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1065 Wagner Rd � . , � DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 , (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT ,Accnunt �: 990005876 '��x�l�€.�EH�: f3000000515 Billcd 'f'o: Freedom Homes Sia�r�i�ri;iar�,in��:; � ; i R�fer�E�ce fVanie: �2or2e_..,IoN�s` LacationiAdc�r�ss: WagonerRoad- . f'ro�c�s�c9 ���i(ity: Residence -J Pri���rty S�iz�: 2 Acres . � ATC E�urnb�r: 5936 ,, . 1�ti 1�jY **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC has been installed $b in compiiance 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 S 0�'� Tank Date -3/ Tank Size »a0 Pump Tank Size -� Bedrooms: � System Installed By:✓�� �Q(��Q'-� Installer# Date: l� /Z GPS Coordinate: � � ��Y , / ' �"�i 2• If�' r�-��' F��(L � �� ,, � �d �d � � , � Environmental Health Specialist Date: � V'- DCHD 11/06(Revised) , , DAVIE COUNTY ENVIRONMENTAL HEALTH �� � � P.O.Box 848/210 Hospital Street � Mocksville,NC 27028 �I � (336)753-6780/Fax#(336)753-1680 rn � 1 REPAIR IMPROVEMENT PERMIT �' AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Accr���t #: 990005876 '��x�1�I.%�H#: f3000000515 BiEl�d To: Freedom Homes SuE�s�i�i�ior� irif�: Refe►��E�ce N����: LacaiionrAddr�s�: Wagoner Road- f�ropc�seii F,��:i€ity: Residence � ��c���r�.y Siz�: 2 Acres wT� NU�v►�r $�3(G' Site Type:Repair O Expansion O a��"�1��3fhis���uthorization 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 IP/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��� Type of Water Supply: �County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD)��Tank Size l�� GAL.Pump Tank_�GAL. Trench Width�� Max.Trench Depth�� Rock Depth/�A Linear Ft.� Site Modifications/Conditions/Other: p�~�o Q�'d G(���^t 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# 336 753-6780. �a, _ -_ � � �.� _ a• �' � , �—�, �'/6 � '"" �Q/..�( �� �`. �� I°`��"� � -. �� .. � �� � � �,5 V �� a � �9 ) Environmental Health Specialist Date:� (' 2 DCHD 11/06(Revised) . . . Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005876 Tax PIN/EH#: f3000000515 Billed To: Freedom Homes • Subdivision Info: Address: 1124 Charlotte Hwy Location/Address: Wagoner Road- City: Troutman Property Size: 2 Acres Reference Name: Propo*�NOI�E*��ThRs�mp o ement 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: �iew ❑Repair ❑Expansion Permit Valid for: f�S Years ❑No Expiration, Residential Specifications: #Bedrooms�#Bathrooms 2 #People �/ Basement0 Basement plumbing0 Non-Residential Specifications: Facility Type � #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): . •"'y� Type of Water Supply: �County/City ❑Well ❑Community Well � Site Modifications/Permit Conditions: S stem T e LTAR Initial V v Q l�G � 3 Re air v � C Site Plan • ' � / ' L����� - . _ � —� .s''� ' � .�i���� ��y'� - - � � � � �� �--�� --a.� ���� � , � i � _ �.\ . �. ��;1 . _ � ���-' � - _ � ==-�---�-- ,---.�-.._. �� � � Environmental Health Specialist � Date cs��/� ` i:p.11-06 � , , . ' � , . i . APPLICATION FOR SITE EVALUATION/IMI'ROVEMENT P ATC � �►�� � Davie County Environmental Flealth ��A � P' P.O.Bog 848/210 Hospital Street 'r��y � �� , � ''`u;' ; , ^�"'? A` Mocksville,NC 27028 � � y�_ , � �� �D�� � (33�753-6780/Fax(336)753-1680 ��< ��': ��_ Application For: te Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) �Both���y Type of Application: �ew System ORepair to E�cisting System ❑Expansion/Modification of ExistinQ System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TI�REQUIlZED INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLLETIN for instructions. APPT,TCANT TNFnRMATT(�N Name L W ��� ��fGE�now� ,I-�Qytiti�.S Contact Person ��'I C �it/��L Address 2 ' � v-�} c.�,w Home Phone '7fj�- J�Z8-']p/d City/State/ZIP j��crf��� (��G 9_.�1 fo(� Business Phone 70 L-��'��(n!�,� Email � C`La. o� vu ,C��1 Name on PermidATC if Different than Above ' 0��� �tiFcS Mailing Address �38 �'�.v,o �o�£ l�oP City/State/Zip ,l�1/dlCr'r3�lGG L J�Jr PROPERTY INFORMATION *Date House/Facility Corners Flagged /2 �2 NOTE: A survey plat or site plan must accompany this application. Included: [9�S"ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site lan,no expiration with comj'lete plat.) Owner's Name "C�AP-C�Y �ON�� �l��A,�CL�1�'� ��t,�. �{E Phone Number 7�~�P����a3(`C Owner's Address l�Q�/V�y��oCS� �,oc�p City/State/Zip�(9o�sSu«« w�, Zs��17 Property Address I�oT� Z tN v�e r (Za- City (Mvc�-scn I I c Lot Size 2 -�d Tax PIN# U Subdivision Name(if applicable) Section/Lot# 'Z_, DirectionsToSite: SumM�+ �r� -}•�ih c�� o�n C'A���t�flt_- �hvnl?