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104 Tyler Court Lot 69Davie County. NC ' Tax Parcel Report Tuesday, December 20, 2016 WA"IPili: 'I'tllll lb PIV l- A JUKV1r:Y Parcel Information Parcel Number: F8030A0069 Township: Shady Grove NCPIN Number: 5870631269 Municipality: Account Number: 8306726 Census Tract: 37059-803 Listed Owner 1: HEDBLAD RYAN NICHOLAS Voting Precinct: EAST SHADY GROVE Mailing Address 1: 104 TYLER COURT Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27006 Voluntary Ag. District: No Legal Description: LOT 69 ESSEX FARM PHASE 1 Fire Response District: ADVANCE Assessed Acreage: 0.74 Elementary School Zone: SHADY GROVE Deed Date: 8/2016 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 010260686 Soil Types: Gn62 Plat Book: 0009 Flood Zone: Plat Page: 289 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: EO Ail data is provided as is without warranty or guarantee of any Idnd either expressed or implied Including but not limited tothe Davie County, implied warranties of merchantability or fitness for a particular usa. 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 to NCor arising out of the use or inability to use the GIS data provided by this website. OPERATION PERMIT Davie County Health Department o- 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: RS Parker Homes/Mary Beth . .. -6 Address: 502 Hickory Ridge Dr CRY: Greensboro State2ip: NC 27049 Phone #: (336) 362-8970 (I*,— tor urnce use um *CDP File Number 202238-1 5870631269 County ID Number. Evaluated For: NEW Township: Property owner. RS Parker Homes/Mary Beth Address: 502 Hickory Ridge Dr City: Greensboro State/Zip: NC 27049 Phone #: (336) 362-8970 Address/Road #: Subdivision: Essex Farm Phase: Lot: 69 104 Tyler Ct Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy, 64 East, left on Cornatzer Rd. on the left # of Bedrooms: 4 # of People: *Water Supply: PUBLIC *IP Issued by. 2140 -Nations, Robert *System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140. Nations, Robert Saprolite System? OYes ONo Design Flow: 4 8 0 *Distribution Type: GRAVITY -SERIAL. Pump Required? OYes ONo Soil Application Rate: 0 - a a 5 *Pre Treatment: Drain field Nitrification Field a 1 3 3 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 6 Installer: Frank Transou Total Trench Length: 5 3 4 g• Certification #: 2771 Trench Spacing: — 9 Onches O.C. Feet O.C. EH S: 2140 - Nations, Robert Trench Width: 3 Inches Feet Date: 0 6/ 3 0/.2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 Minimum Soil Cover. a 6 4 Inches Inches Approve{ Status Maximum Trench Depth: 3 6 Inches PW Approved O Mar Maximum Soil Cover 2 4 Inches CDP Fite Number 202238 - 1 Manufacturer. Shoaf STB: 763 Gallons: 1000 County ID Number: 587MI269 Septic Tank Lat. Long: - Installer Frank Transou Date: 04/ 23 /.2 0 1 6 *Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker: ❑ Yes CJ No nforced Tank: ❑ Yes ® No 1 Piece Tank: ❑ Yes 2 No Certification #: 2771 THS: 2140 - Nations, Robert Date: 0 6/ 3 0/ 2 0 1 6 Pump Tank Manufacturer. Installer. PT: Certification #: Gallons: THS: Date: / / Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) Approval Status einforced Tank: ❑Yes ❑ No - ❑Approved ❑Disapproved 1 Piece Tank: ❑ Yes ❑ No _ -� Supply Line Pipe Size: inch diameter Installer. Pie length: feet Certification #: *Schedule: THS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO AppcovalSfatus ❑ ed -O' Disapproved Pump Type: Pump ftguirement Installer: Dosing Volume: - Gal Certification #: Draw Down: Inches THS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve El Yes ElNo App,rove, ,Status PVC unions El Yes ❑ No ❑ Approvetl D Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole El Yes ❑ No CDP File Number 202238 -1 County ID Number: 70631269 Electric Eauinment N EMA 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: Apprdval Status Alarm Audible ©Yes ❑ No> ❑ ADDrove t❑ Disapproved Alarm visible ❑Yes ElNo 2140 - Nations, Robert 'Operation Permit completed by; Authorized State Owner/Applicant Signature: Date of Issue: 0 6/ 3 0/ 2 0 1 6 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 It A. sewage septic system. Rule .1961 