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173 Bath Lane Lot 1t DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax # (336)753-1680 OPERATION PERMIT Account #: 990005528 Billed To: Sugar Valley Airport Reference Narne: Proposed Facility: Residential Tax PIN!EH #: E60000000201 Subdivision Info: LocationiAddress: 173 Bath Lane -27028 Property Size: 1 Ac ATC Number: 5976 **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 Tr f/U S.T. Manufacturer sTank Date10 157 Tank Size Moe, Pump Tank Size_ Bedrooms: 2 System Installed By: 13 xaa aebanl Installer# Date:TQ GPS Coordinate: Q3 6 Aft- uA_ tG /11 1 Environmental Health Speciali DCHD 11/06 (Revised) l2aa -� U fte3 d SUP 0 K 4 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 #: 990005528 Tix P1N/EH #: E60000000201 Billed To: Sugar Valley Airport Subdivision'lnfo: Reference Narne: LocationiAddress: 173 Bath Lane -27028 Proposed Facility: Residential Property Size: 1 Ac ATC Number: 5976 Site Type: KNew ❑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 2 # Bathrooms I # People 2 Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size�0.L Type of Water Supply: ❑County/City KWellunityWell System Specifications: Design Wastewater Flow (GPD) _QY40—Tank Size /000 GAL. Pump Tank ,,� GAL. ,, / Trench Width � Max. Trench Depth L% Rock Depth_/Z��0(, Linear Ft. 00� 'MZV� 61 Site Modifications/Conditions/Other: __ /UU 1���ieG�r�� fl/' ?Sy% l"C ,1%a QAVM f YM n4 70 Contact the Davie County Environmental-ffe—aTth Section for final inspection of this system between 8:30 - 9:30a.m. on the day of installation. Telephone # (336)751-8760. r Environmental Health Specialist Q►'V Date: ' , r�rur� i i mF �uP�,;�P�lt U`s1Qf t Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005528 Tax PIN/EH #: E60000000201 Billed To: Sugar Valley Airport Subdivision Info: Address: 249 Gilbert Road Location/Address: 173 Bath Lane -27028 City: Mocksville Property Size: 1 Ac Reference Name: Proposed Facility: Residential **NOTE* *This Improvement 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: ®New ❑Repair ❑Expansion Permit Valid for: 815 Years ❑No Expiration Residential Specifications: # Bedrooms I # Bathrooms Z # People Z Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) Design Flow(GPD): ado Type of Water Supply: ❑County/City El Well' ❑Community Well L I /, - t -. . i c I A Site Modifications/Permit Conditions: Environmental Health Specialist i.p.l 1-06 I APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Boz 848/210 Hospital Street f av Mocksviil�l6 - 028 (336)753-6,$0/Fax�(33 753-1680 �ppli ion For." ❑1' 1i a'I WWImprovement Pe r `�Au orization To Construct (ATC) ❑ Both vpk�f Ap��a iL ❑Ne m-' ❑Repair to Exis g System Expansion/Modification of Existing System or Facility ***�TTIHS APPLICATION CANNOTB PROCESSED UNLESS ALL OF THE REQUIRED INFOROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPUCANT INFORMATION Name ar' VdLJ Contact Person Address Home Phone' jo - 7;;-,;—;, s9 9 City/State/ZIP p ekS P1 / G Business Phone,3 3 Lo - Emai1,4 4 view eV. limit-r��( Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 7- /,S' NOTE:- A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name' �iereJ-i�i Phone Number Owner's Address City/State/Zip Property Address /7 5 City lyoclZ,-a,& fit? Lot Size Tax PIN# // ," Subdivision Name(if applicable) Section/Lot# LOe2— Z Directions To Site: 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✓130 Are there any easements or right -of --ways on the site? _Yes No Is the site subject to approval by another public agency? _Yes .