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147 Essex Farm Road Lot 6r � Davie Countv- NC Tax Parcel Report Tuesday, December 20, 2016 139 WARNING: TMS IS NOT A SURVEY wamAll data is provided as Is without warranty or guarantee of any fund either expressed or Implied including but not gmgd tithe Implied ntles of merchantabilityor fitness for a pargwlaruse. All users of Davie Countys GIS website shall hold harmless the 101 Parcel Information of Davie, NorthCarolina, Ns agents, co auba^wntraclaa cremployees from any and all claims or causes of action due to Parcel Number: F8030A0006 Township: Shady Grove NCPIN Number: 5870539756 Municipality: Account Number. 8304566 Census Tract: 37059-803 Listed Owner 1: NORTON JAMES P Voting Precinct: EAST SHADY GROVE Mailing Address 1:. 147 ESSEX FARM ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A R-20 State: NC Zoning Overlay: Zip Code: 27006 Voluntary All. District: No Legal Description: LOT 6 ESSEX FARM PHASE 1 Fire Response District: ADVANCE Assessed Acreage: 0.69 Elementary School Zone: SHADY GROVE Deed Date: 12/2014 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 009760322 Soil Types: Gn132 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: Davie County, wamAll data is provided as Is without warranty or guarantee of any fund either expressed or Implied including but not gmgd tithe Implied ntles of merchantabilityor fitness for a pargwlaruse. All users of Davie Countys GIS website shall hold harmless the 101 /'+County of Davie, NorthCarolina, Ns agents, co auba^wntraclaa cremployees from any and all claims or causes of action due to NC orafdng out of the use or Inability to use the GIS data provided by this websbe. - - y .. OPERATION PERMIT oM* Davie County Health Department �s -210 Hospital Street ` P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: RS Parker Homes / Joy Springer Address: PO Box 5967 City: High Point StatefZip: NC 27262 *CDP File Number 136570-1 F8-030•AO-006 County ID Number. Evaluated For: NEW �ownship: Property Owner. RS Parker Homes / Joy Springer Address: PO Box 5967 City: High Point State/zip: NC 27262 Phone #: / \ Phone #: Property Location & Site Information Address/Road #: Subdivision: Essex Farm Phase: Lot: 6 147 Essex Farm Rd Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Cornatzer Rd. Left on Essex Farm Rd. past Beauchamp Road # of Bedrooms: 3 # of People: "Water Supply: PUBLIC ; Nations, Robert *IP Issued7by:21410 `System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *CA issue -Nations, RobertSaproliteSystem? QYes ®No Design Fl3 6 0 Distribution Type: GRAVITY -SERIAL Pump Required? QYes QNo Soil Appli0 a 7 5 *Pre Treatment: Drain field Nitrification Field 1 7 4 5 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines Installer. Frank Transou Total Trench Length: 4 3 6 ft• Certification #: Trench Spacing: — 9 Olnches O.C. 4, Feet O.C. EH S: 2140 -Nations, Robert Trench Width: — 3 Inches Feet 1 0/ 1 7/ 2 0 1 4 Date: Aggregate Depth: inches Minimum Trench Depth: Inches Minimum Soil Cover. Inches Approval Status Maximum Trench Depth: ® Approved O Disapproved Inches Maximum Soil Cover Inches CDP IFile Number 136570 -1 County ID Number: F8-030-Ao-006 Manufacturer. shoal Lat. STB: 760 Long: - Gallons: 1000 Installer Frank Transou Date: 0 6/ 1 4/ a 0 1 4 Certification #: 'EHS: 2140 - Nations, Robert 'Filter Brand: ST Marker. El Yes 19 No Date: 1 0/ 1 7/ 2 0 1 4 Tank: ❑ Yes ® No Approval Status 7rced iece Tank: El Yes El No FINApproved D .Disapproved- Pump Tank Manufacturer. shoat Installer. Frank Transou PT: 42 Certification #: Gallons: 1250 THS: 2140- Nations, Robert Date: 0 6/ 3 0/.1 0 1 4 Date: 1 0/ 1 7/ 2 0 1 4 RiserSealed ® Yes ❑ No Riser Height: I] Yes ❑ No (Min.6in.) Approval Status Reinforced Tank: ❑ Yes ® No p: Approved ❑'Disapproved. 