332 River Oaks Ln a
• •-•- *'�' � .+ DAVIE COLJNTY ENVIRONMENTAL HEALTH �U` /1�ti
, P.O.Box 848/210 Hospital Streef �,�C�
-� Mocksville,NC 27028 J
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT -
Acco�ar�f #: 990005856 � . ;`_. Tax:Pif�f�H#: F90000004103-Site 2 ,
Billc�To: Mike Joyce , ; ;��uk��ivi�ior�:lnfa: �3Z . , ,
Refer�r�ce Na��e: . _ '� LocationiAddr�ss: RiverOaks Lane-27006 ' _ . �:�.;
PrapUser3 Facifify: Residence • � ',•�Pca��rty�Six�: Portion of 107 . - ..'- •
E�TC Nurnber. 5933 . ,, . . .,. ..._ . ._... ., . . . . : .
**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:�/Q�Q1'�b S.T�Manufacturer t0E Tank Date�� Tank Size�(j
Pump Tank Size � � Bedrooms: `'3
System Installed By: � V� � •4 Installer# Date:��
GPS Coordinate:
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Environmental Health Specia(is � Date:�
DCHD 11/06(Revised)
• ' '. ,.� '
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DAVIE COiJNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Accau�t #: 990005856 ,�.'��x'Pl�:EH#: F90000004103-Site 2 ' .,
BiEled To: Mike Joyce � : "Su�3divi�ior�.info: � . , ,
� Refer�r�ce Nanie: .' :�LocaiionrAddr�ss: River Oaks Lane-27006 ... . .
Pro�assd F��ility: Residence , .�,., ,. :: .`:., Fro�rer#y Size: Portion of 107 , - ;,' ..,
,�TC Nurnber. 5933 , . .. ��,:�:: ' . . .
Site Type: �Tew ❑Repair ❑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,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change. '
Residential Specifications: #Bedrooms�#Bathrooms�#People 2 Basement0 Basement plumbing❑
� Non-Residential Spec�cations: Facility Type #People � #Seats
� Squaze Footage(or Dimensions of Facility) �
Lot Siz d ' Type of Water Supply: ❑County/City �Well ❑Community Well.
System Specifications: Design Wastewater Flow(GPD)�Tank Size�(�GAL.Pump Tank�GAL.
Trench Width� Max.Trench Depttrl�Q_ Rock Depth� Linear Ft. �� (..���
.Site Modifications/Conditions/Other: ?,C�� O�cS�6 Kk�!(L7(�q
. Contact the Davie County Enviroamental Health Section for final inspection of this system between -
� 8:30—9:30a.m.on the da of installation. Tele hone# 33 751-8760.
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Environmental Health Specialist Date: O�
nrun i i m�ruP�,;�P,��
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AFPLICATION FOR SITE EVALUATION/IMPROVEMENT PERNIIT& ATC
Davie County Environmental Health �
��d.�P P.O.Boz 848/210 Hospital Street ('1/
� ,.` �., A Mocksvill�,NC 27028 ( 5I 1 b��
� � >; 1 � 2012 r
� (33�753-6780/Fag(336)753-1680 �,Q(J�
� -C "�' �
App1i�I _ _ � n/Improvement Pemut C�Authorization To onstruct(ATC) oth
Tvpe of Application: �New System �Repair to Existin�System ❑Expansion/Modification of Existin�System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI�REQUIRED �
INFORMATION IS PROVIDED. Refer to the INFORMATIOI�I.BiIL�.ETIN for instructions.
APPT,TCANT TNF(�RMATTON
Name 1 v 1,(�� �UC� Contact Person �!� Jc�H c e� .
Address 4S�p }-�� '�. �iome Phone f 3 3�0)�'i Z�(- Z-�5��'
City/State/ZIP W- D��- 2 l Co Business Phone (�)�('�2� 13�'j}
mail ✓ �o CQ S(o 00 .GO-Yr� �
Name on Permid TC if D�erent tha Above e
Mailing Address Sc�.z� ity/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged '7' /� �7i
NOTE: A survey plat or site plan must accompany this application: Included: ite Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no eacpiration with complete plat.)
