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284 Jamestowne Dr (2)DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990005268 Tax PIN/EH #: 5759-71-5404 Billed To: Harold Frank Subdivision Info: Reference Name: Location/Address: Jamestowne Drive -27028 Proposed Facility: Residence Property Size: 8 Acres ATC Number: 4972 **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 anygiven period of time. VC rtrt� d� System Type: S.T. Manufacturer Tank Date3 5 Tank Size 06 Pump Tank Size '110.2 ,C.t tt7 Date 2 �� System Installed By: 01� OA O' L& E.H. Specialist: K DCHD 11/06 (Revised) �v-e (k, Vr • 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 #: 990005268 Billed To: Harold Frank Reference Name: Proposed Facility: Residence ATC Number: 4972 Tax PIN/EH #: 5759-71-5404 Subdivision Info: Location/Address: Jamestowne Drive -27028 Property Size: 88Acres Site Type: QNew ❑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 �" # Bathrooms # People D— Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 9 Cti G(t5 Type of Water Supply: ❑County/City ell ❑Community Well System Specifications: Design Wastewater Flow (GPD) a.K o Tank Size�ry GGAL. Pump Tank "&UAL. Trench Width 3 O e Max. Trench Depth 3 % f Rock Depth 13. Linear Ft.a 70 � Site Modifications/Conditions/Other: As stated in 15A NDAC 18A.1969(5) CJS 04 49 s t o W u a 5 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. N \ (Ctb 1v sc�� V XV` \.-J / I r ('0 V� s eq a l lr a a Environmental Health Specialist iDate: DCHD 11/06 (Revised) • Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 '!,"X\ (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005268 Tax PIN/EH #: 5759- ,1-5404 Billed To: Harold Frank Subdivision Info: Address: 137 Ralph Road Location/Address: Jamestowne Drive -27028 City: Mocksville Property Size: 8 Acres ,, w 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: [ fNew ❑Repair ❑ExpansionPermit Valid for: 03 Years ❑No Expiration Residential Specifications: # Bedrooms d ^^ � # Bathrooms # People dam—Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) / Design Flow(GPD): � Q Type of Water Supply: ❑County/City A ell El Community Well Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1969(5) crMptod systaffis UW also Do MCI Site Plan System Type LTAR Initial cc c 01 Repair 7 -ef q Ir Environmental Health Speciali i.p. 11-06 — / A9�—CI I s 40 4- s -AP0, Applic tion or: Type o pplisti(" ITE EVALUATION/IMPROVEMENT PERMIT & ATC �J avie County Environmental` Health '009 P.O. Box 848/210 Hospital Street Mocksville, NC 27028, (336)751-8760/ Fax (336)751-8786 u tiau on/lmprovement Permit ❑ Authorization To Construct(ATC) Both 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 4wed 7 R71AIk Contact Person Billing Address A Home Phone 3%7. City/State/ZIP r 7-70,7& Business Phone. 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 Name Sig Inn, Phone Number Owner's Address City/State/Zip Property Address i9 mP..S' toL bp 40 OP duaf ize2 City Lot Size Tax PIN# 6159-71-6Yoq Subdivision Name(if applicable) Sectjon/I 90 Directions To Site: LLQ" ft ett/ 4,ea opry simmewAl fUrN W 44 2%X J,-Jn1e/aulA)d12f;w,ym _id LSA e 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 eK Does the site contain jurisdictional wetlands? ❑Yes 2VO Are there any easements or right-of-ways on the site? ❑Yes e'lqo Is the site subject to approval by another public agency? ❑Yes ET14o Will wastewater other than domestic sewage be venerated? ❑Yes C>flo IF RESIDENCE FILL OUT THE BOX BELOW # People 'Z # Bedrooms � # Bathrooms Z Garden Tub/Whirlpool ❑Yes ❑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: e'C;onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water flew 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? ❑ No 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, roposed well location and the location of any other amenities. A"'a L , Site Revisit Charge Property owner's or owner's legal representative signature Q Date Date(s). Client Notification Date: EHS: Sign given ❑Yes ❑No Account # Z� Revised 11/06 Invoice # GoMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System Click Hero To Start Over Quick Search:(County ID or Owner Ni 1 Active Layer. [21UseMap 71-ps M, PARCELS (Map Tips Available) LY Addre 187 „t' �—( 531 y (407) Cfea rid 3 386.23 yr �n n er us to an n 122,2 - 6,183 (41pj 6 —468 2139d) 261-1_4 1, 278 .' � N r' •-. 234 Ni 2984 10 T a� N 3264,ti a ti ,232 is 1 434 " 213 ,f #AMEsTOWN`DR 184 34a-�° _' 322 255 Ep 702 239,i-, 37 � 215 194 21 G:i http://maps.co.davie.nc.usIGoMapslmapllndex.cfm?mainmapservice=gomaps&CFID=4129... 5/4/2009 a 1 1 AAP ICAi3IITn 1 N Billed To: Harold Frank Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation Tax PIN/EH #: 5759-721RODARTY INFORMATION Subdivision Info: Location/Address: Jamestowne Drive -27028 Property Size: 8 Acres Date Evaluated: 5—�% On -Site Well Community Auger Boring / Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % ro- HORIZON I DEPTH 4364 Texture groupC C Consistence Structure Mineralogy HORIZON H DEPTH - y Texture group Consistence " r Structure Mineralogy HORIZON III DEPTH Texture group Consistence 14 Structure Mineralogy HORIZON IV DEPTH lr Texture group Consistence Structure Mineralogy SOIL WETNESS / /— RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE in, 175 SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: V OTHER(S) PRESENT: Nav, t F C/ REMARKS: - L�..OS LEGEND J.9nds ape Position R - Ridge S - Shoulder L -Linear slope FS - Foot slope N = Nose -slope CC - Concave slope CV - Convexslope T Terrace FP - Flood plain H - Head slope Tkxture 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 CONSIST .NCF. Moist 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 dotes 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) TTAR -T.nnv-term arrPntnnrPrate- and/riav/ft) TWIT TT%none in__.:__�� ■■■■■■■e■■e■■■■■■ee■eeee■■■■■■e■■■■■■■■■■■■■■■/■■■■■■■■■■■■■ecce■■ ■■■■■eeeeeeee■e■■e■■e■■e■■ee■e■ee■■■ee■■■e■■/■■e■■■■■s■■■e■■e■ee■■ ■■ee■r�,■■■■■■e■e■■■■■■■■■■■■e■e■■■■■s■::ca��■■e■■■■■■e■■ee■■■■e■ee■ ■■e■■rel■■e■e■■■■■e■■■■■■■■■■■■■■e■e■e■e■e■■e■:::=:=■■eee■■■■ace■■■■ ■■■■cul■■■■e■■■■■■■■■■■■■■■/■■■■■■■■■e■e■e■e■■■■■■r�■eee■■■■■■■■cee■ ■�■/■�t{eee■■e■■■ee■eee■■■■■■■■■■■■e■■eee■■■e■eeeeeri■e■■■eeee■■■■■■■ ■■■■■tl{■■■■e■■■■■e■■e■■■■■e■■■■■■■■■■■■e■■■eseeee■lre■eee■eee■eee■■■ ■■■■e�lnee■eee■eee■■ee■e■■■■■■e■■■ e■■■e■■■■e■■e■■I�e■■■■■■■■■■■e■■■ ■■■■■Ise■■■■■■■■■■w�■■■■■■■■s■■■■■■■■■■■■■■■■■■■■■u■■■■■■■■■■■e■■■■ ■■■■■■■■ee■■■e■■■�c���.■■e■/■■■■■■■■■■■■■■eeeeeee■{■e■■■ee■■ee■e■e■■ ■■■■■�■■■■■■■■■■■■■r��w�u■■■■■e■■eee■■■■■ee■■ee■e■e■ue■■eeee■e■■eeee■ ■■■■■Illi■■■■■■■■■■■■rJlt►\ie■■■■■■■■■■■■■■■■■■■■■■■■■■It■■■■■■■■■■■■■■■■ ■■eerier■■e■■■ee■■■■■■■ne■4r■s■i■e■�`■■■■■■■■■■■■e■■■■■■■e■■■e■e■■■e■ ■■■■rttr■■■■■■■■■■■■■■■u��■t,l■■■■e■■a■■■■■■■■■■e■■■e■■■■ee■■■■■e■■ee■■ ■■■■rlllr■e■eeee■■■■tri■■■■■■■■■■■■■■i■■■■■■■e■■/■■■■.■■■■ee■■■■■■■■■e■ ■■■■roue■■■■■■c�■wew■■■■■�■■■e■■■■.■■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■■■ IiiiiiMAiiiiiiiiiiiit ' INMEMEiSEMMES EMMr■ir■iiSEEMS ■■■■■■■■■■■■■■■■■■■■■■■■■■e■■tt■■s■ee■erl■e■■■eeee■ee■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�Ir■■■■■■■■■■■rte■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■