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223 Essex Farm Road Lot 16Davie Countv. NC Tax Parcel Report Tuesday, December 20, 2016 223 215 23 LL [all WARNING: THIS IS NOT A SURVEY All date is provided as is wlho dviarranty or guarantee of any Rind eitherupressed or Implied Including but not limited to the Implledwamngesofinemhardabllityorfihressforaparticularuse.AliusersofDavieCounty'sGISwebsgeshallholdhartnlessthe a Davie, North Carolina, Is agents,consultants, contractors oremployees fromany and a1 claims or causes M action due to out ofthe use orinabirdyto usethe Gla data provide!byfhiswebsla Parcel Information ,_�� - . Parcel Number: F803OA0016 Township: Shady Grove NCPIN Number. 5870640785 Municipality: Account Number. 8304099 Census Tract: 37059-803 Listed Owner 1: STAPLETON WILLIAM SCOTT Voting Precinct: EAST SHADY GROVE Mailing Address 1: 223 ESSEX FARM ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: ZIP Code: 27006 Voluntary Ag. District No Legal Description: LOT 16 ESSEX FARM PHASE 1 Fire Response District: ADVANCE Assessed Acreage: 0.69 Elementary School Zone: SHADY GROVE Deed Date: 9/2014 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 009680209 Soil Types: GnB2 Plat Book: 0009 Flood Zone: Plat Page: 290 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: [all Davie County, �+County NCoradsing All date is provided as is wlho dviarranty or guarantee of any Rind eitherupressed or Implied Including but not limited to the Implledwamngesofinemhardabllityorfihressforaparticularuse.AliusersofDavieCounty'sGISwebsgeshallholdhartnlessthe a Davie, North Carolina, Is agents,consultants, contractors oremployees fromany and a1 claims or causes M action due to out ofthe use orinabirdyto usethe Gla data provide!byfhiswebsla ;r HEALTH.DEPARTMENT RELEAS Davie County Health Department 210 Hospital Street P,O. Box 848 Mocksville NC 270.28' Phone: 336-753-6780 Fax: 336-753-1680 Applicant: William Scott Stapleton:: Address: 223 Essex Farm Rd City: Advancd State/Zip: NC 27006 Phone #: (336) 97179842 For Office Use Only \ 'CDP File Number- 193866 1 =- 1`8�030-AO-016 - County ID Number. EIaluated For HDRNVWC PERMIT VALID 0 5 1 9 a 0 a 0 UNTIL %Property Owner: William Scott Stapleton Address: 223 Essex Farm Rd City: Advancd State2ip: NC 27006. PhoneM (336) 971-9842 �. Property Location 8 site Inform ation Address223 Essex Farm Rd Subdivision:, Essex FarmPhase: Lot_ 16- .Road#Advance..................... NC 27006 - SINGLE FAMILY Township: 'Structure: DI ti *of Bedrooms 4. IN of people:- 'Water Supply: PUBLIC Basement: [-] Yes ❑ No 'Proposed Improvement: Pool rec one Hwy 64 E. left on Comatzer Rd on Left past Beauchamp Rd "'Type of Business Total sq. Footage: No. Of Employees 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 5/ 1 9/ a 0 1 5 —U� Authorized State Ageni � **Site Plan/Drawing attached.** 0O Hand Drawing 01mport Drawing, Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 19386,6 -1 v County File Number: F8 -030 -AO -016 Date: 0.5 / 1 9 / 2,0 .1 5 Olnch Scale: , OBiock ON/A I C IVSD — I vZ3 5 Davie County Health Department QD��s I� Environmental Health Section P.O. Box 848 t? `21U Hospilstl Strccl OU K� C:ourier#:O9-LO-Uti Mocksville, NTC 27028 Plwne: t93td - 753.67311 ON-SITE WASTEV (Check One) Replacement Name: W. Mailing Address Detailed Directions Email Address: TION Fau (336) - 7S3- I680 (Work) plc CO✓✓1 — r!,r�+- j, moa cs Aarth r IL yl in ostx Property Address: iv: — ' a.23 Esser �r,n., O / trah(P �Ve a)aa6 -0 3^ Q - 0/0 Please Fill In The Following In ormation o he EXIST�FVG Facility: ` ! iS``� a Jv ' \'xName System Installed Under: ? Type Of Facility: 6, STAf } C£ Date System Installed (Month/Date/Year): ac M Ir Number Of Bedrooms:`Number Of People: V Is The Faciliry Currently Vacant? YesN® If Yes, For How Long? Any Known Problems? Yes ON If Yes, Explain: Please Fill In The Following Information About The NEW Facility: TypeOFFacility: ri ^ - Gro J P6 C! )-- - Number Of Bedrooms: Number of People Pool Size: '? Gar4ge Size: Other: 1 Requested By:(Si ure _ _ _ Date Requested: \ � -- For Environmental Health Office Use Only Approved Disapproved - Comments: Environmental Health Specialist Date: +The signing of this fonn 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: Cash Check Money Order # Amoum3 Date: Paid By: Received By: Account #: Invoice #: i DAVIS COUNTY ENVIRONMENTAL HEALTH P-0.Boz 348/210 Hospital Sbeet Mocksville,NC 27028 (336)751-8760 Fax 0(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990000955 Taz PIN/EH#i 5670-84.2265.16 Billed To: Samnaz,Inc. Subdivision Info: Essex Farm Lot#16 Reference Name:`Mike Masoud Location/Address: Comatzer Rd-27006 Proposed Facility: Residence. Property Slze: 100x300 ATC Number: 4829 �� Site Type: HNaw ORepair OExpansion - -- "NOTFi*This Authorization to Constrict(ATC)MUSTBE ISSUED by the Davie County Environmental Health Section prior to issuance of any building pnia t(s),(in compliance-with Article 11 of G.S.Chapter 130A Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems), THIS AUTHORIZATIONTO CONSTRUCTIS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation If site plans,plat orthe intended use change. ..::.. - .. -Residential Specifications::.#Bedrooms, #Bathroo `S #People BasementO Basement plumbingO Non-ResidentialSpedfrcations: Facility Type - #People_#Seats_-_ SquaieFootage(orDimensionsofFacility)- -- - `_- Lot size G (Ai cri Type of Water Supply: 0cminty/city ❑Well C]Community Well System Specifications•.. Design Wastewater Flow(GPD)M6_ Tank Siu j-rdWGAL.Pump Taiilcl" GAL. _ -- - TreachWidth36 •I-Max.TrenchDeptb_L4 Rock Depth-I," LmearFt.J SileMadiScations/Conditions/Other: AS stated to 15r NG^ �rsw 3969(5 / Contact the Davie County Environmental Health Section for final inspection of this system between i 8:30-.930aan.oiithe diy of fiistalliti6n..Telephone#(336)751-8760. 'At r„v ?S�'.� � A ria 'l r••� ,c,r I 31 t V h 5}nl�sl.baic -1 an�c�..ir rack ; ��Q.tt:cd Isvironmental Health Specialist .Daic: ,�i•cm n ens m.S�..ar - _ . afwatar S'uY' �a�f� GAL,A ,�,ank � GAL. P� •' D, ;Sn tcwat�c plow {C FD) -.f,� # 1-114 x,�ste;*ax Ft � � 5 "'itmchI� ` `V-- o CDom.,- -� 1ltl� N . n CGm �5vlcvs 110 Ic r& kui DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 990000955 OPERATION PERI faz PIN/EH #: 5870-64-2265.16 Billed To: Samnaz,.lnc. Subdivision Info: Essex Farm Lot # 16 — Reference Name: Mike Masoud Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: �1 100x300 ,- - ATC Number: 4829 ¢23 gi **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," 'but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. System Type: S.T. Manufacture;5 Tank Date i Tank Size Pump Tank Size Jra_ jo8� �� Q System Installed By: ��E5dN1&t'elAtit6 E.H.Specialist:JA Naito -,ns Date: Davie County Health Department Nvr10 t836 � Environmental Health Section �. 