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342 Salmons Rd � , DAVIE COUNTY ENVIRONMENTAL HEALTH . M , P.O.Box 848/210 Hospital Street , - � ' - ' _ Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT ' . �ccou�t #: 990005184 '��x Plh€fEH#: E00000051 8iflc�To: Steven Yountz Sufadivisior�'lnfc�::�. Refer�E�ce Na�ie: � LocationrAdc�ress: Salmons Road-27028 Pro�os�d Faciiit�: Residental � P�operty Size: 10.01 Acres � t�T�'*'���`T���s3uance 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:_,�S.T.Manufacturer ��,v� Tank Date_1� Tank Size c�o Pump Tank Size � � System Installed By: E.H.Specialist: Date: 2D/L GPS Coordinate: , � , l . . �� t'N � ��i , �1,0 6 . 0 a ,� - . _ � ,. DCHD 11/06(Revised) E— -•, DAVIE COUNTY ENVIRONMENTAL HEALTH . ' � ` P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �cc�u�t #: 990005184 �'�x PI�[.%EH#: E00000051 BiEle�Ta: Steven Yountz Su��ivi�ion Info: Refer�E�ce Name: _ Loc�iioniAddr�ss: Salmons Road-27028 Prnposed F�cility: Residental • -� � P�o�erty Size: 10.01 Acres > � � - �TC Number: 5875 _ Site Type: EfNew ❑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 FIVE YEARS. This ATC is subject to revocation if site plans,plat , or the intended use change. Residential Specifications: #Bedrooms 3 #Bathrooms eL #People�Basement�Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) �y r2c�J . Lot Size . A.G�� Type of Water Supply: ❑County/City �VVell ❑Community Well 2 od . System Specifications: Design Wastewater Flow(GPD)7� Tank Size�GAL.Pump�Tank�GAL. Trench Width��Max.Trench Depth��rRock Depth •� Linear Ft.y34• A� stated in 15A NCAC t8A.1�89(5� Site Modifications/Conditions/Other. �+„�pn,T=gd ��Cat€m� �}�,��Isa be t�s� Contact the Davie County Environmental Health Section for.fnal inspection of this system between 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760. '. 1�-f 7—�/. � ` � - � { . � �_ .��/)pl�' /�/'P!� ��� , r � _ . � I \ �. J ' . .. � � ... �, �r///! i I�.�' �l ' _ � ' � . � . o � _r �� [�o' � Aebr. . 1?5 ,��- p� �( � ���� 3�ar j ...__y� i �'w Q � � ) ._,__ _ , I �, 7-�'f — .�- ' �" y � �_ ._.. -- �i - —� � � �i-- IG � �,e.11�c�e t34o . Environmental Health Specialist � �i:!/ Date: � —� r�o� DCHD 11/06(Revised) . ' •_ . - .' 1 . . . . . ' . .; '` ', '', � � I�avie Counfy Environmental �ealth ' P.O.Box 848/210 Hospital Street • Moci�sville,�IC 27028 (336)751-8760/Fax(33�751-87�6 INIPROVEMENT PERMIT � �b0000a51 � Account #: 990005184 . Tax PIN/EH#: 5801-56-5426 Billed To: Steven Yountz Subdivision Info: Address: 220 Pine Forest Lane Location/Address: Saimons Road-272028 City: Mocksviile Properry Size: 10 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 --� �-- constr-uction/installation.o£a tvasteiYater system or the issuance.of a building ermit in com liance with _. P . -�-- -p_. Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is svbject to ��� � �� -'. revocation if site plans,pIat or the intended use change. Permit Type: ew ❑Repair ❑Expansion Pemut Valid for: Yeazs ONo Expiration Residential Specificationr. #Bedrooms ` �Bathrooms��People�Basement0 Basement plumbin�❑ - 1Von-Residential Specifications: Facility Type �People �Seats . Square Footage(or Dimensions of Facility) • Desig�Flow(GPD): 1 �� Type of�'ater Supply: 0 County/City C�Vell �Community Well Site Modifications/Permit Conditions: �s ��a�� ►n Z�,q 4�r�C .�$ri.�.gE •� . . - b. >. , . Q�7 � :lg8 , S stem T e LTAR Initial oc 7�� . a-�S Re air c� y c .�'� , Site P1an . /L/Z3.4 ti � . � � . , � � � . �� l � ,� h I �{ (� a (�,:��P;/ T'tf.ea � � � . � ���o, b ,�°, t � � � ,o 0 1; �� .�H•��•��� s�c p y:c. � I �r�� . � �_ - — I � ��'►�IoVI.�� ����c }az4.y� a'En�•K 1 0� -Y`-r, —, cv �� � � = — 3.�r.