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482 Powell Rd (2)Account #: 990004310 Billed To: Paul Gale Reference Name: Proposed Facility: Residence_ ATC Number: 4664 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital. Street Mocksville, NC 27628 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5718-59-7324 Subdivision Info: Location/Address: 482 Powell Road -27028 Property Size: 65 acres **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 systenl,will function s isfactorily for any given period of time. / .Z s�v'ri-- 4. 15ae& /A70 c> System Type: S.T. Manufacturer --k. 7Tank Date Tank Size Pump Tank Size System Installed By: � C "'A C, C� i E.H. Specialist, c Date: 7 -i o - o y C' l'. j % / 51 -C vvk ESC I' 1J( DCHD 11/06 (Revised) Oq U' Ou lc •CC. -- +•'� DAVIE COUNTY ENVIRONMENTAL HEALTH 1 P.O. Box 848/210 Hospital Street Mocksville, NC 27028�All (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004310 Billed To: Paul Gale Reference Name: Proposed Facility: Residence ATC Number: 4664 Tax PIN/EH #: 5718-59-7324 Subdivision Info: Location/Address: 482 Powell Road -27028 Property Size: 65 acres Site Type: ❑New ❑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 61 # Bathrooms y, 5# People � Basement R -Basement plumbing LY Non -Residential Specifications: Facility Type # People # Seats 1 Square Footage(or Dimensions of Facility) Lot Size �`�C �O{� Type of Water Supply: ❑County/City ❑Well ❑Community Well 12S-0 System Specifications: Design Wastewater Flow (GPD) 7 Zy Tank Size-�" GAL. Pump Tank GAL. Trench Width 36 ` Max. Trench Depth Rock Depth Linear Ft. Vo Site Modifications/Conditions/Other: As stated in 15.E NCAC J,9A-JPAq(F;) accepted vmem, m�tr iso hi use 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. C o10 Environmental Health Specialist DCHD 11/06 (Revised) � S.ctO7t� l�t�5 fit tysl� trG`n Jos`tst✓tµ� i T 0" -.,Jet e -e a.'- 140-ta ��0 r ut?-t✓ e.eu et Way too OW F1 ate: 2 7 APPLICATION FQ,R SITE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Health Department a-0 Environmental Health Section e P.O. Box 848/210 Hospital Street Mocksville, NC 27028 u 1 �1 c (336)751-8760/ Fax (336)751-8786 `, Alt, 0.,.r cement Permit Authorization To Construct(ATC) Both Apr, J ***IMPORTANT*** 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 -Fa v(,. kt, Contact Person �>t, C Billing Address _ .gZ {�ot.�7 - _-, _ Home Phone _�(o -_�f2 6..� City/State/ZIP A_Business Phone Mq— 5 �� Name on Permit/ATC if Different than Above3,316 7 ��� Yo Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey'plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Street Address—q(92 t?owSc.c_ AD „ City MOCKS Tax Tax PIN# 5-71g- -m` / Subdivision Name Section/Lot# Lot Size / p'X 3con Directions To Site: s E T _T'c rnA) i`Z-r1,,�► �- n . ) A. )(-)A , Date House/Facility Corners Flagged 0342 8 O 7 ' 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? ❑YesXNo Are there any easements or right-of-ways on the site? ❑Yes (No Is the site subject to approval by another public agency? ❑Yes�(NO Will wastewater•other than domestic sewage be generated? ❑Yes No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms q& Garden Tub/Whirlpool/Yes ❑No Basement:)Yes ❑No Basement Plumbing: 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: Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water Xi 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? <N0 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 of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules on the above described property located in vie Countyand owned by ?AA__ f4. (= IAL-fE lit c &k") 1 'ZI Site Revisit Charge Property owner's or owner's legal representative signature Date ;ven ❑Yes ❑No -d 2/06 Date(s): Client Notification Date: EHS: Account # Invoice # rY, � --- `� � , .u�� . . • � � •r� a�7.'Y.t1 �M�3' �",�� ' n� `. �� `.?"Jla � . .�. +1� n .;': , .c ... . .. . .�., 1 . r' � .. ,' � - �/ . . . , .���� .:.,::,. :..�_: . ,.,.,. ,'� _ •-. . 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I�14��',' �°. ,...�� �� '� 1 R n D 5i78 NN Rn C (as pan} 826 -- l 1 1 RnC j 3114 (2.74P) Z74 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004310 Tax PIN/EH #: 5718-59-7324 Billed To: Paul Gale Subdivision Info: Reference Name: Location/Address: 482 Powell Road -27028 Proposed Facility: Residence Property Size: 65 acres Date Evaluated: r`"--5 _Q % Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 3 4 -r 7 Landscape position Slope % HORIZON I DEPTH p— U Texture group C G C c Consistence r Jz`L r tik y Ilf-I Structure M 4 r ue 1 1 Mineralogy 1 "l 1 • t HORIZON II DEPTH Texture group L L L Consistence r d , f Structure 6e, 514 Mineralogy ,' % 1 t Z t HORIZON III DEPTH 36 -9ock 1 - Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE G'14.4 - a d - `f fl- 36, CLASSIFICATION CLASSIFICATION LONG-TERM ACCEPTANCE RATE p ; 6.7 SITE CLASSIFICATION: � _ S I-- A "k -2 - LONG -TERM ACCEPTANCE RATE: O •3 REMARKS: EVALUATION BY: � (I .Ll d%(,13 =i-_ e, r OTHER(S) PRESENT: LEGEND Landscape Position 1 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 CONSISTFNCE Mdq 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 Mineralog 1:1, 2:1, Mixed otes 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) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004310 Tax PIN/EH #: 5718-59-7324 Billed To: Paul Gale Subdivision Info: Address: 482 Powell Road Location/Address: 482 Powell Road -27028 City: Mocksville Property Size: 65 acres Reference Name: Proposed Facility: Residence **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: Clew ❑Repair ❑Expansion Permit Valid for: k!�Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms y - # People 41 BasementYbasement plumbing [4-- Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): �� Type of Water Supply: ❑County/City RWell ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial A. C -e WG. Repair c 1, 11O.3 i.p.11-06