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106 Crestwood Ct f OPERATION PERMIT ice use711) Davie County Health Department EEvaluated umber 188019-1 210 Hospital Street P.O.Box 848 mber. Mocksville NC 27028 r. NEWPhone:336-753-6780 Fax:336-753-1680 Applicant: True Homes Property owner: taylor Williams Address: 2649 Brekonridge Centre' Drive, Address: 433 Roslyn Road cdY: Charlotte Cly: Winston-Salem State2ip: NC 28110 State/Zip: NC 27104 Phone#: (704)400-6143 Phone#: (336)293-6790 Propeqy Location & Site Information - Address/Road#: Subdivision: 'Summer.Hill Farms Phase: Lot: 27 106 Crestwood Court = Advance NC 27006 Directions - 1-40 East, exit Hwy 801 going south, right on Structure: SINGLE FAMILY Markland Rd #of Bedrooms: 3 #of People: *Water Supply: PUBLIC "IP Issued by. 21ao-Nations,Robert *System Classification/Description: TYPE III S.SYSTEM WISINGLE EFFLUENT PUMP *CA issued by: 2140.Nations,Robert Saprolite System? OYes ONo Design Flow: 3 6 0 *Distribution Type: PUMP TO GRAVITY Pump Required? „ Yes QNo Soil Application Rate: 0 a 7 5 *Pre Treatment: - Drain field rNknification Field 1 3 0 9 Sp- ft• *System Type: INFILTRATOR QUICK4STANDARD n Lines 3 Installer Ronnie Overbee Total Trench Length: 3 a 7 ft. Certification#: 1143 Trench Spacing: 9 2inches O.C. — Feet O.C. *EH S. 2140-Nations,Robert Trench Width: 3 Inches gFeet Date: 0 8 1 a S / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches Approval Status Maximum Trench Depth: 3 6 ® Approved Dlsapprovetl Inches Maximum Soil Cover. a 4 Inches CDP File Number 188019 - 1 Septic Tank County ID Number: ' Manufacturer: wrnS Lat. STB: 363 Long: Gallons: 1000 InstallerRonnie Overbee Certification#: 1143 Date: 0 5 / 3 1 / . 0 1 6 *EH S: 2140.Nations,Robert *Filter Brand: POLYLOK Dual PLA 22 With Pipe Adapter ST Marker. E] Yes ® No Date: 0 8 / 2 5 / a 0 1 6 Approval Status Reinforced Tank: ❑ Yes ® NO , 1 Piece Tank: ❑ Yes ® No '® Approved❑ Disapproved Pump Tank Manufacturer: Wms Installer: Ronnie Overbee PT. 62 Certification#: 1143 Gallons: 1000 *EH S: 2140-Nations,Robert Date: 0 6 / 1 3 / a 0 1 6 Date: 0 8 / a 5 / a 0 1 6 RiserSealed Q Yes ❑ No RiserHeight: ® Yes ❑ No (Min.6 in.) - _ Approval Status Reinforced Tank: ® Ye S ❑ NO ® Approved❑ Disapproved 1 Piece Tank: p Yes ❑ No Supply Line Pipe Size: a inch diameter Installer, Ronnie Overbee Pipe Length: 1 5 6 feet Certification#: 1143 *Schedule: 40 *EH S: 2140-Nations,Robert Pressure Rated O Yes ❑ No Date: 0 8 / a 5 / a 0 1 6 Approved fittings ® Yes ❑ No -Approval Status3Up ® Approved❑ Disapproved Pump Requirement Pump Type: Chandler Installer. Ronnie Overbee Dosing Volume: - Gal Certification#: 1143 Draw Down: Inches *EH S: 2140-Nations,Robert *Chain: ROPE Date: 0 8 / a 5 / 2 0 1 6 Valves Accessible O Yes ❑ No Flow Adjustment Valve O Yes ❑ No Check-varve ® Yes ❑ No -�Approval`Status1 PVC unions p Yes EJNo ® ;Approved❑ Disapprovetl . Vent Hole Q Yes ❑ No Anti-siphon Hole p Yes ❑ No qDP File Number 1$$019 - 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent (Q Yes ❑ No Installer: Ronnie Overbee Box 12 inches Above Grade Q Yes ❑ No 1143 Certification#: Box Adj.To Pump Tank [i] Yes ❑ No Conduit Sealed 0 Yes ❑ No THS: 2140-Nations,Robert Pump Manually Operable M Yes ❑ No 0 8 / a 5 / a 0 1 6 "Activation Method:PIGGYBACK Date: Alarm Audible (E Yes ❑�No =APProyal Status ® Approved❑ Disapproved; Alarm Visible Yes ❑ 2140-Nations,Robert *Operation Permit completed by: Authorized State Agent. Date of Issue: 0 8 / .1 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 III B. sewage septic system. - Rule.1961 requires that a.Type TYPE III B. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: SYRs. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCedified Operator: NIA 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 entity with a certified operator or a private certified operator for the 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 entity with 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 entty prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entty,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 0Import Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 1$$019 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksviile NC 27028 Date: Olnch Scale: . OBlock ft. Dra, in Drawing Type: Operation Permit ON/A �r CONSTRUCTION For office use Only AUTHORIZATION *CDP File Number 188019-1 °= Davie County Health Department County ID Number. 