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123 Essex Farm Rd Lot 3
1 OPERATION PERMIT or ice use UnIV • �rQ„t� Davie County Health Department *CDP File Number 191917-1 210 Hospital Street 't? P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For. NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: RS Parker Homes/Joy Parker Property owner RS Parker Homes/Joy Parker Address: 502 Hickory Ridge Address: 502 Hickory Ridge CRY: Greensboro Cdy: Greensboro State0l): NC 27409 Statelip: NC 27409 Phone#: (336)978-7120 Phone#: (336)978-7120 PropertyPropeqy Location & Site Information Address/Road#: Subdivision: Essex Farm Phase: Lot: 3 123 Essex Farm Road Advance NC 27006 Directions Structure: "SINGLE FAMILY Hwy:64 East, left on Comatzer Rd On left past Beauchamp Rd. #of Bedrooms: 4 #of People: "Water Supply: PUBLIC *IP Issued by. 2140-Nations,Robert *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes O No Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump Required? OYes ONo Soil Application Rate: 0 2 7 5 *Pre Treatment: Drain field rNo cation Field 1 7 4 5 Sq•fi• *System Type: INFILTRATOR QUICK 4 STANDARD rain Lines 4 Installer: Frank transou Total Trench Length: 4 4 0 ft. Certification#: 2771 Trench Spacing: _ 9 Onches O.C. Feet O.C. *EHS: 2140-Nations.Robert Trench Width: _ 3 Oinches (j)Feet Date: 0 7 / 0 9 / 2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 2 4 Inches Approval Status Maximum Trench Depth: 3 6 ® Approved 0 Disapproved Inches Maximum Soil Cover. 2 4 Inches CDP File Number 191917- 1 County ID Number: ` Septic Tank Manufacturer: Shoat Lat. STB: 760 Lang: , Gallons: 1000 Installer Frank Transou Certification#: 2771 Date: 0 3 / a 8 / a 0 1 5 •_..•.'"'• *EHS: 2140.Natkm.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter Date: 0 7 1 0 9 / 2 0 115 ST Marker Yes [E NO - � . Reinforced Tank: ❑ Yes ® No = Approval Status ❑ pprovetl❑ Disapprove 1 Piece Tank: No ❑ Yes CJ Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6in.) ! � Approval Status Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved , Piece Tank: ❑ Yes ElNo Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification#: *Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Date. / Approved fittings ❑ Yes ❑ No „ Approval Status L7 Approved❑i.Disapprave y Pump eqyl[gment Pump Type: Installer. ('*'Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chad: / Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ No Approval Status= PVC Unions [IYes ❑ No ❑: Approved❑ ,'Disapprovetl Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 NO CDP File Number 191917- 1 County ID Number: Electric E ui ment NEMA 4X Box or Equivalent [❑ Yes ❑ No Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approwtal Status Alarm Audible 13 Yes ❑ No ❑-Approved❑ .Disapproved Alarm Visible ❑ Yes 13 No - 2140-Nations,Robert 'Operation Permit completed by: Authorized State Agent: ___ Date of Issue: 0 7 0 9 2 0 1 5 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 a A. sewage septic system. Rule.1961 requires that a Type. TYPE ii A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: WA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCedified Operator. N/A Reporting Frequency By Certified Operator. NIA Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness 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 for a 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 entity prior to the issuance of an Operation Permit for a system required to be maintained by public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance 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. 12)Hand Drawing 41mport Drawing **Site Plan/Drawing attached.