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346 River Oaks Ln � ' OPERATION PERMIT o� i�e se n v Davie County Heaith Department � �CDP File Number 120153-1 ��'��. 210 Hos ital Street , r � P Fs000000aios P.O. Box 848 County ID Number: ��`a-"'� Mocksville NC 27028 Evaluated For: NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Carlton and Wendy Terry Property Owner: Carlton and Wendy Terry Address: 346 Rive�Oaks Lane Address: 346 River Oaks Lane ��Y� Advance �dY= Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336)940-5994 Phone#: (336)940-5994 Pro ert Location 8 Slte Informatlon Address/Road#: Subdivision: Phase: Lot: 346 River Oaks Lane Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East left on Hwy 801 go about 5 miles. Right on Underpass road at Advance Florist. Go to Bailey #ot eedrooms: Road on right in curve. Go toward end River Oaks on #of People: (eft. "'Water Supply: NEw vvE�� "IP Issued by. 2�a0-ntations,Robert "System Classification/Description: `CA issued by: Saprolite System? QYes QNo Design Flotv: a 4 � Pump Required9 *Distribution Type: QYes QNo Soil Appl�ation Rate: � _ 3 � 0 tPre Treatment: Drain field N drification Field S4'ft' 'SySi@ttl Typ@: �NFILTRATOR QUICK 4 STANDARD No. Drain Lines a IfISt8A8f: Bnan McDaniel Grading Total Trench length: a 0 0 �- Ce�tification#: ��18 Trench Spacing: _ Olnches O.C. ('�Feet O.C. =EHS: 214o-Nations,Roaen T�ench Width: _ Qlnches QFeet Date: � 3 / 0 4 / a 0 1 4 Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Approval Status Inches Maximum Trencn oeptn: � Approved� Disapproved Inches Maximum Soil Cover: Inches � CDP Fiie Number 120153 - 1 County ID Number: Fs000000a�os • Se tic Tank Shoaf Lat. � Manufacturer. - Long: STB: �60 - Gallons: 1000 Installef: B��an McDaniei Certification#: ��18 Date: 0 8 / 3 1 / a 0 1 3 'EH S: 2140-Nations,Robert `Fiiter Brand: POLYLOK PL-525 ST Maricer: ❑ Yes ❑ No Date: � 3 / 0 4 / a 0 1 4 Reinforced Tank: ❑ YeS ❑ NO Approval Status 1 Piece Tank: ❑ YeS O No 0 Approved� Disapproved Pump Tank Manufacturer. instaner: • PT: Certification#: G ailons: "EH S: Date: / � Date: � � RiserSealed ❑ Yes ❑ No RiserHeght: ❑ YeS ❑ NO (Min.6 in.) Approval Status einforced Tank: ❑ Yes O No Q Approved❑ Disapproved 1 Piece Tank: ❑ YeS ❑ NO Supply Line Pipe Si�e: 3 inch diameter Instaaer. Pipe Length: 5 feet Certification#: 'Schedule: 40 "EH S: Pressure Rated ❑ YeS ❑ No Date: � � Approved fittings ❑ Yes ❑ No Approval Status D Approved❑ Disapproved Pump Type: Instader: Oosing Volume: — Ge� Certification#: Draw Down: Inches 'EHS: 'Chaa�: � � Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N o Check valve p Yes ❑ NO Approvat Status Pvc unions ❑ Yes p No p Approved 0 Disapproved Vent Hole ❑ Yes ❑ N o Anti-siphon Hole p Yes ❑ NO � CDP File Number 120153 - 1 County ID Number: F9000000a�os Elect�ic E ui ment NEMA 4X Box or Equivalent p Yes ❑ NO InstaAer. Box 12 inches Above Grade p Yes ❑ NO Certification#: Box Adj.To Pump Tank p Yes ❑ NO Conduit Sealed p Yes ❑ NO 'EHS: PumpManually0perable p Yes ❑ NO � , `Activation Method: Date: Approval Status Alarm Audible p Yes ❑ No p Approved O Disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit compieted by: Authorized State Agent: %��'�`�" "'/" 0 / Date of Issue: 0 3 � 0 4 � a 0 1 4 This system has been instaqed in compliance