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131 Cedarpark Dr OPERATION PERMIT F-CDPFi[eNumber ice Use Only Davie County Health Department 193147-1210 Hospital Street P.O. Box 848 umber, Mocksville NC 27028 Evacuated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: T ant: True Homes Property owner: Taylor Williams ress: 2649 Brekonridge Centre'Drive Address: 2990 Bethesda Place City: Charlotte Cay: Winston-Salem State0l): NC 28110 State/Zip: NC Phone#: (336)457-6682 phone#: Property Location & Site Information Address/Road#: Subdivision: Summer Hill Farm Phase: Lot: 35 131 Cedarpark Drive Advance NC 27006 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: *Water Supply: PUBLIC *System Classification/Description: *IP Issued by. 2325-Mitchell.Brittany TYPE III B.SYSTEM MINGLE EFFLUENT PUMP *CA issued by: 2140-Nations,Robert Sap rolite System? ( Yes QNo Design Flow: 4 8 0 *Distribution Type: PUMP TO GRAVITY Pump Required? - @Yes QNo Soil Application Rate: 0 3 *Pre Treatment: Drain field (Nitrification Field 1 6 0 0 Sq.ft• *System Type: INFILTRATOROUICK4STANDARD o. Drain Lines 5 - Installer: Ronnieoverbee otal Trench Length: 4 0 0 ft. Certification#: 1143 Trench Spacing: — 9 ()Inches O.C. . Feet O.C. *EH S: 2140•Nations,Robert Trench Width: 3 Inches — Feet Date: 0 8 / 2 , 5 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Approval Status Inches Maximum Trench Depth: 3 6 Inches ® Approved G] Disapproved. _ Maximum Soit Cover. a 4 Inches CDP File Number 193147 - 1 County ID Number: , Septic Tank Manufacturer. WMS Lat. STB: -363 Long: Gallons: 1000 Installer: Ronnie Overbee Certification#: 1143 Date: 0 5 / 3 1 / x 0 1 6 *EH S: 2140-Nations,Robert *Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker El Yes ® No Date: 0 8 / 2 5 / a 0 1 6 Reinforced Tank: C] Yes ® No Approval Stetus Piece Tank: ❑ Yes ® No 'CI Approved❑ disapproved r Pump Tank Manufacturer. wMS Installer. Ronnie Overbbee PT: 92 Certification#: 1143 Gallons: :1000 *EH S: 2140-Nations,Robert .Dater 0 6 / 0 9 / a 0 1 6 Date: 0 8 1 a 5 / a 0 1 6 RiserSealed Q Yes ❑ No RiserHebht Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: p Yes ❑ No ® qpp"roved❑ Disapproved.; 1 PieceTank: p Yes._.. ... ....❑ No Supply Line Pipe Size: a inch diameter Installer. Ronnie Overbee Pipe Length: 1 a 4 feet Certification#: 1143 *EH S: 2140-Nations,Robert *Schedule: 40 Pressure Rated CI Yes ❑ No Date: 0 8 / x 5 / 2 0 1 6 Approved fittings. ® Yes ❑ No Approval Status Approved❑ Disapproved Pump e u e (' Pump Type: Chandler InstallerRonnie Overbee Dosing Volume: - Gal Certification#: 1143 Draw Down: Inches *EHS: 2140-Nations,Robert *Chain: ROPE 0 8 / .2 5 / a 0 1 6 Date. Valves Accessible p Yes ❑ No Flow Adjustment Valve p Yes ❑ No Check-valve R Yes ❑ No Approval Status f , PVC Unions 1 Yes ❑ No p Approved[ Dls pprovetl Vent Hole ❑ Yes ❑ No Anti-siphon Hole 0 Yes ❑ No CDP,File Number 193147 - 1 County ID Number: Electric Equipment N EMA 4X Box or Equivalent ® Yes F1N o Installer Ronnie Overbee Box 12 inches Above Grade Q Yes El No 1143 Certification#: Box Adj. Pump Tank ® Yes ❑ No Conduit Sealed no Yes ❑ No *EH S: 2140-Nations,Robert Pump Manually Operable ® Yes ❑ No g ig / a 5 / 2 0 1 6 *Activation Method:PIGGYBACK Date: 'Approval Status Alarm Audible p Yes ❑ No Alarm visible ® Yes ❑ No ®.Approved❑ Disapproved 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 8 / a 5 / a 0 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A,Rules for Sewage Treatment and Disposal,15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE Ill B. sewage septic system. _ Rule.1961 requires that a Type .TYPE III B. septic system meet the following criteria: Minimum System Review By The Local Health Department: SYRS. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator. WA Reporting Frequency By Certified Operator. NIA Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operator forthe life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit fora system required to be maintained bya public or private management entity, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 193147- 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Scale: . OBlock Drawing Drawing Type: Operation Permit ON/A � _ __ I y a �- H 1I l i0. i I I � l 11 i CONS'TRUC'=TION For office Use Only AUTHORIZATION 'CDP File Number. 1931417-1 uU_, _ Davie County Health Department County ID Number.210 Hospital Street �pi �� Evaluated For. NEW P.O. Box 848 r W� Township: Mocksville IDI PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336- 53-1680 0 6 / a 1 / a 0 a 1 Applicant: True Homes Property Owner: Taylor Williams Address: 2649 Brekonridge Centre'Drive Address: 2990 Bethesda Place City: Charlotte CRY: Winston-Salem StatefZip: NC 28110 State2ip: NC Phone#: (336)457-6682 Phone#: Property Location & Site Information rAddress/Road #: Subdivision: Summer Hill Farm Phase: Lot: 35 Cedarpark Drive ance NC 27006 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally 71nchesSaprolite S stem? Minimum Soil Cover. 1y OYes ONo Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches SoilMaximum Soil Cover. Application Rate: 0 3 a 4 Inches 'System Classification/Description: 'Distribution Type: Septic Tank: 1 0 0 0 _ Gallons 'Proposed System: 1-Piece: OYes @No Pump Required: ®Yes ONo OMay Be Required Nitrification Field 1 6 0 0 Sq. ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 3 1-Piece: OYes ®No Total Trench Length: 4 0 0 ft. GPM—vs— ft. TDH Trench Spacing: — 9 ®Inches O.C. Dosing Volume: _ Gallons O Feet O.C. Trench Width: — 3 _ @Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O 111 O IV Dann 1 of Z CDP File Number 193147 - 1 County ID Number: ❑ Open Pump System Shebt Repair System Required:@Yes ONO ONo, but has Available Space rrDesign System Trench Spacing: 9 Q Inches 0. ification: Provisionally Suitable — e Feet O.C. Trench Width: QInches w: 4 8 0 — � 0 Feet Soil Application Rate: 0 3 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover 1 a Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nildfication Field 1, 6 0 Inches Sq.ft. No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 0 0 ft Pump Required: @Yes ONo OMay Be Required Pre Treatment: ONSF OTS-I OTS-II - *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and maybe Issued atthe sane time the Improvement Permit issued(NCGS 130A-336(b)}If the Installation has not been completed during the period of validity of the Constr=tlon Permit,the information submitted In the application for a permit or Construction Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become Invalid,and maybe suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONo Applicant/Legal Reps. Signature: Date:_ *Issued By: 2140-Nations.Rob Date of Issue: . 0 6 / a 1 / a 0 1 6 Authorized State Agent. Malfunction Log Oyes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • CONSTRUCTION AUTHORIZATION 193147 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 6 / 2 1 / 2 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock ft. QNIA . � a ( _ 00 6 r i �l I J-1 ;4 -1..........Ll 1 1 1 1- 1 1 1:J-1-1- 1 1 1 1 � I I � fey �� ► I--,-- c� CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 193147- 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: ,e s / 21 / � ® a. s Civ �— a 5 -c l G Click below to Import an image from an external location: Drawing Type:Construction Authorization r- 10 14 l� 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(336) 753-1680 Application For: ❑ Site�valuation/Improvement Permit CYAuthorization To Construct(ATC) ❑ Both Type of Application: 2NewSystem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed True Homes Contact Person Jackie Self Billing Address 2649 Brekonridge Ctr Dr Home Phone (704) 238-1229 City/State/ZIP Monroe NC 28110 Business Phone-(704) 238-1229 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 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 