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362 Cornwallis Drive Lot 12 HEALTH DEPARTMENT RELEASE For Office Use Only *CDP File Number 192847-1 Davie County Health Department H 210 Hospital Street County ID Number: ' P.O. Box 848 HDRMWC - , Evaluated For. Mocksville NC 27028 —_ ) Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 4 / 1 3 / a 0 a 0 UNTIL: Applicant: Fred and Julie Smith Property Owner: Fred and Julie Smith Address: 362 Cornwallis Drive Address: 362 Cornwallis Drive City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)403-1660 Phone#: (336)403-1660 Property Location&Site Information Address362 Cornwallis Drive Subdivision: Pudding Ridge Phase: Lot: 12 Road# Mocksville NC 27028 SINGLE FAMILY Township: *Structure: Directions #of Bedrooms: 4 #of People: hwy 158,left on Farmington,Left on Pudding Ridge on the left *Water Supply: PUBLIC Basement: F�Yes❑No Type of Business: Total sq.Footage: No.Of Employees: *Proposed Improvement: Pool charad— *Release Conditions Remaining Original CA and OP for the sepric system was designed to accomodate proposed pool and meets the setbacks. 645 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ONO Applicant/Legal Reps.Signature: *Date: *Issued By: 2140-Nations,Robert *Date of Issue: 0 4 / 1 3 / a 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** Hand Drawing O Import Drawing Davie County Health Department 1836 nvironmental Health Section ' ..= , AH C�,+�F' P.O.Box 848 } � 210 Hospital Street I ' ►. 3 Courier#: 09-40-06 1 1 Mocksville,NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: Pc e l 6.1 -T, 'c n^ Phone Number 3 3 6,—`"� 3-l6 4 y (Home) Mailing Address:_ 3LQQ (Work) M o ck-s ��"� Cbl Email Address: cSr� `� 4 C' •/1-e� Detailed Directions To Si1'Tte: /'✓h i n 4 Property Address: j Please Fill In The Following Information About The EXISTING Facility: �UU(J<<��J iL �Q7Name System Installed Under: LC C4f l fY Type Of FacilityC ((� C Date System Installed(Month/Date/Year): ;�)CX�s '7 Number Of Bedrooms:__'�_Number Of People: --Is_The- ility�tlyX=ant?Yec._&_If Yes,For How Long? Any Known Problems? Yes & If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: -: d1 ( dL-A n Of Bedrooms: Number of People Pool Size: Garage Size: Other: Requested By: Date Requested:�� For Environmental Health Office Use Only Approved Disapproved Comments: Enviromnental Health Specialist Date: *The signing bf this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: C.assh-�'Ch Money Order # Amount:$ Date: Paid By: r�2d�✓'v c (s+ SYVI Received By: Account#: ��02��1 Invoice#: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 310 Account #: 990003916 Tax PIN/EH#: 5841-05-7564 Billed To: Bruce Aubrey Subdivision Info: Pudding Ridge Lot# 12 Reference Name: Shannon Conrad Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Pro a Size: see ma ATC Number: 4410 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .^1900 Sewpagge Treatment and Disposal Systems). THIS � 90 AUTHORIZATION FOR WASTEWA ` PYWIV44ID FOR A PERIOD OF FIVE YEARS. Environmental Healt Specialist tore: Date: s/AVoff 25-� rL C OF COMP TION �f **NOTE** The issuan o s i o etio indicate the system describe Improvement/Operation Permit has been ins lled •co 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Sys ems" sh N be taken as a guarantee that the system will function satisfactorily for any given period p1e t� 0 qi 2d 1 P� s ' Iz' "tAA fit, StpTtL I 1-19 Septic System Installed By: Environmental Health Specialist's Signatur /j, ate: DCHD 05/99(Revised) DAVIE COUNTY HEALTH DEPARTMENT ��1�•0` 1 t Environmental Health Section P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003916 Tax PIN/EH#: 5841-05-7564 \ Billed To: Bruce Aubrey Subdivision Info: Pudding Ridge Lot# 12 Reference Name: Shannon