210 Hospital Slrcct OO U x'L Courier #: 0.9-10-06 Mockstillc, NC 27028 Pliown 10i) - 753.6780 ON-SITE WASTED (Check One) Replacement, Name: Mailing Detailed Directions Property +` d.C3 C.tsmen Please Fill In The Following In ormation 6 RECEIVED MAY 13 2015 EALTH F7 Fat: (3N -753-IIAO (0m Name System Installed Under: 7 Type Of Facility: �C S; tv) t -f - Date System Installed (MonihlDate/Year): .2190 Number Of Bedroomt:__L_Number Of People:_o� Is The Facility Currently Vacant? Yes lG) If Yes, For How Long? Any Known Problems? Yes Na If Yes, Explain: Please Fill in The Following Information About The NEWFacility: TypeOFFaeility: -�*� Cfo r,� Pr)Q)._ NumberOfBedrooms: Numberofpeople Pool Size: . r 1 � t �'� Gar ge Size: Other: Requested By: i �. rr 9, Date Requested: (Sign ure For Environmental Health Office Use Only Approved Disapproved Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee ji (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account #: Invoice #: C4't'A 4- e ivv''- DAVIS COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Sheet Macksville, NC 27028 (336)751-8760 Fax # (336)751-8786 ATC Number: 4629 Site Type: 0<aw ORepair OExpausion "NOTE" This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications:,#Bedrooms #Batlroomv�'�#Peoplc—�_BasemmtOBasement plumbingO Non -Residential Specifications: Facility Type # People _#Seats^- SquareFootage(orDimensions of Facility) Lot Size . (Aa arm Type of Water Supply. 06mminty/City O Well OCommunity Well System Specification' Design WastewaterFlow (GPD)/1o6 TWA Size 1jd00 GAL. Pump Tank," GAL. TIenehWidth (e "Max. Trench Depth 36" RockDepthl�sl LinearFt. siva SileModiScations/Conditions/Other: A5 stated in 15n NCAC 4SA. e o .r --- ..As -1M,31 �. .._.Y took 1 l0 P Lu� Ml`v 1s}a Q, 1 5rla-sk 0)c-jferrCi.cs ex COVACL-r 6radx yeironmental Health S M I I M!. rn.";.Al �Q'J v - a ! -- AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990000955 Tax PIN/EH M 5870-64.2265.16 Billed To: Samnaz, Inc. Subdivision Info: Essex Farm Lot # 16 Reference Name: Mike Masoud Location/Address: Comatzer Rd -27006 Proposed Facility. Residence- Property Size: 100x300 ATC Number: 4629 Site Type: 0<aw ORepair OExpausion "NOTE" This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications:,#Bedrooms #Batlroomv�'�#Peoplc—�_BasemmtOBasement plumbingO Non -Residential Specifications: Facility Type # People _#Seats^- SquareFootage(orDimensions of Facility) Lot Size . (Aa arm Type of Water Supply. 06mminty/City O Well OCommunity Well System Specification' Design WastewaterFlow (GPD)/1o6 TWA Size 1jd00 GAL. Pump Tank," GAL. TIenehWidth (e "Max. Trench Depth 36" RockDepthl�sl LinearFt. siva SileModiScations/Conditions/Other: A5 stated in 15n NCAC 4SA. e o .r --- ..As -1M,31 �. .._.Y took 1 l0 P Lu� Ml`v 1s}a Q, 1 5rla-sk 0)c-jferrCi.cs ex COVACL-r 6radx yeironmental Health S M I I M!. rn.";.Al �Q'J v - a ! -- WOW u YY QAA A1m' Tl, f Z`ypp ofP/��+r � GAL, P ?P� , GAL. f3 11 All"014- t�fs Sizs.•�— �Ia��s�yu u��sroerr���{cy#P•.�n���'�py�{, �.R � tD t� z iaeaz pt. s I c off: IASI r . . Gnw�Y�Ba�Irq'am .���`�5 �� i r - ..+r rrr •..•.+ .rr+ w+•. ter_ :'1. , r - _ :{ � ` OLJ- Marg., S t c „ FY DAVIE COUNTY ENVIRONMENTAL HEALTH ar(g/� P.O. Box 8481210 Hospital Street' �� Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990000955 Tax PIN/EH #: 5870-64-2265.16 Billed To: Samnaz, Inc. Subdivision Info: Essex Farm Lot # 16 Reference Name: Mike Masoud Location/Address: Comatzer Rd -27006 Proposed Facility: Residence Property Size: 100x300 ATC Number: 4829 Site Type: SNew ORepair DExpansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental . Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. - Residential Specifications: #Bedrooms#Bathrooms,3'h#Pecple—�--BasementOBasementplumbing❑ Non:ResidentialSpecifications: Facility Type # People— #Seats_ Square Footage(or Dimensions of Facility) at Size 01 lt--tCzor L Type of Water Supply: EK`8unty/City 17Well ❑Community Well System Specifications: Design Wastewater Flow (GPD) y�6 Tank Size j�aaU GAL. Pump Tank/, GAL. TrenchWidth5ii Max. Trench Depth 3t -r( Rock Depth torr Linear Ft. 59� SiteModificatiions/Conditions/Other: As stated in 15A NCAC 18A.1969(5) uepted ,"tent may Isur e M Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. r 51ple.-Sk &OX rovironmental Health Specialist —i ill raAe Date: ;), - I �a -10 `'t ezf tot LA R004 ���� vl ltp, VV V ILGI p 1(lOG GY�JIII f• Y/YJ3 ---,��� •-•• ••[\��! ••P''••• peviv Il;uuubtl. tlrtvntlYli in.. J.YbL fJl �U fee, P. 4. I ICAT R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental. Health PAL Box 848/210 Hospital Street 'ASN Mocksville, NC: 27028 1 6S.11E (356)751-8760/kax(336)757-8786 Ae Evaluationtimprt•vement Permit C Authorization Io Constfunl(ATC) L Both ONew System Olepair to Fzistme System Ohxpansion/Modificahion of Existing System or Facility, ***1MPORTAN7***THIS APPLICATION CANNOTE&'PROCESSED UNLESS ALL OF THE RBQUIREA INFORMATION IS PROVIDED. Raft. to the INFORMATION BULLhTIN for instructions. Name to be Billed G{ . Gs-� 'A.! �_C onset Person. Billing Address �l.0 (r�tHmne Phone- City/Slate/ZIP —fM_a s�� t Business Phone Name on Pcrmit/ATC if nierod PROPERTY INFORMATION I *Date HousuFacilityCarers Flagged NOTE: A survey Flat or site plan musraccompanythis application. Included: O Silo-Plan-OPlat(lo scale) nn (Peii is valid for 60 months v-ith site plan, huh expiation with complete plat.) Owner's Name 1 -VIA &� t1__�tLi ( __. Phm,c Number Owner's Address h_ * a e= Cly/State/Zip Property Address C.ty Lot Size irnrlVZnn TaxPIN#'S '10--L.4-2L65--iC Directions To Site: If the answer to any of the following qurstions.is "yes', supporting docummtltion must be attached:' 0 Are there any existing wastewater systems on the site? t1Ye< Does the site contain jurisdictiunal wetlands? 0Yin Are there any easements or fien-of-ways on the site? OYa..Ofq - ls the site subject to'approvat F. y another public agency? Oyes Efr�o1 _ Will wastewater ether diary domestic sewhim be eeuerated? O Yes CiN0 IF RESIDENCE FILL OUT TITC. BOX BELOW # People # Bedreoms # Badly Garden Tuh/Wl»rlpool es ONo Basement: DYes. o BaserientPlunlbing: L]Ycs 6NQo IF NON -RESIDENCE FILL OLT THE BOX BELOW Type of Fac.i.l.irtyBihsiness� . 1 Total Square Footage of Building )Z #People #Sinks. 1- # Commodes - #'Showers _ # Urinals_ _ Estimated Water 'Usage (gallons PC - day (Attach docL.mcntation of similar facility water consumption) FOODSERVICE ONLY: #Seals Type systemrequestedj Ctle/Lventiom! OAcccptcdUbmovadve-L7Altcanative-OOther__ _ Water Supply Type: ial ounty/City'Ar;itcr 0 New Well Ohm ;Ling Well O Community Well Do you anticipate additions or expansichu; of the facility this system is intenced to serve? 0 Yes erfgo _ If yes, whal type? _ ------ This is to cctiiry that the information pwvidedOn this application is etre anti correct tothe best of my knowledge. 