** a" OPERATION PERMIT ` 191917- 1 Davie County Hearth Department CDP File Number: 210 Hospital Street P.O.Box County File Number: Mocksville NC 27028 �,- Date: ,\.4 Scale: 0Inch , QBlock Drawing Drawing Type: Operation Permit b ON/A F-1 F7 f T Ya G Y I I I � Ic00 I7 F F I T- CONSTRUCTION For Office Use Only AUTHORIZATION r*CP Fil-e Number 191917;-1 °= Davie Count Health Department Y p ntyID Number. 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 3 / 1 / a 0 a 0 Applicant: RS Parker Homes/Joy Parker Property Owner: RS Parker Homes/Joy Parker Address: 502 Hickory Ridge Address: 502 Hickory Ridge City: Greensboro City: Greensboro State/Zip: NC 27409 State/Zip: NC 27409 Phone#: (336)978-7120Phone#: (336)978-7120 Property Location & Site Information Address/Road#: Subdivision: Essex Farm Phase: Lot: 3 123 Essex Farm Road Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Cornatzer Rd On left past #of Bedrooms: 4 Beauchamp Rd. #of People: "Water Supply: PUBLIC System Specifications CF1owMinimum Trench Depth: a 4 : Provisionally Suitable Inches Minimum Soil Cover. OYes @No 1 a Inches 4 $ 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 5 Maximum Soil Cover. a 4 Inches "System Classification/Description: "Distribution Type: GRAVITY-SERIAL TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) SeptlC Tank: 1 0 0 0 _ Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes @No Pump Required: OYes ONo @May Be Required' Nitrification Field 1 3 4 5 $q.ft. Pump Tank: 1 0 0 0 Gallons No.Drain Lines 5 1-Piece:OYes @No Total Trench Length: 4 3 6 ft. GPM vs— ft. TDH Trench Spacing: - 9 @Feet Inches O.C. - O.C. Dosing Volume: Gallons Trench Width: Inches 3 - 8Feet Grease Trap: Gallons Aggregate Depth: inches -, � - - - - Pre:Treatment: ONSF OTS-1 OTS-11 Septic Tank InstallerGrade level Required: OI OII O III OIV Dana i of Z • CDP File Number 191917- 1 County ID Number. © Open Pump System Sheet Repair System Required:@Yes ONo ONO,but has Available Space rDnesign System Trench Spacing: 7et O. . 9 ification: Provisionally Suitable — E63 .C.Trench Width: Q w: 4 8 0 - 3 _ V Feet Soil Application Rate: 0 - 1 7 5 Aggregate Depth: inches Minimum Trench Depth: a 4 "System Classification/Description: Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480,GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches "Proposed System: 25%REDUCTION N krification Field 1 7 4 5 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 5 "Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 3 6 R, Pump Required: Oyes ONo @May Be Required Pre Treatment: ONSF OTS-1 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 forwastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe same time the Improvement Permit issued(NCGS 130A-=(b)�If the Installation has not been completed during the period of validity of the Construction 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 became Invalid;and may besuspended or revoked(.1937(8))..The person owning or,controlling the system shall be responsible for assuring compliance with the laws,ndes,and permit conditions regarding system location.Installation,operation,maintenance,monitoring,reporting and repair (1838(b)). Applicant/Legal Reps.Signature Required? Oyes ONo Applicant(Legal Reps.Signature: Date:. 'Issued By: 2140-Nations,Robert Date of Issue: . 0 3 / 1 7 / a 0 1 5 Authorized State AMalfunction Log OYes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 191917- 1 210 Hospital Street P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 3 / 1 7 / 2 0 1 5 Q Inch Drawing Drawing Type: O !Construction Authorization Scale: . . OBlo NA ` . ft. - tl6a o _ R i � c 1 1 OT ( v pI/ U I r 1 � ads C- APPLICATION FOR SITE EVALUATION/IMPROVEMENT PEIIEEMED Davie County Environmental Health P.O.Box 848/210 Hospital Street D te; 3-1 Mocksville,NC 27028 i (336)753-6780/Fax(336)753-1680 Application For:Xsite Evaluation/Improvement Permit Authorization To