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209 Sawgrass Drive Lot 715OPERATION PERMIT �. Davie County Health Department 210 Hospital Street .� P.O. Box 848 =' Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Isenhour Homes Address: 3411 Healy Drive CRY: Winston-Salem State2ip: NC 27103 Phone #: (336) 659-8211 Property owner: Oak Valley LTD Associates Address: PO Box 10 . !CRY: Bethania :State0p: NC 27010 Phone #: 1 -roper[ Locduon & . Ite rnrormanon Address/Road M Subdivision: Saddlebrook Phase: Lot: 715 209 Sawgrass Or Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy, 158, right on Hwy 801 right on Mocks Church Rd. right on Beauchamp road on the rignt 1# of Bedrooms: 4 # of People: *Water Su I ' PUBLIC VF Y. . *IP Issued by. 'System Classification/Description: TYPE III B. SYSTEM VV/SINGLE EFFLUENT PUMP *CA issued by: 2140- Nations, Robert Saprolite System? QYes @No Design Flow: 4 8 0 * PUMP TO GRAVITY Pump Required? *Dist Q. Yes QNo Soil Application Rate: 0 2 3 5 *PreTreatment: Drain field N drification Field 1 7 4 5 Sq. ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 8 Installer: FrankTransou Total Trench Length: 4 , 5 0 ft. Certification #: 2771 Trench Spacing: — 9 BFeetO.C. Inches O.C. 'EH S: 2140 -Nations, Robert Trench Width: — 3 @Feet Inches 0 7/ 0 6/ x 0 1 6 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, a 4 Inches Approval Status Maximum Trench Depth:3 6 91 A❑Approved Inches - Maximum Soil Cover. a 4 Inches CDP File Number 198618-.1 County ID Number: f . Septic Tank Manufacturer. Shoal Lat. STB: 763 Long: Gallons: 1000 Installer FrankTransou Date: 0 4/ 1- 1/ x 0 1,6 Certification #: 2771 *EHS: 2140 - Nations, Robert *F11te r B ra n d: POLYLOK PL -1 22 With Pipe Adapter ST Marker: ❑Yes ❑ No Date: 0 7/ .0 6/ a 0 1 6 nforced Tank: ElYes CC NO Approval Status Z 1 Approved ❑ Disapproved 1 Piece lank: ❑Yes ©No Pump Tank Manufacturer Shoat Installer Frank Transou PTI 1363 Certification #: 2771 Gallons: 1000 —• *EHS: 2140 -Nations, Robert Date: 0 4. / 1 .1 ./ x 0 1 6 Date: 0 7/ 0 6/ 2 0 1 6 RiserSealed'Pol Yes ❑' NO RiserHeght: ®-Yes _- ❑ No (Min.6in.) ApprovalStetus Reinforced Tank: ❑Yes !] No® Appoved ❑ Disapproved 1 PieceTank..-❑� . Yes ❑ Supply Line Pipe Size: a inch diameter Installer. Frank Transou Pipe Length: 1 5 0 feet Certification *EHS: 2140 - Nations, Robert *Schedule: 40 Pressure Rated ® Yes ❑ No Date: 0 7/ 0 6/ 2 0 1 6 Approved fittings (] Yes ❑ No Approval Status 'RA AD ❑;Disappro`ved ; Pump Requirement Pump Type: zoeter Installer. Frank Transou Dosing Volume: - Gal Certification#: 2771 Draw Down: Inches *EHS: 2140 - Nations, Robert *Chain: Data: 0 7/ 0 6/.1 0 1 6 Valves Accessible O Yes ❑ No Flow Adjustment Valve ® Yes ❑ No Check -valve El Yes El No Approval Status PVC Unions O Yes ❑ No! , ® Approved ❑ "D' IE Vent Hole [i] Yes ❑ No Anti -siphon Hole 2 .Yes ❑ NO CDP<File Number 198618-1 electric / NEMA4X Box or Equivalent p Yes ❑ N0 Box 12 inches Above Grade ❑r Yes ❑ No Box Adi.To Pump Tank [E Yes ❑ No Conduit Sealed p Yes ❑ No Pump Manually Operable p Yes ❑ No *Activation Method: PIGGYBACK Alarm Audible [E Yes ❑ No Alarm Visible p Yes ❑ No County ID Number: Installer: FrankTransou Certification #: 2771 'EH S: 2140 -Nations, Robert 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 0 7/ 0 6/ 2 0 1 6 _ Owner/Applicant Signature: _. ..<_ This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for,r__. : 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 septi0 system. - - - = Rule -1961 requires lhata Type TYPEIIIB. septic system meetthe following criteria: Minimum System Review ByThe Local Health Department: SYRs. Management Entity: OWNER --Minimum System Inspection/Maintenance Frequency By Certified Operator: - WA Reporting Frequency By Certified Operator: N/A 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 entilywth 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 entitywith a certified operatorforthe 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 Permitfor a system required to be maintained by a public or private management entity, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. it shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing OlmportDrawing ° � **Site Plan/Drawing attached.