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170 S M Whitt Dr , � ' ' DAVIE COUNTY ENVIRONMENTAL HEALTH � P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT Accour�t #: 990005455 '��x FI�I.�EH#: 5726-79-3590 Billc�[Tc�: Pam Hunter Suf�divisior� Info: . Refer�nce Na��e: LucatianiAddr�ss: S M Whitt Drive-27028 PropQsed Faci€ity: Residence Pro�er�y Size: 21 Acres ATC Nurnber: 5099 **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:�_S.T.Manufacturer ��+��c Tank Date c�.30 Tank Size/QOD Pump Tank Size / _ � '1 ,jL�� / System Installed By:� be `s "6"���` E.H.Specialist: � ��v� Date: / �� -������ i o�� �i5' 115' 1�'� � S� �°� , , DAVIE COUNTY ENVIRONMENTAL HEALTH •-�� -----r P.O.Box 848/210 Hospital Street ' ' Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �cc��a�t #: 990005455 T�x P1k�iEH#: 5726-79-3590 Biilcd 70: Pam Hunter Suf�divi�ior� info: }�efer�nce Rfan�e:: LocationiAddr�ss: S M Whitt Drive-27028 Pro�c�sQd Facifity: Residence Pco��r�y Siz�: 21 Acres ATC Nur7lbef: 5099 Site Type: GdNew ❑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�_Basement❑ Basement plumbing❑ Non-Residential Specitications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size �� C.0 Type of Water Supply: �County/City OWell ❑Community Well System Specifications: Design Wastewater Flow(GPD)�Tank Size�_GAL.Pump Tank�GAL. Trench Width�� Max.Trench Depth_� Rock Depth� Linear Ft.L�c��� Site Modifications/Conditions/Other:��/'e(d(',���� �lo� �7���LCC>'�� �--- Contact the Davie County Environmental Health Section for fnal inspection of this system between 8:3 — :30a.m.on the da of installation. Tele hone# 336 751-8760. � � �l �; � — � — ��' , .�-�-, . ° c �� --�� � � � �� , ; , , 5�. � . ��;� , � � '_� � � , �� .�a��' Environmental Health Specialist 1 Date: Z ��l DCHD 11/06(Revised) • � Davie County Environmental Health � . ' � ' P.O.Box 848/210 Hospital Street Mocksville,NC 2�028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005455 Tax PIN/EH#: 5726-79-3590 Billed To: Pam Hunter Subdivision Info: Address: 170 S.M.Whitt Drive Location/Address: S M Whitt Drive-27028 City: Mocksville Property Size: 21 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. Permit Type: �New ❑Repair ❑Expansion Permit Valid for: l�5 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):7�� Type of Water Supply: �County/City ❑Well ❑Community Well Site Modifications/Pe it Conditions: �' � • R . . � � � S stem T e LTAR Initial ' ' Re air �{ Site Plan �T <,�. • � �� . �. . ,�{�,�'' �� '�._ � 1t'�� • ' ' Environmental Health Specialis Date li 2�N� � i.p.11-06 . . Y _ '�..`�_ .:. ' ._. �-_' l� � � Q�� 'I FOR SITE EVALUATION/IIvIPROVEMENT PERMIT&ATC �� � r � �,• � Davie Coanty Euvironmental Heatth d �!� �,:_,'. � � P.O.Boz 848/210 flospitsl Street � �; F' � Moelcsville,NC 27028 ��I� � L MAR 1 8 2010- ;� c��s�c�soiFu���s3-i6so Si�e Eval 'on/Improvert�ent Pcrmit ❑AuthoriTation To Consuuct(ATG7 ❑Both ENVIRO�YP,�POf.P4�� �'Frew s � ❑x�r w�sy� ❑Expansion/Modification of Exisiing System or Facility ••THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TIIE REQUIRID INFORMA170N IS PROVIDID. Refer w the INFORMATION BULLEfIN for iagtructionx APPLICANT INFORMATION Name to be B�71ed �� T7��1 Contact Pecson tr'd�i �`� B�71ing Address � � ?