�� ' ��3 �'o Q r�N s �a . Ennronmental Health Specialist Date f l�l/� . ., , , . M . c '�' ��� ' /��l��i ' . \./ � IC�A2�O�T�F SITE EVALUATION/IMPROVEMENT PERMIT & ATC �� Davie County Environmental Health P.O.Box 848/210 Hospital Street eY. -- Mocksville,NC 27028 � (336)753-6780/Fax(336 53-1680 Application For: ❑ Site Evaluation/Improvement Permit uthorization To Construct(ATC) ❑ Both �� Type of Application: ❑New System ❑Repair to Existing System OExpansion/Modification of Existing System or Faciliry ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TH�REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. , APPLICANT INFORMATION � Name S'�cuL,� (bv��'l�"Z Contact Person l' Address a2 0 �i n �/tst Home Phone y y? -2 g5�/ � City/State/ZIP Moc.ksv; � NC . �rJO2g BusinessPhone ��6-S8o-/9g�3 Name on PermidATC if Different than Above • Mailing Address � City/State/Zip PROPERTY INFORMATION *Date House/Facilit Corners Fla ed NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit�is valid for 60 months with site plarr;no expiratiori with complete plat.) Owner's Name__s�c%r� �/ovt✓y�'Z Phone Number,3',3�SS�'/9�o Owner's Address City/State/Zip � Property Address $'a/n,onS /Qo City /�a.kS�,'//.� Lot Size JD a�iLs Tax PIN# Sg0/-Sb-S�/2( Subdivision Name(if applicable) Section/Lot# � � Directions To Site: n�;vt f- en�l � Sa o�s oq ahc� n�w d�;�-�'Ati is on le��. , . If the answer to any of the following questions is•"Yes",supporting docu�ntation must be attached: Are there any existing wastewater systems on the site? Yes V No Does the site contain jurisdictional wetlands? �es �io 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 ✓�To IF RESIDENCE FILL OUT THE BOX BE�OW � � #People �_ #Bedrooms �_ #Bathrooms 2 Garden Tub/Whirlpool O�Yes ❑No Basement: ❑Yes .�No Basement Plumbing: ❑Yes .�JNo IF 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 system requested: �d'Conventional ❑Accepted ❑Innovative OAlternative- OOther Water Supply Type: ❑ 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 4'1 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 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 determine compliance with applicable laws and n .�I understand that I am responsible for the proper identification and labeling of property lines and corners and locatin fla 'ng r ing th e/facility location,proposed well location and the location of any other amenities. � Property owner's or o r s e al representative signature Site Revisit Charge Date(s): ��22.��2 Client Notification Date: Date EHS: Sign given �Yes ❑No � Account# � o ' Revised 11/06 ' Invoice# i . , .� .-..� � , � , DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION L'ROPERTY INFORMATION Account #: 990005184 Tax PIN/EH#: E00000051 Billed To: Steven Yountz Subdivision Info: Reference Name: LocatioNAddress: Salmons Road-27028 Proposed Facility: Residental Property Size: 10.01 Acres Date Evaluated: ,�j�5� ^/ � � � Water Supply: On-Site Well Community Public Evaluation By: Auger Boring `� Pit ,� Cut FACTORS 1 2 3 4 5 6 7 Landsca e sition L Slo % HORIZON I DEPTH . p � 7 Texture rou G C 6'i Consistence � $ Structure � E Mineralo ^ HORIZON II DEPTH �7 � Texture rou G v Consistence � Structure � 4R Mineralo " Q HORIZON III DEPTH ' Texture rou Consistence Structure . • � Mineralo - � HORIZON IV DEPTH Texture rou � Consistence Structure Mineralo SOIL WETNESS . / RESTRICTIVE HORIZON � � SAPROLTTE � CLASSIFICATION S , LONG-TERM ACCEPTANCE RATE .Z �. 7 • SITE CLASSIFICATION: �_ 2 Z EVALUATION BY: ' �d ' LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: REMARKS: S J>C ✓ G�' i�) l ' ✓Y� �< �j�': LEGEND �,I'T T,an s ane Position R-Ridge S-Shoulder L-Lineaz slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-F7ood plain H-Head slope T�ctul� . . 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 �415� VFR-Very friable FR-Friable FT-Firm VFI-Very firm EFI-Extremely�rm ' � � NS-Non sticky SS-Slightly sticky S-Sticky � VS =Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S�Tll�tuL@ ' SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky , SBK-Subangulaz blocky;. 