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191 J & L Farm Ln• DAVIE COUNTY ENVIRONMENTAL HEALTH • P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 989900093 Tax PIN/EH #: 5735-88-0737 Billed To: Shelton Construction Services Subdivision Info: Reference Name: Con Shelton Location/Address: JK Farm Lane -27028 Proposed Facility: Residence Property Size: 53.63 Acres ATC Number: 4807 **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," Wfiliall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. i1 _ System Type: S.T.- Manufacturer /10G Tank Date / Tank Size_ Pump Tank,Size System Installed By: i l I�� 4j1 E.H. Specialist:4, t2l)ate: --------------------- "'`` LUv-t q kt yx� 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 #: 989900093 Tax PIN/EH #: 5735-88-0737 Billed To: Shelton Construction Services Subdivision Info: Reference Name: Con Shelton Location/Address: J&L Farm Lane -27028 Proposed Facility: Residence Property Size: 53.63 Acres ATC Number: 4807 Site Type:eNNew ❑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 2 Basement❑ Basement plumbing Non -:Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility)) Lot Size 3 Type of Water Supply: ❑County/City ,<ell ❑Community Well System Specifications: Design Wastewater Flow (GPD)' ZZO Tank Size 1000 iAL. Pump Tank GAL. Trench Width -& � � - . Trench Depth 26 3o "Rock Depth W Linear Ft. Z70' Sitr.�)fications/Conditions/Other: 'i Vk, GUJ � L✓[ti1-�, /�:`L rAjontact the Davie County Environmental Health Section for final inspection of this system between bvironmental Health 5 nrun 11M4IPPvicarl) P N FOR EVALUATION/IMPROVEMENT PERMIT & ATC 3 2001 avi County Environmental Health SAN P. . Box '848/210'Hospital Street TFa ASH Mocksville, NC 27028 c> EN`�Rop�ipu (336)751-8760/ Fax (336)751-8786 Application or: valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Appl ation: ❑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 Contact Person Z 54— Billing Address. 12 15 y 14., L Y w Home Phone City/State/ZIP /1�7 , �� _.: ! I ,-J • G . - z -7 v 'Z Business Phone 3 y S - 2- Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 2 G NOTE: A survey plat or site plan must accompany this application. Included: O.Site"Plan ❑Plat(to scale) (Permit is valid for 60 months with site PI, no expiration with complete plat.) Owner's Name _ �nPhone Number -,/'Cl 4S- Owner's Address 2`1 L= City/State/Zip Property Address City Lot Size -_75. O -S %1tr L Tax PIN# 1"4 00 0 c) go 5735 --99- 6757 Subdivision Name(if applicable Section/Lot# Directions To Site: G-/. J . : _ L /_ S_ : /_ , /_ J � , - �T 4� L . - / _ If the answer to any of the following questions is "yes", supporting documentation mus be attached. Are there any existing wastewater systems on the site? ❑Yes Does the site contain jurisdictional wetlands? ❑Yes 14No Are there any easements or right-of-ways on the site? ❑Yes lNt/ Is the site subject to approval by another public agency? ❑Yes Cmi Will wastewater other than domestic sewage be generated? ❑Yes ONe" IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Z Garden Tub/Whirlpool ❑Yes &No Basement: ❑Yes 2N6- Basement Plumbing: ❑Yes Cable 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; 2Zobventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑ County/City Water ew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 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 comers and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Prop own is or owner's legal representative signature Date(s): 1 -5 C s Client Notification Date: Dae EHS: Sign given ❑Yes ❑No Revised 11/06 Account # 3 Invoice # ' ,* m Y0000vu sS b M SURVEY DOES NOT PURPORT TO REFLECT ANY OF THE FVUQ K W04 4AY BE S APPLICABLE TO THE A9XCT REAL T5 THAT WERE 1ASIBL.E AT THE TIME OF NAKING THIS SVRYEY; BUIL.OINC SETBACK LINES; RESTRICTIVE COVENANTS: SU9 M%QN ANY OMER FACTS THAT AN ACCURATE ANO CURRENT TITLE SEM:W," MAY OtSCLOSE, ROOD STUDY, MM -AM DELINEATION OR ENVIRONMENTAL INSPECTION BY SURVEYOR. rAWAM P. A NMIA F. BLATT N PARCEL bW40000003 DB. 160, PG 449 WWAN P. dt & L FARM LANE KENNETH L. GO MENOUR N/F PARCEL T4000(�54 (PRNATE) r-- DB. 1633, PG. 233 A. ;1:1 Nft po 5/a' m IPO 5A, IPO 5/r m R a/a' RB jZ - LEOLA EDWARDS N PARCEL IM4000000 (PT.) DB. 52, PG. 461 E IPO 5/8' RB 0 7s1.W I KEVNPARNCEL. A5t)0000006 99. 