-�f ON ('oL•,�r � ,�i y�-o� (oQ l�n�f 15v1 C��a.�v �'l�vrc� Lc� a�► U,a 4 Nt� Cv f �s v.� I1�' LY�GG�'S -f,ra� /Q f�� 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 t/No Does the site contain jurisdictional wetlands7 _Yes ✓IQo Are there any easements or right-of-ways on the site? Yes �To Is the site subject to approval by another public agency? Yes ✓No Will wastewater other than domestic sewage be generated? Yes �o TF RF,�TnF,NC;�,F1T,T,nI JT THF,RnX RFT.nW #People �_ #Bedrooms �_ #Bathrooms Z Garden Tub/Whirlpool B'1'es ❑No Basement: ❑Yes C�'o Basement Plumbing: ❑Yes C�o JF.NnN-RF,STDF,NCF,FTT,1„niJT THF RQX RF.I,nW 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 Type system requested: ❑Conventional ❑Accepted 1�I2�novative ❑Alternative ❑Other Water Supply Type: �ounty/City Water ❑New Well ❑Eausting Well ❑ Community We�l Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C3� 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 stak' g the house/facility location proposed well location and the location of any other amenities. --�^�''`�� ��,�� Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 5'(l�'� z Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# � b 7� ��— Revised 11/06 Invoice# �-TC�N�-# �l�fS / o � L ' • u ' ' • ' ,.� �J 5�, � a� � � ��� �. �'" � �� U � ,I 1N/C/L�P.6 � � 1�.�'��� ,�o(�"�'� ��'� � , � ��:��a� 6�R. �.���� ��� � �. ,q� 2 •��y �Ye�� 1" EXISTING �� �m-����„��0 SOLID IP,ON �� �� �,: . � ��� �' �,' ��� � ����� �}� � ' ��� I 6��'� � � '9 � � NEW "" � .. ��71 IRON �����.c�,,,,.. � � . . '/ �3 p��a �? �`iU->> ��,���'� � ��� ��� � � 3 �d31C/db'�r �t� J-��` '���J�` , �'��� RIR SP�IfE � s�CaeFm � "\ `�' / � , NElY �� �`C/L RG � �� E1�ilrJNE . e� _/i-.S' �w-���' �l , ��� �s ��: �_ ��v v �• �--- (�~�°� ,��' � U�,itUUICEO m� '��'e" POII�R � 3 � ° � _e�� _ EXiSTInG . 4 p�� `� � IRCN � �) \v���" �� -. ...:...:_ . `4 d `�� _....�... � _. .......��� � � .. `�—�f � �: .�.���-�v��� �(�o. � � � 7 f��.��� �.�. -���`G' �'o�I ... .^�C�L IRE ..`'� � � � � C�, �� 1� �s�� ~ � � � � �l� ` � �.�i� � �,/ � �! �, RIR SPiS(�• . ��'� � . �� . V. � IN C/l i.',�� -' o ��� s �.°��� t:f �o ��� 0." ,� ��� �—.m �_ na� u ��� G�K-� � `" `/� Ui�.;AURNED �_0���' ���� ..�, , !'OINT a � ��Q v o � � = n'�..,. �''O7� � � � ¢ S o '� t J �' 4. � .L. �, �IRONJC I� ` , � .�9��1.��'� � �. � .�o�o ��� _�^ N �s �.y/ ' � /�, c. a�d o �`3 ii. � � P � `;�=-� C,�, � ;; � � � � ���i �isrir�c� r�tv� � Que� �' ��+ ���. iRor� �r��-,.��...a-� l31.i1•# iFo�i � c �� �> �w� ;s%„ �'tT� `b� p ��`i 88' -`� �� ---"-,. =:z�•-.��. —��,y� E � @ �,*�:S a�T-� ' t 'r"`�� _., �..v o v e�-.� � e;�r � � ' � ' � ' � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site,Evaluation � APPLICANT INFORMATION ' PROPERTY INFORMATION Account #: 990005876 l'ax PIN/EH #: f3000000515 Billed To: Freedom Homes Subdivision Info: Reference Name: Location/Address: Wagoner Road- Proposed Facility: Residence Property Size: 2 Acres Date Evaluated: � �o �z Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition Slo e % G% � e 'o HORIZON I DEPTH � Texture rou C Consistence �/ Structure y � �i�, f G Mineralo /.'� � �.% HORIZON II DEPTH .. O %3 Texture rou Consistence U Structure Mineralo 1 HORIZON III DEPTH -� Texture rou Consistence Structure R, ' G Mineralo ` r� HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION �-r' LONG-TERM ACCEPTANCE RATE • ? SITE CLASSIFICATION: �/ EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ' OTHER(S)PRESENT: REMARKS: ' LEGEND i.�ndscaoe 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 Tcxtur� 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 .oNsr�T .Nc . MQist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely�rm �Y.e.t NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic a�YT11CtuI� SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineraloev • • 1:1,2:1,Mixed lYQi�S 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 Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance ra[e-gaUday/ft2 DCHD OS/OS(Revised) ■��■■��■��■■���■�■��������■■�■■■�������������■■�������■■■���■■■■■■ ■���■��■■�■■�■���■■����■��■■e■■■��������s�■■■■������■■■■■■■■����■ ■�����■�■■■�■■���■�■�■�����■�s■■ ■���■■�������■���■����■■■�����■■ 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