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193 Greywood CtHEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street hA d ed P.O. Box 848 Y Mocksville NC 27028 For Office Use Only *CDP File Number 137239-1 E7 -140 -AO -016 County ID Number. valuated For. HDR/WWC Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 4 / 1 1 / .2 0 1 4 UNTI I Applicant: The Pool Store, LLC Address: 914 Yadkinville Rd City: Mocksville State/Zip: NC 27028 Phone #: (336) 941-0155 Property Owner. Todd and Melanie Major Address: 193 Graywood Ct City: Advance State0p: NC 27006 Phone #: Property Location & Site Information Address 193 Graywood Court Subdivision: Reland Place Road# Advance NC 27006 'Structure: SINGLE FAMILY # of Bedrooms: 4 'Water Supply: WA Basement: R Yes ❑ No 'Proposed Improvement: Pool 16x32 # of People: Phase: Lot 16 Township: Directions hwy 158 Left on Redland Rd. Left into Redmeadow Drive Right on Graywood to end. Type of Business: Total sq. Footage: No. Of Employees: Installation of pool approved with accompanying installation of appropriate french drain between pool and septic system. French drain must be installed one foot deeper than the lowest trench bottom. French drain may not come within one foot of the ground surface and must exit the ground by single pipe to discharge collected water. For questions on installation please refer to Rob Nations, REHS for Davie County Environmental Health. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONo Applicant/Legal Reps. Signature: *Date: / / *Issued By: 2325 -Mitchell, Britt *Date of Issue: 0 4 / 1 1 / .2 0 1 4 Authorized State Agent:IDI� h'(111bMtA _ "bite Plan/Drawing attached." O Hand Drawing Olmport Drawing 2 3' HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 137239 - 1 County File Number: E7 -140 -AO -016 Date: 0 4/ 1 1/ 2 0 1 4 Davie County Health Department Pts t� ItECEIVF vironmental Health Section R flat 3 1-3 (LI L P.D. Box 848 L 210 Hospital Street �p O U Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 751 - 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: POOH STOi�-L. L�i Phone Number �j��` /t-/1r455%SJ (Home) Mailing Address: 'c�/ q 54=P kIA J)�II& % (Work) 66 C'k-s'V', l /6 N c--, Email Detailed Directions To Site: Please Fill In The Following Information.About The EXISTING Facility: Name System Installed Under: A rC4 C.)1—S U 1 i AJ Type Of Facility: 1C.6 :9 tL\6N Date System Installed (Month/Date/Year): Z - 6 D Number Of Bedrooms:__�(Number Of People:_ Is The Facility Currently Vacant? Yes G If Yes, For How Long? Any.Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: R 1G r't5v �. �, bx3lumber Of Bedrooms: _q Number of People Requested By:Date Requested: 3! (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: I Vl 5+tA j I a-1 0 Vl d-�- +�J�I S> Obbj 15 CA VVY8W A 1A11'1'rA QQft)VVjGjAtCain 1ClA i n . i< ,� ' 15 .�vOv�n se.C sy 6-V nn _ Environmental Health Specialist. *The signing of this form by the Environmental Hei0th Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Money Order #. Paid By: Received By:_ Account #:�Invoice #: Date: 40o — �7 ej V Account #: 990001597 Billed To Reference Name: Marquis Building )DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5861-28-2285 Subdivision Info: Redland Place Lot # 16 Location/Address: Graywood Court -27028 Proposed Facility Residence Property Size: see ma ATC Number: 3934 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWA CON N IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur, : Date: %Z CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. 1CIO tC r Septic System Installed By:�-�'� Environmental Health Specialist's Signature: Date: c _ DCHD 05/99 (Revised) • DAVIE COUNTY HEALTH DEPARTMENT Z • Environmental Health Section P. O. Box 848/210 Hospital Street MockvAlle, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990001597 Tax PIN/EH #: 5861-28-2285 Billed To: Marquis Building Subdivision Info: Redland Place Lot # 16 Reference Name: Location/Address: Graywood Court -27028 Proposed Facility Residence Property Size: see map ATC Number: 3934 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type (f::�t #People #Bedrooms 1 — #Baths Z . Dishwasher: M/ Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: d Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 1.��i ACQFS Type Water Supplyoo-'J�' Design Wastewater Flow (GPD) Site: New T( Repair ❑ System Specifications: Tank Size CCU GAL. Pump Tank GAL. Trench Width Rock Depth I -Z Linear Ft.14W Other: Ll STT-i�Tf)t3 > Required Site Modifications/Conditions: 1 )2�cA u- 0,)c ��LP � o�F' �U►JI�,Ttf>-I, �s'1-� �O p� Pea. IMPROVEMENT/OPERATIOI"ERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 « BELOW FINISIIED GRADE. ****NOTICE: Contact a representative of the Ta vie County Health Department for final inspection of this system between 8:30 a.m. X19:30 a.m. or 1:00 p.m. to 1:30 p.m. on the da installation. Telephone # is (336)751-8760.