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604 Junction RdDAVIE 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 #: 990005461 Tax.PINIEH #: 5726-58-9277 Billed To: Jeremy Harris Subdivision Info:: Reference Name: David Harris LocationrAddress: 604 Junction Road -27028 Proposed Facility: Residence r ,,, '= Property Size: 11.72ac ATC Number: 5111 Site Type: mew ❑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 I or the intended use change. Residential Specifications: # Bedrooms- # Bathrooms # People Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 7 .'7 ;L Type of Water Supply: ,RC unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) <.O Tank Sizely, O'CaAL. Pump Tank GAL. (I (a I% / Trench Width 3(o Max. Trench Depth k8 Rock Depth ( a. Linear Ft. -6—U 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. -Tf I l�— pra:+.%A-"- ts-y 47f V, ,Aft Environmental Health Specialist /f� Date: 14e C DCHD 11/06 (Revised) 1 Account #: 990005461 Billed To: Jeremy Harris Reference Name: David Harris Proposed Facility: Residence ATC Number: 5111 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 OPERATION PERMIT Tax:P€N7EH #: 5726-58-9277 i Su€ad€visiQn €nfd:; = ;? Local€on!Address: 604 Junction Road -27028 . • Pct7par#y-Size: 11.72ac **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 betaken as a guara ee that the system will function satisfactorily for any given period of time. a System Type S.T. Manufacturer 11�d Tank Date ` Tank Size v Y YP —�- Pump Tank Size System Installed By: �[,a&. Specialist: Date: > GPS Coordinate: Al 3 6 5--1 - O qq (7 O DCHD 11/06 (Revised) f Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005461 Tax PIN/EH #: 5726-58-9277 Billed To: Jeremy Harris Subdivision Info: Address: 604 Junction Road Location/Address: 604 Junction Road -27028 City: Mocksville Property Size: 11.72ac Reference Name: David Harris 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 Permitis subject to revocation if site plans, plat or the intended use change. Permit Type: l7lVewy❑Repair~❑Expansion Permit Valid for: -❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms # People Basement❑ Basement plumbing❑ vu Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility)_ Design Flow(GPD): 3 G O Type of Water Supply: D&unty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Re air cc If 1'-0N Environmental Health Specialist i.p.11-06 Date /Q — "v AP L ON FOR IT LUATION/IMPROVEMENT PERMIT & ATC' WVDa ie C unty Environmental Health t �l O. B x 848/210 Hospital Street ocksville, NC 27028 3-6780/ F 6)753-1680SOI �I Application For: ite Evalujtion/Improvement Permit orization To Construct (ATC) ❑ Both Type of Application: mew 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. A PPT TC A MT TMP011? A4 A TIONT Name � 5 Contact Person"_N�01, AddYess kr,0A1 c \ Home Phoma ( �.-`C.( Z,- S I L19 City/State/ZIP ' n C ") Q Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flaeeed 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.) _/ t Owner's Name -i� r- �' "C"C��r �� Phone Numbe &1 -`� Owner's Address..b 0 .� �,� nc� ton KG\ • City/State/Zip Q Property Address c� : y e City IS 4z-.,1 Q Lot Size i�.�o2 e -L Tax PIN#;j` A(o_ 17� Subdivision Name(if applicable) Sec- on/Lot# _ Directions To Site: SOA i `1V1.IV `t 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 ''No Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? _Yes _1 _P`es No Is the site subject to approval by another public agency? ATO Will wastewater other than domestic sewage be generated? _Yes Yes / o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes f -No" Basement: ❑Yes Uo- Basement Plumbing: ❑Yes 2< 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: K-onventional [?'A`ccepted ❑Innovative ❑Alternative ❑Other Water Supply Type: D ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes WTO 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 ��_wlo. ting and flaggin or staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: _ Date EHS: Sign given ❑Yes ❑No Account #�i Revised 11/06 Invoice # ra S-2 '7g5ip 0 lu duq OTOZ/9z/c ILS06068=NHXOIADWL6118=(IIADLugo*dt,,Lu/dttu/sdulNog/sn-ou-oTA-ep-oo-sdt' H: 9JO I 32ud SID sdeWODk APPLICANT INFORMATION