1 understand that >""..e.,.;tklh. ATQfsI iuuad hereafter are subject to suspension or nvocstion if the site is altered, the intended use changes, or if the information subuned in this applintion is falsdred or clanged: Iherebf grant right of ergryro the Authorized Representative of rhe Davie County health Depargnmt to conduct necessary inspections to determine compliance with applicable laws and rules. Iundcrsrmd that I am responsible for the pn>jcr identification and labeling •if properly lines and corners and locating and flagging or Slaking the houselfaciliry locgtimr, I reposed well location and the loeatio i of any odta anxnities. .r Site Revisit Charge Property' or uwo�,Aifal teprasenlative 9 nature Darc(s): _ /C Client Notification Date: Dale r'.._" EMS: Sign given ❑Yts ONo - Account p oRss� Revised 11/06 Igmiieff -//� A FROM = PHILLIP R BPLL.CO T5' FAX NO.. 336-755260 c.i. «. a.v vv• «fr..• • . Feb. 21 2008 10:52AM P1 iB t7 NOTA CERT/W COPY FOR ILLUSTRATION PURPOSE' ON(Y 7N15 DRAWNG LS NOT FOR RE=)?DA770N LS -4894, T - - 24,1' R r r 24.1'- .0 m N ESSEX FARM RD 40 0 40 80 120 GRAPHIC SCALE — FEET OCT.29. 2007 10:31AM Mail PSC N0,260 P. 19/40 Davie County Environmental Health P -O. Boi: 848/210 13ospitel Street Mockaville, NC 27028 (336)751-8760/ F2x (336)751.8786 Account -P- 990004425 I YMovzA2LM.?FltJ1PINlEH #: 5870-64-2265.16 Billed To: PSC Development Corp. Inc- Subdivision Info: Essex Farm. Lot # 16 Address: PO Box 340 Location/Address: Cornatzer Rd -27006 City: Mocksville Reference Name: Brad Coe Properly Size 0:691 acre Pfoposed Facility:.. Residence *+'NOTE**This 3niprovemeat Ferwit DOFS NOT authorize the construction of a wastewater system. An eiwhomation To Construct a wastewater system roust be obtained 5rom this office prior to the croshuction/instanation of iiwastewater system or the issuance of a building perwit(in compliance with Article- l l of G.S. Chapter 130A, WE, t water Systems). This Improvement permit is snbieet to revocation if site plans, plat or the intended nse change. PamitType: 'a$cw Oltepair.Dlb:paasion PeanitValidfar. WYeais DNoExphmtion Bssidential Specificalioga: #Bedrooms,#Bathrooms_____(!Peop]t_____-BasemeatO Basement plumbing o Non-ResidentialSpecificafions: •FaciktyType #People•` -#Scat%_ SquareFootage(orNinawionsofFieility) Ik1PZOw(OPD): Ud • . Type ofwaterSupply: @Govnty/City Owa OCommimitywell SiloModifications/PemitCbnditions: Ilr ntalod in OA NCAC iBA.icJ8.4t.5� 8p�tpt0� Sy.,U'�r rs"Mifp Igu� OSL" cc 1 44 AP ION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health - OP.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 `-"`- (2♦1i� qp Fo ' ite Evaluation/Improvement Permit D Authorization To Construct(ATC) - D Both p [cation: ONew System ❑Repair to Existing System DExpansion/Modification of Existing System or Facility IMPORTANPv` THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED - INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions, 73 Nam6 to be Billed ASC Acrye"PrrrAr eat, Contact Person Billing Address 'A.o.Q?r 3f0 Home Phone City/State/ZIP ZAw",.ce,> rrc. z7 -D28 - Business. Phone Name on Permit/ATC if Different than Above Mailing Address - - City/State/Zii 7S/' 7300 rxOrhtcartrvrvruvLvttvty - - -mate Housetracuity comers riaggeo NOTE: A survey plat or site plan must accompany, this application. Included: 0 Site Plan lat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name ,DSe�peyrifaalf�z+i cAt, lyre. Phone Number 75'/-73� Property Ad Lot Size_ Subdivision u me answer to any or me rouowmg questions -is yea-, suppomng micumenunio-p musr