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162 S Benson Lane Lot 9. DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990003401 Tax PIN/EH #: 5746-48-6106 Billed To: Ken Durham Construction Subdivision Info: Twin Cedars Phase II Lot # 9 Reference Name: Location/Address: S. Benson Lane -27028 Proposed Facility: Residence Property Size: .85 Acre ATC Number: 4791 **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:i S.T. Manufacturer �� Tank Dateq Tank Size 6 Pump Tank Size A System Installed By: / E.H. Specialist: tAf hate: DCHD 11/06 (Revised) • DAVIE COUNTY ENVIRONMENTAL HEALTH rd P.O. Box 848/210 Hospital Street Mocksville, NC 27028 / Z/II/07 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990003401 Tax PIN/EH M 5746-48-6106 Billed To: Ken Durham Construction Subdivision Info: Twin Cedars Phase II Lot # 9 Reference Name: Location/Address: S. Benson Lane -27028 Proposed Facility: Residence Property Size: .85 Acre ATC Number: 4791 Site TypeXw ❑Repair ❑Expansion **NOTE** This Authorization to Constrict (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 yy�� Square Footage(or Dimensions of Facility) Lot Size �.�'�•iL Type of Water Supply�unty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank SizeAL. Pump Tank GAL. " l� „ 1 Trench Width Max. Trench Depth Rock Depth12-"Linear Ft. '25 Site Modificatio /Conditions/Other: 10�AL, 6� 4 ►�M70'¢-� -'�X V 11=' c,F Vaof. i! t.J: 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. 0 13V Environmental Health DCHD 11/06 (Revised) Emn La �� M As st&ted In 15A NCAC 18A.1969(5) accepted Systems may also be used 07 t, EomprovementPennit I� R SITE EVALUATION/IMPROVEMENT PERMIT & ATC DavieCounty Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 N (336)751-8760/ Fax (336)751-8786 valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New 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 to be Billed K� �t Det ✓�A Uyv. Contact Person S/ -J en e -- Billing Address a o 20 & / D 2 Home Phone --I ? H — @L & `� City/State/ZIP Q c>oj ee l4 �., t ec t1J Co / `� Business Phone 0 -- c, - ;? o Name on Permit/ATC if Different than Above Address PROPERTY INFORMATION *Date House/Facility Corners Flagged / /1/ 2,1 7 NOTE: A survey plat or site plan must accompany this application. Included: P'Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name %vin A ;e-- e, Phone Number -75/ ,moi � y Owner's Address -Ji4o ity/State/ZipXoC-Z u, %/e 1UC. d 7,;1 Z Property Address ) n i _ City /1iG��✓ ; I �� Lot Size S etc✓ e� Tax PIN#_IA, qV &10(q _ Subdivision Name(if applicable) % c _• , .� C ec.% rl S Section/Lot# 5ej r ,O. , Directions To Site: o l SDS i 1., jure r k- DoT c,,it o Oec-Jl o h c• c,%z it, ; cz r �+ r ► �T ��, �� If the answer to any of the folio mg questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Dyes P<o Does the site contain jurisdictional wetlands? Dyes "o Are there any easements or right-of-ways on the site? Dyes UNo Is the site subject to approval by another public agency? Dyes Cairo Will wastewater other than domestic sewage be Qenerated? ❑Yes L&o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _ #Bathrooms �_ Garden Tub/Whirlpool es ❑No Basement: ❑Yes Flo Basement Plumbing: ❑Yes LRIo 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:. IKonventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: [B'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? 