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159 South Madera Drive Lot 25Permitr= L D YIE C9 Y HEALTH DEPARTMENT Name: r V '��� EnviKonmental Health Section PROPERTY INFORMATION / Directions to pro erty: P.O. Box 848 ILI Mocksville, NC 27028 Subdivision Name: Phone #: 336-751-8760 1111 G �l �1 if�(rS �f' Section: Lot: AUTHORIZATION FOR WASTEWATER 71SYSTEM CONSTRUCTION Tax Office PIN:# - G� r4 r��y,��, tf ,�✓ � AUTHORIZATION NO: ® Q 2 R 8 5 A Road Name: fi Zip: z **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION -7 3 �� uO IS VALID FOR A PERIOD OF FIVE YEARS. RONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE `5 f # BEDROOMS 2 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ' V TYPE WATER SUPPLY O • DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE I oao ' r 3 pOr SYSTEM SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK —AIIAGAL. TRENCH WIDTH �ROCK DEPTH LINEAR FT. OTHER QT aSf0 K-e^CA[.,.c1,er, REQUIRED SITE MODIFICATIONS/CONDITIONS: -TT IMPROVEMENT PERMIT LAYOUT cOV1 G y b -P 5-C,1 U G kc `e X t.5tI ✓► r 1 1 . L 1,-C Ek151-*"S lc.., /c rte, 1 ��fi A �� N 5� Pty � c.., r5 � c ✓1 ., FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02 (Revised) Account #: 989900225 Billed To: Jeff Ferguson Reference Name: Proposed Facility: Residence ATC Number: 4550 DAME COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5749-63-6844.25 Subdivision Info: McAllister Park Lot # 25 Location/Address: McAllister Park -27028 Property Size: 300x105x319x **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:_ S.T. Manufacturer :�4MNC Tank Date Tank Pump Tank Size System Installed By: —��P--JIGS 6'PAZ> j q.H. DCHD 11/06 (Revised) IC0O 20to, I o `�— e��s= 7c.o' t a�. —I aX T b ,i DAVIE COUNTY ENVIRONMENTAL HEALTH n� P.O. Box 848/210 Hospital Street Mocksville, NC 27028 JQ jo (336)751-8760 Fax # (336)751-8786 14 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900225 Tax PIN/EH #: 5749-63-6844.25 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 25 Reference Name: Location/Address: McAllister Park -27028 Proposed Facility: Residence Property Size: 300x105x319x ATC Number: 4550 **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 1 I of G. S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specification: Building Type .r wis��- #People #Bedrooms 3 #Baths 3 i Basement w/Plumbing: ✓Basement/No Plumbing Commercial Spec tion: Facility Type #People #People/Shift #Seats Lot Size 0.' � Water SupplyCltJ�Jl�iDesign Wastewater Flow (GPD) � Site: New System Specifications: Tank Size I GAL. Pump Tank T GAL. Trench Width3iZ Trench Depths I I MAX Rock Depth s�_ Linear Ft. 3L—f`J Other: " 4�PFy�b 2`�a.�JLi �taJ 5�� I 'I bl!3 .1 &)TIoJ Required Site Modifications/Conditions: J ��M LL CQ l )j t ��.° r pn%p Contact the Davie County Environmental Health Section for fmaf inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. ()O—op LI J%F, \2J st 67— — q0, 320' i)9-&. k- 1,9 ���7 1rt•J►.S t .-� �� Environmental Health DCHD 11/06 (Revised) 3 ♦- Z• - co A I Zzli LO --fAQJ -z7c-* 300. 00' w vil A All 4N ni 13 0?"-). 0 0 �Ail lot, Q-2 �16 "IN R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health Q 2 9 2p06 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 ca it onY'`�i�Rpfl�� gew� ion/Improvement Permit ❑ Authorization To Construct(ATC) eBoth of A ion: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 � USori .L ✓ Contact Person Billing Address Home Phone 4'0 - ' 73_ City/State/ZIP 7 Business Phone 4:�l . 79 2 5 Name on Permit/ATC if Different than Above. Address PKUPEKI'Y 1NEUKMA IUN City/State/Zip *Date House/Facility Uorners NOTE: A survey plat or site plan must accompany this application. Included: VSite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's vJGY� Phone Number Owner's Address City/State/Zip Property Address 1,c4 City Lot Sipe Tax PIN# Subdivision Name(if applicable Directions To Site: / S" -r'c, Section/Lot#_9-5— 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? Dyes Colo Does the site contain jurisdictional wetlands? Dyes UNo Are there any easements or right-of-ways on the site? Cr'i'es ❑No Is the site subject to approval by another public agency? Dyes 1X<6 Will wastewater other than domestic sewage be generated? Dyes ❑No IF RESIDENCE FILL OUT THE BOX BELOW. # People # Bedrooms -- # Bathrooms , / Garden Tub/Whirlpool des ❑No Basement. YC►? No Basement Plumbing: [Kes ❑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 Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: V'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 If yes, what type? G • 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 staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge p7 ty o or owner's legal representative signature Date(s): /I- � / `0 C Client Notification Date: Date EHS: Sign given Dyes ❑No Account # Revised 11/06 Invoice # 300 1 vy ' 3(9' PJ 0W ►h4(210rZS APPLICATION FOR SITE EVALUATION/IhIPROVEhiENT PERMIT t% Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street APR 7 3 20 05 NC 27028 �5 (336) 751-8760�RON MFNT ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE E INFORMATION IS PROVIDED. pRefer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed !�'-lu•%c( ��� L �� Contact Person �� i� v t Mailing Address (p ��� / -I i f! ('eE? J' �S'�' Home Phone/C>-.Z L7` City/State/ZIP �:�� �'r�'+`� cy ��=�`� 7163 Business Phone 1e) 7 ' 4i 41 - 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip i 3. Application For: 13"Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: 0- Conventional ❑ conventional modified ❑ innovative 6. If Residence: it People # Bedrooms ,.,� ,,.., � , � - � #Bathrooms � 2Dishwasher ❑Garbage Disposal 00ashing Machine ❑Basement/Plumbing ❑Basemont/No Plumbing 7. If Business/Industry /other: verify type # Commodes # Showers # Urinals IF FOODSERVICE: t1 Seats 8. Typo of water supply: 2-6ounty/City # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, wliat type? ***IMPORTANT*** CLIENTS AIUST COAfPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN AIUST BESUBAM7- ED by (lie client with TIIIS APPLICATION. Property Dimensions: n f c17—tt, Tax Office PIN: t/ - 4 3-" � y • Property Address: Road Name '5/4 t, '1 212- �-- L t" oc'D , « of 1q'A cQ hof -, c 1- 1VRITE DIRECTIONS (from Mocksville) to PROPERTY: City/Zip If in a Subdivision provide information, as follows: Name: M l � Section: / Block: Lot: Date lionic corners flagged: 257,* - This is to certify that the information provided is correct to the best of my knowledge. I understand that any perniit(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 ant responsiblefor all charges incurred fi•oiu this application. I, Hereby, give consent to the Authorized Representative of the Davie County I-Iealtli Department to enter upon above described properly located in Davie County and owned by to conduct all testing procedures as necessary to determine the site suitability. R �� DATE SIGNATURE TIIIS ARE, MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Sign givcn—'b—)D Site Revisit Charge Datc(s): Client Notification Dale: EIIS: Account No. l 0/ d0 0 3'S Revised DCIID (05/03 Invoice. No. f ' ' DAVIL COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION •Account 9900035 Tax PIN/EH #: 5749-63-6844.26 Billed To: Richard Short Subdivision Info: McAllister Park Lot # 26 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: bs platted Date Evaluated: 29 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 % s HORIZON I DEPTH D —17 - Texture groupL Consistence , Structure Mineralo HORIZON II DEPTH , Texture group 5"C-Q;hr.S'C-L} Consistence Structure K Mineralo HORIZON 111 DEPTH 33 - Texture group L s L Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE 5 CLASSIFICATION S LONG-TERM ACCEPTANCE RATE fj,3 SITE CLASSIFICATION: T�> EVALUATION BY: N; LONG-TERM ACCEPTANCE RATE: �' S OTHER(S) PRESENT: REMARKS: � &-o G 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 MQL51 VFR - Very friable FIZ - 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 • I Srnr)me ''e -d Permittee §-, - , DA IE C0 1�TY HEALTH DEPARTMENT s7 EnviWnmental Health Section PROPERTY INFORMATION P , x 848 t Directions to property; MocksvillavilleNC 27028 Subdivision Name:—r— CI Phone #: 336-751-8760 Section: t Lot: AUTHORIZATION FOR �+ ., , t - ( r �} ! r'//r^,•N' cr '�� WASTEWATER Tax Office PIN:# rtr� - I'� rrq SYSTEM CONSTRUCTION AUTHORIZATION NO: Q 0 2 fK3 5 A Road Name: n ' " r Zip: IG **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIN 1IAL SPECIFICATION: BUILDING TYPE # BEDROOMS 2 # BATHS � # OCCUPANTS GARBAGE DISPOSAL: Yes or No s 4 v ti M COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY CO DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE V i 660 SYSTEM SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR `FT. nTUFu ctSlp ^`r°��4C�itn REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT U t j b -C,. �oN ��i1 � f �l�r.51'�✓I 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE PAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1 OPERATION PERMIT SYSTEM INSTALLED BY: " i AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02 (Revis ) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑ E N0� S Name: � �� � � %� � � � PhoneNumber: ���' � �� � (Home) Mailing Address: AM R• (Work) Detailed Directions To Property J Please Fill In The FollowingInformationAbout The Existing Dwelling. Name System Installed Under: V? �-,/Type Of Dwelling: Wea S -e- Date System Installed(Month/Day/Year):_-1,6' () Number Of Bedrooms:�Number Of People: Is The Dwelling Currently Vacant? Yes ❑ No,pi If Yes, For How Long? Any Known• Problems? Yes ❑ No Yes, Explain; Please Fill In The Following Information About The New Dwelling. ,19 1 </2e Type Of Requested By: (Signature) Number Of People: Date Requested:_ I — 6 For Environmental Health Office Use Only Approved C_ Disapproved ❑ Comments: i Gt �1/ ! a C G s / �i i" 7 • Cfi / i t �A <rejkjjo©(Q%e_ ItIQ iht7n l�G'/r/1Yl 117 G a!n0 / - Environmental Health to-7✓��� *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount: $ a Date: Paid By: Received By: Account #: /Z�' Invoice #: 65V