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128 West Chinaberry Court Lot 22RMIT or ice se n v vie CountyHealth Department 'CDP P,lie`NumberK asonaozz P.O. Box 848 County ID,Numberi. Mocksville NC 27028 Evahwted.For. NEW Phone: 336-753-6780 Fax: 336-753-1680 Township: Applicant: John C Call Property Owner: John C Call Address: 8920 Stokes Ferry Rd Address: 8920 Stokes Ferry Rd CRY: Salisbury CRY: Salisbury State2ip: NC 28146. State/zip: NC 28146 Phone #: (336) 341-3302 Phone #:' (336) 341-3302 PropertV Location &Site Information Address/Road #: Subdivision: South Arbor Phase: 2 Lot: 22 128 West Chinaberry Court Mocksville NC 27028 Directions 601 S left onto Deadmon Rd Turn right into South Structure: SINGLE FAMILY Arbor # of Bedrooms: 3 # of People: 4 •Water Supply: PUBLIC `System Classification/Description: *IP Issued by: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPDILESS)+CA issued by:SeproliteSystem? QYes ®No Design Flow: 3 6 0 + GRAVITY -SERIAL Pump Distribution Type: QYes *No Soil Application Rate: 0 3 'Pre -Treatment: Drain field Nitrification Field 1 6 2 0 0 Sq. ft. *System Type: No. Drain Lines Installer: Sherman Dunn Total Trench Length: 3 a.. 8 ft, Certification #: Trench Spacing:— 9 Inches O.C. gFeetO.C. +EHS: 2140 -Nations, Robert Trench Width: — 3 Inches 8Feet 1 2 5/ 2 0 1 4 Date:, . _/ ;1 Aggregate Depth: Inches Minimum Trench Depth: Inches Minimum Soil Cover. APprovial�status Maximum. Trench Depth;; Inches I � a ®iApprovetl❑ Drsapprove`d Inches Maximum Soil Cover: Inches CDP File Number 122448-2 Manufacturer. shoal STB: 76D Gallons: 1000 Date: 0 8/ 3 0/ 2 0 1 4 'Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ST,Marker: ❑. Yes ®.No einforced Tank: ❑ Yes ®'No' , 1 Piece Tank: ❑ Yes F No County ID Number: 'Ks oso�o-o22 Let. sP. Long: Installer: Sherman Dunn Certification #: 'EHS: 2140 - Nations, Robert Date: 1 2/ 1 5 / 2 0 1 4 Pump Tank Manufacturer. Installer: PT: Certification #: Gallons: 'EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No RiserHeight: ❑ Yes❑ No (Min.6 in.)T " . P pproval Status einforced Tank: ❑ Yes ❑ No 011iAPOOVed ❑ !Disapproved 1 Piece Tank: ElYes El No Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification #: 'Schedule: 'EHS: Pressure Rated ❑ Yes ❑ NO Date: Approved fittings ❑ Yes ❑ N0 Approval Status '❑ Approved ❑` Disapproved Pump RequIrement Pum T e: P yP 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 _ ❑ Approvedp Disapproved. . Vent Hole ❑ Yes ElNo = Anti -siphon Hole ❑Yes ❑ NO Y CDP File Number 122448-2 NEMA4XBox orEquivalent. ❑ Yes Box 12 inches Above Grade ❑ Yes Box Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes `Activation Method: Alarm Audible ❑ Yes Alarm Visible ❑ Yes County ID Number: K5 -060A0-022 ❑ NO Installer: ❑ No Certification#: ❑ No ❑ No 'EHS: ❑ No Date: El NO � "A.pproval Status ❑ iApproved ❑ iDtsapproved ❑ No 2140 - Nations, Robert *Operation Permit completed by: AuthorizedState.g A er< Date of Issue: 1_ ol ( 1 5 / 2 0 1 _4 This system has been installed in compliance with applicable NC General Statutes: Article 11; Chapter 130A; Rules for Sewage 'ConstrructionATreaOuthor¢ationent and ljhisipropertyissere d.bya ef,,Seq.:and,allcseltons:,of the wagesepticsyst ttent,Permitand b a TYPE n A. septic system: Rule .1961 requires that a Type TYPE tl A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA 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 entity with a certified operator or 6 private certified operator forthe life of tfie septic system. Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by:a public; or private management entity, unless the system ioh, responsibilities and a ties of the eownerandesa. 