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192 Kluenie Rd . . , • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 . . (336)753-6780/Fax#(336)753-1680 ��' OPERATION PERMIT a2 Accou�t #: 990003249 Tax PINr'�H�: 5736-35-1770 BiElcd TQ: Larry&Sandy Lucas Su�a�ii�risiorl lnfo: � Re:fer�r�c� t�a��: LocatianrAddr�ss: Kluenie Road-27028 � � f�rnpc�s�ed F��;i€ity: Residence t�co�er#y�iz�: 2.2 Acres � � f�TC Nu�b�r: 5013 **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 �0 Tank Date l! ' Tank Size�GG Pump Tank Size -��J � C� 1 System Installed By a��1.e(� E.H.Specialist: � Date: 1 �d�—� � �: � O '� '�' �. d � ' � ti�, �� r J' . _ ti V V cY ` �o ~ K `� K �} � � � _ �d F 1 `a. '� � � � . , (� � � � � , a � � _. � � � � �� l ��. �. �� -� DCHD 11/06(Revised) �� j�(�,GG��j( �� , �.. .� ; � 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 : Accc►u�it #: 990003249 �'�x�INiEH#�: 5736-35-1770 Bi{!c�To: Larry&Sandy Lucas Sufa�i�i;.-ia►� infc�: � R�fer�r�ce Name: �JZ�JdYj,4 �Q�%�1/v LocationiAddr�ss: Kluenie Road-27028 F'ropc�s��c9 F��c,iEity: Residence P�aper�y Six.�: 2.2 Acres a�TC hEut�be�`: 5013 Site Type: BNew ORepair ❑Expansion � **NOTE**This Authorization to Constiuct(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 Specitications: #Bedrooms�#Bathrooms � #People Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) w Lot Size d_� Type of Water Supply: ❑County/City ell ❑Community Well O� System Speciiications: Design Wastewater Flow(GPD)��Tank Size �)O GAL.Pump Tank GAL. 1� I Trench Width 3 4 Max.Trench Depth oc� Rock Depth� Linear Ft.3 lQ d � � Site Modifications/Conditions/Other: �.Pna,�tt�yat msNmav al�o�be used ��"�'�d-�'�� Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. VV�¢ �� ` � —� � S�p�t�. .�'�r S� � . ,� o,�,,, a �Tcr �0 � �NUs��u7'L s�;c ,r•ar 7�0 ,$�`r o�,�-/ ' .t •. •v ` � /° '� , • � r � S�P�f1 c %!�S'� lla 1 i o.�, � � � � /y �6 � � � o d✓�^5 ; ,� � -+� �rehcl� b 4 t� � M Q't' ��{ �� N�i r� � � D� � �� \ T O (/ /Li �/�rr. � / �`�nvironmenta�Healt�Specialist Date:��d , DCHD 11/06(Revised) ��37L . , ' �. ' � Davie County Environmental Health ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990003249 Tax PIN/EH#: 5736-35-1770 Billed To: Larry&Sandy Lucas Subdivision Info: Address: 173 Valhalla Trail Location/Address: Kluenie Road-27028 City: Mocksville Property Size: 2.2 Acres 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: �1New �Repair ❑Expansion Permit Valid for: .P15 Years ❑No Expiration �� ~ Residential Specifications: #Bedrooms 3 #Bathrooms � #People Basement❑ Basement plumbing❑ } ,, Non-Residential Specifications: Facility Type • #People #Seats Squaze Footage(or Dimensions of Facility) /11`�� Desi Flow GPD :� 4� T e of Water Su 1 : ❑Coun /Ci �W"ell �Communi Well � � � ) YP PP Y tY tY tY - As stated in 15A N�1�C 18,�.1�69{5) Site Modifications/Permit Conditions: accepted Systems may alw.o b� used S stem T e LTAR Initial �c 't� Re air a� kd Site Plan /•- _ � •``�a\��L r ,�L'��,� � r. � �qd,' - _- 0 � r��s ��,��`� �p ' �r �� ` �� : t� r �\� �` C6 ��/ t•��co� __ , � .� , � Q � ..P� ,� ,�� `� � C1 an. � Environmental Health Specialist Date ll � �'Q f i.p.l 1-06 • � , � : ., ' . ,.:_= •► � . • • ,�APPL �� ' � ITE EVALUATION/IMPROVEMENT PERMIT & ATC ;�, ��. � `�;��,i'� avie County Environmental Health � "�� P.O.Box 848/210 Hospital Street � :, �� '•� � � Mocksville,NC 27028 � � �� '�; �,� �` 3G}�6�/Fax(336)'�Si=�'T� � � \.��. . � �. 753-�780 Z63 /b8 Appli �► n r: ' t provement Permit ❑ Autharization To Construct(ATC) ❑ Both Type o ppli id�,``��•,�,4�,-. P g Y P g Y h' , stem ❑Re air to Existin S stem ❑Ex ansion/Modification of Existin S stem or Facili ***IMP T***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORI�(IATION'IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. , . APPLICANT INFORMATION Name to be Billed (,� . ��n C 4 S Contact Person s q,.�2 Bilfing Address Home Phone_3 3C� � 7 S� - S(v �$ City/State/ZIP_��c S�j�1�, . �• C Z 7 o Zg Business Phone_3 3Co- �l ly- �150 �c.e r� � Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY 1NFORMATION *Date HouselFacility Corners Flagged - `a� 7-0°/ NOTE: A suryey plat or site plan must accompany this application. Included: I�Site Plan ❑Plat(to scale) (Perinit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name_� Le�r r�/ W• �cn GA S Phone Number_"3 3(� � �Sl-.�68'$ Owner's Address !�3 1� c�� l�e� �� g '�T�V`• City/State/Zip wl o c K Sv i I le ,iU.