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244 Tittle TrailAccount #: 990004171 Billed To: Tommy Lowder Reference Name: Proposed Facility: Residence ATC Number: 4572 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5811-65-0225 Subdivision Info: Location/Address: Tittle Trail -27028 Property Size: 15 acres **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 Tank Date ��"z� Tank Size lepO Pump Tank Size System Installed By: �K j�L"E.H. Speci ist: to a� i DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 �( (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004171 Tax PIN/EH #: 5811-65-0225 Billed To: Tommy Lowder Subdivision Info: Reference Name: Location/Address: Tittle Trail -27028 - Proposed Facility: Residence Property Size: 15 acres ATC Number: 4572 **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 FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type 1A #People #Bedrooms _#Baths Basement w/Plumbing: T Basement/No Plumbing Commercial Specification: Facility Type #People #People/Shift #Seats Lot Size L ype Water Supply I Design Wastewater Flow (GPD) 2W Site: New of epair S stem Specifications: Tank SizeWD GAL. Pump Tank _GAL. Trench Width -S� ' Trench Depth Rock Depth (2.,, Linear Ft. L4 I�► STi2l ��l As stated in ^ 5A NCAC 181A.196905'Other: «•r a�cn L-9 use act;cpt����rx;s a� Required Site Modifications/Conditions:•- ( K ke-up 10cW-,p4& 00-L -T i T T L t N Z4 the Davie County 8:30 - 9:3& ironmental Health Section for foal ins; on the day of installation. Telephone # k PiZe?'-t 1� 011 Enviro e Zth Spfalist —(::: DCHD 11/06 (Revised) ON It 1015 sr - M tr1 J• of this system between ;1-8760. Date: AL;�t1��1 EOTE EVALUATION/IMPROVEMENT PERMIT & ATC avie County Environmental Health A N6 2007 I P.O. Box 848/210 Hospital Street Mocksville, NC 27028 E[N! ','4MEPJTAL HEALTH (336)751-8760/ Fax (336)751-8786 App ica ion to vement Permit Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing Syst m ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed L, Lo,.0 o -oz Contact Person /ocn ry-! 1 Billing Addressy5! i -7 ❑Yes 2No Q,Q , Home Phone 334--- 34-._City/State/ZIP City/State/ZIP � rd , e , 7 D CZ- Business Phone 33(-- 3 4i `=t - `5 3 3c:) Name on Permit/ATC if Different than Above. Mailing Address tate/Zip PROPERTY INFORMATION *Date House/Facility Corners 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 plan, no expiration with complete plat.) �� I Owner's NameT G1] p-1 �/ (, . v wy -� P Phone Number Owner's Address City/State/Zip Property Address l % -� (.rz C r< CityrYl o 6 (--1 S' u t' ( I � Lot Size 15 /- C 1Z p 5 Tax PIN# 51 / 5 Z Z! Subdivision Name(if applicable) Section/Lot# Directions To Site: (DO I - N 4-o L i � � G �Q, G � i� l) r -, -f- �/ J I � 4-0 41`� i l � I 4.11 L/ '✓ Ip �'� W le Iu /` .L �-y / ,vw 6 A i- 5 Cc? v r- is &J i u -- 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 2No Does the site contain jurisdictional wetlands? ❑Yes R'No Are there any easements or right-of-ways on the site? ❑Yes 2No Is the site subject to approval by another public agency? ❑Yes BNo Will wastewater other than domestic sewage be generated? ❑Yes Leo IF RESIDENCE FILL OUT THE BOX BELOW # People 3 # Bedrooms I # Bathrooms 3 Garden Tub/Whirlpool ❑Yes []No Basement: ❑Yes P(No Basement Plumbing: ❑Yes XNo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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: F1 onventional ❑Accepted ❑Innovative ❑Alternative ❑Other, Water Supply Type: ❑ County/City Water blew Well El Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes "o 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or �sttaking the house/facility location, proposed well location and the location of any other amenities. t�jV, c ,", -��`� Site Revisit Charge Property er's or owner's legal representative signature D 1-16—.07 Date ate(s). Client Notification Date: EHS: Sign given ❑Yes �Ko Account # q/1 Revised 11/06 Invoice # I EC \NJ V APPLICAJQN SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street ENV1RONh4EN1AlHFA�iH Mocksville, NC 27028 gAV1EC0Ut1T`r (336)751-8760/ Fax (336)751-8786 Application For: ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed ? Contact Person 1 1 m A wr .-N bhi p.- h ( Billing Address C, Home Phone 3,1(,_ qO- City/State/ZIP Business Phone 53(0- 391'r 'Dr�_ Name on Permit/ATC if Different than Above, Mailing Address City/Sta PROPERTY INFORMATION *Date House/Facility Corners Flagged A�3 - �?