** ' 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: Isenhour Homes Address: 3411 Healy Drive City: Winston-Salem StatefZip: NC Phone #: (336) 659-8211 'For Office Use DO `CDP File Number 198618-1 0 7/ 0 5/ a 0 a 1 Property Owner: Oak Valley LTD Associates Address: PO Box 10 City: Bethania 27103` Statefzip: NC 27010 Phone #: Address/Road #: Subdivision:. Saddlebrook Phase: Lot: 715 209 Sawgrass Dr Advance NC 27006 Directions - ' Hwy 158, right on Hwy 801 right on Mocks Church Rd. Strtiature: SINGLE FAMILY__ right on Beauchamp road on the rignt # of Bedrooms: 4 # of People: *Water Supply: PUBLIC Site Classification: Provisionally Suitable Saprolite System? OYes ®No Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: 1 7 4 5 Sq. ft. 8 1 a 4 3 6 ft. Minimum Trench Depth: a 4 Inches Minimum Soil Cover. 1 a Inches j Maximum Trench Depth: a 4 Inches Maximum Soil Cover. 1 a Inches *Distribution Type: PUMP TO GRAVITY Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes OQ No Pump Required: Yes ONo OMay Be Required Pump Tank: 1 0 0 0 Gallons 1-Piece:OYes ®No GPM—vs— ft. TDH 9 QInches O.C. DosingVolume: _ Gallons r Feet O.C. "Inches 3 Feet Grease Trap: Gallons inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01 011 OIII OIV oe�e I MQ CDP File Number 198618-1 County ID Number. ❑ Open Pump Syslem Sheet Repair System Required: *Yes ONO ONO, but has Available Space epair SVstem Trench Spacing: 8 O Inches 0. 'Site Classification: Provisionally Suitable - • Feet O.C. Trench Width: OInches Design Flow: 4 8 0 - a s Feet Soil Application Rate:0 a 5 Aggregate Depth: inches "System Classification/Description: TYPE III B. SYSTEM w/SINGLE EFFLUENT PUMP 'Proposed System: 35% REDUCTION Nitrification Field 3 a 0 sq. n. No. Drain Lines 5 Total Trench Length,— 3 5 0 g Minimum Trench Depth: a 8 Inches Minimum Soil Cover. i 1 a Inches Maximum Trench Depth: 4 a Inches Maximum Soil Cover. a 6 Inches 'Distribution Type: PRESSURE MANIFOLD Pump Required: OYes ONo (May Be Required PreTreatment: ONSF OTS -1 OTS -II "Site Modifications No grading orconstruction activfty is allowed in areas designated for system and repair without approval of Health Department. i "Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Richard Ferris, licensed soil scientist, layed out two systems for property showing that an Initial system could fit a 25% reduction and the repair 50% reduction. This permit was revised to reflect to accomodate the 25% reduction. This Authorization for Wastewater System construction shall bevalid for a person equal to the period of validity ofthe Improvement Permit, not to exceed five years, and may be Issued atthe sametlme the Improvement Permit Issued (NCGS 130A -336(b)). If theinstallatlon has not been completed during the period of wlldity, of the Construction Permit, the Information submitted In the application for a permit or Construction Authorization Is found to have been Incorrect, falsified or changed, or the siteis altered, the pernitorConstruction Authorization shall became Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible forassuring 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 Authorized State Agent: Date of Issue:. 0 7/ 0 5/.1 0 1 6 Malfunction Log OYes ®Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department r' 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number. 