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2864 Cornatzer Rd OPERATION PERMIT or ice use n ty �s fit. Davie County Health Department [Evaluated Fite Number 122818-1 210 Hospital Street G8-000-00-oot P.O. Box 848 y ID Number. Mocksville NC 27028 For.:NEWPhone:336-753-6780 Fax:336-753-1680 ship: Addlress: icant: Gray Potts Property Owner. Gray Potts 104 Sycamore Park Lane Address: 104 Sycamore Park lane City: Advance City: Advance State2ip: NC 27006 State/Zip: NC 27006 Phone#: (336)998-8409 Phone#: (336)998-8409 ProveProvertv Location & Site Information Address/Road #: A �( Subdivision: Phase: Lot: Cornatzer Ro Advance 27006 Directions Structure: SINGLE FAMILY. Hwy 158 right on Hwy 801, right on Cornatzer Rd. Or _ corner of Cornatzer Rd. and Rabbit Trail #of Bedrooms: #of People: *Water Supply: PUBLIC *IP Issued by. *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: Seprolite System? OYes ®No Design Flow: 3 6 0 * GRAVITY-SERIAL Pump Required? Distribution Type: ()Yes ( No Soil Application Rate: 0 3 'Pre Treatment: Draln field FNorifDraiiin' n Field 1 -2 0 0 Sq. ft- *System Type: INFILTRATOR QUICK 4STANDAR D Lines 3 Installer: Mike Singleton Total Trench Length: 3 0 0 ft. Certification#: 1810 Trench Spacing: 9 Olnches O.C. • Feet O.C. 'EH S: 2140-Nations.Robert Trench Width: _ 3 Olnches *• Feet Date: 0 6 / 1 1 / 2 0 1_4 Aggregate Depth: inches _ Minimum Trench Depth: 3 6 Inches Minimum Soil Cover4 �ApprovatStatus' Inches Maximum Trench Depth: 3 6 E°Approved O Disapproved Inches Maximum Soil Cover. 2 4 Inches CDP Fite Number 122818 - 1 Septic Tank County ID Number: 08-000-00.001 Manufacturer, Shoaf Lat. STB: 760 Long: Gallons: 1000 Installer. Mike Singleton Certification#: 1819 Date: 0 1 / 0 8 / .2 0 1 4 *EHS: 2140-Nations.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes E N o Date: 0 6 / 1 0 0- 0 1 4 / al Reinforced Tank: ❑ Yes 2 NO Approv5"talus i Piece Tank: ❑ 'Yes - ® No ® Approv>rd( :��Dlsapproved ; Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS: Date: Date: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑. No ❑ Approved❑:Disapproved K�T nk: ❑ Yes ❑ NO Supply Line Poe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: 'ENS: Pressure Rated. ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO ApprovatStatus D Approved© D77 isapprovetl Pump Requirement Pump Type: Installer. Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Cham: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status; PVC unions ❑ Yes ❑ No ❑. Approved CO Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO CDP File Number 122818 - 1 County ID Number: G8-OMOO-001 Electric Equipment NE�4X or Equivalent El Yes El No Installer: Box 12 inches Above Grade E) Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EH S: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: �Appro�yal Status a �; Alarm Audible ❑ Yes_ - - -- ❑ NOe Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No -- .....__ 2140-Nations,Robert *Operation-Permit completed by: .vAuthorized State Agent* - - - Date of Issue: 0 6 / 1 0 / a 0 1M 4 Owner/Applicant Signature: This system has been installed in with applicable NC General Statutes:Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal,15A NCAC 18A.1900 et. Seq.,and as conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE 11 a sewage septic system. Rule.1961 requires that a Type TY'E II A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: WA _ Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator. WA - 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 for the 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 for a system required to be maintained by a 