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185 Will Boone Rd � _ ` • _U � ' ' ' . DAVIE COUNTY ENVIRONMENTAL HEALTH (�� P.O.Box 848/210 Hospital Street Q{� �''� Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 OPERATION PERMIT �ccount �: 989900093 "��x PIf�€fEH#: 5756-07-0091 Bifle�� T�: Shelton Construction Services S��a�i�fi4ior� Ir3�o: Re:�er�E�ce P�t3r��e:: LocalionrAdt�r�ss: 185 Will Boone Road-27028 f�rc�pc��c� F;��:ility: Residence �rn��rty Six.e: 1.65 Acres t�TC Nu�'tb�3': 5020 **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. 3I— I 0 >- �. fG� r o�o System Type: �f"/��S.T.Manufacturer �Y t Tank Date Tank Size I Pump Tank Size __D- ; ��1/'/'y--__. _y_,G System Installed By: .ri v - l( L E.H.Srecialist• Cr ��ate: � . ��. I,� � Q� � �,�C • � �� :--- --_ / ( . � y �-•��• .. �� / . - . ' � I � , � � , ., z� � �. ,� �- ��,�,, � , I � ' �� _ �� . I �� 1 � � � � � � ' I � � ` � ` � f 1 ( � _-- -------------- ._ . ______----______ -- --r� ,�._._ w, t( .��..� �2� DCHD 11/06(Revised) ' . ./ , i 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 ,Acc��nf #: 989900093 �"�x P1�€;EH�: 5756-07-0091 �ifl�s�Te: Shelton Construction Services ��k��ii�fi�iar� I��: R�€er�E�ce �Ear��e: Lac�iianiAd�r�ss: 185 Will Boone Road-27028 F�rc��c�s��;c� F��;ility: Residence I�rn�r�:r�.y S�iz�: 1.65 Acres E�T� i�Iu�'tbe3': 5020 Site Type: ew ❑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 Speci�cations: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size /, � �ua"" Type of Water Supply: �ty/City ❑Well ❑Community Well a System Specifications: Design Wastewater Flow(GPD) 3G� Tank Size �/ d GAL.Pump Tank GAL. /� /i � Trench Width 3 4 Max.Trench Depth� Rock Depth �2 �� Linear Ft. �� As st�teti in 1,�'iA I�C�iC �E3'"+ '1�?�"15f Site Modifications/C nditions/Other: , Contact the a ' Environmental Health Section for final inspection of this system between 8:30—9:30a.m. of installation. Tele hone# 336 751-8760. \ e- ��`" � b `O V" M � (� �S � r �� . fv� .`t � � a� Qo- V h � ` y � � j �� 7� 5 � ` � �g _ — �•�� h-� �2ao a --� � nvironmental Health Specialist"� Date:�3 DCHD 11/06(Revised) ; �� . � ' Davie County Environmental Health P.O.Box 848/210 Hospit�l Street Mocksville,NC 27028 � (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 989900093 Tax PIN/EH#: 5756-07-0091 Biiled To: Shelton Construction Services Subdivision Info: Address: 1257 Highway 64 West Location/Address: 185 Will Boone Road-27028 City: Mocksville Property Size: 1.65 Acres Reference Name: Proposed Facility: Residence - ' **NOTE**This Improvement Permit DOES NOT authorize the construction ofa wastewater system. An Azrthorization 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: ❑ ew ❑Repair �Expansion Permit Valid for: QS Years ❑No Expiration Residential Specifications: #Bedrooms 3 #Bathrooms�#People ) Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD)r�+�� Type of Water Supply: ounty/City ❑Well ❑Community Well �'�S Stated in 1,�`iA NCl�C 18-�.19E�!5', Site Modifications/Permit Conditions: acceptecl Sv�tPms m�;� al�,r. >, • S stem T e LTAR Initia — Re air Site Plan y ` �.��C �,'�` �0. �d� , ��`� �� 6 � h � s ' � i `�D �( �� - ' )� � � �� 5�� c� o t 5 � �w,-� Environmental Health Speciali Date �/�/� �C 9 i.p.l l-06 ------np (� . : ', � . �• . t5 lJ � Q V 15 i�PPLICATION FOR SITE EVALUATION/IMPROVEM ERMIT & ATC Davie County Environmental Health NOV — '� 2�9 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 ��IROt�h4ENTAL HFAITH ' (336)751-8760/Fax(336)751-8786 DAVIECOUNTY Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) �h Type of Application: {�.tdew Sys''tem ❑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 ��t��j� �LJti�,TI:—�t;j�o,�/ Contact Person ��'Y" J 'U L�tii Bilfing Address I�57 U S - ��% Home Phone ` �/'�c"� " ��:% 'r... City/State/ZIP �'`��5��(� /1:�� '7��'/ �BusinessPhone ��/5 —Z�%�� <,� Name on Permit/ATC if Di ferent�han Above 7(� � ��^�-`� Mailing Address 5 � _ C`c- City/State/Zip 1`� �' � I< <� �C('. ' z " PROPERTY INFORMATION *Date House/Facility rners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ite Plan ❑Plat(to scale) (Pernut is vali for 60 months with site plan,no expiration with complete plat.) Owner's Name ��' < /�"1'��,5 .,. Phone Number Owner's Address � " � �I f • % City/State/Zip ��C/j.S�'�.c', /Z.