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230 Wagner Rd � ' DAVIE COL�NTY ENVIRONMENTAL HEALTH ' �. ' ,"' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 � OPERATION PERMIT �cc�ur�t #: 990005636 �'ax f�l�f:%�H�: 5820-02-9638 Site#2 Bi!lc;c�Ta: Michael and Stephanie Burton �u�5di�i�io►� Ir�fo; ` Refer�r�ce €�a��: LocaiioniAd�r�as: Wagner Road-27028 Pro�c�sQc9 F;��:9lity: Building Pro��r�y S�iz�:: 46 Acres . - . ��*��*The74suance 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.Manufacture�� Tank Date 2_� Tank Size�Q Pump Tank Size System Installed By:�/"/R/L /�� YI�,Q� E.H.Specialist: / G�W�I( Gtti�'ate: ZO/ GPS Coordinate: _..._;,,� �✓ ,� � . . ! � � \� � � I 3 , . � ?Xll7l�' �'' W ��W v 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 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION ' Acct�ur�t �: 990005636 T�x�1�€i�N#: 5820-02-9638 Site#2 � Billcd 7�: Michael.and Stephanie Burton Su�ic�ivi;iori I�f�: . Refer�r�ce i�a��e:: LocaiionfAdde�ss: Wagner Road-27028 f�ro�c�sQci F�cilit3r: Building 1�ro��rty S�ix.�:: 46 Acres Site Type: �A1ew �Repair OExpansion a�TC �lumbe��: 5741 **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 Specitications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ - Non-Residential Specifications: Facility Type Q a�� #People #Seats � . Square Footage(or Dimensions of Facility)��' Lot Size CC Ll •G�j' Type of Water Supply: ❑County/City C�.Well ❑Community Well �6 ,�r System Specifications: Desigr►Wastewater Flow(GPD) � �� Tank Size�GAL. Pump TankJv GAL. �� /i � Trench Width 3� Max.Trench Depth�� Rock Depth �� Linear Ft. � Site Modifications/Conditions/Other. AS stated in 15A NCAC �.SA.1�69(5 V 1 V Jv Contact the Davie County Environm$ntal Hea Sec ion ' ectio ' stem b tw 8:30—9:30a.m.o�t�da of install� ` Tele hone# 336)751-8760. / ` � / � - g�o / � � �� N� � . o F��,� �, � \ � ` , 1 \ �� . - . � � � . 1 I�`�3� ��r";� d�o�°� � Environmental Health Specialist Date: ��7` /v ' DCHD 11/06(Revised) ' ' ' , ' ; Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 . IMPROVEMENT P�RMIT Account #: 990005636 Tax PIN/EH#: 5820-02-9638 Site#2 Billed To: Michael and Stephanie Burton Subdivision Info: Address: 133 N. Claybon Drive Location/Address: Wagner Road-27028 City: Advance, Property Size: 46 Acres Reference Name: Proposed Facility: Building **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. _ _._. � ---- ._._._. . ._... __ _. _ ..--.--_. .. __.._. _ ___._ .�_ _ ._ ______ _ ..__.._ Permit Type: QNew ❑Repair ❑Expansion Permit Valid for: �5 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms�#People Basement�ement plumbing�� Q ��o// 8ta��j Non-Residential Specitications: Facility Type l�A��^ �� #People �#Seats ' Square Footage(or Dimensions of Facility) y$Ob Design Flow(GPD): �� Type of Water Supply: ❑County/City �1 ❑Community Well 1�15 StF�ted in 1.,;� N�A . �r, ��.•.,,_. Site Modifications/Permit Conditions: �,^s� � v ^� � ,f' J:7tf�t;, in�,1, +f;;,, h,., � �cat� S stem T e LTAR Initial cG f �• � Re ai c -f O• �S Site Plan , ,�.d � ��u � .f�G �� ` 5 C� a a ��` � � L �;� . � Q u�; `' - � �o � � .. � � . ,� � ; . 1 /Q � �� ` �t..Q �N -�� • Environmental Health Speciali Date �� i.p.l l-06 � � �-ti. ��`'�� OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC t Davie County Environmental�Iealth �.� � '�U�� P.O.Box 848/210 Hos ital Street �a� � 2 P � � Mocksville,NC 27028 .::.:,,�,. ��; __ _ _ (33�751-8760/Fax(336)751-8786 Application For: ite E�v uation/Improvement Permit ❑ Authorization To Construct(ATC) 0 Both Type of Application: C�Qew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Faciliry ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION n 33�-5�ev-�[.�c�'j Name to be Billed � � .o � �<� ntact Person 1��1<<�fl�L C��-�o� Billing Address �N p Home Phone �7 �- �t� S�-( City/State/ZIP ,�, Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged �`��- � NOTE: A survey plat or site plan must accompany this application. Included: ite Plan ❑Plat(to scale) (Pemut is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name o Phone Number��(,�7�(- 7 S c��— Owner's Address� City/State/Zip � c�, Il� �. Property Address L.V qtc-� iZ ,�c�t�o� CitY � � 2 7a a--� Lot Size ''(t. �,,L�-t S Tax PIN#P�• ��f Do�113� c / Subdivision Name(if applicable) Section/Lot# V/7��#� Directions To Site: - o � ,�,.