w�h applicable NC General Statutes:Article 11�Chapter 130A, Rules for Sewage Treatment and Disposa1.15A NCAC 18A.1900 eL Seq.,and aq conditions of the Improvement Permit and Construction Authorization.This p�operty is served by a sewage septic system. Rule.1961 requires that a Type septic system meet the following criteria: Minimum System Review ByThe Local Health Depa�tment: Management Entity: Minimum System InspectionMlaintenance FrequencyByCertified Operator: Reporting Frequency By Certified Operator: Rule .1961 requires that a Type IV and V septic systems desgned fora home/business owne�must maintain a valid contract w�h a public management entitywdh 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 shatt be executed between the system owner and a management entrty priorto the issuance of an Operatan Permit for a system required to be maintained by a public or private management entdy. unless the system ownerand ceRified operator are the same. The contract shall require specific requi�ements fo�maintenance and operation, responsibiities of the ownerand systems operator,provisions that the contract shall be in effect foras Iong as the system is in use, and other requirements for the continued proper performance of the system. R shall also be a condition of the Operation PeRnit that subsequent owners of the systems execute such a contract. g• Hand Drawing Olmport Drawing . **Site PIan/Drawing attached.** ' OPERATION PEBp�l1T . Davie County Heaith Department CDP File Number: 120153 - 1 210 Hospital Street F90000004109 P.o.soxsas County File Number: Mocksviile rvc 2�02$ Date: / / Q Inch Drawing Drawing Type: Operation Permit Scale: , . , pe�ock = .ft. QN/A !,— � i �� I-�--�--- i --� � —�—;---�—_____i__.`._�._�----�.{--�__�_f__...�__�___.� �--+ —*— —�- — i - i ' — !--�------�_ � � � I 1 I � I i� � f i � I 1 i I � � ! i � �—�� --•—�_ �_—. � I � � i � i � � -- � �� p � t I�—� � j---�— � I � a — �� _ � � � � I —�_—.-��—� —1 ,_—t � F_—� � I � ( �� 1 i � � 1 i ! � � � i � ,---� - ' .- -- - -� —,___..___._.�_� i +__ ____��_.., _ f � � � _ � ,�.\ �.�i._ ��_ _ I ( ._ � � � �� __ �� _ �� ,. _�_._ _.� _i _,.._._ _�_ _.�__ _�____. I '� '� � � �1 i_ _ =i�I ; ��_ I I..�_ � ��__�_ �� ' � i � � i�l. �_ i __� � ---- i I i i �__ i--�—�--�__.__ � _�.�E �_� � . ____� � _ � � � ; � � � �_ , � �_ _�-----,. i� _, � -_ � � ; � ! � , , ; ; �� ( , i ! (_��1_! !______1�_�� —� �� L__�_!�i_—�. ! � � � _i�I �---.�____;—_ � �_ _ ��-,'c p _ � � d �0 � i � 3 I I � ( I � �I �� (�� I___.�____�..____� +-- �---� —•-- -._ I r /� ' � } � � � ' 7--- � � i � � � � i i I _ � ( � I � � i� i - --- i - —!--�- - -�+.._ I i _._._�._._._. �.�.____,�_�, , : _ .. I � � j � ! i � ��' , �,�,v+/� r �- `'��a i� E � : � ! �---� --- - - ---'--� —-'-_ __ -G - ---� -_ '_ __ _,._ �_�_.T i __ ` � i i , � __�_ � _2�_ _�___� � � f i � _� , _ a � _,_.� __ _ � � I� I _ ._ 1�� _ � ___. � _.F' ��V , , �` �_ f_ .I �_______�_ _! _ I j 1 � �_ _� ____� _�, _ —�.�-- , ----� ; ;_ ;._ _ _�_ �_ ; __,_____, _.; _� _, .;_ � � , � , �� i �.� , �~ ,� Iw I� � , � _ � � E f— .._i —i i -- —� —i- �..I_��. __}_� __..�._--__ _ _ _ _.� ._ . �._ __ _.� � _ _ _ 'p � I � ; � � , 1 I 1 ; ► ! � ► ! �Q �� ! �t� ._ _ __.__ _. . _ . _ ._ _� �___.__�__ _ _ �_ -�� j i �_ �_ _i � I i ► I _�-�---i - �- � a�c- -�_--.___i �_, 1 � � ' � '� ; i �� .