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122 Gilbert Road Lot 5Applicant: Yadkin Builders Address: 258 Ralph Road City: Mocksville State/Zip: NC 27028 Phone : (336) 467-7601 'CDP File Number 122806-1 5841-97.7322-5 County ID Number: Evaluated For: NEW � Township: Property owner: Glenda Gale Sink Address: 1522 HSA Lane City: Winston-Salem State/Zip: NC one: (336) 259-7170 Property Location & Site information r Address/Road »: Subdivision: Furches Farms Phase: lot: 5 Gilbert Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 TM of People: 2 'Water Supply: N'A 'IP Issued by: 22,14 - Daywalt. Andrew 'CA issued by: 2244 - DayM1:alt. Andrew Design Flow: 6 0 0 Soil Application Rate: 0 2 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: G n n ft. Directions 1-40 to Farmington Rd. got Pinebrook Dr at corner of gilbert Rd and Pinebrook School Rd. 'System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? OYes ONo 'Distribution Type: GRAVITY -SERIAL Puma Required? ()Yes ()IJo 'Pre -Treatment: Drain field Sq. ft. Olnches O.C. Feet O.C. Sinches Feet inches I.linimum Trench Depth: 3 6 Inches I.linirn= Soil Cover. Inches I.taximum Trench Depth: 3 6 Inches I\aximum Soil Cover: Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: McDaniel grading Certification »: 'EH S: 2244 - Da�valt. Andrew Date: 0 9/ 1 3/ 2 0 1 3 Approval Status O Approved El Disapproved 1 OPERATION PERMIT ti Davie County Health Department r•>' 35 210 Hospital Street " P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Yadkin Builders Address: 258 Ralph Road City: Mocksville State/Zip: NC 27028 Phone : (336) 467-7601 'CDP File Number 122806-1 5841-97.7322-5 County ID Number: Evaluated For: NEW � Township: Property owner: Glenda Gale Sink Address: 1522 HSA Lane City: Winston-Salem State/Zip: NC one: (336) 259-7170 Property Location & Site information r Address/Road »: Subdivision: Furches Farms Phase: lot: 5 Gilbert Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 TM of People: 2 'Water Supply: N'A 'IP Issued by: 22,14 - Daywalt. Andrew 'CA issued by: 2244 - DayM1:alt. Andrew Design Flow: 6 0 0 Soil Application Rate: 0 2 Nitrification Field No. Drain Lines Total Trench Length Trench Spacing: Trench Width: Aggregate Depth: G n n ft. Directions 1-40 to Farmington Rd. got Pinebrook Dr at corner of gilbert Rd and Pinebrook School Rd. 'System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? OYes ONo 'Distribution Type: GRAVITY -SERIAL Puma Required? ()Yes ()IJo 'Pre -Treatment: Drain field Sq. ft. Olnches O.C. Feet O.C. Sinches Feet inches I.linimum Trench Depth: 3 6 Inches I.linirn= Soil Cover. Inches I.taximum Trench Depth: 3 6 Inches I\aximum Soil Cover: Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: McDaniel grading Certification »: 'EH S: 2244 - Da�valt. Andrew Date: 0 9/ 1 3/ 2 0 1 3 Approval Status O Approved El Disapproved CDP f ile N um ber 122806-1 Faanufacturer shoat STB: Gallons: Gallons: 1000 Date: Date: 0 4/ 1 0/ 2 0 1 3 'Filter Brand: N o Riser Height: ❑ Yes ❑ ST %larker: ❑ Yes ❑ No Reinforced Tank: ❑ Yes ❑ NO 1 Piece Tank: ❑ Yes ❑ No Manufacturer. County ID Number: 5841-97-7322.5 C TanK Lat. Long: Installer: Certification ::: *EHS: 2241- Daywilt. Mdrew Date: 0 9/ 1 3/ 2 0 1 3 Approval Status El Approved ❑ Disapproved Pump Tank PT: Gallons: Date: Riser Sealed ❑ Yes ❑ N o Riser Height: ❑ Yes ❑ No (tAin.B in.) nforced Tank: ❑ Yes ❑ NO 1 Piece Tank: ❑ Yes ❑ No Pipe Size: inch diameter Pipe Length: feet 'Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Installer: Certification _": *EHS: Date: Approval Status ❑ Approved ❑ Disapproved unniv Line Installer: Certification::: 'EHS: Date: / / Approval Status El Approved ❑ Disapproved J Pump Type: Installer: / Dosing Volume: - Gal Certification n: Draw Dorn: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ No Flom Adjustment Valve ❑ Yes ❑ N O Check -valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes 0 No CDP1=ile Number 122806-1 N EMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Seated ❑ Yes Pump Manually Operable ❑ Yes 'Activation rdethod: Alarm Audible ❑ Yes Alarm Visible ❑ Yes 'Operation Permit completed by; Authorized State Agent: C o u n ty I D N u m b e r: 5841-97-7322-5 GIC{.AUL; MgUI d111CIR ❑ No Installer: ❑ No Certification::: ❑ No ❑ No 'EHS: ❑ No Date: ❑ NO Approval Status El No C3Approved ❑ Disapproved 2244 - Da}nsalt. Andrew Date of Issue: 0 9/ 1 3/ 2 0 1 3 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 II A. sewage septic system. Rule .1961 requires that a Type TYPE n A. __,__ septic system meet the following criteria: Minimum System Review ByThe Local Health Department: ranagement Entity: OWNER IJ inimum System Inspectionilwl aintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator: N!A Rule .1961 requires that a Type IV and V septic systems designed fora homelbusiness 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 .1 x361 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 priorto the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Pemnit that subsequent owners of the systems execute such a contract. DHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Activity Code: S-19 2Q-1 - OP issued NEW Type 11 Quick 4 Total Time:(HH111.1) 0 1 Hours 0 0 Minutes OPERATION PERMIT Davie County Health Department CDP File Number: 122806-1 210 Hospital Street 5841-97-7322-5 P.O. Box 848 County File Number: hlocksville NC 27028 Date: O inch Scale: Drawing Drawing Type: Operation Permit , ON/A = ft. pNf i 5�t Edi Davie Countv. NC Tax Parcel Report Thursday, December 29, 2016 Parcel Number: NCPIN Number. Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: WAKNI1NG: '1'Mb 1J 14V'1' A NUKVL+ Y No Parcel Information FARMINGTON Elementary School Zone: E50000003308 Township: Farmington 5851067619 Municipality: Flood Zone: 8302422 Census Tract: 37059-802 PENDERGAST ALMA Voting Precinct: FARMINGTON 122 GILBERT ROAD Planning Jurisdiction: Davie County MOCKSVILLE Land Value: Total Assessed Value: NC 27028 6.015 ac Pinebrook School Rd LIFE ESTATE 6.01 5/2015 009890804 10 32 Zoning Class: DAVIE COUNTY R-20 Zoning Overlay: DAVIE COUNTY QD Voluntary Ag. District: No Fire Response District: FARMINGTON Elementary School Zone: PINEBROOK Middle School Zone: NORTH DAVIE Soil Types: MrB2,EnB Flood Zone: Watershed Overlay: DAVIE COUNTY Outbuilding 8r Extra Freatures Value: Total Market Value: 161 Davie County, NC All data is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. Ali 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 or arising out of the use or inability to use the GIS data provided by this website. OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Yadkin Builders Address: 258 Ralph Road City Mocksville State2ip: NC 27028 Phone #: (336) 467-7601 Address/Road #: Address: Gilbert Road City: Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: 2 *Water Supply: N/A 'IP Issued by. 2140- Nations, Robert *CA issued by: 2244 - Daywalt, Andrew Design Flow: 4 8 0 Soil Application Rate: 0 2 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: *CDP File Number 122806-1 5841-97-7322-5 County ID Number. Evaluated For. NEW Township: /Property owner. Glenda Gale Sink Address: 1522 HSA Lane City: Winston-Salem State2ip: NC 1\ Phone #: (336) 259-7170 Subdivision: Furches Farms Phase: Lot: 5 S () n ft. Minimum Trench Depth: 4 8 Minimum Soil Cover. Maximum Trench Depth: 4 8 Maximum Soil Cover: Directions 140 to Farmington Rd. got Pinebrook Dr at corner of gilbert Rd and Pinebrook School Rd. *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP Saprolite System? QYes ONo Pump Required? PRESSURE