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 Property owner's or owner's legal representative signature Date(s): /Z D Client Notification Date: Date EHS: Sign given Dyes ❑No Account # J 7yI Revised 11/06 Invoice # APPUCATION FOR SITE EVAIVAT10N/IMPROVEMENT PERMIT & ATC Davie County Health Department V - ' En vimmenfa//lea/lfi SftWon P.O. Box 848/210 Hospital Street D Mocksville, NC 27028 (336)751-8760 * * * ZMPCRTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL Tiila._IMOUIRED IXFORM ATION IS PROVIDED. Refer to the INFORMATION BULLETIN fo ins " ••` HEAITH 1. Name to be Billed /iii a��= Contact Person / (i��i)L1� 5�J/'v�L'�/ii.l�✓ )sailing Address City/state/ZIP 2. Name on Pe—'t/ATC it Different than Above Boma Phone Business Phone 41'7 L- 5,61e Mailing Address City/State/Zip 3. Application For: •Jp�/Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. system to service: House 0 Mobile Home 0 Business 0 Industry 0 Other 5. If Residence: C i?eople L ( # Bedrooms 3 # Bathrooms / �1' - Z— Ef Dishwasher 0 Garbage Disposal 0 aching Machine n Basement/Plumbing O Basement/No Plumbing 6. If Business/Industry/Other: specify type # Commodes # People # sinks # showers # Urinals # Nater Coolers IF FOODSERVICE: d Seats Estimated Water Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Comnwnity e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes ❑ No If yes, what type? ***IMPORTANT•** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: i 3 O fdOv WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tax Office PIN: # % ¢� q� 2--3 4 6(' Di/�) (o % �: ��1+tc�./ fid% Property Address: Road Name %� X d City/Zip Pcvr'0hry C.C,✓7 If in a Subdivision provide information, as follows: -�q Name: ��/�/ lG'2,¢2 5 o 11`Z & MAP 10f 7 1qq Section: 2-- Block: Lot: -77' +6� Date Property Flagged: lbo- i J MAP IS IS 141 g This Is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit(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, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct al esting procedures as necessary to determine the site suitability. DATE � � SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN ci all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/98) Account No. 3 Invoice No. SYY • ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section �� u1 SECTION LOT Soil/Site Evaluation � APPLICANTS NAME �C✓ l�U DATE EVALUATED I'd I 6Q PROPOSED FACILITY iqq'T1D^�liS'G PROPERTY SIZE qE M4'� � O ?L � SUBDIVISION �W�N Cl�D4�5 ROAD NAME W -AL -T W 1L.SE!!J Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 23 4 5 6 7 Landscape position y' Slope % 4 HORIZON I DEPTH 6 - CC Texture group c- C L Consistence n1-; a% , Structure Cy A13 IL Mineralo HORIZON II DEPTH 0 G-30 Texture groupF} Consistence Structure ' 1< Mineralogy�. HORIZON III DEPTH .- Texture group0 CS Consistence r S, Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLTTE 5 CLASSIFICATION LONG-TERM ACCEPTANCE RATE I 0.e27gp SITE CLASSIFICATION: cJ EVALUATION BY. -(' 2 LONG-TERM ACCEPTANCE RATE: D• J5 OTHER(S) PRESENT: ci',�T�� REMARKS: T -V I LI, A.%, r ar cz VA Q_ 1 Z pc t �. DCHD (01-90) 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 Moist 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 No ON ME No ii ME ■■ ■■■E■■■■ ■■ME■■■■ ■E■EME■■ ■EM■■M■■ ■EMM■■■■ ■EMMEM■■ ■■E■EM■■ ■■■■■■■■ ■■M■■EM■ ■■■■■■M■ ■■E■■EM■ ■■M■■ME■ ■■M■E■E■ ■■M■■EM■ ■MOMEMM■ ■■■M■■■■ ■■■M■MM■ ■■■■■■■■ ■■■■■■■■ ■■■■■■■■ ■e■e■■■■ ■■■■■■■■ ■E■■■■■■ ■■■■■■■■ MEMO■■■■ ■E■■■■■■ ■■■■■■■■ ■■■■■■■■ NEON MEMO MEMO ■■■■■■%■■■■■ ■■■■■R■■■■■■ ■■■■■K!