� i � � i � �� ; ! � I , �-1 � l i � _.e,: E � ___ `_ ;__ _ �___--;�; 1_ __�_�_;____ �� ,__ �__ ' ; � � � � I I _ �---� - � -' !3_c.�r �L ! � 1 � E I (�—j i � i ;- ---r � � �j-- ; .-----1 �__._I__ �___;___; � � I j � � � I � i i � � � I �� I � � � � _i— .__'—.._; �— —� - i ` __.�._____.i� �_i__! �—� � �---_�---!---� ` � -- --f — — � � --��. ► '— — — + _ I � i , ; , , �_.. _�_ _, _._�_� _�_.�.._�__ _;__� � � I i I� � � i i i I i I i � � ____..�__._.� __ � ' � _� i ; � ____�--- - -b..,�__� _,.__. _�_..�,_-.,--- -�-- ;- -� , i i i _ I � �� a.0.+ � � ( _ �w. I __ __ � _ I _�__ � ._ i .._. ' _._.. ! — � _�__.^ _l.� � -i-�--I I - - - - �- ``-�--` , t-. ' _�`_ ._�_ � � , i ; I , I !_�" � _� i �____ I I � ��__ a �_;__�--'— —,-- -- --- � � C! _.;_�__� i ; , -;-- -, � i _r -_�-- i -�- � �-�- -�_ _ �__ i � __� � i ! _.��I�.1 i _ '� � � :� I� � � '��_�_�__�_�� V._;__.�_ �_ � � ;; � __ �� _._� ,.__._ _.._ , � i � i � � I ' I � � ' ___.1_ I ' i I � �� 1 � � � � r � �,��c�� —� � � —� E - ' ��. � � .- ' f � � ---1- j --- � � �� ____ � �_-�_ � __� _�_ . - - -- -_�_ _, .�._ _ _ I _� i__I _� _j �� o ;�.du�� _.�___.__ ____{___:__, �-.__�.. .��- � .____.__�.__� � , ,� �__l.� � I �_1_ I I �_?-- ! - -�— �_� 1 _ ; �___� � ! � " ' " ' CCINSTRUCTION For Office Use Only ' " AUTHORiZATION �CDP Fite Number 120153-2 �7��``� Davie County Health Department County ID Number: F90000004109 � ; '�' �`� 210 Hospit�i Street Evaluated For. NEW � , °.�M;;,. P.O. Box$48 Township: MOCkSVIII@ NC 27028 PERh11T VAUD UNTII: Phone:336-753-6780 Fax: 336-753-1680 1 0 � 2 5 � 2 0 1 8 Applicant: Bili Cariton Terry,Jr Property Owner: Carlton Terry Address: 107 N. Hemingway Court Address: 346 River Oaks Lane CdY� Advance C�y: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: (336)749-0413 Phone#: {336)940-5994 Propertv Location & Site Information Address/Road #: Subdivisan: Phase: Lot: 346 River Oaks Lane Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East left on Hwy 801 go about 5 miles. Right on Underpass road at Advance Florist. Go to Bailey Road on #of Bedrooms: 2 right in curve. Go toward end River Oaks on left. �of Peopte: 2 'WaterSupply: NEwwELL System Specifications Minimum Trench Oepth: Site Classificatbn: Ps 3 6 lnches Minimum Soil Cover. Saprolite System? QYes QNo InChes Design Flow: 2 4 p Maximum Trench Depth: 3 6 Inches Soil Applicatan Rate: � . 3 Maximum Soil Cover: Inches *System Classificatan/Description: 'Distnbution Type: 7YPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons "PfOpOSed Sy5t6t11: 25%REDUCTION 1-Piece: Q Yes Q N o Pump Required: aYes �No OMay Be Required Ndrfflcation Fietd Sq. ft. Pump Tank: Gallons No. Drain Lines 1-Piece: QYes QNo Total Trench Length: 2 p � ft GPF11—vs-- ft. TDN Trench Spacing: _ Qlnches O.C. Dosin Volume: _ Gaflons oFeet O.C. 9 Trench Width: _ �Inches Feet Grease Trap: Gallons Ag�regate Oepth: inches Pre-TrQatment: C�NSF OTS-I O'TS-II SepticTank InstallsrGrade Level Required: Q� QII C,�III C,�IV �,.,.,. , ..�� CDP File Number 120153 - 2 Counry ID Number. F9000o00a�09 ❑ Open Pump System Shec Repair System Requi�ed:OYes O No ONo, but has Available Space epair SYstem T�ench Spacing: Q Inches 4. 'Site Classification: PS — Q Feet O.C. Trench Width: Inches Design Flo�v: 2 4 � _ (�Feet Soii Applicatan Rate: � . 