1013 Cornatzer Rd OPERATION PERMIT ice se nv
Davie County Health Department EEvaluated
Number 120746- 1
'T 210 Hospital Street H600000093
P.O. Box 848 umber:
'�=-'—• EXISTING
Mocksville NC 27028 r.
Phone:336-753-6780 Fax:336-753-1680
Applicant: Luther and Hilda Potts Property owner: Luther and Hilda Potts
Address: 1013 Comatzer Rd Address: 202 Williams
CRY= Advance City: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: Phone#:
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
1013 Cornatzer Road
Advance NC 006 Directions
Struc u SINGLE FAMILY Hwy 64 E. left on Cornatzer Road
#of People:
'Water Supply: NIA
'IP Issued by. 'System Classification/Description:
'CA issued by:
SaproliteSystem? OYes G)No
Design Flow: NIA Pump Required?
Distribution Type:
QYes QNo
Soil Application Rate: 'Pre Treatment:
Drain field
Nitrification Field 1 2 0 0 Sq.ft. 'System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines 3 Installer: Sherman Dunn
Total Trench Length: 3 0 0 It. Certification#: 7 d
Trench Spacing: g _ 0 0 Qlnches O.C.
()Feet O.C. 'EH S: 2140-Nation.Robert
Trench Width: 3 _ 0 0 Inches
OFeet Date: 0 4 / 2 4 / a 0 1 a
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 1 Inches Approval Status
Maximum Trench Depth: 3 6 Inches E[EE proved El Disapproved
Maximum Soil Cover: a 4 Inches
�UUiB zo
CDP File Number 120746- 1 County ID Number: H600000093
Electric Equipment
NEMA 4X Box or Equivalent ❑ Yes ElNo Installer.
Box 12 inches Above Grade ❑ Yes E3 No
Certification 9:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No 'EHS:
Pump Manually Operable ❑ Yes ❑ No
'Activation Method: Date: /
Approval Status
Alarm Audible El Yes 13No ❑ Approved❑ Disapproved
Alarm Visible 1:1 Yes 13 No
2140-Nations,Robert
'Operation Permit completed by:
Authorized State Agent: Date of Issue: 0 4 / a .4 / a 9 1 3
This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq.,and aA conditions of the Improvement Permit and
Construction Authorization.This property is served by a sewage septic system.
Rule .1961 requires that a Type septic system meet the following criteria:
Minimum System Review ByThe Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator:
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 entitywith a certified operator or a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule.1961 (2)(e)requires a contract shall be executed between the system owner and a management entity priorto the
issuance of an Operation Permit fora system required to be maintained bya public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner end 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 Olmport Drawing
**Site PIanlDrawing attached.**
Total Time:(HH:MM)
Activity Code: S-19204-01?issued NEW Typo 11 Quick 4 a Hours 3 0 Minutes
CDP File Number 120746 - 1 Septic Tank County ID Number: H600000093
t Manufacturer. Lat.
Long: ,
STB:
Gallons: Installer:
Date: / / Certification#:
*EHS:
*Filter Brand:
ST Marker: ❑ Yes ❑ NO Date:
Reinforced Tank: ❑ Yes ❑ No Approval Status
1 Piece Tank: ❑ Yes D No D Approved❑ Disapproved
Pump Tank
Manufacturer Installer:
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
RiserSealed ❑ Yes D No
Riser Height: ❑ Yes ❑ NO (Min.6 in.)
Approval Status
Reinforced Tank: ❑ Yes D No ❑ Approved D Disapproved
1 Piece Tank: ❑ YeS ❑ NO
Supply line
FPipeize: inch diameter Installer:
gth: feet Certification#:
dule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes D NO Approval Status
D Approved D Disapproved
Pump Reggirement
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ NO Approval Status
PVC unions ❑ Yes D No ❑ Approved D Disapproved
Vent Hole ❑ Yes D No
Anti-siphon Hole 0Yes 0 No
OPERATION PERMIT
Davie county Health Department CDP File Number: 120746 - 1
• 210 Hospital Street H600000093
P.O.sox 848 County File Number.
Mocksville NC 27028 Date: 0 4 / ,2 4 / 2 0 1 3
Q Inch
Drawing Drawing Type: Operation Permit Scale: 1 . (, Block = 1 0 .ft.