requires that a Type TYPE It A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER - Minimum System Inspection/Maintenance FrequencyByCertified Operator. N/A Reporting Frequency By Certified Operator. NIA 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 entitywth 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 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 ownerand certified operator are the same. The contract shall require specific requirements formaintenance 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. OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. BOX 848 Mocksville NC 27028 Drawing. Drawing Type: Operation Permit CDP File Number: 202236- 1 County File Number: 5870631269 Date: ! --- 0 Inch Scale: OBlock ON/A i I -w+..r+... ,.s...u.n. t ..rrrr. .•xr�aw.n -.r...�w.r ....rr�.�.. F—«*+ �y1 .s.+wwvw r� CONSTRUCTION _ For Office Use Only AUTHORIZATION *CDP File Number >202238-1 °'- Davie County Health Department County ID Number. 5870631269 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 4/ 0 7/ a 0 a 1 Applicant: RS Parker Homes/Mary Beth Deal Address: 502 Hickory Ridge Dr CRY: Greensboro StatefZip: NC 27049 Phone #: (336) 362-8970 Address/Road #: 104 Tyler Ct Advance Structure: # of Bedrooms: # of People: *Water Supply: NC 27006 SINGLE FAMILY 4 PUBLIC Property Owner. RS Parker Homes/Mary Beth Deal Address: 502 Hickory Ridge Dr City: Greensboro StateRip: NC 27049 Phone #: (336) 362-8970 Subdivision: Essex Farm Phase: Lot: 69 Directions Hwy 64 East, left on Cornatzer Rd. on the left System Specifications \Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Sa rolite System? Minimum Soil Cover. 1 a p y QYes QNo Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 , a a 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY -SERIAL TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S t; T k' *Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: up �c an . 1 0 0 0 Gallons 1 -Piece: QYes ®No Pump Required: QYes (J)No QMay Be Required a 1 3 3 Sq. ft, Pump Tank: Gallons 5 1 -Piece: QYes QNo 5 3 3 ft. GPM—vs— ft. TDH 9 @Inches O.C. Dosing Volume: Gallons Feet O.C. g — ` 3 @Inches Feet Grease Trap: Gallons inches Pre Treatment: ONSF OTS -1 OTS -11 SepticTank InstallerGrade Level Required: OI 011 0111 OIV Donn 1 ^f *1 CDP File Number 202238 - 1 diounty ID Number. 5870631269 ❑ Open Pump System Sheet Repair system Required:Vres vivo vivo, DULnasHvanaDie Space 'Site Spacing: 9 Inches 0.n: Classification:Provisionally suitable — Feet O.C. Design Flow: 4 8 0 Trench Width: Inches _ 3 Feet Depth: Soil Application Rate:Aggregate 0 a a 5 inches Minimum Trench Depth: a 4 "System Classification/Description: Inches TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover 1 a Inches '`Proposed Maximum Trench Depth: 3 6 System: 25% REDUCTION Inches Maximum Soil Cover: 4 Nitrification Field a 1 3 3 .2 Inches Sq. ft. No. Drain Lines 5 "Distribution Type: GRAVITY -SERIAL Total Trench Length: 5 3 3 Pump Required: (Yes @No tOMay Be Required "I Pre Treatment: ONSF OTS -1 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 bythe 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 AuthoiizaUon for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Penn it, not to exceed five years, and maybe 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 maybe suspended" 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? OYes ONO Applicant/Legal Reps. Signature: Date:. / / ''Issued By: 2140 -Nations, Robert Date of Issue:. 0 4/ 0 7/.2 0 1 6 Authorized State Ag t: Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie,County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 202238 -1 County File Number: 5870631269 Date: 04/07/016 Q Inch Scale: QBlock QN/A X14/ d Wato l ----- ------ ----- -E I F NFF CONSTRUCTION AUTHORIZATION , Davie County Health Department 210 Hospital Street CDP File Number: 202238 -1 P.O. Box 848 5870631269 Mocksville NC 27028 County File Number: Date: 04/ 07 /2016 Click below to import an Image from an external location: Drawing Type: Construction Authorization S lei 0,::i le I d oC) / 4 l( (0 c, 'aG r— /k-o ,e,7 L v P\ C-� T N FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC 3 16 Davie County Environmental Health `L P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 �pp1i .