651, PG. 503 ct�:re; OLA STOKE €'OMT IN `'—aoNr IN CTTm CRm 6>5 5,� R9 V P01MT H 527.ts _ c �i 2,336.133 'SOFT, 53.63 ACRES �I 11 I� IF KEVIN dt AZALEE STOCKTON N j W1WAN P. PARCEL X500000006 KENNETH L COMD40UR N/F 09. 657 PG. 503 D8CEL16.3, �4 � AUCOMM OMNM OLD 57M LEW EDW ARDS N/F PARCEL ,}M400000 m (PT.) . lJ ti ''�.varlr IN cmc C PQ 51Y FU m7j$ R9 IP5 S,E RDPORIT IN 052M3' UW I RB Or R'0 1* or I ti CO ii Qi N cd log 4 SQ FT 11 2,336j133 ' 1L 53.63 ACRES ri IPO S/r Fe 0 764.7!6' j l w It w 1r 07 � W 4• rr a: a i, i 7'd5 h 35.69 N 81'42 241.92 A CS S. ROBERTS NAF NNrFER N. do D8. i 4.' 41A AU -M N P Y �� 959 ARpA• ZLMAN N Da V500000007076, PG 61 GoMAPS - Davie County NC Public Access I I Page 1 of 1 Davie County, NC - GIS/Mapping System o -w Click Here To Start Over Quick Search: (County ID c 10 m+{ Active Layer. r tdse Map Tips gars m- 0 '' Q ' PARCELS (Map Tips Available) Map Layers l Results I GnC2 - http://maps.co.davie.nc.usIGoMaps/map/ uiia&c n?maimnapservice=gomaps&CFID=4129... 1/3/2008 . GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System aPv � —Click � Click Here To Start Over t, ,^+, � � h Active Layer. U Use Map Tips c+OV 4� I�le 0 .� PARCELS (Ma--pTis Available) Page Page 1 of 1 Quick Search: (County ID c GIS Map Layers I Results http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?maimnapservice=gomaps&CFID=4129... 1/3/2008 ..GoMAPS - Davie County NC Public Access . Davie County, NC - GIS/Mapping System 4P'su�A t^y ,m�rrrr, Click Here To Start Over A. LO Active Layer. U Use Map Hips SOU ,W E j*' , �P, t PARCELS (Map Tips Available) — r Page 1 of 1 Quick Search:(County ID c Map Layers ( Results GIs http://maps.co.davie.nc.usIGoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=4129... 1/3/2008 GoMAPS - Davie County NC Public Access Davie County, NC - GIS/Mapping System Page 1 of I Click Here To Start Over Quick Search: (County ID Active Layer. F TIPS GIS mm' PARCELS (Map Tips Available) `-�k -1 Map Layers I Results http://maps.co.davie.nc.usIGoMapslmaplIndex.cfm?mainmapservice=gomaps&CFID=4129... 1/3/2008 DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section Soil/ Site Evaluation APPLI T.IDiFO,T3A�ATwl ` Tax PIN/EH #: 573$Y INFORMATION Billed To: Shelton Construction Services Subdivision Info: Reference Name: Con Shelton Location/Address: J&L Farm Lane -27 28 Proposed Facility: Residence Property Size: 53.63 Acres Date Evaluated: Ti t "Water Supply:.,, On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 5 6 7 Landscape position,: Slope % HORIZON I DEPTH —2b d -, Texture grow Cf G} Consistence. '7 S5 Structure o Mineralogy HORIZON II DEPTH '` % —Z Texture; rou .. C 4 , - Consistence ` Structure -Mineralogy L HORIZON III DEPTH Texturegroup.� Consistence ` Structure Mineralogy HOMZON.IV'DEPTH u Texture,gfoup. Consistence Structure s Mineralo SOIL WETNESS RESTRICTIVE HORIZON-- SAPROLITE — — -- CL.ASSIFICATION LONG-TERM ACCEPTANCE RATE c7 . ? -- J. -SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: Luc%, � l� A4Tl At -2Y0' A4ZIq' 6- REMARKS: L GEND I;andscape 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 •::MO1St '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 , '4 Horizon depth - In inches Depth of fill - In inches ;', `� •, , ,�' E _ Restrictive horizon - Thickness and inches from land surface :` Saprolite - S(suitable), U(unsuitable) .r Soil wetness - Inches.from land surface to free water or inches from land surface tosa�l colors with 6hr6ma 2 or less „, , , ' Classification - S(suitable), PS(provisionaIly suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 (Revised) ; ;r s ti , - ■ ■ ■ ■ ■1 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 989900093 Tax PIN/EH #: 5735-88-0737 Billed To: Shelton Construction Services r Sftbdivision Info: Address: 1257 Highway 64 West Location/Address: J&L Farm Lane -27028 City: Mocksville Property Size: 53.63 Acres Reference Name: Con Shelton 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 constructionlinstallation 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: .21I ew ❑Repair ❑Expansion Permit Valid for:xYears ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms Z # People Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats r� Square Footage(or Dimensions of Facili lJty) Design Flow(GPD): o Type of Water Supply: ❑County/City�Kell ❑Community Well Site Modifications/Permit Conditions: L Initial R anair Environmental Health i.n.11-06 LTAR C� • 3 so, 5L` Date' 1!t(Z