1Piece Tank: ❑ Yes ®No Supply Line Pipe Size: a inch diameter Installer. Frank Transou Pipe Length: 1 6 g feet Certification #: THS: 2140 - Nations, Robert Schedule: ao Pressure Rated 19 Yes ❑ NO Date: 1 0/ 1 7/ 2 0 1 4 Approved fittings ® Yes ❑ NO Approval Status Approved ❑ Disapproved Pump Requirement Pump Type: zoener Installer. •FrankTransou Dosing Volume: — Gal Certification #: Draw Down: Inches THS: 2140 - Nations, Robert *Cham:1 Date: 0/ 1 7/ 2 0 1 4 Valves Accessible I] Yes ❑ No Flow Adjustment Valve I] Yes ❑ No Check -valve ® Yes ❑ No Approval Status. PVC unions ® Yes ❑ No ®"Approved D Disapproved Vent Hole ® Yes ❑ No Anti -siphon Hole ® Yes ❑ No CDP File Number 136570 - 1 County ID Number: F8-030-Ao-006 / Clnwfriw Cn nit nrnnnf NEMA4XBoxorEquivalent ❑* 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 ❑ Yes ❑ No Approval Status ❑, Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 1 0/ 1 7/ 0 0 1 4 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 B. sewage septic system. Rule .1961 requires that a Type TYPE III B. septic system meet the following criteria: Minimum System Review By The Local Health Department: 5YRs. Management Entity. OWNER Minimum System InspectionlM aintenance Frequency By Certified Operator. N/A Reporting Frequency By Certified Operator. wA 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 entitywith 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 ownerand 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 136570 - 1 County File Number: F8-030-na006 27028 Date: O Inch Scale: . . .OBIOck ON/A No ■■■ ■■ No ON ■■ MEN����� L . ■ ■No ■ m■■ ONE m No ■. ■ MEQ EMEM ■■■■■■ MMM ME I ' ■■ ■■■■ MMM ■■■MEN MEN ■�■■ ■ ' ■ ■■ ME MEQ .O MOM ■■■ ME ME ■■■ ■■■ MEN ■E ■ ■ M ME ■■■ ■■■■ ■■■■ ■■■■■■■■■ MO■■ ■■■ ■■■ ME ■ ■ANN ■■■ ■.■■■■■■■■■■■ M■MMEMEM■■n ■ M ■■ M� MMEN EN .■■■■■■■■■■■■■■■■m ■ ■■■■■■■■■■■■■■■■■■■■■ME: ■■■■■■■■■■■■■■■■■■■■■■ ■ MEN IME vv MMM MMMMM MEMM OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC CDP File Number: 27028 County File Number. F8 -030-A6.006 Date: ,_,_,1,_,_,/. Click below to Import an Image from an external location: Drawing Type: Operation Permit - AUTH91 Davie Co �n f _ 210 Hospitall P.O. Box 848 JCTION ZATION Health Department Mocksville ` NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: RS Parker Homes / boy Springer Pro I Address: PO Box 5967 Ad( For Office Use Onl 'CDP File Number 136570-1 County ID Number: FM30-AO.006 Evaluated For: NEW Township: 0 3/ a 1/ a 0 1 9 Owner. RS Parker Homes / Joy Springer PO Box 5967 City: High PointCity: High Point StatefZip: NC 27262 1. StatefZip: NC 27262 Phone #: Phone #: Address/Road #: 147 Essex Farm Rd Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: # of People: `Water Supply: PUBLIC Subdivision: Essex Farm Phase: Directions Hwy 64 East, left on Comatzer Rd. Left on Essex Farm Rd. past Beauchamp Road 'Proposed System: 25% REDUCTION Nitrification Field ' No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: 'Aggregate Depth, f 1 7 4 5 Sq. ft. ep c an . 