258 Cornwallis Drive Lot 1 r
OPERATION PERMIT EEvvaluated
ice se n v
� - Davie County Health Department umt�er 139083-1
f 210 Hospital Street
P.O.Box 848 mber;
Mocksville NO 27028 r NEWPhone:336-753-6780 Fax:336-753-1680
Applicant: Siena Signature Homes Property Owner: Siena Signature Homes
Address: 195 Burkeview Court Address: 195 Burkeview Court
City: Lexington City: Lexington
State2ip: NC 27295 ''State2ip: NC 27295
Phone#: (336)577-3388 Phone#: (336) 577-3388
Property Location & Site Information
Address/Road#: Subdivision: ucu 0 Pj Phase: Lot:
258 Cornwallis Drive' J
Mocksville NC 27028 Directions
structure:- SINGLE FAMILY Hwy 158 East lefto on Farmington Rd. Left on
Pudding Ridge.Left on Cornwallis Drive, second part
0 of Bedrooms: 3 lot on right
#of People:
*Water Supply: PUBLIC
*IP Issued by. *System Classification/Description:
TYPE 111 E.PPBPS GRAVITY DOSED SYSTEM
*CA issued by: 2140-Nations,Robert
SaproliteSystem? OYes QNo
Design Flow: 3 6 0 * GRAVITY-PARALLEL d-box Pump Required?
Distribution Type: tom' ( Yes C7No
Soil Application Rate: 0 a *Pre Treatment:
Drain field
N7rification Field 1 8 0 0 Sq.ft- *System Type: PPBPS
No. Drain Lines 7 Installer: Brett McMahan
Total Trench Length: 3 0 0 ft. Certification#: 1120
Trench Spacing: — 8 Olnches O.C.
(•)Feet O.C. *EH S: 2140-Nations,Robert
Trench Width: a Inches
gFeet Date: 0 1 / 0 8 / 2 0 1-5
Aggregate Depth: inches
Minimum Trench Depth: 2 8 Inches
Minimum Soil Cover. 1 a Approval,Status
Inches
Maximum Trench Depth: 4 2 Inches ® Approved Disapproved
Maximum Soil Cover: 2 6
Inches
CDP File Number 139083 - 1 Septic Tank County ID Number:
`
Manufacturer. Shoat Lat.
STB: 760 Long: ,
Gallons: 1000
Installer: Brett Mcmahan
Certification#: 1120
oat�: Osl a � / a � 14
*EH S:
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker. El Yes ® No
Date: 0 1 / 0 8 / 2 0 1 5
Reinforced Tank: C] Yes ® NO �PPalStatus
1 PieceTank: ❑ Yes ® No
, Approved❑ Disapproved
Pump Tank
Manufacturer. Installer.
PT: Certification#:
Gallons: *EH S:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ NO (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes ❑ No =❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes.. ❑ No
Supply Line
Poe Size: inch diameter Installer.
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date: / I
Approved fittings [IYes ❑ NO Approval Status
❑ Approved U,Disapproved
Pump Requirement
Pump Type: Installer.
Dosing Volume: Gal Certification#:
Draw Down: Inches THS.
*Chain: I
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes El o Appmp,Status .
PVC unions ❑ Yes ❑ No ❑=Approved❑ Disapproved f
Vent Hole ❑ Yes ❑ N o
Anti-siphon Hole El Yes ElNo
CDP Filq Number 139083 - 'I County ID Number:
Electric Equipment
NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EH S:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes D No Q Approved❑ Disapproved,
Alarm Visible ❑ Yes ❑ No
2140•Nations.Robert
*Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 1 / 0 8 / 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 III E. sewage septic system.
Rule.1961 requires that a Type TYPE III E. septic system meet the following criteria:
Minimum System Review ByThe 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 fora home/business owner must maintain a valid contract
with a public management entitywkh 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 systema
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 tong 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.
E)Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 139083 - 1
Davie County Health Department CDP File Number: r
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Olnch
Drawing Drawing Type: ON/A Operation Permit Scale: . ONft.