198618 -1 County File Number. Date: 07/05 /20 16 W W Olnch Scale:. . .OBlock ON/A MNMEMMMMMMMMMMMMMEMM MEN MMMEMMMMEMMEMMIEMMEMMMMMM MMMNMMMMMMMMMMMMMIEMMMMEM MMOMMMMMEM MMM NO WE MEMO MMMMMMMMMM MMMIEMM MMMIEMMMM ME MMMMME ON MMM ME MMM SEEM M EMMMMM EMM MEN ME MMMMMMM CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 198618 -1 P.O. Box 848 Moaksviile NC 27028 County File Number: Click below to Import an Inpage from an external Date: 07/ 05 /2016 Drawing Type: Construction Authorization t 3 Cs3 j h�o`F t �o " I�op4. -743 ---------- k za sl.n.F 1 SL hl A 114 Ne) to in L -L of r" t ,:•��.,`��' tip rets �9}� di cit v rii'' 1 t t sw s' E--- t ,•. tz Iz t4� 1 a, TeR�b _ t 3co '3 ll' y � i ", , ; , 9 3 3,7.x• , � SaM,�Q1t pyQor.�2 t'.�-�-' - o t5 fl 1 (ol S• � 33 i. , .501 r-. _ i. 49, 15(�2-RH38 0S #ed 50 i % Ni -12 o� •[��-511.1 � Z� � � - - �� `/` ' ` 14 40 ' Ln C G � C � Z C 4ONYTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street 1' P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Isenhour Homes Address: 3411 Healy Drive CRY: Winston-Salem State0p:. NC Phone #: (336) 659-8211 Address/Road #: 209 Sawgrass Dr Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 'Water Supply: PUBLIC Classification: PS LPP 27103 Address: CRY: State/Zip: Phone #: Subdivision: Saddlebrook SeproliteSystem? OYes ®No Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 'System Classification/Description: TYPE IV A. ANY SYSTEM WITH LPP DISTRIBUTION `Proposed System: 50% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. 'CDP File Number 198618 -1 County ID Number. Evaluated For.- NEW Township: i a/ 0 9/ a 0 a 0 Oak Valley LTD Associates PO Box 10 ti Bethania NC 27010 Phase: Lot: 715 Directions Hwy 158, right on Hwy 801 right on Mocks Church Rd. right on Beauchamp road on the rignt Minimum Trench Depth: a 8 Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 4 a Inches Maximum Soil Cover: a 6 Inches 'Distribution Type: LOW PRESSURE PIPE Septic Tank: 1; 0 0 0 Gallons 1 -Piece: OYes ®No Pump Required:®Yes ONo OMay Be Required Pump Tank: 1 0 0 0 Gallons No. Drain Lines 4 1 -Piece: OYes ONo Total Trench Length: a 9 1 ft GPM—vs— ft. TDH Trench Spacing: 8 QInches O.C. Dosing Volume: Gallons BFeet O.C. — Trench Width:Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -11 Septic Tank InstallerGrade Level Required: '01 OII OIII OIV D... a ,sl CDP File Number 198618-1 County ID Numt'rer ❑ Open Pump System Sheet Repair System Required:®Yes ONO ONo, but has Available Space /Repair System Trench Spacing: 8Inches 0! 'Site Classification: PS LPP — t► Feet O.C. Trench Width: Inches Design Flow: 4 8 0 — a • Feet Soil Application Rate: 0 Aggregate Depth: - a � 5 inches Minimum Trench Depth: a 8 Inches *System Classification/Description: TYPE It A. COW SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS), Minimum Soil Cover .1 a Inches 'Proposed System: 50% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 5 Total Trench. Length: a 9 1 ft. Maximum Trench Depth: 4 a _ Inches Maximum Soil Cover: a 6 Inches 'Distribution Type: LOW PRESSURE PIPE Pump Required: Oyes ONo. OMay 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. i "Permit Conditions The issuance of th is permit by the Health Department in no way guarantees the issuance of other permits. The permit holder Is responsible forchecking with appropriate governing bodies in meeting their requirements. ; This Authorization for Wastewater System construction shall bevalid fora person equal to the period of validity ofthe Improvement Penni; not to exceed five years, and may be issued atthe smetime the Improvement Permit Issued (NCGS 130A-336(11)} If theInstallation has not been completed during the period of validity of the construction Permit, the information submitted in the application for a permit