279 Shady Knoll Ln �
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Da�ie Couni.y Health Department
4�►s j� Environmental Health Section ' s,.,. � .
, P.o. Box 848 . �; �, - .
210 Hospital Street � .'
C� '�. �
Q U�'S. Courier#:09-40-06 :
� Mocksville,NC 27028 �
Phone:(336)-753-6780 Fax:(336)-753-1680
' ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection .
Name:_�l.l(l(,(01'� �l�fi/�G`L Phone Number �3�C '`[70����P�C (Home)
Mailing Addtess: 02�`7 �(� �Ll D�r (�'j 33�(` `t�!�_ Q/�� (Work)
-Jl/�v��:s�f(� nI� a►�oag .
Detailed Directions To Site: �QVI L ��l�I���1'Y►4 �Q� .t f�f�l ��" �/�'l�'D�YV�(��.�J2(���
►"� �I OYhG t?h. (��'f" A;f' CD��,c�nS
Property Address: �'�g 5�lGtf�� �VI Q(� �.N
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under:�(�{,Uli C� tttl MLS Type Of Facility: Qf S 1(.'<<,Yl Gt
J \
Date System Installed(Month/Date/Year): l�eL o���o'Z Number Of Bedrooms: 3 Number Of People:_�
Is The Facility Currently Vacant? Yes � If Yes,For How Long?
Any Known Problems? Yes � If Yes,Explain:
Please Fill In The Following Information About The NEW Facility: .
Type Of Facility:. �j(�1 S� �Q!'1L15 �Q�iY1 Number Of Bedrooms:�Number of People /V I/�
. Pool Size: - Garage Size: /��� Other:
Requested By: it —� ^ Date Requested: 2— f y—� y
(Signature)
For Environmental Health Office Use Only �
Approved Disapproved
Comments:
Environmental Health Specialist Date: � —' �� `' � y
*The signing of this form by the Environmental Health Staff is in no way intende ,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment Cash Check Money Order # Amounr$ Date:
Paid By: Received By.
Account#: Invoice#:
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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
OPERATION PERMIT
. Accaunt #: 990005405 '�ax PlNfEH#: 5718-00-864E
Bifled 70: Asuncion "Chon" Martinez Subtfivisior� Iri�o: aZl�
Refer�E�ce Name: LocaiiortiAd�r��s: Shady Knoll Lane-27028
Proposed F��ility: Residential' Pcoperiy Size: 10.268 Acres
ATC k�urnber: 5025
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article I 1 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. � �.
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System Type: ��� S.T.Manufacturer���u�Tank Date � Tank Size (�
' Pump Tank Size ��r00Y!'6S � .
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S stem Installed B � � 7/n E.H`�S � �F a ��' d���
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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
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �
� Accour�t #: 990005405 � . ..., .� T�X:PIE�!EH#: 5718-00-8646-Well ..
.
Biflcd To: Asuncion "Chon" Martinez ._ ..: � Su�divisian�it�:fu,; ::•� :�,;:,;;::,: . . � � ,� �� �
Refer�nce Na��e: . • :_::iocationiAddress: 279 Shady Knoll Lane-27028 : ` . ..
Pro�osecJ FaciEify: Residential Well . . •-:. Pfb��rty���ix�:����'�10.268 Acres < " . . :�.
,
t�TC Nuanbsr: 5025 ._. , . r :;�.'.� � ; :. �� . . .
..,..:.. .,
- ' .Site Type: �I�Tew ❑Repair OExpansion
**NOTE**This Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Environmental
Health Section prior tp 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 � #Bathrooms d•�#People�Basementl9't3asement plumbingC�—
Non-Residential Specifications: Facility Type #People #Seats
� Square Footage(or Dimensions of Faciliry) .
� Lot Size �� qG/'!f� Type of Water Supply: ❑County/City [B�Vell OCommunity Well
00 0
System Specifications: Design Wastewater Flow(GPD)��d Tank Size��� GAL.Pump Tank. ���GAL.