'The he contract shall require specific requirements formaintenance and operasystem owner end certified op systemsoperator; provisions that the contract shall be in effect foe 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 0import Drawing **Site Plan/Drawing attached.** °' OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawine Drawing Type: Operation Permit CDP File Number: 122448 - 2 County File Number: Ks-060ao-022 Date: / I W W O Inch Scale:. . .OBlock ON/A v-- ' • CONSTRUCTION AUTHORIZATION r " ' Davie County Health Department 210 Hospital Street 1 P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 I, For Office Use Only 'CDP File Number 122448-1 County ID Number: K5.060A0.022 Evaluated For: NEW Township: Applicant: John Cali Property Owner: Address: 8920 Stokes Road Address: . CRY: Salisbury State/Zip: NC 28146 Phone #: (336)757-6033 Address/Road #: Subdivis 128 West Chinaberry Court Mocksville NC 27028 Structure: # of Bedrooms: 3 9 of People: 4 'Water Supply: PUBLIC Classification: PS Saprolite System? OYes OQ No Design Flow: 1 3 6 0 Soil Application Rate: • 0 3 '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: .3 0 0 ft. City: State/Zip: Phone 9: 0 9/ 1 0/ 2 0 1 8 South Arbor J Phase: 2 Lot: 22 Directions 601 S left onto Deadmon Rd Turn right into South Arbor Minimum Trench Depth: 2 4 Minimum Soil Cover. Maximum Trench Depth: 3 6 Maximum Soil Cover: Inches 'Distribution Type: PUMPTOGRAVITY Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes @No Pump Required ®Yes , ONo OMay Be Required Sq. ft. Pump Tank: 1 0 0 0 Gallons 1 -Piece: OYes Q p- GPM—vs— ft. TDH Inches Inches Inches Inches O.C. Feet O.C. Dosing Volume: _ Gallons QInches Feet Grease Trap: Gallons inches Pre -Treatment: ONSF OTS -1 OTS -II / Septic Tank Installer Grade Level Required: 01011 0111 01V 11 CD14ile Number 122448-1 it *Site Classification: ps Design Flow: 3 6 0 Soil Application Rate: 0 3 *System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP 'Proposed System: 25% REDUCTION Nitrification Field Sq. ft. No. Drain Lines Total Trench Length: 3 0 0 It. County ID Number: KS -060A0.022 No ONO, but has Available S Trench Spacing: Trench Width: Aggregate Depth: ❑ Open Pump System Sher inches 8lnches 0.1 Feet O.C. 8lnches Feet Minimum Trench Depth: 2 4 Inches Minimum Soil Cover. Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: Inches 'Distribution Type: GRAVITY -PARALLEL (eq. d -box) 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, '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 be valid fora person equal to the period of validity of the Improvement Permit, not to exceed flue years, and maybe Issued at the same time the Improvement Permit issued (NCGS 130A -336(b)} If the Installation has not been completed during the period of validity of the Construction Perm I% the Information submitted In the application for a permit or Construction Authorization Is found to have been Incorrect, falsified or changed, or the site Is altered, the permit or Construction Authorization shall become Invalid, and maybe suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location. Installation, operation, maintenance, monitoring, reporting and repair (1936(b)). Applicant/Legal Reps. Signature Required? Oyes ONo ApplicanVLegal Reps. Signature, Date: / - / '9ssuedBy: 2244-oaywall.Andrew Date of Issue: 0 9/ 1 0/ 2 0 1 3 Authorized State Agent: Malfunction Log Oyes ®Hand Drawing Olmport Drawing TotalTime:(HH:MM) **Site Plan/Drawing attached.