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1078 Wyo Rd DAVIE COUNTY ENVIItON1VIENTAI,HEALTH �, P.O.Bax 848/210 Hospital Street . . � Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004241 Tax PIN/EH #: 5833-99-1353 Billed To: Howard Jones Subdivision Info: Referenee Name: Location/Address: Wyo Road-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 4603 **NOTE**The issuance of this Operation Pernut shall indicate the system described on the ATC has been installed in compliance with Arlicle 11 of G.S. Chapter 130A, Secrion.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.Manufacture Tank Date� Tank Size �/ d �d � � Pump Tank Size a ��--- �" `i —aZ Sk�2� , System Installed By:��.c,�c� ��<-.�:1�t�-.� E.H. Specialist: u� OG'C �. ate:��3 ��� i ; � ` i ti���� ^�� � ��� � � g� � �� f p Q �� , � � �� i� � �� i � � ��� � � l o� ( �t'� � �J�r�"�� � ' + � __..___.L.c'�� `�_�`,--- Lb� � �i'" ; I �e' .r-� CChc ar'k`f�� (' �r � � i _ , 6�k + � �``� �' . , � � ��Y � � � + � . �� J y �/� � � � ` ; � ---'�_..-�� �-�' �..�'-�V'._�� ._.__�_.-,...-_ _'_..��_'-. .- .. .._� DCHD 11/06(Revised) ��a-�,__ � �---�--� `_ � � � �� � 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 #: 990004241 Tax PIN/EH #: 5833-99-1353 Billed To: Howard Jones Subdivision Info: Reference Name: Location/Address: Wyo Road-27028 Proposed Facility: Residence Property Size: 2 acres ATC Number: 4603 Site Type: ❑New ❑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 #People #Seats Square Footage(or Dimensions of Facility) Lot Size a �rr-e 5 Type of Water Supply: �unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��o� Tank Size ��GAL.Pump Tank�/�oaGAL. r Trench Width 3�c �� Max.Trench Depth 3LP� Rock Depth �� Linear Ft. �D O –7�Yate� In 15A R'C�C $#}'�`` @ Site Modifications/Conditions/Other: �������d 5�✓st9rn:� m�N �Icn�,��5,3 ' Contact the Davie County Environmental Health Section for final inspection of this system between j . 8:30–9:30a.m.on the da of installation. Tele hone# 336 751-8760. ___.--__ I�e,. �6 1�1 � �;, L,,!� � 5'.�pT��'�p.�� 4J� � � pw�.P �1�k � � ' � �t I ���a� ���� � � I _ - -� � ����� ^ � � I �_— �_3� -- — _, F (3– '�� `S–O�'�— ; b� r ��X',� ,— ^ t `� � �—--�-5— �o� Environmental Health Specialist ��%!%� Date: � �.� '�? DCHD 11/06(Revised) , • � , �� ` ' �T� R SITE EVALUATION/IMPROVEMENT PERMIT & ATC \ � �► Davie County Environmental Health �'�j�j}� P.O.Box 848/210 Hospital Street �.`� � 2��� Mocksville,NC 27028 ' ��'' �E� ' ` (336)751-8760/Fax(336)751-8786 ��'��,��; �.. �_K�tSt1 pplic t' �;,�t:�',� t�e,�val ' provement Permit ❑ Authorization To Construct(ATC) ❑ Both e of Applic � ' . ew 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 7- �•,� � � � lv' 1 � Contact Person Billing Address .S - .' 'D•��1� � ! �"�- Home Phone .�3G?-�e'r/ - 3 t�/:� City/State/ZIP C-I�,'/►�'�T�'/�'• �.�/��m �'1�'- Z 7/0�. Business Phone 3;L� - 7 b'z-- �3 3..� Name on PermidATC if Different than Above Mailing Address ' City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Fla ged �� NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pernut is valid for 6�0; months with site plan,no expiration with complete plat.) (/ Owner's Name �Q N ('C�SIt;��.1./ Phone Number ���"'�'.3�� Owner's Address City/State/Zip PropertyA dress Vp OC�CI City � Lot Size c� �C(t'-S Tax PIN#��S 3�- 9-/c35� Subdivision Name(if applicable) Section/Lot# Directions To�S�it : ST � T � M ih� � v/�/ ' G!/"�U � C� ��J ir�'uF Crc�S.S 4�� �1�� 7(,lrN ' ( ' Li<.�j-F (.� Gr/v � ' =c� .. ��'1 " fl i' �- `lU(� ?' i�A If the answer to any of the following questions is"yes",s pporting documeh ation must be attached. t;ZrY�r/� . Are there any existing wastewater systems on the site? ❑Yes$1Vo Does the site contain jurisdictional wetlands? ❑Yes gi�10 Are there any easements or right-of-ways on the site? ❑Yes.