MANIFOLD 'Distribution Type: (3)Yes ONo 'Pre -Treatment: Drain field Sq. ft. Qlnches O.C. Feet O.C. Inches OFeet inches Inches Inches Inches Inches 'System Type: INFILTRATOR QUICK 4 STANDARD Installer: brian mcdaniel Certification #: 'EH S: 2244 - Daywalt, Andrew Date: 1 1/ 1 5/ 2 0 1 3 Approval Status M Approved O Disapproved GDP FW Number 122806 -1 County ID Number: 5841.97-7322-5 5eotic Tank Manufacturer. shoat 9/ 2 0 1 2 Lat. Yes ❑ No RiserHeight: ❑ Yes Long: , STB: Yes ❑ No 1 Piece Tank: 2 Yes Gallons: 1000 Inches Installer: Date: 0 7/ 1 6/ 2 0 1 3 Certification #: Valves Accessible ❑ Yes ❑ No 'EHS: 2244 - Daywalt. Andrew 'Filter Brand: ❑ Yes ❑ NO ST Marker. ❑Yes ❑ No Date: 1 1/ 1 5/ 2 0 1 3 nforced Tank: E] Yes ❑ No O Approval Status Vent Hole ❑ Yes ❑ No p Approved ❑ Disapproved 1 Piece Tank: [I Yes ❑ NO Pump Tank Manufacturer. shoat PT: Gallons: 1000 Date: 1 0/ 1 9/ 2 0 1 2 RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) nforced Tank: ❑ Yes ❑ No 1 Piece Tank: 2 Yes ❑ No Pipe Size: 2 inch diameter Pipe Length: 1 0 3 feet 'Schedule: 40 Pressure Rated ® Yes ❑ No 4pproved fittings 0 Yes ❑ No Installer: Certification #: 'EHS: 2244 - DaywalL Andrew Date: 1 1/ 1 5/ 2 0 1 3 Approval Status El Approved ❑ Disapproved upply Line Installer: Certification #: 'EHS: Date: / / Approval Status 0 Approved ❑ Disapproved J Pump e u e Pump Type: Installer. Dosing Volume: — Gal Certification #: Draw Down: Inches 'EHS: 'Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ NO Check -valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No O Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole 0 Yes 0 No CDP File Number 122806 - 1 NEMA 4X Box or Equivalent Box 12 inches Above Grade Box Adj. To Pump Tank Conduit Seated Pump Manually Operable 'Activation Method: Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2244 - Daywatt. Andrew 'Operation Permit completed by: Authorized State Agent: Approval Status ❑' Approved ❑ Disapproved Date of Issue: 1 1/ 1 5/ 2 0 1 3 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 ByThe Local Health Department: 5YRS. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: WA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entity with a certified operator or 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 priorto 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 for maintenance and operation, responsibiities 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. (S)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Activity Code: S-19 304 - OP issued NEW Type III Ouick4 Total Time:(H KM 1.1) 0 1 Hours 3 0 Minutes Electric Equipment County ID Number: Wt -97-7322-5 ❑ Yes ❑ No Installer: ❑ Yes ❑ No Certification #: ❑ Yes ❑ No ❑ Yes ❑ N o 'EH S: ❑ Yes ❑ N o Date: Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2244 - Daywatt. Andrew 'Operation Permit completed by: Authorized State Agent: Approval Status ❑' Approved ❑ Disapproved Date of Issue: 1 1/ 1 5/ 2 0 1 3 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 ByThe Local Health Department: 5YRS. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: WA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entity with a certified operator or 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 priorto 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 for maintenance and operation, responsibiities 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. (S)Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Activity Code: S-19 304 - OP issued NEW Type III Ouick4 Total Time:(H KM 1.1) 0 1 Hours 3 0 Minutes OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 122806 - 1 County File Number: 5841.97-7322-5 27028 Date: 0 Inch Scale: 0131ock ON/A ------- --- CONSTRUCTION - For Office Use Only AUTHORIZATION 'CDP File Number 122806.1 Davie County