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114 Elberon Ct Lot 2OPERATION PERMIT Davie County Health Department ° ¢ 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Robert K. Richardson Sr Address: 2970 Kecoughtan Road City: Pfafftown State/Zip: NC 27040 Phone #: (336) 992-6220 *CDP File Number 231889 - 1 5758027859 County ID Number: Evaluated For: NEW �ownship: /Property Owner: Land First Development Address: PO Box 712 City: Yadkinville State/Zip: NC 27055 Phone #: (336) 992-6220 Property Location & Site Information Address/Road #: Subdivision: Marbrook 114 Elberon Court Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 2 *Water Supply: N/A *IP Issued by: *CA Issued by: 2140 - Nations, Robert Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: Phase: Lot: 2 Hwy 64 East left on John Crotts Rd. left in Marbrook *System Classification/Description: TYPE III G. OTHER NON-CONV. TRENCH SYSTEMS Saprolite System? '.,Yes X, No *Distribution Type: GRAVITY -SERIAL Pump Required? 0 Yes X No, *Pre -Treatment: Drain field 1 3 0 9 Sq. ft. 5 330ft. 9 0Inches O.C. (9 Feet O.C. 3 Olnches (9 Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: ) 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK STANDARD Installer: Frank Transou Certification #: 2771 *EHS: 2140 - Nations, Robert Date: 0 3/ a Q/ a 0 1 7 Approval Status 0 Approved ❑ Disapproved CDP File Number 231889 - 1 Manufacturer: shoat STB: 760 Gallons: 1000 Date: 1 1/ 3 0/ a 0 1 6 *Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ST Marker: ❑ Yes 0 No Reinforced Tank: ElYes ❑ 0 No \ \Piece Tank: ❑ Yes 0 No Manufacturer: PT: Gallons: Pump Type: Date: / Riser Sealed ❑ Yes Riser Height: ❑ Yes Reinforced Tank: ❑ Yes \ 1 Piece Tank: ❑ Yes / Pipe Size: Pipe Length: *Schedule: Pressure Rated ❑ Yes Approved fittings ❑ Yes County ID Number: 5758027859 septic i anK Lat. ❑ No ❑ No (Min. 6 in.) ❑ No ❑ No Long: Im Installer: Frank Transou Certification #: 2771 *EHS: 2140 - Nations, Robert Date: 0 3/ a a/ a 0 1 7 Approval Status 0 Approved ❑ Disapproved Pump Tank Installer: Certification #: *EHS: Date: Approval Status ❑ Approved ❑ Disapproved Supply Line inch diameter Installer: feet Certification #: *EHS: ❑ No Date: ❑ No Approval Status ❑ Approved ❑ Disapproved / Pump Type: Dosing Volume: - Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ NO Anti -siphon Hole ❑ Yes ❑ No Installer: Gal Certification #: *EHS: Page 2 of 4 Date: Approval Status ❑ Approved ❑ Disapproved CDP File Number 231889 - 1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: Alarm Audible ❑ Yes Alarm Visible ❑ Yes *Operation Permit completed by_ Authorized State Owner/Applicant Signature: County ID Number: 5758027859 ❑ NO Installer: ❑ No Certification #: ❑ No ❑ NO *EHS: ❑ No Date: Approval Status El No ElApproved ❑ Disapproved El No 2140 - Nations, Robert Date of Issue: 0 3/ a a/ a 0 1 7 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 G. sewage septic system. Rule .1961 requires that a Type TYPE iii G. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed for a 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 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 a 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. 9 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3of4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit Q, 6 V CDP File Number: 231889 - 1 County File Number: 5758027859 27028 Date: / / O Inch Scale: O Block O N/A h Page 4of4 0 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit 5758027859 Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaining 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 ICAT ,V F ITE EVALUATIONAMPROVEMENT PERMIT & ATC `� avie County Environmental Health ASN P.O.'Box 848/210 Hospital Street 6�M�N�P`l Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Applic n or: 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 BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed c-v.s� 1-:A— Contact Person ne Billing Address__��$ Hoy Home Phone City/State/ZIP ( _Ca �4 c. / a J,C y 7y©1�2 -Business Phone o 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: ite Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number �J? -ssc)3 Owner's Address Rol Sv L, City/State/Zip d lL C,,re-0- Z 2630Ca Property Address 6,pN C.ra IZ-d- City Svc �-S'v;l Lot Size 6-0e— Tax PIN# Subdivision Name(if applicableT ) r k Section/Lot# Z- Directions To Site: Htt V (OL4 L h- Tv�+r [r G le�. S �, ;v:s ti. 0 G e 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 ❑3qo Does the site contain jurisdictional wetlands? ❑Yes DlTo- Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject to approval by another public agency? es ❑No Will wastewater other than domestic sewage be generated? ❑Yes BTgo- IF RESIDEN E FILL OUT THE BOX BELOW eVt�� 3�Pd room #People #Bedrooms *— #Bathrooms 7� Garden Tub/Whirlpool BY—es ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑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: ❑Uonventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ CommunityWell Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 3-lgo- If yes,what type? (.cels G'E�x�rE;/1Zr.vs Lc� This is to certify tha a information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Property er' or owne s legal representative signature Date(s): ,,2�}=r�� Client Notification Date: Date EHS: Sign given ❑Yes ❑No /z Account# Revised 11/06 Invoice# . JOHN_.CROTTS R .-.. f [ r '!1-f� .L1'i ti• N �... e .[�{ s 'S• ' a1{ N _i Ikil � co O ' _ 4r �I I �1�� f 6/ MSR^Y YKI• 'Y ,fie. J'zalr+ �r•� A�? R. i'. ""- 1 �' r ,++ f• rs,:�tsYe:w; . �j,,'t l� T f -;,t( 4 'f'- _ +• .g' i ?t D'�f . . MV te i r c'.Rr" :- 1 . �( f � -,[ ?{..f . :'v'�v • 014 Sol ke � t ^77, r . �F'F �*�f:, '' 4t Myr.•? �✓... (' ��` � s3 _ � I Jr'i , r F -� [ f��'� ! S 1 r ,- '}r r� .- - _..._ --_ __ . ..,jam_. I . ) #' w + , JOHN CROTTS RD 4763 " was u 7648 sn' (63e1 � m �A (1,p,` co ��3 PaD GnB N nmol 7210 X614) % I 081811 _ 91141 fo CeB21 X81' V BtF 63 co I w PcC2 CeB2 GaD - CN N w 6144 jl �]1�A GnC2 i N 6 GnB2 - tit7 - �aw nm3 ,s�o � R 9543 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004173 Tax PIN/EH#: 5748-83-9141.02 Billed To: Land First Development Subdivision Info: Marbrook Lot#02 Reference Name: Location/Address: John Crotts Road-27028 Proposed Facility: Residence Property Size: see map Date Evaluated: 11 10K) Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position 1. L Slope% Zp HORIZON I DEPTH Texture group { Consistence 1 Structure C_(4 Mineralogy HORIZON H DEPTH Texture group Consistence ; Structure Mineralogy HORIZON III DEPTH Texture groupfi Consistence s Structure Mineralogy HORIZON IV DEPTH Texture group L 5.40 5tj Consistence 7F35 Structure C Mineralogy5 , SOIL WETNESS — RESTRICTIVE HORIZON 141 — SAPROLITE U CLASSIFICATION S LONG-TERM ACCEPTANCE RATE Q O.as SITE CLASSIFICATION: EVALUATION BY LONG-TERM ACCEPTANCE RATE: �• OTHER(S)PRESENT: REMARKS: �4'U t. tv�o�L l�1 !_� 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 3y1t 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 lis 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) L Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004173 Tax PIN/EH#: 5748-83-9141.02 Billed To: Land First Development Subdivision Info: Marbrook Lot#02 Address: 228 NC Hwy 801 North Location/Address: John Crotts Road-27028 City: Advance Property Size: see map Reference Name: Rodney Bailey 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: Zew ❑Repair ❑Expansion Permit Valid for: 0 Years E11�4o Expiration Residential Specifications: #Bedrooms —3 #Bathrooms 2 #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) � Design Flow(GPD): 2 Type of Water Supply: SCounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: System Type LTAR Initial C, rf Repair Q. 'J —15 Site Plan i J 9 � t , s Environmental Health Specialist Date t? i.p.11-06 Davie County;NC Tax Parcel Report Wednesday,November 9, 2016 134 .� f 135 124C.'\d , t 547 ,114 127 557 104 WARNING: THIS IS NOT A SURVEY Parcel Infor>nation Parcel Number: J5170A0002 Township: Mocksville NCPIN.Number: 5758027859 Municipality: Account Number: -�.,.82526365 Census Tract: 37059-805 Listed Owner.1c_�� LAND.FIRST.DEVELOPMENT-LLC, Voting Precinct: NORTH MOCKSVILLE COUNTY i Mailing Address-1: PO BOX 712_ - Planning Jurisdiction: Davie County City:., YADKINVILLE. Zoning Class: DAVIE COUNTY R-A i State NC Zoning Overlay: Zip Code:. - 27005-0000 Voluntary Ag.District: No Legal Description:-.--- LOT 2 MARBROOK Fire Response District: MOCKSVILLE Assessed Acreage: 0.69 Elementary School Zone: CORNATZER Deed.Date:,- .T= - - 4/2006 = _ Middle School Zone: WILLIAM ELLIS Deed Book/Page: 006600100 Soil Types: CeB2 Plat Book: 0009 Flood Zone: Plat Page: 152 Watershed Overlay: DAVIE COUNTY Building Value: 0.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 29000.00 Total Market Value: 29000.00 Total Assessed Value: 29000.00 161 AlldataIsprovided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, implied warranties of merchantability or fitness for a particular use.All users of Davie Countys 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 NC or arising out of the use or Inability to use the GIS data provided by this website.