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167 South Madera Drive Lot 24DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 989900225 Tax'-PIN/EH #: 5749-63-6844.24 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 24 Reference Name: E Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 105x334x104x ATC Number: 4732 **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. 414, U System Type:` 1�� S.T. Manufacturer ri':" Tank Date / � Tank Size Pump Tank Size i System Installed By: Q /i1 e 6 a [/terE.H. Specialist: (0 / - Date: —�5 a G►J rvl.eP w i 2 APPLICATION FOR SITE EVALUATION/INIPROVEAIENT PERMIfI� 0 Davie County Health Department EnvironmentalHeaith Section P.O. Box 848/210 Hospital Street APR 73 Mocksville, NC 27028 Z0�5 (336) 751-8760 ENVIRON TAI ij, ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. ^nRefer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ,�-lu,."�C I��c —4— Contact Person e Mailing Address ��/�,Sj� /-/ i / �E'_y' .S4— Home Phone7S__ ',O •.2 City/State/ZIP L<�-.., �'F� c /� �`ti 7/Cl} Business Phone --le) -7 e,Sf -2-Y 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: IT Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: 2 --House 11 Mobile Home 11 Business El Industry El Other S. Typo system requested: 0_ Conventional ❑ 'conventional modified ❑ innovative 6. If Residence: # People ? # Bedrooms ,..,� ,.., � , � - #Bathrooms .Z 13Dishwasher []Garbage Disposal [Rashing Machine ❑Basement/Plumbing ❑nasemont/No Plumbing 7. -If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: It Seats 8. Type of water supply: 2 County/City 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 ❑-No If yes, what type? ***1111P0RTAN7'*** CLIENTSAIUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eitlier a PLAT or SITE PLAN AfUST BE S1JBAf17`rED by the client witli TIIIS APPLICATION. Property Dimensions: n Tax Office PIN: # 3 ^ Property Address: Road Name (5/4 1.iI `� City/Zip WRITE DIRECTIONS (from Mocksville) to PROPERTY: If in a Subdivision provide information, as follows: Nanic: Section: Block: Lot: Date ]ionic corners flagged: This is to certify that the inforniation provided is correct to the best of my leiowledge. I understand that any permits) issued hereafter arc subject to suspension or revocation, if the site plans or intended use c]iange, or if the information submitted in this application is falsified or changed. I, also, understand that I ant responsible for all chaises incurred fi•oln this application. I, hereby, give consent to the Autliorized Representative of the Davie County IIcaltli 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. p�-- DATE' �.3 - SIGNATURE TIIIS AREA MAY BE USED FOR DRAVVING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit C1111-ge Datc(s): Client Notification Date: EHS: Sign giVCIl Account No. 97000 35 Revised DCIID (05103 Invoice No. APPLICANT INFORMATION Account FF: at5uuuuu35 ` Bifled To: Richard Short Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTME, NT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5749-63-6844.25 Subdivision Info: McAllister Park Lot # 25 Location/Address: Sain Road -27028 Property Size: as platted Date Evaluated: Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position H1 Slope % HORIZON I DEPTH - 1 Texture group Consistence t$ Structure L Mineralogy�- HORIZON lI DEPTHZ- Texture group 51 tr Consistence �+ Structure 1L Mineralogy HORIZON III DEPTH 3 - 32 Texture group Consistence rl r, -_ss Structure Mineralogy HORIZON IV DEPTH Texture grotip41i;^(1 Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE Q -Z; SITE CLASSIFICATION: f� `3 ,�a EVALUATION BY LONG-TERM ACCEPTANCE RATE:2 OTHER(S) PRESENT: REMARKS: a�J)lt�> fqhdO Z5; `-Q ' aAr M,)M 9ACC AAtL43u5 A�?AJO 10-W 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 AMA 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(uttsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 PCI II) 05/99 (Rcviscd) AP &A*E EVALUATION/IMPROVEMENT PERMIT & ATC vie County Environmental Health O .O. Box 848/210 Hospital Street Mocksville, NC 27028 t „�U ( 36)751-8760/ Fax (336)751-8786 Applicat n Fo'C p�J} ement Permit ❑ Authorization To Construct(ATC) moth Type of plication: letSystem ❑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 US 0e, J, 4,C Contact Person Billing Address PO o Home Phone City/State/ZIP a , C RC1Ce i Business Phone -?-?6 '5/9 7225— Name G%25— Name on Permit/ATC if Different than Above Mailing Address City/State/Zip YKUYBKI'Y 1N 11UKMA TUN "*hate House/ractltty Corners NOTE: A survey plat or site plan must accompany this application. Included: V§ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name - <i-/ Phone Number Owner's Address City/State/Zip Property Address) � % _S abl?r 44r City ./A i ✓ .