Williams Development Group Phone Number (336) 293-6790 Owner's Address 433 Roslyn Road City/state/zip Winston Salem NC 27104 Property Address 131 Cedarpark Drive,Advance, NC 27006 City Advance Lot Size .76 acres Tax PIN# G814OA0035 Subdivision Name(ifapplicable) Summer Hill Farms Section/Lot# 35 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 VNo Does the site contain jurisdictional wetlands? ❑Yes VNo Are there any easements or right-of-ways on the site? []Yes lallo Is the site subject to approval by another public agency? ❑Yes igNo Will wastewater other than domestic sewage be generated? ❑Yes VrNo IF RESIDENCE FILL OUT THE BOX BELOW #People 5 #Bedrooms 4 #Bathrooms 2.5 Garden Tub/Whirlpool ZYes ❑No Basement: ❑Yes ZNo Basement Plumbing: ❑Yes ZNo 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:.RIConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 2 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 pdqules. Iunder d that I m responsible for the proper identification and labeling of property lines and corners and loca mg d fl ging o kin house/facility location,proposed well location and the location of any other amenities. Propert3f owner's or owner's leg 1 representative signature Site Revisit Charge ): Client Client Notification Date: Date EHS: Sign given ❑Yes DNo Account# Revised 11/06 Invoice# DRAWING,NAME: P:\2016\160111\Survey\160111_survey.dwg — PLOT — 6/1/2016 7:32 AM �—�,� Ap I ~1 13 0,9� GRID NOR1N 83(2011) N 0 I ~`1p•RY PRELIMINARY SQ FT. WAL SF 70 B/G` =998t SF I 5'PUBLIC S/W" 0-- SF I I 1 sqP;32,107.E D TJS 1 ) LOH91 DR/VF HOUSE—RIW 474* SF SYOEWALK 119t/SF 2821 SF 1 3 I I PORCH. 142*Sr HYAa 91-SF PA 770.- 100.* Sr :PA WSOD ltdB/G: 16.WO-* SF SE£D/STRAff- 7,334-- SF UND/SIURBED: 7,275.* SF Lor J6 N CN 2 LOT J7oo• I sw -, s, 36 a 2• O I ,5x84' 1.7.9 IPROPOSEDHOVX ' N I `PAD ' I 20LJ � L835O. ' 40,FY Cava 2 cmw [10•S/DEWALK EASEMENT [ [ [ 4117 EUnMITY EASEMEN NO2'44'19" I CEDARPARK DRIVE 124.57' I (50'PUBLIC R/W) I TRUE HOMES PLOT PLAN OF CEDARPARK DRIVE LOT 35 OF SUMMER HILL FARM PHASE 1, SEC7701V 4 ADVANCE GRAPHIC SCALE SHADY GROVE TOWNSHIP, DA WE COUNTY 60 30 0 60 120 MAP RECORDED/N PLAT BOOK 12 DATE: 5/31/?Of6 1" = 60 FEET Ar PACE 146 DRAWN BY. r't DAVIS • MARTIN • POWELL ENGINEERS & SURVEYORS PRELIMINARY PLAT 6415 OLD PLANK RD,HIGH POINT,NC 27265 Not for Rseordotbn,Conveyone0.or Sola (336)8864821 1 WWW.DMP-INC.COM I LICENSE:F-0245 IMPROVEMENT PERMITr*CDPFileNumber For Office Use only " 193147- 1 Davie County Health Department210 Hospital Streetunty ID Number. P.O.Box 848 Evaluated For. NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 4/17I2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Pennit. Applicant: True Homes Property Owner: Taylor Williams Address: 2649 Brekonridge Centre' Drive Address: 2990 Bethesda Place CRY: Charlotte City: Winston-Salem State2ip: NC 28110 State2ip: NC Phone#: (336)457-6682 �Phone#: Property Location & Site Information r ad#: Subdivision: Summer Hill Farm Phase: Lot: 35 land Road NC 27006 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: *Water Supply: PUBLIC System Specifications nitial S stem *Site Classification: Provisionally Suitable Minimum Trench Depth: Inches Saprolite System? OYes @No Maximum Trench Depth: Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 3 0 0 1-Piece: OYes ONo Pump Required: (F)Yes ONo OMay Be Required *System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:0 Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: Inches Soil Application Rate: 0 3 0 0 Maximum Trench Depth: Inches - - - - "System Classification/Description: Pump Required: OYes ONo O May be Required TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 193147:. 