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 owner and 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 122818 - 1 Davie County Health Department CDP File Number: 210 Hospital StreetG8-000.00-001 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch u Scale: . OBloctc ft. Drawing Drawing Type: Operation Permit- ON/A I � I i -N-n L S-, F)t II I I � � I I S =-06NSTRUCTION For Office Use Only AUTHORIZATION *CDP Fite Number 122818-1 Davie County Health Department County ID Number: G8-000-d0-001 f 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 8 / 2 1 / 2 0 1 8 Applicant: Gray Potts Property Owner: Gray Potts Address: 104 Sycamore Park Lane Address: 104 Sycamore Park Lane City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336)998-8409 Phone#: (336)998-8409 Property Location & Site Information Address/Road #: Subdivision: Phase: Lot: Cornatzer Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 right on Hwy 801, right on Cornatzer Rd. On corner of Cornatzer Rd. and Rabbit Trail #of Bedrooms: #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: 2 4 rDesign ssification: PS Inches Minimum Soil Cover. e System? OYes (DNo Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: Maximum Soil Cover: 0 3 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons "Proposed System: 25%REDUCTION 1-Piece: OYes O N o Pump Required: OYes @No OMay Be Required Nitrification Field Sq ft Pump Tank: Gallons No. Drain Lines 1-Piece: OYes ONo Total Trench Length: 3 0 0 ft. GPM—vs-- ft. TDH Trench Spacing: _ 9 @FeetInches O.C. Dosing Volume: _ Gallons Trench Width: 3 6 - Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer G rade Level Required: O I OI1 0111 O IV CDP File Numtjer 1122818 - 1 County ID Number:G8-000.00-001 ❑ Open Pump System She( Repair System Required:@Yes ONO ONO, but has Available Space rDesign System Trench Spacing: E13 Inches 0. ification: Ps — 9 Feet O.C. Trench Width: Inches w: 3 6 0 — 3 6 Feet Soil Application Rate: 0 - 3 Aggregate Depth: inches Minimum Trench Depth: 2 4 Inches *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR480 GPD OR LESS) Minimum Soil Cover. Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines "Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 0 0 ft. Pump Required: QYes QNo OMay Be Required Pre-Treatment: ONSF OTS-1 OTS-11 *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 wlidity of the Improvement Permit,not to exceed five years,and may be issued atthe sametime the Improvement Permit issued(NCGS 130A-336(b)}If the Installation has not been completed during the period of wlidity of the Construction Permit the Information submitted In theapplication 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 inwlid,and may be suspended or revoked(.1937(g)).The person awning or controlling the system shall be responsible for assuring compliance with the taws,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: 2244-DaywalL Andrew Date of Issue: 0 8 2 1 2 0 1 3 Authorized State Agent:QA Malfunction Log Oyes QHand Drawing Olmport Drawing Total Time:(FIH:MM) **Site Plan/Drawing attached.** 0 1 Hours. 0 0 Minutes Page 2 of 3 ` CONSTRUCTION AUTHORIZATION 122818 - 1 Davie County Health Department CDP File Number: 210 Hospital StreetG"00-00.001 P.O.Box 848 Caunty File Number: Mocksville NC 27028 Date: 0 8 / 2 1 / 2 0 1 8 0Inch Drawing Drawing Type: Construction Authorization Scale: , QBlock =, Q N/A ? r , i -------- 0 0L , 3)(1cd edL , , i Account #: 990003806 Tax PIN/EH M G8060'd0001 Billed To: Gray Potts Subdivision Info: Rabbit Farm 3 Lot#P/O 76 ACRES Address: 104 Sycamore Park Lane Location/Address: Rabbit Farm Trail-27006 City: Advance Property Size: 5.60 Acres Reference Name: new map needed Proposed Facility: Residential t' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION &g&MRTY INFORMATION Account #: 99000380 Tax PIN/EH#: G80 Billed To: Gray Potts Subdivision Info: Rabbit Farm 3 Lot#P/O 76 ACRES Reference Name: new map needed Location/Address: Rabbit Farm Trail-27006 Proposed Facility: Residential Property Size: 5.60 Acres 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 Slope% HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group . Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY- LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: 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 S'Yet 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 ]dotes 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) T TAR -T.nnv-term ArrP..ntnm-P rata-anihig0ft) TWIlf IT%n inc m ,117 rM&Ct121 114 11g� 12O 2909 t 11 ,2788 2 18 P G' �284G' 2 15 949 rt Fa r- 01 1f7 1^45 X146 `r l T OPev�N All data is provided as is without warranty or guarantee of any kind either expressed or Implied including but not limited to the implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of 0 b 14 Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. Printed.AUg 16, 2013 n ` APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC - Davie County Environmental Health , LVED P.O.Bog 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: 0 Site Evaluation/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 BUI. .ETIN for instructions. APPTJCANT INFORMATION Name / Contact Person Address BoaX Home Phone U City/St1te/Z1P U Business Phone Email Name on Permit/ATC ifDyf'qre t than Above , GL Mailing Address -k (2— _ City/State/Zip PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany thi application. Included: ❑ Site.Plan ❑Plat(to scale) (Permit is valid for 60 mon with s plan,nq expiration with complete plat.) � � 3s Owner's Name' ' Y Phone Number Owner's Address City/State/ 'p Property Address CityldrJi� Lot Size _TaxPIN# Subdivision Name(if applicable) Section/Lot# 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 KNo Are there any easements or right-of-ways on the site? Yes No Is the sitg:subject to approval by another public agency? Yes,?,VNo Will wastewater other than domestic sewage be generated? Yes o TF RESIDENCE FIT J,01 TT THF ROX RFLOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No IF NON-RESIDENCE FILL OTJT THE BOX.IBLOW Type of Facility/Business 5 m 1-r4'x1-1 Total Square Footage of Building D #People # Sinks #Commodes # Showers #Urinal Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: Aconventional ❑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?'L7 Yes ;EQ 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 faWfied 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 resp 'bl for the proper identification and labeling of property lines and comers and locating and flagging or s the house/f ty 1 o proposed well location and the location of any other amenities. Property own is or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: lo A11q; Sign given ❑Yes ❑No ^ ! Account# Revised 11/06 �� I2 ' Invoice# 30� � 1 .2909 r —ccurraTZER RD- - '� Crf, 2915 284G J \� 299 rc (� OP All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied r, � (NV tr warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. P rI n+led.J U n 26, 2013 r '• Qppraisal,Card Page 1 of 1 1V\� • 1 •1 j 1. DAVIE COUNTY NC 6/26/2013 11:57:52 AM [71'. TTS GRAY A P0T75 BETTY Return/Appeal Notes: G8-000-00-001-08 atzer RD UNIQ ID 968320 SPLIT FROM ID 11570 32000 ID NO:5870724857 COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1 0 val Year:2013 Tax Year:2013 6.330 AC