Construct(ATC) ❑Both Type of Application: Klew 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. Refcr to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION ` Name to be Billed f S Nom-e-s!s Contact Person J 0 SID f i Billing Address0 Home Phone�0• ^7 City/State/ZIP C Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facili Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is lid fo 60 months with site plan,no expiration with complete plat.) Owner's Name 5 tY1�S Phone Number (-g4j- Owner's Address cTCQ L _ City/St te/ ip O I'O lJC L Property Address S City CL Lot Size Tax PIN# — I Subdivision Name(if applicable) Section/I,ot#_") I Directions To Site: S riqfiF nri n r n CU LL'(r } 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 o Docs the site contain jurisdictional wetlands? l7Yes Are there any easements or right-of-ways on the site? Dyes Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? Dyes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool es ❑No Basement:❑Yes o Basement Plum ing: ❑Yes No 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:xonventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:xcounty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes ANO 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 1914ing an agging or staking the house/facility location,proposed well location and the location of any other amenities. P eRj own is or owner legAI representative signature Site Revisit Charge ): Client Client Notification Date: Date EHS: Sign given Dyes GNo Account# I ` 1 Revised 1 t/06 Invoice# CIL 1�3l r R-20 SETBACKS: FRONT: 45' 7032' 1 1"E SIDs (STREET): 25' 100.00' REAR: 30' SETBACK r,?,.W. I I CD 0 N co I I to co -, Q I I O o �li IoCOl 0o I Ioo o I I � I I � PROPOSED ig I RESIDENCE _ I I 25.02' _ 50.W 2q.00 SETBACK O O 10' UTILITY EASEMENT PRELIMINARY 'S 7°32 00" W 100.06'm PLOT PLAN FOR: RSP BULEDERS ESSEX FARM ROAD LOT 3 OF ESSEX FARMS, PHASE 1 50' R/W (PUBLIC) P.B. 9 PC. 289 GRAPHIC SCALE 0 20 40 a Rmill Enginning, Inc. 8518 Tdad Drive Colfax,NC 27235 IN FEET Phone:336-852-9797.Fax: 336-852.9766 1 inch — 40 ft. NCBELS C-0950 DATE: 03-05-2015 REF: PR0J\1831-01\dwg\ESSEXFARM.dw9 L I SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Applicatio P�i� �uation/Im ement Permit ❑Authorization To Construct(ATC) ❑Both V�l CgNew ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility *** ANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED FORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION 73 Name to be Billed ASC 10c V66opKrNT mat./fie Contact Person %o.PRy &e7c v:C Billing Address A•o.Q�X ,3fo - Home Phone City/State/ZIP AJC- Z 7oZ B Business Phone 7S/- 7300 Name on Permit/ATC if Different than Above Mailing Address City/State/Zi PROPERTY INFORMATION *Date House/Facility Comers Fla ed 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 A5-- ,O6rye6aAzfFr+i calf QAC- Phone Number 7S/-73-'�O Owner's Address eO4X r' City/State/Zip /t/oecn�iw�r /�G 17oZ9 Property Address City Lot Size ax PIN# Subdivision Name(if ap licable) Es = SectiioAot# 3 Directions To Se: C 5 2 !f^TZP� 'T GrYLt , S4Cc f the answer to any of the following uestions is"yes",supporting documentatiogg must be atlAched. Are there any existing wastewater systems on the site? Dyes E p Does the site contain jurisdictional wetlands? Dyes❑fI0 Are there any easements or right-of-ways on the site? EKes❑ o Is the site subject to approval by another public agency? Dyes Will wastewater other than domestic sewage be generated? Dyes QNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms _ !;6 #Bathrooms Garden Tub/Whirlpool❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: Dyes ❑No 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: l5Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:C3'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 understand that I am responsible for the proper identification and labeling of property lines and comers and locating an ging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Prope r s or o er's legal representa re Date(s): 7 Client Notification Date: Date EHS: Sign given Dyes❑No Account# Revised 11/06 Invoice# 301.00' 0o b N 00' �9 'o 30100 Sq.Ft. ' o WYWAY ustee ^ 0.691 Ac.