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175 Laurel Brook Ln DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Account M 990004307 Tax PINIEH#: 5863-57-0622 Billed To: Erik and Carol Blankenship Subdivision Info: Laurel Brook Lot#4-1A Reference Name: LocationlAddress: 175 Laurel Brook Lane-27006 Proposed Facility: Residential Addition Property Size: 5.365 ATC Number: 5014 **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:.,/,i; 'jW S.T.Manufacturer Tank Date Tank Size Pump Tank Size System Installed By: Z<tea,&66A.2l E.H.Specialist:JAAdq,--1j4Lnte: 4vi La ` ya DCHD 11/06(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH 1 I P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION . Account #: 990004307 Tax PIN.,EH#: 5863-57-0622 Billed To: Erik and Carol Blankenship Subdivision Info: Laurel Brook Lot#4-1A Reference blame: Location/Address: 175 Laurel Brook Lane-27006 Proposed Facility: Residential Addition Property Size: 5.365 ATC Number: 5014 Site Type: 2<eewRepair ❑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 #Peo le Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type Qva p ty yp #People #Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City eVVell ❑Community Well System Specifications: Design Wastewater Flow(GPD) Q t Tank Size ��GAL.Pump Tank OEiAL. Trench Width -34 Max.Trench Depth f� Rock Depth_/eA Linear Ft. 10106 As eptstated in 15Atem N may 18Aalso be 69 *, yI�U Site Modifications/Conditions/Other: arr.P ed Systems may also be us Contact the Davie County Environmental Health Section for final inspection of this system between 8• — f installafiQn. Tele hone# 336 751-8760. i Q(.t 10G N •r ,a°yah .�.._ . r - 5 f Ir Environmental Health Specialist Date: 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 #: 990004307 Tax PIN/EH#: 5863-57-0622 Billed To: Erik and Carol Blankenship Subdivision Info: Laurel Brook Lot#4-1A Address: PO Box 1514 Location/Address: 175 Laurel Brook Lane-27006 City: Mocksville Property Size: 5.365 Reference Name: Proposed Facility: Residential Addition **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: ew ❑Repair ❑Expansion Permit Valid for: CSS Years ❑No Expiration ~T ' Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ da'i's�'Csc�►"�� Non-Residential Specifications: FacilityType qtr #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): :.100 Type of Water Supply: ❑County/City ell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: accepted Systems may also be usedd System Type LTAR Initial (�} RVal'i ne # acxti h Site Plan t n V (06 1 Ila i� C-t P Environmental Health Specialist Date i.p.11-06 PPLI 9AN SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 E�t`j1 p01 ��u (336)753-6780/Fax(336)753-1680 Ap cation For: 11 Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Zoth Type of Application: ❑New 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. APPLICANT INFORMATION Name to be Billed iv��� Contact Person Billing Address F Home Phone 2�0691 L City/State/Z1P is> Business Phone Name on Permit/ATC if Different than Above - i Mailing Address � City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 mon hs,with site plan,nq expiration with complete plat.) Owner's Name C` 1n Phone u b Owner's Address f - v.� City/State/Zip Property Addre s city Lot SizeC, Tax PIN# ( 00XZn 7 Subdivision ame(i applicable) Section/Lot# tt / Dir ions To Site: - 17— I r ks 2 If the answer to any of the following qu tions is"Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? ;Ns _No Does the site contain jurisdictional wetlands? _Yes V<o Are there any easements or right-of-ways on the site? _Yes , -Io Is the site subject to approval by another public agency? _Yes ;No Will wastewater other than domestic sewage be generated? Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms _ #Bathrooms / Garden Tub/Whirlpool es ❑No ement: E]Yd MN6 Basement Plumbing: ❑Yes �o IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/BusinessLI& r a Total Square Footage of Building 1 a6O #People eD #Sinks I — #Commodes # Showers t #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: C eo-nventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well xisting 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 Dep -ment to conduct necessary inspections to determine compliance with applicable laws and rules. derst at �p Bible for the proper identification and labeling of property lines and corners and loca' ging t th o ' /facility location,proposed well location and the location of any other amenities. �--' Site Revisit Charge Property owner's or owner's legal representative signature l Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# -� Revised 11/06 Invoice# '7 S DAVIE COUNTY HEALTH DEP NT Environmental Health Se tion 6 P.O.Boz 848/210 Hospital S eet Mocksville,NC 27028 (336)751-8760 IMPROVEMENT(OPERAT N RMIT Account #: 990001776 Tax PIN/EH#: 5863-57-1695Wm Billed To: Waters&McGuire Building Co. Subdivision Info: Laurel Brook Lot#4-1A Reference Name: Location/Address: Griffith Road-27006 Proposed Facility: Residence Property Size: see map ATCb r: 2915 **NOTE* is�mprovement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. ii Residential Specification: Building Type #People _ #Bedrooms \-:P- #Baths Dishwasher Garbage Disposal Washing Machine Basement w/Plumbing;,PiBasement/No Plumbing: Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: Lot Size �1 C Type Water Supply &�11 Design Wastewater Flow(GPD).cfK Site: New.O" Repair❑ System Specifications: Tank Size y p /DDS GAL. Pump Tank GAL. Trench/Width c1� Rock Depth /��Linear Ft Other: -��df Z111A!/1 4� _ Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S) IF 6°°BELOW FINISHED GRADE. ****NOTICE: Contact a representaj a avie Coun alth Department for final inspection of this system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m. to 1:3 e a o i tion. Telephone#is(336)751-8760.**** �C.j V \ Environmental Health Specialist's Signature: Date: DCHD 05/99(Revi DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section " Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004307 Tax PIN/EH#: 5863-57-0622 Billed To: Erik and Carol Blankenship Subdivision Info: Laurel Brook Lot#4-1A Reference Name: Location/Address:. 175 Laurel Brooka e-27006 G Proposed Facility: Residential Addition Property Size: 5.365 Date Evaluated: �� Water Supply: On-Site Well Z Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4- 5 6 7 Landscape position Slope% HORIZON I DEPTH Texture groupG Consistence Structure K1/ 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 3 SAPROLITE CLASSIFICATION P 41 LONG-TERM ACCEPTANCE RATE h / SITE CLASSIFICATION: J EVALUATION BY: G LONG-TERM ACCEPTANCE RATE: © • OTHER(S)PRESENT: i REMARKS: 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 CONSISTRNCR Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 1�'et 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 lYQtes 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.nna-term nrrPntanrP rate- anUrinv/ft7 nc)nc