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119 Crestwood Ct OPERATION PERMIT or Ice se n v < Yes Davie County Health Department *CDP File Number 188263-1 210 Hospital Street � - P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For: NEW Phone: 336-753-6780 Fax: 336-753-1680 Township: Applicant: True Homes Property Owner: Taylor Williams Address: 2649 Brekonridge Centre' Dr. Address: 433 Roslyn Road City: Charlotte City: Winston-Salem State/Zip: NC 28110 State/Zip: NC 27104 Phone#: (704)400-6143 Phone#: (336)293-6790 Property Location & Site Information Address/Road#: Subdivision: Summer Hill Farms Phase: Lot: 33 119 Crestwood court Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Hwy 801 , Left on Markland Rd #of Bedrooms: 4 #of People: *Water Supply: PUBLIC *IP Issued by: 2140=Nations,Robert *System Classification/Description: - TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? O Yes (9 No Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump ReQ.Yes �Nwireod? Soil Application Rate: 0 . 3 a 5 *Pre-Treatment: Drain field Nitrification Field 1 4 7 6 Sq.ft. *System Type: CHAMBER No. Drain Lines 6 Installer: Ronnie Overbee Total Trench Length: 3 6 9 ft. Certification#: 1143 Trench Spacing: _ 9 Q Inches O.C. ®Feet O.C. EHS: 2399-Eldridge,Tiffany Trench Width: _ 3 Q Inches Q9 Feet Date: 0 8 / a 6 / a 0 1 6 Aggregate Depth: 3 0 inches Minimum Trench Depth:2 4 Inches Minimum Soil Cover: 1 aInches Approval Status Maximum Trench Depth: 3 6Inches ® Approved ElDisapproved Maximum Soil Cover. a Inches Page 1 of 4 CDP File Number 188263 - 1 County ID Number: Septic Tank r Manufacturer: WMS Lat. STB: 793 Long: Gallons: 1000 Installer: Ronnie Overbee Certification#: 1143 Date: 0 7 / 1 9 / .1 0 1 6 *EHS: 2399-Eldridge,Tiffany *Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker: El Yes El No Date: 0 8 / 6 / a 0 1 6 Reinforced Tank: El Yes El No = Approvais tatus 1 Piece Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved Pump Tank Manufacturer: WMS Installer: Ronnie Overbee PT: 121 Certification#: 1143 Gallons: 1000 *EHS: 2399-Eldridge,Tiffany Date: 0 7 / 0 5 / .1 0 1 6 Date: 0 8 / a 6 / a 0 1 6 Riser Sealed ® Yes ❑ No Riser Height: ® Yes ❑ NO (Min. 6 in.) ° Approval Status Reinforced Tank: ® Yes El No Approved❑ Disapproved 1 Piece Tank: ® YeS ❑ NO Supply Line Pipe Size: 3 inch diameter Installer: Ronnie Overbee Pipe Length: 6 0 feet Certification#: 1143 *Schedule: ao *EHS: 2399-Eldridge,Tiffany Pressure Rated ® Yes ❑ No Date: 0 8 / a 6 / a 0 1 6 Approved fittings ® Yes ❑ NO Approval Status ®=Approved� Disapproved Pum Type: Chandler Ronnie Overbee Pump Requirement rPump Yp Installer: sing Volume: - Gal Certification#: 1143 Draw Down: Inches *EHS: 2399-Eldridge,Tiffany *Chain: ROPE Date: 0 8 / a 6 / a 0 1 6 Valves Accessible ® Yes ❑ No Flow Adjustment Valve ® Yes ❑ NO Check-valve ® Yes ❑ No Approval Status PVC Unions ® Yes ❑ No ® Approved❑ Disapproved Vent Hole ® Yes ❑ No Anti-siphon Hole ® Yes ❑ No Page 2 of 4 CDP File Number 188263 - 1 County ID Number: Electric Equipment NEMA 4X Box or Equivalent N Yes ❑ NO Installer: Ronnie Overbee Box 12 inches Above Grade N Yes ❑ No 1143 Box Adj.To Pump Tank ® Yes ❑ NO Certification#: Conduit Sealed N Yes ❑ No *EHS: 2399-Eldridge,Tiffany Pump Manually Operable N Yes ❑ No O s / a 6 / x 0 1 6 *Activation Method: Date: Approval Status Alarm Audible El Yes ❑ No ® ,=Approved❑ Disapproved Alarm Vsible ❑ Yes ❑ No 2399-Eldridge,Tiffany *Operation Permit completed by: Authorized State Agent: 4P4 M-11 Date of Issue: 0 8 / 3 0 / 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 -- 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 a A. sewage septic system. Rule.1961 requires that a Type TYPE n A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule.1961 requires that a Type IV and V septic systems designed for a home/business 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 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 OPERATION PERMIT 188263 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.sox 848 County File Number: Mocksville NC 27028 Date: O Inch Drawing Drawing Type: Operation Permit Scale: , 0 N%A k ft. ................................................... ................................. ................................................ .....................................................................,.................,................. ....... ... _ ,... . ............1.. .................... .l ) . 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Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street CDP File Number: P.O.Box 848 Mocksville NC 27028 County File Number: Date: . . / Click below to import an image from an external location: Drawing Type:Operation Permit, Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Charactersers �. Rememeinfng 4000 Septic Tank: Chaactere Remaining 4000 Pump Tank: cnaradera ... Remaining 4000 Supply Line: Gla'BLIBl9 Remaining Y 4000 Pump Requirements: c„eractws Remaining 4000 Electrical Equipment: Characters Remaining 4000 P1 P2 P3 CO.NATRUCTION For office Use only AUTHORIZATION *CDP File Number 188263-1 =="'�" Davie County Health Department County ID Number. 210 Hospital Street -ForEvaluated NEW .� �. P.O.Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 6 / . 0 9 / a 0 a 1 Applicant: True Homes Property Owner: Taylor Williams Address: 2649 Brekonridge Centre'Dr.Suite Address: 433 Roslyn Road 104 City: Charlotte City: Winston-Salem State2ip: NC 28110 State2ip: NC 27104 Phone#: (704)400-6143Pone#: (336)293-6790 Property Location & Site Information Address/Road#: Subdivision: Summer Hill Farms Phase: Lot: 33 119 Crestwood court Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Hwy 801 , Left on Markland Rd of Bedrooms: 4 - #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 r sification: Provislonauysuitable InchesS stem? Minimum Soil Cover. 1ay QYes QNo Inchesow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 2 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: QYes QNo Pump Required: QYes QNo QMay Be Required Nitrification Field 1 4 7 6 Sq. ft. Pump Tank: Gallons No. Drain Lines 5 1-Piece: QYes QNo Total Trench Length: 3 6 9 ft GPM—vs— ft. TDH Trench Spacing: 9 @Feet O.C. g Inches O.C._ Dosin Volume: Gallons Trench Width: — 3 @Inches Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: QNSF QTS-1 QTS-II Septic Tank Installer Grade Level Required: Q I QI I Q III Q IV Donn 1 of Z i CDP File Number . 188263 - 1 County ID Number.. ❑ Open Pump System Sheet Repair System Required:OYes ONo ONo, but has Available Space rDesign System Trench Spacing: 9 �Inches O. . ification: Provisionally Suitable — e Feet O.C. Trench Width: Inches w: 4 8 0 — 3 Feet Soil Application Rate: 0 3 a 5 Aggregate Depth: inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover 1 a Inches Maximum Trench Depth: 3 6 Inches 'Proposed System: 25%REDUCTION , N krification Field 1 4 7 6 Sq.ft. Maximum Soil Cover. a 4 Inches No. Drain Lines 5 *Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 -6 9 f Pump Required: QYes ONo OMay Be Required ' - Pre Treatment: ONSF OTS-I 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 bythe Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for wastewater System Construction shall bevalid fora person equal tothe period of validity of the Improvement Permit,not to exceed five years,and may be issued atthe sametime the Improvement Permit issued(NCGS 130A-336(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 Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps.Signature Date:. *Issued By: 2140-Nations,Robert Date of Issue: . 