** Page 2of3 0 1 Hours,0 0 Minutes ' . CONSTRUCTION AUTHORIZATION 122448 - 1 Davie County Health Department CDP File Number: 210 Hospital Street - - K5-060A0-022 P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0 9/ 1 0/ 2 0 1 3 Q Inch Drawing Drawing Type: Construction Authorization Scale:. ON/AOBlo= QN/A i l � 1 _ I � IMPROVEMENT PERMIT �* Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville INC 27028 / For Office Use Only *CDP File Number 122448 - 1 County ID Number. Ks-060Ao-022 Evaluated For: NEW Township: wnship: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 8/1/2018 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: John Call Address: 8920 Stokes Road City:, Salisbury State/Zip: NC 28146 Phone #: (336) 757-6033 Address/Road #: 128 West Chinaberry Court Mocksville NC 27028 Structure: # of Bedrooms: 3 # of People: 4 *Water Supply: PUBLIC /Property Owner: Address: City: State/Zip: hone #: Subdivision: South Arbor Phase: 2 Lot: 22 Directions 601 S left onto Deadmon Rd Turn right into South Arbor Repair System Required:(&Yes ONO ONO, but has Available Space Repair System *Site Classification: Ps Minimum Trench Depth: a 4 Inches Soil Application Rate: g 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes O No ® May be TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) \*Proposed System: 25% REDUCTION - Page 1 of 3 Minimum Trench Depth: a 4 Inches Saprolite System? O Yes ® No Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 3 1 -Piece: OYes ®No Pump Required: OYes O No ® May Be Required *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR Pump Tank: 1 0 0 0 Gallons *Proposed System: 25% REDUCTION 1 -Piece: OYes ®No Repair System Required:(&Yes ONO ONO, but has Available Space Repair System *Site Classification: Ps Minimum Trench Depth: a 4 Inches Soil Application Rate: g 3 Maximum Trench Depth: 3 6 Inches *System Classification/Description: Pump Required: OYes O No ® May be TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) \*Proposed System: 25% REDUCTION - Page 1 of 3 CDP File Number 122448 - 1 County ID Number: K5 -060A0-022 *Site Modifications ❑ Open Fill Sheet 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. Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to ® scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters). Plat The Improvement Permit shall be valid without expiration with plat (means a property, surveyed prepared by a registered land surveyor, drawn to a scale of one Inch equals no more than 60 feet, that Includes: the specific location of the proposed facility O and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale). The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions, the rules, or this article. This permit is subject to revocation If the site plan, plat, or Intended use changes (NCGS 130A -335(f)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring, reporting, and repair (.1938(b)). Applicant/Legal Reps. Signature Required? OYes ®NO Applicant/Legal Reps. *Issued By: 2244 - Daywaallt�t,,Andrew Date of Issue: 0 8 / 0 1 / a 0 1 3 Authorized State Agent:t/l�tJ X A& 0 Create a without Expiration? O Create CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** TotalTime:(HH:MM) 0 1 Hours 0 0 Minutes Page 2 of 3 Activity Code: S4 - IP'S issued: new, valid for 60 mos. IMPROVEMENT PERMIT Davie County Health Department - _ 210 Hospital Street - - P.O. Box 848 Mocksville NC 27028 Drawine Drawing Type: Improvement Permit I I i CDP File Number: 122448 -1 County File Number: I<5-060no-022 Date: O Inch Scale: O Block O N/A ' i I )OD APPLICATION FOR SITE EVALUATION4MPROVEMENT PERMIT & ATC Davie County Environmentat health � M In 41 C iv. nira wOI&XV ��iv "MIntal airbci Dib! Mocksville,NC 27028 3 (336)753-6780/Fax (336)753-1680 Ap-ZiUmtinn For: D Site Fvahratinn/—Fpm, menet Permit AnFhnrisssfir,n Tn Cr,netmrt,lATC\ 0 Bnth Type of Application: ONew System ORepair to Existing System OExpansionWodification of Existing System or