126 Summer Sweet Dr Lot 8 3-�z•off
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• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
• - Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
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Account #: 989900093 Tax PIN/EH#: 5880-50-5715
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#8
Reference Name: Location/Address: Summer Sweet Drive-27006
Proposed Facility: Residence Property Size: 0.737 ac
ATC Number: 4730 ' � ntiS
**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 S nXF Tank Date 10.29.0? Tank Size (ISL
Pump Tank Size N/l- 7 4
System Installed B n
Y Y� Ra4h 11'1:4I 4A E.H. Specialist: Date:
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DCHD 11/06(Revised) (44
-• DAVIE;COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 - (�0
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900093 Tax PIN/EH#: 5880-50-5715
Billed To: Shelton Construction Services Subdivision Info: Magnolia Acres Lot#8
Reference Name: Location/Address: Summer Sweet Drive-27006
Proposed Facility: Residence Property Size: 0.737 ac
ATC Number: 4730 Site Type: ew ❑Repair ❑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�'�#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size C•?5 Cr C t Type of Water Supply: [rCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) 4$y Tank Size GAL../P1pp Tank,"/ GAL. �f
Trench Width Max.Trench Depth 3(eRock Depth-J-)1` Linear Ft._ 00_(��
Site Modifications/Conditions/Other:
Contact the Davie County Environmental Health Section for final inspection of this s bet en
8:30—9:30a.m.on the day of installation. Telephone#(336)751-&M61-1
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Environmental Health Specialist Date: �� )S- Q /
DCHD 11/06(Revised)
APPLICATION FO ITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Environmental Health
P.O.Box 848/210 Hospital-Street
Mocksville,NC 27028
O ,�,,````((,��,�� (336)751=8760/Fax(336)751-8786
Applic or: �+S<ite Evaluation/ ovem nt Permit Authorization To Construct(ATC) ❑ Both
Type o p i ation: 0 ❑Re ' to Existing System\\ ❑Expansion/Modification of Existing System or Facility
•,a NMS
***IM ORTAN ** PLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFO PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed < h )�"�- _ , •-� - Contact Person
Billing Address 1-2--,;:-7 V S 14 ✓ G y W Home Phone
City/State/ZIP i-,r1 d k s- it .✓ G -7 o i Business Phone 3 / '9--2 v v
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged 21--2k -7
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan 021at(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name <;4 _ 4. - ,4, Phone Number 3`I 1'-z ou �o
Owner's Address, '' - _ City/State/Zip
PropertyAddress en- r _ � ) : 4,,< , City-ZIt.".
Lot Size e '7 s 4 e e5 Tax PIN# SS S U Sv -9-'7/ S'
Subdivision Name(if applicable) t,"l „ /:.. A, , 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 G
Does the site contain jurisdictional wetlands? ❑Yes 0310
Are there any easements or right-of-ways on the site? ❑Yes o
Is the site subject to approval by another public agency? Oyes 9N'o'
Will wastewater other than domestic sewage be generated? ❑Yes
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms 3 #Bathrooms 2• Garden Tub/Whirlpool es ❑No
Basement: ❑Yes ON6 Basement Plumbing: ❑Yes EkNe
IF NON-RESIDENCE FILL 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; nventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: �bun /CityCS-- Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 24
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 corners and locating and flagging
or staking the house/facility location,proposed well location and the location of any other amenities.
� 7 �� Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
-3 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# X093
Revised 11/06 Invoice# r (e�
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• DAVIE COUNTY HEALTH DEPARTMENT
' • Environmental Health Section SECTION_,-LOT.
Soil/Site Evaluation
APPLICANT'S NAME li?Il�z t DATE EVALUATED
PROPOSED FACILITY n PROPERTY SIZE
SUBDIVISION __ �� /`t ROAD NAME iPe i l/'e l/
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH i< </
Texture grou1_
Consistence
Structure
Mineralogy
HORIZON II 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
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE <<
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: J OTHER(S)PRESENT:
REMARKS:
LEG
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
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
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)
LIAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)
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