Conrad Location/Address: Cornwallis Drive-27028 Proposed Facility: Residence Property Size: see map ATC Number: 4410 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An.AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type buir #People Z, #Bedrooms 7 #Baths `? Dishwasher:/11f Garbage Disposal: Cd Washing Machine Basement w/Plumbing: 9 Basement/No Plumbing: El Specification: Facility Type #People / #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �� Design Wastewater Flow(GPD) YP Site: New u Repair❑ n System Specifications: Tank Size/000 GAL. Pump Tank 1000 GAL. Trench Width4/-� Rock Depth Z' Linear Ft. Other: As stated in 15A NCAC 18A.1969(5) accepted Systems may also be use Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROYED';.EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.**** F Environmental Health Specialist's Signature: ( Date: DCHD 05/99(Revised) APPLICATI SITE.EVALUATIONAMI1ROVEMENT PERMIT&ATC • nn avie County Health Department nvironmental Health,Section .0.BOX 8481210 Hospits.l Street O Mocksville,NC 27028 r�•�QF1 (3 6)751-8760/Fax(336)`51-8786 iicai�04 r.XSite Evalu �� m;xovemen ermit 0 Authorizr:tion To Construct(ATC) 11 Both IMPORT P ON CANNOT BE PROCESSED L NLESS ALL OF THE REQUIRED Refer to the INFORMATION BULLE;TN for instructions. APPLIC FORMATION Name to be Billc8Z, U E Coatact Pt rsZc�—,-c uB Billing Address_ l caDl ull,l� (' f- Pome Phone '7 3Z- C'• ZS City/State/ZIP (&1—t j Nk-N Vc Business Phone -�3• �a5i •�'— ]t5�6 4� Name on Permit/ATC if Different t:uart Above Mailing Address City/S:ate/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan m u it accompany this application (Permit is valid for 60 months with site plan,no expiration with cou iplete plat) Street Address 2t;'e�t-nwu�e.0 Is Dic. City jo_' Sv I Tax PIN#✓rB41Id ,> Subdivision Name Ubb(^X3. l AGI= Section/Lot#/1��Lot Size Z D�►'gctions To Site: 67ici J 6N7'gi. 1$'q0, rina(,Yar1 D j 44V-,-7�09J F-V Ob/^t6• ql)I -60r Date Houset'Facility Corners Flagg:d If the answer to any of the following questions is'yes",supporting documer ration trust be attached. Are them any existing wastewater systems on the site? OY-s fiSNo Does the site contain jurisdicdonal wetlands? OY,;s YNO Are there any easements or right-of-ways on the site? OY.!s ENO Is the site subject to approval by another public agency? OY,:s @No Will wastewater other than do niestic sewage be generated? OY.3 QNo IF RESIDENCE FILL OUT TH G BOX BE W 1#People #Bedmoms #Bathroom, 3 Garden Tub/Whirlpool tomes nNo 13asement:)Wes CNo Basement Plumbing: Wes ONO IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business _ Total Square Foorage 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:Wonventional OAccepted 01nnovative OAIn native 00ther Water Supply Type:*YQounty/City w ater 0 New Well nE>:isring Well 0 Community Well Do you anticipate additions or expans::ans of the facilitythis system is inters Jed to serve?0 Yes ONO If yes,what type? This is to certify that the information lirovided on this application is true an i correct to the best of my knowledge. I understand that any pennit(s)or ATC(s)issued hertmiler are subject to suspension or revoc rtion if the site is altered,the intended use changes,or if the information submitted in this appy ration is falsified or changed I undo stand that lam responsible for all charges incurred from this application. I hereby grant ight of entry to the Authorized Repn sentative of the Davic County Health Department to conduct necessary inspections to determine compliance with applicable lav,s and rules on the above described property located in Davie County and owned by��_• 't- /L►moo Site Revisit Charge 'Property owner's or owner's legal regresentativ signature Date(s):_ k-7t;— Client Notification Date: EHS:_ Sign given t7 Yes ONo Account# twl t7 Revised 2/06 Invoice# Nee rrU box WIWI CIC-4336& Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760/Fax(336) 751-8786 May 17, 2006 Mr. Bruce Aubrey 8 Woodwild Trail Metuchen,NJ 08840 Re: Pudding Ridge, Lot# 13, #12 Tax Pin#: 5841-05-8308 Dear Mr. Aubrey, As requested, a representative from this office visited the above site April 11, 2006,and May 17, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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. Improvement Permit System To Serve: e— Wastewater Design Flow: System Type: ❑Conventional �'Kccept d ❑Innovative ❑Alternative ❑Other System Location: ;Pa 0tZ,/� P Valid: 115 Years ❑No Expiration Site Modifications/Permit Conditions: Enviro ntal Health Special Date ps-i.p.letter 2/06 ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �l©G a DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well L�� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position oe Slope % HORIZON I DEPTH Texture group Consistence Structure MineralogX 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 707; 77 If LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: Z/ EVALUATED BY: LONG-TERM ACCEPTANCE RATE- — OTHER(S) PRESENT: REMARKS: S�� .x/10 �� O 1 .�C�,�a.-✓` LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 May-.10-06 06:46A Shannon Conrad 3367233179 P.03 w Lot /_� • - Preliminary L.0. Setback Requirements: No building shall be located on any Lot nearer to any Lot line than the Davie County zoning or subdivision ordinance will allow: provided. however,without approval of the ACC, even if such Lot line proximity would be permitted by said ordinance, no building shall be located on any Lot nearer to any Lot line as follows. (1)No building(including any eaves, steps and porches attached thereto)shall be located on any Lot, nearer to the front property line than Sixty (60)feet without approval of the ACC. (2)No building (including any eaves. steps and porches attached thereto)shall be located on any Lot, nearer to the side property line than the greater of(aa) Fifteen(15)feet or(bb) 10%of the Lot width at the front line of the building: provided, however, notwithstanding the foregoing,on any corner Lot the sideline setback from the side street shall be twenty-five(25)feet. (3)No building(including any eaves, steps and porches attached thereto)shall be located on any Lot, nearer to the rear property line than Fourty(40)feet. 1 Block 10'x 10' f-40' 240' 20MIN r t 7 ---J-..� •..•1..-J--- --1..- --J---t•--J-__l-_J___L..a---�•__J-__t-.J..•t.•. .__►_.J__.f-.A•..►-- t. 1 ., i i ;1. ; 20 wise 1 � I _ 1 1 1 .�..�. .►__�- -�--�_ MM,i,1.1!�I!I.M�h{ ,� M, .;Y,.!N.:4",.,. 1�. --i-- �_.i._i'-.�.. 1.--i__�_- -- 'r•• �__�.-.r_-1-../... - --�--F--i---r__ 180' 1 1 1 1. t.. 1. / I .' • 1 1 1 179 ...�. •--v---r--•-j........-- POOL ....... --- --1---�--•---�•. .►.- ----------------- --►---..:.----- -- REAR l : : : 1 (HOUSE: 66': _- i -_` FRONT ---+- -`--;--;--; -;--;------ 20x30 ---;-- -—.4----------�-- -�--J --�1 1 :56'wide --F -�- F--aI--F-- ---F--1 1 --F-- ---F-- ----------F-- -F-- ---F-•1---F-- ---F-- deep --: House L ...1 .-'-' ---,-_;'-.;.•;----------;--� '-- ---r--1---.---r-•r•- -r-- ---r-• 1,---r__ to be De -- 1---t--i---F-r---t--�---F--{---t--;---t--i---t--i---�--1- -t--�F80'Estimate-t---t-- 4---E--4---F r ---f--i---F--f---1---4---F--1...F--1---l­--4---F-•4---F--j--- -- ---r-- ---F-- r r r���...J1..f.�r��...`J.�.r r r,�/.��Iw r✓��t•i.r.J...1 _4--F--i--- -A. h--4---�__i--t--i-•h--�-- F--i--E--i- F--�--h-- 1 1 1 ; / 1 1 I / "-h--1---F--1-^t-• 20'MIN 266' House+Stake.Lo12-043006.x1s 5/10/2006 p h �r/` . in- JQI ui R i k N oc `t c- r N;.In 4 � 4 t , ��V/ l�.�.ice.'•„t !; 1 vim% i CD cq s �y t.. 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