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■■■■���■����■����■■��������■��■��������■���■�������■�■���■fLi�l���■ ■■����■���■�■�■■■��■���■�������■ ■�■■�������■���■�����������k►■�� ■■■■�l��S��■�■■�■����■■�0■������■■■�������■�■�■����■■�■����■�■��i+% ■s■��■��o�■■���■e����■��■■����■■�■��■�s■e�■����■�s�■�e■���■■�a■�►:� t ^ ; � � -. � � � Davie County Environmental Health P.O.Box 848/210 Hospital Street � ,.f Mocksville,NC 27028 ,.: � (336)753-6780/Fax(336)753=16$0 WELL PERMIT �cc�unt �: 990005184 i"�x€�l�f.%EH#; E000000��1—i�IP,�� , ;. ,,, -- ,,,_, Billcd To: Steven Yountz - , ; Su�di�isiar� lnfc�::: ` ' � Refer�r�ce Name: ': . ` ::.LocatianiAddr�ss: Salmons Road-27028 ` � F'ropt�s�c9 Facility: Residential Well . � . . ° P�'���r�y Siz�:'.:���0 Acres . , _ . �TActi�ons of�the�mp�oyees of the Davie County EH Section shall in�no way be taken as a guarantee thaf this well will produce water of any particular quantity or quality or for any amount of time. This permit is valid � for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New�r Repair ❑ Abandonment ❑ Proposed Well Location Diagram Certificate of Completion Diagram S eP�`v � ��° - ., �c _ ,' ' � ! _ _--!' � � l j , - �a_ - � �� I � ��--f � � — � � ���� \` �� �' (�� �, � , w � — — — � I � ..�..� Comments: �. � Driller:� ,/� ��,,t �o �r r S� �� c.�c���r��� ��u�� �Or ' � �4r�:C Gt/`�,J,��� �J�J.n1 O�K c,/f�iti" ertification#: _ '�G�u y ���1,,/ �.r e��)(���� Grout Inspected: J �'/ ""✓ �" � ���,p�G_ Well Head Inspected: �� 7//7�)Z GPS Coordinates: �' � 6 �• 7 EHS: Date• '`�30�� EHS• � ate: � �/ ���7//z W.P:7-08 �� � ' ' •' ' � APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780./Fax(336)753-1680 ' ***IMPORTAN7S4** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION Name J���✓� Iiov��n-FZ Contact Person S�ci/c,r� You✓1fz- Address O ;n G �r�s�- [,,�. Home Phone `l9�-2 85`a City/State/ZIP_ M o��f✓�'1 t �G �'�D,�� Business Phone 33 6�58�-19$$ Name on Permit if Different than Above � Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application: Included: � Site Plan ❑Plat(to scale) - Owner's Name S�M� AS ��ovf Phone Number Owner's Address City/State/Zip Property Address $'li o,�t � , City�vcksvi/e,�G Lot Size 10 U�r�s Tax PIN# �bb0000�/'�I/P�� Subdivision Name(if applicable) Section/Lot# Directions To Site: n�;� � �n� � S'�`mons ��� TirM �e�-►- o,��-. . r,'l,Cl✓�+N f'�� gvrf ��� � InfO �'�c Wafl�k. DEVELOPMENT INFORMATION � Permit Type: New Well� Well Repair Well Abandonment Other(specify) Facility Type: Residential�_ Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO X Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing wafer supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. Signed Date ` Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# � , Invoice# ����_ . . , � .----°—" ' DAVIE COUNTY ENVIRONMENTAL HEALTH ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)Z53-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �ccn�a�t #: 990005184 T�x Pl�€.��H#: E00000051 BiElc� 7c�: Steven Yountz Suk�divi?�iaf� ln��: Refer�E�c� �1����: � � _ LocaiioniAddr�ss: Salmons Road-27028 F'ropc�sei� Fa�ility: Residental � � • � �'�o��rfy Six.�: 10.01 Acres � a�TC Nut�b�r: 5875 Site Type: E�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 Specitications: #Bedrooms 3 #Bathrooms � #People '�'� Basement❑ Basement plumbing❑ � Non-Residential Specifications: Facility.Type #People #Seats Square Footage(or Dimensions of Facility) y.2c�.) " Lot Size , A.Gr� Type of Water Supply: OCounty/City �Vell ❑Community Well 2 �d . System Specifications: Design Wastewater Flow(GPD)J� Tank Size �� 6 GAL.Pump Tank�GAL. � Trench Width��Max.Trench Depth��ZrRock Depth •� Linear Ft.�34• Site Modifications/Conditions/Other: ��pt�ted in 15A NCt�C �8�a.19S�15� , . ptsd �j�at�r�� m���l�,��t�� �s� 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. ' 1�-(")�.�/. � ` � . � � ` � • (� ,���p'l►� f7!'P� �$p , r � I � �j � � • �i'��' , 7,1.4� � � o _r_ "� ��� � Aebr. . 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