or Construction Authorization Is found to have been 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 for assuring compliance with the laws, rides, and permit conditions regarding system location, Installation, operatioh, maintenance, monitoring, reporting and repair -(1936(b)). Applicant(Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: _ / 'Issued By: 2140 -Nations, Robert.Date of Issue: 1 a/ 0 9/ a 0 1 5 Authorized State Agent Malfunction Log Oyes ' s ®Hand Drawing OlmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION u Davis CountyHealth Department 198618 - 1 CDP File Number: 210 Hospital Street P.O. Box 848 County File Number: Mocksville NC 27028 Date: 12/09/.10 1 5 W W Q loch Drawing Drawing Type Construction Authorization Scale:. . . OBlock = t QN/A e,a [� w d^ 7-1 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 198618 -1 P.O. Box 848 Mocksville NC 27028 County File Number: Date:.1.2./ �/ 09 /2015 Click below to Import an Image from an external location: Drawing Type: Construction Authorization APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC - (�� A Davie County Edvir`ontnehtal Ae'a4tti_ - �,p„yX"' r P O. $8x 948/210',i'os411a1_$tWegk x ( 2i) 75 . (33�7536780/k'ax (336)753-1690 \\ Application For. O Site Evaluationlimprovement Permit D Authorization To Construct(ATC) }oth Type of Application:�I law System DRepeir to Existing System OExpansiodModitScation ofExist. System or Facility *••IMPORTANT••• THIS APPLICATION CA TBE PROCESSEDUNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name tope Billed 1501 O YIAQ 5, Contact Person �k0 h[7tQ 0neV1Y Billing Address Home Phone City/State/ZIP C, Business Phone KS Name on PermiVATC if Different than Above a -1\.v3 _ #People #Bedrooms #Bathrooms_ Garden Tub/Whirlpool 7,Yes ONo Ra2ement• nVes rWa Basement Plum ine: DYes OND 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 requesteed.- conventional DAccepted DIi111DVative DAltemative OOlher Water Supply Type: ytyounty/City Water D New Well ❑Existing Well R Comm`unityWell Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes tlno 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. 1 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 propertylines and comers and 'locatigg and fla ging or staking the house/facility location,proposed well location and the location of any other amenities. 1,, . I% 1/n., C ^^ R Site Revisit Charge Property mvner's or owner's legal-a'present rve signatate Date(s): Client Notification Date; Date EdS: - Sign given DYes ONo Revised 11/06 Account # LIN 2 Invoice # 010 PROPERTY INFORMATION e *Date HouseMacility Comers Fla ed 11 NOTE: A survey plat or site plan must accompany this application. Included:Site Plan OPlat(to scale) (Permit is valid for 60 months with 'te plan, no expiration with completdplat.) Owner's Name CkAK\1 ovS It 4 Sr, 5 C1A-Irt Phone Nbgr_�_ Owner's Address n 0 rb I n -- City State2ip �tt'C'VvG'Y�t A T Property Address W � CitY� I��1 Subdivision ns To Site(ifapplicable)_,, �i� •� 1'ction ra"-T �C) Lot Size .-1m(i Tex CPOCTS Directions To Site: �•e,fld. ldna n vim_ SaVill - If the answer to any of the fol otving questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? Oyes-ko Does the site containjurisdictional wetlands? Oyes o Are there any easements or right-of-ways on the site? OYes�o . Is the site subject to approval by another public agency? ' Oyes o Will wastewater other than domestic seweee be aeneraled7 DYes o ' #People #Bedrooms #Bathrooms_ Garden Tub/Whirlpool 7,Yes ONo Ra2ement• nVes rWa Basement Plum ine: DYes OND 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 requesteed.- conventional DAccepted DIi111DVative DAltemative OOlher Water Supply Type: ytyounty/City Water D New Well ❑Existing Well R Comm`unityWell Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes tlno 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. 