Trench Width ��v�, Max.Trench Depth 3L��Rock Depth I '�. � Linear Ft.�
¢�� S�tated in�NCAC 18A.1� �
Site Modifications/Conditions/Other: aCo�pted Systems may also be uSe
. Contact the Davie County Environmental Health Section for final inspection of this system between
� 8: 0=9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist �i�%��i���G� Date: `�r�(� " `�
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' i • �. DAVIE COUNTY ENVIRONMENTAL HEALTH
• P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Accou�t #: 990005405 '��x Pl�ffEH#: 5718-00-864E
Bific�Ta: Asuncion "Chon" Martinez Suk�divisiarz info: �Zg
Refer�E�ce Na��e: Loc�tianiAdc�r�ss: Shady Knoll Lane-27028
Propc�secl Fa�iEify: Residential' P�o�eriy Siz�: 10.268 Acres
a�TC E�umber: 5025
**NOTE**The issuance ofthis 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. � ✓ /� � � a..
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System Type: �� S.T.Manufacturer��Q u Tank Date � Tank Size�
Pump Tank Size ��rvoms �. �
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System Installed By: e� �-/� E.H`Specialist: V(1 ��a Date: ���d���
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DCHD 11/06(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
- AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
: .
• �` � '�a�c'Pl�€.�EH#: 5718-00-8646-Weil . � - . ,
t�cc�u�t #: 990005405 . . . ., ..,
8iilcd Ta: Asuncion "Chon" Martinez ::.:�:-::: ; SuE�tiivi�ion:l�fi�, . .:�; ��,.�::.. `
, . . . ... ;� ...,.
Re€er�E�ce Nan�e: . _::LacaiioniAddr�ss: 279 Shady KnoII Lane 27028: ; . ,''. '.. ...
Proposed Fa�i€ity: Residential Well = �� :. PEa��r#y��ix.�;;;,�;M0.268 Acres�; , , , -���
ATC Nurnb�r: 5025 � . , ,-. r:;�5 � ,
� Site Type: �'New ❑Repair ❑Expansion .1•
� • _
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior tq 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 d•�#People�BasementC�'�sement plumbingQ�
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
' Lot Size_ �� qG/'!� Type of Water Supply: ❑County/City [B'Well ❑Community Well �
� o,
System Specifications: Design Wastewater Flow(GPD)��a� Tank Size��� GAL.Pump Tank. ���GAL.
Trench Width ���, Max.Trench Depth 3(i!�Rock Depth 1'�.�� Linear Ft. '�33
¢t� St�ted in 1�A�1CAC 18A.1�
Site Modifications/Conditions/Other: �CCepted Systems may also be uSe
Contact the Davie County Environmental Health Section for tinal inspection of this system between
8: 0=9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health Specialist Date: ��r'p�� ' %
DCHD 11/06(Revised) . '
' � Davie County Environmental Health
� P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT �
Account #: 990005405 Tax PIN/EH#: 5718-00-8646 '
Billed To: Asuncion "Chon"Martinez Subdivision Info:
Address: 527 Mountview Drive Location/Address: 279 Shady Knoll Lane-27028
City: Mocksville Property Size: 10.268 Acres
Reference Name: �
,Propo�s�d F I�t�• Re�sidence
. NO�T� '�his mprovement 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: ew ❑Repair ❑Expansion Permit Valid for: �5 Years ❑No Expiration 'M,
Residential Specifications: #Bedroo�_#Bathrooms��#People�BasementB'Basement plumbing0�
Non-Residential Specifications: Facility Type � #People #Seats
Squaze Footage(or Dimensions of Facility) ,
Design Flow(GPD): 3�� Type of Water Supply: OCounty/City e7Wel1 ❑Community Well •
Site Modifications/Permit Conditions: �
S stem T e LTAR
Initial �.
