201 South Madera Drive Lot 20DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name:
Proposed Facility: Residence
ATC Number: 4695
Z
1
Tax PIN/EH #: 5749-62-6976
Subdivision Info: McAllister Park Lot # 20
Location/Address: S. Madera Drive -27028
Property Size: 3/4 acre
**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 S;44V7a(S4: Tank Date
Pump Tank Size n
System Installed By: e"Vb 1 M' 1 Ll` L� E.H.
Sizel t)�E:>
DCHD 11/06 (Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH �/� to
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900093 Tax PIN/EH #: 5749-62-6976
Billed To: Shelton Construction Services Subdivision Info: McAllister Park Lot # 20
Reference Name: Location/Address: S. Madera Drive -27028
Proposed Facility: Residence Property Size: 3/4 acre
ATC Number: 4695
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 3 # Bathrooms Z5 # People 2- Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size b .7Lo 44RC Type of Water Supply�ounty/City ❑ Wff�ell ❑ Community Well
System Specifications: Design Wastewater Flow (GPD) 31,eVTank Size y0GAL. Pump Tank GAL.
Trench Width 3C Max. Trench Depth 34'11 Rock Depth A Linear Ft. :;
Site Modifications/Conditions/Other: A&'"b 2,Q JJ S�{Sl`A
V � 5' !-}uJS—,1G W I&
Contact the Davie County Environmental Health Section for final inspection of this system between
Environmental Health
DCHD 11/06 (Revised)
q-01.) .
iD4I
APPI
D
ADDlicat on For:
EVALUATION/IMPROVEMENT PERMIT & ATC
p ° vie County Health Department
nvironmental Health Section
.O. Box 848/210 HospitalStreet
Mocksville, NC 27028
i%vovjH 6)751-8760/=To
8786
11aluation/Improvement Permit Construct(ATC) ❑ Both
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
NametobeBilled ��,•viContact Person
Billing Address 125-7 0 bel l,J Home Phone
City/State/ZIP x'11 c. V s -1= li , Business Phone 3 = oto
Name on Permit/ATC if Different than Above
Address
PROPERTY INFORMATION
City/State/Zip
NOTE: A survey plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Street Address Cityi'+7�.-y-: ))-r- Tax PIN# ,�77 2 Gi �' 691 %
Subdivision Name �'!'l /� 11� .S %� 1C Section/Lot# Z a Lot Size S) t
Directions To Site: S 3-a .S . — 4 A 4----
/---
-.---/=e 4. ig,-. L _S L /J. _ 3 —4 / -�-
Date House/Facility Corners Flagged C- /.3, —7
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 CSP r
Does the site contain jurisdictional wetlands? ❑Yes ER46--
Are there any easements or right-of-ways on the site? ❑Yes aim
Is the site subject to approval by another public agency? ❑Yes ❑Ko
Will wastewater other than domestic sewage be generated? ❑Yes C
IF RESIDENCE FILL OUT THE BOX BELOW
# People 'Z # Bedrooms _� # Bathrooms 2. � Garden Tub/Whirlpool es ❑No
Basement: ❑Yes � 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
Type system requested: lP�Anventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:ounty/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?
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 understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to detern .n com
259pliance with applicable laws and rules on the above described property located in
Davie County and owned by � 17
ope vner' or owner's legal representative signature
-7
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Sign. given ❑Yes ❑No_ Account # 99OW q3
Revised 2/06 153 Invoice # —
1�1 5
' | `
� .
| | ~~ |
| | �
| . .
| '
| | '
[ | |
|PLAT OF SURVEY FOR:
SHELTON CONSTRUCTION SERVICES'
3O 15 O 3� 60 90
.
AREA /3,5 77 A C.DATE: 6/015/07 CIT PH D
BEING^ALL OF L"' ^"
/NCLUDES 'S�R� 1727 F�WSCALE- IN FEET wvALLST[R pApK SUBDIVISION (�9 y .PQ. ) <
/nuc IN rHr um`,cw/.r To~"c=o m""" ^,..",, I.I'Nr,T ""�. /
/
11 U14.1111M
N�m���
mm~-- ��
n
L_\
NORTH
p.pLA7
�e�'-----
— \
\
\\
.
opmpACE
�
'
.
/
/
/
`
-- '
\
LOT 21
/
20,p*fD
\
\
\
\
\\
. \
\\
existing
N 90'00'00' E
iron
\`
331.83
\
\ \.
\
\\
.\
\�
\
.
\
\\
LOT 20
\
\
\\
�u
10
AkEA 0. 762 ACRES
C3
\.
cu
\ \
1
\
|
.
/
/
y
�m
CH 20.41
-- --- IAIMMUM BUILDING SETBACK LINE
/
R = 35. 00
289.59
' | `
� .
| | ~~ |
| | �
| . .
| '
| | '
[ | |
|PLAT OF SURVEY FOR:
SHELTON CONSTRUCTION SERVICES'
3O 15 O 3� 60 90
.
AREA /3,5 77 A C.DATE: 6/015/07 CIT PH D
BEING^ALL OF L"' ^"
/NCLUDES 'S�R� 1727 F�WSCALE- IN FEET wvALLST[R pApK SUBDIVISION (�9 y .PQ. ) <
/nuc IN rHr um`,cw/.r To~"c=o m""" ^,..",, I.I'Nr,T ""�. /
/
11 U14.1111M