210 Hospital Street 1y Evaluated For. NEW P.O. Box 848 ownship: Mocksville 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 6 / a 1 / a 0 a 1 Applicant: True Homes r roperty Owner: taylor Williams Address: 2649 Brekonridge Centre'Drive, ddress: 433 Roslyn Road Suite 104 City: Charlotte City: Winston-Salem StatefZip: NC 28110 State0p: NC 27104 Phone#: (704)400-6143 Phone#: (336)293-6790 Property Location & Site Information FAddress/Road M Subdivision: Summer Hill Farms Phase: Lot: 27 twood Court NC 27006 Directions Structure: SINGLE FAMILY 1-40 East, exit Hwy 801 going south, right on Markland Rd #of Bedrooms: 3 #of People: "Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Inches Minimum Soil Cover. 1 a Saprolite System? OYes ONo Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . a ? 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: PUMP TO GRAVITY TYPE II A CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons 'Proposed System: 25%REDUCTION 1-Piece: Oyes ®No Pump Required: ®Yes ONo OMay Be Required Nitrification Field 1 3 0 9 Sq.ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 3 1-Piece: OYes @No Total Trench Length: 3 a y ftGPM—vs— ft. TDH Trench Spacing: _ 9 Inches t 0 C C O . Dosing Volume: _ Gallons Trench Width: — 3 . @Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 011 0111 OIV pnnn 1 of Z CDP Fite Number 18$019 - 1 County ID Number. ❑ Open Pump System Sheet Repair System Required:OYes ONO .ONO, but has Available Space rDesign System Trench Spacing: 9 Q Inches O. . ification: Provisionally Suitable a Feet O.C. Trench Width: 0Inches w: 3 6 0 — , 3 Feet Soil Application Rate: 0 a 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover 1 a inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover. a 4 Nitrification Field 1 4 4 0 Inches Sq.ft. No. Drain Lines3 *Distribution Type: GRAVITY-SERIAL ' To#al Trench Length: 3 6 0 � Pump Required: OYes ONo ( May Be Required Pre Treatment: ONSF OTS-I OTS-ll *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 wayguarantees 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 bevalid fora person equal tothe period of validity of the Improvement Permit,not to exceed five years,and may be Issued at the same time the Improvement Permit issued(NCGS 130A-336(b)}If the Installation has not been completed during the period of validity of the Construction Perna,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 may be suspended or revoked(.1937(g)).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)). Applicant/Legal Reps.Signature Required? OYeS ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: . 0 6 / a 1 / a 0 1 6 Authorized State Age Malfunction Log OYeS ; @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 ' CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 188019 - 1 210 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: . Qslock QN/A �16 _Pr 8. CAI CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 188019 - 1 P.O.Box 848 Mocksville NC 27028 County File Number. Date: .0 .6 / 2 1 / 2 0 1 6 C ck b lI �nr�tImport an image fro'tfi an ext malt tion: Drawing Type:Construction Authorization r _ w C� \J -7 ),C) r� 0 was z�' ,IMPROVEMENT PERMIT ForofflceUse omv fCDouPntyFile Number 188019- 1 Davie County Health Department 210 Hospital Street ID Number: P.O. Box 848 Evaluated For. NEW Mocksville. NC 27028 Township: Phone:336-753.6780 Fax:336-753-1680 PERMIT VALID UNTIL: 9116/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: True Homes Property owner. taylor Williams Address: 2649 Brekonddge Centre' Drive, Address: 433 Roslyn Road City: Charlotte City: Winston-Salem State/Zip: NC 28110 State2ip: NC 27104 Phone#: (704)400-6143Phone#: (336)293-6790 Property Location & Site Information rMress/Road#: Subdivision: Summer Hill Farms Phase: Lot: 27. arkifand Road vance NC 27006 Directions Structure: SINGLE FAMILY 1-40 East, exit Hwy 801 going south, right on #of Bedrooms: 4 Markland Rd #of People: *Water Supply: PUBLIC System Specifications nitial S stem *Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Saprolite System? OYes ®No Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 2 7 5 1-Piece: OYes @ No Pump