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237 Ijames Church RdDAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005127 Tax PIN/EH #: 5820-40-1904 Billed To: County of Davie Subdivision Info: Reference Name: Location/Address: 237 Ijames Church Road -27028 Proposed Facility: Residence Property Size: 3.81 Acres ATC Number: 4891 **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 anyn period of time.' --.1 4 S.T. ManufacSystem T urer Tank Date Tank Size / /J% O Pump Tank Size T� System Installed By: j _amu ' �'IOti� E.H. Specialist: i�_ ate: �I� G DCHD 11/06 (Revised) „ DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751=8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005127 Tax PIN/EH #: 5820-40-1904 Billed To: County of Davie Subdivision Info: Reference Name: Location/Address: 237 Ijames Church Road -27028 Proposed Facility: Residence' Property Size: 3.81 Acres ATC Number: 4891 Site Type: ❑New ❑Repair ❑Expansion **NOTE** This Authorization to Constrict (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 # People Basement❑ Basement plumbing❑ Non -;Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size a D t2 Gf,-t' Type of Water Supply: JerCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) ?( Q_Tank Size GAL. Pump Tank6 GAL. TrenchWidth 3 te Max. Trench Depth Rock Depth Linear Ft. Site Modifications/Conditions/Other: As stated in 15A NCAC 18A.1969(5) accepted Systems mai k"SoOu ase 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. koh ID ( ox” 3( LO Environmental Health Specialist Date: t9l J �U nriTTl 1 1 M4 (R ot,i c a rl l Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005127 Tax PIN/EH #: 5820-40-1904 Billed To: County of Davie Subdivision Info: Address: 123 S. Main Street Location/Address: 237 Ijames Church Road -27028 City: Mocksville Property Size: 3.81 Acres Reference Name: Proposed Facility: Residence **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: ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms % # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Z Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 ce-P Type of Water Supply: ounty/City ❑ Well ❑ CommunityWell As stated In 15A NCAC 183A.1969(5) Site Modifications/Permit Conditions: rPn�tQ_d Systems may also be used System Type LTAR V ! Initial 4 -CA d�— Re air o Environmental Health Specialist i.p.11-06 3 a Date 2761 APPLICATION FOR SITE EVALUATIONAMPRO Davie County Environmental Health �j)lIL9 P.O. Box 848/210 Hospital Street Mocksville, NC 27028(; JUL (336)751-8760/ Fax (336)751-8786 2 1 2008 I Application For: Aite Evaluation/Improvement Permit ❑ Authorization To Const ct(ATC)ENyIR- I Type of Application: �ew System ❑Repair to Existing System ❑Expansion/Modificatton tN acility 'IMPORTANT " THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION rn,c Aeq�31, �.Z,39 -3j iia Name to be Billed eov A ve" o7C Contact Person (A- .fro t/cee )`— Billing Address Home Phone City/State/ZIP ra V t Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION . *Date House/Facility Corners Flagged 7 -Z4 -OV NOTE: A survey plat or site plan must accompany this application. Included: "ite Plan ❑Plat(to scale) (Permit is"valid' or 60 months with site plan, no expiration with complete plat.) Owner's Name '11-14 Mr V 7y- Phone Number j` } Z 5',57G i Owner's Addressz-3? �� 7m c ��u dA 1,d City/State/Zip -t%c !cs vi 74- --%/Z Property Address_ &9,7, Z'j� /,*ywKs G .,,,,Amac/ City 141101v/7� Lot Size 3 . F( >c,."o Ta�PIN# -S-k7 o yo !yo f Subdivision Name(if applicable) Section/Lot# Directions To Site: /tu-y Ga! ,✓ l•s r�•-� �Qli� �t �o�� 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 •B b Does the site contain jurisdictional wetlands? ❑Yes -B Vo Are there any easements or right-of-ways on the site? ❑Yes-BNo Is the site subject to approval by another public agency? ❑Yes GNo Will wastewater other than domestic sewage be generated? ❑Yes 8'No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms '— # Bathrooms Garden Tub/Whirlpool ❑Yes t$No Basement: ❑Yes �No 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: conventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: �tounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 'RPNO 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 riles. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the h"/facility location, proposed well location and the location of any other amenities. Lll Site Revisit Charge Property o ' oro er's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes Ao Account #NTT Revised 11/06 Invoice # l� Map Frame Page 1 of 1 Davie County, NC - GIS/Mapping System OPasc Click Here To Start Over Quick Search:(County ID c Active Layer. ❑Use map wps GTE 11 is 00' F 9 °� PARCELS (Map Tips Available) Map Layers i Results 1672-f 178ft Z' http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&CFTOKEN=616408... 7/18/2008 APPLICANT INFORMATION Account #: 990005127 Billed To: County of Davie Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: 'DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation gROPERTY INEORMATION J Tax PIN/EH #: 5820-40-19U4 Subdivision 820- - Subdivision Info: Location/Address: 237 Ijames Church Road -27028 Property Size: 3.81 Acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH d.- Texture group . CA, C Consistence . , Structure Qk ltvjn Mineralogy HORIZON H DEPTH tPd Texture group Consistence Structure k- 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: _ � EVALUATION BY: vacah S ',LONG-TERM ACCEPTANCE RATE:0. OTHER(S) PRESENT: 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 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 17, VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm '3i'et 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 MineraloQv 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) T me n r