- 11 4= 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 Ian, no expiration with complete plat.) Owner's Name ( tiUrn�r� �� 1�' Phone Number Owner's Address City/State/Zip Property Address Le -7-r A S I City r J< Lot Size % (`P Tax PIN# S¢ I -1; O Subdivision Name(if applicable) Section/Lot# Directions To &1641V OC --F L, 0 (A (1 okw.ck M If the answer to any ofVie following questions is "yes", supportinff docu%Intation must be attached. Are there any existing wastewater systems on the site? ❑Yes @l�o Does the site contain jurisdictional wetlands? ❑Yes 1:X10 90 Are there any easements or right-of-ways on the site? 0 Yes Is the site subject to approval by another public agency? []YesAo Will wastewater other than domestic sewage be generated? []Yes C1lo TF R1P4Q1n1PNf'1P FTT T. C)TTT TNF RC1X RPT.C)W # People v v.# Bedrooms_ # Bathrooms_ Garden Tub/Whirlpool Yes ❑No Basement. p'i'es No Basement Plumbing: ❑Yes to IF NON -RESIDENCE FILL -OUT THE BOX BELOW Type of Facility/Business 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: (VConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water VNew 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 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Propertt owner's or owner's legal representative signature Date(s): !+ Z y�� /; Client Notification Date: Date T EHS: Sign given ❑Yes /0 Account # 4171 Revised 11/06 Invoice # 5793 r 808 d6b8'Z 0 � qZ CSZ6 N V6b8 Z 895 5zzo ze uw Y �IAeo " g mam zo UW G PN i r i / / / / oz90 aI 2 __l i s �H a , 2 849A 9753 Q 251 APPLICANT INFORMATION Account ' #: 990004171 Billed To: Tommy Lowder Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #:.5811-65-0225 Subdivision Info: -- Location/Address: Tittle Trail -27028 Property Size: 15 acres..; Date Evaluated: 2 Q r On -Site Well Community Auger Boring Pit Public FACTORS 1 2 3 4 5 6 7 Landscape position F '3 Slope % S HORIZON I DEPTH O -1 0- C- I Z © -r Texture group t✓ CL G-- Consistence; �. _r SS . 7 ,� -Structure Sok 5 S < Mineralogy el -Ty C� } HORIZON II DEPTH -32— 2 j - L( ^ Texture group Consistence G SS S ` S Structure ?flc _ k A. G C Mineralogy HORIZON III DEPTH Z fi — Texture group . Consistence Ifr Structure P < A?-., ft Mineralogy -1- HORIZON IV DEPTH -3 C F Texture groug 1% oS Consistence ."Structure VL_ Mineralogy SOIL WETNESS - '^ RESTRICTIVE HORIZON Z SAPROLITE ) tJ CLASSIFICATION PS u1 S ; -34 LONG-TERM ACCEPTANCE RATE 2 b •27 ^ '- o, 2S SITE CLASSIFICATION: PS LONG-TERM ACCEPTANCE RATE: REMARKS: _ EVALUATION BY: LEGEND OTHER(S) PRESENT: Landscape Posifi n 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 Texture 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 MQisi VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm I'LA NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed LYQtss 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 - gal/day/ft2 DCHD 05105 (Revised) ■■■■■.■■■I.■■■■■■■■/.■■■Sir~trl■r■.■■■■■■■■■.■■■■■.■Il■■■■■■■■■■.■■■.■■ i MEMNONMEMNO: Monson �lMONOMER E ::::::A:::C:: 'A u1 4 ,o �R/4 apt. RUTH DB. 6q ET 'L R v v� rod` G 171Qe' h �• G ip" 2�^4 +� 41 Q n/ M a QQQ stone 6 O M� w ivO cb """.i+. 83• p6' 32" :E -- a., �, ego• y �Q 972.99 Lalp O eip �alp -� O � J v AREA 2:15-0535 ACRES _ w O fD n tP M M O co 1412.00 w � nip I � AREA � 15• 0534 ACRES CAR m o D w M .'_ N 64'.35' 1i",.W 12.53 I' nfp 20 P�OPOSED EASEMENT AREA15:0535 ACRES a SEE j FOR SIP S 05° 40' 59" W 141: 36 ; 185.76 �I r r4p 20 easement — r ' ri SEE D.B. 96 PG. 141 'I AREA 15.0 EASEMENT 15.0 35 ;,i CHARLES W TIITLI ACRES D8.139 PG. 717 ..�'..� 1414.66 :. /` . f -alp Davie County Environmental Health P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004171 Tax PIN/EH #: 5811-65-0225 Billed To: Tommy Lowder Subdivision Info: Address: 8497 Lasater Road Location/Address: Tittle Trail -27028 City: Clemmons Property Size: 15 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: effl& ❑Repair ❑Expansion Permit Valid for: ,2'S Years ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms 3 # People BasementErtasement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): � Type of Water Supply: ❑County/City 9<11 El Community Well Site Modifications/Pt Conditions:t -0a %1Z �^ Site Plan N Environmental Health i.p.11-06 System e LTAR Initial �7Jo.I-1l. 2 Repair G1 a1e:�1Tt���L cam. A o" c7l-' 'S:0' Hoch Date Jas _10,.,_07 09:25a Tommy Lowder 336766-4071 P.2 jf -3-36, 3 r�^ 5330 d z � � k S� O c� Q, 7-1 #1 E 172 . `b