**** 1Z ,v,w, 'ous I � Environmental Health Specialist's Signature: \ DCHD 05/99 (Revised) o s�(L4) J co rn �� 34,067 Ft. t Sq. J sir 1 5 0.782 Acres± co -P ca ►j N 79,583 Sq. Ft. 1.827 Acres± r 1 C4 - o v Radius CD N 83-03'57" E-5-0-.00- r�y`S oGs 418.900 oJ 0 60,595 Sq, Ft 1.391 Acres± O' 33,771 S q. -- ►� 0.775 Acre 626.10'( Tot — __. BLa f f er N84735 Dec 03 04 01:34p Gordon Whitney 336 940-6947 p.l APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department D EnvitronmentalHealth Section P.O. Box 848/210 Hospital Street D n Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED D�C INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 2oo4 1. Name m 6a Billed 1"�s�2 �tf•) i,11..oti.J tr J-Fx- Contact. Parson 4,LQyJ (R Tk�[Pv �I/t�fQViV!£N ,t' Hailing Addmas1P_ Nome Phone Q b -Lg47 W7V/f �. T'K yfR,w City/State/rIP ky(}NC£ NC_ Z"?no(n Business Phone 3'i'S - 315`1', ry 2. Name on Permit/ATC if Different than Above Mailing Address city/State/Zip 3. Application For: O Site Evaluation AImprovement Permit/ATC fl Both 4. System to service: I,��House ❑ Mobile Home O Business ,t f] Industry ❑ Other S. IfResidence: t/o People # Bedrooms 4- Y Bathrooms 2 ;/Z '4-ishrashel L1 CarDage Disposal Xwaahing Machina 11 Basement/Plumbing %Oas,a L/No Plumbing 6. If Business/Industry/Other: Specify type I People # Sinks N Commodes # Showers I Vrinals I Fater Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7, Type of water supply: O County/City C Well U Community a. no you anticipate additions or expansions orthc facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? "•*IMPORTANT***CLIENTSMUSITCOMPLBTETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: —59 "XP I_rt WRITE DIRECTIONS 1from Mocksville) to PROPERTY: Tax Office PIN: h �,So 2-41226574� L. 3 T I- eeroc-,An.Ao PA Property Address: Road Name _czem 0,.,n C•r. Le FT Trp -ran City/Zip &yAAI,s_ 01- zip TAtr� �5� If in a Subdivision provide information, as follows:N Q . Name: _k9i.AN D IR -LICE Section: I Block: Lot: j— Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted In this application is falsified or changed I, also, anderstand that I am responsiblefor all charges incurred ftont this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing proccdt res as necessary to determine the site suitabilit i DATE SIGNATURE I THIS AREA MAY BE USEL FOR DRAWING YOUR SITE PLAN (include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Datc(s)• Client Notification Date: J �Jj Account No. Gj Revised DCHD (01/99) Invoice No. �� / Rec 03 04 01:34p Gordon Whitney rr / f I 336 940-6947 1pe7 P- C? L) A1,10 p.2 11 :� 4o' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Q Davie County Health Department Environmental Health Section QFC P.O. Box 848/210 Hospital Street 3 ZC�� Mocksville, NC 27028 (336) 751-8760 &VIRdA'Z7EN DAV/frnTAC HEAt ru ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed We -V'` ?w D -11 Mailing Address City/State/ZIP 2. Name on Permit/ATC if Different than Above Mailing Address Contact Person Home Phone 71D �o Business Phone %,2 City/State/Zip 3. Application For: ["Site Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to Service: ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms 171L, Dishwasher CI Garbage Disposal U Washing Machine Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Industry/Other: # Commodes Specify type # Showers # People # Sinks # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 9-County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? 6 -yes ❑ No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: 5 Tax Ofrce PIN: # :'��- 3197-" Property Address: Road Name ZZZ41tld City/Zip If in a Subdivision provide information, as follows: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Lv 2/ Namc:�E Section: Block: Lot: I -Vrr IGDate Property Flagged: Ii;2 ^—J'- e �- This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth Department tv- to enter upon above described property located in Davie County and owned by ,L�l%//i�P �n� .1 "Xf1 f 5 to conduct all testing procedures as necessary to determine the site suitapility. SIGNATURE TI -IIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Revised DCHD (07/99) Site Revisit Charge Datc(s): Client Notification Date: EHS: Account No. Invoice No. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 989900136 Billed To: Westview Development Co. Reference Name: Proposed Facility: Residence Property Size PROPERTY INFORMATION Tax PIN/EH #: 5861-38-2199.18 Subdivision Info: Louise Smith Adams Lot # 18 Location/Address: Redland Road -27006 see map Date Evaluated: 12-123D Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH ig— I) — Texture group Consistence ; Structure Mineralogy HORIZON II DEPTH rzQ .Q 2— r 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: 11 11-1 LONG-TERM ACCEPTANCE RATE: C), L REMARKS: EVALUATION BY: `- tm L"A ►-r OTHER(S) PRESENT: 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 Wet NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised)