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181 Foster RdW • DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 Account #: 990000763 Billed To: Travis Cooley Reference Name: Proposed Facility: Residential ATC Number: 5957 REPAIR OPERATION PERMIT Tax PIN/EH # K20000002702 Subdivision Info- i � 1 LacahoniAddress: 2.6W- Foster Road -27028 Properly Size: 28 Acres **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 1 1 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: �r S.T. Manufacturer 6h00 + Tank Date _ 54("Tank Size Pump Tank Size Bedrooms System Installed By: Q "JU I a H [ T -Inspector#: 4 Z Date: 1 C' GPS Coordinate: Environmental Health Specialist: DCHD 11/06 (Revised) Date:'l(O DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 8481210 Hospital Street Mocksville, NC 27028 (336)753-6780 /Fax # (336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000763 Tax PINIEH #: K20000002702 Billed To: Travis Cooley Subdivision lnfn: Reference Narne: €-ocalion/Address: 267 Foster Road -27028 Proposed Facility: Residential Property Size: 28 Acres ATC Number: 5957 Site Type: VNew ❑ 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 chance. Residential Specifications: # Bedrooms S # Bathrooms .2- # People Basement ELBasement plumbingdl Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City XW llt ECommunity Well System Specifications: Design Wastewater Flow (GPD) _211 Tank Size GAL. Pump Tank --� GAL. Trench Width �(Rk Max. Trench Depth —3(_ e Rock Depths Linear Ft. Site Modifications/Conditions/Other: Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. Environmental Health Specialist r)('PT) 1 1104 (_PP6QPrh GF IVAM TION FOR SITE EVALUATION/MDROVEMENT PERMIT EDavie County Eavironmental Healtr 2012 P.O. Box II MIG Hospital Street O d JUL3 1 Mocksvi e, NC 2702Ey, 3 (336)7534M Fax (336) 753-I6Ee e// BY; on Fat U Site Evaluabot✓Impravemrnt Permit 7 AuthorialionToCoastruct(ATC) lol6h O Type ofApplicatian: -Acw Systcm uRgrair t., Existing Systcm ❑ExpansuirModi&xtioo of Existing System or Facility •"IMPORTAWPO* THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED 1 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. I APPLICANT INFUKMA Name to be Billed 1"(d4 L'5 Lem CAw t caatact Pusan Tra v "y axle ley Billing Address Hoole Pboae 3'rrfe — �i L- z - -- Citrslatdm K,i Bwaintss Phase Nano on Pe FuWATC d D&rrwt dm Above Address PROPERTY FNFORMAMON 'Date House/Facility Corners Flagged / • 15 I NOTE A survey plat or site plon on" accompmy tits appUcedon. Included: Wgirc Plan O Hat(to ,sale) (Pe int is Ned trot 60 months with site Pink no anpirari , wiA cordae pial-) owaws Naaoe Craw, ,✓ Le Phone Nm*w -6 A '44Z -Z-, IV- Owaer•s Adorers cdy/st.ee- Mac4cs1m Iii 14L� =_-Ir Property Cityi1hD[�G51i i�A JJ t ��L11TGl tf LotSise Tat PIN# h Z/VWQOL7 Sttbditrision Natne(if applicable) SectioofLod mccemnis;To Sam irtt�:i.ArQGItatt. CA tv Richt. t0 11054L4- To 4G�.'{.lrls% L lel If the aaswar to any of the Wowing questiaas is •yen, srtppottittg #oamattatiag rant be soaehed. Ase Were arty existing unwivater syafeas na the aft? CIYes e Don the tats corium jaisd Moral wed ood17 ]Yrs 9No An dere may easements or right-of-ways as be sem? OYes Vwo Is the site subject to appsowl by another ptilic agsocy- OYn 7'f Io Sled] wastewater other ditto doaaeaec surm be stseraftV -,Yes tyke IF RFSMENCE FILL OUr THE BOX BELOW # People # Bedrooms # Bathrooms Z Garden Tub/Whirlpool Wes CNo Basement: ca CIN., Basement Plumbing: gYes CNo IF NON -RESIDENCE FULL OUT THE BOX BELOW Type of Fadlidy/8as n