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1448 Liberty Church Rd � ' . - DAVIE COUNTY ENVIRONMENTAL HEALTH :' ,� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990001357 Tax PIN/EH#: 5812-27-1495 Bilied To: KEVIN Nunn Subdivision Info: � Reference Name: Location/Address: 1448 Liberty Ch Rd-27028 Proposed Facility: Pool House Property Size: 9 Acres ATC Number: 4897 **NOTE**The issuance of this Operation Pemut 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: �G q� S.T.Manufacturer C�S Tank Date 1 Z'l•�Y Tank Size oQ� Pump Tank Siz� � i � Q p System Installed By: /vN1ni� i d� E.H.Specialist: �G� Date: /'2"�� L. � � , ^ � � I I � �, I�`��'',y �p� � ��S�z �r 1�� I �'��5 �,�d'"'� � 1 I . �- .. ---' I �^�" � � � _ � � �°� � � ^ . � `, � 1/� y��. . ` Qae l �� ►,L3�" �st� _ 9iMkt , ` \ ' - �. ,�`� y�` � �j�' � c1� �� . J�Ver,+`` _ . r` , $D+� �C'f"'�,�..� ^ � l.� DCHD 11/06(Revised) � . � • • DAVIE COUNTY ENVIRONMENTAL HEALTH �� P.O.Box 8481210 Hospital Street (;I�aJ�4� Mocksville,NC 27028 � (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990001357 • Tax PIN/EH#: 5812-27-1495 � Billed To: KEVIN Nunn Subdivision Info: Reference Name: . Location/Address: 1448 Liberty Ch Rd-27028 Proposed Facility: Pool House Property Size: 9 Acres ' ATC Number: 4897 Site Type: �1New ❑Repair ❑Expansion *#NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pemut(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatrnent 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) LotSize ��'�1� Type ofWater 3upply: C�County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��Tank Size 1,�GAL.Pump Tank��GAL. [� /� �, � Trench Width �L Max.Trench Depth -3L Rock Depth .�a Linear Ft. �QU As stated in 15H NCAC 1aA.19S9(5 Site Modifications/Conditions/Other: accepted Systems may also be us�� 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. �� , � ,tia � r _h\�� /`�' �i��v , �,�,l��v� . , i —�`'`�-L ` �_ I �p rc� � t�u"�' ' ( av-h� C9 � � — --.�� oc� _� Q��l.�cuh'e- I i , �� `�il� �' ��li��l;'e,.,fl ',51 ( �.,�,�o.,fl�.�� ,— ' r /� �!] Environmental Health Specialist � Date: v nrNTl 1 1/(lh(R r.visPrll Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990001357 IMPROVEMENT PER��'N/EH#: 5812-27-1495 Billed To: KEVIN Nunn Subdivision Info: Address: 1448 Liberty Church Road � Location/Address: 1448 Liberty Ch Rd-27028 City: Mocksville � Property Size: 9 Acres . Reference Name: Proposed Facility: Pool House **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. Pemut Type: ew ❑Repair ❑Expansion Pernut Valid for: 5 Years ONo Expiration Residential 5peci�cations: #Bedrooms #Bathrooms #People Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type o, -er #People #Seats Square Footage or Dimensions of Facili ) n Design Flow(GPD):�� Type of Water Supply: ounty/Ciry OWell ❑Community Well Site Modifications/Permit Conditions: accepted Systemsrmay also�be us�d S stem T e LTAR Initial -�Y� Re air � SitePlan (� �� t ,��h,�,�i � � � � ��P�� .,G �.�� I .� I 7�6� S`�� t�'j r v� ` � � 0 r �� i�'� QD�'C�" �. __ 1 �J��"� n�� — � .— � ��5ta' , `---, � � \�0 1 � ' \1(�µ(•'* � � �.. ►��QO _ �z� - z�,-�:�i s{�� G�,-�� z� ��u�r ��.� Environmental Health Specialist Date . ,3 .- �g � . .; , • APPLICATION FOR SITE EVALUATION/IMPROVEMEN R�II(� ��T� � Davie County Environmental Health r -- P.O.Box 848/210 Hospital Street � , Mocksville,Nc 2�o2s ' AUG 1 1 2078 _ (336)751-8760/Fax(336)751-8786 � ----___ Er1��+�,�,��,.�rr�.�f��iH � Application For: p.Site Evaluation/Improvement Permit ❑ Authorization To Construct( TC) �, �atl�;,,;,,,��Y Type ofApplication: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Ex�sting ys e ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UI�TI�ESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION � Name to be Billed �..0 ��V �u�v��r--� Contact Person ��v.