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357 Singleton Rd � � DAVIE COUNTY ENVIRONMENTAL HEALTH ��� ' -�,_; P.O.Box 848/210 Hospital Street `�"�'� ' Mocksville,NC 27028 s� (336)751-8760 Fax#(336)751-8786 � 3 �� l AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003304 Tax PIN/EH #: 5765-00-1880 � Billed To: Nathan Foil Subdivision Info: Reference Name: Location/Address: Singleton Road-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4614 Site Type: ❑New ❑Repau OExpansion **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 y #Bathrooms3•#People �� BasementC�Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats � Square Footage(or Dimensions of Facility) /� � Lot Size ��i-c Type of Water Supply: ❑County/City fdWell �Community Well , System Specifications: Design Wastewater Flow(GPD)�� Tank Size�4�GAL.Pump Tank�1�AL. . � Trench Width���Max.Trench Depth J?G � Rock Depth l��� Linear Ft. .5 33 As stated in 15A NCAC i�.A.S.3�i�(.�i� Site Modifications/Conditions/Other: ����,QTe�s-t�;�;�-��T�:o-�?:s�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. �4� �- - � / � ��` / ij _ `-�T' ` � � � Q. � � �'� ` � ' � � 'C �� ro_�a � 1 � � � \ \ � \� 9Q� (� :- . � \� `� �?���, �\ � � \ �'3 't�� \ �y � � . o��,� ��"• ,� ��� � � � ,� "�' °� . � �Pc. �, ` � � � �� �• . �'�, c`� ��c� �� � _ . � s �� . , � .� ��. . v v� � � _ �, 4 3 � y' � `� t� � �, . �,� , �____.r'�:_� , Environmental Health Specialist Date:���3 Q' 7 DCHD 11/06(Revised) . • , DAVIE COUNTY ENVIRONMENTAL HEALTH ' . .� • , P.O.Box 848/210 Hospital Street :" . Mocksville,NC 27028 (336)'751-876Q Fax#(336)751-8786 � OPERATION PERMIT Account #: 990003304 Tax PIN/EH#: 5765-00-1880 � � Billed To: Nathan Foil Subdivision Info: �sy , Reference Name: Location/Address: Singleton Road-27028 �� �f�`l Proposed Facility: Residence Property Size: see map . �o C7 ATC Number: 4614 **NO�'E**The issuance of this Operation Pennit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S.Chapter 130A,Secrion.1900"Sewage Treatment and Disposal Systems," but sl�all in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Cp r( / � 'lJ� � �_ �.� System Type:�S.T.Manufacturer �"'''� Tank Date Tank Size�U Pump Tank Size � � System Installed By: i �h Q� `C �9'� E.H. Specialist: 1 Q�a� Date: �" D ���-��-� � 'o�' 3 � ' � �v � �� - (a GG �` . �� �'� � ��` - �� �` ��� - 5�.� , � � \�,�K L / \ 1�� . ` G�p�' �' e� ��l 5 P.� DCHD 11/06(Revised) �, . ...... � � �1�C� SITE EVALUATION/IMPROVEMENT PERMIT & ATC DDavie County Environmental Health � 200i , P.O.Boz 848/210 Hospital Street F�B � Mocksville,NC 27028 ' n (33�751-8760/Fax(336)751=8786 �NVIRGPlMENZ A1.HEALTH , A lication For:D��� ' �''�ry ion/Improvement Permit ❑ Authorization To Construct(ATC) oth '�'' T ication: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFOItMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions: APPLICANT INFORMATION � � r-- Name to be Billed_ ���-�1cn� �'vi� Contact Person���,_ �/ Billing Address�C 9 .�'� j�t,.0 �U/S�,..{-ti Home Phone 3 3G�-�1��(-y�J�, City/State/ZIP �I��l��s.�,�(�. ,�1/�-�-=�c�� Business Phone 3�C � 3i'�/-y9'// � ; . � ,; Name on PermidATC if Different than Above �`� '�. Mailing Address ' City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged o2 ��{ 0 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) - (Pernut is va�for 60 mon�th with site plan,no expiration with complete plat.) � Owner's Name t'lo� �( !� I:,1 � Phone Number J�� �i`/�'77�1� Owner's Address 3 7Srn.,/r�o� • • City/State/Zip '��-��� l� %b C �'L�,� Property Address` ,5�,w�z City �:c.��l /N Lot Size Tax PIN# 57����f�Q ' SubdivisionName(if applicable) Section/Lot# Directions To Site: (�c�l .S�„�h -b <.(�e;,�, I�f il � . . 