0 6 / 0 9 / 2 0 1 6 Authorized State Agent: Malfunction Log OYeS ; ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 188263 - 1 210 Hospital Street P.O.Box 848 County File Number. Mocksville NC 27028 Date: 0 6 / 0 9 / 2 0 1 6 Q Inch Drawing Drawing Type: Construction Authorization Scale: . QBlock QN/A I I �b I - �ani T � CONSTRUCTION AUTHORIZATION 4 ' Davie County Health Department 210 Hospital Street CDP File Number. 188263` 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0 .6 / 09 J a 0 1 6 Click below to Import an Image from an external location: Drawing Type:Construction Authorization a APPLICATION FOR SITE EVALUATION/IMTROVEMENT PERMIT & ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT"`**THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed True Homes Contact Person Jackie Self Billing Address 2649 Brekonridge Ctr Dr Home Phone (704) 238-1229 City/State/ZIP Monroe NC 28110 Business Phone (336) 992-2477 Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Williams Development Group Phone Number (336) 293-6790 Owner's Address 433 Roslyn Road City/State/zip Winston Salem NC 27104 Property Address 119 Crestwood Court City Advance Lot Size .69 acres Tax PIN# G814OA0033 Subdivision Name(if applicable) Summer Hill Farms Section/Lot# Directions To Site: 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? El Yes ZNo Does the site contain jurisdictional wetlands? ❑Yes igNo Are there any easements or right-of-ways on the site? ❑Yes 9No Is the site subject to approval by another public agency? []Yes ZNo Will wastewater other than domestic sewage be generated? ❑Yes 9No IF RESIDENCE FILL OUT THE BOX BELOW #People 5 #Bedrooms 4 #Bathrooms 2.5 Garden Tub/Whirlpool ZYes ❑No Basement: ❑Yes ZNo Basement Plumbing: ❑Yes Z]No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People # Sinks #Commodes # Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)' FOODSERVICE ONLY: # Seats Type system requested: OConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: 2 County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes © No If yes,what type? This is to certify that the 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 . I understan t I am resp risible for the proper identification and labeling of property lines and corners and locatin and agg' g-or sta ' the &Yfacility location,proposed well location and the location of any other amenities. Property o er's or owner's legal rep sentative signature NtA Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 11/06 Invoice# Pd. DRAWING NAME •P:\2016\160154\Survey\160154—survey.dwg — PLOT — 5/25/2016 4.00 PM PfinlM/NARY SO FT WAL SF 70 B/* JZ079.* r 5'PUBLIC 5/W.` 0.*S- 158.39 (F APPLICABLE) HOUSE: 1,686.* SF S86 144113T DAYW HO ISE R/W: 1,043* Dr R/N-Bla 272.* SF &DEWALK.•33.*SF PORCH.• 98.*SF —'-- HYAa 9.*SF 30,010.* SQ.f!`. c�►vG s>tacw 9.* 5F Lor u scn m e/a 14,164.* RY SEW/.T RAN! 9,836.* SF ' — UNOVS'IURBED.• 4r8?7.* Sf' SEED/ E' T UNE I m > ' h I PA 170 I 12X12' LOT 34 CCNL: a3 �r /am 3rx°3cp' SOD I ^ c^p Lor 32 C4 HVAC m o 10' 66.67' h PAD�� I 3X3 PROPOSED O N /' a / g'h 12' 66.65' / 51.7?' POR / 3 / E E m DRIW �, 3 / 10'S/DEWA�(C EAmwDV r E E ��•�/ Et 10'unurY EASrMENr E E Lor x C 1 o OWsnift w L10uRr (50 PUBLIC R/W PDP P.a 1Z PC 146) I N8776'39"W 139.72 1 LU Curve Tab/e \ �� Curve Length Radius Chord Bearing Chord Distance TRUE HOMES Cl 21.05 25.00 S68'30'13"W 20.43 PLOT PLAN OF 119 CRESTWDOD COURT LOT 33 OF SUMMER HILL FARM PHASE 1, SECnON 4 AD VANCE GRAPHIC SCALE SHADY GROVE TOWNSHIP, DAME COUNTY 50 25 0 50 100 DAZE: 5/15/7016 am m BY: U MAP RECCiRDED 1N PLAr BOCK 12 1" = 50 FEET Ar PACE 146 CHECKED BY.' SW DAW. 5-25-2016 DAMS • MARTIN • POWELL ENGINEERS & SURVEYORS PRELIMINARY PLAT Not for Rkardctia+.Connymw,or Salty 6415 OLD PLANK RD,HIGH POINT,NC 27265 (336)8864821 1 WWW.DMP-INC.COM I LICENSE:F-0245 - IMPROVEMENT PERMIT For office useonly [Evaluated File Number 188263-1 r � Davie County Health Department 210 Hospital Street y ID Number. " For. NEW