Re air '?
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Site Plan
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Environmental Health Specialist Date //�—oc�o ' ��
i.p:ll-06 � '
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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 _
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account �: 990005405 7ax PIt�:EH#: 5718-00-8646-Well
Bill�d 70: Asuncion "Chon" Martinez Suiadivisior� Infc�: .
Refer�r�ce N�n�e: LocaiioniAddr�ss: Shady Knoll Lane-27028
Propossc9 Faci€ity: Residential ' �ro�arty Size: 10.268 Acres
E�TC Number. 5025 Site Type: - _ ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MiJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article I 1 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� Basement asement plumbingB�
Non-Residential Specifications: Facility Type #People #Seats
G G/��Square Footage(or Dimensions of Facility) �
Lot Size(�1. ��� � Type of Water Supply: ❑County/City ell ❑Community Well
/,t,� O . .– -._
System Specifications: Design Wastewater Flow(GPD) (.��V Tank Size�a�GAL.Pump Tank ,��GAL:
, �1 l, / � � 1_
� Trench Width ��! Max.Trench Depth� Rock Depth �� Linear Ft.�� ----
'� As stated in 1�A NCAC �8A.1�69(5)
Site Modifications/Conditions/Other: �ceP t�Systems m2�� alg� ba as��'
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.
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DCHD 11/06(Revised) -
� � �
� , . Davie County Environmental Health
. P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680 �
IMPROVEMENT PERMIT
Account #: 990005405 Tax PIN/EH#: 5718-00-8646-Well
� Billed To: Asuncion "Chon"Martinez Subdivision Info:.
qddress: 527 Mountview Drive Location/Address: Shady Knoll Lane-27028
City: Mocksville Property Size: 10.268 Acres
Reference Name:
Proposed Facility: Residential Well
**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: ew ❑Repair ❑Expansion Permit Valid for: C35 Years ONo Expiration �y~
Residential Specifications: #Bedrooms�#Bathrooms �• #People�Basement�sement plumbingCY
Non-Residential Specifications: Facility Type #People #Seats .
Square Footage(or Dimensions of Facility) �
Ne.��-�-rM'�
Design Flow(GPD): �� Type of Water Supply: ❑County/City ell ❑Community Well
as stated in 15A NCAC 18A.19E9(5
Site Modifications/Permit Conditions: accepted Systems may also bc+ �����
. S stem T e LTAR .
Initial
Re air
Site Plan
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� `�h �, i�'� �� SITE EVALUATION/IMPROVEMENT PERMIT&ATC
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i � '�'' �� ` Davie County Environmental Health
I �, P.O.Boz 848/210 Hospital Stt�eet
, :' �EG _ 3 2009 Mo��v�,xc z�o2s _
:,,, �:, (33�753-6780%Faz(33�753-1680
�L_.Appli r � > p valuatio pmvement Pemiit ❑Authoiization To Conshtict(ATG� �Both
T�bt`�A ew System ❑Repair to E�dsting System ❑Expansion/Moditicatioa of Existing System ar Facility
DA'I� �
"�"ATPORTANT'•'THIS APPLICATION CANNOT BE PROCF�SED UNLESS ALL OF TIiE REQUiRED
INFORMATION IS PROVIDID. Refer to the INFORMATION BULLETIN for instr�tions.
APPLICANT INFORMATION
Name to be Bllled�LtYI(�(D��A h u �f-�i tl P_? Contact Person eh o n �Q.�-E�f1 LZ
Billing Address Home Phone
City/State/ZIP ,��� G NL �70 $ Business Phone � c��cF(p�- D I?SG
Name on PermidATC if D�erent than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facil' Corne�s Fla ed '�� l '0�
NOTE: A survey plat or site plan must eccompany this application. Included: Site Plan OPlat(to scale)
(Petmit i valid for 60 months 'th s'te plan,no expiration with complete plat)
Owner's Name Phone Number.�3(0-7!!S"a�fe?9
Owner'sAddress 30 1 City/State/Zip_WiMSfDh-SQ.IC�/JL?7/Dt�
Property Address City I�.��SUi�(�
Lot Size Tax PIN#
Subdivision Name(if pplicable) Section/Lot#
DirecdonsToSite: _�ViL �i�.i t r�ri�-� on s l�v KYI / �.R11�
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If the answer to any of�he following queslions is`�es",supporting documentation must be attached.