Required: @Yes 0 N OMay Be Required *SystemClassification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes @No Repair System Required:@Yes ONO ONO, but has Available Space Repair System CSSC ite Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches H Application Rate: 0, _ a 5 Maximum Trench Depth: 3 6 Inches "System Classification/Description: Pump Required: @Yes ONo O May be Required TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25%REDUCTION �� Page 1 of 3 CDP File Number 188019 - 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. a *Permit Conditions The issuance ofthis permit bythe Health Department in no wayguarantees the Issuance of other permitsThepermt holder is responsible for checking with appropriate governing bodies in meeting their requirements. provement Permit shall be valid for 5 years tram date of issue with a site plan(means a drawing not necessarily drawn to Site Plan Thein O state that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the e site forthe proposed Wastewater system,and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land survayor,drawn to a scale 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 waders. 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 plan,plat,or Intended use changes(NCGS 130A-335(f)).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(A 938(b)} Applicant/LegalReps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 9 / 1 6 / .2 0 1 5 Authorized State Age OValid without Expiration? ate CA? @Hand Drawing Olmport Drawing ; **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 188019 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: . pBlock QNIA = 4 ft -- CL 't�$� _ Y 01 � i IMPROVEMENT PERMIT Davie County Health Department ' 210 Hospital Street CDP File Number: 188019 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 0 9 I L1.L6 1 a 0 1 5 Click below to Import an Image from an external location:Drawing Type: Improvement Permit • APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmeetal Health P.O.Boz$481210:Hospital Street Mocksville,NC.27028 (336)753-6780FFia (336)753-1680 Application For:X Site Evaluation/Improvement Permit i':Authorization To Construct(ATC) F-Both Type of Application: XJNew System DRepair 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 True Homes Contact Person Attn: Permitting -. Billing Address 2649 Brekonridge Centrd Dr.,Ste 104 Home Phone N/A City/State/ZIP Charlotte,NC 28110 Business Phone (704)400-6143 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:F Site Plan 7Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Ta for Williams Phone Number 336 293-6790 Owner's Address 433 Roslyn Road city/staterzipWinston- a em, NC 271M Property Address City Advance, NC Lot Size Tax PIN# Subdivision Name(if applicable) Summer Hill Farms Section/Lot# 7 Directions To Site: From 1-40, 901 South, Right on Markland Road 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? 1—Nes Q(Io Does the site contain jurisdictional wetlands? _JYes IXNo Are there arty easements or right-of-ways on the site? GYcs 4(No Is the site subject to approval by another public agency., L.Yes IXNo Will wastewater other than domestic sewage begenerated? :JYes XNo IF RESIDENCE FILL OUT THE BOX BELOW #People 4 #Bedrooms 4 #Bathrooms 2.5 Garden Tub/Whirlpool _Yes XNo Basement:UYes XNo Basement Plumbing: '.:JYes XNo 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 J Type system requested: XConventional ['Accepted -Ilnnovative ::Alternative ,Other Water Supply Type:XCounty/City Water r-New Well =-Existing Well ;Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?_Yes X 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 understand that I am responsible for the proper identification and labeling of property lines and comers and locating and Ilaeei tte�fof�.s ien house/facility location,proposed well location and the location of any other amenities. Property owrte's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given [Yes❑No Account# 9Y10 D Revised 11/06 Invoice# •N � �z,�x�� a�►Z . �u�� 1�� o�} ' DAVJE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/Site EvaluaItion ;APPLICANT INFORMATION I PROPERTY INFORMATION True Homes i Markland Road 704 400-6143 Summer Hill Farms Acers: Lot# I t Water Supply: On-'i te Well Community Public Evaluation