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289 Cornwallis Drive Lot 25 ' or ice Use Only OPERATION PERMIT Davie County Health Department *CDP File Number 157640- 1 210 Hospital Street E5-020-A00-25 ' P.O. Box 848 County ID Number: .meq Mocksville NC 27028 Evaluated For: NEW Phone: 336-753-6780 Fax: 336-753-1680 Township: Applicant: Robert E. Martin Property Owner: Robert E. Martin Address: 226 Townpark Drive Address: 226 Townpark Drive City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (704) 301-2770 Phone#: (704) 301-2770 Property Location & Site Information Address/Road#: Subdivision: Pudding Ridge Phase: Lot: 28 289 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Farmington Rd, left on Pudding #of Bedrooms: 5 Ridge Rd. Left on Cornwallis, on left #of People: *Water Supply: PUBLIC *IP Issued by: 2140-Nations,Robert *System Classification/Description: *CA issued by: 2140-Nations,Robert Saprolite System? O Yes (9 No Design Flow: 6 0 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Re uired? Q Yes XNo Soil Application Rate: 0 a 7 5 *Pre-Treatment: Drain field r cation Field a .2 0 6 Sq.ft. *System Type: 25%REDUCTION INNOVATIVE OR rain Lines 5 Installer: Aquadriu Trench Length: 5 6 0 ft. Certification#: 2ss4 Trench S acin OInches O.C. p g' — 9 Q Feet O.C. EHS: 2399-Steelman,Tiffany Trench Width: 3 OInches _ Q Feet Date: 0 8 / 0 7 / .2 0 1 5 Aggregate Depth: 1 a inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Approval Status Maximum Trench Depth: 3 6 Inches ® Approved n Disapproved Maximum Soil Cover: 4 Inches Page 1 of 4 CDP File Number 157640 - 1 Septic Tank County ID Number E5-020-Aoo-25 ' Manufacturer: Shoaf Lat. STB: 964 Long: Gallons: 1500 Installer: Aquadrill Date: 0 a / 1 7 / a 0 1 5 Certification#: 2494 *EHS: 2399-Steelman,Tiffany *Filter Brand: ST Marker: El Yes El NO Date: 0 8 / 0 a 0 1 5 / ............... Reinforced Tank: ❑ Yes ❑ NO Approval Status 1 Piece Tank: ❑ Yes ❑ No ® Approved ❑ Disapproved Pump Tank Manufacturer: Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ NO (Min. 6 in.) Approval'Status` Reinforced Tank: ❑ Yes ❑ NO ❑ Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ NO Supply Line Pipe Size: 3 inch diameter Installer: Aquadrill Pipe Length: 6 feet Certification#: 2694 *Schedule: 40 *EHS: 2399-Steelman,Tiffany Pressure Rated ❑ Yes ® NO Date: 0 8 / 0 7 / a 0 1 5 Approved fittings X❑ Yes ❑ No Approval Status'' ® Approved ❑ Disapproved Pump Requirement Pump Type: Installer: Dosing Volume: - Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No Page 2 of 4 CDP,File Number 167640 -' 1 County ID Number: E5-020-a,0o-25 Electric E ui ment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: Alarm Audible 0— YeS —E] NO Approval Status ❑ Approved❑` Disapproved Alarm Visible El Yes El No 2399-Steelman,Tiffany 'Operation Permit completed by: ale� Authorized State Agent: Date of Issue:. 0 8 / 0 7 / 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 sewage septic system. Rule .1961 requires that a Type iz ,(�[ septic system meet the following criteria: Minimum System Review By The Local Health Department: Management Entity: Minimum System Inspection/Maintenance Frequency By Certified Operator: Reporting Frequency By Certified Operator: 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 mainta p 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. ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 OPERATION PERMIT 157640 - 1' Davie County Health Department CDP File Number: 210 Hospital Street County File Number: E5-020-A00-25 P.O.Box 848 Mocksville NC 27028 Date: 0 8 /,10 .101 5 0 Inch Drawing Drawing Type: Operation Permit Scale: 0 Block 0 N/A . ................... ................ . .......... .......... .............-J.............................................. .......... ......................... .................. .......... ................ ........... ........................................ .... ...... ....................... ................ ............. ............ .................. ............ .......... .................... .............................. ............................................................... ........................... .............— ........................ ................... 1 1)0 ........................ .................... CY 4f Q, ............. ............ .......... . ...................... ............... .......... ............. .......................... ......................... Gay ................... . ........ ...................... ...................... � �oUse _I ! j D I r o o .......... .................... ------------- _V E'bo ....................... 0 ............ ............... Page 4 of 4 Pi P2 P3 CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 157640- 1 Davie County Health Department County ID Number: E5-020-Ao0-25 210 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 1 / a 9 / a 0 a 0 Applicant: Morgan & Parker Builder Property Owner: Chris &-Romy Gaskin Address: P...0. Box 770 Address: 153 Cornwallis Drive City: Clemmons City: Mocksville State/Zip: NC 27012 State/Zip: NC 27028 Phone#: 336-399-5602 Phone#: 336-399-5602 Property Location & Site Information Address/Road#: Subdivision: Pudding Ridge Phase: Lot: 28 289 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Farmington Rd, left on Pudding Ridge Rd. Left on Cornwallis, on left #of Bedrooms: 5 #of People: *Water Supply: PUBLIC System Specifications - - - - - - Minimum Trench-Depth:- Site ept :- - - - - - - - - - --- - (Design assification: Provisionally Suitable a 4 Inches te System? OYes (9 No Minimum Soil Cover: 1 a Inches Flow: 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank: 1 a 5 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field a a 0 6 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece: OYes ONo Total Trench Length: 5 5 1 ft, GPM--vs- ft. TDH Trench Spacing: O Inches O.C. - 9 (9 Feet 0.C. Dosing Volume: _ Gallons Trench Width: 3 Olnches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 O TS-II Septic Tank Installer Grade Level Required: 01 011 0111 01V Page 1 of 3 • CONSTRUCTION AUTHORIZATION 157640 - 1 Davie County Health Department CDP File Number: 210 Hospital Street County File Number: E5-020-Aoo-25 P.O.Box 848 Mocksville NC 27028 Date: 01 / a9 / .1015 O Inch Drawing Drawing Type: Construction Authorization Scale: , O Block Q N/A �Lkj - - - - - - - - --- _ - ..... --- - - - _ __ _ ............ _ { I C V� - -- - �.- - - - -- ------ ----- --------------- --------------- ----- 6. --- - -! _�_ -- - - �-- - - -- �- N � J . .. Page 3 of 3 P1 P2 CONSTRUCTION For Office Use Only AUTHORIZATION *CDP File Number 157640- 1 Davie County Health Department County ID Number: E5-020-Aoo-25 _ 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 1 / a 9 / a 0 a 0 Applicant: Mor AN + P4 I(aL Bu I&r Property Owner: C h�IS I ibmi 6�0 Address: ?,© ,9-1-70 Address: IT3 &P-M W,4110 DPL- City: am Rxa� City: N1050 i I l ei State/Zip: NC 2„7 Z State/Zip: NC Phone#: 3cg ( �—��(p(,� Phone Property Location & Site Information Address/Road#: Subdivision: Pudding Ridge Phase: Lot: 28 289 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Farmington Rd, left on Pudding Ridge Rd. Left on Cornwallis, on left #of Bedrooms: 5 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign ssification: Provisionally suitable Inches Minimum Soil Cover: 1 a Inches System? O Yes ()No low: 6 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank: 1 a 5 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field a a 0 6 Sq.ft. Pump Tank: Gallons No. Drain Lines 4 1-Piece: OYes ONo Total Trench Length: 5 5 1 ft. GPM--vs-- ft. TDH Trench Spacing: _ 9 ®O Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 CDP File Number 157640 - 1 County ID Number: E5-020-Ao0-25 ❑ Open Pump System Sheet Repair System Required:0 Yes O No O No, but has Available Space rDesignFlow: System Trench Spacing: 9 0 Inches O.C. ification: Ps Shallow Placement — ®Feet O.C. Trench Width: D Inches 6 0 0 _ 3 Feet Soil Application Rate: 0 a 7 5 Aggregate Depth: inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover: 1 Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Nitrification Field a a 0 6 Sq.ft. Maximum Soil Cover: ) 4 Inches No. Drain Lines 5 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Total Trench Length: 5 5 1 ft. Pump Required: OYes ®No 0 May Be Required Pre-Treatment: O NSF OTS-1 OTS-11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema�m 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. Rema��y 2000 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 130A-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 permit 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 (1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature? Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 1 a 9 a 0 1 5 Authorized State Agent: Malfunction Log OYes 0 Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 157640 - 1 Davie County Health Department CDP File Number: 210 Hospital Street E5-020-A00-25 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 01 / a9 / ,) 0 1 5 O Inch Drawing Drawing Type: Construction Authorization Scale: . O Block � _ _ ! .......... O N/A - ..._ - - ' --J --A I (Q V .... _.�............... .... -- _..... �.... -- ........ - ...... ... _ _ . _ I iQK I -- f ... ..- ...i 7 P1 1 _iIL a ; i __ b_a _ VALL __..h ---- -- _I -J- ..................... ........ j 'i _ 1 I I i i Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION . Davie County Health Department 210 Hospital Street CDP File Number: 157640 - 1 P.O.Box 848 E5-020-A00-25 Mocksville NC 27028 County File Number: Date: A1./ —,29 / a0 15 Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 P1 P2 fte APPLICATION FOR SITE EVALUATIONANTROVEMENT PERMIT C ZOWD 'P.41P Davie County Environmental Health xMocksville,NC 27028(336)753-6780/Fax:(323 753-1680 ' Type of &Nmv System oRenairmExisting System OExpansiontModification of Existing System mFacility LW20RTAN7***1111S APPLICATION CANNOTBEPROCE=D UNLESS ALL OF THE REQUIRED � INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instnictions. APPLICANT INFORMATION Name to be Billed Bogr 4)VPRKF& tq!�O�Mdp,,,on BiUh=:Ss 1 .0. BOX-1�10 Home Phone 5L OIL 115 Name on Permit/ATC if Different than Above CHRMS, 1 ROMI G F&K-ZO-t PROPERTY INFORMATION *Date House/Facility,Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included:tr9itc Plan DPlat(to scale) (Permit is va4d for 60 months ith s ite )Ian,no expiration with complete plat.) If the answer 11b any of the following questions is"yes7',s4porting documentation must be attache(L Are there any existing wastewater systems on the site? 0yes 046 Does the site containjurisdictional wetlands? Dyes Am" Are there any easements or right-of-ways on the site? Ely.ate-7 Is the site subject to approval by anottirr public agency7 Dyes Will wastcwatcrother than domestic sewage he gencrated? Dyes i�o`� IF RESIDENCE FILL OUT THE BOX BELOW #People 11" #Bedrooms A4, #Bathrooms BasemenlT�DYcs %W- Basement Plumbing. DYes MC — o Garden Tub/Whirlpool 0�fto IF NON-RESIDENCE FELL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building_� #People Estimated Water Usage(gallons per day)---------Y(Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: mm�"utimnal o^..»td ouumv.U" o/uurn^uv. o Water Supply Type: /City water oNew Well osm,fingnau ocomummmwell Do you anticipate additions to"erve? Yes 0 NO _ Ility this system is If yes,what type? of the fa PL�AV gloom This is to certify that the information provided on Us application is true and correct to the best of my knowledge. I understand! that any permit(s)or ATC(s)issued hereafter am subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this application is fiiIsified 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 house/Wility location,proposed well location and the location of any other amenities. Site Revisit Charge Property owneef or "s le signature Client Notification Date: Date EHS: Sign given Dyes ONo Account# Revised 11/06 Invoice N Lor Pa=W. Rra6E Vwrd O PiMb PA CE 0 Q U � ; r 80" a (100' j ui Ql 4 N CoRNWA«zS �(Z• ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION I PROPERTY INFORMATION I G i Moe, '356? qq9-T115 X64 95 3 , 1 , 033A o-, 1 , Water Supply: On- ite Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS f 1 2 3 Off 5 6 7 Landscape position J Slope % HORIZON I DEPTH I Texture group Consistence i Structure Mineralogy HORIZON H DEPTH I Texture group ! Consistence r Structure Mineralogy f t HORIZON III DEPTH ' Texture group Consistence Structure I I Mineralogy ! HORIZON IV DEPTH Texture groupf Consistence ! i Structure l l Mineralogy SOIL WETNESS I C RESTRICTIVE HORIZON SAPROLITE I CLASSIFICATION I LONG-TERM ACCEPTANCE RATE 1 SITE CLASSIFICATION: I EVALUATI N BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: LEGEND } Landscapg 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 SII;,-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay I f CONSISTRN 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 Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky L-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsui�table). 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) Tco --nn r ..__ •_ -----"---�-`- -- �---icn - IMPROVEMENT PERMIT For Office use only *CDP File Number 157640- 1 r Davie County Health Department County ID Number. E5-020-Aoo-25 210 Hospital Street P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 9/19/2019 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Robert E. Martin Property Owner: Robert E. Martin Address: 226 Townpark Drive Address: 226 Townpark Drive City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 �._Phon�e#. �(704)�301770Phone#: (704)�301770 Property Location & Site Information Address/Road#: Subdivision: Pudding Ridge Phase: Lot: 28 289 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Farmington Rd, left on Pudding #of Bedrooms: 5 Ridge Rd. Left on Cornwallis, on left #of People: *Water Supply: PUBLIC System Specifications Initial S stem *Site aSSI Ica IOn: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? O Yes (9 No Maximum Trench Depth: 3 6 Inches Design Flow: 6 0 0 Septic Tank: 1 a 5 0 Gallons Soil Application Rate: 0 a 7 5 1-Piece: O Yes ®No Pump Required: OYes 0 No O May Be Required *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes O No Repair System Required:®Yes ONO ONO, but has Available Space Repair System *Site Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes ®No O May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 • CDP File Number 157640 - 1 County ID Number: E5-020-A00-25 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Reaa�m'g 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. R.mair�9 750 The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to Site Plan scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the (9 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 site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision 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 Department and Local Health Department 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 permit is subject to revocation if the site plan,plat,or intended use changes(NCGS 130A-335(o).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(.1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature: Date: "Issued By, 2140-Nations,Robert Date of Issue: 0 9 / 1 9 / a 0 1 4 OValid without Expiration? Authorized State Agent:q��l�'�s ���� O Create CA? ®Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 157640 - 1 Davie County Health Department CDP File Number: 210 Hospital Street E5-020-A00-25 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Improvement Permit Scale: , O Block O N/A ft. - — - - ...� .......I f i I _. --- --- . ---- ------. — ------- --- --- i ......... 1 I I � . --- - ....... - __ _ .. ......-- I � � I .....� �s I i --- - -- - -- _. .... - ! - _ , ............. .................... — . -.. f __ __.... _ --T .. __..........................____ -- ..... ' f i j _ _ . I - d- _ -- -- ---_- - ------- CPO co ir .... - _ _ - - .. Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 157640 - 1 P.O.Box 848 E5-020-A00-25 Mocksville NC 27028 County File Number: Date: .0.9./.1.9. /..10 14 Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 IMPROVEMENT PERMITFor Office Use Only *CDP File Number 157640-1 Davie County Health Department r d 210 Hospital Street County ID Number: E5-020-A00-25 P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 9/19/2019 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Robert E. Martin Property Owner: Robert E. Martin Address: 226 Townpark Drive Address: 226 Townpark Drive City: Advance City: Advance State/Zip: NC 27006 State/Zip: NC 27006 Phone#: (704)301-2770 Phone#: (704)301-2770 Property Location & Site Information Address/Road#: Subdivision: Pudding Ridge Phase: Lot: 28 289 Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158 East left on Farmington Rd, left on Pudding #of Bedrooms: 5 Ridge Rd. Left on Cornwallis, on left #of People: *Water Supply: PUBLIC System Specifications Initial System *Slte asSl ICa lOn: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? O Yes 9 No Maximum Trench Depth: 3 6 Inches Design Flow: 6 0 0 Septic Tank: 1 a 5 0 Gallons Soil Application Rate: 0 a 7 5 1-Piece: O Yes ®No `J Pump Required: OYes ®No O May Be Required *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ONO Repair System Required:®Yes O No ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes ®No O May be Required TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 157640 1 E5-020-Aoo-25 - CDP File Number County ID Number: *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema 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. Remaining 750 Site Plan The Improvement Permit 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 surveyor,drawn to a scale of one Inch equals no more than 60 feet,that Includes:the specific location of the proposed facility O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat also means,for subdivision 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 Department and Local Health Department 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 permit is subject to revocation If the site plan,plat,or intended use changes(NCGS 130A-335(f)).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(.1938(b)). Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 9 1 9 x 0 1 4 OValid without Expiration? Authorized State Agent-Q,_ O Create CA? ®Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 157640 - 1 Davie County Health Department CDP File Number: 210 Hospital Street E5-020-A00-25 P.O.Box 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Improvement Permit Scale: O Block O N/A ft. d � 716. Of I ... [0 oo of ill Page 3 of 3 P1 P2 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 157640 - 1 P.O.Box 848 E5-020-A00-25 Mocksville NC 27028 County File Number: Date: -0.9./ 1.9. /..2 0 1.4. Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 fig/2,8 is[114 *i13:l 3._, 74. .?E,oFt 1'n_EH r t;aF Vis" VP ' APPLICAT EVALUATIONAMPROVENIENT PERF' &. ,ATC 9�eDv%e bounty Environmental Hca)kb P.O. Box 848/210 Hospitni Street i Mocksville,NC 27028 (336)753-6780/rax(336)753-1680 Application For ,/ilc I?vahratinn/improvement Permit ^ AUth0ri7ation, To Construct(ATC.) C Loth Tyre of Applicatinn' 1JNe« Syst m E'Repair to F..xisting Syst'cm nFxpansionwodificat.ion of F.,;,Nisti.ng Systcrn or ricility **AfP0R.r,1Nr1-** THIS APPLICATION C,4NNOTBE PROCESSED UNLESS ALL OF TBP VUQUIUD i iN1 FOn4ATinN IS PROVIDED. Refer to the INTFORMATION, BU.LLF:TTN for imt actions. -J i APPLICANT TNTORAVIATI )N N1.11llc _ _ Robert E; Martin— Contact Person _ Address 226 Townpark Drive Hdmc Phorw 704/301 .2770 t.-ity/Stnici7i1' Advance INC 27006 -Btisrnc'ss Phone 'Namc on PertniVn..TC ifDOZr•of than Above -.- M.ailittg A(ldre.sN City!Statei71p ------_-_ PRO PR.TY INi:ORMATJON _ _ _*Date HouserFrtciiitti' Corners k'l<7*cd __— NOTE': A 5r!rvev plit or site pinA must acco3nlTnny thi s application included: ^ Sit (Pohl it i^- a';id for 60 mo'nths with site nim;,no expiration with complete•p?at.) Owner's Nasi Robert !E Martin —I'honc Numlicr—_ ��j O�.; 226 Townpark Drive Cit lSts'eu ce_NCg� Owner's s A.� � Proper!.v A(. resti Cornwa . .lia Drive — t'ityMocksville ----.._.__..._.. I..,ot Si7� Acre+ - i Sathdiv ision Namr,(if applicabl ) c ----Section/L,t -6 Directions To �it.r: _ d Sltccify i'rohl�em C'c:ccrring' � con I,,MI/M /Il S i 1 - Jc�b� � IP RESIDENCE 1,11-1- Oi T THE BOX I3EL OW if Pcor{e -- 91 Redrnoms S _ 11 Bathrooms _.