1 County ID Number. *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarentees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. `. Site Plan The Improvement Permit shall be valid for 5 years from date of Issue with a site plan(means a drawing not necessarily drawn to sale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the M site forthe proposed Wastewater system,and the location of water supplies and surfacewaters). Plat The Improvement Permit shalt be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a sale of one inch equals no morethan 60 feet.that includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the issuance and may revoke the permits for failure of the system to satisfy the conditions,the rules,or this article.This permit is subject to revocation if the site pian,platy or Intended use changes(NCGS 130A-335M).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring, reporting,and repair(.1938(b)� ApplicanVlLegai Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature, Date: "Issued By: 2325-Mitchell,Brittany Date of issue: 0 4 1 3 2 0 1 5 • OValid without Expiration? Authorized State Agent: 0Create CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • IMPROVEMENT PERMIT 193147 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 04 / 17 / 2 0 1 5 Q Inch Drawing Drawing Type: Improvement Permit Scale: , psiock QN/A r- - VAMT. _ i i\ CDP. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC / j l q 7 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: i,Site EvaluatioMmprovement Permit C Authorization To Construct(ATC) ❑Both Type of Application: i 1New System 0Repair to Existing System CExpansion/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 lobe Billed 7r-,4e ",,5 Contact Person J& -r [Sit Blasi e.,- Billing 'erBilling Address Z6 GI G lire(<o Ce,ike 0.% Home Phone Zfs7 &G P Z City/State/ZIP 0-1lnw 1,9 f9t?�2 //0 Business Phone tlg blL 0 7 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included:a Site Plan CPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name_ i At•,.I e r W, 14 rx S Phone Number Owner's Address q0 6te?,j ; P acs e_�-`5k bOY(Lity/State/Zip&eu ,,ky, -ale.,,,/)c— Property Address City Lot Size Tax PIN# Z Subdivision Name(ifapp cable)_S�„�„9,er. „.- Section/Lot# 7� Directions To Site: ,/�4LG K S 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? CYes❑No Is the site subject to approval by another public agency? ❑Yes❑No Will wastewater other than domestic sewage begenerated? ",]Yes❑No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms Iq #Bathrooms Garden Tub/Whirlpool IJYes --,No Basement: OYes ONo Basement Plumbing: OYes CNo 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:9onventional CAccepted Clnnovative CAlternative ❑Other Water Supply Type:,�ICounty/City Water ❑New Well i7 Existing Well C Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C Yes VNo 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 loeatin and A �8�nor staking the houselfacility location,proposed well location and the location of any other amenities. Site Revisit Charge Properlyowner/s r's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# Revised 11/06 Invoice# j 4 Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990005132 IMPROVEMENT PYIR"AN/EH M 5779-77-4502.35 Billed-To: AM&JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#35 Address: 4001-J Country Club Road location/Address: Markland Road-27006 City: Winston-Salem Property Size: see map Reference Name: Proposed Facility: Residence "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 perrnit(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: Ergew DRepair DExpansion Permit Valid for: G4ears ONo Expiration Residential Specifications: #Bedroomsq#Bathroomsq#People Basement �asement plumbingCY Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): _ Type of Water Supply: CrCounty/City DWell ❑CommunityWell As stated in 15A NCAC 18A.19e9(5l Site Modificatioms/Permit Conditions: ac:eP to ort _Rystemsmay also System Type LTAR Initial c Repair ., 0 2k SitePlan � �pl Y t\0 lki y �D �Yd Environmental Health.eni-rialict Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990005132 