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 0IV� � Does the site contain jurisdictional wetlands? OYes C3No Are there any easements or right-of-ways on the site? ❑Yes �10 ' Is the site subject to approval by another public agency? ❑Yes C�3� Will wastewater othei than domestic sewage be generated?�� ❑Yes I�o IF RESIDENCE FILL OUT THE BOX BELOW #People , #Bedrooms #Bathrooms 3 � Garden Tub/Whirlpool �s ❑No - Basement: es ❑No Basement Plumbing: ❑Yes C�3�o 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 Typesystemrequested:, onventional ❑Accepted �Innovative ❑Alternative �Other Water Supply Type: ❑ County/City Water [�7New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? � Yes [YNo � If yes,what type? This is to certify that the information provided on this application is true and conect to the best of my lmowledge. I understand that any pernut(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 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 ouse/facil� lo ation,proposed well location and the location of any other amenities. w � -- � �/� % Site Revisit Charge Property owner's or owner's legal representative signature Date(s): — -�`7 Client Notification Date: Date EHS: Sign given DYes ❑No Account# � Revised 11/06 Invoice# ��� �: . � _ _ _ _ _ — — ,i x �i / �':r�.�.-: . �;�; . .}:` / '� .� . . .. / . 37��.� �� � _��___., . . . �� ,' �1 I rn i � � cn �' ,�w-^ �'iri.' ' - � �� 0 I � �'��_. . _ ._ Zy _ / 714 �� � � � � PcC2 � I � 152 �,5 z6A� � � ! � ---rt� 150 , e �2% � � � , i � � I � � �� � '� (9.89A) (11.60A) J ,,, (13 01A) � R3 I' ^ � /p ;� � 1880 PCBZ � 6830 � 1738 � � � M � �Q I � � � O � °' � � M j � I � �1.98A) � I � . � � � 3477 � � � � ' ao _ _ _ __ _ ' E��NROPC .. . � _ Si7 , : � �-. . . -�. ._.I_ � - --__�_ _ _ —�— _o__------ _ _ 15j �s . SR 1821 � S1NG _ - --_ - - - - , ' � ,.-' -_--- ------.__-- --- . ��1ro1 -- —r ------ __ � csas� l� . . , ' DAVIE COUNTY HEALTH DEPARTMENT � ' Environmental Health Section _.-. � • , . ' Soil/Site Evaluation APPLICANT INFORMATION pROPERTY INFORMATION • - Account #: 990003304 Tax PIN/EH#: 5765-00-1880 Billed To: Nathan Foil Subdivision Info: Reference Name: Location/Address: Singleton Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: '''� ~ � —.�-- 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 4�- L. � Slo % � HORIZON I DEPTH - /� .� Texture rou 5 L Consistence �- g ,' �p�Y + ;,� '"• Structure . C�r,..,i v� Mineralo :� \i � - HORIZON II DEPTH ��� a --/ Texture rou L C Consistence N f; 1 P . Structure ' y �G � • • Mineralo � � ('r HORIZON III DEPTH —�{ Texture rou � _L, Consistence � � _ ,/' Structure � � C Mineralo ��1 i'/ HORIZON IV DEP"TH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRIGTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE p .3 SITE CLASSIFICATION: i�f1v `?U r��;.��_j'� EVALUATION BY: ` w LONG-TERM ACCEPTANCE RATE:��. OTHER(S)PRESENT: REMARKS: � � LEGEND ' Landscape Position . ' 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 Test�rg , 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 . . �Q1SL VFR-Very friable FR-Friable FI-Firm - -VFI-Very fum EFI-Extremely firm 3'�.' t � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S � ,r . SC-Single grain M-Massive.f CR-Crumb GR-Granulaz ABK-Angular blocky �` ��Yq, SBK-Subangulaz blocky PL`=Platy PR-Prismatic � Mineraloev ,�� • 1:1,2:1,Mixed ' Llo�r� � 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 . 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' • �h`ty v*M� £.'� . .. � • Z//� ; �f .K av��t�`. .• _� ' . . . . . .. , � . �.. ' . 1 ' . ' ' • I . ' ''{�•� ' • . ' • , . ' L -.' . �.� . . . .