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' CONSTRUCTION For office use only
' AUTHORIZATION *CDP File,Number 189083-1
Davie County Health Department County ID 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 1 a / 1 5 / a 0 1 9
Applicant: Siena Signature Homes r
operty Owner, Siena Signature Homes
Address: 195 Burkeview Court ddress: 195 Burke view Court
City: Lexington City: Lexington
State2ip: NC 27295 State0p: NC 27295
Phone#: (336)577-3388 Phone#: (336)577-3388
Property Location & Site information
Address/Road#: Subdivision: Phase: Lot:
258 Comwallis Drive'
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 East lefto on Farmington Rd. Left on Pudding
Ridge.Left on Cornwallis Drive, second part lot on right
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: 3 6
Site Classification: Provisionally Suitable 7,nchesMinimum Soii CoverSaprolite System? OYes ®No 18Design Flow: 360 Maximum Trench Depth: 36 nces
Soil Application Rate: 0 . a Maximum Soil Cover: 1 8 Inches
*System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPE III E.PPBPS GRAVITY DOSED SYSTEM Septic Tank;
1 0 0 0 Gallons
*Proposed System: 5o%REDUCTION 1-Piece: OYes *No
Pump Required: OYes @No OMay Be Required
Nitrification Field 1 8 0 0 Sq.ft. Pump Tank: Gallons
No.Drain Lines 6 1-Piece:Oyes ONo
Total Trench Length: 3 0 0 ft GPM—vs— ft. TDH
Trench Spacing: — 8 OInches O.C. —
. � Feet O.C. Dosing Volume: Gallons
Trench Width: 2Feet
Inches
a Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01 Oil 011 Div
Dann 1 MIA
CDP File Number 139083 - 1 County ID Number.
❑ Open Pump System-Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System Trench Spacing: Inches O. .
ification: Provisionally Suitable $ e Feet O.C.
Trench Width: ( Inches
w: 3 6 0 — ar Feet
Soil Application Rate: 0 - a Aggregate Depth: inches
Minimum Trench Depth: 3 6
"System Classification/Description: Inches
TYPE III E.PPBPS GRAVITY DOSED SYSTEM Minimum Soil Cover: 1 g Inches
"Proposed System: 50%REDUCTION Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover: 1 8
Nitrification Field 1 8 0 0 Inches
Sq.ft. - -
No.Drain Lines "Distribution Type: GRAVITY-,PARALLEL(eq.d-box)
6
TotaiTrench Length; 3 � 0 ft. Pump Required: QYes �,QNo QMay Be Required
Pre-Treatment: ONSF OTS-i OTS-II
"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 by the Health Department in no way guarantees 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 Consb=don shall bevalid fora 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(NCOS 1301-=(b)�If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted in theappticatlon fora 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 shatt be responsible for assuring compliance
with the laws„rules,and permit conditions regarding system location,installation,operatlon,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: . 1 a / 1 5 / a 0 1 4
Authorized State Ag Malfunction Log OYes
@Hand Drawing 0lmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 139083- 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 12 / 1 5 / 2 0 1 4
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . Qfflock
Q N/A
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s •- Davie County Health Department County ID 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 6 I a 0 I a 0 1 9
F
ant: Siena Signature Homes Property Owner. Siena Signature Homes
ss: 195 Burkeview Court Address: 195 Burkeview Court
City: Lexington City: Lexington
State/Zip: NC 27295 State/Zip: NC 27295
Phone#: (336)577-3388 Phone#: (336)577-3388
Proaerty Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:wallis Drive'
e NC 27028 Directions
Structure: SINGLE FAMILY Hwy 158 East lefto on Farmington Rd. Left on Pudding
Ridge.Left on Cornwallis Drive, second part lot on right
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System ftedfications
Minimum Trench Depth: a 4 Inches
Site Classification: Provisionally Suitable
Minimum Soil Cover: 1 a Inches
Saprolite System? O Yes 9 N
Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 a Maximum Soil Cover. a 4 Inches
*System Classification/Descdption: *Distribution Type: GRAY-PARALLEL(eq.d-box)
TYPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank
1 0 0 0 Gallons
*Proposed System: 25%REDuc'nON 1-Piece: O Yes ®No
Pump Required: OYes ®No O May Be Required
Nitrification Field 1 8 0 0
Sq.fk Pump Tank: _ Gallons
No. Drain Lines 5 .1-Piece: OYes ONO
Total Trench Length: 4 5 0 {(, GPM—vs— ft. TDH
Trench Spacing: 9_ 2Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width: _ 3 0Inches
®Feet Grease Trap: Gallons
Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-ll
Septic Tank Installer Grade Level.Required: 01 011 0111 01V
1J vrcu I unit vyoawn yucca
Repair System Required:®Yes ONO O No, but has Available Space
rDesign
r System Trench Spacing: 9 O Inches O. .
ssification: Provisionally suitable — Feet O.C.
