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165 Turkeyfoot Rd (2)DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax 4 (336)751-8786 OPERATION PERMIT Account #: 990004237 Tax PIN/EH #: 5801-21-5621 Billed To: Palletone Subdivision Info: Reference Name: Location/Address: Turkey Foot Road -27208 Proposed Facility: Office Property Size: 26.56 acres ATC Number: 4605 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article I I 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: IIBW J"�S.T. Manufacturer Tank Date Tank Pump Tank Size System Installed By: . 4PW "Dl)kirJ E.H. G t,t b �t c� f DCHD 11/06 (Revised) 2 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 #: 990004237 Billed To: Palletone Reference Name: Proposed Facility: Office ATC Number: 4605 Tax PIN/EH #: 5801-21-5621 Subdivision Info: Location/Address: Turkey Foot Road -27208 Property Size: 26.56 acres Site Type:,Xew ❑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 Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type }-([,jam # People # Seats Square Footage(or Dimensions of Facility) -"%ZC�> (I ZX(cD-) Lot Size�p, f -IO A6�6 Type of Water Supply: 21!ounty/City ❑ Well ❑ Community Well System Specifications: Design Wastewater Flow (GPD) 100 Tank Size IC/VGAL. Pump Tank GAL. 1% of i Trench Width � Max. Trench Depth 3y Rock Depth 12 Linear Ft. --rte, � r � Site Modifications/Conditions/Other: 1 tJ5�LL � C ►-� w►` KE � `J �{� � 1 L171 rA . / _ ,--% . _ . — _ _ c Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 - 9:30a.m. on the day of installation. Telephone # (336)751-8760. . —1-' As stated in 15A NCAC 1FA.1969(5� accepted, Systems relay also be use ��C.e-7- AfMoK , #7 'q I JO'? Environmental Health Specialist � � � )Dato-t DCHD 11/06 fKeviseill`--- - ��----_---=---- K N Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004237 Billed To: Palletone Address: 165 Turkeyfoot Road City: Mocksville Reference Name: Proposed Facility: Office Tax PIN/EH #: 5801-21-5621 Subdivision Info: Location/Address: Turkey Foot Road -27208 Property Size: 26.56 acres **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: ,flew 13Repair ❑Expansion Permit Valid for:�Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People 2 # Seats Square Footage(or Dimensions of Facility) "-728 C t2xt o� Design Flow(GPD): IC -10 Type of Water Supply: Zt-ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair 62 r t Wix i 62 r Wix � a 62 r A P� � VOW- V I (� CAT OR SITE EVALUATION/IMPROVEMENT PERMIT & ATW O 6 �Q01 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 pplication Q Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ,X Both e pplication: kNew 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 & I f l rQ /1 'e- Contact Person %-nGc 1l j y Billing Address / 1, 5' 7&(,, ke y foo t ^c<«l Home Phone City/State/ZIP _ AA,-cAS ✓`, 11e ",V L, Z70 -:IK Business Phone 3 3 -Y 1i 2- S -a- 5 Name on Permit/ATC if Different than Above 11'a Ale to, 1 F Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: q Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's sName- t* .: �s z Phone Number r Owner's Address City/State/Zip Property Address City Lot Size_ ;�_C , S—& A Tax PIN# Subdivision Name(if applicable) _ Section/Lot# W ions To S' e: (L 4 W . �'Yl e�� i P K(, (��rn/ / ln f. L11&P,t� f06f C If the answer to any of the followiiig questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes KNo Does the site contain jurisdictional wetlands? ❑Yes ANo Are there any easements or right-of-ways on the site? ❑Yes ENo Is the site subject to approval by another public agency? ❑Yes ©No Will wastewater othei than domestic sewage be generated? ❑Yes SNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Te,,, ,,,- 