• . .. . •��';'� � . ;��... ' � .. �_. .. Davie County Environmental Health � . - P.O.Bog'848/210 Hospital Street � Mocksville;NC Z7028 (336)751-8760/Faz(336)751-8786 IMPROVEMENT PERMIT Account #: 990003304 Tax PIN/EH#: 5765-00-1880 Billed To: Nathan Foil Subdivision Info: Address: 7369 Highway 801 S Location/Address: Singleton Road-27028 City: Mocksville Property Size: see map 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: ew ❑Repair �Expansion Pernut Valid for: O�Years ❑No Expiration � Residential Specifications: #Bedrooms � #Bathrooms 3/�#People � BasementL�'Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): y � Type of Water Supply: ❑County/City �ell ❑Community Well Site Modifications/Pernut Conditions: S stem T e LTAR Inirial � c Re air � U- � Site an O � �� I�1�-�-�wc ti� / � - � _ , � _ , � `� � _ .. dy . �y . 4� p��� �� � �. �-`�-�0 ��.r `� � .� sy �- � � � r '" ' c a� 4, � � � � � � � . � � � �Q x c� ��S Environmental Health Specialist �`-!'3 �6 ? i.p.l l-06 , � , ��!':t� • Y�. �ESIDENTIAL wELL corrsr�tvcrt�rr�coRn � �� �� �� S . . . ���, � I North CaroGna lleparmient of�nviconment and Natur.il Kwoa�es-Division of Wafer Qunlity . .... .c•;,?i=,_: ��'''�°""` WELL CONTRAGTOR CERTIF7C�►:`�ION# � �3 G 1.WELL CONTRACTOR: � • • • f. DISINFECTION:Type �H Amount� S MG �T��W �/, l�r D�v n 9- WATER ZONES(depth): Well Contractor(Individuaq Name From ��I.S� To ��6� From To Yadkin Wel�. Company, IriC. From � 30' To�� From To Well Corthador Company Name From �� 'To .��� From To STREET ADDRESS 19.08 Hamptonville Road 6. CASING: Thickness/ Depth Diameter Weipht Material Hamptonville NC 27020 From�To S9 �t. .i�S" s�k-aI f�c City or Town State Zip Code From To R. 3c 36 �. 468-4440 From To Ft. Area code- Phone number . T. GROUT: Depth Materiai Method 2.WELL INFORMATION: From�_To 3 Ft.�[a f Cc+w� I� c� � SITE WELLIDffi(ifapplicable)�� c! ` $�% From�_To��Ft. R�.,'�o��f� � STATE W ELL PERMIT#{if applicable) From To R. DWQ or OTHER PERMIT#(if appGcable) 8, SCREEN: Depth Diameter Slot Size Material WELL USE(Check Appt'�cable Box): ResideMial Water Supply� From To R. in. in. p From To Ft. in. in. DATE DRILLED �— �cI ' 0 g From To R. in. in. TIME COMPLETED 3,0 V AM❑ PM� 9. SAND/GRAVEL PACK: 3.WELL LOCATION: �P� S¢e Material - ' � From To Ft CITI(: C.x�e+^�t e COUNTY av L From To Ft. .3�r J/h s/2 �� �d From To Ft (Street Name,Number , mmunity,Subdidsion,Lot No.,Parcel,T.ip Code) 'TO/POGRAPHIC/LAND SETTING 10.DRILLING LOG p�siope pValiey pFfat pRidge ❑Other ' From To � Formation Description (check appropriate box) ,� � S'3 �� � IATITUDE 3 :rV � 23f� � �m„�-y„��,��� S3 '- 30� ' �'I„[ 6�a,,,•�� LONGITUDE�,.(Z� 2�i ��f� °1°�1°'alfmmat I,atitudeAongitude source: �GPS pTopograptric map pocafbn of wel must be shown on e USGS topo mep and atfached to this form ifnot using GPS) 4.YVELLOWNER� Hicjh IGh� r.�����t �vG+i I�ev� OWNER'S NAN� ul- t ne t r STREET ADDRESS City or Town State Zip Code L_�- �it- SPrial Np� Si�P c�ff ` Area code- Phone number /l/6/�I ,S"�-rj/7 " 11. REMARKS: 5.YYELL DETAILS: 3oa � a. TOTAL DEPTH: " b. DOES YVELL REPLACE EXISTIN(3 WELL? YES❑ NO�{ !.) 1 DO HEREBY CERTiFY THAT 7HIS W ELL WAS C�NSTRUCiED IN ACCARDANCE W RH c. WATERLEVELBeIowTopofCasing: O FT. �snNca.cx,weu.conisrnucrar�srnaoazos,ANDTHATACOPYOFTH{S (Use'+'jf qboye Top of Casing) RECORD HAS BEEN PROVDED TOTHE WELL oNVNER. d. TOP OF CASINC315 � FT.Above Land Sudace' ��stGC/v � [�� 3 '� 'U� `Top of casing tertninated aUor below land surface may require SIGNATURE OF CERTIFlED W ELL CONTRACTOR DATE a variance in accbrdance witl�15A NCAC 2C.0118. / �Q e. YIELD(gpm): �4' METFiOD OF TEST �r P�P PR�NT D NAM F PER�CONSTRUCT NI G THE WELL ' !y►.�8 f�A B ' Submit the orlginal to the Division of Water Quality within 30 days. Attn:Intormatlon Mpt, Fortn GW-1a 1617 Mafl Service Center—Ralelgh,NC 27699-1617 Phone No.(819)733 7018 ext 568. Rev.7105 Date site visited _3—l-07 by ��Q pennit - � �o Qi(I �o Co��' �'1euc�.o1� �-Fi ��c�d -�'co�F�f' u. �'P��� . � � �C!t�-1 336-�.S�o � nj.r.z � 4 c1 . �� ►—,�� .. _.