� ti1 Billing Address ll�►�1,8 I�.�1n�sa-.:.:; C l.� �3. �-Iome Phone �1�i�i.- ��t� �ity/State/ZIP �(�[��.�.U,T_�L �l-l�c� Business Phone 'z'��(�- '-1,�j;-�n l�'C7 Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) (Pernut is�valid for 60 months with site plan,no expuation with complete plat.) , Owner's Name ��,�r,� 11u v�� Phone Number � � � � ` Owner's Address ��M g 4..k�,es-i�..t C�- �. , City/State/Zip Property Address Cx.v�n Ci ' Lot Size � laC.��_ Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: 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? �Yes [�No Are there any easements or right-of-ways on the site? ❑Yes L�No Is the site subject to approval by another public agency? ❑Yes I�No Will wastewater other than domestic sewage be generated? ❑Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People �_ #Bedrooms #Bathrooms Garden Tub/Whirlpool OYes �No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No ��b\ �,�� . 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 documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested:. ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C] No If yes,what type? � This is to certify that the information provided on this application is tcue 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 detennine compliance with applicable laws and niles. 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/facili location,proposed well location and the location of any other amenities. Site Revisit Charge Property owi er's or o er's legal representative signature f �� Date(s): �- t \— � Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �� / Revised 11/06 Invoice# ��,��'�Y � , � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville,NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT❑ REMODELING ❑ RECONNECTION o Name: �� /✓if�n/� Phone Number: �Z�Z�� (Home) Mailing Address: /�� L i��v L'�i. �� .33l�- �S/-G/�0 (Work) �,�/)r,,/L /'��n 2Y Detailed Directions To Site: ��/�� `T. l�� .;�ls� ��i. /� Property Address: �� GDC��,� /� Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: ��di� /l�tiis//r/ Type Of Dwelling:��/lu Date System Installed(Month/Day/Year):��27-2v�'y Number Of Bedrooms:_'�Number Of People: '� Ls The Dwelling Currently Vacant? Yes❑ No� If Yes,For How Long? Any Known Problems?Yes❑ NoB� If Yes,Explain: Please Fill In The Following Information About The New Dwelling: . Type Of Dwelling: ��L�r�%�� .9��N mber Of Bedrooms: N1� Number Of People: /�� R uested B : ��'—'�'' Date Requested: � — l � � V� �1 Y (Signature) For Environmental Health Office Use Only Approved � Disapproved ❑ Comments: Environmental Health Specialist Date '"'The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guazantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. Paymenr Cash❑ Check❑ Money Order❑ # Amoun� $ Date: Paid By: Received By: Account #: Invoice #: . • • . � � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 . Account #: 990001357 Tax PIN/EH#: 5812-37-2689 Biiled To: Kevin Nunn Subdivision Info: Reference Name: Location/Address: Liberty Church Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2525 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems): THIS AUTHORIZATION FOR WASTEWATER CO �U N IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: jt'i QO CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in complianc with Article 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall ' O AY � t en as a guarantee that the system will function satisfactorily for any given period of time. N � (�rJl:� �� ,^.� o�::%� .X n3' . . - x . N 'v� � � -� � N N v � $� �R, �e.