ce amzcneu. Are there any existing wastewater systems on the site? - DYes Blp - - Does the site containjurisdictional wetlands? OYes ONO Are there any easements or right-of-ways on the site? Bles ❑ o Is the site subject to approval by another public agency? DYes QNB� - - - Will wastewater other than domestic sewage be generated? DYes RNo People - #Bedrooms :4 #Bathrooms Garden Tub/Whirlpool DYes ONo 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:��2fcdnventional DAccepted Olnnovative OAltemative OOther Water Supply Type: O'County/City Water D New Well OExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes 0 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 agging or Braking the house/facili location, proposed well location and the location of any other amenities. Site Revisit Charge .Rope r r oro er's legal represents re Date(s): _ Client Notification Date:' Date _ EHS: Sia 'OYe ON - Account# gn gry n s o Revised 11/06 Invoice , DAME COUNTY HEALTH DEPARTMENT Environmental. Health Section n Water Supply: Evaluation By: On -Site Well Community Auger Boring - Pit I Public ✓ FACTORS 1 So /Site Evaluation 3 4 5 6 7 APPLICANT INFORMATION (_ PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 5870-64-2265.16 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 16 Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: 0.691 Ac. Date Evaluated: — 2Q) —d 77 Water Supply: Evaluation By: On -Site Well Community Auger Boring - Pit I Public ✓ FACTORS 1 2 3 4 5 6 7 Landscape position (_ L Slope % : 2 ] HORIZON I DEPTH — Q p — p , Texture groupC C ; C Consistence - N Structure 5 K k k ,.. Mineralogy HORIZON H DEPTH Texture group_ Consistence .+ Structure 6 k V t,wc .-Mineralo - - _ eye HORIZON III DEPTH. Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence ,. Structure . .. ..Mineralogy.- - - - SOIL.WETNESS RESTRICTIVE HORIZON .SAPROLITE CLASSIFICATION ;iuV � ],e' .�. LONG-TERM ACCEPTANCE RATE o •7.7 � . ?Z o : ? 7 ITE CLASSIFICATION:'- J u } pl' l� T S EVALUATION BY:' Ob �" a t:0 o-6 t 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 to SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE. Moist :VFR - Very friable FR - Friable FI - Firm - VFI - Very firm EFI - Extremely firm 35'et . 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 Angularyblocky SBK - Subangular blocky PL- Platy PR - Prismatic Mineralogy, 1`.1, 2:1, Mixed IYnies - �• 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 igal%day/fU DCHD 05/05 (Revised) j Davie County Environmental Health P.O.Rox 848/210 hospital Street Mocksville, NC 27028 .(336)751-8760/ Fax(336)751-8786 Account #: 990004425 IMPROV EMENTPERT)4*FIN/EH#: 5870-64-2265.16 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 16 Address: PO Box 340 Location/Address: Cornatzer Rd -27006 City: Mocksvilte 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. Permit Type: GKew ❑Repair. ❑Expansion Permit Valid for: &--TYears DNo Expiration Residential Specificaii ons: # Bedrooms- #Bathrooms_#People— BascmentO Basement plumbingO Non -Residential Specifications_ : Facility Type # People # Seats_ Square Footage(orDimensions of Facility) Design Flow(GPD): ' Type of Water Supply: R ounty/City Dwell .D Community Well Site Modifications/Permit Conditions / stated in 15A NC_AC 18A.1989(5� �{% y`.— of It15 m$y-ai5� uE�i7u� System Te LTAR Initial acce? o C.)--75— - Repair - - 0LCceOtC-Q 0.a.75 too -t-e 30/ Iqb 4609 IrV. r•K _ L0.�Nb'ao 5-0 r'.. -r Date lb—l�—o7 l,Q