Account # Billed To Reference Name Proposed Facility: Water Supply: 990005461 Jeremy Harris David Harris Residence On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5726-58-9277 Subdivision Info: Location/Address: 604 Junction Road -27028 Property Size: 11.72ac Date Evaluated: _i — (q - 10 V 4 Communitv P lic EvaluationC i• 1 Landscape position HORIZON I DEPTH Texture group ConsistenceF.2If" ��-- ur/ l MM Mineralogy r�rUMM��4M Consistence r►ira i�r�rr�. ��� HORIZON III DEPTH Texture group Consistence HORIZON IV DEPTH Texture group Consistence Mineralogy SOIL RESTRICTIVE HORIZON CLASSIFICATION ��i�tt��.L1ti»/1►���I SITE CLASSIFICATION: C/ LONG-TERM ACCEPTANCE RATE: �' 7 REMARKS: EVALUATION BY: `G' w.��!C ✓o d jl OTHER(S) PRESENT: 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 CONSISTENCE 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 Mineralog,v 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) TTAR - T.nnn-term ArrPntnnrP rate - nal/rlav/ft? GoMaps GIST ,r- � � Page 1 of 6 J � N C N—j; 5i w 4 � # 7 t � 357 - N C) 495 1 360 I N I n. W A! N 4 SOF f as) i u1 Ati-R r M iC wAr � L�Jue �^ �e rT n N � U3 2` 82ft 258 61 http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=81197&CFTOKEN=89090571 3/26/2010 • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005461 Tax PIN iEH #: 5726-58-9277 Billed To: Jeremy Harris Subdivision Info: Reference Name: David Harris Location/Address: 604 Junction Road -27028 Proposed Facility: Residence Property Size: 11.72ac ATC Number: 5111 **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: S.T. Manufacturer Tank Date Tank Size. Pump Tank Size System Installed By: E.H. Specialist: Date: GPS Coordinate: J DCHD 11/06 (Revised) r ' Davie County Environmental Health P.O. Box 848/21,0 Hospital Streit - Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT 4 Tax PIN/EH #: 5726-58-9277 Subdivision Info: Location/Address: 604 Junction Road -27028 Property Size: 11.72ac **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 l l of G.S. Chapter 130A, Wastewater Systems). This Improvement Permitis 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 D-- Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD). Type of Water Sup ty: CiCc init r i y� 11 ❑Community Well `.; As stated in MA N Site Modifications/Permit Conditions: accepted Systems may also be i�sc System Type LTAR Initial 7 Repair d Site Plan Account #: 990005461 Billed To: Jeremy Harris Address: 604 Junction Road City: Mocksville .Reference Name: David Harris .Proposed Facility: Residence 4 Tax PIN/EH #: 5726-58-9277 Subdivision Info: Location/Address: 604 Junction Road -27028 Property Size: 11.72ac **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 l l of G.S. Chapter 130A, Wastewater Systems). This Improvement Permitis 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 D-- Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD). Type of Water Sup ty: CiCc init r i y� 11 ❑Community Well `.; As stated in MA N Site Modifications/Permit Conditions: accepted Systems may also be i�sc System Type LTAR Initial 7 Repair d Site Plan j r Qat r All 1 t r �i� p%f S���u 1 /YXr✓� % Environmental Health Specialist i�GJ')� Date i.p.11.06 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 Accnunt #: 990005461 Tax PIN/EH #: 5726-58-9277 Billed To: Jeremy Harris Subdivision info: Reference Name: David Harris Location/Address: 604 Junction Road -27028 Proposed Facility: Residence Property Size: 11.72ac ATC Number: 5111 Site Type: 0N—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 # Bathrooms #People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type . # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: KCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) (r—o Tank Size ka ov GAL. Pump Tank GAL. Trench Width 3—C Max. Trench Depth 7 G Rock Depth a Linear Ft. 4 V Site Modifications/Conditions/Other:As stated in 15A NCAC 18A.1969(5� a LedSysternsin., U)sa—is,,—ns Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day o1 -installation. Telenhone # (336)751-8760. Dru.t"\ s -t P� s y Sit Mka 'e a IM r11 w�► p�Paeit w a.I Environmental Health Speciali DCHD 11/06 (Revised) \�oU 0 -It pair 00, � A.7 14 sw M Ir a T Q Date: 0 A 0