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122 Caudle Meadows Drive Lot 708Applicant: The Veritas Group Inc Property Owner. The Veritas Group Inc a. Address: PO Box 528 OPERATION PERMIT - Davie County Health Department 27285 State/Zip.' NC 27285 210 Hospital Street Phone #: (336) 404-1522 P.O. Box 848 Location & Site Information Mocksville NO 27028 SubdWsion: Saddlebrook @ Sawgrass Phase: Lot: 708 Phone: 336-753-6780 Fax: 336.753-1680 Applicant: The Veritas Group Inc Property Owner. The Veritas Group Inc Address: PO Box 528 Address: PO Box 528 City: Kemersviile Cay: Kemersville State/Zip: NC 27285 State/Zip.' NC 27285 Phone #: (336) 404-1522 Phone #: (336) 404-1522 Provertv Location & Site Information Address/Road #: SubdWsion: Saddlebrook @ Sawgrass Phase: Lot: 708 Caudle Meadows Drive Advance NO 27006 Directions Structure: SINGLE FAMILY Hwy 158 right on hwy 801, right on Mocks Church Rd. right on Beauchamp Rd. road on right # of Bedrooms: 4 # of People: y: PUBLIC j System Classification/Description: . TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) : 2140 -Nations, Robert rDesignFlow: Saproiite System? ®Yes QNo 4 8 0 OistributionType: GRAVITY -SERIAL Pump Required? QYes QNo on Rate: 0 .2 7 5 'Pre Treatment: Drain field Nlrification Field 1 7 4 5 Sq. It. 'System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 4 Installer: Frank Transou Total Trench Length: 4 4 2 ft. Certification #: 2771 Trench Spacing: -9 Inches O.C. • Feet O.C. 'EH S: 2140 - Nat ons. Robert Trench Width:Inches —. 3 BFeet 0, 8 / 1 1/ x 0 1 5 i Date: _ Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 1 4 _ Inches Approval Status MaximumTrenchDepth, 3 6 '� Approved❑ Dlsapproved� Inches Maximum Soil Cover: 2 4 Inches CDP File Number 191385 -1 Manufacturer. Shoaf STB: 760 Gallons: 1000 Manufacturer. Date: 0 5/ a 4/ a 0 1 5 *Filter Brand: POLYLOKPL-122 With Pipe Adapter ST Marker. ❑ Yes ® No nforced Tank: ❑ Yes 0 No 1 Piece Tank: ❑ Yes R No Date: / / County ID Number: - Lat. Long: Installer: FrankTransou Certification #: 2771 *EHS: 2140 - Nations, Robert Date: 0 8/ 1 1 / 2 0 1 5 'Approval Stl. atus App'roved ❑ El— Pump Pump Tank Manufacturer. Installer. PT: Certification #: Gallons: *EHS: Date: / / Date: RiserSeeled ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced rank: ❑ Yes ❑ No ❑ Approved ❑ Disapproved 1 Piece Tank: ❑Yes ❑ No . .. Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification #: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings ❑Yes ❑ NO Appioval Status Approved ❑ ,Disapproved Pump Requirement 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 i. ,Approval; Status s PVC Unions ❑ Yes ❑ No E] 'A Disapproved Vent Hole ❑ Yes ❑ NO Anti -siphon Hole ❑ Yes 0 No CDP File N umber' d 91385 -1 NEMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj.To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: Electric ❑ No ❑ No ❑ No ❑ No ❑ No Alarm Audible ❑ Yes ❑ No `. Alarm Visible ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed by: County ID Number: Installer. Certification #: *EHS: Date: / / Approval Status ❑°"Approved ❑ Disapproved= Authorized State Agent: 1 _--"'O",4Date of Issue: 0 8/ 1 1/ 2 0 1 5 Owner/Applicant Signature: 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 at. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served bye TYPE a A. sewage septic system. - `Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria: - Minimum System Review ByThe Local Health Department: N/A ,. __Management Entity: OWNER Minimum System Inspection)Maintenance Frequency By Certified Operator: WA Reporting Frequency By Certified Operator: IVA Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the 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) (a) 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 bye public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements form aintenance 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. ft shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. (F)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: 191385-1 County File Number: 27028 Date: W W ` O Inch Scale: OBlock ON/A NOREEN MEN ONO o.;.smommoommoommommo� me MENNNOMMENEEMMEN No MMENOMEN MEMNON / 5=111110 ME IN IN ME No moommomommomommomm ME ■ No � ME No o ■a MEME■ ■EN ■ m■ MENEM -CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. BOX 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: The Veritas Group Inc Address: PO Box 528 City: Kernersvilie State/Zip: NC Phone #: (336) 404-,1522 Address/Road M Caudle Meadows Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC For Office Use Onlv 'CDP Flle Number 1913857"':1 °'' i,ghl"I County ID Number. , Evaluated For I NEW 0 3/ 1 7/ a 0 a 0 Owner: The Veritas Group Inc Address: PO Box 528 City: Kemersville 27285 State2ip: NC 27285 Phone #: (336) 404-1522 Subdi4ision: Saddlebrook @ Sawgrass Phase: Classification: Provisionally Suitable Saprolite System? Oyes ®No Design Flow: 4 8 0 Directions \ Hwy 158 right on hwy 801, right on Mocks Church Rd. right on Beauchamp Rd. road on right I 1 Minimum Trench Depth: a 4 Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY -SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 _ Gallons `Proposed System: 25% REDUCTION 1 -Piece: OYes OQ No Pump Required: 'OYes®No OMay Be Required Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece; OYes ONo Total Trench Length: 4 3 6 ft, GPM—vs— ft. TDH Trench Spacing: Inches O.C. 9 . ®Feet O.C. Dosing Volume: _ Gallons Trench Width: Inches — 3 BFeet Grease Trap: Gallons Aggregate Depth: inches PreTreatment: ONSF OTS -1 OTS -11 Septic Tank lnstallerGrade Level Required: 01 OII 0111 OIV Dena 4 ^f'A CDP File Number 191385 - 1 County ID Number.. ❑ Open Pump System Sheet ONO ONO, but has Available '"��" �' ""' *Site Trench Spacing: Inches O: 9 Feet O.C. Classification: ,Provisionally Suitable — Trench Width: Q Inches 3 gFeet Design Flow: 4 8 0 — Depth: Soil Application Rate:Aggregate 0 - a 7 5 inches Minimum Trench Depth: a 4 Inches *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD_OR LESS) Minimum Soil Cover 1 i2 Inches *Proposed Maximum Trench Depth: 3 6 Inches System: 25% REDUCTION Maximum Soil Cover. a 4 Nitrification Field 1 7 4 5Sq. ft. Inches No. Drain Lines *Distribution Type: GRAVITY -SERIAL 4 Total Trench Length: 4 '3 '6' Pump Required: Oyes ®No OMay Be Required it. \ Pre -Treatment: ONSF OTS -1 OTS -11 , *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 wayguarantees the Issuance of other per fts. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit not to exceed five years, and maybe issued atthe sanetims the improvement Penult issued (NCGS 130A336(b)} If the installation has not been completed during the period of validity ofthe Construction Permit, 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 permit or Construction Authorization shall became invalid, and maybe suspended or revoked (.1937(g)). The person owning or, controlling the system shall be responsible forassurintg compliance with the laws, rules, and permit conditions regarding system location, Installation, opera0on, maintenance, monitoring, reporting and repair (1939(b)). _ Applicent/Legal Reps. Signature Required? OYes ONO ApplicenVLegal Reps. Signature: Date:, / / *Issued By: 2140 -Nations, Robert Date of Issue: 0 3/ 1 7/ 2 0 1 5 Authorized State Agent Malfunction Log OYes I,+' ®Hand Drawing OlmportDrawing **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: 191385 -1 County File Number: Date: 03/13/2015 W W Q Inch Scale:. 0131ock ft. APPLICATION FOR SITE EVALUATION/IMPROVEWNT PERNIIT & ATC RECEIVED Davie County Environmental Health P.O. Box 848/210 Hospital Street PA Mocksville, NC 27028 Date: /� (336)753-6780/ Fax753-1680 Application For: D Site Evaluation/improvement Permit Authorization To Construct (ATC) D Both Type of Application: DNew System DRepair to Existing System DExpansion/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 INFORMATION Name —17ig- UeC�6,5 Gtoo,y . ?Ju= Address V-0. t5oyc City/State/ZIP Crr�e15 ✓! / !