�To Is the site subject to approval by another public agency? ❑Yes�A10 Will wastewater o7her than domestic sewage be generated? ❑Yes�No IF RESIDENCE FILL OUT THE BOX BELOW #�'eople #Bedrooms #Bathrooms Garden Tub/Whirlpool es ❑No - Basement: OYes qDF�� Basement Plumbing: OYes�01�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�H'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 C9'1Vo If yes,what type? i _ \ This is to certify that the information provided on this application is hue and correct to the best of my knowledge. 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 infotmation submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Heaith Department to conduct necessary inspections to deternune compliance�n�ith 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. . /r- -�--�••- �'���=��j� ����� � Site Revisit Cnerge Preperty o�mer's nr owner' egal representative signature ' Date(s1: ��,�- O`- ,�G�� Clie.it Notification Date: Date �HS: Sign given ❑Yes ❑No Account�# �� -�� Revised 11/06 Invoice# ' � . �� `.� �� . � �, � � ��,����� ���°`�'`G�� �������°�" �� �,� ,��'s��t�^� � � "� �'' � .��, � .� n� x � ;� '��;< < �.,,� �"" ��." �; ;` , ",° � ....���' d,�` �..�i4 O��� , � � �. .. .. p ��^�,� �,���R y� ; �- �°�� � _ � ����� � ,�; ��^�(^i ��, ��.+ � ,r^, „ � � � =.�� � ��,°� �4 � I �'�� s � �'m�.+�",�F �a �.:.s � �:..'r�� iw.�i._ � ��f � ,},. �.a »ig �� '.*�. 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N , �� � � ���e`��` �� � 2. � '� , , : : � _ ����� � � � ( f �������� , , - - 4 : . 69 � , �. . �� ; 90 � � � � �' � � ��� 145 , : . U_�_ , > > 2 � � ; �� ���_~''��� �� � � '� � fi 94 � c� ' �� �_ � ► ' • DAVIE COUNTY HEALTH DEPARTMENT r� • • Environmental Health Section Soil/Site Evaluation ' � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004241 Tax PIN/EH#: 5833-99-1353 Billed To: Howard Jones Subdivision Info: Reference Name: Location/Address: Wyo Road-27028 � 1 Proposed Facility: Residence Property Size: 2 acres Date Evaluated: � �� L �� � Water Supply: On-Site Well Community Public�' Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e position L - ' • ' ' Slo e% HORIZON I DEPTH - � U- G" -2. � Texture grou G � G G Consistence Structure /c �' � Mineralo .�( � %1 HORIZON II DEPTH — � Texture rou G f L :G Consistence ` r ✓� Structure � k . r(� � Mineralo : � ' � 1: ( ' HORIZON III DEPTH Texture rou I Consistence Structure Mineralo - ! HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .'�, , �, SITE CLASSIFICATION: � J - �ti^-S���L`-� EVALUATION BY: 1 v �Q ��G�� LONG-TERM ACCEPTANCE RATE: D'� OTHER(S)PRESENT: REMARKS: LEGEND i.andccape 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 TgxLuTg 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 �ONSIST .N . . Nlofs� VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 13.'e.t � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic S.�r1iCYurg SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky � SBK-Subangular blocky PL-Platy PR-Prismatic � Mineralogv �� 1:1,2:1,Mixed �"�� T ��''�"'�"' Notes �f- ' Y,, � 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 DCHD OS/OS(R� � . ' � , Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004241 Tax PIN/EH #: 5833-99-1353 Billed To: Howard Jones Subdivision Info: Address: 524 Mill Pond Drive Location/Address: Wyo Road-27028 City: Winston-Salem Property Size: 2 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. Pemut Type: ew ORepair ❑Expansion Pernut Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms � #Bathrooms �- #People �- Basement❑ Basement plumbing❑ Non-Residential Specif cations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 �� Type of Water Supply: �ounty/City ❑Well ❑Community Well Site Modifications/Pernut Conditions: S stem T e LTAR Initial .� �v�j Re air �c-� �Q� Q�•Z Site Plan �J - �sj' L h � �. � � \ i� I I �� � �� r �f� `4 -� . I� � P `, -�I� �Ky �,�' � I � t���` �L� � I �� ., Environmental Health Specialist Date � — o� � —d� i.p.l 1-06