< For Evaluation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both y e of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT Name to be Billed .SSCV6GoOKrN7' Contact Person 72iRRy ,&t TG c;Z Billing Address A.c -d-X 3fo Home Phone City/State/ZIP _ cersu� 4c- Z 7018 Business Phone 7S/ ' 7300 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip FKUYLKi Y I Nt'UltMAHUIN 10ate kiouse/kacility Uorners k1aggea NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan lat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name AT,-. e%, iaG Phone Number 7S/ - 73-0 Owner's Address fo,&X 2 City/State/Zip�6oga.,zca,,r A -Y- 17oLs Property Ad ess City Lot Size . Tax PIN# �7t7� -� / Subdivision Name(if ap licable) Ess.=x Fw rs Sectionn/� �ot# (09 If the answer to any of the following questionslis "yes", supporting documentatiogg must be attsched. Are there any existing wastewater systems on the site? ❑Yes CtNp 2po Does the site contain jurisdictional wetlands? Dyes Are there any easements or right-of-ways on the site? Cies ❑ o Is the site subject to approval by another public agency? Dyes n� Will wastewater other than domestic sewage be generated? Dyes C31tIo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms _!;6 # Bathrooms Garden Tub/Whirlpool'DYes .❑No Basement: Dyes ❑No Basement Plumbing: Dyes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facilitywater consumption) FOODSERVICE ONLY: # Seats Type system requested: 16nventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: BICounty/City Water ❑ New Well ❑Existing Well ❑ Community Well, Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes ❑ No 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 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 an Lagging or staking the house/facility location, proposed well location and the location of any other amenities. Prope r s or o er's legal representa re Site Revisit Charge Date(s): 7 Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # -�� 73 v DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION rROPERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 58 b'4-'ZZ1;5-b Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 69 Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: 0.736 Acre Date Evaluated: R " 1-7 - 7 Water Supply: On -Site Well Community Publicy Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca a position L Slope % ° P-.. a HORIZON I DEPTH G --" d- q — c l Texture group C e C Consistence ) r Q ,T Structure 6 k mil( Mineralogy - g)c e HORIZON H DEPTH ' Q =- c t Texture group; C. Consistence P P) r Structure (� Mineralogy HORIZON III DEPTH Texture group Consistence . Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON l^ SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 5 - SITE SITE CLASSIFICATION: �J� Su-� ltl� EVALUATION BY:�/ LONG-TERM ACCEPTANCE RATE: —C�- 5 OTHER(S) PRESENT: REMARKS:, L Lj-S•-r� QS a IaS �`�i Gf/�c� ✓c7tf ��^ Ca►M��G�}0�-5 LEGEND a� a `� `r� -� � .eau y Landscape Position R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope 'e L A Li 0. 'fid d CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope aq lit Vs yt.�it/(/1 Texture ( I 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 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 Mineral= 1:1, 2:1, Mixed LYoS�s Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS (provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/05 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004425 Tax PIN/EH #: 5870-64-2265.69 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 69 Address: PO Box 340 Location/Address: Cornatzer Rd -27006 City: Mocksville Property Size: 0.689 acre Reference Name: Brad Coe Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans, plat or the intended use change. Permit Type: C7New ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or'Dimensions of Facility) Design Flow(GPD):4116 Type of Water Supply: ounty/City ❑Well ❑CommunityWell Site Modifications/Permit Conditions: los stated in 15A NCAC 18A.1969 5a0eepted systerrrs ay also —I - Site Plan System Type LTAR Initial -eck -L�%it,�► Re air .e t i o r% d • �- t 5.t st-evK �,,,Q ,p a iY � P.