3 Aggregate Depth: inches � Minimum Trench Depth: 3 6 Inches 'System ClassificatanlDescription: TYPE II A COW SYSTEM(SINGLE-FAh11LY ORd80 GPD OR LESSJ Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 'Proposed System: 25%REDUCTION Inches Maximum Soil Cover: Ndrification Field Inches Sq. ft. No. Drain Lines *Oistnbution 7ype: Gw�vmr-SERuu. Total Trench Length: 2 � � ft Pump Required: Q'�es �No �May Be Required Pre-Treatment: ONSF QTS-1 �TS-II 'Site Modlfications No grading or construciion actNity is allowed in areas designated tor system and repair without approval of Health Department. 'Pe�mit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holde� is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorizatlon tor Wastewater Systen Construction shall bevalid tor a person equal to the period of wlidity ot the ImprovaneM Permi�not to exceed fiv�e years,and may be Issued atthe sametime the Improvement Pertnit Iswed(NCGS 130A-336(b)}If theinstallation has not been completed du�ing the perfod ot wlidiry of the Construction Pertnit the Iniormadon wbmttied in the appllcation for a permit or Constructlon Authorization is found L�have been incorrect,falsified or changed,or�e site ls altered,it�e pertnit or Constrvction Authorization sh�ll become inwlid,and mry be suspended or revoked(.1937(g)).The person owNng or controlling the system shall be responsible for assuring oompliance wlth the laws,n�es,and permit condiUons regarcling system locatlon,Inslallatlon,opention,maintenancg moni�oring,reportfng and r�air (1938(b)). ApplicanULegal Reps. Signature Required? OYes UNo ApplicanULegal Reps. Signature� Date: � � "Issued By_ 224a-Daywalt.And�ew Date of Issue: 1 0 / 2 5 � 2 0 1 3 Authorized State Agent: f�laliunction Log pYes (�Hand Drawing C>Import Drawing TotalTime:(HH:��1t�ta **Site PlanlDrawing �attached.** Page 2 of 3 � � Hours, 3 0 f.t inutes ' ' ' ' � CONSTRUCTION AUTHORIZATION 120153 - 2 • . - Oavie Counry Health Oepartment CDP File Number: 210 Hospital Street F900000D4109 P.o.sox sas County File Number: Mocksville NC 27028 Date: 1 0 / 2 5 / 2 0 1 3 Q Inch Drativina Drawing Type: Construction Authorization Scale: . . , OBioc�c = Q N/A ---_____ ---- _.. — - -- _ . ___ .__ ---__._ _.______ _ __.__-- . ____ __---_--._ ____ _. _--.. ._. _._ __- -._ __. � ; � � ! ; � � � i �� '� � � � , . . . . _ _ , . . . , . . . ' � ; , , i ,, . . . , .. ... _._.______. . . --.._.___ __.__ __. ___ . __ .... ___.. , � _. . . : : . . __ . . . _ . . , _ ; � � ��.. 4-5 � ' ' , !_ _ __ -- . . _ . __. . , _ . _ ---- , . ____ . __ . . _ __ .__ __ t�__ _ _ _ _ �� ,w+✓ti, ; ; ,' ' ' ; : . . . . . : , _ ��_ � � ; � Sr ; � ��' ; . � __ _ . . _ ; . , . ; _ . . , . ; . . , ; . ; , � $� , � , r _ _ . . : . . _ . . . _ . _ __ : _ . _. . , , � _ � .. . , , , . _ . _ _ _ . . . __ . _ _ . , . . _ __ _ __ , �� . . , � �� . � , : , � �. , . . _ _��: . . _ � : .�� . . . �a �� . _ . 1l . 22� . : : 3 . . . , . : �� : _ . - ►�• . . � �o�z�`<� �,� ;N c,�p � .._ ... � . . ' � IMPROVEMENT PERMIT Fo�o��useon�y � `CDP File Number 120153-2 • ��"Z� Davie County Health Department � ��.�.