Health Department County ID Number: 5841-97-7322-5 `r'n tt as s 210 Hospital Street p Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 8 1 1 6 2 0 1 8 Applicant: Yadkin Builders Property Owner: Glenda Gale Sink Address: 258 Ralph Road Address: 1522 HSA Lane City: Mocksville City: Winston-Salem State2 ip: NC 27028 State/Zip: NC Phone -: (336) 467-7601 Phone.:: (336) 259-7170 /AddressiRoad Subdivision: Furches Farms Phase: Lot: 5 Gilbert Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY 1-40 to Farmington Rd. got Pinebrook Dr at corner of gilbert Rd and Pinebrook School Rd. of Bedrooms: 3 of People: 2 'Water Supply: NtA ,'Site Classification: PS Saprolite System? QYes QNo Design Flow: n u n Soil Application Rate: 0 2 'System ClassificationiDescription: TYPE III B. SYSTEM WISINGLE EFFLUENT PUMP `Proposed System: 251% REDUCTION Nitrification Field Sq. ft. No. Drain Lines Minimum Trench Depth: 4 8\ Inches Minimum Soil Cover. Inches Llaximum Trench Depth: 4 8 Inches Maximum Soil Cover: Inches 'Distribution Type: PRESSURE MANIFOLD Septic Tank: 1 0 0 0 Gallons • 1 -Piece: QYes QNo Pump Required: ()Yes QNo Qftay Be Required Pump Tank: 1 0 0 0 Gallons 1 -Piece: QYes t,ONo Total Trench Length: 8 0 0 ft GPIJ—vs-- ft, TDH Trench Spacing: Inches D.C. — _ 9 _ 8Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 6 ()Inches QFeet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank InstallerGrade Level Required: 01 011 0111 011/ Page 1 of 3 CDP File Number 122806-1 County ID Number: 58,11.97-7322-5 Open Pump System Sheet Repair System Required: V res V lvo Vlyo, DUL na5 HVallaIJIe JpaGe /Repair System Trench Spacing: Inches O. "Site Classification: PS — 9 Feet O.C. Trench Width:Q Inches Design Flow: 4 8 0 _ 3 6 8 Feet Aggregate Depth: Soil Application Rate: 0 2 inches fvtinimum Trench Depth: 4 8 Inches 'System Classification/Description: TYPE 111 B. SYSTEM WISINGLE EFFLUENT PUMP Minimum Soil Cover. Inches Maximum Trench Depth: 4 8 'Proposed System: 250, REDUCTION Inches Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines 'Distribution Type: PRESSURE MANIFOLD Total Trench length: 8 0 0 ft. Pump Required: OYes ONo 01-.9ay Be Required 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 by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be lssued at the same time the Improvement Permit Issued (NCGS 13OA-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 beers incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance. monitoring, reporting and repair (1958(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicantil-egal Reps. Signature: Date: "Issued By: 221.1- Dayvralt, Andrew loft Date of Issue:. 0 8 / 1 6 / 2 0 1 3 Authorized State Agent: __Q1,f/kak2'' Malfunction Log OYes OHand Drawing Olmport Drawing Total Time. -(HH 1,51.1) **Site Plan/Drawing attached.** Page 2 of 3 0 1 Hours Minutes S-8 - CNS issued - new CONSTRUCTION AUTHORIZATION 122806 - 1 Davie Munty Hebb Department CDP File Number: 210 Hospital Street 5841•97.7322.5 P.O. Box848County File Number: Mocksville NC 27028 Date: 0 8/ 1 G 12 0 1 3 Olnch Scale:O Di'awing Drawing Type: Construction Authorization . QN/A = ft. APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health p P.O. Box 848/210 Hospital Street Dai; Mocksville, NC 27028 lr3''`�.,+ (336)753-6780/ Fax (336)753-1680 Application For: 0 Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Exvansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULI.,ETIN for instructions. APPT:TC;ANT INFORMATION NameY. KJ� f3tAILOgiRS Address 52-59 IVAI, W )e b - City/State/ZIP M CKSYI li(iGL% M C- Email adklnk�ui Srs 4E►00 , Cd/h Name on Permit/ATC if Different t an Above Address Contact Person $uDDy mc-4Doto Home Phone .33' - 4(0-7 - 706 / Business Phone 336 - 7 —70 rv,C. -J PKUPEKI'Y 1NFUKMAIIUN `r*Date House/Facility