The URL can be used to link to this page

1329 Ridge Rd (2) � ;:.. , ` DAVIE COUNTY ENVIItONMENfA.i.HEALTH , � � P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 •• .. � (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990003600 Tax PIN/EH#: 5707-16-6912 Billed To: David Plagemann Subdivision Info: Reference Name: Location/Address: Ridge Road-272028 Proposed Facility: Residence Property Size: 6 acres ATC Number: 4615 ' **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC l�as been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems," but sball in NO WAY be taken as a guarantee tbat the system will functian satisfactorily for any given period of time. �/ `a '7 System Type: � a� S.T.Manufacture 4a"� Tank Date'3 �� Tank Size r.6 C�� Pump Tank Size � System Installed By:' �a�{ V�c�C�«E.H. Specialist:��Date: � G �� i � `�6 � �o� � � � �a` � f . , Q1 -'�_ . � r � � � � cl' � `_"� ' jp �, � ,1, �. ,,- -r f � K \ . H � � � � _ ��,\ . � Q. � `P `,�---- ` \ / c�1� `�G� /" � —� �� c� . Gr I - �' 2� r (pl'� ncxn i iio6�x�isea� , - I ,1 * .. - - DAVIE COUNTY ENVIRONMENTAL HEALTH �� . P.O.Box 848/210 Hospital Street 3'�� Mocksville,NC 27028 . (336)751-8760 Fax#(336)751-8786 � AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003600 Tax PIN/EH #: 5707-16-6912 Billed To: David Plagemann Subdivision Info: . Reference Name: Location/Address: Ridge Road-272028 Proposed Facility: Residence Property Size: 6 acres ATC Number: 4615 Site Type: ew ORepair ❑Expansion **NOTE**This Authorization to Construct(ATC)MLJST 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,Secfion.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 !Z Basement❑ Basement plumbing0 Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size � � Type of Water Supply: �ty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) (c D Tank Size�p�AL.Pump Tank�GAL. Trench Width 3 G , Max.Trench Depth��Rock Depth �� Linear Ft. �� s stated in 15A NCAC 1�;A.1M'i�{5) Site Modificarions/Conditions/Other: �►cce�ted Syste�ns may al�a h�! used Contact the Davie County Environmental Health Section for final inspection of this system between � 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. � ..__ �� b �r _ � .i5 �oM !��M�,/�— _ �/ �� / �°' � �_`�``•`�/� _ ,7r / x 9"'`.�',�D - P.�4 'tkc.(c�5 ,3�, „ � $ �'�1�� - � ,�`hAx �tp��t � �o' f �o,`_ \� `�` � � ' _�y ltit;N.cP��7-�. � �\ � �� .a.. coK�Q�.� � 9�ad,� �,° . • , �� .,, s � t � �` D�� t, � - �, „ .� Environmental Health Specialist Date: �� Q � DCHD 11/06(Revised) • ,.._,._,,.. ;�. . oa .� � � ` ION ITE EVALUATION/IMPROVEMENT PERMIT & ATC D 006 Davie County Environmental Health DEC 2 7 2 r.0.Box 848/210 Hospital Street �a// �� Mocksville,NC 27028 2/_ /j 2 p RONME�p�H� (336)751-8760/Fax(336)751-8786 C��' ��Y � �lJ� J�7� � oAwticouNn App ' or: Site Evaluation/Improvement Permit �uthffriz�ti O To Construct(ATC) ❑ Both �1�� Type of Applic ion: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility `�' ,��iocJ ***IMPORTANT'`**THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED �� K INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instnzctions. ' �G(� APPLICANT INFORMATION �� Name to be Billed J� � Iv � Contact Person /�/t�l � �`� Billing Address ' ' l Home Phone��y �a 9 y3 '� City/State/ZIP �/� . O Business Phone �/�y y6�3.� - �J�74-. Name on PermitlATC ifD�erent than Above S�G}'V11.� Mailing Address City/State/Zip PROPERTY INFORMATION �` � �� *Date House/Facility Comers Flagged � �?7 6 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is v lid for 60 onths with site plan,no expiration with complete plat.) � Owner's Name � � Phone Number �6�}'Y1� Owner's Address City/State/Zip Property Address City ' Lot Size (Dl90Q�5 Tax PIN#5��/�- Subdivision Name(if applicable) Section/Lot# Directions To Si Y�: (� �- P (�dN ,(1�;�F ��'Ii�� Z� oN �Z,q h�t-. .. If the answe to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes 0'�Io Does the site contain jurisdictional wetlands? ❑Yes H'lffo Are there any easements or right-of-ways on the site? ❑Yes 93Qo Is the site subject to approval by another public agency? ❑Yes 01�0 Will wastewate�other than domestic sewage be generated? ❑Yes 03Go IF RESIDENCE FILL OUT.THE BOX BELOW " #People �#Bedrooms #Bathrooms �-. � Garden TublWhirlpool ❑Yes �o Basement: DYes o Basement Plumbing: ❑Yes 0'140 IF NON-RESIDENCE FILL OUT THE BOX BELOW �� ,rType of Facili.tyBusiness 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: �onventional ❑Accepted �Innovative ❑Alternative ❑Other Water Supply Type:.F�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 ,�'�10 If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my lrnowledge. 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 applicarion is falsified or changed. I hereby grant right of entry to the Authorize�'Representative of the Davie County Health Deparhnent to conduct necessary inspections to determine compliance with applicable laws and rules. I understan that I am responsible for the proper identification and labeling of properiy lines and corners and locating and flagging or sta 'ng hous f ility location,proposed well location and the location of any other amenities. '/ � � � ��~—� � , Site Revisit Charge • Pro erty er's or o er's legal representative signature , Date(s): �� ' � Client Notification Date: Da e EHS: Si n iven �Yes �No Account# ��_ g g Revised 11/06 Invoice# ,�gg�_ .� - ��' �! � ^� `r ri�� + t� , � s:� � �, .F i � � _ F K �� !�� j � �. y ti� ° � � � � 4 � �� S � � 1 i �t ��Y� �: t '. _ -0„ � � �i r I ( �� f� ,..�. .� A F � �t � " �� t ~ ." . � o,L x" k V ' k � , 4 y � T �: �� ~ 1 � � ' _ Y 5 ) 3 } fl E�: {��a' II' � \ N( � � ' �F � � �; ' � ��i: ` � -' � .f,+ I ��_ ..f:. y d � _ , y ' ` t , , - ` � �!''` - 'I r � 1 p � � � ' �v L a z. q wF .. � i ui ' ' r P �_ n ,� 5� i �� . i9�.� ` '� I x :'L�96 � ':` � .�c :. : � � ¢7 - � v� � ��,-. �.�..'- ' � ,y�- I� �a, t� " -`' `�� ° �7 �� I � '' 1_ >� �SW l� .' k � s6 ` ,;" �= —.�_ :_�,,:�.�"`„ �, � _ �hl �S � �� 8890 ' ��,� � � �1�, U �� .(do5 z? � V � � �� k� . � — — — � � _ _ A. � I a' ' � . ':'- � _ � / � ^ I^I \ W _ _ _L � I 1l� `i a,�\ � i �I S ^5.1^' p> � � _ _ _ _ _ _ _ _ _ — _ I O„ . .J V V J ��\1 �� v�;1 I ' - 3 '� 4��' z �69 � �� : � � � � �s ra:. ,�,�*� � �r � �. "'`7' �,'F`�'�� 5� S o � �� * ' 'r.: k '-n f ai . � �j' /1 �/�� , .fF *: v�..i_. Jt 7 ., Z-��Yy�xlA (�u.... �J YV �.k�F �a '"�i4`F '.� '�,� �Sw `V 4 x ? � < �',��q{ �_.... �Sw : �J a � � (s� � �� z8a� � �� , � ` �;`� /2��j ��. �� ` zea� �. ; � � �� y �� . . . �ri . 0 m s�� '7 /� .� . . � (+t4. ::� r z > _ �'�� hJ Ci�aJ _ � .�>, . �OG � z � k , ,` Y F �� O'6� r � �`��`l � �� 2s� �i , � �Y/99'E) r � Q�:. y � set - �� _ , � ` ' _ - � k : ,� .��oz>, � � � yr q � ` ` � 6£bL i ,r�� ,-��.— -a a� E858 y, ; , ,� z (b'6Z 4)` " � a�:' I.. �' Y'. K.� 1� :_ - ,s. > a t :� ' `<�t/9L �) N� ` , , r,�v;� ..�_ E ;- �" �, l t P � �j �� V� C` E�. � i.�-...+� - �l -- r �£ . l�'.�" h.�t ',yJ �::'s r 7 r , 'i,,� -`c y:J . .; - :'� s; ;.f;> zr x . �' - .: � �.V ' r : . � ' s 3 ��f t .. • . ¢ a Pt � .': �7'� r in 4ll ::��1 9'� . . �. . � n� . �� ' �. • ' " ,. ,c • J DAVIE COUNTY HEALTH DEPARTMENT ��' � '� Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003600 Tax PIN/EH#: 5707-16-6912 Billed To: David Plagemann Subdivision Info: Reference Name: Location/Address: Ridge Road-272028 Proposed Facility: Residence Property Size: 6 acres Date Evaluated: �- ��2'�� , Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition G L L G Slo e% � �� - HORIZON I DEPTH C� - � -y Q- - Texture grou L G , Consistence Structure �' �� Mineralo ' l �� '�k �" 1 � \ HORIZON II DEPTH Texture rou Consistence Structure Mineralo HORIZON III DEPTH ' Texture, rou Consistence Structure • Mineralo HORIZON IV DEPTH . Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE � .Z — ..Z � SITE CLASSIFICATION: d Vj L�p EVALUATION BY: �,�.��Y3�.r� � �LONG-TERM ACCEPTANCE RATE: � • -Z 5 OTHER(S)PRESENT: �l•�� U I�c ,�� ' ��e� REMARxs: LEGEND i, n s ,pe Position R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Tgxt�lLC . 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 _ ONSI4 .N . . MQ]SL 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-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed �� 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-gaUday/ft2 . DCHD OS/OS(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 #: 990003600 Tax PIN/EH#: 5707-16-6912 .Billed To: David Plagemann Subdivision Info: Address: 1329 Rid e Road � 7F 9 Location/Address: Ridge Road-272028 City: Mocksville Property Size: 6 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. � Pernut Type: C�ew ❑Repair ❑Expansion Permit Valid for: WS Years ❑No Expiration Residential Specifications: #Bedrooms��#Bathrooms�,�#People�Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): .3�-� Type of Water Supply: l�'County/City ❑Well ❑Community Well � Site Modifications/Peimit Conditions: S stem T e LTAR Initial Q.a 3 Re air F.e_ �� Site Platt $3d � " . ,o c�a �+,j J r�-�a�N' , �__ �01 ' � � � . � � �i . -��Q`� F � � A -� d }�r-� li t � � � '3 Q ' 'y _, � � �csr s.e,/�� C ��t� " T � "� 1'1 S �� z-�, ,�;� ( n . � �, Q ,� �� t� �; � ,� , � � ; . _ _ ,� �� , ,. _ �,� Environmental Health Specialist Date� " �3`-U� i.p.l l-06