� 210 Hospital Street County ID Number: F90000004109 � � P.O:Box 848 Evaluated For: NEW •�,� ;:: Mocksville � � NC 27028 Township: , Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 9�25/2018 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. - Applicant: Bill Carlton Terry, Jr Property Owner: Carlton Terry Address: 107 N. Hemingway Court Address: 346 River Oaks Lane City: Advance City: Advance State2ip: NC 27006 State2ip: NC � 27006 � Phone#: (336)749-0413 Phone#: (336)940-5994 Pro e Location & Site Information Address/Road#: Subdivision: Phase: Lot: 346 River Oaks Lane Advance NC 27006 Directions structure: SINGLE FAMICY Hwy 64 East left on Hwy 801 go about 5 miles. Right #of Bedrooms: 2 on Underpass road at Advance Florist. Go to Bailey #of People: 2 Road on right in curve. Go toward end River Oaks on left. *Water Supply: NEW WELL . S stem S ecifications Initial S stem � � `Site assi ica ion: PS Minimum Trench Depth: 3 6 Inches Saprolite System? �Yes �No Maximum Trench Depth: 3 6 � _ � - Inches . Design Flow: a 4, 0 Septic Tank: 1 � 0 0 Galtons Soil Application Rate: 0 . 3 1-Piece: 0 Yes �No � � Pump Required: �Yes �No �May Be Required . "System Classification/Description: � TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons *Proposed System: 25%REoucTioN 1-Piece: � O Yes �No Repair System Required:�YeS O No ONo, but has Available Space . Repair Svstem � � *Site Classification: PS Minimum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 3 Maximum Trench Depth: 3 6. Inches *System Classification/Description: Pump Required: � QYes �No O May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR ' LESS) . `Proposed System: 25°�o REDUCTION Page 1 of 3 , . . CDP File Number 120153 -2 - Counry ID Number. Fs000000a�os . *Site Modifications ❑ Open Fill Sheet � � 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 b�r the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. Site Plan rne Improvement Permlt shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to � scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the site for the 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 O surveyor,drawn to a scale of one inch equals no more than 60 feet,that includes:the specific location of the proposed facility and appurtenances,the slte for the.proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivisfon 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 Departrnent and Local Health Departrnent 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 perrnit is subject to revocaUon if the site plan,plat,or intended use changes(NCGS 130A�35(�).The person owning or controlling the system shall be responsible for assuring compliance � with the laws,rules,and pertnit conditions regarding system location,installation,operetion,maintenance,monitoring, reporting,and repair(.1938(b)). ApplicanULegal Reps.Signature Required? �YeS �NO � _ • ApplicanULegal Reps.Signature: • Date: � � 'Issued By: 22`t4-Daywalt.�,a�ew Date of Issue: 0 9 I � S / a 0 1 3 . . OValid without Expiration? Authorized State Agent: �C�eSte CA? � �Hand Drawing .Olmport Drawing � � **Site Plan/Drawing attached.** Total Time:(HH:MM) � 0 1 Ho�� 0 0 Minutes � Page2of3 � Activity Code: S-4-IP'S issued:new,valid for 60 mos. � IMPROVEMENT PERMIT 120153 -2 Davie Counry Health Department � CDP Flle Numbel': 210 Hospital Street F900o0004109 � P.o.Box sas County File Number: . Mocksville rvc 2�o2a Date: / / . �Inch Drawin� Drawing Type: Improvement Permit Scale: , , O Block . . 0 N/A J ft. 1 , �.