Comers Flagged NOTE:. A survey plat or site plan must accompany this application. Included: 9 Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name' '&WA104- C -AW 51ITk- Phone Number336-Z5'1-7/70 Owner's Address I !F2Z NKA LanfE ...City/State/Zip 0-6- PropertyAddress & I I,Ot4l KV • L -VT b City /vtU GKr v Ivc,e Lot.Size Tax PIN# 77 - 732.?.' Subdivision Name(if applicable) FUiCOltGS r4KrhS Section/Lot# .5 Directions To Site: S- 40 -ro r*Rrn rJ&1Dr! (80 go O PlI'V50900K Dip , CD 2►+IK- OF CstN3Ekf' RD #Ny pweloicox 56ki)t_ i2D . If the answer to any of the following questions is "Yes",supporting docu�aentation must be attached: Are there any existing wastewater systems on the site? Yes No Does the site contain jurisdictional wetlands? Yes ✓No Are there any easements or right-of-ways on the site? Yes 7No Is the 'siigsubject to approval by another public agency? _Yes ✓No Will wastewater other than domestic sewage be generated? Yes ;'No TF RESIDENCE FIT J, OI TT T14F BOX RFLOW # People# Bedrooms 3- # Bathrooms 3 Garden Tub/Whirlpool ❑Yes RNo Basement: DYes Basement Plumbing: ❑Yes LR�qo TF NON -RESIDENCE FTT,L, OUT THE B0X.BFd..0W 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: iconventional ❑Accepted ❑innovative ❑Alternative ❑Other Water Supply Type:EJ County/City. Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? "I7 Yes RINo 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 ie County Heal partme t to conduct necessary inspections to determine compliance with applicable laws and rules. I un r that m re sible f roper i ntification and labeling of property lines and comers and locating and flagging or s the h e/ ac' ' 1 cati ,pro ed w 11 location and the location of any other amenities. Site Revisit Charge Property owner's or owner's representative signature -rDate(s): Client Notification Date: D to I EHS: �� 1226 cV Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # SC P rl c J�J 1 , No�'t(� _1 0 L©T' 5 UI t,WIf R.> YADKtrJ Ru cLDCPS �z58 RAWH kD. M (5 a<SftWf ITC. 7-70Z? OLopy mi-iAmws - 331-q67 --70to/ Pizopaet> I4-ou5tg I c 7.7-oO 51.4. Davie County Environmental Health P.O. Bot 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account M 990005156 Tax PIN/EH #: 5841-97-7322.5 Billed To: Ellen Furches Subdivision Info: furches Farms Lot # 5 Address: 128 Pinebrook Drive Location/Address: Pinebrook School Rd. -27208 City: Mocksville Property Size: 5.92 Acres Reference Name: 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 construcHon/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: cw ORepair OExpansion Permit Valid for: 5 Years ONo Expiration Residential Specifications: # Bedrooms #Bathrooms # PeopleBasementO Basement plumbingO Non-Residentlal Specifications: Facility Type # People # Seats L�Q Square Footage(or Dimensions of Facility) Design Flo%v(GPD): `U Type of Water Supply: OCounty/City OWell OCommunity Well As statf:i l Site Modifications/PermitConditions: System Type LTAR I Initial I X c+I—f 114 n ... 6.1 Site Plan wA . Environmental Health Specialist i.p. 11-06 Cg. C1 00� Jam`-i3�n f r Date —Dg 4 , Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990005156 Tax PIN/EH #: 5841-97-7322.5 Billed To: Ellen Furches Subdivision Info: Furches Farms Lot # 5 Address: 128 Pinebrook Drive Location/Address: Pinebrook School Rd. -27208 City: Mocksville Property Size: 5.92 Acres Reference Name: 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: CENew ❑Repair ❑Expansion Permit Valid for: [33 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats L/Q Square Footage(or Dimensions of Facility) Design Flow(GPD): `U� Type of Water Supply: ❑County/City ❑Well ❑Community Well As stated in 15A NCAC 13AA-53i3I Site Modifications/Permit Conditions: 47=cr- lnl' rd Svr'ty;rw; rn"= ' rho rv, r+! Initial Site Plan