Q N/A
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i y .,CONSTRUCTION For Office Use Only
*CDP File Number 120746- 1
AUTHORIZATION
Davie County Health Department County ID Number.H600000093
210 Hospital Street Evaluated For: EXISTING
.awl. P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 / 0 1 / 0 0 0 6
Applicant: Luther and Hilda Potts Property Owner: Luther and Hilda Potts
Address: 1013 Comatzer Rd Address: 202 Williams
City: Advance City: Advance
State2ip: NC 27006 State2ip:. NC 27006
Phone#: Phone#:
Property Location 8 Site Information
rAddress/Road#: Subdivision: Phase: Lot:
1013 Comatzer Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 E. left on Cornatzer Road
#of Bedrooms:
#of People:
'Water Supply: N/A
System Specifications
Minimum Trench Depth: Inches
Site Classification:
Saprolde System? DYes QNo Minimum Soil Cover. Inches
Design Flow: Maximum Trench Depth: Inches
Soil Application Rate: Maximum Soil Cover:
Inches
*System Classification/Description: 'Distribution Type:
TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
_ _ Gallons
*Proposed System: 25%REDUCTION 1-Piece: DYes ONo
Pump Required: DYes ONo OMay Be Required
Nitrification Field
Sq.ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: DYes ONo
Total Trench Length: ft GPM—vs— ft. TDH
Trench Spacing: —
8Feet O.C. g inches O.C. Dosing Volume: a 0 _ Gallons
Trench Width: Inches
8Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank InstallerGradeLevel Required: OI OII OIII OIV
Pagel of 3
CDR�ile Number. . •1 120746 - County ID Number: H600000093
' ❑ Open Pump System Sheet
Repair System Required:OYes ONO ONo, but has Available Space
rDesign
System
Trench Spacing: Q Inches O.
ification: Ps — 0 9 Co Feet O.C.
Trench Width: r Inches
w: 3 6 0 _ 3 6 Feet
SoilAggregate Depth:
Application Rate: 0 - 3 inches
Minimum Trench Depth: a q Inches
*System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover
Inches
'Proposed S a Maximum Trench Depth: 3 6
Po System: 25lo REDUCTION Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines "Distribution Type: GRAVITY-PARALLEL(eq.d•box)
Total Trench Length: 3 0 0 ft Pump Required: Oyes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-ll
"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 valldity of the Improvement Permit.not
to exceed five years,and may be issued at the same time the Improvement Permit Issued(NCGS 130A-336(b)}If the installation has not been
completed during the period of valldity of the Construction Permit,the Information submitted in the application for a permit or Construction
Authorization Is found to havebeen Incorrect,falsified or changed,or the site Is altered,the permit or Constriction Authorization shall become
invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rites,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: 2244-Daywalt,Andrew Date of Issue: . 3 / a 5 / a 0 3
Authorized State Agent: A tj I in, ry Malfunction Log OYes
GHandibrawing Olmport Drawing TotalTime:(HH.-MM)
**Site Plan/Drawing attached.**
Page 2 of 3 Hours. 3 _ 0 Minutes
. CONSTRUCTION AUTHORIZATION
'-- Davie county Health Department CDP File Number
210 Hospital Street H600000093
P.O.Box 848 County File Number ,
Mocksville NC 27028 Date: 0 3 / 5 / 0 2 0 3
Qlnch
Dm'%ving Drawing Type: Construction Authorization Scale: . O = ft.
QN/A
I ;
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Pane 3 of 3
s IMPROVEMENT PERMIT For Office Use Onl
'CDP File Number 120746-1
• ,'. Davie County Health Department
r= 210 Hospital Street
County ID Number:H600000093
P.O. Box 848 Evaluated For: EXISTING
Mocksville NC 27028 Township:
Phone:336-753-6780 Fax:336-753-1680 PERUIT VALID UNTIL: 3/25/2018
'NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Luther and Hilda Potts Property owner: Luther and Hilda Potts
Address: 1013 Comatzer Rd Address: 202 Williams
Cty: Advance City: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: Phone#:
Pro a Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
1013 Comatzer Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 E. left on Cornatzer Road
#of Bedrooms:
#of People:
'Water Supply: WA
S stem Specifications
nitial S stem
.Site Classification:
Minimum Trench Depth: Inches
Seprolite System? QYes QNo Maximum Trench Depth:
Inches
Design Flow: Septic Tank:
Gallons
Soil Application Rate: 1-Piece: QYes QNo
'System Classification/Description: Pump Required: QYes QNo OMay Be Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
'Proposed System: 25%REDUCTION 1-Piece: QYes Q N o
Repair System Required:0 Yes ONo ONO, but has Available Space
rsoiiticl,
epair System
Classification: PS Minimum Trench Depth: a 4 Inches
pplication Rate: 0 3 Maximum Trench Depth: 3 6 Inches
'System Classification/Description: Pump Required: QYes (2)No Q Maybe Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25%REDUCTION
Pagel of 3
120746- 1 H600000093
fDP File Number County ID Number.