� �, � � �� . � . . . � ,� �� . , . �� . �� . �� . - 1 `� , . . �n , . , o . �' � - � . Page 3 of 3 . � P1 P2 � � IMPROVEMENT PERMIT � Davie County Health Department � 210 Hospital street � �. CDP File Numbe►': 120153-2 P.O.Box 848 • F90000004109 Mocksville NC Z�o2s County File Number: � Date: .0.9,� .a.5. �.a.0.1.3. Click below to import an image from an external location:Drawing Type: Improvement Permit . Page 3 of 3 � P 1 P2 / / _� . %., � �-j , ,-� �� '., , i, . APPLICATION FOR SITE EVALUATION/IMPRUVEMENT PERMIT&ATC � �� Davie County Environmental Health ��a '��` P.O.Boa 848/210 Hospital Street v Mocksville,NC 27028 ✓��,, 3 (336)753-6780/Faa(336)753-1680' , � �. ` Applicahon For. Site Evaluat�on/Improvement Permit Authorization To Construct(ATC) Both �� Type of Application: New System Repair to Existing System Expansion/Modification of Existing System or Faciliry � •••IMPORTAN7"��THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMA7'[ON IS PROVIDED. Refer to the INFORMAT[ON BULLEITN for instructions. APPLICANT INFORMATiON Name l��/� ��I� Contact Person �'w Ifr,.?�.,�.y Address d Home Phone ��-9 Ho•Sf 9Y City/State/ZIP /{v(�awc� NC ��6 Business Phone 336• 3�!9-o y/3 Email J/4�gCTP_ y/�DTF� �/�T EmaiI:QTR�PEoP[E� yifUi�?-`Y.If/� Name on PermidATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION �Date House/Facili Comers Fla ed ' 3 NOTE: A survey plat or site p18n must accompany this application Included: Site Plan Plat(to scale) (Permit is valid for 60 months with site plan,no e�cpitation with complete plat.) Owner's Name G Q �./�-e Tc�r r � Phone Number D g 9 n /'- / ,, n Owner'sAddress� ��F/Ir ��i,t5.5 (..(L/�/� City/State/ �q��Oo�O /�07 Zip 2''?�a�� Propecty 6 Address City Lot Size �.�L Tax PIN# �,9 ��S q o q/ �, �� 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? �es No Does the site contain jurisdictional wetlands? Yes N� Are there any easements or right-of-ways on the siteT _Yes ✓No Is the site subject to approval by another public agency7 Yes t�o Will wastewater other than domestic sewage be enerated? Yes N IF RESIDENCE FILL OUT TI�BOX BELOW #People Z� #Bedrooms 2 #Bathrooms��` Garden Tub/Whirlpool Yes N Basement: Yes Basement Plumbing: Yes No IF NON-RESIDENCE FILL OUT TI�BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(ga(lons per day) (Attach documentation of similaz facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: onventional Accepted Innovative Altemative Other Water Supply Type: County/City Water New Well Existing Well Community Weli Do you anticipate additions or expansions of the facility this system is intended to setve7 Yes �9J If yes,what type? Signgiven Yes No Account# ��`�� Revised 11/06 � Invoice# /��,/� C.�� Z 0�53 -� Z- `f� �`�I l / �, • ' '� ' . This is to certify that the infortnation provided on this application is true and correct to the best of my lrnowledge. I understand that any permit(s)or ATC(s)issued hereaRer 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 flagging or staking the house/f 'ity location,proposed well location and the location of any other amenities. � Site Revisit Charge Date(s): Property o s or owner' gal r sen ve si e Client Notification Date: � O�� EHS: Date Sign given Yes No Account# Revised 11/06 Invoice# ' ', ' ' ' �`�� ,� a° s�� x $aAey Road � �a ° � �y g 4' �� +ca� (3dl Caitcn tary.Jr. '+"�p � W��t� �'.