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138 South Madera Drive Lot 9_ • . DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax 4 (336)751-8786 Account #: 990003524 Billed To: Greg Parrish Reference Name: Proposed Facility: Residence ATC Number: 4637 OPERATION PERMIT Tax PIN/EH #: 57149=63-4705:09 Subdivision Info: McAllister Park Lot # 9 Location/Address: S. Madera Drive -27028 Property Size: 0.59 **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. System Type: 1 S.T. Manufacturer c Tank Date 3"�i` Tank Size Pump Tank Size J System Installed By.. EOAV3 II±�C �' �--E.H. S J DCHD 11/06 (Revised) c' D �LIO� SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street IMAAR 1 g 2001 Mocksville,.NC 27028 (336)751-8760/ Fax (336)751-8786 1t Permit94cuthorization To Construct(ATC) ❑ Both 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 Billing AddressS City/State/ZIP 7 0 t Name on Permit/ATC if Different than Above Mailing Address ' Contact Person �.- _ Home Phone /__736 Business Phone City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flacmed J�-_0 0 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan (Permifis valid for 60 months with site plan, no expiration with complete plat.) Owner's Name �, r��,, L � Phor ❑Plat(to scale) Owner's Address City/State/Zip Property Address City rac.l Lot Size �;_o ez C Tax PIN# , O 14t�,V706_- Subdivision Name(if applicable) Section/Lot# Directions To Site: L r , �2 / -�- �✓ - D� If the answedo any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes DN6" Does the site contain jurisdictional wetlands? ❑Yes UNcf Are there any easements or right-of-ways on the site? ❑Yes ON - o" Is the site subject to approval by another public agency? ❑Yes D.No Will wastewater othei than domestic sewage be generated? ❑Yes QNtS"_ IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms -" # Bathrooms .3 Garden Tub/Whirlpool ZY—es-nNo Basement: ❑Yes (� Basement Plumbing: ❑Yes MNe--' 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 Type system requested:. ❑G6"nventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑-dounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No 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 s bmitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie Co�inty Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand t at I am resp le for the groper identification and labeling of property lines and corners and locating and flagging or staking th' house/faci)Ay 196tion, proposed well location and the location of any other amenities. /u Pro'party ownU 's .or owner's legal representative signature r Dat Zb Sign given ❑Yes ❑No2 Revised 11/06 Site Revisit Charge Date(s): Client Notification Date: EHS: Account # 3�Z Invoice # / n It . APPLICATION FOR SITE EVALUATION 141PROVEMENT PERMIT Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street APR Mocksville, NC 27028 l 3 2005 (336) 751-8760 FNVI/?ONMFNT ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE E klir INFORMATION IS PROVIDED. �iRefer Ito the INFORMATION BULLETIN for instructions. 1. Name to be Billed �L i-�u•%tC Sk 4,• Contact Person �� i� ✓v Mailing Address/L-/ ! / �E� �(' �5�� Home Phone City/State/ZIP G� w �'1 �'� ��t �� �`� 7/Q } Business Phone -416 7 e ..Z� 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: C1 Site Evaluation ❑ Improvement Permit/ATC ❑ Both 9. System to Services L'THOuse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: ld' Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,.., p , �- � #Bathrooms 2Dishwasher ❑Garbage Disposal LB97ashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type. # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: tl �Seats Estimated Water Usage (gallons per day) 8. Typo of water supply: [E!' County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ■R11' ***I,IIPORTANT'' CLIENTS AIUST COAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN AfUST BES1113AI1T'IED by the client witl: THIS APPLICATION. Property Dimensions: 4-5 n Iv, WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Officc PIN: It Property Address: Road Name '5/4 t') 14�( City/Zip If in a Subdivision provide information, as follows: Name: M f}ll iS-k r- P+r k Section: Block: Lot: / Date home corners flagged: -1/- .Z':;l.-cis, This is to certify that the information provided is correct to the best of my luiowledge. I understand that any permi(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, liereby, give consent to the Authorized Representative of the Davie County IIealth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. s ,- DATE t SIGNATURE I TIIIS AREA MAY BE USED FOR DRANVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn Revised DCIID (05/03 Site Revisit Charge Dalc(s): Client Notification Date: EI3S: Account No. _ Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH #: 5749-63-6844.09 Billed To: Richard Short Subdivision Info: McAllister Park Lot # 09 Reference Name: Location/Address: Sain Road -27028 _ Proposed Facility: Residence Property Size: as platted Date Evaluated: t%'�o Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH 1_ Texture group Consistence —r S "S5 Structure 515 Mineralogy HORIZON II DEPTH 7. 7 - Texture rou Texture S; G Consistence S re- C' Structure Mineralogy HORIZON III DEPTH t? -`i Texture group Cl: s; +50 Consistence i* -f' S Structure 3 Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE . 3 SITE CLASSIFICATION: Y LONG-TERM ACCEPTANCE RATE: 0, EVALUATION BY: OTHER(S) PRESENT: REMARKS: 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 CONSISTENCE ois VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm .Wet 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 Mineralogy 1:1, 2:1, Mixed Notes 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 nr; in osmo (Revi w(i)