� � �ti l�� If e wer t y of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes L� Does the site contain jurisdictional wetlands? ❑Yes C�o Are there any easements or right-of-ways on the site? ❑Yes C�3'G�o Is the site subject to approval by another public agency? ❑Yes C�'1Go Will wastewater other than domestic sewage be generated? OYes C�� IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: OYes ❑No IF NON-RESIDENCE FIL OUT THE BOX BELOW Type of FacilityBusiness "� Total Square Footage of Building - H�o�#People #Sinks� #Commode �_ #Showers_____�_ #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested;, onventional ❑Accepted ❑Innovative ❑Alternative OOther Water Supply Type: ❑ County/City Water CYNew Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes � 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 tbat 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 information submitted in this application is falsified or changed. I hereby grant right of enhy to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and rules. I understand that I am responsible he r identificarion and labeling of property lines and corners and locating and flagging or staking the house/facility lo ion, opose well loca6on and the location of any other amenities. r Site Revisit Charge Property owner's or owner's legal representative signature Date(s): s��_�� Client Notification Date: Date EHS: Si iven �Yes ❑No J �g �Y. " Account# �(p� Revised 11/06 f�d, �' Invoice# _/��_ � '�� f ��0,`�.5� �GoMa�s GIS Page 1 of 6 ,,, ^.,, I i � � I --i � ' - ----� � __-_� : � �� --i , �� I I _ _ ------a � � - � ��. I � ��, -��r.�I�� c�-�l1cr i i � i � �a � �i , � , � �� i ! � _ � � � � ; _� �I rw...' v.....r..wS ...H?..v ,i".:fw,,,u " - � I «,w�� , ' ��.: .mva .._r.y . . f� -' ��-�-r �:'..µ.u.��..�-J- ,....�.�.,,.�;.a. . — �� ,,, s �... � ...- .,_ w... �3� � -- __ �pqr�,� g �r,� t`'" � �,7 -- � �i ' �1 1 S ( R .'�'! _ K,i �• {,;��' ,, q� , -� . . �� . �,�_��} �� , '}.,�.'�. a i 4�`��,m . ��_ __ .�,ti� . � I •"v��a. . �� '.�;: *f:,y�h 1 __I,� . ��+ ' � � -..4 g . I "4�4h,� . �3 I N� 'K.� i I �,\`�1 5�x . �i . �� '.� d � / /( 1,\ �gi [{� I �� / y\1� ` t�� -t r,.��,w 4'l-�`T_ -�"�;�".�a. )."';,�,'.,r �.'�.=.4� =''_'-- ___. ; `--- LJ�` 1 5i� � -�_ .�"�'�� p � L T i��I i— ��,il,�., ., �_i�,,:(;, -. —i--y CL ,. ._ �. � � �t 1 i � � �I � � -"�-;-� � � I � �I�I � I ' I I I i � �•+�� - �1 i i � � _ _-,,,,_�_ , i '",. _.J j `1__ � � � i � �i � � _- _= � I '�a,� � I i =-,'t �, _1 �-_:_-__ � � i �-- __� �1��L i 's �_____-: �-__ � i �------ �� -_ � ��_-_-_= — � I j ; ; __ __ -�---r--,, , , , ; � -= == � � � � � ; - - i _J �, � --Y_ � � ; � � ,� .� � ., -�____ __� ! __ ��'L'e�111 f�'i � � 1�t ti L—� . � � , � htt»•Uman.c r.n claviP.nr. iic/C'rnManc/man/man.cfm?C'FTi�=41�9X�(',FT(�KEN=61640881 2/21/2011 ,�, . -.�, � DAVIE COUNTY HEALTH DEPARTMENT ' ' Environmental Health Section Soil/Site Evaluation , APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005636 Tax PIN/EH #: 5820-02-9638 Site#2 Billed To: Michael and Stephanie Burton Subdivision Info: Reference Name: Location/Address: Wagner Road-27028 Proposed Facility: Building Property Size: 46 Acres Date Evaluated: 3"" � "— l�_ Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position L-. Slope% HORIZON I DEPTH 0- �— Texture grou C Consistence ,n - Structure 5 � Mineralo ^ $ ^ � HORIZON II DEPTH Texture rou Consistence Struc[ure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE CJ , / �// ' r SITE CLASSIFICATION: � � EVALUATION BY: 7��v� �� S LONG-TERM ACCEPTANCE RATE: � OTHER(S)PRESENT: ��p'e�� REMARKS: ' 4� 1�t � � it i /'C�10 t Y��'/' IGv1 LEGEND i,andsca�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 T�xtnr� 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 ('ONSISTENCF, 1Y14i�f� VFR-Very friable FR-Friable FI-Firm VFT-Very finm EFI-Extremely firm � 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 Mineralogv_ 1:1,2:1,Mixed LY9t�� 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) iTAR _T.nnv_tPrm ar�pntanrP rafP_ aal/�ia��/ft7 r�nrrr�nc�nc m___:__��