P.O. Box 848Mocksville NC 27028 hip: Phone:336.753.6780 Fax:336-753-1680 PERMIT VALID UNTIL 9/16/2420 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit FPhone#: ant: True Homes Property owner. Taylor Williams ss: 2649 Brekonridge Centre` Dr. Address: 433 Roslyn Road ..,. Charlotte City. Winston-Salem Zip; NC 28110 State/Zip: NC 27104 (704)400-6143 Phone#: (336)293-6790 Prol2erty Location & Site Information rMAddress/Road#: Subdivision: Summer Hill Farms Phase: Lot: 33 arkland Rd Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Hwy 801 , Left on Markland Rd #of Bedrooms: 4 #of People: *Water Supply: PUBLIC System Specifications nitial S stem *Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches Saprolite System? OYes ®No Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 3 2 5 1-Piece: OYes ®No Pump Required: OYes OQ No OMayBe Required *System Classification/Description: TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons LESS) *Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:QYes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: 2 4 Inches Sail Application Rate: 0 3 2 5 Maximum Trench Depth: 3 6 Inches *System Classificatioh/Description Pump Required: Oyes ®No O Maybe Required TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25%REDUCTION Page 1 of 3 CDP File Number 188263 - 1 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 Plan The Improvement Permit shad be valid for a years from date of lssue with a site pian(means a drawing not necessarily drawn to scale that shows the existing and proposed property lines with dimensions,the location of thefacility and appurtenances,the site forthe 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 surveyor,drawn to a scale of one Inch equals no morethan 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 pian,plat,or intended use changes(NCGS 130A•3W(Q).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, mporOnS and repair(A 938(b)} Applicant,/Legal Reps.Signature Required? OYes ONO ApplicantlLegal Reps.Signature: Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 9 / 1 6 / 2 0 1 5 Authorized State Agent: OValid without Expiration? g O C reate CA? (9)Hand Drawing Olmport Drawing ; **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 188263- 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Qlnch Drawing Drawing Type: Improvement Permit Oft Scale: Blo k C _I 1 ILA 40 -T IX v -k, ;- 06 T r�� .- i IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 1$$263- 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: 0 9 1 1 6 / 2 0 1 5 Click below to Import an Image from an external location:Drawing Type: Improvement Permit R-;�'�"'•c-'-. �� ,.. • ��j�r•�'/1��'r'',►�`7:lj�I`.i'r "��1.J�1�1�.�'i::j .,;r_ '1:�: .:1. —/� �/��� : 1 t. _� ., (50' Public R/W). 20' Asphalt Cedcarpark Drive 10. Ik � F _ .30 / 300 �3I�j< i a � APpkITION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health Date: •`�/��/� P.O.Box US1210-Hospital Street Mocl6vifleo NC.27028 Received bvr-- .`( (336)753-6780f lr (3U)753-1690 Application For.X Site Evaluation/Improvement Permit i Authorization To Construct(ATC) F Both Type of Application: )1New System :]Repair to Existing System '!Expansion/Modification of Existing System or Facility *0 4IMPORTANP*0THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed True Homes Contact Person Attn: Permitting Billing Address 2649 Brekonridge CentrLi Dr.,Ste 104 Home Phone N/A City/State/ZIP Charlotte,NC 28110 Business Phone (704)400-6143_ Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date Housc/Facil ity Corners Flagged NOTE: A storey plat or site plan must accompany this application Included:i s Site Plan JPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Taylor Williams Phone Number 336 293-6790 Owner's Address 433 Roslyn Road City/State/ZipWinston- a em, NC ZIM4 Property Address City Advance, NC Lot Size Tax PIN# 7 2 SubdivisionName(ifapplicable) Summer Hill Farms ,7 J Section/Lot# Directions To Site: From 1-40, 801 South--Right on Markland Road 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?.'