-5Garden T'ul�,Vbirlpool -Ye s No i 17semen+• ' Yes '.!No 13a^crnent Plumbing- ^Yes 7-iNo IF NON-RESID 17.NCE TILL OUT THE BOX BELOW Tyreoi'T'aoility/l3usir,e s j_ _ �_Totsl Squaxc l oolagc ofl3atilding _�. r1 People____ - Sinks i _ r; Cbrnrrro�ic-s _ # Showers _ Urinals t stimated Water Usno l!;alioni Tier day)—_ (llttaelt dottnnent:ttic�n oCstmiia?'Iarility watC Ccsllsiltnpt.,on) 1 1.170013SERVICEON'T,V: i' Seat: Type s���tr n,reqncst:.ct iC'oir.7r_njiontl rL!cccepted 'Tnnovative -Alternative fitlter Water Supply Tvpe: ,.:?. tmty/Cit, Water '_I New W(.-,IlnF..xistirg Wcll ri Commurnt-v WCI1 Do you wi icipate additinns or exnp n-ions of the fncility this system is intendcd to Scrvc? C' Yes '7 1\70 This is to certify that the infnrmati n provided on this application is truc and correct to tltc best rfm),knowledge, t understand that any pertrih(s)or ATC(s)issued hereafter are suhjcct to Suspension nr revocation if the site is altered,tate intended trse changes,or irthe information subtpitted in this applic::rtion is falsified or changed, t herd>y Zra.it right of entry to the A.utiterircd ', Rcprescntativc ra}�thc Uavic C'.atlnty I-Ie 'th be rtre,crai to conduct necessary iraspeetions to deteeminc compliance with a:pplicabJc laws and rules. I u . e and hal 'a. s c for the proper idertirication and labeling of property lines and corners and locrting:incl fla i s t u ility location,proposed well location and the)oration of any other amenities. �- Sitc.Revisit Charge Property rnv iCr g legai'rcrreSentat.ive i -I bale's j -P O/1—e ,Client Notif.ic.ntlon Datc: i ate r 'i 115 Sign givrn . IYc° N,n j ,lccoutlt 14 - Rrvised 11;0(, fl i i i i i � I t f i i 12G1 ; l 1 1 .` r • 1 t�J an ` ', 46 37 IV N .L •r'n I f 3M, 1 ' .bmt? ;`k 0. r � rT� i i ( col, N� Printe :Aug 28, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied i I warranties of merchantability or fitness for a particular use. All users of Davie County's 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 t6 or arising out of the use or inability to use the.GIS data provided by this website. r ! DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section; E Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION I kbo(4 Al d(ib.d fru u,ollfs1��. 4 X10 M -PM0 ! Water Supply: On-Site Well Community Public i Evaluation By: Augbr Boring_ •i Pit I Cut FACTORS i 1 2 3 4 5 6 7 Landscape position Slope % a HORIZON I DEPTH .— W Texture group ! G L Consistence ! / Structure ! MineralogyI HORIZON H DEPTH Texture group L Consistence Structure ! G Mineralogyj HORIZON III DEPTH ! j Texture group Consistence i j Structure I Mineralogyr HORIZON IV DEPTH Texture group Consistence } Structure I Mineralogy SOIL WETNESS i RESTRICTIVE HORIZON ! SAPROLITE CLASSIFICATION ' LONG-TERM ACCEPTANCE RATE •Z"T SITE CLASSIFICATION: EVALUATION BY: Jja Y�'d n LONG-TERM ACCEPTANCERATE: 7 OTHER(S)PRESENT: 7\elr1v � t REMARKS: r. LEGEND Lnndscape Position R-Ridge S-Shoulder ! L-Linear slope FS-Foot slope N-Nose slope j CC-Concave slope CV- onvex slope T-Terrace FP-Flood plain H-Head slope TexturC 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 I SC-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 Structure ! SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky �! SBK-Subangular blocky !PL-Platy PR-Prismatic � IjI Mineralogy f 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) j 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 TA n i ...-... a- -----.--- •- --1/J___iC.n '^ .. t _ � J DAVIE'COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / NAME (x/11 DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 2 3 4 Landscape position Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f G r Texture group Consistence i Structure ,v.6e 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: EVALUATED BY: LONG-TERM ACCEPTANCE R TE: OTHER(S) PRESENT: REMARKS: e'ia? �a l O 'J9�a IV 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 .3C-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(01-901