126 Southern Magnolia Dr Lots 3 & 4 DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT.
Account #: 990005974 Tax PINIEH#: G910OA004
Billed To: Seth &Jessie Carter Subdivision:Info- Wagnolia Acres Lot#"4, .
Reference Name: Location/Address: Southern Magnolia Drive-27006
Proposed Facility: Guest House property Size: 1,527 Acres
ATC Number: 5997
**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 /000
Pump Tank Size Bedrooms: '
System Installed By:gnCn m an t' f Installei#. Date:
GPS Coordinate:
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Environmental Health Specialist Date:
t
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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005974 '.' Taz PlN/EH#: G910OA004
Billed To: Seth &Jessie Carter ':Suladivisionanfo: ,:Magnolia Acres Lot#4
Reference Name: ;. Location/Address: Southern Magnolia Drive-27006
Proposed Facility: Guest House Property Sizer 1.527 Acres
ATC Number: 5997
Site Type: ANew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior tq 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 N subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms _#Bathrooms 1 #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size . Type of Water Supply: ❑County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) Tank Size l DD GAL.Pump Tank / GAL.
Trench Width Max.Trench Depth_ Rock Depth Linear Ft. OeO` a 67,6
Site Mo
c i
Contact the Davie Countynvironmental He 1 Section for final inspection of this system between
8:30=9:30a.m.on the day of installation. Telephone#(336)751-8760.
Li
g I �
API
79�a
IL-1 '
Environmental Health Specialist I Date: I I
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 #: 990005974 Tax PIN/EH#: G910OA004
Billed To:,'Seth &Jessie Carter Subdivision Info: Magnolia Acres Lot#4
Address: 126 Southern M49no14Drive Location/Address: Southern Magnolia Drive-27006
City: Advance Property Size: 1.527 Acres
Reference Name:
Proposed Facility: Quest 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.
Permit Type: %New DRepair DExpansion Permit Valid for: R5 Years DNo Expiration
Residential Specifications: #Bedrooms _#Bathrooms _#People Basement0 Basement plumbing
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): ,Qyp Type of Water Supply: PGCounty/City DWell OCommunity Well
Site Modifications/Permit Conditions:
System Type LTAR
Initial o P64ACm
-Repair I asojo
Site Plan
tc yo t lc(6c tjn
�i
yl pol -f V
[' °e
_s
Environmental Health Specialist ('Itedl Date (
i.p.11-06 /
Wfildreo ea eP e$n OJW
•
'APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC 906
Davie County Environmental Health 0 `
P.O.Bog 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: ite Ev tion/Improvement Permit ❑Authorization To Construct(ATC) ❑ Both
Type of Application: UWw System ❑Repair to Existiniz System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT"**THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name Contact Person c---,o,, .S IJA ,
Address _S Home Phone
City/State/ZIP ni-- e -�,--7o o to Business Phone 3 3 t- 3
Email
Name on PermitIATC if Different than Above
Mailing Address j2.'5- -7 lJ 5 tAk1,V 6 y IAA City/State/Zip t!?j 0 5., , G•z7vZ
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE:_ A survey plat or site plan must accompany this application. Included: ite Plan ❑Plat(to scale) j
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name' 5 44-J- Phone Number
Owner's Address)Z C. 5 , }-[,.._ yn r./ 0-T City/State/Zip A-.4,,, _ ,j_ c_.. z.-7 v a c.
Property Address
Lot Size /. S-2:-7 /+,,, s Tax PIN# & 7 10 o Ad 04
Subdivision Name(if applicable) /t'7-S o J;_ A,_-,- S Section/Lot# 3
Directions To ite: &'0 / 1-,
If the answer to any of the followin 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 jzNo
Are there any easements or right-of-ways on the site? ,Yes No
Is the site subject to approval by another public agency? _Yes 4,,t44o
Will wastewater other than domestic sewage be generated? Yes✓Nlo
TF RF,SIAF.NCF FIT J,OT JT THF,BOX BFLOW
#People #Bedrooms J #Bathrooms 1.S� Garden Tub/Whirlpool ❑Yes o
Basement: ayes ❑No Basement Plumbing: Lames ❑No
TF.NON-RF,STDENCE FIT.T.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: onventional ❑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 ❑No
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 comers and locating and flagging
or staking the house/facility location,propose well location and the location of any other amenities.
Site Revisit Charge
Pr ertyowner' r o is legal representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice# �,���
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1
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005974 Tax PIN/EH#: G910OA004
Billed To: Seth &Jessie Carter Subdivision Info: Magnolia Acres Lot#4
Reference Name: Location/Address: Southern Magnolia Drive-27006
Proposed Facility: Guest House Property Size: 1.527 Acres Date Evaluated: /q N Z
Water Supply: On-Site Well Community Public k
Evaluation By: Auger Boring X Pit Cut
FACTORS 1 2. 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH r)- -(,
Texture group St L ISCL
Consistence I-Q_
Structure VUL6
Mineralogy
HORIZON II DEPTH -
Texture group C
Consistence
Structure L S
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION I Q
LONG-TERM ACCEPTANCE RATE cc 3
SITE CLASSIFICATION: j. EVALUATION BY:
LONG-TERM ACCEPTANCE RATE. OTHER(S)PRESENT: (-OVA
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
CONSISTENCE
NlQist
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
Mineralogy
1:1,2:1,Mixed
Tues
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)
LTAR-Long-term acceptance rate-gal/day/ft2 DCHD 05105(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT •
Environmental Health Section SECTION--/-LOT
Soil/Site Evaluation
APPLICANT'S NAME -f//�/I� DATE EVALUATEDD �r
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ��i�GJ�/>r� � AC ROAD NAME
Water Supply: On-Site Well Community Public L�
Evaluation By: Auger Boring Pity Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L.
Slope%
HORIZON I DEPTH
Texture groupL L
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupG
Consistence i
Structure ,t/l 5WC
Mineralogy . '/ A.
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE c
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
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
CONSISTENCE
oist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
tructure
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
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)
LTAR-Long-term acceptance rate-gal/day/t2
DCHD(01-90)
Davie County Health Department
18 j�` Environmental Health Section
P.O. BOX 848
-L 210 Hospital Street
Q U Courier# : 09-40-06
Mocksville, NC 27028
Phone:(336)-753-67.80 Fax:(336)-751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
by
Name: L l _l'Xhone Number (Home)
Mailing Address: 12 5 v S /�wY Z `/ 3 �'�`� r" Z��1, (Work)
1`7 IV-C- 2_7�-z S, Email e--
Detailed
Detailed Directions To Site: '-j
Property Address: j 2 (.. S d 1 _ /"1— , �• v
Please Fill In The Following Information.About The EXISTING Facility:
f
Name System Installed Under:5), Type Of Facility: e O • �L -— -
Date System.Installed(Month/Date/Year): z /�g Number Of Bedrooms:Number Of People:
Is The Facility Currently Vacant? Yes (�If Yes,For How Long?
Any.Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: "' ' L ^ Number Of Bedrooms: 0 Number of People
Requested By: Date Requested: 2-
( ature)
For Environmental Health Office Use Only
pproved Disapproved
Comments: Al ✓1CLL1 � jVG /
�O U rI Ci G�'7�dYI
Environmental Health Specialist Date: 1 Z
*The signing of this form by the Environmental He6fh 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 # Amount:$ Date:
Paid By: Received By: 414 4 1114-1Z/
Account#: Invoice#: