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153 In & Out Ln• ' J DAVIE COUNTY ENVIRONMENTAL HEALTH ,!t P.O. Box 848/210 Hospital Street elf Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 Account #: 990000850 Billed To: Tim Williams Reference Name: Proposed Facility: Residence ATC Number: 4666 OPERATION PERMIT Tax PIN/EH #: 5880-28-4239 Subdivision Info: Location/Address: In & Out Lane -27006 Property Size: 150x1020 * *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: G ' 44 S.T. Manufacturer S I%aa F Tank Date TankSize /4V Pump Tank Size /✓/o9' System Installed By: Z1 M A/,V C!/11� A. Iff E.H. Specialist: _Date: 4" /-'o DCHD 11/06 (Revised) Y.( DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksvillo, NC 27028 (336)751-8760 Fax #(336)751-8786 ATC Number: 4666 Site Type: V1;ew ❑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 3 • Type of Water Supply: Q'County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) -3 (O Tank Size ), d od GAL. Pump Tank '� GAL. r Trench Width Max. Trench De th 3 c Linear Ft3 7 J p '.PAQ 4&w4N/14 f Site Modifications/Conditions/Other: 'As etW4dl in 251 P'0s.0 ' ~ 13139(5) S 57�'�� accepted -Sys n-iay be Y 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. fjva� o 4 G17 1�ok-sem 0 Environmental Health Specialist? ;<' �� Date: DCHD 11/06 (Revised) AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000850 Tax PIN/EH #: 5880-28-4239 Billed To: Tim Williams Subdivision Info: Reference Name: Location/Address: In & Out Lane -27006 Proposed Facility: Residence Property Size: 150x1020 ATC Number: 4666 Site Type: V1;ew ❑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 3 • Type of Water Supply: Q'County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) -3 (O Tank Size ), d od GAL. Pump Tank '� GAL. r Trench Width Max. Trench De th 3 c Linear Ft3 7 J p '.PAQ 4&w4N/14 f Site Modifications/Conditions/Other: 'As etW4dl in 251 P'0s.0 ' ~ 13139(5) S 57�'�� accepted -Sys n-iay be Y 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. fjva� o 4 G17 1�ok-sem 0 Environmental Health Specialist? ;<' �� Date: DCHD 11/06 (Revised) 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 Ap lication iii alit aluation/Improvement Permit "uthorization To Construct(ATC) ❑ Both Ty of Apples' n: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF. THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Y14Z lGf'h S Contact Person Billing Address c Home Phone City/State/ZIP e!!9,./ vw, c. p Business Phone 336 —,7 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facility Corners 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 Nam 44 '�iPr�: J Phone Number �/r�-�� Owner's Address bmf , i7i�:-'S /2 City/State/Zip �,--4&u,- Property Address Z`jJ Lot Size 1,5-6 aC /D�?t� Tax PIN#.SF!2 Q - 2 B - S�Z3 Subdivision Name(if applicable) Section/Lot# _ Directions To Site: _ 2 U ( % cl n %7 S 'ed /2".0 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 Lo Does the site contain jurisdictional wetlands? ❑Yes LP3tf . Are there any easements or right-of-ways on the site? ❑Yes PN'o Is the site subject to approval by another public agency? ❑Yes DN6 — Will wastewater othei than domestic sewage be generated? ❑Yes Colo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool es ❑No Basement: ❑Yes o Basement Plumbing: ❑Yes 3N 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:. 2t nventional ❑Accepted ❑Innovative ❑Alternative OOther Water Supply Type: 9,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 -Pm 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 understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. tc -ti, ` Site Revisit Charge Prope o er's or owner's legal representative signature Date(s): r/ /j, - Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # 1-17 AAK O 1-17 AAK I T APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT , • Davie County Health Department nvironmental Health Section n P.O. Box 848/210 Hospital Street it Mocksville, NC 27028 Ll li4 JUN - 9 2006 336)751-8760/ Fax (336)751-8786 t6 Appli ation der-4iteve Jprov ent Permit ❑ Authorization To Construct(ATC) ❑ Both o ENVIRONMENTAL HEALTH Qt' *** CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED IT611 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for � C� V&innstruct'ons. APPLICANT. INFORMATION� -<q / Name to be Billed � Contact Person _120 d c 4 7 STv tJF Billing Address Z107 R t mm i✓ t ✓n40 410 Home Phone -- City/State/ZIP Q-A N CSL t N C 270 0 U Business Phone 3 3 G `1 °J $ q 7 3 Name on Permit/ATC if Different than Above. Mailing