Facility ***M0RTAN7*** THIS APPLICATION CMVOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name Contact Person City/State/ZIP7�`�y NC aR1 Business Phone n(y�1Q/ ISN ) Email: Name on Permit/ATC if Different than ` L Above Mailinv,Address 0tV1gNtee"in PROPERTY INFORMATION *Date House/Facility Comers Flagged 6 NOTE: A survey plat or site plan must accompany this application Included: O Site Plan OPlat(to scale) (Permit is valid for 66 mnmhe with aitP,glan,nn px�icaiinn with rnm�lrfe'ntat.l - Owner's Name <S��Phone Owner's Address Property Addressl Lot Size 1 Subdivision Name( Directions To Site: Citv, If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? Yes No Does tiresite contamiunsdacuonarwenanas7 _'Y'es� N'o Are there any easements or right-of-ways on the site? Yes No Is the site subject to approval by another public agency? Yes No Will wastewater other than domestic sewage be generated? Yes ' No D() 01 TE RESIDTE FILL 01 IT THE BOX BELOW # People # Bedrooms . 3. # Bathrooms Garden Tub/Whirlpool ❑Yes lqo Basement: OYes .VVo' Basement Plumbing: ❑Yes -kNo IF NON -RESIDENCE FILL OUT THE BOX BELOW { ;1; dr Type of Facile Business. # People—^` yp , ty Total Square Footage of Buildtng # Sinks # Commodes # Showers # Urinals FODDDSERVICE ONLY: ,# Seats ., •:L- t uc,u r u .+i t v,i.<tt ;+.. „i n.i !.e .n q 14 p:;. •7A J L i ni. Type system requested: ❑Conventional pAccepted ❑Innovative ❑Alternative ❑Other R understand..Aat(j- '-th identification- �u4 responsible for, e proper and labeling of property fines and comers and locating and flagging or .stalong the l�ouse&Cdiq to cation, proposed Felllocationand.the locationofanyotheraw-enities,- Frbpeily owner's or owner s legal representative i,J i Ji ; ---- - -- Da*s): AJ Client Notification Date: Date EHS: i 1 T 111 Q MW L A 141 I WTC)[A /_7 of,- L&I'l )iA:V.(J. I 1I.001 P. /'LIC)i 1J."I . A JCV,,A -71 --- — 1t,1.V. �V f 1 i 2 e: I IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 122448-1 P.O. Box 848 K5 -060A0-022 Mocksvllle NC 27028 County File Number: Date: 0 8 / 0 1 /.1013 Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 unde I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or staldng the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature a -5•l Date ): Chent Client Notification Date: EAS: `. IMPROVEMENT PERMITFEvaluated Office Use Only er '122448-1 •~""�• Davie County Health Department 210 Hospital Street ber: K5 -060A0.022 P.O. Box 848 NEW Mocksville NC 27028 Phone: 336.753-6780 Fax: 336-753-1680 PERMIT vauo uNnu 8/1/2018 'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: ,John Call Propertyr�Owner Address: 8920 Stokes Road -I r( .l /address;` Cay: Salisbury City: State/ZiP: NC 28146 Statefzip: �` a L - r Phone #: (336 ) 7576033 Phone #: Address/Road #: Subd 128 West Chinaberry Court Mocksville NC 27028. Structure: _ # of Bedrooms: 3 # of People: -4 'Water Supply: PUBLIC South Arbor Phase:_,2 Lot Directions .: 601 S left onto-Deadmon Rd Turn right into South Arbor... Repair System Required:®Yes ,ONo ONO, but has Available Space Reaair System `Site Classification: PS Minimum Trench Depth: 2 4 'Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 1 h 'System Classification/Description: Pump Required: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 250% REDUCTION Page 1 of 3 nc as QYes QNo 'QlvlaybeRequired' Minimum Trench Depth: 2 4 Inches Seprolite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 3 6 0 Septic Tank: 1 0 0.0 Gallons Soil Application Rate: 0 3 1 -Piece: QYes ®No Pump Required: QYes QNo ®May Be Required 'System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR Pump Tank: - 1 0 0 0 Gallons LESS) *Proposed System: 26% REDUCTION 1 -Piece: QYes ®No