Are there arryy existing wastewater systems on the site? ❑Yes B�10
" Docs the site contain jurisdictional v�ttlauds7 ❑Yes�10
Are there any easements or right of-ways on the site? ❑Yes�To
Is the site subject to apptoval by anuthet public agcncy? ❑Yes�10
Will wastewater other than domestic sevt�age be generated? ❑Yes�Io
IF RESIDENCE FILL OUT TF�BOX B
#People � #Bedrooms #Bathrooms Gazden Tub/Wlurlpool es ❑No
Basement: es ❑No Basement Plumbmg: C�'es ❑No
IF NON-RESIDENCE FILL OUT Tf�BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentadon of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: �Couventional ❑Accepted OInnovative ❑Alfemative ❑Other
Wata Supply Type:❑Cotmty/City Water �'Ne�v Well �Existing Well ❑Community Well
Do you enticipate additions or e�cpansions of the facility this system is iute�idcd to serve7 O Yes C�'No
If yes,what type?
This is to certify that the inforniation provided on tlus application is hve a�correct to the best of my knowledge. I understand
that any penuit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the infotmation submitted in this application is falsified or ckianged I hereby grant right of enUy to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and ivles. I understand that I am responsible for the proper identification and labeling of property lines and comets and
locating and flagging or staking the house/facility location,proposed well Iceation a�d the location of any other emenities.
��•Q""`"'"-`�''� MO`�k"r`'�-z ��}'�Z Site Revisit Charge
Property owner's or ow�r's legal repiesentative si�ature
Date(s):
/Z. �3•d 9 Client Noti£ication Date:
Date EHS:
�-,�
Sign givea ❑Yes ONo I. _ L Account# ,_Z�0� �
Revised 11/06 CY�^�'� � � '✓G��v"� Imoice# _�
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�� • ; ' ' DAVIE COUNTY HEALTH DEPARTMENT
' ` , • Environmental Health Section
- Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005405 Tax PIN/EH#: 5718-00-8646
Billed To: Asuncion"Chon"Martinez Subdivision Info:
Reference Name: Location/Address: Shady Knoll Lane-27028
�ro��sed Facility: Residence Property Size: 10.268 Acres Date Evaluated: ` _1
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Water Supply: On-Site Well / Community Public '
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Evaluation By: Auger Boring � Pit � Cut
FACTORS 1 2 3 4 5 6 7
` Landsca e sition
Slope%
HORIZON I DEPTH --'>
Texture grou ' � t f_
Consistence 'r-
Structure '� < � /L
Mineralo " p "" S '
HORIZON II DEPTH , C�,- U = L� �'
Texture rou � (.,_ �L
Consistence �1`• +.. 5i 5r� �
Structure S , ' f G,(j
Mineralo � ' �
HORIZON III DEPT'H
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION %
LONG-TERM ACCEPTANCE RATE -) 7 1� '� Q. 1��
SITE CLASSIFICATION: 5 EVALUATION BY: ��C���.-�'�•''
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LONG-TERM ACCEPTANCE RATE: � `2�� OTHER(S)PRESENT:
REMARKS:
LEGEND
Landccane 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
Tgxtuig •
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
� CONSISTENCR
1l�i�s�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm. EFI-Extremely firm
�
� NS -Non sticky SS -Slighdy sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
S r, ,r .
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic .
Mineraloev
1:1,2:1,Mixed
No s
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
e Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
;
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