�. Z7oZR Property Address Ci Lot Size Z . Z. � Q C r� Tax PIN# 'r � l� O Subdivision Name(if applicable) Section/Lot# Directions To Site: F r o w� P1 o C K v'I 1 . o W� o . /� a h �h i� d o►1 arov LoY' If the an er to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes �To Does the site contain jurisdictional wetlands? ❑Yes fj�No Are there any easements or right-of-ways on the site? ❑Yes�INo Is the site subject to approval by another public agency? ❑Yes C�No Will wastewater other than domestic sewage be generated? ❑Yes No ]F RESIDENCEFILL OUT THE BOX BELOW #People #Bedrooms � #Bathrooms Z Garden Tub/Whirlpool ❑Yes ONo Basement: ❑Yes [�10 Basement Plumbing: ❑Yes No . IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentatiori of similar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested:.�1Conventional ❑Accepted ❑Innovative ❑Alternative OOther �� Water Supply Type: ❑ County/City Water �New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of th,e facil�this system is intended to serve? ❑ Yes �No If}�es,what�e? - This is to certify that the information provided en this applicztion is trae zr.3 correct to the best of my?�otiv?edbP. I understznd that any perxnit(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 enhy to the Authorized Representative '" of the Davie County Health Deparhnent to conduct necessary inspections to determine compliance with applicable laws and ruies. � I understand that I am responsible for the proper identification and labeling of properiy lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. • � �� Site Revisit Charge Prop rty owne s or owner's legal representative signature Date(s): /D - D 7� O� Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �Z7'�_ Revised 11/06 Invoice# �1`� i . 1' , �. �"—�- b��'� �bn ��I-�a+.�b� , � ) ' � � �'�.L b�� '�ti 1 bn ��/ ! � I j > �J ) ! i . `, ! � r,::��„,,� � �' f ' " -� 1 a.��y - r v � � � + � � � , s ' ' � 1 � � � � � ( �aa � auo � �, o s�a��1 `t-�°� � � � ' ' f�. _� , - _ _ _ _ - _ . � __� . � � � ) 1 � 'a.a�y .. � + z �z � t � ) � � � � . J , ., , • .�_• �Ur,a. i, . u,,••+11"^ Y`"a. 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Active L�yer. 0 Use r�Jap Tps � � � � � 0 �PARCELS(Map Tips Available)�� Map La}�ers � Toais � Help � �inks; � A�ddress/NamefParcel5earch � Results -----�--------_.. ------- ---- — " � '�+2 � � ia� �- ' �{ � VALHALLA_TRL��-- �� { � - kr��,Lr� �� -- . - �� i —` : 1 - � , $ti �+ i � . � --.,.�[` � ��- � <4F' �_-- � Jt �,�� r f R�'+�'�� (I .: i�Ir �a Lb•� �. J�� ,� I � -�� f J r t � I - j �� ti� r� � � � f ��'� — f �� 4'',� �� j�i� `'�,-�--�� ! ��]., '� :` � / �'� f � ' ��,,%' ti I � . , '� ' � ,'��Qv � �� Cht3C�-Li'J_ -_-_ � ~�� , �� - - IS.�� , � � � . ,��1 . � � �� : ��,� ``�. 002 .;�� l _� r r'�--��t' /�r.. �,� l`�-�__ , r�-� P`---� ♦ � • fittp://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=4129&CFTOKEN=61640881&initialize... 10/14/2009 ' � � '�' ' � DAVIE COUNTY HEALTH DEPARTMENT � '• Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION �'ROPERTY INFORMATION Account #: 990003249 Tax PIN/EH#: 5736-35-1770 _Bilied-,Td: Larry&Sandy.Lucas Subdivision Infa Reference Name: � Location/Address: Kluenie Road-27028 Proposed Facility: Residence Property Size: 2.2 Acres Date Evaluated: � ,''� ' ` Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e position ` Slope % HORIZON I DEPTH _ / - 1( Texture grou C Consistence �'� �* Structure ,C Mineralo HORIZON II DEPTH � - , Texture rou C Consistence � i r S tructure Mineralo HORiZON III DEPTH Texture rou �Consistence Structure � • Mineralo � r HORIZON IV DEPTH ' ( Texture rou Consistence Structure ; Mineralo SOIL WETNESS RESTRICTIVE HORIZON / � SAPROLITE / / CLASSIFICATION LONG-TERM ACCEPTANCE RATE p, SITE CLASSIFICATION: �� EVALUATION BY: � �� , / � r� LONG-TERM ACCEPTANCE RATE: �' �S OTHER(S)PRESENT: n�T e l.t� �G��_�_I —) . � �` REMARKS: � L GEND j,andscaoe 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 ; .ON�I�T ,N , �I91S� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFT-Extremely firm �ti:. � � � ;. �•= "'*« � NS -Non sticky SS -Slightly sticky S -Sticky VS-Very Sticky ,_ •�" ' -,4 NP-Non plastic SP-Slightly plastic . P-Plastic VP-Very plastic ' - .�� tructure �. SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic � ' �ineralo�v 1:1,2:1,Mixed Notes Horizon depth-In inches " ' Depth of fill-In inches f ' 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) - iTAR -T.nno_trrm a�rentanrP TATP� OAUAAVIft7 Tl�T7T AG/AC /T"']"d♦