1 0 0 0 _Gallons 1 -Piece: OYes ONo Pump Required: OYes QNo OMay Be Required Pump Tank: Gallons 4 1-Piece:OYes QNo 4 3 6 ft, GPM—vs— ft. TDH —9@Inches D.C. FeetO.C. Dosin Volume: _ Gallons 3 SInches Feet Grease Trap: Gallons inches Pre Treatment: ONSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01 011 OIII OIV Page 1 of 3 Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover.1 a SaproliteSystem? OYes QNo Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover. 2 4 Inches 'System Classification/Description: `Distribution Type: GRAVITY -SERIAL TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) S f T k' 'Proposed System: 25% REDUCTION Nitrification Field ' No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: 'Aggregate Depth, f 1 7 4 5 Sq. ft. ep c an . 1 0 0 0 _Gallons 1 -Piece: OYes ONo Pump Required: OYes QNo OMay Be Required Pump Tank: Gallons 4 1-Piece:OYes QNo 4 3 6 ft, GPM—vs— ft. TDH —9@Inches D.C. FeetO.C. Dosin Volume: _ Gallons 3 SInches Feet Grease Trap: Gallons inches Pre Treatment: ONSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01 011 OIII OIV Page 1 of 3 CDP File Number 1365M 1.tt County ID Number: F8 -030 -AO -006 ❑ Open Pump System Sheet ReoairSvstem Reauired:OYes ONO ONO, but has Available Space r 'Site Trench Spacing:Inches O! 9 8 Classification: Provisionally suitable — Feet O.C. ` Trench Width: Inches 3 Design Flow: 4 8 0 — Feet Aggregate Depth: Soil Application Rate:e a 7 5 � inches 'System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover 1 a Inches Maximum Trench Depth: 3 6 'Proposed System: 25%REDUCTION Inches Maximum Soil Cover: a 4 Nitrification Field 1 3 4 5 Sq. ft. Inches No. Drain Lines 4 'Distribution Type: Total Trench Length: 4 3 6 Pump Required: Oyes ONo OMay Be Required ft, � 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. 7! 'Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other pernits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. °"• 2( This Authorization for Wastewater System Constriction shall bevaild for a person equal to the period of wlidity of the Improvement Permit, not to exceed five years, and maybe Issued atthe smetime the Improvement Permit Issued (NCGS 130A336(b)} If the installation has not been completed during the period of validity of the Construction Permt%the information submitted in the application for a permit or Construction Authorization Is found to have been Incorrec%falsified or changed, or the site Is altered, the pemitt or Construction Authorization shall become Invalid, and maybe 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? OYes ONO Applicant/Legal Reps. Signature: Date: / / 'Issued By.- 2140 -Nations, Robert Date of Issue:. 0 3 / a 1 / a 0 1 4 Authorized State Agent: "y/ Malfunction Log OYes ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 i CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number. 136570 -1 County File Number: F8 -030 -AO -006 Date: 03/11/.2014 W W Inch Scale:. . . OBlock QN/A MENEM MESE MENEM MENEM MENEM■ MENEM NONE MEMEM ■ MEMO■ MEMMEMENNENEMEME MMMMME°EE MMEMEE NENNE EEEMN ■EEE MOMM MEMME NONE MENEM N i ,MNM , ■ME NE ;ME MENEM MENEM MEMMM MENEM EEEEE MENEM MENEM MENEM NEE 0 ■■MEN EEEE EEmom MMMEN 0 N EENM MM EEE MOENM 0 M ■ MEN OMEN ONE ■EEE MMEME ON ON NEN MM S M ■ ■ ■ ■ N M ■ MENEM MENEM MMEME MMS MENEM SEEN M NEVEM MEMEN NEM No , ■ MMEME MENEM . r ■ EME Paae 3 of APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC V 'Davie County Environmental Health _ - P.O. Bos 848/210 Hospital Street - blocksvilleiNC 27028 - - - _ -• - - ' (336)753-6780/ Fax/(336) 753-1680 Application For: GdSite Ev LIuatioNlmprovement Permit - C�Authmization To -Both Type of Application: LPTwSystem ::Repair to Existing System GExpansion/ModificationofExisting System or Facility _ - *'*/dfPORTANP-* THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. - AFPLIUANI INVOKMAI ION - - Name to be Billed R5 C Contact Person Q Gp"icq- - " _ Billing Address -Home Phone - - City/State/ZIP - Business Phone // q19'- f, �y S Name on Pemtit/ATC if Different than Above 1� OC, 33(__ L1b- ! zo• - Mailing Address - City/State/Zip PROPERTY INFORMATION - *Date House/Faclli Comers Fla ed NOTE: A survey plat or site plan must accompany this application. Included: C Site Plan lat(te scale) (Permit is ali for 60 m i the w' t site plan, no expiration with complete plat.)- Owner'i Qr 0 Phon Nu be Owner's Address City/State/Zip I� C Property Address city ,Q_, Lot Size - - SubdivisionName(ifappGcable) ectio ot# - -- Dire ti ns To Site: .I 4 — - - If the answer m any of the following questio is •yes", supporting documentation must be at ached. _ Are there any existing wastewater systems on the site? - I7Yes K� y - ' Does the site contain jurisdictional wetlands? ❑Yes GKI - - " Are there any easements or right-af--ways on the site? CYes SdGo� Is the site subject to approval by another public agency? CYes L�1��Qo n - Will wastewater other than domestic sewage be generated? CYes telrlo 5 / IF RESIDENCE FILL OUT THE BOX ELOW " #People OL # Bedrooms # Bathrooms Garden Tub/Whirlpool Dyes o Basement: []Yes o - Basement Plumbing: Dyes EN6, " IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacitityBusiness - 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:_ onventional CAccepted []Innovative []Alternative []Other - Water Supply type: C"Comty/City Water C New Well CE.cistin, Well[] Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? C Yes 0 - - - •. If yes, what type? This is to certify that the information provided on this application is We 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 f the Davie County Health Department to conduct necessary inspections to determine compliance with applicable. la and rule, understand that I am responsible for the proper identification and labeling of property lines and comers and - - 9 ca pin A f "ins or staking the houselfacility location, proposed well location and the location of any other amenities. - P p rt} wn iso owner's legs epresenmtive signature Site Revisit Charge Client Notification Date: Date EHS: Sign givenCYes CNo _ - Account 1365 Revised 11/06 - Invoice # - � - .KV: rl(W \1YJ1111 \O�Iy\I�"ay.uq�wu�y �i � �, .., - � - .KV: rl(W \1YJ1111 \O�Iy\I�"ay.uq�wu�y �i APPLICATION FOR SITE EVALUATION/IhIPROVEAIENT PERhill Davie County Health Department EnvironmentaiHealth Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 WW mlN' Lar �3 / --------------- APR 73 2005 71811 YYl ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE hi$p INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for inatructioa - 1. Name to be Billed_/�c�hi.•z,,(A - ilC �� Contact Person' �/�✓�^ e Mailing Address ([// iC1� / 1 t / CccS"1— - Nome Phone -7 . City/State/ZIP LLJYnI.'�'F�'Yy. �X ih'ti .%/Q_} Business Phone '416 -7, Y 44V 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip /•' 1. Application For: 13'site Evaluation - ❑ Improvement Permit/ATC - ❑ Both- 4. System to Services 2 H..oUsse ❑ Mobile Homo 11 Business ❑ Industry 13 Other S. Type system requested: Gg Convontional❑ conventional modif ❑ innovative e. If/R: # People ? $Bedrooms #Bathrooms .