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566 Merrells Lake Rd � � . . . � � , � ' ' DAVIE COUNTY ENVIRONMENTAL HEALTH • . , - . P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT �ccount #: 990003931 Tax PIN/EH#: 5768-45-8312 Billed To: Kurt Musselman Subdivision Info: Reference Name: Location/Address: Merrells Lake Road-27028 Proposed Facility: Residence Property Size: 11.99 acres ATC Number: 4976 **NOTE**The issuance of this Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A,Section.1900"Sewage Trearinent 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:„� ' �;'�, } � ,�Manufacture�,,� Tank Date . Z�' Tank Size /l�, �C Pump Tank Size� � System Installed By: Lc; � c��e E.H.Specialist: ' � �,�ate:-���t`-= �� tl �10� � ��Q�. � � �� � �, , /� '� i � �� ' I U\ / � \ � � ��y� ��� � - �/, (�` �^: y�� � � \ C.\ 7 . J � ����f - � � __._______.... ._...----___ �_ ��373� DCHD 11/06(Revised) ► � • I � . � . . / V'1 . r. r ' ` � �, . DAVIE COUNTY ENVIRONMENTAL HEALTH .�7 ��4�� ` ' P.O.Box 848/210 Hospital Street / Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003931 Tax PIN/EH#: 5768-45-8312 Billed To: Kurt Musselman Subdivision Info: Reference Name: Location/Address: Merrells Lake Road-27028 Proposed Facility: Residence Property Size: 11.99 acres ATC Number: 4976 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 pernut(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 asement plumbing� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) GLot Size—���—Q'G/.CS Type of Water Supply: ounty/City ❑Well ❑Community Well � System Specifications: Design Wastewater Flow(GPD),,����Tank Size���GAL.Pump Tank���GAL. � �- �� „ �3 � � Trench Width�� Max.Trench Depth� Rock Depth �� Linear Ft. ti �s s'i�ted in 15A NCAC 28r�.1�J69(5} � � Site Modifications/Conditions/Other: ����trd Syut+sm� rn�/ aisu bt u�ed � /� Contact the Davie County Environmental Health Section for tinal inspection of this system between / I 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. 1 R�a .. � � ,� a,,� G � r � �fl�se�� y , � � F �� t 6 ��� t _r�5 1 a� 2� 3 � � fi ����J� r,- fi �?o � � 3T3 Envirorunental Health Specialist G - Date: � � "] �� � DCHD 11/06(Revised) . � 1, . ' � . . � ' � �A���-�fiI ��,. � OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC ��`� ��`� ���}���� Davie County Environmental Health � " .� � 20�9 P.O.Box 848/210 Hospital Street ���� Mocksville,NC 27028 • ,1 �����t� ' (336)751-8760/Fax(336)751-8786 `� � ��:R��f������y�y+:l� �Applicati�n FHr• rte Evaluation/Improvement Permit �Autharization To Construct(ATC) ❑ Both ype o p ication: C�ew System ❑Repair to Existing System �Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORhIATION`IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed_�1�.*�— J�'lliS��`�t� Contact Person Bilfing Address�{ � .g� �g 3 Home Phone ?� �Cc,—�•Z.,�j / " �/QGi City/StaXe/ZIP�b� _ � Z7D zg Business Phone Name on PermitJATC if Different than Above Mailing Address City/State/Zip - PROPERTY INFORMATION *Date House/Facili Corners lagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name �fL�— �- �u.Ssc=lrye��! Phone Number �- 2��� la�' Owner's Address�D. Q��-x f�� City/State/Zip Or tr� stl C ' Property Address City . Lot Size �; / rr��, Tax PIN# �� Subdivision Name(if applricable) Section/Lot# DirectionJs To Site: (, y1�S •��c� 0 P� �C.e .