-e—Al 4 r4 Environmental Health Specialist Date �S Environmental Health Specialist Date R-20 SETBACKS: FRONT: 45' SIDE: 15' SIDE: 25'(STREET) REAR: 30' TYLER COURT 50' R/W (PUBLIC) 1 0 Lq (c SETBACK J— N83.43' 31 " If CX 126.81' R 1599.37' NEGATIVE ACCESS EASEMENT GRAPHIC SCALE 40 0 20 40 80 ( IN FEET ) 1 inch = 40 it. 101 u ► •► PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 69 OF ESSEX FARMS, PHASE 1 P.B. 9 PC. 289 Flaming 69intainst Inc. 700 Carnegie Place Greensboro, NC 27409 Phone: 336.852.9797 . Fax: 336.852.9766 NCBELS C-0950 DATE. 03-21-16 REVISED DATE: 03-28-16 REF: PR0J\1831-01\dwg\ESSEXFARM.dwg 126.28= — 1— I SETBACK 138.44' I 1 I PROPOSED RESIDENCE �I h1 t I I I� LLI L DW I O L 1 - LSIGN EASEIuPn, 1 0 Lq (c SETBACK J— N83.43' 31 " If CX 126.81' R 1599.37' NEGATIVE ACCESS EASEMENT GRAPHIC SCALE 40 0 20 40 80 ( IN FEET ) 1 inch = 40 it. 101 u ► •► PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 69 OF ESSEX FARMS, PHASE 1 P.B. 9 PC. 289 Flaming 69intainst Inc. 700 Carnegie Place Greensboro, NC 27409 Phone: 336.852.9797 . Fax: 336.852.9766 NCBELS C-0950 DATE. 03-21-16 REVISED DATE: 03-28-16 REF: PR0J\1831-01\dwg\ESSEXFARM.dwg s AhO APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Bos 848/210 Hospital Street Mocksville, NC 27028 n // (336)753-6780/ Fax (336) 753-1680 1 t� , Application For: ,4'Site.Evaltiation/Improvement Permit authorization To Construct(ATC) ct(ATC) G Both Type of Application: kew System Repair to Existing System=Expansiou/Nlodification of Existing System or Facility ***G6IPORTANP** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION N0&4-0 Name to be Billed RS ( Nom-eS _Contact Person f L �� � Billing Address 0 %dC HomePhone',3W—� �C 40�C� City/State/ZIP 7� C Business Phone tj�T--9541—(n[o�Q X14 Name on Permit/ATC if Different than A Mailing Address rrcvrr-mi r uvrvtctvttiltvtN Tuate tiouseitacin Corners flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale) (Permit is slid fo 60 months with site plan, no expiration with complete plat.) Owner's Name 5 Q Phone Number3�P'� Owner's Address l City/State/&C!, po c) &:C ca Property Address City j-V1i VQYVC•e, Lot Size t Tax PIN# 5$ 124a Subdivision Name(if applicable) ' Section/Lot# Directions To Site: r I S n V-1 d r el i'nrncf FIr icz. I- A n If the answer to any of the following eestions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Does the site contain jurisdictional wetlands? ❑Yes o E)Yes Are there any easements or right-of-ways on the site? ❑Yes • o Is the site subject to approval by another public agency? ❑ Yes Will wastewater other than domestic sewage be generated? L, Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms Garden Tub/v,Vhirlpool (,Yes ENo Basement: ❑Yes o Basement Plum ing: ❑YesxNo IF NON -RESIDENCE FILL OUT THE BOX BELOW- Type ELOW 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: Xonventional GAccepted EInnovative ❑Alternative 7 -Other Water Supply Type:XCounty/City Water C New Well _Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? - Yes Ifyes, what type? �No 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 pennit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable latus and riles. I understand that I am responsi a for the proper identification and labeling of property lines and corners and d h c c' i location, proposed well location and the location of any other amenities. P oe ow r owner leg 1 representative signature Site Revisit Charge ' Date(s): Client Notification Date: Dat EHS: Sign given - Yes -No Revised 11/06 . b2-�2 2 2 Account # Invoice 9 R-20 SETBACKS: FRONT: 45' SIDE: 15' SIDE: 25'(STREET) REAR: 30' TYLER COURT 50' R/W (PUBLIC) S 82828'00" Ar— GRAPHIC — N83.43'31'W CH 126.31' R 1599.37' GRAPHIC SCALE 40 0 20 40 80 ( IN FEET ) 1 inch = 40 & HOME DIMENSIONS NTS PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 69 OF ESSEX FARMS, PHASE 1 P.B. 9 PC. 289 Fleming 69intaing, Inc. 700 Carnegie Place Greensboro, NC 27409 Phone: 336.852.9797 ,, Fax: 336.852.9766 NCBELS C-0950 DATE: 03-21-16 REF: PR0J\1831-01\dwg\ESSEXFARM.dwg