1 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 propertylines and comers and 'locatigg and fla ging or staking the house/facility location,proposed well location and the location of any other amenities. 1,, . I% 1/n., C ^^ R Site Revisit Charge Property mvner's or owner's legal-a'present rve signatate Date(s): Client Notification Date; Date EdS: - Sign given DYes ONo Revised 11/06 Account # LIN 2 Invoice # 010 SITE PLAN \E -"/ -I Ci GALE: I'= 30'-0' �H�a -�a r wP40 r \ \ 0 mm \ r / s � \ i, APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County'Enviro.nmental Health- P.O. Box 848/210 Hospital Street - Mocksville, NC 27028 - .(336)753.6780/Fax .(336)753-1680 Application For: O Site Evaluation/Improvement permit '' O Authorization To Construct (ATC) O Doth Type of Application. ONew System ORepair to Existing System OExpansio lIModification of Existing System or Facility •VMPORT-4M... THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF TH&REQUIRED 1ORhfATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name Da -,rJ66 - - Contact Person j4.,�wassi. IKy 1, II _ Address IM0 A,,") IrAi- 16ek Home PhoneT City/State/71P �ttiw j(h C 1ef360 Business Phon�{�L Name on Permit/ATC if Different than Above I'RUFk.K1Y INFORMATION - - . *Date House/Facility Comers Flaeeed NOTE: A survey plat or site plan must accompany this application. Included: n Site Plan OPlat(to scale) (permit is valid for 60 months with site plan•, no expiration with Owner's Name 0,PA Horns, complete plat.) Owner's Address. 24 Ami—I6,, itt9� d... •F,_ 1\OA Phone Nttmbe City/Styto/Ztp /1'ie Property Address Lot Size_26P:rZ — Tax PIN# ? 2 Clty /stn . Subdivision Name(if applicable) 3WIPhrnek 715_ Directions To Site: _Section/Lot# 915. If the answer to any of the following questions is"Yes',supponing documentation must be attached: Are there any existingwastewater systems on the site? ._Yes No -� Does the site coatainjurisdictioaal wetlands? Yes' No Are Otere any casements or right-of-ways on the site? No _Yes Is the site subject to approval by another public agency? - Yes No - - Will wastewater other than domestic sewage be generated? " _ YesNo People # asement: OYes ONo 1F NON -RESIDENCE FILL OUT THE BOX BELOW Oyes Type of Facility/Business - Total Square Footage of Building_, #People # Sinks # Commodes # Showers ' _ - #Urinals Estimated Water Usage (gallons per day) (Attach documentation df similar facility water consumption) FOODSERVICE ONLY: Seats - Type system requested: t2(Conventional OAccepted OInnovative OAltemative- Liblher_jyra/)nrJ Water Supply Type: O County/City Water .O New Well OExisting Well O Community Well Do you anticipate additions orexpansions of the facility this system is intended to serve? O Yes - O 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 permits) 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 heroby grant right of entry to the Authorized, Representative of the Davie County Health Department to is necessary,inspections to determine compliance with apphcabl'e'r . laws and rules. I understand that I'a n responsible for the proper identification and labeling of property lines and comers and ' lucalifng and flagging or he housdfecilicy location, proposed welt location and the location of any other amenities.. Proper owner's or owner's legal representati a signature - . Site Revisit Charge Datc(s):_ Chcnt Notification Date: ENS: Signgiven Oyes ONO - - ACCmant# Revised 11106 _ _ _ Invoice'# - APPLICATION FOR SITE EVALUATIONAMP WVEMENT PERMIT & ATC Davie County Health Department Environmental Health 8eetion P.O. Box 848/210 Hospital Street • MocksvWe, NC 27028 (336)751-8760/Fax(336)71-8786 Application For. ❑Site E"101ionAmpnvemem Perm"[ O Authorial on To ConstrucQATC) nBoth "'IMPORTANY'" THIS APPLICA•l11 INFORMATION IS PROVIDED. Re'er Name to be Bill Billing Address City/State/ZIP _ Name on Permit/ATC if Different t1an Mailing Address _ A survey plat or all (Pewit is valid for Directions To Site: must accompany this applicatiom uhs with site plan, no expiration v ESS ALL for insuu, Phone sPhone 'JO ....,.,,,,..._._.._�e.