Repair System Required:®Yes ,ONo ONO, but has Available Space Reaair System `Site Classification: PS Minimum Trench Depth: 2 4 'Inches Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 1 h 'System Classification/Description: Pump Required: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) 'Proposed System: 250% REDUCTION Page 1 of 3 nc as QYes QNo 'QlvlaybeRequired' IMPROVEMENT PERMIT " Davie County Health Department 210 Hospital Street P.O. Box 848 h9ocksville NC 27028 Drawing Drawing Type: Improvement Permit Page 3 of 3 CDP File Number: 122448 - 1 County File Number: K'-060AO-022 Date: Qlnch Scale: , QBlock QN/A CDP File Number 122,448-1 County ID Number. KS-060AO-022 'Site Modifications ❑ Open Fill Sheet 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. Site Plan The Improvement Permtt shall be wild for 5 years from dateof Issue with a site plan (means a drawing not necessarily drawn to. O sale that shows the existing and proposed property lines with dimensions, the location ofthefadllty and appurtenances, the e site forthe proposed Wastewater system, and the location otwater supplies and surfacewaters). Plat The improvement Permit shall be wild without expiration with plat (means a property surveyed prepared by a registered land surveyor, drawn to a sate of one inch equals no more than 6e feet, that Includes: the specific location of the proposed facility O and appurtenances, the sitefor the proposed Wastewater system, and the location of water supplies and surface waters. Plat also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale). The Department and Local Health Department may Impose conditions on the Issuance and may revoke the permits for failure of the system to satisfy the conditions, the rules, or this article. This permit is sub)ectto revocation If the she plan, plat, or Intended - use changes (NCG 9 130A335(q). 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, malntenance, monitoring, reporting, and repair (.1938(b)). Applicant(Legal Reps. Signature Required? OYes @No Applicant(Legal Reps. Signature; Date: / / Issued By: 2244-Daywalt,Andrew Date of Issue: 0 8 . 0 1/ 2 0 1 3 Authorized State Agent. OValid without Expiration? 0Create CA. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** TotalTime:(HH:MM) 0 1 . Hours 0 D Minutes Page 2 of Activdv Code: S-4 - IP'S issued: new, valid for 60 mos. ,' Y � ' APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC J?XDa ty vie Coun Environmental Health 3 i P.O. Box 848/210 Hospital Street RECEIVED Mocksville, NC 27028 a�tueaa ' (336)75376780/ Fax (336)75371680.:.0 Application For: )Q Site Evaluation/improvement Permit D Authorization To Construct (ATC) '® Both Type of Application: ❑New System DRepair to Existing System DExpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name V O y( C U Contact Person h n Address-� fiVl a Home Phone 1?Qo--)S7— City/State/ZIP (p03 r a��`t( BusinessPhone��o -X11l 3C�� Email W � 11 tS al \J�)o . (. O f \ Email: Name on ermit/ATC if Different than Above Mailing Address I> City/State/Zip 10- IVWei VWAweIQRMNuI:rMLOW 11MITMA,_6is�a/�tlhrL .,KSiS�FI0"=. -,,II NOTE: A survey plat or site plan must accompany this application. Included: D Site Plan_�?Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name ��(�(a\� Phone Number0`7�]-(d13� Owner's Address (� O City/State/Zip_SE&le Property Address \al� i0,A (`Y1\CC( Lf (, City Lot Size : h PA S-1- Tax PIN# Subdivision Name(if applicable)� Section/Lot#E(l Directions To Site: (00 f { \ \e d er,C>>P ry\ `2 1 Ai Len Yj(:16N If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes )LNo Does the site contain jurisdictional wetlands? _Yes )LNo Are there any easements or right-of-ways on the site? _Yes \ G No Is the site subject to approval by another public agency? _Yes �No Will wastewater other than domestic sewage be generated? Yes "1No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 25 # Bathrooms�c Garden Tub/Whirlpool OYes EWo Basement: []Yes $No Basement Plumbing: ❑Yes *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: ❑Conventional ❑Accepted ❑Innovative DAltemative ❑Other Water Supply Type: f County/City Water D New Well DExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes 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 corners and locating and flagging or staking the I cation, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): 1 -au - 12, , \�� Client Notification Date: Date z EHS: Sign given DYes DNo Account # . Revised 11/06 Invoice # Appraisal Card Page 1 of 1 DAVIE COUNTY NC 7124/2013 4t05:19 PM RTER BARRY Retum/Appeal Notes: KS -060 -AO -022 CHINABERRY LT UNIQ ID 20720 2526788 ID NO: 5747216867 COUNTY TAX (100), FIRE TAX (100) CARD NO. l of l .W Year: 2013 Tax Year: 2013 LOT 22 SOUTH ARBOR SECTION 2 1.000 LT SRCw InspeOion ralseE bv 19 on 05/20/2008 05004 FAIRRELD TW -OS - C- EX- AT- LAST ACTION 20120529 ONSTRUCTION DETAII MARKET VALUE DEPRECIATION CORRELATION OF VALUE OTALPOINTVALUE ER.BASE - BUILDING USE MOD Area UAL RATE RCN EYS AYE - 0.EOENCE TO ADJUSTMENTS 97 00 1 1 %GOOD IEPR. BUILDING VALUE - CARD OTALADIUSTMENT TYPE: Vacant EPR. OB/XF VALUE - CARD ACTOR 4ARKET LAND VALUE - CARD 22,00 TOTAL QUALITY INDEX STORIES: - OTAL MARKET VALUE -CARD 2200 OTAL APPRAISED VALUE - CARD 22,00 OTAL APPRAISED VALUE - PARCEL 2200 OTAL PRESENT USE VALUE- PARCEL OTAL VALUE DEFERRED - PARCEL OTAL TAXABLE VALUE - PARCEL 2200 PRIOR BUILDING VALUE - - BXFVALUE 0 LAND VALUE 25,00 - RESENT USE VALUE EFERRED VALUE - - OTALVALUE 2500 PERMIT CODE I DATE I NOTE I NUMBER AMOUNT - - ROUT: WTRSHD: SALES DATA FF. RECORD DATE DEE. LUL INDICATE SALES BOOK IPAGE M R TYPE PRICE D929 003 6 013 QC C V 0673 889 B 2006 WD K V 1700 73 888 8 2DD5 WD C V 0207 842 12 1998 WO U V 0112 568 12 1980 WD U V HEATED AREA NOTES SUBAREA UNIT DRUG % SITE ANN DEP % OB/XF DEPR GS RPL OD UA DESCRIPTION T NIT PRICE CORD IDG L/ FACT Y - RATE V COND VALUE TYPE AREA CS OTAL OB XF VALUE REPLACE UBAREA DIALS BUILDING DIMENSIONS LAND INFORMATION HIGHEST THERADJUSTMENTS TOTAL - "D BEST USE LOCAL FRON DEPTH/ - C..D ND NOTES ROA LAND UNIT LAND UNT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAGE DEPT SIZE MOD FAR RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES FR RES 010D 0 1 0 1 1.0000 0 1.0000 22,000.00 1.00C LT 1.00 n,000.00 220 VOTAL MARK- LAND DATA 22,000 OTAL PRESENT USE DATA http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=K506OA0022 7/24/2013 DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 848/210 Hospital Street' Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003990 Tax PIN/EH #: 5747-21-6867 Billed To: Swicegood Construction Company Subdivision Info: South Arbor 2 Lot # 22 Reference Name: Kyle Swicegood Location/Address: West Chinaberry Court -27028 Proposed Facility: Residence Property Size: **NOI19* Thmber: 4417 is In Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit (in compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms #Baths Dishwasher: ❑ Garbage Disposal: ❑ Commercial Specification: Facility Type Lot Size Type Water Supply System Specifications: Tank Size Other: Required Site Modifications/Conditions: Washing Machine: ❑ - Basement w/Plumbing: ❑ . #People #People/Shift #Seats Design Wastewater Flow (GPD) GAL. Pump Tank GAL. Trench Width Basement/No Plumbing: ❑ Industrial Waste:, ❑ Site: New ❑ Repair ❑ Rock Depth Linear Ft._ IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW FINISHED GRADE. " "NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m, to 9:30 a.m, or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: I DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 8481210 Hospital Street Moclamille, NC 27028 (336)751-8760 Account #: 990003990 Tax PIN/EH #: 5747-21-6867 Billed To: Swicegood Construction Company Subdivision Info: South Arbor 2 Lot # 22 Reference Name: Kyle Swicegood . Location/Address: West Chinaberry Court -27028 ruNuacu auuny. �caua we r i W.. 