-r Peoples Geek Road DD 875 f G?bk �� pIN;5890059091 VICINITY MAP NTS �i� r��t 2,t�II pG 69 \� a 9��e'' pQ \ \ A��tQ.�s e� •�S, \ �e 1� 2`Ij:�9 �` 2�.�+ O °\ �\\� � �.r 6,�s � T \ �\ r S 69'16'40'E 322.71' �R ��s�„�l �. R 2?9�F �'�,'3' � o \ ��cP' ��• � � � EIR _�'o � / �� 122.7' � 1 m� � � � \ "c� � �u` ,n / �ca / � 1�6, � N Tract 2a y � � 2.864 Acres aw�.i�r� g P�d I 24,7C5 Sc�. R 1713 895 f'G 264 �'� G I'�e --�� [3tl1 Ca�lta,fem�.Jr� pIN:5890059091 �� tract 2,f'C3 II f'G 69 �. � ��G�,� � , '�� 3 \ PIN:5890059091 � �— '�e' y"�� tract 2,Pfi II f'G 69 /_.. _ ` /\ ,�.,� � �� \ � � � � / �y •� � � � � o� / � \ +18.0 16.0' `� / h N 220 \ h {.� P�°p°'ed � � 33.7• � / � Gange g w \ 1 00' � I � 6asting 2 story o I / \� 4 36.00 o under constrvcGon / �R �GARAGE DETAtI / \ 97.0' � (not to xale� \ � � oera� � SITE PLAN FOR (not to xale) � B ill C arlton Te rry, Jr• I ccrtify that this map was drawn under my supernsion from an � - - � Wendy Joyce Terry actual survey made under my supernsion(DB 900 PG 523); 346 River Oaks Lane that the relabve positaonal Shady Grove Township, Davie County �ra�y of the 5urvey is 0.04: NORTH CAROUNA and that this map meets the Standards of Practice for Land 100' S0' 0 100' 200' 300� Surveying�n North Carolma (21 NCAC 56.1600). REVISED: 09�11�13 — �� DAiE ,1p9 �I pRAWN ProFessional L�nd Surveyor Added garage �-=�00' 04/19/13 0255 JCA/MCF �� LEGEND �`�� ► �,� EIR D(ISTING IRON KOD �CS � PIN PARCEL IDENTIFICATION NUMBER NTS NOt 70 SCALE L A N D S U R V E Y I N G Notes: Allen Geomatics. P.C. (C-3191) I. PIN:5890 1 4 5 904 P� BOX 89, Advance. NC 27��6 2.DB 900 P6 523 (336) 782-3796 3. Lot 2a,PB I I PG 69 www.AllenGeomatics.com � Appraisal Card Page 1 of 1 . � � '� • , , � DAVIE COUNTY NC 9 19/2013 30:22:14 AM � ERRY BILL GRLTON)R TERRY WENDY JOYCE Retum/Appeal Notes: F9-000-00-041-09 � 46 RNER OAKS LN UNIQ ID 968300 SPLiT FROM ID 968256 2515734 NN:01-NEW BUILDING ID N0:5890145904 Q . COUNiY TAX(100),RRE TAX(100) CARD NO.1 of i � eval Year:2013 Tax Year:2014 2.664 AC BNLEY RD TRACT 2A 2.864 AC 2.864 AC SRC� � ralsed b 17 on OB 03 012 07003 VEOPLES CREEK RD 7W-07 C- EX- AT- LAST ACTION 20130917 ;;i CONSTRUCiION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE 'T F oundatlon-3 UC Under 0.8000 . � ntinuous Footin 5.0 onstrvc[ion { C. ub Floor System-4 ER.�� BASE Standard 0.0000 � $•� 5 MO Area UA RA7E RCN EYB AYB REDENCE TO MARKEf � Merlor Walls-21 � ate 6rick 34.0 01 Ol 6 455 134 93.60 0547 01 Ol %GOOD 80.0 EPR.BUILDING VALUE-CARD 484 38 ooMg SWc[ure-03 TYPE:Single Family Residen[ial Single Family Residential EPR.OB/XP VALUE-GRD ,y ble S.0 ARKET LAND VALUE-CARD 32,41 O 5T0 WES:3-2.0 S[ories OTAL MARKET VALUE-CARD 516,79 Z oofing Cover-03 . p hatt or Com Itlon Shin le � 3.0 - nterbr Wall Constnxtton-5 . OTAL APPRAISED VALUE-GRD 516,79 all Sheetrock 26. OTAL APPRAISED VALUE-PARCEL 516,79 nterbr Watl Construdion-6 ustom Interior OA � nterlor Floor Cover-12 OTAL VRESENT USE VALUE- 486,02 aMwaod 50.0 26� ARCEL nteAor Floor Cover-14 r OTAL VALUE DEFERRFD-VARCEL 30,77 q ��S� OTAL TAXABLE VALUE-PARCEL 486,02 o.o Z�� R1S 16' eaurg FuN-04 IecMc 1.0 ZZ' PRIOR 1433� UILDING VALUE eaGng Type-10 39, BXF VALUE 22,33 eat Pum 4.0 ND VALUE r Conditionfng Type-03 �� (.