Owner's Name ���I� C� �-fv� TG✓'r�-( Phone Number �3 3(.,���U-S9�}5F
Owner's Address I V�- N. {��r-,.�;,-� W G-f- City/State/Zip /�v�r•c..s� �pJC 2 c��o
� Property Address (Z i ver C�a.�5 �- _ City
Lot S ize Tax PIN# 1=-��00 0 0 0`�-E-(��S r�
Subdivision Name(if app icable) Section/L t#
Directi s T Site: , �Q 0 - (/ Gc �2L` �� �2
�2 5 i G�12� n/
If the answer to y of the following questions is"Yes",suppo ' g documentation must be attached:
Are there any existing wastewater systems on the site? _Yes�/No
Does the site contain jurisdictional wetlands? Yes 6,�To
Are there any easements or right-of-ways on the site7 Yes
Is the site subject to approval by another public agency? Yes
Will wastewater other than domestic sewage be generated? Yes o
TF RF,STnF,NC;F FTT.T,ni TT THF,RnX RF,T,nW
#People 2 � #Bedrooms 3 #Batt}rooms �. Garden Tub/Whirlpool ❑Yes o
Basement: i7�es ONo Basement Plumbing: �Yes +�To
TF NnN-RF,STDF,NCF..FiLI,niJT THE RQX�3EL<OW
T e of FacilityBusiness Total Square Footage of Building #People
�inks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: e'Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: O County/City Water �H'New Well ❑Existing Well ❑ Community We�l
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes i0'No .
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 appIication is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie Count}�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 stakin the po e/f ility location,proposed well locarion and the locarion of any other amenities.
Property owner's o owner's eg representative signature � Site Revisit Charge
� Date(s):
L�•l�'�2 Client Notification Date:
Date EHS:
� C�� �2 lti�3 � � �
Sign given ❑Yes ONo Account# ����
Revised 11/06 Invoice# JQ-=_ -__
GoMAPS - Davie County NC Public Access �: :
,�-.. `'� WATERSHED STRUCTURES
.i/`�Q�,� � 0 - -. =
���-� � ., — WATER BODIES � .
� � C�UNTY BOUNDARY
,�
r� : STREETS
I � ` � �a,��'�' RAILROAD CENTERLINE
�
� PARCELS
� CRY LIMRS
� SERMUDA RUN
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� �����ti � � COOLEEMEE
� � � DAVIE COUNTY
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� N10CKSVILLE
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—_ __�t,��„t,� � DAVIDSON
:0 DAVIE
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�\ �/ I ' Wednesday,April 18 2012
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***WARNING:THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map. .
-1 ;
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' � DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005856 -Tax PIN/EH#: F90000004103-Site 2
Billed To: Mike Joyce Subdivision Info:
Reference Name: • LocatioNAddress: River Oaks Lane- 006
Proposed Faciliry: Residence Property Size: Portion of 107 Date Evaluated: L �
Water Supply: On-Site Well � Community Public
,� Evaluation By: ' Auger Boring `� s Pit � - ^" Cut
;_ .
� FACTORS 1 2 3 .: 4 5 6 7
Landsca e sition � �
Slo % o _. ��. - 0 6
_ . HORIZON,I DEPTH C9� _' 6 �
�'`'Texture rou
Consistence —�' �
Structure - � C
Mineralo . ;I ;l
HORIZON II DEPTH -
Texture rou G -
Consistence : F/Z
Structure a�
Mineralo �; ,( t
HORIZON III DEPTH �{..
Texture rou
Consistence
Structure +
Mineralo •
HORIZON IV DEPT'H
Texture rou � �
Consistence ' •
- Structure -
Mineralo � . �
SOIL WETNESS
RESTRIGTIVE HORIZON � ,
SAPROLITE '
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �� EVALUATION BY:�' ':+i�� �'s �'�'�°�.
LONG-TERM ACCEPTANCE RATE: • OTHER(S)PRESENT:
REMARKS• _ �
LEGEND
i, nds a�e 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 ,
, :Te�ct� �
` `��v 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 . ,.
ON4I�T .N . .
�4]S.�
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 .
S�Lti�.tuL� •
SC-Single grain M-Massive CR-Crumb GR-Granular. ABK-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
�ineralo� .
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-gaUday/ft2 . DCHD OS/OS(Revised)
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� � ° ' �. •� Davie County Environmental Health
' � � � �� � . � P.O.Box 848/210 Hospital Street
Mocksville;NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005856 Tax PIN/EH#: F90000004103-Site 2
Billed To: Mike Joyce Subdivision Info:
Address: 4570 Havencrest Road `
Location/Address: River Oaks Lane-27006
City: Winston-Salem Property Size: Portion of 107
Reference Name:
Prop�c�'.��i�j�������c�ment 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: 91New �Repair �Expansion Permit Valid for: S/JS Years ❑No Expiration
Residential Specifications: #Bedrooms�#Bathrooms � #People o BasementG�Basement plumbingf8'
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 3 U Type of Water Supply: �Count�/City �lWell OCommunity Well
• Site Modifications/Permit Conditions:
S stem T e LTAR .
Initial Q ` GL 2 1.
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Site Plan
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Environmental Health Specialist • Date L' � /Z
i.p.l 1-06
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