IMPROVEMENT PFiR AN/EH#: 5779-77-4502.35 Billed To: AM&JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#35 Address: 4001-J Country Club Road Location/Address: Markland Road-27006 City: Winston-Salem Property Size: see map Reference Name: Proposed Facility: Residence **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: fff�ew ❑Repair DExpansion Permit Valid for: 015"Years ONo Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement(3'Basement plumbingQ' Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): _ Type of Water Supply: 0-6ounty/City OWell OCommunity Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: arre ted Systems may also be tic- System Type LTAR Initial A c .P Repair Site Plan 0"� of 5° �t Q 1`t�a �� aero Environmental Health Specialist Date APPLICATION,., VALUATION/IMPROVEMENT PERMIT & ATC County-Environmentai Health Box-848/210 Hospital Street �f, ! Mkksville,NC '11619 51=8760/Fax(336)751-8786 Application For: q Site E aluatio ement P it ❑Authorization To Construct(ATC) /Both Type of Application:, y t�iifQ epair sting System ❑Expansion/Modification of Existing System or Facility ***IMPORT` T*** 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 L LQ- Contact Person J��� W ie5i- Billing Address Jl i 4 cso CJJ b hd Home Phone Gig Cs-S;Lf 14 City/State/ZIP I.,J-S C 2'1 Business Phone 1�S—�SD�S/n�1399'�1�3Z Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners F gged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name LLC Phone Number ?CS5-525 Owner's Address%qo 1 S Czyn�,v 9r L RZd -- City/State/Zip W-S a C 29Y241 Property Address City Lot Size Tax Tax PIN# — Subdivision Name(if applicable),Su -1 n rner 1 ,11 �rra-- Section/Lot# Directions To Site: 1 .+ t S tXArL0A^J AW; C11'rediv &cr65S 4& Cl w ' �- > > If the answer to any of the following questions is'yes",supporting documentation mussf be attached. Are there any existing wastewater systems on the site? ❑Yes ag Does the site contain jurisdictional wetlands? ❑Y tl 0 Are there any easements or right-of-ways on the site? 10 es ❑No Is the site subject to approval by another public agency? ❑Yes NKK Will wastewater other than domestic sewage be generated? ❑Yes IF RESIDENCE FILL OUT THE BOX BELOW #People 4 . #Bedrooms9— Bathrooms 4 Garden Tub/Whirlpool Wres ❑No Basement: es ❑No Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW +1 JA Type of FacilityBusiness 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:. VolInventional ❑Accepted• ❑Innovative ❑Alternative ❑Other Water Supply Type: M 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 240 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 comers and locating and flagging or staking use/.facility location,proposed well location and the location of any other amenities. Site I seyisit Charge r p owner's or owner's legal representative signature Date(s): Z Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT -�` Environmental Health Section c Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005132 Tax PIN/EH#: 5779-77-4502.35 Billed To: AM &JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#35 Reference Name: Location/Address: Markland Road-27006 Proposed Facility: Residence Property Size: see map 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 11 1- Slope% Z Z HORIZON I DEPTH -1 _ Z• Texture group S G GL G Consistence Structure Mineralogy CRAV HORIZON H DEPTH I E- Texture group5G L Consistence Structure r 1L Mineralogy HORIZON III DEPTH _ - (, Texture groupL L GCS Consistence 1 5n Structure MineralogyS HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS / e__ RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ' _ OTHER(S)PRESENT: �Y1 ` I� 6-4a V1 i REMARKS: 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 EFI-Extremely firm 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 lYQteS Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface 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