$�' ' 1j2� RESENT USE VAIUE ntra� a.o 28'0 f8E rooms/BaNrOoms/Half-Bathrooms - EFERRED VAWE z2,42� 1 OTAL VALUE 22 33 /a/i 19.0o gp5 3��, rooms -2FU5-3LL-0 � ¢2' G� ' �t 9 5�2FUS-2LL-0 CERMIT e alf-Bathrooms . � CODE DATE NOTE NUMBER AMOUNT = -1 Fus-o LL-0 1��PT�� Z�� (flce � 40' q.�' OUT:WTRSHD: o AS-0 NS-0 LL'0 �' . . Z2� U�� SALES DATA o OTAL VOINT VALUE 122.00 . b` IO FF• NDICAT � BUILDING AD7USTMENTS . . YL� ECORD ATE EE SALES o ize 3 Size 0.870 `� 15 00 PAG M R DE VR2CE e ha Desl 4 FACTOR 4 1.050 � 0900 523 8 01 WD E V � uali 4 ABAVG 1.200 � � � OTAL AD]USTMENT FACTOR 1.10 OTAL QUALiTY INDEX 13 � HEATED AREA 5,396 Click on image to enlarge N07es PLiT PER PLAT-2012 SUBAREA '- UNIT ORIG% SIZE ANN DEP % OB/XF DEP GS OD UA DESCRIPTIO T N VRICE COND BLDG / FACT Y EY RATE V COND VALU TVCE AREA %RPL CS OTAL OB XF VALUE � AS 3 49 10 32773 � � . GD 58 2476 � ' � � OP 38 3 1275 � .. " ' . . P 4 1519 . �ti � , S 1 90 16058 � � O 70 328 BM 3 0 2 5749 DD 19 2 365 �� IREPLACE 1-None . UBAREA OTALS 10,7 5,47 � UiLDING DIMENSIONS BAS=516W35515W16WSW16N7W22N16ESN22E42N7E2856E2515E20Area:3494;FOV=53W8N3E8Area:24;FGD=N28W22513E2535E20Area:586;WOD=N7E2 857W28Area:196;FOP=514W26N14E26Area:364;F5P�W23536E5N22E16N14Area:404;UBM=544WIOSISW40N7W22N16ESN22E40N7E20N7E7Area:306 . �PTO�W60514E40N7E20N7Area:700•FUS�N22E22N24E2657W459E28516W33514W39Area:1902•TotalArea:10734 ND INFORMATION � TMER AD7USTMENTS TOTAL IGHEST AND USE LOGI FRON DEPTH/ LND COND ND NOTES OA LAND UNIT LAND UNT TOTAL ADJUSTED UND UND EST USE CODE 20NING TAGE EPT SIZE MOD FAGT RF AC LC TO OT TYPE PRICE UNITS TYP AD75T UNIT VRICE VAIUE NOTES � URAL AC 0120 0 0 1.5240 4 0.7500 10-15+00+00+00 pD 9,900.0 2.8 AC 1.14 11,315.7 . 3240 � � OTAL MARKET LAND DATA 2.8 32 41 � GRIII 5210 0 0 1.0000 5 1.0000 590.0 2.5 AC 1.00 590.0 151 � RSTI 6110 0 0 1.0000 5 1.0000 415.0 0.30 AC 1.00 415.0 12 OTAL GRESENT USE DATA 2.8 1 64 http://maps.co.davie.nc.us/ITSNedAppraisalCard.aspx?parce1=F90000004109 9/19/2013 y • � f � � , " DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section � � SoiliSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION River Oaks Lane Bill Carlton Terry,Jr F9-000-00-041-09 336 940-5994 2.864 AC Water Supply: On-Site Well '��- Community Public Evaluation By: Auger Boring Pit f�. Cut FACfORS 1 � 4� � , 4 5 6 7 Landsca e sition j� Slope% a/0 �Q. HORIZON I DEPTH _ „ p d��,, Texture grou � 1!. k: .p"ct�.C"( �° .�. Consistence ^„�,; Structure �bC �«; Mineralo ,��w f HORIZON II DEPTH �;,..••�'�" •!,/ Texture rou � _ Consistence (`:� Structure �� Mineralo 1:► � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEP'TH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION !� . LONG-TERM ACCEPTANCE RATE .� � � SITE CLASSIFICATION: �S EVALUATION BY: • LONG-TERM ACCEPTANCE RATE: � � OTHER(S)PRESENT: � �� . REMARKS: Q, > f LEGEND j.andscane Position . R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-F1ood plain H-Head slope � T.�xLulg . 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 ANSISTF.N . . M�iS� VFR-Very friable FR-Friable FI-Firm VFT-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 � r� jr • SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky � SBK-Subangular blocky PL-Platy PR-Prismatic Mine alogv 1:1,2:1,Mixed LI� 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 rinv-trrm ac�rntanrP ratP_ oallrlav/ft� rnTrr�nrrne m___•. +.