Trench Width: 0 Inches
low. 3 6 0 — 3Feet
Soil Application Rate: 0 a Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: 3 0 Inches
TYPE III E.PPBPS GRAVITY DOSED SYSTEM Minimum Soil Cover. 1 c2 Inches
*Proposed System: OTHER Maximum Trench Depth: 3 6 Inches
Nitrification Field
Maximum Soil Cover. 1 8 Inches No. Drain Lines 6 1 8 0 0 Sq.ft. *Distribution Type:
Total Trench Length: 3 0 0 ftPump Required: Oyes O No O May Be Required
Pre-Treatment: O NSF OTS-1 OTS-II
*Site Modifications chww
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
750
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. �
200
This Authorization for Wastewater System Construction shall be valid for a person equal to the 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 13DA-336(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 permft 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
(19W(b))•
Applicant/Legal Reps.Signature Required? OYes ONo
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 6 a 0 a 0 1 4
Authorized State AgentMalfunction Log OYes
(&Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Donn')of Q
210 Hospital Street
P.O.Box 848 County File Number:
Mocksvilie NC 27028 Date: 06 / a0 / a014
O Inch
Drawin Drawing Type: Construction Authorization Scale: . O Block
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210 Hospital street139083- 1
CDP File Number:
P.O.Box 848
ModcsviUe NC 27028 County File Number:
Date: 0.6.120./ .2014
Click below to Import an Image from an external location: Drawing Type:Construction Authorization
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental Health ]PAID
gECE P.O.Box 848/210 Hospital Street �+ar
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
Application For: Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both
Type of.Application:ANew 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 r P_ A -.Sn Q 40M&n , Contact Person-- n(AI OM P
Address Home Phone
City/State/ZIP L:ed,,I C Business Phone 336 -32-1 -3 34g
Email_ -)nemm e mA ti _C�r
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: CU Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name tgN o,c V, Phone Number
Owner's Address City/State/Zip
Property Address City
Lot Size I el CC 2 Tax PIN# 070-A -OD l
Subdivision Name(if applicable) nq Q,-.Ace Section/Lot#
Directions T Site: 107T,CICe A-32
V n act 1
Specify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
#People W #Bedrooms 3 #Bathrooms S Garden Tub/Whirlpooles ❑No
Basement: Wes ❑No Basement Plumbing: ❑Yes eo Xy
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: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:4county/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 60
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 Dave County Health Department to conduct necessary inspections to determine compliance with applicable
laws an es. I uncle d that I am responsible for the proper identification and labeling of property lines and corners and
locatin an fl gging t king the house/facility location,proposed well location and the location of any other amenities.
Prope wner's or own is legal representative signature
Site Revisit Charge
Date(s):
• t Z r ZO (Y Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice#
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Appraisal-Card ` Page 1 of 1
DAVIE COUNTY NC 6/12/2014 10:01:22 AM
ICH DIANA L Return/Appeal Notes: Parcel:ES-020-AO-001
RNWALLIS DR PLAT:0006/089 UNIQ ID 6331
5483000 ID NO:5841060684 Own(
COUNTY TAX(100),FRE TAX(100) CARD NO.1 of 1
eval Year:2013 Tax Year:2014 LOT 1 PUDDING RIDGE 1.000 IT SRC=InspeCbn
ralsed by 02 on 06/2 2007 06103 PUDDING RIDGE TW-03 Cl- FR-08 EX- AT- LAST ACTION 20130404
ONSTRUCFION DETAIL MARKET VALUE DEPRECIATION CORRELATION OFVALUE
OTAL POINT VALUE Eff. BASE
BUILDING USE MOD Area UAL RATE RCN EYB AYB REDENCE TO
ADJUSTMENTS 97 00 %GOOD EPR.BUILDING VALUE-CARD
TOTAL ADJUSTMENT TYPE:Vacant EPR.OB/XF VALLE-CARD
ACTOR 4ARKET LAND VALUE-CARD 57,00
TOTAL QUALITY INDEX STYLE: OTAL MARKET VALUE-CARD 57,00(
0TAL APPRAISED VALUE-CARD 57,00
WALL APPRAISED VALUE-PARCEL 5700
WALL PRESENT USE VALUE-PARCEL
OTAL VALUE DEFERRED-PARCEL
OTAL TAXABLE VALUE-PARCEL 57,00(
PRIOR
WILDING VALUE
BXF VALUE
AND VALUE 54,00
RESENT USEVALUE
EFERRED VALUE
TAL VALUE 54,00
PERMIT
CODE I DATE I NOTE I NUMBER AMOUNT
OUT:WTRSHD:
SALES DATA
FF.