� Will wastewater other than domestic sewage be generated? Yes ✓No IF RESIDENCE FIT J, OT JT TT4.F BOX BFT.OW # People -� # Basement: ❑Yes o _ Bathrooms Garden Tub/Whirlpool ❑Yes bin es�XNo i� IF NON -RESIDENCE FIT, I, 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: Aonventional ❑Accepted ❑Innovative ❑Alternative ❑Other. Water Supply Type: ❑ County/City Water ❑ New Well Wxisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑)4 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 avie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I and r tand that I am respo able for the proper identification and labeling of property lines and corners and locating and flagging ors ing the house/facijK jbcation/proposed well location and the location of any other amenities. roperty owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Dat EHS: Sign given ❑Yes ❑No ow Z-0 Nb Account # Revised 11/06 Invoice # Oa' fry �07 3 • �: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005528 Tax.PIN/EH #: E60000000201 Billed To: Sugar Valley Airport Subdivision Info: , Reference Name: Location/Address: 1173 Bath Lane- 2 Proposed Facility: Residential Property Size: 1 Ac 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 L Slope % -Ch' o HORIZON I DEPTH Texture groupL Consistence Structure r MineralogyL HORIZON H DEPTH 0 --gr Texture group; Consistence P7 yq, JFL Structure Mineralogy `t 7 2- t HORIZON III DEPTH Texture groupK" L• Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence - Structure Mineralogy SOIL WETNESS _ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: P1 EVALUATION BY: LONG-TERM ACCEPTANCE RATE. 2 OTHER(S) PRESENT: REMARKS: �I�_(�4G� y ` U. 1114 Al2 S(/�S/�P %lam L 6?[ N'�6 Gf� �'.�i!o." 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 Moist VFR Very friable FR - Friable FI - Firm VFI - Very firm EFli- Extremely firm 3y -d. 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 05105 (Revised) ■!■■■■■■!■■■■■■!■!■■■■■■i■■!�■■■■!1■■■■■!:1■■■III■■■■■■■■■■■■!■■■■■■■■ ■■■■■//■/■■■/■■■■/■■/■■■/■�Ilr/■■■■1J1■■/■■117'■/■111■■/■/■■■■//■■■■■//■■■ ■■■!■■■■■■■■■■■■■■■■■■■■■■iii■■■■ilii■■■■■�i�■■■I'1■■■■■■■■■■■■!■■■■■■■■ ■■//■■■■■■/■■/■■■■■■/■■//■■//■■■■■/■■/■G■■■■■111■■■/■■■/■■■■■///■/■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ (2190) B ATE 1 LN A r (2190) B ATE 1 LN 74 Latitude;. r 74 Latitude;. APPLICATION FOR ITE EVALUATION/IMPROVEMENT PERMIT & ATC C� avie County Environmental Health P.O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 P �� Application For:' a valuation/Improvement Permit ❑ Authorization To (strucC(AIe)-; ZOBi Type of Application: ❑New System ❑ Repair to Existing System ❑ Expansion/Moiffication of Existing Sst4n or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPT .TCANT INFORMATION Name _'W_ Address : L. S City/State/ZIP Email .Q 0 A -T Name on Pern Mailing Address I10014ur,Tv Lei 01 Contact Person a,, fiakIL Home Phone s99 z 3usiness Phone 3 X 31'7/ *Date House/Facility Corners NOTE:. A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid mop�� with site plan, no expiration with complete plat.) 'y�?g �9 7/ Owner's Name' !% ,� >1 'e�'� Phone Number Owner's Address 249 Gil City/State/Zip PropertyAddress f 7 3 6A-rW City Lot Size / Tax PIN# .SSSS"/ 2- 9 90 F&Oo4o0002Ol Subdivision Name(if applicable) Section/Lot# Directions To Site: plv F6jwQ1< g leFf 6:a(, AL old 464`,11" 4,> '-r, t &7;— _P oIx . 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? ✓No Is the site subject to approval by another public agency? _Yes Yes ✓1`io Will wastewater other than domestic sewage be generated? _ Yes ✓�o TF RESTTIENCE FTT,T, OT TT THF, BOX BELOW # People # Bedrooms eor # Bathrooms a Garden Tub/Whirlpool ❑Yes Ao Basement: ❑Yes R% Basement Plumbing: ❑Yes/)<No TF 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 4 Type system requestedXConventional ❑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 >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 ui#rstand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or itaking the house/cility 1 on, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): % = 1 Client Notification Date: ate EHS: Sign given ❑Yes ❑No Account # Z Revised 11/06 /„ Invoice #