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146 Madison Rd ' ' r ....,w � . � � . � . .,. . DAVIE COLTNTY HEALTH DEPARTMENT , ' � Environmental Heaith Section � R O� P.O.Boa 848/210 Hospital Street 5� � Mocksville,NC 27028 (336)751-8760 Account #: 989900644 Tax PIN/EH#: 5728-79-8112 �,,�' Billed To: Madison Angell subdivision �nfo: `y���AG�l50 N �=(� Reference Name: Location/Address: Madison Road-27028• Proposed Facility: Residence Property Size: -"^_."-_-�-*� f�.7�1� ��i ATC Number: 4541 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,Sewa e Tr ent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTR ION ALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signa re: Date: / � 266 CERTIFICATE OF COMPLETION **NOTE** The issuance ofthis Certificate ofCompletion shall indicate'the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO Y be taken as a guarantee that the system will function satisfactorily for any , given period of time. , � '_ � ^�� , �, `'��� ��,, , /q ` , , /� 8 io � ��� � ��,,� N� � �c�F �oac���,� �a�Kc�o-��) � � r Septic System Installed By: L•'"'�"'�� � i Environmental Health SpecialisYs Signature: � 7 DCHD OS/99(Revised) � � ,� , , DAVIE COUNTY ENVIRONMENTAL HEALTH •�� ": P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900644 - Tax PIN/EH#: 5728-79-8112 Billed To: Madison Angell Subdivision Info: Reference Name: Location/Address: Madison Road-27028 Proposed Facility: Residence Property Size: 22.35 acres r, ATC Number: 4541 Site Type: ❑New ❑Repair ❑Expansion **NOTE**This Authorization to Construct(ATC)MLTST BE ISSUED by the Davie County Envuonmental Health Section prior to issuance of any building pernut(s),(in compliance with Article.l l 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 �� #Bathrooms2�.� #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �� �`'Z.�� Type,of Water Supply: �unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)3tGO Tank Size��?EX''-�('AL.Pump Tank GAL. ,, �� �� t � Trench Width�� Max.Trench Depth''`.�',...� Rock Depth N 4.. Linear Ft. � �. � ` Site Modifications/Conditions/Other: ��tr�1� 25 iZ�1�.Y'.�lo.� '[-- S1�l.l..� o•J �-c+JT'ctiS12 4� �S' 0 1-! — �„� �C` o � �.-�,� �� Contact the Davie County nvironmental Health Section for final inspection of this system between * 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. ;: �--w�l�la� . 3� �' �'�� Lir�1�,S 1�.! �.� � ` � � , �, � 4� � p- . �� �`nl�s ��-vts� �� �� ;- � ��'� • _ � �x.�.���S '�R-` � � <�� � �' G � .� � � � � � u � � ��, � � � ,� 5 w.�:., ,. , , , N-S� ?s _. �z,�� , : . ..�� x�__. ; .. 4- � �c�P U,J� � __ Environmental Health Specialist Date: � 9 a 7 ��✓1��>. � DCHD 11/06(Re�ised) �. DAVIE COUNTY HEALTH DEPARTMENT �� }-. Environmental Health Section �� , � P.O.Boz 848/210 Haspital Street lp���U� Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900644 Tax PIN/EH#: 5728-79-8112 Billed To: Madison Angell Subdivision Info: Reference Name: Location/Address: Madison Road-27028 Proposed Facility: Residence Property Size: 22.35 acres ATC Number: 4541 **NOTE**This Improvement/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 "` x WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. } � [� � Residential Specification: Building Type �l�l�� #People #Bedrooms 1 #Baths �•5 Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement wlPlumbing: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: � Lot Size�5��X2GO� Type Water Supply 71J1�( Design Wastewater Flow(GPD) �g� Site: New� Repair❑ System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width �� Rock Depth�Linear Ft.7�� ocn�: /���r�> �,����c��� ��T�v.