�-p�7a� Email white✓P,E L S . ed-' — Name on Permit/ATC if Different than Above ^— Mailing Address wMm»a swei►;asi:+wra4C91►1 Date Home Phone isinessPhone 33G-yar/tS'a� NOTE: A survey plat or site plan must accompany this application. Included: D Site Plan DPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name T7 --e en &-s lo'roo Phone Number 33 Owner's Address d•134x S�'p2 «ners+�f t�,e City/State/Zip /vim �' Property Address P_(►�u C It ML� City Lot Size Tax PIN# r7 Subdivision Name(if applicable) IL Ik!!< Section/Lot# /(i Directions To Site: 5so/ So%.A� •-,e U.16« /5).,!.1 Specify Problem Occurring: IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathrooms .2 •S Garden Tub/Whirlpoo J4Yes DNo Basement: OYes Po Basement Plumbing: ❑Yes 0&0 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: Oonventional DAccepted ❑Innovative DAltemative ❑Other Water Supply Type: Vounty/City Water D New Well DExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ko If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my Imowledge. 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 corners and locating and flagging or �C@ ng hoes / ' ' location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given DYes []No Revised 11/06 IV, Account # —� Invoice # N �Or 310 2 z X)VaL32 d A Nv3N m Q W ¢:, �_ { ()' Sv 0 x ow m cN - Tag FY Q=z Iy t` o o H _ m Q LL r• H W g I,� o EN D my 3 a O 2 O z :� s9'o6 )Ovam Imm AY - - - - I 0 O O q _ - Z Q f N z 3.££.ZS.00N AvM—d0 1FI9s1 ollBod As - 2 K W-2 W � y v ❑ I � -�n Q z W 'z q} '� ia(l Sd OTM Man S4 z mr rc4 o F F m •- o s W, og. z APPLICATION FOR :+ITE EVALUATION/IMP ROVEMENT PERMIT & ATC )Davie County Health Department Environmental Health Section HOP P.O. Box &18/210 Hospital StreetMocksville,NC 27028 (336)751-8760/ Fax (336)7:51-8786 Application For. O Site EvatuetionMtBavement Permit O Amhorizat on To Conshvct(ATO O Both - ••?MPORTAANrP ' THIS APPLICATION CANNOTBE PROCESSED UPILESS ALL OF THE REQUB2ED INFORMATION IS PROVIDED. Re:'er m tate INFORMATION BULLET:Y for instructions. APPLICANT INFORMATION_' QaI< Alt G q Name to be Billed A -f o 4 ' Cortact Person Billing Address P_a Hume Phone City/State/Zll l . 2.� "� IOI BBusiness Phone_ Z^UD Name on Permit/ATC if Different Ilan Above ^ . NOTE: A survey plat or site plan must accompany this application (Permit u vagd for 60 months with site plana, an expiration with coaplete plat.) Street inion s�� -a�---City' Ti PI Subdivision Name ay. �SectioM.o{ii ,�0.�ogf-S,i�u*_ Directions To Site: u Date House/Fscility Comets Flagged M A v,,L If the amwer to any ofthe following questions is "Yes". supporting documcmatiopp mmtbe aczebed. Are them any existing IMLAMrter systems on the site? OYta QtyiC Dow the site contain jurisdictional wetlands? OYss Flo - An there guy <ssemmm or right-of-ways on the site? OY: s BNo Is the site subject to approval Sy mother public agency? OYs s ONO —11 ....... he eemrated? OYza ONo IF RESIDENCE FILL OUT TBI" BOX BELOW C ve t r n #People #BedrXeM #'Sa ores Garde»Tub/WI»ripool OYes ONo Basement OYes ONo Basse:nempl ing: OYes ONo IF NON -RESIDENCE FILL OL"TTHEBOXBELOW - Type of Facility/BusinessTotal Square Foolage of Building_ #People # Sinks # Commodes # Sbowcrs _. _ # Urinals Estimated Water Usage (gallons por day) (Attach doc,mrentation of similar facility water consumption) FOODSERVICE ONLY: #Seals Type systemrequested: WCanventioml OAccepted ❑lmovative OAltemative nOther. Water Supply Type: Aunty/City Fater D New Well OFiisting Well O Community Well Do you anticipate addition or expammm of the facility this system is intended to serve? O Yes 0<1 If yes, what type? Ibis is to certify that lir infommation:,irovided on this application is true and correct to the best of my knowledge. 