� esesidence BDiahwasher ❑garbage Disposal Mashing Machine ❑Basement/Plumbing ❑Dasemont/No Plumbing 7. If Busineas/Industry /other: verify type # People - # Sinks # Commodes # Showers - # Urinals # Water Coolers IF FOODSERVICEs # Seats Estimated Water Usage (gallons per day) _ S. Typo of water supply: 91 aunty/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If Ycs, what lyric? ***1AIP0RTAN1*** CLIENTS MUST COAIPLETETim REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN At UST EESUBAf1rfED by the client with THIS APPLICATION. Property Dimensions: iA 7 Tax Office PIN: . if p Properly Address: Road Name Hca _ _ <S/� r IJ I , City/zip If in a Subdivision provide information, as follows: Name: M °R e)S-iet' R+ k Section: Block: Lot: L WRITE DIRECTIONS (from Moclwvilic) to PROPERTY: home corners Ragged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permil(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified m• changed. 1, also, understand that f ant responsible for all charges incurred froln Ilds application. I, hereby, give consent to the Authorized Representative of the Davie County health Depar(inent to enter upon above described property located in Davie County and owned by to conduct all testing proceduresas necessary to determine the site suitability. `. DATE 3 OS� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITU PLAN (Include all of the following: Existing and proposed property limes and dimensions, structures, setbacks, and septic locations). --91— ivA)b / (05103 ' EIIS: Account No. Invoice No. _ DAVIE, COUNTY HEALTH DEPARTMENT �.-�.. Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION A, Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS - 2 3 4 5 6 7 Landscape position Slope % HORIZON 1 DEPTH D - Texture group Consistence Structure Mineralogy HORIZON II DEPTH -?-II19 Texture group Consistence . S Structure.' Mineralogy HORIZON III DEPTH 21 ^ 3°s �S1 Texture group -- Consistence 1!5 F N ..Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy. SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE FTI SITE CLASSIFICATION: EVALUATION BY: LONG-TERM ACCEPTANCE RATE: ©• � OTHERS) PRESENT ;REMARKS: 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 stick SS - Sly htl stick S - . Y �g Y Y .Sticky VS -Very Sticky NP -Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure 'SC - Single grain M - Massive CR Crumb OR - Granular ABK - Angular blocky SBK - Subangular blocky PL Platy PR -Prismatic Mineraloev 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 1 DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC - . Davie County Environmental Health ...... - - P.O. Box 848/210 Hospital Street - Mocksville, NC 27028 % '(336) 753-6780/Fax j336} 753-1680 �- - - - - ApplicationFor. /Site Ev Iuationflmprovement Permit /Authorization To Construct(ATC) t .th - Type of Application: System n_Repair m Existing System OExpansion/ModiEcafion of Existing System or Facility 1,VPORT,hVP-* THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED ' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions - Name to be Billed O C �� 0� Contact Person. Billing Address Home Phone City/State/ZIP - Business Phone Name on Permit/ATC if Different than Above l� Cl. City/ Mailing Address - —� State/Zip FKUYCICI Y I141"UKMA11UN -Date House/Fatuity c NOTE: A survey plat or site plan must accompany this application. Included: D Site (Permit is ali for 60 ranths ' site plan, no expiration with complete plat.) Owner's Name Owner's Address - _City/State/2 Property Address City IM Lot Size_ -(A_ CLC_ —Tax PIN# 0 (a twer to any or me renewing questions is -yes-, supporting aocumemanon most oe anacnea. VPyG' Are there any existing wastewater systems on the site? Dyes Does the site contain jurisdictional wetlands? DYes FN Athere any easements or right-of-ways on the site? Am CYes SdGo� Is the site subject to approval by another public agency? Dyes �i Will wastewater other than domestic sewage be generated? DYes VX r b M_ scale) #Pee le, .