`�r No�S�; Septic System Installed By: �i�� L� Environmental Health Specialist's Signature: Date: � � �/ DCHD OS/99(Revised) . • ' � � , ' DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section � Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990001357 Tax PIN/EH#: 5812-27-1495 Bilied To: KEVIN Nunn Subdivision Info: Reference Name: Location/Address: 1448 Liberty Ch Rd-27028 Proposed Facility: Pool House Property Size: 9 Acres Date Evaluated: �'� L�-�� Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition Slo % � HORIZON I DEPTH G—?G Texture grou Consistence Structure , Mineralo HORIZON II DEPTH Texture rou � L Consistence Structure _ Mineralo � HORIZON III DEP'TH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON' � SAPROLITE " CLASSIFICATION LONG-TERM ACCEPTANCE RATE �Z SITE CLASSIFICATION: l�'� S EVALUATION BY: ��h "r-� ..r-- LONG-TERM ACCEPTANCE RATE: ' �7 OTHER(S)PRESENT: �,�j -P csi`�}/� �l.cPil REMARKS: . LEGEND T,andsca,pe Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope Textui� � 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 AN4IST�.N . II'I�iSt _ 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 MineraloQv 1:1,2:1,Mixed LYQts,� 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) � T TAD i...,.. �o.... nn..o..�n....o..+�e ...+1/.7.,../Ah � - � - Tl�TiT!1C/AG m'-'."�♦ �� DAVIE COUNTY HEALTI3 DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street �� (� Mocksville,NC 27028' w" (33G)751-8760 � Account #: 990001357 Tax PINIEH#: 5812-37-2689 Billed To: Kevin Nunn . Subdivision Info: Reference Name: Location/Address: Liberly Church Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 2525 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental . Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CO N IS ALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa re: Date: jti �IU CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been installed in complian with Article 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall ' O AY t en as a guarantee that the system will function satisfactorily for any given period of time. %v (�r�t:� �L'� ,,,,.3 o�j;;� ,X x� . � - . .N �'V� N � ,. N � .� 5� . �R, ��r No�s�, Septic System Installed By: �f�� u"� ' , `;, / Environmental Health Specialist's Signature: Date: !� U'� ✓ DCHD OS/99(Revised) . . . . . . .. . . . , -� - - - . , r 5 . � . ' '� P .. .' . . . ' . � .�. ' .. ... . . . . ,. . . . . ' Da�ie County Health Department ��is f� Environmental Health Section , .� : P.O. Box 848 � � � � � , S„ 210 Hospital Street O U �'� Courier# : 09-40-06 '• 1911 Mocksville, NC 27028 Phone:(336)-753-6780 ON-SITE WASTEWATER CERTIFICATION F�:(33s>-�5a-isso (Check One) Replacement Remodeling Reconnection Name: ��...�1 � C� ` `��`..�� Phone Number �`�`�-` �� (Home) Mailing Address: �� i ��..� C-`'� �J` � (Work) Email Address: Detailed Directions To Site: �D� , `�\ �"t C,U `��`i � � `�`` �' 1 C�L`��\\�\`� �� ProUertYAddress: �� r-�`�e ��•.,� C,�� iC� - Please Fill In The Following Information About The EXISTING Facility: �e�.� � 5��r� c� � } � Name System Installed Under: � V� �\ \..t�� Type Of Facility: S/ `" �`�� q Date System Installed(Month/Date/Year): � � �'/�S Number Of Bedrooms: � Number Of People: � Is The Facility Currently Vacant? Y� � If Yes,For How Long? Any Known Problems? Yes N� If Yes,Explain: Please Fill In The Following Information About The NEW Facility: �-�f.��c�e•�� G �G� ��°�e"l�=�. Type Of Facility: �'��/� ..P a� i Number Of Bedrooms: � Number of People � Pool Size: arage Size: Other: .s-'� Requested By: � ---- Date Requested: � - �U � �� (Signatur ) Far Environmental Health Office Use Only Approv Disapproved Comments:��,o��y i J�J�;r.� � /��f' �u/(d l G`/�'�/.e ��D�.� /' S I?OC.�f. � . Environmental Health Specialist .�`��% � Date: ��4- ��. *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # �C-G Amount:$ Date: 7—3G� '- Paid By: Received By: C¢.'�./l��ydl�./� Account#: Invoice#: '