- If the aoswerto any ofthe following questions is "yes", supporting docuniamatiop most be attached. Are there any existing wasmwder systems on the site? OYis Does the site contain jurisdictional wetlands? Ms X. Are there any easements or ripht-of-ways on the site? OYcs ONO 1, the site subject to approval'uy another public agency? OYr s ONo IF RESIDENCE FILL OUT THI?BOX BELOW (v b '.t SA V�IUh #People #Bednwms_ a a ams Gardcn Tub/Whirlpool OYes ONo n_.......^..� w. e. Yes ONonv— mO IF NON -RESIDENCE FILL OL'T THE BOX BELOW Type of Facility/Business Total Square Footage of Building_ #People # Sinks # Commodes # Showers _.— # Urinals Estimated Water Usage (gallons per day) (Attach doc.onentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested: t(Couventimtl oAccepted Olune"tive oAhernative nother water Supply Type: ([County/City B'etor - O Now Well OFxisting Well O Community Well Do you anticipate additions or expam,ons of the facility this system is intended to serve? O Yes 9<1 If yes, what type? _ This is to certify that the information rimvided on this application is true end correct to the best of my knowledge. l understand that any permits) or ATC(s) issued heneaf.w em subject to suspension or revoe ation if the site is altered, the intended use changes, or if the infiernation submitted in ilia application is falsified or changed. I unde rstand that lam responsible forall charger incurred from this application. I hereby grant right of entry to the Authorized Repmenmtive of the Davie County Health Deparhneut to conduct necessaryons ej�mune cam fiance with applicable lama and rules on the above described property located in Davie CO. Inspection p (AH,Q[r[nhfra f�•- W6� oawLcac7ly��'Ir^kf,�+i +aa-{iM Site Revisit Charge E C E 9 Late I V Sign given LIYes ONo Account Revised 2106 Invoice# &J / 1!/ APA 6 2006 D 12 Carr - 3 Sq. Ft. romage 5�1 1 30,894 Ft. 33,426 Sq. N, ;q. Ft. 28, r Ott , Kassel n Kassel 190 859 .327 O 35,081 Sq. Ft. Ej I. 243' 115 j 30,488 Sq. Ft. 270 33+9 Sq I . Ft. 1 264 (07 30,J50 Sq. rt. i I 1 260 118 I1 4 30,(660 Sq Ft. 255 I CSI 30474 Sd . Ft SL. Andrews Golf Villas Section OB, Phase 11, Seatton 2 Plot Book 8, Page 21 „IAS i%915 34,956 Sq. rt. 35,486 Sq. Ft. 145 142' k I f r-- —22i— at.30,080 Sq. Ft. 227 �i i T—� plef ICY I I I Z. 251 �16100 , C� " I (20 a! 30,;137 Sc{. Ft. ��01 — 0 P ) 'R d de p- 7po' Qbl, 1V 1626 b T A F1 30,030 Sq. Ft. 30,078 Sq. Ft. O 30,078 Sq. Ft. 30,040 Sq. Ft. �k 23r---, f J //� 0 . T ,51,107 Sq. Ft DAME COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003765 Tax PIN/EH #: 5871-25-2458.10 Billed To: Oak Valley Associates Limited Partne Subdivision. Info: Sawgrass Lot # 10 Reference Name: Bo Davis Location/Address: Beauchamp Rd -27096 Proposed Facility: Residence Property Size: See map Date Evaluated: # D Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit / Cut FACTORS 1 2 3 4 5. 6 7 Landscape position Slo e% . HORIZON I DEPTH p Texture group, Consistence —• . Structure A siz, Mineralogyc HORIZON H DEPTHy • - Texture group -15-,c a -Sr Consistence r Structure _ ' Mineralogy HORIZON III DEPTH Texture grou ; Consistence .. A Structure IAI. + i Mineralogy , HORIZON IV DEPTH Texture group_ " . .. .. Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE . CLASSIFICATION LONG-TERM ACCEPTANCE RATE I O. O SITE CLASSIFICATION. EVALUATION BY: LONG-TERM ACCEPTANCERATE D 3 OTHER(S) PRESENT: - REMARKS: ;.. )t �I ►1%ta(� .. - : LEGEND '. " tion , , .. .:. .,. .. .. .. ...:... Landscape Position " .'