#Bedrooms #Bathroom—_ Garden TubWhirl oolDYes. [1996aement:Beo Basement Plum me. DYes 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: 11<nventional CAccepted Dlnnovative CAltemative COther S Water Supply Type: LL_`0-ty/City Water D New Well CExisting Wel D Community yWWell Do you anticipate additions or expansions of the facility this system is intended to serve? C Yes If yes, what type? -- - This is to certify that the information provided on this application is tme and correct to the best of my knowledge. 1 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 f the Davie County Health Department m conduct necessary inspections to determine compliance with applicable I and rale understand that I am responsible for the proper identification and labeling of property lines and comers and 1 ca' 1 n ft. min or staking the house/facility location, proposed well location and the location of any other amenities.. Pr p rt) wn is o owner's legs epresentative signature - , Site Revisit Charge Date(s): Client Notification Date: Do - - ERS: Sign given -CYes CNo Account # ` OR ✓ O Revised 11106 - Invoice# 4 0 6.63' o 13.38' PROPOSED o o \1.00' N RESIDENCE 20.00' 12.33' L o 12.42' 20.20' SETBACK 10' LMLrry EASEMENT N07032'00"E 100.00' ESSEX FARM ROAD 50' RIW (PUBLIC) GRAPHIC SCALE - 40 0 zo b so IN FEET) 1 inch = 40 it -.' HOME DIMENSIONS NTS PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 8 OF ESSEX FARMS, PHASE I P.B. 9 P0. 289 �r�ieg Engier.�ing, pec. 106Ca riglePt o 6iwnft%NC274N Plane:3364524W a Fans 3364524166 NCBELS C-0950 DATE: 01-30-14 .REF: PROJ\1831-01\dwa\ESSEXFARM.dw9 I ro 40.75' CID � w zu �` IR 0 o of o o PROPOSED I ` RESIDENCE R n 19.71' 4.00' cli 0 6.63' o 13.38' PROPOSED o o \1.00' N RESIDENCE 20.00' 12.33' L o 12.42' 20.20' SETBACK 10' LMLrry EASEMENT N07032'00"E 100.00' ESSEX FARM ROAD 50' RIW (PUBLIC) GRAPHIC SCALE - 40 0 zo b so IN FEET) 1 inch = 40 it -.' HOME DIMENSIONS NTS PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 8 OF ESSEX FARMS, PHASE I P.B. 9 P0. 289 �r�ieg Engier.�ing, pec. 106Ca riglePt o 6iwnft%NC274N Plane:3364524W a Fans 3364524166 NCBELS C-0950 DATE: 01-30-14 .REF: PROJ\1831-01\dwa\ESSEXFARM.dw9 p� . 2 3 2001 FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC_ Davie County Environmental Health - - P.O. Box 848/210 Hospital Street - ,Mocksville,NC 27028 - (336)751-8760/Fax (336)751-8786 1 nprovement Permit D Authorization To Construct(ATC) O Both Sys[em ]Repair to Existing System 'J l7Expansion/Modification of Existing System or Facility S—TA PORTANT'rr THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED ' INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. - nrra.rt,nava aavrvavavanaa�av r ���� Name to be Billed -ASC/Jc V6coprt�.+7 �'gt_, i�c- Contact Person 7a fRY J em i,[ Billing Address A0:Q,x3.,Ko Home Phone - City/State/ZIP &Qgz t .4c- L los 8 Business Phone - Xy - 73" a Name on Pemtit/ATC if Different than Above - NOTE: A survey plat or site plan must accompany this application Included' 0 Site Plan (Permit is valid for 60 months with site plan, no expiration with complete plat) Owner's Name�OSe ,OcNELoirIEN% calf iaG Phon Owner's Address fo By j fa - City/State/Zip_ Property Addr ss - City - Lo[ Size • Tax PIN#o— SectioV/Lot#� Subdivision Name(if applicable) eS5�x FAAn Number 76/-73 