1 understand that any permit(s) orATC(s) issued hared: are eubjeet m suspension m revue ation if the site is altered, the intended me changes, or if the information submitted in this application is falsified or changed 1 undr atand that lam respansiblefor all charger inearred from this application. I hereby grant right of eeny to the Authorized Rope aentative of the Davie County Health Departmeutto conduct necessary inspections name compliance with applicable lava and rules an the above des�mibJjeed, �prroperty Wanted is Davie unty, and ow,eeddbY^ ll/n%I• gSjB(.l Nf+'ir LI rI• Pw/n""'S�'n t7onrc l,,w An Site Revisit Charge EHS: Sign given DYes ONO Revised 2106 Account# Invoice # EM V LS =APR6D W Davie County He: r.v. (336)' .May 1, 2006 Oak Valley Associates, Ltd. Partnership Attn: Bo Davis 3401 Healy Drive Winston-Salem, NC 27103 u Re: SAWGRASS Proposed Subdivision / Lot # Caudle Tract / Beauchamp Road Tax PIN# 5871252458 Dear Client(s): As requested, a representative from this office visited the above site April 11, 12, 18, 2006 to perform site evaluations. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. . This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Server 4 82 QG51lit= Wastewater Design Flow: 4FC) System Type: ❑Conventtionnal ?Jcepted ❑Innovative ❑Alternative ❑Other System Location:I«= ibt7l� Valid: 2 'years ❑No Expiration Site Modifications/Permit Conditions: f 4-J1 inri Enviro c' ist jDat ps-i.p.letter 2/06 y lz 3 Sq. Ft..l rotno9e Es 30,894 es_ dC:OUrSe Drive SL. Andrews Golf Villas n Section 98. Phate II, Section -2 Plot Book 8, Page 21 S Ft. Q I \Q e FI Sq. • p\g° n 33,426 Sq. Ft. 9 \9s\ O 35,081 Sq. Ft. E:1 , 148. _ = 4Ft. 243'88 5q. Ft. 270 ler0 co N I 16 I w op i o 33,69 Sq. Ft. , I � zsa Kassel I 17 ' n Kasselv, igo 859 30,1 50 Sq. Ft. F1 ^I 327 18 1 B I J 30,060 Sq. Ft. n 34,956 Sq. Ft. la 35,486 Sq. Ft. 145'- 142' "t— —♦ 0 227'— 'Ii a �^ n II !� 30,080 Sq. Ft. 0 30,080 Sq. R. i I 4 �I f 30, 74 Sc{. Ft. � I 1 ./A I 251 20 4th m erOw J 30,137 Sd. Ft. I a1nPI 22' >O1 626 ba dR�Csli _ 9ht Of Ways 6�1 .1,,a1 LSI T 30,078 Sq. Ft. O 30,078 Sq. Ft. in O i 30.040 Sq. Ft. 237 O I 31,107 Sq. Ft. yl0 \P ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003765 Tax PIN/EH #: 5871-25-2458.03 Billed To: Oak Valley Associates Limited Partne Subdivision Info: Sawgrass Lot # 03 Reference Name: Bo Davis Location/Address: Beauchamp Rd -27006 Proposed Facility: Residence Property Size: see map Date Evaluated: 4112 -IOC -0 Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit Cut .FACTORS 1 2 3 4 5; 6 7 Landscape position LL .'-,Slope % HORIZON I DEPTH Texture groupG. .. .' .G' - Consistence Structure S3 S3 -Mineralogy HORIZON H DEPTH _ 30 Texture group Consistence, Structure g Mineralogy. -HORIZON IH DEPTH --7-7 Texture group O(S,L, 5; Consistence Structure yv\ Mineralogy HORIZON IV DEPTH Texture group Consistence .: .... Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON. •. _ SAPROLITE .,., CLASSIFICATION LONG-TERM ACCEPTANCE RATE p. 'SITE CLASSIFICATION: EVALUATION BY: , 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 - Floodplain 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 ENCE CONSIST I , VFR =Very friable FR -Friable FI -Firm VFI -Very flim EFI -Extremely firm _ NS = Non sticky Slightly sticky" S Sticky VS = Very la NP - Non plastic SP' Slightly P -Plastic VP -Very pplastish c Structure SC - Single grain M Massive, CR Crumb GR - Granular ABK -Angular blocky SBK - Subangular blocky PL - Platy - PR Prismatic • MineraI6 : 1: 1, 2: 1, Mixed Horizon depth - In inches ... r d , Depth of fill'- In inches r = i Restrictive horizon 'Thickness and inches from an surface 1 Soil Wetness - Inches) n hes)from land surface to free water or inches from .' ;. m land surface to soil colors wtt6 chroma 2 or less . . Classification-,S(suitable), PS(provisionally;suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)