CORNATZER RD 6.330 AC 6.330 AC SRC=ralsed b 17 on 09 27/2012 07003 PEOPLES CREEK RD TW-07 C- EX- AT- LAST ACTION 20121228NSTRUCTION DETAI MARKET VALUE DEPRECIATION CORRELATION OF VALUETAL POINT VALUE Eff. BASE -1 BUILDING USE MOD Area QUAL RATE RCN EYB AYB REDENCE TO N C7 ADJUSTMENTS 971 00 1 1 1 %GOOD EPR.BUILDING VALUE-CARD x OTAL ADJUSTMENT TYPE:Vacant EPR.OB/XF VALUE-CARD > ACTOR MARKET LAND VALUE-CARD 52,70 9 TOTAL QUALITY INDEX STORIES: OTAL MARKET VALUE-CARD 52,70 OTAL APPRAISED VALUE-CARD 52,70 TOTAL APPRAISED VALUE-PARCEL 52,70 TOTAL PRESENT USE VALUE-PARCEL TOTAL VALUE DEFERRED-PARCEL OTAL TAXABLE VALUE-PARCEL 52,70C PRIOR UILDING VALUE BXF VALUE 22,33 ND VALUE RESENT USE VALUE EFERRED VALUE OTAL VALUE 22,330 PERMIT CODE I DATE I NOTE I NUMBER AMOUNT OUT:WTRSHD: SALES DATA FF. m RECORD N7�01A DEED INDICATE SALES OOK AGER TYPE / PRICE m 0897 172I— Q IV 5000 �j HEATED AREA NOTES 0 012 SPLIT SUBAREA UNIT ORIG% SIZE ANN DEP % OB/Xf DEPR. a GS RPL OD UA DESCRIPTIO T N PRICE GOND LDG# FACT V RATE V GOND VALUEc TYPE AREA CS TOTAL OB XF VALUE o '. [..GHEST EPLACE 0 AREA ALS LDING DIMENSIONS No INFORMATION THERADJUSTMENTS LAND TOTAL BEST USE LOCAL FROM DEPTH/ LND COND ND NOTES OA UNIT LAND UNT TOTAL ADJUSTED LAND LAND CODE ZONING TAGE EPT SIZE MOD FACTRF AC LC TO OT TYPE PRICE UNITS TYP AD3ST UNIT PRICE VALUE NOTES ALAC 0120 554 0 1.2370 4 0.6800+0315-10-OS-OS PD 9,900.0 6.33 AC 0.841 8,325.9 5270SHAPE LOC AL MARKET LAND DATA 6.33 52,70AL PRESENT USE DATA http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=G80000000108 6/26/2013 •. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION o q S yoamores Par)LL �Orry �4Z�. gip✓ �c Z-700,6 (�.33Lq 4e,re! I Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape p2sition Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture Aroup Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND Landscape Position f R-Ridge.i 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 CnNSISTFN . . Moist VFR-Very friable FR-Friable FI-Firm VFI-.Very firm EFI-Extremely fur 2Ygt 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 i Mineralogy j 1:1,2:1,Mixed p eS 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) ITAR -inno_tP.rm annPntanrh rate- oalhinv/ftl TInT Tr%nc lnc If"_..:__AN -71 Sd 76 o) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990003806 Tax PIN/EH #: G800000001 Billed To: Gray Potts Subdivision Info: Rabbit Farm P/0 I&Ae res Address: 104 Sycamore Park Lane Location/Address: Rabbit Farm Trail -27006 City: Advance Property Size: 5.60 Acres 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: 45 Years ❑No Expiration Residential Specifications: # Bedrooms_ # Bathrooms #People Z. Basement❑ Basement plumbing Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):3&0 Type of Water Supply `County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type .. i _ RLIC TION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC "� �6A)T .- Davie County Environmental Health M 7 P.O. Boa 848/210 Hospital Street Mocksville NC 27028 (336)753-6780/ Fax (336) 753-1680 f airon For. ❑ Site Evaluation/Improvement Permit ❑ Authorization To Combuct(ATC) ❑ Both 1 1�" Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility "IMPORTANT1" 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 � /� ti Contact Person 514M La— Billing Address 5 "- Home Phone O City/State/ZIP f/ Pte- -527 el , Business Phone O - 3 E Name on Permit/ATC if Different than Above Mailing Address Citv/State/Zin PROPERTY INFORMATION *Date Home/Facility Comers NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) ' (Pem»t is;��1j'd for��l(o1 m albs w) sitq`pl nq piration with complete plat.) Owner's Name )YJ� 13 ; rry ,per fY f�ifi91��.%phone Number Owner's Address City/S te/ ip Property Address r City. Lot Size_ /'eSiax PIN#5YM/ do G!9000a"o I Subdivision Name(if a licable) Sectio `,_ -- Directions To Site: �i ` T A- --See 0",.V/- 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? Dyes wti , Does the site contain jurisdictional wetlands? Are ❑Yes 9M6'— there any easements or right-of-ways on the site? ❑Yes f9 o Is the site subject to approval by another public agency? Dyes Will wastewater other than domestic sewage be generated? Dyes [#iso IF RESIDENCE FILL OUT THE BOX # People :L # Bedrooms 3 # Bathrooms Garden Tub/Whirlpool PYcs i]No Basement: Oyes tido^ Basement Plumbing: Dyes UNe­ 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: i6eonventional ❑Accepted ❑Innovative ❑Alternative []Other Water Supply Type: L'YCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes a4 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 permits) 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 es. I unders responsible for the proper identification and labeling of property lines and comers and locati d fl i-10- ity-location, proposed well location and the location of any other amenities. Property owner' or owner's legal representative signature Date(s): Site Revisit Charge Client Notification Date: Date EHS: Sign given Dyes ❑No Account # 34M Revised 11/06 Invoice # RK*IT OF WAY OF W FROM PREVIOUS PLATS, SURVEYOR DDNOTLOCATE ANY DEEDED PUBLIC RNV S IRONS PLACED AT ALL CORNERS EXCEPT AS NOTED -THIS PROPERTY IS SUBJECT TO ANY EASEMENTS. AGREEMENTS, OR RIGHTS- OF-WAY OF RECORD IF ANY. PRIOR THE DATE OF THIS PLAT AND WHICH WERE NOT VISIBLE AT THE TIME OF MY INSPECTION. -ALL AREAS BY COORDINATES 00 / J 4 -,,'AU ! 000 ! CN C) I ! ! v ! ! ! H007S C4VOWW COMPANY hW DB 426 PG 163 PRV / 5B70721903 - IPF Man Pipe Found - IRF Men Rod Found- - FC Fan of Cub W Chord Flied for ro*Ootln al.......-.......—.��'dad�............Y. F bon R Radius This "__day of .........-.-.......--.....-...—....»-. 20.... - Ply line - R,,V Rioht-of-woy - L Length of L1ave - XFMR Dectrled Tranafamr and reowded in Plat Bool_.._.. P"s__ CA CenteNne - AU Arial Utaty 012045-1 - EP Edof P"" ge - OI Cawete Monument Farad Fling Fr Paid: M. BRENT SOW. DAME Co. Register of Deeds - FH Fie Nydrnt 812 Burke Street Winston—Salem, NC 27101 Phone If 336-631-9805 Email: mutatllibOgmail.com _ C SCALE -1 er 50 JJO f� 00 50 25 Y� C-806 / ! ! H0075 RABBIT FARM LIM/ PARTNERSHIP DB 208 PG 518 l PIN/ 5870710361 \ I j ssly�� � � oDsnNa 1r w �F ASPHALT • 6 PAVEM¢W— F // � Y PT FNw \ / ATF 'kit h / LATS PB6PG73 / RABBIT FARM PHASE 10 4V to / Qin / IPF SE PROPERTY / CORNER LAT 3 PS 6 Pa 73 •�t1 CAR07"4;, �PQQtE#31py9`/�+'9 SEAL E "LK \ rh1 QP'�^_ � \ 'qt4 013 S9 P p R/ 777 yl y Aces eel � \ \ w4), 040 Ift H007S RABBIT FARM LIMITED PARTNERSHIP TOTAL AREA DB 208 PG 518 275537 Sq. Feet � PIN f 5870710361cK 6.33 Acres � _ � � IP �`•r+ PRELIM/NARY, NOT FOR DEEDS, SALES \ \ � i � h OR CON �EYANCES _ � � 3163 ��' \�� tPT A�J w Surveyor Certification for Subdivision OWNER, \ \ dUA�Ev�'��� ®� L - rWAM FRANKLIN TATUM P„�.�,, d La yy, ayar, Numb or _ HOOTS RABBIT FARM artify to one or more of the faWrMrg " Indicated by on R \ AL a Treat the plat is of a ■r ay that rant" a asmwln of Ind wdMh the ren of a LIMITED PARTNERSHIP b. That this plat Moet aysumey that -In such poporttiion oof a camtyormun pony C/O JIMMY HOOTS \ 0p0a not is unregulated ce to on arelnnn that repdates parcels of lamC 306 SHERWOOD FOREST RD _ d7iC1@ _ e That thin plat Is of a .r way of on exletug parcel or paws of land: CaVZROL CORNER d. That this plot is of a aawy of another eategoryt such as the recombination of