+/- 00 50' R - 0 109. S 82" /r 61' - ES S 82'-28'-00" -1G N 301.00' N 00 ® I r: 30098 Sq.Ft. o 60 3 0.691 Ac.+/- 0 _o tom\ o S 82'-28,- ^ + o I Ln 301.00' n _ � 0 00 I I 'o,0 N N 0 a 3010Sq.Ft.q• b I o N c 0.691 Ac.+/- o ; C; I + S 82'-28'-00' E I. I N 301.00' } I _ . © I W S 82'-28'-00 30100 Sq.Ft. o 100.00' ~.E --` S 82'-28'-oo- 0.691 Ac.+/- 00' $J 9 8f' 90.39. _o I S.82'-28'-00" rZON 301.00' to C)oO Co 30106 Sq.Ft. } 0.691 Ac.+/- o WILi- + S ^I L� ' + 82'-28'-00 u o NN L;E Qn 01.00' or\oo00 oWM 0 0 � c0 . 30100 Sq.Ft. I N O M o 2 0.691 Ac.+/- 0 o Z S 82'-28'-00" b 301.00' E + 3 0 03 00 30100 Sq.Ft. J o 100.00= _ 9.65; 3 0.691 Ac.+/- 00 `n N 82•_28=00" yy C� oTYWA Y 50. S 82'-28'-00" E f 3 S'82'-28-00 REW (pUb11C) 301.00' w r -126.28'_ _ C C? Q2 �j -83.37= _ 00 30100 Sq.Ft. W 0.691 Ac.+/- o } o W } S _o 82-28'-00" E o ss W 301 b 10 32070 Sq.Ft. o - rn .00' I - � N v: 0.736 Ac.+/. I M N f 30001 Sq.Ft. , e I I n N 0.689 Ac.+/- ^ I 30010 Sq.Ft. I of `e9ot� in `c`eas 0.689 Ac.+/- (a Z N t\ C1- ca f Z N -�� Nr30� afgn L { -�- e$rnt: 30`,b C2 JN C6____ ---C3--- 4.58 ntva e'ORNATZER1oRpo-, an esMt. AD -R 1616 rtro hydrant rve Radius Chord Bearing and Distance Arc Length 1599.37' N 74'-12'-50" W 304.15' \ 304.61' 1599.37' N 80°-33'-58" W 50.03' 50.03' 1599.37' N 87°-35-03" W 89.08' 89.09' 35.00' S 59'-55-01". E 26,84' 27.55' i rr 50.00' S 47°-48'-22" E 18.12' 18.22' r 1599.37' N 83'-43'-31" W 126.31' 126.35' 35.00' N 74'-59'-02" E 26.84' 27.55' a 50.00' N 80°-23'-13" E 46.87' 48.79' i 50.00' S 51'-10'-24" E 35.00' 35.76' 0 50.00' S 10'-11'-55" E 35.00' 35.76' 1 50.00' S 30'-46'-33" W 35.00' 35.76' 2 50.00' S 86'-30'-33" W 57.71' 61.52' DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH#: 5870-64-2265.03 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot#03 Reference Name: Brad Coe Location/Address: Cornatzer Rd-27006 Proposed Facility: • Residence Property Size: 0.691 Ac. Date Evaluated: Water Supply: On-Site Well Community Public V Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 %1 1 1 0 4 5 6 7 Landscape position L- L_ (_ Slope%_ : Z 11 HORIZON I DEPTHp-40— Q- d- 37 Texture grouC' C Consistence i r P+/- Structure rStructure hP_ !C Mineralogy 5F .S Eklp HORIZON II DEPTH `I G - -4(7 °3 — Texture group G Consistence r . i r f r Structure 515 K Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION cx LONG-TERM ACCEPTANCE RATE ,) '7 SITE CLASSIFICATION:�Lt abler EVALUATION BY: _� s vr— 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 oamSC-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 St 'ctur 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 1 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 05/05 (Revised) Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004425 Tax PIN/EH M 5870-64-2265.03 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot#03 Address: PO Box 340 Location/Address: Cornatzer Rd-27006 City: Mocksville Property Size: 0.691 acre Reference Name: Brad Coe 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: 9?<ew ❑Repair. ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms 4 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: 5eounty/City ❑Well ❑CommunityWell A5 stated in 15A NCA,C 18A.1969(5) Site Modifications/Permit Conditions.tepled Systems may also be usetld System Type LTAR Initial Repair d 1 0. ;L.7 site Plan 30� 1! c v p Ooh Ya Des/1^�/-e a ^ t� Environmental Health Specialist Date — l