Ttrtal Square Foubp of Buildling People # Sinks # Camwtodes A SMowers /urinals En stirnated Waltz Usage (gallons per day) (Altacb downtotradon of sunilar facility water comamption) FOODSERVICE ONLY: # Seats Type syttsmrequested: C-Aaxpted Olmovauve JAkereativc 1-01her. Water Supply Type: U County/City Water U New Well Amstiog Well G Community Well Do you anticipate dditions or expansion of the facility this system is intended to serve? U Yes If yes, what type' LAO This is to certify that the mformatice provided on this application is nue 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 lithe site Is altered, the intended use changes, or if tlrc information submitted in this spplica on is falsified or changed I hereby Umrx tigbt of entry to the Aulhonasd Representative of the Davie County Health Depsrmlent to conduct oecessary, inspections to dere nine compliance with applicable laws and rules. 1 understand that 1 am responsible for the proper identification and labeling of property lines erred comers and logyng and Oa)gmg o_rsUJtiltg the InotaalfaciQy location. prepared well Lealitte and the location of any crier asenities. Site Revisit Cbarge Property awner's or owner's kgd mfireserratire stgpatare Dnte(s): 3 rL arms Nobiliauaa DM-- Date at:_Dale EFM: 5rgn given U Yes U Vo Aetotust N ?0000 70 Revised 11..6 Invoice N L•d 0ti£ZZ6b9££ JeUMO d0y.l l Z 9L Inr DAVIE COUNTY HEALTH DEPARTMENT Environmental health Section P. a_ an SM18 stmt Madan -16, MC 27'628 � I336j741-Vfio IMPROVEMENT/OPERATION PERMIT Account #: 990000763 Tax PINJEH #: 5706-89-2450 Billed To: Travis Cooley Subdivision Info: Reference Name: Travis Cooley Location/Address: Foster Read -27D28 Proposed Facility: Residence Property Size: 28 Acn s ATC Number: 2169 **NOTE** This hnprovement/Opetation Permit DOES NOT attdxWiW th*,�tractioq of a septic tank system of any wastewater system. An AU'!MRIZAT?ON FOR WAS TEWA SYSTEM CO ON tnt�t be fined ¢ora this Dgmrtment prior to the constructimVmstallation of em or ft of a bail diazi in compliance with Article 11 ofG_S. Chapter 130A, Wastewater S_ Section .145 ihatmezipasal Systems). THIS RAW IS SUBJECT TO RIZVOCATIM PLANS QR THE MI MDHANGIL YOUR WA3I'1;WATER SYSTEM CONTRACTOR 4ir SIE' '-!M PmV..—VT Em- 1r.—T 5-fT ft Residential Specification: BuRding Type #PeopEe r1" 1t ahooms V #Baths Dishwasher. Or-- Garbage Disposal: ❑ Wash "e. M__'_'BasaneW WjFhvrtbing: ff_�"SasemenvNo Plumbing: Q Cxnmercial Specification: Facility Type #People 41'eopwShill OSeats Industrial Waste: ❑ Lot Size� -+= Type 4er Suppjy L Design Wastdwater Flow (GPD) r Site: New Repair O r r System Specifications: Tank Size GAL. Pimip Tattle GAI.. Trench Width 3try Rock th F? DepLinear Ft.SV 01hqr,t e' `i9c e-u.f�S Required >ke Madifi=M90gedgm s: Tj aj T4&9 1S i044C d.,a— 7'16400 Si V 444M_ IMlMQ �+-IEIYTIOPKK4T1OlYpBRKff i,AY#6UT- APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW Fil` - -------*-� •��•_crntarta repremntative of the Davie County Health Department for final inspoctim ofthis SYS ap>, to 130 ppm. as the day of tasaliation. Telephone # is (3M)7514 76Q • EdC.ti1 Std OF LA—Sln- � L�'� :.- ♦� \ NEXT t�i.�TR.