aieting WINSTON-SALEM, NC 27104 SEE PS 6 PG 49 P4 proela a nrt-erasotter ed covey or rwepuM on to e definition of a rhbmwrn; PHONE: # 336-345-0950 _ a That the Information avalaWe to this evwyr Y such that I om unable to mala a detem inatlnn to the beet of my Professional awry as to proAsioru contained In JEANETE 0. CORNATZER a thwwo d. masa TAX MAP REF. G8-000-00-001 L -31d3 DB 640 PC 706 -yryr---uUmse �---- TAX PIN 5870710361 PIN f 5870811392 TOTAL AREA 6.33 ACRES P& m CORNATZER ROAD SI TE Nor m scALE .S££ we I9 IPF 4, LI — Cp 27MMERFAMILY LLC DB 520 PG 668 PIN / 5870836578 NO APPROVAL REQUIRED BY THE DAVIE COUNTY PLANNING DEPARTMENT' PLANNING DIRECTOR Un /C REVIEW OFFICER'S CERTIFICATE 11 ------ REVIEW OFFICER DF DAVIE COUNTY CERTIFY THE PLAT TD WHICH THIS CERTIFICATION IS ATTACH MEETS THE STATUTORY REQUIREMENTS FOR RECORDING REVIEV OFFICER -'- -- DATE CERTIFICATE DF OWNERSHIP 'I (VE) HEREBY CERTIFY THAT I AM (WE ARE) THE OWNERS) TIF THE PROPERTY DESCRIBED HEREON, WHICH IS LOCATED IN THE SUBDIVISION JURISDICTION OF DAVIE COUNTY AND THAT I HEREBY ADOPT THIS SUBDIVISION PLAN WITH MY FREE CONSENT, ESTABLISHED MINIML41 BUILDING SETBACK LINES AND DEDICATE ALL STREETS, ALLEYS, WALKS, PARKS, AND OTHER SITES AND EASEMENTS TO PUBLIC OR PRIVATE USE AS NOTED. ------------------------------- OWNERS DAtE ------------------------------- OWNER DATE Surveyor Certification for Closure L WLUAM FRANKUN TATUM cortify Not this Pia o" dram ander my Deed tram on oaWal WMF::al So*-.Oy — Pe �alcc�deevbUan noordw in that the ratio of preaWon n calculated le 1:10.004 trot Bae Plat an prepared In accordance with 0S e7-30 as mended. Tstnw my original eignobwa goonee mmber end eeoh -l`3163 S......_..._..-.-..-rve Suyor U—se Numberben This the. -.-.-.-..._..day of .............._......-........-...—....»... 20.- PLAT MAP HOOTS RABBIT FARM ZIMMERMAN FAMILY LLC TOMisH6y11 -- PB 8 PO 61 -- oA1E JOB NO. SHAD GROVE -- -- -- SR i 161621•ASPHALT RIBBON PAVEMENT _ 6-15-12 012045-1 CORNATZER ROAD McAnally Land Surveying, P.C. 812 Burke Street Winston—Salem, NC 27101 Phone If 336-631-9805 Email: mutatllibOgmail.com _ C SCALE -1 er 50 JJO f� 00 50 25 Y� C-806 / Fr -- AU — —AU -CAU —AU Pi —AU Pr °em uxE oe r,ero,m -� PT - POE __AU -� AU AU —AU __AU \ POLE --AU __AU __AU `PT POLE 24 22 Sq. Feet I 5.60 Acres EA OUTSIDE RAILR AD RIGHT OF WAY l ! ! H0075 RABBIT FARM LIM/ PARTNERSHIP DB 208 PG 518 l PIN/ 5870710361 \ I j ssly�� � � oDsnNa 1r w �F ASPHALT • 6 PAVEM¢W— F // � Y PT FNw \ / ATF 'kit h / LATS PB6PG73 / RABBIT FARM PHASE 10 4V to / Qin / IPF SE PROPERTY / CORNER LAT 3 PS 6 Pa 73 •�t1 CAR07"4;, �PQQtE#31py9`/�+'9 SEAL E "LK \ rh1 QP'�^_ � \ 'qt4 013 S9 P p R/ 777 yl y Aces eel � \ \ w4), 040 Ift H007S RABBIT FARM LIMITED PARTNERSHIP TOTAL AREA DB 208 PG 518 275537 Sq. Feet � PIN f 5870710361cK 6.33 Acres � _ � � IP �`•r+ PRELIM/NARY, NOT FOR DEEDS, SALES \ \ � i � h OR CON �EYANCES _ � � 3163 ��' \�� tPT A�J w Surveyor Certification for Subdivision OWNER, \ \ dUA�Ev�'��� ®� L - rWAM FRANKLIN TATUM P„�.�,, d La yy, ayar, Numb or _ HOOTS RABBIT FARM artify to one or more of the faWrMrg " Indicated by on R \ AL a Treat the plat is of a ■r ay that rant" a asmwln of Ind wdMh the ren of a LIMITED PARTNERSHIP b. That this plat Moet aysumey that -In such poporttiion oof a camtyormun pony C/O JIMMY HOOTS \ 0p0a not is unregulated ce to on arelnnn that repdates parcels of lamC 306 SHERWOOD FOREST RD _ d7iC1@ _ e That thin plat Is of a .r way of on exletug parcel or paws of land: CaVZROL CORNER d. That this plot is of a aawy of another eategoryt such as the recombination of aieting WINSTON-SALEM, NC 27104 SEE PS 6 PG 49 P4 proela a nrt-erasotter ed covey or