'y v1n . ATC Number: 4417 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal. Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 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. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: .V R SITER SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department Environmental.Health'SectionP.O. Box 848/210 Hospital Street Mocksville, NC 27028(336)751-8760/ Fax (336)751-8786 Application For: D Site Evaluation/Improvement Permit Authorization To Construct(ATC) D Both ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. rU-ri .LSI UN i Name to be Billed SWI toab� 4�rv3f i.�GA sN e`v Contact Person /�Wt e S�✓' c` % c'° v Billing Address VSY 1/a H Home Phone City/State/ZIP 1nvc tsv.'/ e , N C =?7ollez Business Phone Name on PermitIATC if Different than Above. Mailing Address YK rr11<I Y ENV U.MVIAI iuiN NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) , / Street Address_ W -e& C-ewxc— C�- City P-0c-(a'.,1/1c Tax PIN# 671%'11-6FO Subdivision Name SL- %c , 0-kko4_ Section/Lot# em o22 Lot Size Directions To Site: 44 � (t•, I _S -L[ -Y.- Date . Date House/Facility Comers Flagged 5 -IRI -06, If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes 990— Does the site contain jurisdictional wetlands? ❑Yes Vfo Are there any easements or right-of-ways on the site? ❑ Yes ;I Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes Ko IF RESIDEN E FILL OUT THE BOX BELOW # People# Bedrooms — # Bathrooms —9r— Garden Tub/Whirlpool es oNo Basement: es ONo Basement Plumbing: ❑Yes 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 systemrequeste�onventional ❑Accepted ❑Innovative ❑Alternative Water Supply Type�ZCounty/City Water D New Well ❑Existing Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes D No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified of changed. I understand that I am responsiblefor all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine comp}�ance V applicable laws and rules on the above. described property located in Davie County and owned by iLst� G�irrT� a 71f)04 Site Revisit Charge Property owner's oro ner siJ al repre ntative signature Date(s): Client Notification Date: Date EHS: Sign given 0Yes ONo Account# 8g90 Revised 2/06 Invoice # ° Plat Book 6, Poge ,:J 02, I � n I I W EIP S 86°15'00"E 208.71' 3TOtal EI 3 SII i+i N �.104.35'� 1=04/6 I o 1 j/ 1 N O I M N m l I HCl N M111 i� ► !II I o gII a� �,o 0 [� IS 89°09'15"E 191.32' Totall S 86°15'0 EJ I V� � ILS 860 5'0 P 45,74 `— —145.58' — -EIP ' 1 0� EIPEl 22 N I . �'o. I" M 23 z O .J \ C, FI 21 o h ^� LO 209.40 t,�N w g20: .off �p�O idtl,i M A h� kA, N h O Z. I I 4, 25 IZ P ^ a� to . .'111- :1<- - - _ 10_Uttlity E°_ement j L w N i' f � L/7l liGt ��IIWo N U it 1� 31 1mv O fn m— TOO -EI �I � I I m 0 � o IN � I�ss1 � S 86°15'00"E I S 88 3 W EIP - T-0, f" . 100.00 0� O r°o7i Q�o I I I t tn z Q I wl 26 N N n M 0 ,OtO N ;ZZj 10'X 70' SE . ��tt .001" -- W N 84« 55_45"W e 4 �S Fa rn .fin 60' Pub P10' Ute 134.00�'—c 1�3 t it V • I 3 ap�at.. Wi*I $ , rn c 'I 16 yl u _ 50'— _U I I N 8405545"W 1127,48" Total Parcel 24 Car., T. Carter D;4:Oaok 44 0 001 M. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P V I5 V 0 G Davie County Health Department q� Environmental Health Section FEB 2 8 1996 y P. O. Box 665 wj l7 n - Mocksville, NC 27028 1. Application/Permit Requested By T. Kyte SWdceg00d agent b0A MA. /MAh. Roa WoodwaAd - 300 South:Matn StAeet Home Phone 704-634-1010 Mailing Address MUCKSVILLE N. C. 27028' Business Phone 704-634-2222 "2:° Name on Permit if Different than Above 3: Application for: General Evaluation ❑ Septic�Tank Installation Permit 4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown as -2 5. If house, mobile home: SubdivisionSection Lot # ❑ Basement/Plumbing No. of People 3/4 ❑, Basement/No Plumbing No. of Bedrooms 3 ® Washing Machine Z No. of Bathrooms Q Dishwasher `Dwelling Dimensions 1300 .6q. beet +- ❑ Garbage Disposal 6.:If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes N No. of Urinals No. of Lavatories A No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: © Public ' ❑ Private ❑ Community 8., Property Dimensions See attached map Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes DcNo If yes, what type? 'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: PROPERTY INFO MIATION REQUIRED: rr� Tax Office PIN: 0 .577 PROPERTY ADDRESS, as follows: Road Name: South AAbbt city: MockAyitze. N. C. SUBMIT A PLAT WITH THIS APPLICATION. Revisions effective October 1, 1995. P:This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. 1 ebAuaAy 26, 1996. T.'Kyte -W4-cegood, agent bort DATE Re CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 0 2. 1 DO NOT OWN the property.. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized represent ive of.th vie C my lea aartment to enter upon above described property located in Davie County and owned by �0 00 to conduct all testing procedures as necessary to determine said site's suitability for a ground absor tion sewage treatment and disposal system. T. y l � ego d tebkuahy 262 1996 g1 DATE-8IGNATVRE ' ..' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section v w Soil/Site Evaluation q NAME DATE EVALUATEDq� ADDRESS v S ��= PROPERTY SIZE DD:k 9A 70 t PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public Evaluation By -Z l Auger Boring Pity_ Cut FACTORS 1 2 3 1 4 Landscape position -5 S L Slope Z ^F4 -'$ °o °o HORIZON I DEPTH 61' Texture group Consistence Structure 2 Mineralogy` HORIZON II DEPTH n 1tl Texture group Consistence IF T Structure Qui Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS -_S RESTRICTIVE HORIZON SAPROLITE -- CLASSIFICATION YPI I e-5- LONG-TERM ACCEPTANCE RATEI I t SITE CLASSIFICATION: \� �'S- EVALUATED BY:�Z_��(�� LONG-TERM ACCEPTANCE RAT \t� sOOTHER(S) PRESENT: --- w O NR - REMARKS: __� \A - S z�4 Z 1.. 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 -:lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam SC -Sandy clay SIC -Silty clay C -Clay CONSISTENCE Moist VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm Wet NS -Non 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 Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD rot -9m n The -surveyor Is responsible for verifying thot the: location of the house Is In fullcompliance with all state, local, municipal and any recorded architectural requirements (I.e., setbacks. buffer, etc.), and that the house will not encroach Into any' easements, buffers, wetlands, etc. CHINABERRY 60' PUBLIC R/W PROPOSED IMPROVEMENTS ON: CUSTOMERW: JOHN CALL ADDRESS: 0 CHINABERRY CT. COUNTY: DAME CITY/STATE/ZIP: MOCKSVILLE, NC 27028 SCALE: 1" = 40'-O" PIN �/: 57 7216567 DATE: 08/07/13 REVISED: wTHIS PLAT DRAWING BASED UPON DOCUMENTATION SUPPLIED BY -�O RF I ISFO FOR RI III ❑IN(. DFRAAIT GPPI ICGTIDN ONI1 30' REAR SETBACK 15' SIDE' SETBACK (TYP) LOT 23 40' FROM SETBACK 10' UTILITY EASEMENT CrYP•) AREA OF DISTURBANCE: 5900 SF .135 ac.