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206 South Madera Drive Lot 16DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street ' + Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005854 Tax PIN/EH #: H519OA0016 Billed To: John Paterson Subdivision Info, . McAllister Park Lot # 16 Reference Name:: LocationiAddress: 206 S. Madera Drive-27028 Proposed Facility: Residential Property Size: 1.020 Acre - ATC Number: 5915 **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 514rej Tank Date %L/3 Tank Size /000 Pump Tank Size i Bedrooms: 3 DCHD 11/06 (Revised) 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 Account #: 990005854 "fax PINIEH #: H519OA0016 Billed To: John Paterson Subdivision into: McAllister Park Lot # 16 Reference Narne: LocalioniAddress: 206 S. Madera Drive -27028 Proposed Facility: Residential Property Size: 1.020 Acre ATC Number: 5915 Site Type: IVNew ❑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_ 5 # Bathroomsd /Z- # People Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats— Square Footage(or Dimensions of Facility) Lot Size .01 01C Type of Water Supply: gCounty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow'(GPD) �%i� Tank Size 1000 GAL. Pump Tank GAL. It I / Trench Width � Max. Trench Depth_ Rock Depth Linear Ft.�('� S"b AS stated in 15A' NCAC 188AAS3 t51Site Modifications/Conditions/Other: oceepted Syctn!2-1ne.M9/ Contact the Davie County Environmental Health Section for final inspection of this system between '8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. 69 1 f Olt Von . C5�-59 ironmental Health Specialist Date: lJ 2 DCHD 11/06 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005854 Tax PIN/EH #: H519OA0016 Billed To: John Paterson Subdivision Info McAllister Park Lot # 16 Reference Name: Location/Address: 206 S. Madera Drive -27028 Proposed Facility: Residential Properly Size: 1.020 Acre ATT*ft?Lb�" Thtsrimprovement Permit DOES NOT authorize the construction of a wastewater system. An Authorization 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: ANew ❑Repair ❑Expansion Permit Valid for: Ij5 Years ❑No Expiration Residential Specifications: # Bedrooms3 # Bathrooms& # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):36_ •Type of Water Supply: it County/City []Well ❑Community Well - Site Modifications/Permit Conditions: System Type LTAR Initial / Repair o 13 Site Plan 2 Health Speci 11-06 w V t� 1. v D Date / Co,l,.� M►kc.�1�i��..-/�waal�, � 336..��fS_67v� (fie Wim' 114 4.4 a- a sit §_J9-,-htr., APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (33 )753-1680 Application For: ❑Site Evaluation/Improvement Permit Authorization To Construct (ATC) ❑Both Type of Application: �lew System ❑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 - 6 K 'N VATEMA Contact Person �J;ti o ep'1'ul--sop Address 3 iaO (t(LrA01j D CL11I-J E Home Phone City/State/ZIP W loJ ,rON— ,SAum, ►J C 'xi In Business Phone Name on Permit/ATC if Different than Above Mailing Address Jdpci& "/41"tl�ao •C�vn-t PROPERTY INFORMATION *Date House/Facility Corners Flagged V�� // 2 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Pen -nit is vajafor 60 mp}�ths with site plan, no expiration with complete plat.) Owner's Name � 6HO 1�f}'T'E2Soo PhoneNumber7�C-3046x8 Owner's Address 3 lao f2M 0 N D Q p tjrc. City/State/Zip W I PSTou -S(Iun!!� N C X11—a Property Address Cit Lot Size Tax PIN# Ar Subdivision Name(if applicable)ML A1_LtsTti2. A21C Section/Lot# 16 Directions To Site: If the answer to any of the following questions is-"Yes",supporting docurn tation must be attached: Are there any existing wastewater systems on the site? _Yes VN Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? _Yes _vivo Yes _ Is the site subject to approval by another public agency? Yes o Will wastewater other than domestic sewage be generated? Yes TNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 3 # Bathrooms a 1 2 Garden Tub/Whirlpool ❑Yes No Basement: ❑Yes )(No Basement Plumbing: ❑Yes W -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: (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? llNo 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 pennit(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 m responsible for the proper identification and labeling of property lines and corners and locatin an agging ors�akin he se/facility location, proposed well location and the location of any other amenities. �•( `' Site Revisit Charge Prope ner's or owner's legal representative signature / I I Date(s): `t— �� olp �')_ Client Notification Date: Date EHS: ow �# � 13 (QZ Sign given ❑Yes ❑No Account # Revised 11/06 Innvoice # • APPLICATION FOR SITE EVALUATION/Ih1PROVEAIENT PEI Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 hospital Street Mocksville, NC 27028 (336) 751-8760 ne,J fA.4p Lor Il© APR 7 3 2005 I ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 21 1. Name to be Billed 'S-1-1 Contact Contact Person �� %) �� �' Mailing Addressf I ! ! Home Phone 7, --� 7� City/State/ZIP S;, L�%� ��'�`� �le­­t ,t7/Q /C>•2- 3 Business Phone 41e) 7 C/.L� 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 0"Site u Evaluation ❑ Improvement Permit/ATC ❑ Both Site 4. System to Service: CQ—House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: O' Conventional ❑ conventional modified ❑ innovative 6. if Residence: # People ? # Bedrooms #Bathrooms �,� Washing L7Dishwasher ❑Oarbago Disposal Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks _ # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) S. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑-Nv� If yes, what type? ***IMPORTANT*** CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESURAI17-FED by the elicit witl: TIT IS APPLICATION. Property Dimensions: Q !-fel Tax Office PIN: i 7}-%— Property Address: Road Name (5/4 t li1 J City/Zip If in a Subdivision provide information, as follows: Name: M e 6 I iS4-er WRITE DIRECTIONS (from Mocksville) to PROPERTY: J Section: Block: Lot: Date home corners flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any pernzil(s) issued hereafter arc subject to suspension or revocation, if the site plans or intended use cliange, or if the information submitted izi this applicatioii is falsified or charged. 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 Health Department to enter upon above described properly located in Davic County and owned by to conduct all testing procedures as necessary to determine the site suitability. DATE ' 13- O S SIGNATURE TIIIS 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 Sign given Revised DCIID (05/03 Datc(s): Client Notification Date: EHS: Account No. Invoice No. i ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account M 989900035 Tax PIN/EH #: 5749-63-6844 Billed To: Richard Short St4odivision Info: McAllister Park Lot #J Reference Name:, Location/Address: Sain Road -27028 Proposed Facility: Residence Prope-ty Size: see map Date Evaluated: Water Supply: Evaluation By: On -Site Well J Community Auger Boring Public Cut SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE:_ ©3 OTHER(S) PRESENT: REMARKS:�Q2�7iZ- 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 Mois 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 ruct rc '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 DCI ID 05/99 (Revised) Landscape position HORIZON I DEPTH Texture group Consistence Mineralogy 7 -j HORIZON 11 DEPTH Texture group Consistence �� - : sr■■�enr,����� Mineralogy groupTexture Consistence HORIZON IV DEPTH Consistence Structure Mineralogy SOIL WETNESS SAPROLITE TIASSIFIC• SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE:_ ©3 OTHER(S) PRESENT: REMARKS:�Q2�7iZ- 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 Mois 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 ruct rc '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 DCI ID 05/99 (Revised) Reports Davie County, NC Tax Parcel Report L_n ( 16 , M r -A LLkgrErc PA>Rx S MA D? -RA 9�9-lq (j, *WARNING: THIS IS NOT A SURVEY!* This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public primary information sources should be consulted for verification of the information contained on this map. The County and mapping company assume no legal responsibility for the information contained on this map. Notes: Thursday, 3/22/2012 C Parcel Number: PIN Number: ccount Number: Listed Owner #1: Listed Owner #2: Mailing Address 1: Mailing Address 2: ity: State: Zip Code: Legal Description: Acreage: 7 R w Al DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900035 Tax PIN/EH #: 5749-263-6844.16 Billed Ta: Richard Short Subdivision Info: McAllister Park Lot # 16 A� Reference Name: Location/Address: Sain Road -27028 Proposed Facility: Residence Property Size: sde map Date Evaluated. — Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut r SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �. REMARKS: EVALUATION BY: l OTHER(S) PRESENT: bt \k-4 o LEGEND Landscape Position I2 - 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 is 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 VI' - Very plastic Structure 'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy i 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 DCI ID 0.5/99 (Revised) Landscape position HORIZON I DEPTH KOBE Consistence HORIZON 11 DEPTH Texture group ■rar��������� Consistence HORIZON III DEPTH Consistence HORIZON IV DEP`rH Consistence Structure Mineral '- SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE *010 SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �. REMARKS: EVALUATION BY: l OTHER(S) PRESENT: bt \k-4 o LEGEND Landscape Position I2 - 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 is 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 VI' - Very plastic Structure 'SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy i 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 DCI ID 0.5/99 (Revised)