(: �Z�>�-S' Property Addr�ss City Lot Size 1 r(:,� ! ' ��'� Tax PIN# ��s�.Li ' C'U�� Subdivision Name(if applicable) Section/Lot# DirectionsTo Site: �;c� 1 5 - L. t7r��z(',�...� �� u.:,.►�"Qom�t - �.� �:-'t;_ 'vti.\�t ,�uej �� 1Y� � 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 �10 Does the site contain jurisdictional wetlands? ❑Yes �Go Are there any easements or right-of-ways on the site? �1�Yes ONo Is the site subject to approval by another public agency? ❑Yes�No Will wastewater other than domestic sewage be generated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People j #Bedrooms � #Bathrooms •�'-- Garden Tub/Whirlpool ❑Yes �.No Basement: ❑Yes 0� Basement Plumbing: ❑Yes ❑No 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 Typesystemrequested: C�Conventional ❑Accepted ❑Innovative OAlternative ❑Other Water Supply Type: ��/City Water ❑ New Well OExisting Well ❑ 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 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 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 deternune compliance with applicable laws and rules. I understand th I a '�e�p�onsible�for the proper identification and labeling of property lines and corners and locating and flagging or stakin� t u /fac i oc sed well location and the location of any other amenities. f '� ��C� ~`__ . . . ; �� ' . � Site Revisit Charge Pro erty o e s or owner's legal representative signature Date(s): '�{j",)=�'" Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# �b �� Revised 11/06 Invoice# 7/��j ' r � . . ' � . ,/ / � UrJ'IJIT—�il�pf7lJ1�1 / ' �J ` I / ' ' i�` \ /•�/ `� p �. J��S, � � � `�` � - - ��.�:�s. D''�• >S CO,sTN�� / �� \\ . , , .�'�, � p�'' 2`��1 �.i � ' . , � / �. �� ON G Gy\� ` / �- � /. CT Ej �� N /./ , /` '��`"~ S �'16'24 E �' � I wn.�7 '�°"' � --� /� � I � f �` �T�'�'16,�14 /� ` � /' P< �� / ?i E i� � . F snr�� ( ��\ � � UNE � I /� `�` /// �t � �� '� ESi OF 'CFNiER ROAp ��^'` `� � �.. I / /i \�C � 1�// 11 � ��'e�,� � /,,�1��' \ QGj �� ` I ��•�'� � � /� ` �� g%�� C� �,'�� I �,� �� c�4.��'/�/" 1 't'� N � /1• ��' � � I ./ �' �� i` \� �� 1 /� i �� t. /� i // [� ' i �A . '� � � I ,�1TADINE F. � H�LLEMAN i �� a N . _ � ,�,8. 342, PG. 718 I �� " � AREA— 1.655 A�. a�cwo�s s�. �eo� 'R/w l �� u a�R ut� s/t� _ -- � � c� '� I i _•�;-'---"" ►�+ �'" ( � _.-- � t �,� .._____- . .��- : �� _ �r' NOTES: . i �.� „�__ - �� _ , ;�� _ , � .__ __ _ - , � = " . o �. TOTAL TRACT= 1 � __-_ _- - � `�` ``�✓ o . ,_ _ - �c ' ��`� � �`� 2. TOTAL AC.= 1.655 AC I ' � __-- '� = p t� _ . 3. X= UNMARKED PQINT r J� � _ _ __ � . _._. ,, _ __ ._ __ _ . , �, ______________ _ !�� l� ( �q ,�b�-'�''�~ � ` a 4. NO NCGS GRID MONU! - . . . \ �_ . ,.�. _. . � `�� "" � . .. . . _ .,. _.. ._. 5. PROPERTY LOCATED � � • . / �, � �� ,�� . _ .. ... _. . -l�" 290.72\!/ "� . � S 87'S8'3b' M► � � � TQTAL• 3�p.7� � °N �a uriu�KEn PaNr .l.---� � � MI PIWED kOAa ' _ �J � � • �1 AT • - �, DAVIE COUNTY HEALTH DEPARTMENT �. ' ° • � Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900093 Tax PIN/EH#: 5756-07-0091 Billed To: Shelton Construction Services Subdivision Infa Reference Name: Location/Address: 185 Will Boone Road-27028 Proposed Facility: Residence Property Size: 1.65 Acres Date Evaluated: �'��- " _ Water Supply: On-Site Well Community Public --'�r Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape osition Slope % HORIZON I DEPTH ,� a > " u Texture grou � � �',' C Consistence i(� ; � Structure j� S (� Mineralo — HORIZON II DEPTH - k' Texture rou Consistence � Structure Mineralo � HORIZON III DEPTH � Texture rou � Consistence , Structure � Mineralo r HORIZON IV DEPTH Texture rou Consistence S tructure Mineralo SOIL WETNESS RESTRICTIVE HORIZON / SAPROLITE " / „/' CLASSIFICATION LONG-TERM ACCEPTANCE RAT � � SITE CLASSIFICATION: EVALUATION BY: F • � ; ,,, � LONG-TERM ACCEPTANCE RATE: v• O'� OTHER(S)PRESENT: REMARKS: �(J l'�S /yI LO/'�� 1•1 �lic�� /JZ Q.� LEGEND i,andscaoe 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�x�u'g 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 C'ON�I�T�,N .E 1�415� VFR-Very friabie FR-Friable FI-Firm VFI-Very firm 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 , tructure SC -Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralo�v 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 Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) TTAR -T.nno-tPrm arrantanra ratP_ aal/rla��/ft7 Tl�TTT ncinc m___:__„