■■■■■■ ■■■■■I]■■■■■■ ■■■■■tl■E■■■■ ■■■■■II■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■e■■■e�M�i■■r■■■■■■e■■■■■■■■■■■■Nee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■ ■Es■NE■■■Nee■e■■■■■■■■■E■NEEN�■■■■■■■■■ ■■■t■■■■■■■■■■■■�i■■■EE■e■■e■■■■■■■■■Nee■ ■■ME■M■■■■■■ ■■■■■■■■■■■■ ■O■■■I■■■■■■■ ■■■■EIMMEM■■■ ■■■■Nr■■■■■■c• ■■E■■I■■■■■■I ■■■ENI■■E■■S■ ■MEMMUM■■■■■E■■ mfa■■■ MEN ■■■■■■ II■■■■■M■■■■■ II■■■■■NEE■■■ II■■O■■■■■■■■ ii■■■■■■■■■■■ u■■■■ee■■■■■ I■■■■■■■■■■■ 1■■■■■■■■■■■ I■■■■■■■■■■■ 1■■■■E■■■■■■ 1■E■■■■■■■■■ I■■■■■■■■■■■ 1■■■■■■■■■■■ I■■■■■■■■■■■ 1■NNE■E■■■■■ 1■■■O■■■■E■■ 1■eeE■■■■EE■ 1■■■■■■E■■O■ I■■■■■■■■■■■ IEEE■■■■■■E■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY t'fC7V1 SUBDIVISION-"j311J i1Q� Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit SECTION_ T DATE EVALUATED I S")aS PROPERTY SIZE Z$l X 17SX?0qS x ROAD NAME 0At,-r- L,JI r--5o.J Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % Q 10!` HORIZON I DEPTH Texture group G i_ 41 L Consistence `v SSSS' Structure Ga Oil Mineralogy1 ,1 HORIZON II DEPTH - Texture group C t Consistence ; 5P Structure k 'R Mineralogy1 "• HORIZON III DEPTH Texture group Consistence 1 Structure IL Mineralogy• HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION M'�� LONG-TERM ACCEPTANCE RATE Q j SITE CLASSIFICATION: i 5 EVALUATIONBY: LONG-TERM ACCEPTANCE RATE: r " • L OTHER(S) PRESENT: 0, ^, ^� REMARKS: �tiw 1 L, . 'Sp ►-Liz -W[: —T0 (-'>0L ,1 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 - Silly clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist 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 DCHD (01-90) ■■IME■■■■■■■■■ ■■IME■■■■MIN■■■ ■NA■N■■■A■■■■ ■■■S■■A■■■■■■ ■E■■■■■■E■■■■ ■IM■■■■■■■■■E■ ■■MIME■■SMI■■■■ MINIM■■■■■A■■■■ ■■■EMI■■■■■■■■ ■■■■E■EAE■E■■ ■EMI■IME■E■OE■■ ■■■■■■MINIM■■■N ■NN■■■■■MINFE% ■■■■EOE►1■I■■■ ■A■■ES■\ENS'!■ ■■■■■■■■U■IMI■ ■■■■■■■■ ■E■■MIN■■ ■■■■MINI■■ ■■■■E■S■ ■■■■■MIME ■■■■■■■■ ■■■■■MINIM NEEM■■■■ ■MINI■■■■■ ■■■■■■■■ ■■■E■■E■ L ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ ■ENN■■ ■■■■E■■EWA■■ ■■■■ri'ii■■■■■■■>•�■■Vii ■E■NON■■■■■■MIR,trW■■ ■Irir■■■■■■OIMMM■■■■■ ■II■KE■ ■■E■■■■EAMMI■ ■■11■Aal:� m■■■■■■A■■■U MEN ■■■E■ ■E■E■ ■MINE■ ■MINE■ ■■■■■ SOMME ■ENE■ ■■■E■ ■■■■■ ■E■■■ ■EN■■ ■A■■■■■■OSS■■■■■■E■■Oso\■H■■■■■■11■\■■■■■■■■■■■■■a!11■■■■■ UMMEMMINMEMNONmommoll HEMI MME�ii HIMMIMMEMENNEN1MENEM ■■■■■■■■■■■■■■■■■■■■■■■■■■■;a■�■ai■ ■■Eta■■.•==�::■■■■■■►�■ ■SSS■■■■■■■■■■■■■■S■■■■■■■■■■►1■11■■G:1■11■■■■■■■■■■■A■■■■■ ■■■■■■■■■■■SSSS■■■■■■■■■■■■■■■\IIS■L'!LAiI■■■■■■■■■■■■■SSS■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■S1\11■■■ISI IS■■■■■■■■■■■■SS■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mai■■II■■gin■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■Mir■■■■�1■II■■■■■■■■■■■■MI■■IM■ ■■■■■■■■■■■■■■■■■■■■■■■IM■A■■■■■■■■■Il■�I■■■■■■■■■■AAA■■■■ ■■■■■■■■■■SSS■■■■■■■■■■■■■■■■■■■ ■■ESI■■■■■■■■SSSS■■■■■ no ■O■■E■■ MIME■■■■ V■■■■■■ AME■■■■ W■■■■E■ ■■MIME■■ ■MSEE■■ ■ME■■E■ ■a■■rs■ ■■►\mom's] MMMEENE ►1■\■IME■ ■■■NE■■ ■■■E■■■■M■ ■■■EE■■■M■ ■■■■■E■■M■ ■A■■■■■■■■ ■E■EMI■■■■■ SEEM■■ ■MENS■■■■4 ■■■■■■■■E■ ■■■■■■■■E■ ■■■■■MINI■■■ MINIM■■E■■■■ ■■■■■■■■■■ ■■■■■■■MIME ■■MAIM■■■■■ ■■■■E■■E■E ■■■■■■■■ L'7 ■MIME■EMI■tad iiii::m=wM iWMMMM■■■■ ■A■■■AIME■■ ■■■■■■■■■■ ■■A■■■■■■■ ■■■■■■■■■■ ■IM■■■■■■■■ ■■■E■A■AA■ ■E■■■■■E■■ ■■■■■■■E■■ ■■■E■■■■■■ ■■EMI■■EMI■■ ■■EAE■■■■■ ■AAA■■■■■■ ■■MINI■■■■■■ ■■■MINI■■■■■ ■■■MINA■■■■ ■■■MINI■■■■■