� ,l�.�Q�/� rc, dn�—�� G�QiU.�L cr.Y� �.t��.. � 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 Q1�To Does the site contain jurisdictional wetlands? ' �Yes.s'1Qo Are there any easements or right-of-ways on the site? ❑Yes.,�To Is the site subject to approval by another public agency? ❑Yes,�To Will wastewater other than domestic sewage be generated? ❑Yes,01�10 IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms #Bathrooms_� Garden Tub/Whirlpool ❑Yes � o Basement: es ❑No Basement Plumbing: �s �No . lF 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�ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ..�f l�o 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 pernut(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 detemune 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 sta ' e house/facility locati n,proposed well location and the location of any other amenities. Site Revisit Charge P operty o r or owner's legal rep sentative signature Date(s): 7 � Client Notification Date: Da EHS: Sign given �7Yes ❑No Account# �a�, Revised 11/06 Invoice# _�"A� _..__. `-`-- _�__._ ��1=� i!!'r I�f.,f�Nifd�)"; ='PCf'("Rl`i _ ._ � V. MANNINC� �� � _ _ _._ _ �-�,, I ���f< i�a, i��n�;r� ;����� AI' I I lAX LOT 5 � `_� U 1 °30`0'J"E� � 1 ;�_�a � ,a�� ,«c���; t>;�f �;F i n � ,. 3.U�- . ;,'; , , ;�_ F,F F�oni� � rr 'J f(;''J},.t r (?AU C�'I • � � j�, � �� �__ _�� � ��7 _ � t.C.F ___._._�.___,..___..__._ ..�---_.�r...___�_..__ � E C5� � ���'�� k�� �(��� ,-�� _....__�____.— �--� ��.,� .�_..__._�------.. ..---____.._.._..__----_-----_.___� �.. S C}1 "3�°C}Q"E. 459.�3° ----- — ; ; ,, ,' ` �i i �� C ,� � , � 1�. �.� , � [�I� � �F`T� �;3" IRnN PIfiE SE�i h7 > > •.Jc3 I 'u, �I � . �,OIITH tDGE C')r THE f3RANCH ;_��4�"<n r�1 �� NE':W t ii� (;ORN"t:R x- r, � � � � N�:�� t�C� i ".�'` h, ►� ' � { (),0� �� ;�C'I2�,; - c��'�, � � n�J ����r� (�j, � �J � +` • � � �� +` 'ER�iY ,�� � ���" - i �i''� � rn ,. �SEIatif;^�"� ,a� ��� `'��`�� it '� _ � PA�:, �, � �. _ �, ����a� LOT ����'� �� .� � � � s � ;0�� ��C�1'�,}':�� �`J �; :). l 00 f� �tI `� , 3�K ��?� .�, � �� .� �. !',C� `..y i I �- � � � Q7 �, '3'� �n tf7 � Q � z __� m cD ; I � f�-t o � ; �, � �. ;,.� r`% ; [k� 't N `.ti i � �� � �� r.� • .-y.� . � .�'��� ' '>��sa � . ;:.� . � , e�-�i �r ; �� �, � o ��C` 1 /-} _ � �� �J,�_ ���,'7�'+�-�, ; �� � e �i� �E'N ; �r _ - ' T U 4r��,l,J`i- ��. I�, . ! i"'w — _ ,c � ' �'iry . u �_'�� � !E' �'-- � , � -� — ____. � '�F��w � �, r� ���r�- �� . _.� �. �' � ' C.l�'.a � ... `c�i; i � . h'.,,�, � � . 1.._. ih �� �- . . �-_- _. l � N� � � •i _ .. . ,��; � S C� , , � _.. _ ., , �, _. _- _ �, ,_, __._._ . _ , ---____a_ _ , i -••-- -. ,' ; r,�� a� p� j �- . 1:�.� , r.. . , __ i �@ , I`� � o�� � _, c�_�____. '�J(� �(�_ r�� � � �� �J �% �! '�{ �Z ,/� ��f nr � � �, � �-� rrtr i - ` �S � g��, 15= _ ____ -.. <' co _ _ rtai�iF i, ��a� A �,� <<, �i i�i ini , �'ii., , - ;—____. <' � i F ->, �__ ! ;.� c ;,�.i �:i4y Ic)UrJl�nr,Y "!}� r<r � �, ' "�� II r,: _.�„ __._...__._._� i: �..-- c* % �....... ,._l; ,�, `, , .� 'v'fV�l `�; i�.;i� f'!`" �cr; � i • � ?,r� ��c. �:�,q .t�J . ',. � , i �•��t ) � f �',���� , �� ���� '1���,j� ���_r�:+�a (;����.�`7 �' �)�'� '��`.