ECORD ATE DEED INDICATE SALES
OOK AGE R TYPE / PRICE
0185 708 12 11991 WD U vi C
HEATEDAREA
NOTES
/S COLDWELL BANKER 2006
0,000
SUBAREA UNIT ORIG% SIZEANN DEP % OB/XF DEPR
GS RPL D VAL ESCRIPTIO T NIT PRICE COND LDG FACT Y RATE V COND VALUE
TYPE AREA CS OTAL OB XF VALUE
REPLACE
SUBAREA
TOTALS I I Tl
UILDING DIMENSIONS
NO INFORMATION
IGHEST THERADJUSTMENTS LAND TOTAL
D BEST USE LOCAL FROM DEPTH/ LND COND D NOTES OA UNIT LAND UNT TOTAL ADJUSTED LAND OVERRIDE LAND
SE CODE ZONING TAGE DEPT SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADIST UNIT PRICE VALUE VALUE NOTES
FR GOLF 0123 0 0 1.0000 0 1.0000 PW 57,000.0 1.00 LT 1.00 57,000.0 5700
-TAL MARKET LAM DATA 57 00
OTAL PRESENT USE DATA
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=E502OA0001 6/12/2014
"fof"Uti 118:38 FAX 336 499 3939
THOMAS LINKOUS PSS Q001
v- `, .2u2 24 06 61:15p' davie ! vhealth 336 751 8786p.2 P(4'. eq o%,
ATION FOR SI VA ON/IMPROVEMENT PERMIT&ATC r
�UL2 $D ou alth Department 1-j
Enviro enta ealth Section
gni Hospital Street j inc F�1ViRONMEN1A�t1FA�T ocicsvilte C 270:8 * pl,e.�st Ir1('.U,l(J�.
'� .a �Q• I1pVlECOU' Fax(336)751-8786 ! /�R
Application F c yviauationflan-rovemcal Permit 0 Authorize tion To Construct(ATC) a Both wP4 I
" •••IMPORTANT'•'1111S APPLICI.TION CAKNOT BE PROCESSED I.NLESS ALL OF TIIE REQUIRED
b, INFORMATION IS PROVIDED.R..ttr to the INFORMATION BULLS:IN for insauctions.
(� l
AprLiCANf INFORMA'T'ION r S
Name to be Billed I f Ctntact Person t _
Billing Address Form Phone
01 -5 NBttsin1es}Phone
' Namc on PctmiVATC if Differ (1 to n Uf�pptv�e iW�f e►'— I Ws+ V `G
Mailing Atidtess't�LIM �vlL( City/State/Zip G
PROPERTY INFORMATION
NOTE: A survey jitat,.or Sita plau trust accompany this application.
(Petttut is valid for 60 reit:pwi;t,h�,site putt.rto expiration wt complete?1 t.) n
Street Address�. e_ CityQLTaa PING SS t!b p bS N_
Subdivision Nam_�c#� � SeetioNLot#,�_Lot Size
Directions o Site:
Date HouselFa )ity Comers F)ng;ed —
ifthe answer to any of the fullowins,rpatiotts is-Yee.supporting docuwrntxtion must be attached.
Are slum any existing wasttvatet systems on the site? Cl-is*o
Does the site contain jtuisdi4ional wetlands? t;'.'es UNo
Are there any easements or z4h"f-ways on tht 00 G'lea WOO
Is the site sdUject to approval by another public agency! G'its UNo I� t r l
Will wastewater other than c mucstic sewage be Retterated•1 d"its SAO vV
`
IF RESIDENCE 17-11.1,OUT TitE BOX BELOW
p People #Bei,roonu a9 Baths s Garden Tub/Whirlpool cs ❑No �tit
Bastxttertt:t4'Ycs 11No Ba:emcntPluriibing: Wes 0No
EF NON-RESIDENCE RU.OUT THE BOX BHLi1W
Type of FacilityBoainess _ Total Square Fo:rtage of Building_ #People -{-�� l
N Sinks _ #Cotama&i #Showets #Urinal, `
Estimated Water usage(gallons•ter day) (Attach dr rcumemation of similar facility water consumption)
FOODSERVICE ONLY: #Seat-
_ Type systemrtrqucsttd: ventitrral OAcccpted 0lrnwvativo OA.1crnetive i]Othsr (�CO(Yj( /
us--
Water Supply Type:AyC'.off unrXity'Rater 0 New Well 131:xisting Wctl 7 Community Well l I
Do yaa anticipate additions or txpansima of the facility this system is int:nded to serve?0 Yes 1YNo
If yes,what type? _ _ w t '/ Id f
` l LJ
This it to certify rhat the information provided on this application is nue end garr=et to the best of my knowledge I vttdetstand that n ky+ J
any permit(s)or ATC(s)issued hem0ter are subject to suspension or rev vadon if the aite Is altered,the intended we changes,or if
the iafartitation submitted in this application is falsified or cbsnged. 1 understand that lam n•rponsible for all charges incurred L( 5 h
frvm ritir applitsrrian. I hereby grata right of entry to the Autboriud Reltresentative of the Davie County Health Department to
conduct necessity inspections to dcarmine cotnpli tree with applicable!iws and rules on the above described praperty located in
Davie County attd owned by
S;ze iS� 6i�Sk