rwepuM on to e definition of a rhbmwrn; PHONE: # 336-345-0950 _ a That the Information avalaWe to this evwyr Y such that I om unable to mala a detem inatlnn to the beet of my Professional awry as to proAsioru contained In JEANETE 0. CORNATZER a thwwo d. masa TAX MAP REF. G8-000-00-001 L -31d3 DB 640 PC 706 -yryr---uUmse �---- TAX PIN 5870710361 PIN f 5870811392 TOTAL AREA 6.33 ACRES P& m CORNATZER ROAD SI TE Nor m scALE .S££ we I9 IPF 4, LI — Cp 27MMERFAMILY LLC DB 520 PG 668 PIN / 5870836578 NO APPROVAL REQUIRED BY THE DAVIE COUNTY PLANNING DEPARTMENT' PLANNING DIRECTOR Un /C REVIEW OFFICER'S CERTIFICATE 11 ------ REVIEW OFFICER DF DAVIE COUNTY CERTIFY THE PLAT TD WHICH THIS CERTIFICATION IS ATTACH MEETS THE STATUTORY REQUIREMENTS FOR RECORDING REVIEV OFFICER -'- -- DATE CERTIFICATE DF OWNERSHIP 'I (VE) HEREBY CERTIFY THAT I AM (WE ARE) THE OWNERS) TIF THE PROPERTY DESCRIBED HEREON, WHICH IS LOCATED IN THE SUBDIVISION JURISDICTION OF DAVIE COUNTY AND THAT I HEREBY ADOPT THIS SUBDIVISION PLAN WITH MY FREE CONSENT, ESTABLISHED MINIML41 BUILDING SETBACK LINES AND DEDICATE ALL STREETS, ALLEYS, WALKS, PARKS, AND OTHER SITES AND EASEMENTS TO PUBLIC OR PRIVATE USE AS NOTED. ------------------------------- OWNERS DAtE ------------------------------- OWNER DATE Surveyor Certification for Closure L WLUAM FRANKUN TATUM cortify Not this Pia o" dram ander my Deed tram on oaWal WMF::al So*-.Oy — Pe �alcc�deevbUan noordw in that the ratio of preaWon n calculated le 1:10.004 trot Bae Plat an prepared In accordance with 0S e7-30 as mended. Tstnw my original eignobwa goonee mmber end eeoh -l`3163 S......_..._..-.-..-rve Suyor U—se Numberben This the. -.-.-.-..._..day of .............._......-........-...—....»... 20.- PLAT MAP HOOTS RABBIT FARM UM/TED PARTNERSHIP TOMisH6y11 COUNTY STATE oA1E JOB NO. SHAD GROVE DAVIE NC 6-15-12 012045-1 REFERENCE DEED DEI 208 PG 518 AND P8 6 PG 49 McAnally Land Surveying, P.C. 812 Burke Street Winston—Salem, NC 27101 Phone If 336-631-9805 Email: mutatllibOgmail.com _ C SCALE -1 er 50 JJO f� 00 50 25 Y� C-806 APPLICANT INFORMATION Account #: 990003806 Billed To: Gray Potts Reference Name: Proposed Facility: Residential Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: G800000001 Subdivision Info: Rabbit Farm Lot # Location/Address: Rabbit Farm Trail -270Q6 Property Size: 5.60 Acres Date Evaluated:O Community Evaluation By: Auger Boring >( Pit Public 4Z Cut FACTORS 1 2 3 4 5 6 7 Landscape position & Sloe % v, JONS HORIZON I DEPTH Texture group Consistence FE Structure Spy Mineralogy, t HORIZON H DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure. . Mineralogy HORIZON IV DEPTH Texture group Consistence Structure - Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , SITE CLASSIFICATION: �S LONG-TERM ACCEPTANCE RATE: 3 REMARKS: LEGEND EVALUATION BY: OTHER(S) PRESENT: &rnw aie 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 33'_et NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic &tructure 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■C�������C�G�i�wiiwn�in+wwii�.iiiiiiiiiiiiiiii�����1����■■■■■■■■■ ■■■■■■■■/■■MEMO ■■/■■■l'■'i"j:fA i. r� s ���;.�����i��r�����������■■in���w■■■■ ■■■■■/■■■■■■■■■■■■■■■■t:liar■■■■■■■■■■■■illi■■■■■■C: � :7■/�.1�.T.i■■■■■■■■■ ■/■■■■■■MEN NONE ■■■■■■■II�'■li■■■■!'L1'lI11''r■■■■f7 ■■\D■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■mi-mm■■■■■auppr-.,Amoi1i■■■■\`■■■■■■■■■■■■■■■■■■■■ ■■■/■■■■/����!e1■■■■■■■�l■■■/■■i:.�!ilk■■■■■■■■■■■■■■■■■■■■■V■■■■■■■■■ ■■■■■■ ■■■■■■■■■■■■H�i�: �'�• ',IiT,�li/�■■■■■lit.r��'��■■f ■■■■■■ ■■/■/■■/■//■■/■//■/■■■■■//■/■/■■■I�ri:�':'ice■■/■■/■■/■■/■■■I�iiC�!��■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■