4i^� O t f" e r Total Square Footage of Building V # People # Sinks # Commodes � / # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system reque§ted:.00onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 9 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 If yes, what type? R No 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. Property ol6er's or er's legal representative signature --41 2 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # � /V / i LU cVdt7 .Q 65) 1 )VIC I .m BZEB rI i (v 99' 9z) t8Ly1 O 1 •I 9� O I tiEgS m (VL9' S) �• b0B6 �N 19021 � v (V969) n I � d J O �) 009 (6S9) 2 m (VEL' Z) 4 �._' l�^.,�,�" ,. k!n: "�yt��:��e"���7` "�Ep'�i . �.. .�� �u�:,, � �.; ��� I� � � r � �aiYr� ,� �.;�.„ � � ��'����^> P' .`�� `� ia . . . \ „at� ''�� I • �� . � x � I � �.. ��i .�i .. . . '�".s.^, . � � ., I .. ,�.�l�fl� .. .. � , agwa,;��� "��.� �:.�i� � , �� � ♦ Ir », �; -a.. . '- ` . . � . . �+&t°^I.'�� . �..k���_ . ... . ��J�', .t . � x?o ^ a ��r ,� a � ��' � s ' � `�� �A �. '�" �:.+w � � _ �� � i a . � a - " �. .. ,� . . . '�:h u�".' 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CeB2 = ��32 117 �. 114 � .��� _ �� � � � � . . « �g�) 2�� �' I � :: _ ,.,., 281 li � � � _ � �. _ � � � , � .. � ,,. r � � _ _ � e � � , ` �� ,, - - ��� ,T = �� , ,. _ = r � �_ � � � ���� �� �� _ 6 � .4�A} ��� ��1 � � : ; �r � � � � 4759 � � � �� � � L ��� � r �� �� � � � �� ,.; � � � C� � � � {�.. � � �� � r �� r ����� � 9I� � � `�� 7z2 � �� � � � t--- � � .: .e�. _.�� �������� �� ���� �� � �. �� �� � � �.��: __ � �� �e . . �� �. � _ � � � _ � d � � DAVIE COUNTY HEALTH DEPARTMENT - Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990004237 Billed To: Palletone Reference Name: Proposed Facility: Office Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: 5801-21-5621 Subdivision Info: Location/Address: Turkey Foot Road- 7208 Property Size: 26.56 acres Date Evaluated: On -Site Well Community Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape sitionL- L Slope % 'T Cv o HORIZON I DEPTH 6>. / eq -6, o - Texture grow C • L . : G L - Consistence ry- 55 SP Structure 4�- I Mineralogy >X V5� Sx"/,47 HORIZON II DEPTH /H `4 - & Texture group S G Consistence f N ,s Structure GIL (4 Mineralogy S HORIZON III DEPTH YW- Texture groupGf Consistence r Structure S�� S, T Mineralogy HORIZON IV DEPTH fl& - 41 -4/ Texture group 5":" L Consistence 0�! S Structure V61.0-1 Mineralogy S: SOIL WETNESS RESTRICTIVE HORIZON - "- SAPROLITE CLASSIFICATION 45 S LONG-TERM ACCEPTANCE RATE a, O • O. SITE CLASSIFICATION: '� / LONG-TERM ACCEPTANCE RATE: 6 EVALUATION BY: G/Cl�S OTHER(S) PRESENT: REMARKS: A -R-1 MS 96' 9 CEJ*- ,4.7.3 Kltr111) '.) _ 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 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 ui VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm 3y -el 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 Mineralog 1:1, 2:1, Mixed 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■eli■■■■■■■■i�J+l�==,Giiia►i��1/!G■■Ileee■■■��■ems■e■■■����� ■■■■■■■■■■I�ee/■e■■■■■■■■■■■i(1e■■■■■[Ilruitl.:�■■11■■■■e■■■■■■■■■■■■■■eII ■■■■■■ *M■■■■ ■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■/■% el�i ■■e■■■■■■■ens■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■e■■■■■■■eur�e■■■ ■■■■■■■■I.■■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■■■■■■■■■■■■■■■■tee■■e■ ■■■■eels■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■firs■■■■■■ ■■■■■I/■■■■■■■■■■■■■■■■■■■■■■■■■e■■ire■■■■■■■■■■■■■■■■■■■■■■1/■■e■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�I■■■■■■■■■■■■■■■■■■■■■■■■■lee■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ell■■■■■■■■■■■■■■■■■■■■■■■ell■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■