Site Revisit(large
Date(s): a)\
roptxty owncrts r ovrttet's legrl rspres atative signature
q'rcat Notification Date: ��e- L\j C ,
ENS: 7
Sign given GYes Clio Account M
Revised 2ro6 Invoice 0
�.Z�-U(o
„07/28/2006 08:40 FAX 336 499 3939 THOMAS LINROUS PSS U004
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. ' DAVIE COUNTY HEALTH DEPARTMENT Zerl l
Environmental Health Section
Soil/Site Evaluation
NAME �/D�C� DATE EVALUATED
ADDRESS PROPERTY SIZE /i4('
PROPOSED FACIILTY �"l's Z LOCATION OF SITE zz&_✓2
Water Supply: On-Site Well ✓ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L
Sloe % �/ L
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH g t
Texture group
Consistence
Structure K
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 RATES ,3
SITE CLASSIFICATION: EVALUATED BY: /7�E
LONG-TERM ACCEPTANCE RATE: OT ER(S) PRESENT:
REMARKS: /� o JJ
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 watet 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(01-901
DAVIE COUNTY HEALTH DEPARTMENT
Y Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004052 Tax PIN/EH#: 5841-06-0684
Billed To: Thomas Linkous Subdivision Info: Pudding Ridge Lot# 1
Reference Name: Location/Address: Pudding Ridge W&78
Proposed Facility: Residence Property Size: 1 acre Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓/Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% 6
HORIZON I DEPTH
Texture groupC
Consistence
Structure
Mineralogy ,
HORIZON II DEPTH
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: �� EVALUATION BY: ' l
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT.
REMARKS: ""G - 1
EGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope I 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 I SIL-Silty loam. CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE '
maw
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
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
LYQteS -
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 05105(Revised)
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Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
'Mocksville,NC 27028
(336)751-8760/Fax(33,6)751=8786
Improvement Permit
August 2,2006
Mr.Thomas Linkous
2408 Tukwila Court
Clemmons,NC 27012
Re: Pudding Ridge,Lot 1
Tax PIN#5841060684
Dear Ms. Linkous,
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 or the intended use change.
System To Serve: Wastewater Design Flow(GPD): Valid: 95 Years ❑No Expiration
System Type: ❑Conventional 21Cccepted ❑Innovative ❑Alternative ❑Other
Site Modifications/Permit Conditions: /0,1!1 ,17,r spa --Id ��«�, J —/r/,
267✓71 Y 9 ld' s stated in
eptp-
15A NCAC 18A (5
sles
site Plan 11111Yalso be used
Environmental Health Specialist Date
i.p.letter 7/06
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07/28/2006 08:39 FAX 336 499 3939 THOMAS LINKOUS PSS 1A 002
GIS Dam Ptint Page Page 1 of 2
Davie County Online GIS Print Page
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*****WARNING*THIS 1S NOT A SURVEY!***** Date:7/25/2006 ec t
This map is prepared for the inventory of real property ate` E 002OA0001
found within this jurisdiction,and is compiled from Number
recorded deeds,plats,and other public records and IN Number 10606U
data.Users of this map are hereby notified that the ur ,f 75483000
aforementioned public primary information sources ICK DIANA L
should be consulted for verification of the information ^er il1
contained on this map.The County assumes no legal Listed
responsibility for the information contained on this er•2
map. ddress 1 604 JANET PLACE
ailing
ess 2
DIEGO
tate
i Code 2115
Lega{
on OT 1 PUDDING R{DG
escripti
a 1.001
Date 19960227
ed Book 1850708
nd Pa e
bt Book
Ist Pae 89
Btalding
slue
adding
Extra
eatures
atue
nd Yalue 48000
otal Marko 8000
http://traps.co.davie.nc.us/websitelmapviewer/parcclprint.htm 7/25/2006