���` T.,t,?'� ' �3' � '� � � I I �( )It=^ j/Ffif � !.){ 1'`) ' -�'� � �'`� �.�..� St'.�� i�.. I.. •I ! .. ,. 1 __ WttL1AM5 RUAD FiEVIE1M __'--�.._ _ _______�_____._.�_., I:� 1J� 1 1.� aert�fy�t# "No Approval fteyuired by the Davie County Pianning Department" meets t� � _- � -� H <,' riwr aU;� � Na crrEt:N ( APprova i!c:)A,li ! �f Kf241 i S ; ________,._ ---- � `,. �AKF RL; _.___._. ._._____.._. ..__.___...._ ..----,---- --..._._._.._..___. �. ', Planning Director Qat� �"s � ` i` Not th� ; , � � , ; ' i ` - _ i ,.� ., _, ri'rYi fi4 � ,� � � y y / ` _ �=7 � �" � �� :� LOCATION I�AP = (r�oT ro sca�E) � � � --` --- -- � ,,,� I -- - � - � � � - W . � - � � �� � � � ,� NOTES: : � � 1. THIS PROPERTY �S SUBJECT TO ANY AND AI.I. ftIGMT{S)—QF--WAY AND ; 4 � OR EASEMENT(5) WHICH MAY 4Ft MAY;NOT R� 0�" RECORD A�a OF"'YHE � ',, � DATE OF THIS SURVEY.AND MAY NOT;8� VISfB�E Uf�ON TH� Gi�QIlNt7. ,� q, " ' • 2. FOR THE BACK DEED REFERENCE �OR 7HIS PRQPERT`f �a��.L���D �OOK � 174 PAGE 47 ,(KURT A. MUSS�L.MAN'S PI��S�NT Q��D) 1.5" IRON PIPE FOUND AT-� : THE N.W. CORNER OF THE f � • ' • 3. THIS PftOPERTY IS PRESENTLY ZONEp R-20 R-A MANNINO PROPERTY DESCRIBED � � IN D8. 144, PAGE 285 Y ' . �� " PROPOSED CONVEYANCE FRO M K U RT A. (CONTROL CORNER) � j� � 4. NEW LOT A IS FOR A � r.� • MUSSELMAN TO JAMES V. MANNINO. _ � }�' , � • 5. NEW I.OT "B" IS TO B� RETAINED BY KUftT A. MUSSELMAN F'OR � . � A NEW HOME SITE - .. , �,,,� - � ��� , ; _ .� ._,. . ,,.,...� .� ._„�.,.� n�=��,.l��"'�,..,����.<.� �, '.w�s . _T . . ' � 1 s � _ ., �I:�P�IC�T� �� � R SITE EVALUATION/IMPROVEMENT PERMIT & ATC � �,�n � �---�`'� ''! Davie County Health Department � � .1 1��, �:::.�.--..� O4 '.,���� � Z��� �, Environmental Health Section ,V� •, �;��.`� �f.,� 2 •� P.O. Box 848/210 Hospital Street �j�, �,'�'�j '�., t: L� Mocksville,NC 27028 �av��pa�E�N� (336)751-8760/ Fax (33�751-8786 A licaf ; �'!'�ite Evaluation/Improvement Pemut ❑ Authorization To ConsWct(ATC) ❑ Both ***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed !L�t �- � l�.tiss.����,., Contact Person Billing Address i� c� Home Phone 9o�J - 3.�� R, City/State/ZIP 1�'Co r�s J,`1 L,� L- z7d�3 Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip - PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Pernut is valid for 60 months with site plan,no expiration with complete plat.) Street Address I�i n.-r-«jl�c �s 1 lZ�, City��,%� Tax PIN# ���S�,'31 Z. Subdivision Name Section/Lot# Lot Size Directions To Site: �'rnw�, �_ L.e-��cr,•� a Crd, Zc� Z;� L.. c-,� l�t f,-�1 s LA,lc.c� . F:rs�' �'.�.,4�rb v�l �7.--�a.� '1-�i-;✓�c c�i.. C.��-� ���a x Z So�,a►s Date House/Facility Corners�'lagged 3-Z9-d b If the answer to any of the following questions is"yes",supporting documeritation must be attached. Are there any existing wastewater systems on the site? �Yes E3�10 Does the site contain jurisdictional wetlands? ❑Yes C�o Are there any easements or right-of-ways on the site? ❑Yes C�o Is the site subject to approval by another public agency? ❑Yes C-I'No Will wastewater other than domestic sewage be generated? ❑Yes C�iQo IF RESIDENCE FILL OUT THE BOX BELOW #People � #Bedrooms 3 �Bathrooms �3 Garden Tub/Whirlpool es ❑No _ Basement: �es ❑No Basement Plumbing: C►�Yes ❑No 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: 1sConventional ❑Accepted ❑Innovative ❑Alternative �Other Water Supply Type: ❑ County/City Water G"New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes M 1�Io 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 pernut(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 inca�rred fi-om this a�plication. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to dete �ne compliance with applicable laws and rules on the above described property located in Davie County and owned by 1�u�� /�/�,�,,, !''�..���..�— � / Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 3—Z g 'Z�b Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# J !3� Revised 2/06 Invoice# �4��" Davie County,North Carolina Spatial Data Explorer Page 1 af 1 . ,. � � . ,. ....� g�� ���.GS.a� ,.. •• �. (13.�Sk) i t��37 ;E €1Q.i�d�3�; • .� :;.,. :55� '�. 'z � E3�� ..� {''' �. :� �;' � . � � � . . �>,i. «:> �: ; . . . 4 �`7 �� �` �j �3).9 V�� '� . t 8�1� � .,._�� f � • � l�o„Vc:.r �'�-+`, s��. ` ��i :��.L;� �t . \ � �7���5834� �: r9 '�'<f�� � � 1 > -:�' �\ 3 �i �'��Y.[4 % `� 5 � 3 . �;:,� ., . ;.: �� r,�� � . � :s��: :51,a�� � � � � � � � �: i � �`, � � � �� . , ��� �,�;,,,,,.::.. ,...... ;;' ;. 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' ' � Soil/Site Evaluation � APPLICANT INFORMATIOIV PROPERTY INFORMATION Account #: 990003931 Tax PIN/EH#: 5768-45-8312 Biiled To: Kurt Musselman Subdivision Info: Reference Name: Location/Address: Merrells Lake Road;2�0�� Proposed Facility: Residence Property Size: 11.99 acres Date Evaluated: �� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring �' Pit Cut � FACTORS 1 2 3 � 5 6 7 Landsca e sition �... Slo % HORIZON I DEPTH /�- /i/9� — (' Texture grou e Consistence Structure Mineralo � HORIZON II DEPTH " ��j�� Texture rou G Consistence �'i .(� Structure ,S �� ..s i Mineralo .-/ HORIZON III DEPTH y ` �" Texture rou � r J�� /J�/ Consistence G ,sG Structure /� �/� Mineralo /.�/ %' HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS �, RESTRICTIVE HORIZON �� SAPROLITE .,/� CLASSIFICATION LONG-TERM ACCEPTANCE RATE �/ , y ,, a SITE CLASSIFICATION: �� EVALUATION BY: �`�� LONG-TERM ACCEPTANCE RATE: ' �r OTHER(S)PRESENT: REMARKS: ��O �Ud✓�`/�S — LEGEND � — � l� ,� � L�ndscane 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 S:ONSIST�.N E �415� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm �'eI 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' � ! _ Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)'`751-8760/Fax (336) 751-8786 , � - April 12, 2006 Mr. Kurt Musselman P.O. Box 162 Mocksville, NC 27028 Re: Merrells Lake Road T�Pin#: 5768-45-8312 • Dear Mr. Musselman As requested, a representative from this office visited the above site April 12, 2006, to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. ' 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 or the intended use change. Improvement Permit System To Serve: ;��itG'���C�� Wastewater Design Flow: �l%?� System Type: `�Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other System Locatio�• � ���ZiZ L � �•� �� . /�; f�'c�at Valid: �1�'ears ❑No Expiration '�� �� '1'Ic:��vl �.j /2��k� - Site Modifications/Permit Conditions: ���C� ''��• � /2- �� Envirorunental Health Specialist Da e ps-i.p.letter 2/06