rr.me answer to any or me rouowmg questions -is yes -, suppomng Oocumemauo most oe mamea. - Are there any existing wastewater systems on the site? Dyes Does the site containjurisdictional wetlands? - OYes ONO Are there any easements or right-of-ways on the site? - Effes ❑ o Is the site subject to approval by another public agency? DYes n1yp - - - Will wastewater other than domestic sewage be generated? DYes ONO #Bedrooms #Bathrooms Garden Tub/Whirlpool DYes ONO 17�.a).D t7 a6715] aJCC�1 aJy1111I�1111 W II:17�:1�)�:7711U1:r� 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: f 6ventional DAccepted Dlnnovative OAltemative DOlher - Water Supply Type: OTounty/City Water - D New Well DExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes D 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 Authori=1 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 gging or staking the housdtacili location, proposed well location and the location of any other amenities. - Site Revisit Charge Property r oro er's legal represents re ' - - Client Notification Date: - - Date - EHS: - Sign given DYes ONO Account# tr - Revised 11/06 - Invoice# - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' Soil/ Site Evaluation APPLICANT INFORMATION PROggERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 5876fi�Z265. Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 06 Reference Name: Brad Coe I' Location/Address: Cornatzer Rd -27006 Proposed Facility', Residence Property Size: ' 0.691 Ac. Date Evaluated: q_ (S-0-7 Water Supply:,. Ori -Site Well, Community Public V Evaluation By: Auger Boring Pit ✓ Cut FACTORS 1 N 3 t (<t // f 4 5 6 7 Landscape position" , l_ • Slope% . ,,,,.� .. ; - .. _ HO ON:I'DEPTH .•, p C,_ 0_ Texturergrou . c c c Consistence , . '.. Ir' Structure k Mineralo HORIZON H DEPTH ` Texture group Consistence^ g. Structure ..: Mineralogy HORIZON UDEPTH Texture group Consistence Structure : 1 Mineralogy. HORIZON IV DEPTH .. Texture group - Consistence Structure Mineralogy - SOIL WETNESS ., . RESTRICTIVE HORIZON SAPROLITE — CLASSIFICATION: a Sie, LI i n v LONG-TERM ACCEPTANCE RATE O.17 G.a7 �[�� SITE CLASSIFICATION: EVALUATION BY: A)CI id tn,S LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS: 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' - 4 SC,- Sandy clay, SIC - Silty clay . . 'C - Clay y' CONSTSTF.NCF. **,?r, ^'^` ' VFR - Very friable FR - Friable FI - Firm VFI - Veryfirm EFI - Extreniely,firm . , ...: 3iet' NS - Non sticky SS - Slightlystick S - Sticky VS - Very Sticky - Y 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 Mirieraln x 1: 1, 2: 1, Mixed' ... _ i iyo 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) w 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 #: 5870-64-2265.06 Billed To: PSC Development Corp. Inc. Subdivision Info:: Essex Farm Lot # 06 Address: PO Box 340 Location/Address:Cornatzer Rd -27006 City: Mocksville Property Size: 0.691 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. PermitType: RS[ew DRepair DExpansion Permit Valid for: in Years (]No Expiration Residential Specifications: #Bedrooms #Batbrooms_# People_ BasementOBasement plumbingO -Non-Residential Specifications: Facility Type # People_ # Seats_ ,- - Square Footage(or Dimensions of Facility) - Design Flow(GPD),: Li sa Type of Water Supply: _ e6unty/City DWell ❑CommunityWell Site Modifications/Permit Conditions- Aa sta IS accepted Systems may also be use System Type LTAR Initial c {--eco C4_ -)L-7 5— Repair I Cke c 4 01-e-03 I Fsvironmental Health �r�oa�✓ �`//'r a 30f