Address PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. -TAX Lo-( 1 1 Z t y✓IA o F'- 8 (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address 1N 0 V 1 (-R NE City AV C- Tax PIN# 58607-$4Z 3'7 Subdivision Name /?Icy- #K&- G 4q4t4J4 Section/Lot# I f Zr `Lot Size C A C t-1 Directions To Site: U rl rJ to 4 c A 5- N C_ W Se t A ICc N C H W $G �U A YO N;4 c\) CE A N v -r ;eOA . TA 1 N r c9V7 LA43 r' " ra,'L Son' , SX �= t S Z o r A -f x- d lac �� Date House/Facility Corners Flagged(o - S - 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 Pf\,O Does the site contain jurisdictional wetlands? ❑Yes AO Are there any easements or right-of-ways on the site? G✓Yes ❑No Is the site subject to approval by another public agency? Tey, es ❑No Will wastewater other than domestic sewage be generated? ❑Yes [Ko IF RESIDENCE FILL OUT THE BOX BELOW # People t- # Bedrooms 3 # Bathrooms Garden Tub/Whirlpool ❑Yes Flo Basement: ❑Yes Lilo Basement Plumbing: ❑Yes C9-io 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: P'Conventional CiAccepted ❑innovative ❑Alternative ❑Other Water Supply Type: C/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 C<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 permits) 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by121 !;7, 1(- VMMA ► qAA i k) 14 c -�" Site Revisit Charge Property owner's or owner' egal representative signature Date(s): V - 8 . Q& Client Notification Date: Date EHS:_ Sign given ❑Yes ❑No Account # Revised 2/06 Invoice # 'APPLICANT INFORMATION Account #: 990004006 Billed To: Rick MABE Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: On -Site Well Auger Boring DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5880-28-4239 Subdivision Info: Location/Address: In & Out Lane-2700jP Property Size: 3.5 acres/Lot#1 Date Evaluated: Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH G �i Texture groupC Consistence ,- Structure Mineralogy y HORIZON III DEPTH Texture groupGG, �— Consistence ;. Structure e' Mineralogy, HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: �J LONG-TERM AACyCJ>EPTANCE RATE:://1 A� EVALUATION BY: OTHER(S) PRES NT: cv�pE G E N D (1, 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 mDht 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 Mineralog 1:1, 2:1, Mixed lYQts� 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 Cl ble f t' S( 't b1 ) PSusu ( 11 t bl ) U( ) asst ica ion sui a e , provisiona y sui a e , ni't a LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) — 5pth Gr enk on Tax Lot 11$ 2 Tax Map n/f Larry Nicks I 09 -158 0 PG 716 T-4� NMP in creek Bed AREA IN QUESTION= ;GAF IRS \ , T-5 4 Lot 1 aL 2 112 part, of Tax . Tan � a FSAREA IN QUES" 1 ,S Control. Corner 3.556 Acres Total- New Property Line 990.14' ` L-3 Lot i C -Part of Tax Lot 112 F^� Tax Map 3t4' EIP Fnd 0 Fencc 3.556 Acres +/- RS r _C_4 Crate Wire Ferce I (Approximate Center Line Tax Lot 113 t Tnv Adan F-8 Tax Lot- 111 Tax; Map l: -8 n/f .lames Sonders 'r sip and }rife Debra E.: Sanders DS 197 ®PG 566 -a ►� c ;t 711 O'o Grave} Win �p 4 (, 17r 5 _ - - - - - ExistiAg 20' Easement, Reference PB ti �o n � .ane 3 '� v` -t Road �_.. :.(See . Note 4) AA t � . IRS Placed in Une Control Corner IRS t 20.08' T � } Doby> Jr. 72.73 i L-5 Total 199f� f,..... Fnd , o 3�4• QR t � PB 5 PG 17 77.27'--• ' Existing 20' Easement Reference +� , S - • bY 1 /2 E1R FCtrans �� , bent )WItness r I 1P F=8 agina'.d K. Vihicker L.T-7 , -r.7.p-PG' 414 5pth Gr enk on Tax Lot 11$ 2 Tax Map n/f Larry Nicks I 09 -158 0 PG 716 T-4� NMP in creek Bed AREA IN QUESTION= ;GAF IRS \ , T-5 4 Lot 1 aL 2 112 part, of Tax . Tan � a FSAREA IN QUES" 1 ,S Control. Corner 3.556 Acres Total- New Property Line 990.14' ` L-3 Lot i C -Part of Tax Lot 112 F^� Tax Map 3t4' EIP Fnd 0 Fencc 3.556 Acres +/- RS r _C_4 Crate Wire Ferce I (Approximate Center Line Tax Lot 113 t Tnv Adan F-8 Davie County Health ] aP artment July 6, 2006 Mr. Rick Mabe 407 Zimmerman Road Advance, NC 27006 Re: Site Evaluation/IP: Site #1 Tax Pin #: 5880-28-4239 Dear Mr. Mabe, As requested, a representative from this office visited the above site June 29, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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 or the intended use change. Improvement Permit System To Serve: hA�Z.-ic Wastewater Design Flow: Q.� a System Type: ❑Conventional .Accepted ❑Innovative ❑Alternative []Other System Location: /y`4s�G' ��7110 0 5 V6, Valid: C3'�'ears ❑No Expiration Site Modifications/Permit Conditions: Environmental Health Specialist Date ps-i.p.letter 2/06