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1819 Junction RdDCHD 11/06 (Revised) .�iu01e� 7�c53 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680. OPERATION PERMIT Account #: 990005503 Tax PIN/EH #: M400000033 Billed To: Scott Smith Subdivision Info: Address: 113 Fostall Drive Location/Address: 1819 Junction Road-27028 City: Mocksville Property Size: 1.76 Ac Reference Name: Jason & Jennifer Jackson Proposed Facility: Residence A7&: 6g 39 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article I 1 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 i D/ Iyl Tank Size Pump Tank Size l System Installed By: E.H. Specialist: ate: 01 - GPS Coordinate: DCHD 11/06 (Revised) .�iu01e� 7�c53 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005503 Tex PIN,EH #: M400000033 Billed To: Scott Smith Subdivision Info: Reference Name: Jason & Jennifer Jackson Location/Address::: ,1819 Junction Road -27028 Proposed Facility: Residence ; Property -Size: 1.76 Ac ATC Number: 5839 Site Type: KNew ❑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 Z # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type #People # Seats Square Footage(or Dimensions of Facility) b0 41 Lot Size �� Type of Water Supply: ❑County/City ,WWW ❑Community Well System Specifications: Design Wastewater Flow (GPD)�Tank Size/XO GAL. Pump Tank4OGAL. Trench Width NQ Max. Trench Depth �� Rock Depth Linear Ft. -26 /O Site Modifications/Conditions/Other:�� 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. T _B: Environmental Health Specialist Date:/%"0 DCHD 11/06 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005503 Tax PIN/EH #: M400000033 Billed To: Scott Smith Subdivision Info: Address: 113 Fostall Drive Location/Address:. 1819 Junction Road -27028 City: Mocksville Property Size: 1.76 Ac Reference Name: Jason & Jennifer Jackson 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: NNew ❑Repair ❑Expansion Permit Valid for: X5 Years ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms 2 # People 2 Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) t Design Flow(GPD):-� ; Type of Water Supply: ❑County/City ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial a, % RhAUEg Repair' Ze bn DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION OWRURTY INFORMATION 05503 Tax PIN/EH #: M$00� Account #: 990 Billed To: Scot Smith Subdivision Info: Reference Name: Jason Droposed Facility: Residence & Jennifer Jackson Location/Address: 1819 Junction Road -2 0t2�8 Property Size: 1.76 Ac Date Evaluated: 8 -g/ Water Supply: On Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % b HORIZON I DEPTH --&C116 Texture group Consistence" Structure Mineralogy 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 ACCEPT CE RATE 3 SITE CLASSIFICATIO EVALUATION BY: LONG-TERM ACCEPT NCE RATE: OTHER(S) PRESENT: REMARKS: Position LEGEND ndc .ape R - Ridge S - Should r L - Linear slope FS - Foot slope N - Nose slope CC -Concave slope Texture V - Convex slope T - Terrace FP - Flood plain H - Head slope S - Sand LS - Loam 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 Moist VFR - Very friable FIZ- Friable FI - Firm VFI - Very firm EFI - Extremely firm' 3YA 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 Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thic ess and inches from land surface Saprolite - S(suitable), U( nsuitable) Soil wetness - Inches fro 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) ITAR - Irmo -term nrrent nre rate - nalhiav/ft7 r.17Tr ncinc m__..__jN ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■I ■■■■■■■■■■■■■■■■I ■■■■■■■■■■■■■■■■I ■■■■■■■■■■■■■■■■I ■■■■■■■■■■■■■■■■I ■■■■■■■■■■■i■■■■■I ■■■■■■■■■■■i■■■■■I ■■■■■■■■■■■A■■■■■ ■■■■■■■■■■■l■'ISA■ ■■■■■■■■■■■SII■■■■ ■■ ■■■■■■ Z■s■■■ ■■■■■■■■■■■■■■■OM ■■■■■■■■■■■o ■■or ■■■■■■■■■■■■■73100 ■■■MI■■■■■■■■c=-.■■ ■■■1■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■ ■■■■I■■■■■■■■i■■■■ ■■■■1■■■■■■■■■■■■■ ■■■Ilaeseeeeee■es■ ■■■1■■■■■■■■■■■■■■ I■■■■■■■■■■■■■■■■ I■■■■■■■■■■■■■■■■ I■■IM■■■■■■■■■■■■■ I■■■■■■■■■■■■■■■■ I■■■■■■■■■■■■■■■■i I■■■■■■■■■■■■■■■■i I■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■► ...............■.■.�.�w�!e■amass..n..�.�.•,!■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ie�n■■�i■■■■■■■■■■■■■■■■■■'.,7■■■■■■■■■■■■■■■■■■I' ■■■■■■�■ ■■ate :�■■■■■■■■■■■■l�=a■■■ 1��■■liei�l■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■cf`S■■■■■■■■r��■■■■iso■■u■-!■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■■■ �wwwri�rwr�rwYlrrw��rr��■■■a!■■■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■e■■■■■■e■■■■■■■■■■■■■iii■c�®1•�■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■r1l:Ibi�5liGi■1■■■■■■■■■■■■■■■■■ii"ii�C'�'niA■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ee■■eeeeeeeed■eeeeeeeeeeeeeeeeeeeeeceecece®cel■®sa��l■ceeaeeeeeeeoo■ PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC G Davie County Environmental Health CjV P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 OG� 1 (336)753-6780/ Fax (336) 753-1680 l� ication For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ,P4 Both ' Type of Application: .—bfqew 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. Name to be Billed �ort�'�n� 3 Contact Person Billing Address 113 fi66 I { r- Home Phone City/State/ZIP n oe..Ks,,,I N, (_ Business Phone -7 "� , tr 1 Name on Permit/ATC if Different than Above sa N Mailing Address IbA,% "�iA .+c -.� v Rt City/State/Zip u: e YKL)FERI Y 1NPUKMAIION 'Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accomparry this application. Included: ate Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name �ts�.a Phone NumberZ ` ,-- Owner's Address ! n.e r City/State2i t..l Nit 'Z?J Property Address %&- 'R City, ,i [ e 71V2 e4 Lot Size %•71.t Tax PIN#3'J33'S�l`l Subdivision Name(if applicable Sectio, Directions To Site:/60/ �o . ... X /� ,ll•t J* 4✓ ��nt�ts. fit./ 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? Does the site contain jurisdictional wetlands? ❑ YesK10 ❑Yes$No Para] # Are there any easements or right-of-ways on the site? 0YesXN0 Is the site subject to approval by another public agency? ❑ Yes o � o 4 Will wastewater other than domestic sewage be generated? ❑Yes No l 0coocc)33 IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms 2— Garden Tub/Whirlpool ❑Yes 9X5— Basement: ❑Yes No Basement Plumbing: ❑Yes N*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: )Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 0 County/City Water ❑ New Well XExistingWell ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? DN. 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 �to alio a �algrstaicing the house/facility location, proposed well location and the location of any other amenities. tSite Revisit Charge Property owner's or owner's legal representative signature Date(s): /a-17 -2j/ / Client Notification Date: Date EHS: 65-6 Sign given ❑Yes ❑No +IU�1 O Account # 3 Revised 11/06 `' Invoice # _l Iah I Ion 2 — — — ole 2 — — Sa 4 - t � Pith LZ