By: Augr Boring -Pit �Y Cut FACTORS f 1 2 3 5 6 7. Landscape position I Slope HORIZON I DEPTH . + k)- ! Texture groupj. L r. Consistence ! LLL �p Structure C jr(0 I i Mineralogy I HORIZON lI DEPTHl; ! _ ! Texture group iConsistence I Structure Mineralogy { i j HORIZON III DEPTH t I Texture groupM I ! Consistence } Structure Mineralogy HORIZON IV DEPTH i Texture group Consistence ! I I Structure MineralogyI SOIL WETNESS I I RESTRICTIVE HORIZON t SAPROLITE CLASSIFICATION 1 LONG-TERM ACCEPTANCE RATE J SITE CLASSIFICATION: I EVALUATION BY: f LONG-TERM ACCEPTANCE.RATE: OTHER(S)PRESENT: REMARKS: l G( i _ L andscape Position LEGEND R-Ridge S-shoulder,' ' L-Linear slope FS-Foot slope NI-Nose slope CC X- Concave slope CV-Zonvex slope T-Terrace FP--Flood plain H Head slope S -Sand LS-Loamy sand SL-Sandy loam. L-Loam SI,Silt SICL-Silty clay loam SII;-Silty loam CL-Clay loam SCL-dandy clay loam SC=Sandy clay SIC-Sil clay C Clay CONSTSTENCEi Very friable FR-F 'able F1-Firm VFI-Very firm �EFI-Extremely firm NS-Non sticky SS-.Slig)tly sticky ' S-Sticky VS-Very Sticky r! NP-Non plastic SP-Slig tly plastic P-Plastic VP-Very plastic StrucWre SC-Single grain M-M 'sive CR-Crumb GR-Granular AB -Angular blocky. SBK-Subangular blocky PL-Platy PR-Prismatic I I Mineralogy 1:1,2:1,Mixed Notes I Horizon depth-In inches Depth of fill-In inches i Restrictive horizon-Thickness and inches from land surface s Saprolite-S(suitable),U(unsu4able). I 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 TA T) T -__ ' .i APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC �yVID Davie County Environmental Health P.O.Box 848/210 Hospital Street 1 l� Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: ❑ 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 CANNOTBEPROCESSED 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 Billing Address 2649 Brekonridge Ctr Dr Home Phone (704) 238-1229 City/State/ZIP Monroe NC 28110 Business Phone (336) 992-2477 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 106 Crestwood Court,Advance, NC 27006 'City Advance Lot Size .69 acres Tax PIN# G814OA0027 Subdivision Name(if applicable) Summer Hill Farms Section/Lot# 27 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 igNo Are there any easements or right-of-ways on the site? ❑Yes 9No Is the site subject to approval by another public agency? El Yes igNo Will wastewater other than domestic sewage be generated? ❑Yes gNo IF RESIDENCE FILL OUT THE BOX BELOW #People 4 #Bedrooms 3 #Bathrooms 2.5 Garden Tub/Whirlpool ZYes ❑No Basement: ❑Yes ZNo Basement Plumbing: ❑Yes YJNo 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: WIConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 1Z 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 2 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 a les. I understrMthat I a re onsible for the proper identification and labeling of property lines and corners and locati g a d fla ging or s ng t o e/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property wner's or owner's legal relfresentative signature Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# DRAWING-NAME: •P:\2916\160149\Survey\160149-survey dwg - PLOT - 6/l/2016 9:39 AM IfIMM/AGRY Sa Fr. N85040 26"W MAL �at Mr s- 160.92# f0' (IF APPLIN&E) HOVM- 1,397** 9r R1W--81 ` 27.3* 9r W W 9'AEWALK 12* 9r S 30' RY WF . . . . . PGwat HVAC: 9*SF CONa SZDa?• 9*-w SCD W RA 2444&t SF ^a. $ SSMA1RAW 4,254*SF -------------- - to I MMSIfA?SM .4589*SF �- 9EED/S7RAW W 30063-* sq.ft. W 2 W W LOT 27 a I Cava S700P QL1 t3 3X3' 1 Om 3 . li q� SOD I HVA •Q' 842' PADC 34 �, W`\ �i i tc g y 3X3 PROPOSED I \t3 HO r' +14 V N 053 m AUX - 19.75' r—a a �I f 40' FY �- CANa 20'PRIYAZE VWM , DRIB DRvvAGE EAmwDvr — E E EE I 10'SIDEWALK EASEMENT o E E E , 10'UALITY EASEMENT 1� S8721 7"E CRESmvw COURT 1oWo'sy6Hr EA-%vENr (50'PUBIC R/W PER P.B. 12 M 146) ---- --- --- TRUE HOMES PLOT PLAN OF CRESTWOOD COURT LOT 27 OF SUMMER H/LL FARM PHASE 1, SEC77ON 4 ADVANCE GRAPHIC SCALE SHADY GROVE TOWNSHIP, DA VIE COUNTY 40 20 0 40 80 DAZE: 5/3112016 aRAiv or M MAP REGARDED 1N PLAT Boar 12 pqECRm Br; SKM 1" = 40 FEET AT PAGE'144 DAZED.. 6-1-2018 DAMS • MARTIN • POWELL ENGINEERS & SURVEYORS PRELIMINARY PLAT 6415 OLD PLANK RD,HIGH POINT,NC 27265 Hot for R«cordatbn,Coov jmum or sd« (336)886-4821 WWW.DMP-INC.COM I LICENSE:F-0245