� t�is�i6vtia�J.��(es ��p � , �y,�I Required Site Modifications/Conditions: ���L�_(�,��� �J-�( ���,�j�%,, �L� l l� c�� t'�r.(,1� � IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF G"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis stem be en 830 a.m.to 9:30 a.m. or 1:00 .m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** 4� , �c�} ��� �z� �: � �� l��JL.S h ; � H.5� �� , � � �-��-+-I ��-� �'' p � 0� � 3-7-03 �0.•�3' d �r �E �• � o I�K sT, dr►u�-�- Grv►�`,e^' ( ,i,�,�,Q. 4�.. � � . � � 1� O Q� �1 et�. •Zo -2 r� � ���v�- � _ ��.� o�� � � � � � � � � `•�� �-'i� � ` ��-vM,. ,�►^�u� ea�.� r�� n� � �W sd�- �r�t+�, acl,�k a..�¢ rw*'�. � !u,..�+-�de�►_ _w�. U �' � � ,n►� b d+�..��tw;, :al �3'� r,,�"` v,�• g'' Environmental Health Specialist's Signature: ' fl�o �u�E �a' , � DCHD OS/99(Revised) " ;. ' �k , . ( , ' � Davie County Health Department 'Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (33�751-8760/Fax(336)751-8786 Improvement Permit T. Madison Angell 276 Madison Road Mocksville,NC 27028 Re: 3/4 Acre Tract/Madison Road Tax PIN: 5728798112 Dear Client(s): 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 consfizction/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 or the intended use change. System To Serve: C�1 astewater Design Flow(GPD):y� Valid: ,�Years ❑No Expiration C.,C System Type: ❑Conventional Accepted ❑Innovative ❑Alternative OOther Site Modifications/Permit Conditions: � �s' ..P2�6�, �. ,�- ite Plan � �� . � , � �� �-- � � � �(P `/�`P��(� ;� ` ,� �1J� - 1 v �'�rit' � _ � � � �� � � � -� , a �, ,9� �� � � � � � � �- � L i� � vP � � 2�D' . l. � l Envir i e h S eci t Date � i.p.letter 7/06 ,: ; , i-. , . _, , I�. / ' C� ' SITE EVALUATION/IMPROVEMENT PERMIT & AT ��r�� V � � avie Count Health`De artment � S� Y P , e � � 3 20D6 � Environmental Health Section �� ��� � ,��� 2 �6 � �� . P.O. Box 848/210 Hospital Street � ,���pL�� Mocksville,NC 27028 �rMRop��co�� (336)751-8760/Fax (33�751-8786 Appli or: 0 Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both ***IMPORTANT'***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instructions. A.PPLICANT INFORMATION Name to be Billed �S���J ` 1 Contact Person ,/f/1,�- �S'1 R-� �'� Billing Address Home Phone�s C. ��l .� �Sl� .ti+ � City/State/ZIP v � ` ► Business Phone � — � � Name on PermidATC if Different th�n Above Mailing Address �.. � C'��s' City/State/Zip �_ v� 2� � r ': PROPERTY 1NFORMATION NOTE: A survey�plat or site plan must accompany this application. (Permit is� lid f r 60 mo�'s/with site plan,no e.xpiration wit om lete pl t.) Street Address ����/�SQ�KfJI' City (f s � ��2 Tax PIN# S7Z�I9����0� Subdivision Name Sec ion/Lot# Lot Size � ' Directions To Site: ( G(� '` 0/v -� � Date House/Facility Corners�Flagged 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�o Does the site contain jurisdictional wetlands? ❑Yes�� � Are there any easements or right-of-ways on the site? OYes��_�'1�V�o ��� Is the site subject to approval by another public agency? �Yes E�'No �� X l:(..CJ Will wastewater otheY than domestic sewage be generated? ❑Yes C�� IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms � #Bathrooms� Garden Tub/Whirlpool ❑Yes ❑No _ Basement: ❑Yes F.