//c Lot Size Tax PIN# Subdivision Name(if applicable Directions To Site: /5vh .4 Section/Lot# L 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 ❑No Does the site contain jurisdictional wetlands? []Yes ❑No Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes ❑No Will wastewater other than domestic sewage be generated? ❑Yes ❑No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms Garden Tub/Whirlpool p�Yes ❑No Basement- 1es ❑No Basement Plumbing: CKes []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: Vcounty/City Water ❑ New Well El 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 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 Prope er's or er' a representative signature / Date(s): g _ q _ L Client Notification Date: Date EHS: i G / Sign given ❑Yes ❑No Account # O p LZJ Revised 11/06 Invoice # .., DAVIE COUNTY ENVIRONMENTAL HEALTH . P.O. Box 848/210 Hospital Street Mocksi ille, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Pd Account #: 989900225 Tax PIN/EH #: 5749-63-6844.24 Billed To: Jeff Ferguson Subdivision Info: McAllister Park Lot # 24 Reference Name: Location/Address: S. Madera Drive -27028 Proposed Facility: Residence Property Size: 105x334x104x ATC Number: 4732 Site Type:)?fqew ❑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 3 # Bathrooms # People Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Lot Size o' 1cJ6AS Type of Water SupplyA 5<ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) <I'ank SizeI�AL. Pump Tank GAL. Trench Width t . Max. Trench Depth ;g Rock Depth_04 Linear Ft. �py Site Modifications/Conditions/Other: �(� �1 ' 1GI� ' Q7Q-stt'�s7Tr�1n,, :BZW R UJK, 4ZO' IS— tt4'QF 0YIc /TZ-Pd-�p!x-f . Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telenhone # (336)751-8760. L+i' Environmental Health Spe DCHD 11/06 (Revised) 1�ijj. -/ is' �Qr�a 0 RSP. Lj�r� Date: f 5—e-f� ��egv5o� plcwllrtiiv /G 7 '�. Mod eget 319 1,05. —7 r � -,.` nq �, 3 ti ►S --33 --- la► wl/ /0 Ll / 33`x' 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 ❑ Name: GI v� y 11-11 r �'_ Phone Number: (Home) Mailing Address: /f, �'�'�ad-�� jJ (Work) Detailed Directions To Site: /-"71I/ e()'^/W/ Property JA /Jr /71(),-/s//r- Please Fill In The Following Information About The Existing Dwelling. Name System Installed Under:.-_]_f_f�_ - I' -"50P'-7 yl G Type Of Dwelling: Date System Installed(Month/Day/Year): Number Of Bedrooms: '3 Number Of People: Is The Dwelling Currently Vacant? Yes ❑ No E' If Yes, For How Long? Any Known Problems? Yes ❑ No Er"' If Yes, Explain: Please Fill In The Following Information About The New Dwelling. Type Of Dwelling: L (r �'� h Number Of Bedrooms: Number Of People: Requested By Approved Disa Environmental Health For Environmental Health Office Use Only 0 _�_ /�G- Requested: ^ , � V '�7 1,4 e- -C *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: $ Date: Paid By: Received By: Account #: voice #: 0 i Go APPLICATION FOR SITE EVALUATION/IAiPROVEAIENT PERMIT' fh Davie County Health Department 0 V Environmental Health Section P.O. Box 848/210 Hospital Street APR r Mocksville, NC 27028 3 2005 (336)751-8760 ff�t'��ONMENT AI fit ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE INFORMATION IS PROVIDED. gRefer {to the INFORMATION BULLETIN for instructions. 1. Name to be Billed Jam'-l�••'LC I��k t� �� Contact Person �� %�vv� C" Mailing Address�� 1 / �E'_�/' S'(- Home Phone /G•-2- -7 City/State/ZIP LL -L S'l �'•� �2,�t 7/Cl } Business Phone �f% 7' 'Y -2-<1 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �13S—�ite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: CQ—House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other. S. Type system requested: Iia' Conventi�o7nal IJ conventional modified ❑ innovative r 6. if Residence: # People # Bedrooms ' �� , 3 - � it Bathrooms I3D� asher ❑Oarbago Disposal Ghla*.hing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals t► Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions or the facility this system is intended to serve? ❑ Yes ❑-Nu If yes, what type? ***IAIP0RT11N7'*** CLIENTS AIUST COAIPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELONV. Either a PLAT or SITE PLAN MUST BESUMV17-FED by the client ivith TIIIS APPLICATION. Property Dimensions: '5 /r:' Tax Office PIN: it 6'-7Y9- 6 3 - L/-• P-7 Property Address: Road Nanie 5�4 " t.i 212 City/Zip If in a Subdivision provide information, as follows: Nanic: /� /3l I ! S -le c'+r % Section: / Block: Lot: WRITE DIRECTIONS (from Mocksville) to PROPER'L'Y: ;-- L i n oL 1-3 r- C, C,l lrc x d /°!a < <- Date hone corners flagged: 41--2-r-�L-0S This is to certify that the information provided is correct to the best of niy knowledge. I understand that any pernlit(s) issued hereafter are subject to suspension or revocation, it 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 responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department to enter upon above described properly located in Davie Comity and owned by to conduct all testing procedures as necessary to determine the site suitability. ^ DATE ��' D�� SIGNATURE / F'-•��, �J N'� TRIS AREA 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). Site Revisit Charge Dalc(s): Client Notification Date: EHS: Sign given ZUD Account No. 2tt `'0o 15 Revised DCHD (05/03 Invoice No. DAVIE COUNTYPEALTII DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account : 989900035 Tax PIN/EH M 5749-63-6844.27 "biiled To: Richard Short Subdivision Info: McAllister Park Lot # 27 Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence -Property Size: as platted Date Evaluated: 2 r - Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2' 3 4 5 6 7 Landsca e position Slope % HORIZON 1 I )EPTH r 2 Texture group r L - Consistence , Structure Mineralogy HORIZON 11 DEPTH Z' Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION PSI LONG-TERM ACCEPTANCE RATE O Z J SITE CLASSIFICATION: 1 -" LONG-TERM ACCEPTANCE RATE: o• REMARKS: EVALUATION BY: A4[— OTHERS) PRESENT: 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 Mau VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm wet NS - Non sticky SS - Slightly sticky IS - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic I 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 VMineralogx 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