JQ Home Phone O — /S
City/State/ZIP j _
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan V`Plat(to scale)
(Permit is"valid for 60 months with.site plan,no expiration with complete plat.)
Owner's Name I Nock—'IPhone Ijuinber
Owner's Address City/State/Zip I&V"ea- /V Z--74,6
Property Address City.
Lot Size Tax PIN# 6-67 Q
Subdivision Name(if applicable) /2 Section/Lot#
Directions To Site: r v46 9e4ttnA4,ftovo h !/'/
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 VNo
Does the site contain jurisdictional wetlands? ❑Yes RfNo
Are there any easements or right-of-ways on the site? ❑Yes &o
Is the site subject to approval by another public agency? ❑Yes JNo
Will wastewater other than domestic sewage be generated? ❑Yes No
IF RESIDENC4E FILL OUT THE BOX B OW
#People #Bedrooms r5#Bathrooms Garden TubfWhirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBiisiness 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 ❑ 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 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 corers and locating and flagging
or stakin a house/facility to ion,proposed well location and the location of any other amenities.
A "�- Site Revisit Charge
Property owner's or owner's legal representative si ture
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
DAVIE COUNTY HEALTH DEPARTMENT
Environmental.Health Section
Soil/Site Evaluation
APPLAM U RF®flNMQ6 T Tax PIN/EH M 587e RTS NFORMATION.
Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan Lot#3
Reference Name: Location/Address: Beauchamp Rd-27006
Proposed Facility:. Residence Property Size: 2.235 Ac Date Evaluated: 5_yam
Water Supply: On-Site Well Community n'" Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH Lly
Texture groupC
Consistence S 12 y S
Structure
Mineralogys
HORIZON H 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 J.�^— ' �,, 1
SITE CLASSIFICATION: � EVALUATION BY.76 'S
LONG-TERM ACCEPTANCE RATE: ' '—^-' OTHER(S)PRESENT. Ss�r .
REMARKS:
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
T
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
CONSISTEN . ,
Moist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
3'ct
NS -Non sticky SS.-Slightly sticky S-Sticky VS -Very Sticky
NP-Non plastic SP-Slightly.plastic P-Plastic VP-Very plastic
StrLcture
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
Notes
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 nrun
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 990005064 Tax PIN/EH#: 5870-65-2977.03
Billed To: Distinctive Properties of Triad Subdivision Info: Mock/Alan Lot#3
Address: 130 Oakhill Road Location/Address: Beauchamp Rd-270Q6
City: Advance Property Size: 2,23x3 Ad,
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construet 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: i!lew ❑Repair ❑Expansion Permit Valid for: ❑5 Years 2<o—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): 1 Type of Water Supply: gCounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1969(5�
acctptt;t Sti,, m—�'ais us
SystemKype LTAR
Initial .2 O
Repair
Site Plan Oil IR
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Environmental Health Speciali Date tj-2.O9
i.p.l 1-06
2213 Cp
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17.024 NB'I'35"� V} t6
111.076' CP L7 p N 8';8'6"
8 919 SF (INSIDER 105,10'
NIR 9,005 SF (INSIDE R/W)
�. CONTROLLED ACCESS N!
15'x 40'SINGLE - -- _.--"—.
ACCESS EASEMENT(TYP.) 15'x 40'SINGLE
*AC ESS EASEMENT(TYP)
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LZ 50.40' N 55'96'12"e
71at Doric 06,Pq.72. L9 90.00' N 78'57'22"W
6 of 1994. L4 65.44' N7'25'12"t
at Dook 06,Pq.49. L5 90.09' N 79'25'21"W
Of 1992. 207 uObP N7'25'12"E
T ara5Merwiey E55ex frust Plat Dock 06,Pq.49, 1,7 48.05' N 8'15'S4"e
mbar 14,2006. L6 96.51' N 9'17'42"e
lot Dook O6,Ni.a9, L9 90.01' N 79'25'21"W
'l of 1992. U01 92.29' N9'11,42"e
LII 52.49' N9'49'43"e
Horizontal cfand 212 90.00' N79'25'21"W
�ornbined Grld Factor LI9 92.94' N 9'49'49"e
I.F.-0.99991022. 114 28b5' N79'25'21"W
ood Naza-d Area
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A Watershed Area
were rot vis ble at
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