�o Basement Plumbing: ❑Yes r�d'o 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 , Typesystemrequested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: �unty/City Water . ❑New Well ❑Existing 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 understand that I am responsible for all charges incurred from this application. I hereby grant right o entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deterinin ompliance ' pplicable laws and rules on the above described properly located in Davie County and owned by '� � . � � � �- 1 . . . . . . � � . . . Site Revisit Charge Property owne ' or owner's legal representative signature � �S Date(s): �, 3 � v (� Client Notification Date: Date . EHS: Sign given Q'1'es ❑No I�, Account# q V��`I" Revised 2/06 � On U�5 r, �"��jq j(�i Invoice# `J' /� R('/ `f v � i � � V ' , � , , DAVIE COUNTY HEALTH DEPARTMENT '•' . � " � ° Environmental Health Section � r Soil%Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900644 � . Tax PIN/EH#: 5728-79-8112 Billed To: Madison Angell _ , Subdivision Info: Reference Name: Location/Address: Madison Road-27028 Proposed Facility: Residence Property Size: 22.35 acres Date Evaluated: I _ Water Supply: On-Site Well Community Public � Evaluation By: Auger Boring /' Pit : ' Cut , FACTORS '� 1 2 " 3 4 ' S 6 7 Landsca e sition (_ (t Slo e% �} � HORIZON I DEPTH �''i� O � / D r Texture rou Consistence ; ; 5 , Structure �� �l� � . � Mineralo �i,; Ss HORIZON II DEPTH - (o -32 � Texture rou � S`C G:� � Consistence - � S' Structure � � Mineralo °a�. � , HORIZON III DEP'TH '{ � �'z,.�► . Texture rou S �l.-�S Sa ` Consistence Fr'SS S -r' ` Structure �1< Mineralo " r ; HORIZON IV DEP'TH � � � Texture rou � �► Consistence �{' 'Structure � Mineralo SOIL WETNESS '— .— "' RESTRICTIVE HORIZON $ - SAPROLITE ^ — - CLASSIFICATION S 5 + LONG-TERM ACCEPTANCE RATE �� d• .3 (,� � Y � SITE CLASSIFICATION: C� � EVALUATION BY:� l.�-1 . �� . , . ' _ � �- LONG-TERM ACCEPTANCE RATE:O •3 : OTHER(S)PRESENT: ���`' �Y...�.� REMARKS: � � LEGEND .::�T, n c ape 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 � Te�turg , ` _ 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 � _ ('ONCiST ,N . . �'1415� � VFR-Very friable FR-Friable FI-Firm VFI-Very firm � EFT-Extremely fum Y� . NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky ` NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic SSr�stlu� SC-Single grain M-Massive CR-Crumb GR-Granulaz :. ABK-Angulaz blocky : SBK-Subangular blocky - PL-Platy PR-Prismatic ; l i Mineralo¢v 1:1,2:1,Mixed - lYQtgs 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 ' Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 DCHD OS/OS(Revised) � �, ��1►��■�■V ■■����������■���■u�■■■���■��■��■���s■���■�i����■■■■■■■��■e�■■����■■ ■■■o�■�■�■���■��■i��■o■�■�■■■■■������,■■���i��■�■��■■��■■��������■�■ ■���■��■�■�■�s■s■n�e■■�■■■■■�■�■ ■�■i■■R�■i����■■�����■■■■�■■��■■�■ ■�■�■■■■�■�■�■�■�11��■�■�■■■■�■■■■�■�■1��111►Q■i/I3Y�■�■■���■�■■��■O■■O■■ ■■��■�■■�■■■�■���1�������■��■�■■�■■■��I�I�r�■I�I�r���■�������■■�■■o�■■■ ■��■■�■■0�■������II��O�■�■��:�■����00�1\\��1���1■��■�Y�■�■O��■■■���■�■■■ 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