►�Ttc�J �1���'� rig a Environmental Health Specialist's Signature` DCHD 05/94 (Revised) �•iltis ��57 �e S 5 FELT 60 p 0 Qe*- p✓tA opb L Date: _6� Z -d 0VZZZ6V9££ iaunnp d0V: I,1 Z6 96 Int Jul 18 12 11:40p Owner 3364922340 p.3 faI t-�'�•i LpJ E n r APPLICATION FOR SITE EVALUATION/ IMPROVEMENT PERMIT & AIC Davie County Health Department Envirvnmentai Ifeaith Senyon P.O. Box 848/210 Hcapital Street Mocksville, NC 27028 (336)751-8760 SEP 21999 , i J ***11' ORTANT*** THIS APPLICATION CANNOT HF PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED., Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ittzpy I `5 LEE Coo LZ Contact Person akwo,/ Nailing Address 2.,&,-7 Foy,64 izJ Home Phone 4��' Z-50-5City/State/ZIP I�t?C +(�V 1 L� N C, 1.70'0 6 Business Phone JON' 2. Name on Permit/ASC if Different than 1lbove Mailing Address City/state/Zip 3. Application For: "Site Evaluation ❑ Improvement Pewit/ATC W'Both s. evatem to Service: X House 11 Mobile Home L1 Business f] Indu_ tri ".4- 5 - 5. if Residence: / People I % Bedrooms i* Bathrooras 3 'lL rt Dishwasher H Garbage Disposal Washing Machine X Basement/Plumbing 0 Basement/No Plumbing 6. If Business/Industry/Other: Specify type (4cme CFF,C` f People # Sinks f Commodes f Showers 11 * Urinals _ ✓ M Nater Coolers IF :''OODSEftVIC%: if Seats Estimated Nater UsaSF (gallons V;.r day) 7. Tarps, of water supply: IJ Coun .:y/City Well S. Do you anticipate additions or expansions of the facility this system is it .ended to sent? If yes, what !ype? fJ Community H Yes 'C�No ***IMPORTANT*** CLIENTS MUSTCOAWLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: ')66 0R4&%trJC X47 Tax Office PIN: Prof !rty Address: noao name Forrrcx City/zip A( - . c . Subdiv;siou provide information, as follows: ...d L: Section: Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: {i Wv (Qi W es Lk� on (�idQe 1CGc. �d�1�6Yu� WEore (moo _3 m; lee, 4 -ft t v ii rinh4 on Gu,a.1.SVL" L--Lrar IQJ' , 5+" d riy-e .c w. ovi -Hie L -Y' ryv . bf:p nc Date Property Flagged: , - •2 This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed I, also, und"and that I cm responsible for aU charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter Upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suiftabilitl DATE Cf` (— Lj (I SIGNATURE PHIS AREA MAI' BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property ines and dimensions, structures, setbacks, and septic locations). r w coy I 25AC. ,�- TR►� s N,�s ` C- Account No. :Q wised a� 511) (07198) ' yJFqf r• 1 Invoice No. St;E 8ack r' --41� t` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION Account #: 990000763 Billed To: Travis Cooley Reference Name: Travis Cooley Proposed Facility: Residence Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5706-89-2450 Subdivision Info: Location/Address: Foster Road -270213 Property Size: 28 Acnes Date Evaluated: `/ [o Community Public Evaluation By: Auger Boring / Pit Cut FACTORS l 3 4 6 7 Landscapeposition L Slope%IS-Cie j-2 HORIZON I DEPTH 0 • d -G - C "Texture rou S : C �� "' Consistence $ 5S C Structure Cie_ C c GOVIV Mineralogy 0 M L;0 m' x"o ovi x.�o : t HORIZON II DEPTH - to 6" - !p 1'7i - '? - S Texture group C_ - C S: Consistence i f t Structure k Mineralogy N`1x ' 2 I HORIZON III DEPTH - ?Z I -I% 1 d - -.6 Texture group C_ Consistence r C, Structurec 1L Mineralogy HORIZON IV DEPTH 24 4 - Texture rou Texture Consistence Structure Mineralogy 2 SOIL WETNESS RESTRICTIVE HORIZON 1 27- SAPROLITE - CLASSIFICATION 05,S uS US LONG-TERM ACCEPTANCE RATE O Z 2- 2 SITE CLASSIFICATION: �S l . �t� To l�c=� c EVALUATION BY: J Lr" 4► - LONG -TERM ACCEPTANCE RATE: ©• Z OTHER(S) PRESENT: REMARKS: <,04L.I-00 SCtL xMi. t:,-XrA A,& "AY 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 Moist 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 Structur SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineraloev 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/ft2 DCHD 05/99 (Revised)