*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 OPlan The Improvement Permit shat be valid for 6 years from date of Issue with a site plan(mearts 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
0 site for the proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one Inch equals no more than 60 feet,that Includes:the specific location of the proposed facility
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(NCOS 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 ONO
ApplicanULegal Reps. Signature_ Date:
'Issued By: 2244-Daywall.Andres' Date of Issue: 0 3 / a 5 / a 0 1 3
Authorized State Agent: OValid without Expiration?
O Create CA?
01-land Drawing Olmport Drawing
**Site Plan/Drawing attached.** TotalTime:(HH:MM)
Hours 3 0 uinutes
Page 2 of 3
Activiv Code:
r IMPROVEMENT PERMIT 120746- 1
Davie County Health Department CDP File Number:
210 Hospital Street H600000093
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type: Improvement Permit Scale: , QBiock
QN/A
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Page 3 of 3
-546fMOIJ DUnr 7Ss 5= 7
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name <elephoneNumber
Address 3 1
4
Mailing Address (if different from above)
Email Address:
Subdivision Name Lot#
Directions ON 6/- rj�1
Date System Installed Name Syste> Installed Under
Type Facility Number Bedrooms Number People Served
Type Water Supply Specific Problem Occurring
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
�037
DAV'IE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Telepho Number
Address A - ZE-rte
Mallinif Address different from above
g ('
Email Address:
'Subdivision Name Lot#
Directions OA)
Date System Installed Name Systeu�LInstalled Under
Type Facility Number.Bedrooms Number People Served
Type Water Supply Specific Problem Occurring
Date Requested 19'��}=/ Info.Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED {
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
i
Appraisal Card Page 1 of 1
DAVIE COUNTY NC 3/19/2013 4:10:55 PM
TTS LUTHER B POTTS HILDA H Retum/Appeal Notes: HS-000-00-093
1013 CORNATZER RD UNIQ ID 13629
8084000 ID NO:5758994834
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1
eval Year:2013 Tax Year:2013 3.3 AC CORNATZER RD 3.200 AC SRC-Inspection
Appraised by 19 on 09/04/2008 07001 SHADY GROVE TW-07 C- EX-AT- LAST ACTION 20110712
CONDETAION MARKET VALUE DEPRECIATION CORRELATION OF VALUE
TOTALCTIPOINT VALUE Eff. BASE °'
BUILDING USE MOD Area UAL RATE RCN EYB AYB REDENCE TO
C
ADJUSTMENTS97 00 %GOOD EPR.BUILDING VALUE-CARD
OTALADIUSTMENT TYPE:Vacant EPR.OB/XF VALUE-CARD 4,50 m
ACTOR ARKET LAND VALUE-CARD 52,02 W
TOTAL QUALITY INDEX STORIES: rOTAL MARKET VALUE-CARD 56,52(
TOTAL APPRAISED VALUE-CARD 56,52
TOTAL APPRAISED VALUE-PARCEL 5652
TOTAL PRESENT USE VALUE-PARCEL
TOTAL VALUE DEFERRED-PARCEL
TOTAL TAXABLE VALUE-PARCEL 56,52C
PRIOR
ILDING VALUE
BXF VALUE 4,50
AND VALUE 52,02
RESENT USE VALUE
EFERRED VALUE
OTAL VALUE 56,52
PERMIT
rE
E DATE NOTE NUMBER AMOUNT
WTRSHD:
SALES DATA
RD ATE DEED INDICATE SALES
AGE R TYPE PRICE
309 15 119c. WD I X I V I Ci
HEATED AREA
n
NOTES
SE HAS BURNED
• SEVERE DAMAGE UPPER STORY
OMPLETELY DESTROYED O
O
SHED DOWN o
SUBAREA UNIT ORIG�Ao ANN DEP 9b OB/XF DEPR c
GS RPL ODE ESCRIPTIO T NIT PRICECOND LDG B AYB EYB RATE V COND VALUE
TYPE AREA CS 8 H SITE 1 4 500. 10 L 199 19971 Sol 1 1001 450 e
[REPLACE OTAL OB/XF VALUE 4 5 AR'LDING DIMENSIONS
DINFORMATION
HEST THERADJUSTMENTS LAND TOTAL
BEST USE LOCAL FROM DEPTH/ LND COND ND NOTES OUNIT LAND UNT TOTAL ADJUSTED LAND LAND
CODE ZONING TAGE EPT SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNITPRICE VALUE NOTES
HOMESIT 0201 400 0 1.4690 4 1.1900 05+14+00+00+00 PW 9 300.0 3.2 AC 1.7 16 256.4 5202AL MARKET LAND DATA 3.20 52 02AL PRESENT USE DATA
J
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=H600000093 3/19/2013
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