Environmental Health Specialist i.p. 11-06 LTAR d 01. V "pir J l-,& -IL Date l0 / � —ac APPLICATION FOR SITE EVALUATIONAMPRO W., Davie County Environmental Health(f P.O. Box 848/210 Hospital Street AUG �� 200 Mocksville, NC 27028 8 (336)751-8760/ Fax (336)751-8786 ENVIR �pN q fENTq(pFq(TH Application For: Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Type of Application: �Iew System ❑Repair to Existing System ❑Expansion(Modification of Existing System or 'IMPORTANT'" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed c ,-,,CetV Contact Person ei4 7" Billing Address 1'�JC// Home Phone— ���- `0 City/State/ZIP c'_/' J ;� Business Phone ��r /V35 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip VKUY1�1Kl Y INIlUK1V1A11UN "Date House/l acility Uorners ti l NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is "valid for 60 months with site plan, no expiration with complete plat.) Owner's Name' ,(/ti , /�i,� t^ C`. ` Phone Number Owner's Address City/State/Zip Property Address Gn. .__. City Lot Size Tax PIN# 5 S i1 ! j,7 `l X322 Subdivision Name(if applicable)yk Lj /u75 1J.v1; Directions To Site: / 5 ►_ n 5`l 1 r -ii rj,'14- he.. If the answer to any of the following questions is "yes", supporting c Are there any existing wastewater systems on the site? Does the site contain jurisdictional wetlands? Are there any easements or right-of-ways on the site? Is the site subject to approval by another public agency? Will wastewater other than domestic sewage be generated? IF RESIDENCE FILL OUT THE BOX BELOW Section/Lot# ,y' r Ar �< aentation must be attached. ❑Yes 1gNo ❑Yes J9No ❑Yes XNO ❑Yes SNo ❑Yes JNNo # People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑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 facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:. IRConventional Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: � County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No If yes, what type? This is to certify that the infon-nation 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 riles. I understand that I am responsible for the proper identification and labeling of property lines and corers and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. �1 Site Revisit Charge Property o mer's of owner's legal representative signature D ?- /f _ 05 Date Sign given ❑Yes ❑No Revised 11/06 ate(s). Client Notification Date: EHS: Account # Invoice # iia• 10.000 Ac. FlwA ww"I I malt .r Irraa NNW a Mor �j_]_ Si.�1�n�I qC-) a+.r:Pa. to r 370 370 370 AUH I � V W �. �� W ri y co� W � cotj Er 11 r F11 R'i ca PUBBROOK DRIVE S' -R- 1437 365 365 365 457 648 CILBE. TRACT 5 AREA = +-5.92 ACRES AREA INCLUDES R/II ap TRACT 6 AREA — +-10.45 ACRES O AREA INCLUDES RIFco n Vcl) G] � O490 04 ° t� 612 ^�. TRACT 4 __—_ DAVIE COUNTY HEALTH DEPARTMENT rt Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990005156 Tax PIN/EH #: 5841-97-7322.05 Billed To: Ellen Furches Subdivision Info: Furches Farms Lot # 05 Reference Name: Location/Address: Pinebrook Schof Rd. -27208 Proposed Facility: Residence Property Size: 5.92 Acres Date Evaluated: ' 16 Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit Public Cut L// FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH —) Texture group(� Consistence Structure Mineralogy HORIZON II DEPTH Texture groupS i G Consistence Structure Mineralogy HORIZON III DEPTH q(6- Texture group(„ Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 'Z o SITE CLASSIFICATION: J EVALUATION BY: LONG-TERM ACCEPTANCE RATE: G • 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 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 W-0 6 �CL 4ciV1 Mineralogy 1:1, 2:1, Mixed LYQtss 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) T TA D T --- +--.....--------- -..+e -11A-141 T %f'TTr% AC /AC in