^i Y� Home Phone — — " cJ City/StateILIP S[/ 'E � O� ��3 —9 U — Name on PermiUATC if Dr�'ereru than Above Mailin Address Ci /StatelL' PROPERTY IIdFORMATION " *Date Housc/Fac7i Comers FI ed � �� � N07'E: A wrvey plat or�ite plan rrwst accompany this application. Included:0 Site Plan OPlat(to scale) (Peemit is v i for 60 m�tl�witl�site p no expiration with complete plat) Owner's Name U lo i Phone Number d� Owner's Adclress � . i r� � City/StatelLip /I�OC/CSV�/ C NC�70� . Property A e �t V� City �t s� . Tax PIN# o vdo 5?Zl�7 -3s90 Subdivision Name(if applic�ble) Section/Lot# _ Dirediqns To Site: 5'i- �.., ' � Q , c, � d o r� — � Yn i 1�. 5� � h�tt r i v�2 �2 -F- - �r� r� �P� �c,17a ��hf If the amwer W any of the foUowing questions is'�es;sappoAing doc�entation must be attached. Are t}�ere mry e�cisting wastewater systeens on the site? ❑Yes� Das tlu siu contain jurisdiaim�al wetlands7 ❑Yes��.. Are tt�ece any easeme�rts or right-of-ways on the site? OYes 43Qo Is the site subject to apprwal by acwther public ageacy/1 OYes f�io Will wastewater otha tt�dotraGc be ge�rerated7 ❑Ya� IF RESmENCE FILL OUT TEIE BOX BELOW #People #Bedrooms�_ #Bathmoms� Garden Tab/Whirlpool es ONo Basement OY�o BasemcntPlumb' : ❑Yes � ff NON-RESIDENCE FILL OUT Tf�BOX BELOW Type of Fac7ity/Business Total Square Footage of Building #People #Sinks #Commodes �Showers #Utinals Estimated Water Usage(gallons per day) . (Auach�on of sim7ar facility water consimmption) FOODSERVICE ONLY: �Seats Type systan roquested: Conventional OAccepted Dlnnmative ❑Altertiative ❑Other Waicr Supply Type:�County/Ciry Water ❑New Well OExisting Well ❑Community Well Do you anticipate addidons or ezpansiocu of tbe facility this system is intended to se�ve7 0 Yes �'No If yes,what type? This is W ctrtify that the infom�ation provided on this application is�ue and correct to the bat of my Imowledge. I�mderstaad ��Y P��(s)or ATC(s)issuad t�ereafter are subject to a�spension or revoption if tlie site is altered,the icdended use changes,or if tl�e information submitted in this application is falsified or c6anged I}�reby p,rant right of entry W the Authorized Representative of the Davie County Health w cooduct e�ary inspecti�s to determi�coropliance with applicable law niles I wideTstar�d that I or pnoper idemification and labeling of property lines and comers and wetl location aod the locffiion of aay other aroenities. owner s or owner's legal representative sig�e Site Revisit Charge ) v ��s): ��"'/ � Client Notification Date: �Date EHS: Sign�ven OYa ONo Account� �� Revised 11/06 Invoice# __� .-s:.=a. .;..i-'�-- ........._"_ _',_r_".,a-- . .___ -......a..,—.- rn:.-.n---. s�.�..—e-�,:�^.�.,:a__ . -" _ " "_ - ' _ _ _ _ _ _ ._4�.�' .J`.+i:._ _' ._ ___' . z.,.— _, ._.' ....... ..�.. , .. , . �...-. .....,..� .. .:._. '"' .: _.. . r. 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'1 :� ` HORIZON I DEPTH • � (��' ' "_` Texture grou : � - , ' ---'� ••Consistence � ' '� 1 Structure . , - �. ::. .,�,. „_, i Mineralo �� _:;�y �_, HORIZON II D�PTH;' • .. • ; l> ` , , Texture mu . `-' - y-•' 1 Consistence � S Wcture ��., t, ....�.._; � � Mineralo _:� ' ' ��' . HORIZON llI DEPTH' Z,. - • Texture rou . .(<.: �• � " Consistence ` � �, *;�;r � Structure • � � Mineralo � � � � HORIZON.IV DEPTH - � ' Texture rou � . Consistence '� � Structnre � '�.;':;i i_.: - • _ - 1 Mineralogy 1 �I, ' , , _ ----- - - --- - - _�- -- - _. � SOiL WETNES� - - RESTRICTIVE HORIZON � SAPROLIT'E � 4� w j�►?�. CLASSIFICATION . LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATION BY:-1� LONG-TERM ACCEPTANCE RATE: .2 OTHER(S)PRESENT: � ' REMARKS: LEGEND .andscane Position , . R-Ridge S-Shoulder L-Lineaz slope FS -Foot slope N-Nose slope CC-Concave slope �CV-Convex slope T-Terrace FP-F1ood plain H-Head slope T�xt�c. 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