..z R -Ridge', S -Shoulder : L -Linear §lope Foot slope ' N -Nose slope T FS _ CC Concave sloe CV p Head sloe Convex sloe T -Terrace FP "= Flood lain H P P P. • t .TeahuS 1 S - Sand LS - Loamy sand „ SL -Sandy loam ". ' L -Loam - +_.SI -Silt SICL - Silty clay loam : SIL - Silty loam CL'- Clay loam _ . Si: -"L - Sandy clay loam SC - Sandy clay "; SIC - Silty clay , : C,- Clay 'CONSISTENCE MOW VFR - Ve friable FR - Friable FI -Firm . ry 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 . : : �..5 r iit SC - Single grain _ " M - Massive CR - Crumb GR - Granular '.. . ABK - Angular blocky SBK - Subangular blocky PL- Platy PR - Prismatic Mineraloev 1:1; 2:1, Mixed 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 oc less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) =.. `.- .. :.-. ..'... '.. 1 LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised) Davie CountyHealth Department:. Environmental. Health Section P.O. Box 848/210 Hospital Street Moeksville, NC :27028 (336)751-8760/ Fax (336)751-8786 May 1, 2006 Oak Valley Associates, Ltd. Partnership Attn: Bo Davis 3401 Healy Drive. Winston-Salem, NC 27103 Re: SAWGRASS Proposed Subdivision/ Lot # 10 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 Serve: 3Wastewater Design Flow: System Type: ❑ConventionalAccepted ❑Innovative ❑Alternative ❑Other System Location: i�is� I`J) D�'--- n Valid: �ears ❑No Expiration Site Modifications/Permit Conditions: �yMFIZLZ� TRANSPORTATION YS STRUCTION N 20 UNTY are the owners of the A within the subdivision iereby adopt this I establish minimum eats, alleys, walks, parks, private use as Noted. Partnership I �`b \Q . iu Date Cl? In �C) 0 } u� I � r, w 00 d- o� Has coM � r7 Cd s a .D (U N88°39'03'E co 79,62' m •` . v I,D d � � o� r M. co PLANNING DEPARTMENT/REVIEW OFFICER FINAL SUBDIVISION PLAT APPROVAL I. John E. I This is to certify that this pial moots the recording requirements my supervisia of the Subdivision MguLa=ions 1Er Davie County, iYri It=1°t9t is 1 : 10,000+ I tsrv[ew 47-30 as anu Offtoer of Davie County, oertify that the map or plat to uAioh this and seal this_ certification L affixed nests alt statutory requirements for recording. Approved Dindor of AawwWlIA-6 + 0f11— Thu the day a1 20 NORTH CAROLINA —DAVIE COUNTY NORTH CAROL Certificate of Approval of Private (on-site) Sewage DisposalSystem I hereby certify that the Davie County Health Department has evaluated th Subdivision formerly entitled SAWGRASS at Oak Valley with respect to conditions established by state law or promulgated thereunder and the sa is found to comply with such criteria and conditions EXCEPT as found in such evaluation. For details of this evaluation and for limitations see th written report on file at the said Department. IMPORTANT NOTICE: THIS CERTIFICATE DOES NOT CONSTITUTE A PERMIT OR APPROVAL OF INDIVIDUAL LOTS IN SAID SUBDIVISION FOR INSTALLATION OF SEWAGE FACILITIES. Si Date County Health Official S00°52'33' 250,00' ` 50.00' I \ 133.63' 132.51 (U I .J � wI w 35,486Sq.Ft. �' (u 10 711 , 0 C71 �d CD OJ 30,08OSq.Ft. 10 N00°17'53'E 00 � o% W 30,080Sc 244,13' Z � I N °J �O 'h�Gr,C'O 34,956Sq.Ft. v 3 106.64' -132.1 � 10' x 70' 576.94' - _ m Sight Easement N00°18'39'E w I S00°52': 99,75' — —101.50' ccuu � �' SS��g- ti a` cc) m 71 a �.0OD c 'q- 721 35,081 Sq.Ft. o I Z 000001151E v 130,088Sq.Ft. w 229.18' 33,069Sq.Ft 1�UN O� 113-� 0 1 (`7 0 C17 I AF�A 715 A:�CU q9 w S1 — 244,43' x. z � 33,426Sq.Ft. / q4' 3 S6 04%1 '� �`' 4. 1 124.^ 20' _ 127.61' `-==� C) ro 0- / F co 719 3 owJ�oA -ape R N61� Jam, 33,897Sq.Ft. �u iT 1 N 30,894Sq.Ft. 0 00 cu 18Sq.F o� T do �p i� Q z ho 0 N G ' 10' x 20' Z Signage Easement 01i - 0� �rE Go S89°48'S4'E /\ 60057' CU 718 M 46,306Sq.Ft. o 0 0