- L-.Yes IKNo Does the site contain jurisdictional wetlands? JYes)(No Are there arty easements or right-of-ways on the site? L-Yes 4iNo Is the site subject to approval by another public agency? L:Yes IRNo ' Will wastewater other than domestic sewage begenerated? JYes RNo IF RESIDENCE FILL OUT THE BOX BELOW #People 4 • #Bedrooms 4 #Bathrooms 2.5_ GardenTub/Whirlpool _Yes Xi No Basement:Utes XNo Basement Plumbing: :'.]Yes ¢(No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: )(Conventional rAccepted -11nnovative '..!Alternative DOther Water Supply Type:X County/City Water r New Well =Existing Well ;Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?. Yes )(No If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. t 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 1 hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable taws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and Il(�.aMrC%f/fl in ghouse/facility location,proposed well location and the location of any other amenities. Property owner's or owner;s legal representative signature " Site Revisit Charge ner Date(s): /iqq L/ Client Notification Date: Date EHS: Sign given CYes ONo Account# Revised 11/06 Invoice# aC�30 Z 1 f.T J, •r �.Jf i 7 r f :" f } i �. t•: t•: t a. 1: •r•f .f Y� r�F. .2 Y- J y. 7 :T �r +t ..i"r _ L _ Jp iii: _ /•: ':�l r r ,y .Sjr•, 1. 2 'i i'•" •r :•J! =rJ:' t r �rr t rJ` r W J. 7: d ,.�,� y. r � 1,�• l� £7 i A7. I _ �. 4 f. < J J f �'/ t .. f L/ }, / / -r h1 /` - Jt v > -�v v �^ � 7 •j1 y�. II w ' 1 �J .}i. -/ -r ! r r: r '• - r I. rr r t '! J F fr / ! r �s ♦ l t ��, J ty / •r r a K J 1 - J/ r \f f .� L. l-- ,.J. , r • �t J ! s /./ tJ .7t1 > f � f: fr •1 J .1 r�: cla V f ! r / \ t♦ ��� � J J ? rrr I r ' f, f r he C)U*rt (50 public /W), 20 P ' DAVIE COUNTY HEALTH bEPARIMENI. Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION ' True Homes I Markland Road 704 400-6143 i Summer Hill Farms Acers: Lot#3-3 i Water Supply: On- ite Well Community Public Evaluation By: Aug r Boring Pit Cut FACTORS j 1 2 5 6 7. Landscape position I Slope%' I HORIZON I DEPTH . 't6 Texture groupiG Consistence 5 P We s I Structure I 9 e j Mineralogy HORIZON H DEPTH _ .. p I Li 49 ! ! Texture group 4 Consistence y5/ y r, ! Structure j Mineralogy HORIZON III DEPTH ( ! Texture group Consistence Structure MineralogyI' ! HORIZON IV DEPTH i Texture group Consistence I I Structure Mineralogy SOIL WETNESS f I C RESTRICTIVE HORIZON SAPROLITE I I CLASSIFICATION 1 LONG-TERM ACCEPTANCE RATE ,3 SITE CLASSIFICATION: l ,EVALUATIQN BY. r LONG-TERM ACCEPTANC RATE: OTHER(S)PRESENT: REMARKS: i LEGEND i 1 T_andscahe Position I R-Ridge S-Shoulder' ' L-Linear slope FS-.Foot slope NI-Nose slope] C -oncave slope CV-�onvex slope T-Terrace FP--Flood plain H Head slope Texture S Sand LS -Loamy sand SL-Sandy loam L-Loam SI,Silt SICL-Silty clay loam SII;-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CQNSISTFNCE N14ist f I VVR.-Very friable FR-Ft'able FI-Firm VFI-Very firm JEFI-Extremely firm Rmt I NS -Nott sticky SS-.Slightly sticky S-Sticky VS -Very Sticky NP-Np'h plastic SP-Slig tly plastic P-Plastic VP-Very plastic ,S ,r I ; SC-Single grain M-M 'sive CR-Crumb GR-Granular . ABK-Ang lar blocky SBK-Subangular blocky i L-Platy PR-Prismatic Mineralogy 1:1,2:1,Mixed Nates i Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable)• I 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) v O Piasb . Tax Map dress: j -lift Installer: EHS , Date:' fl o l Yta Operation Permit Inspection Checklist ❑ Conventional ❑ Chamber ❑ Polystyrene ❑-Other Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement feet 2. Distance from system to well if applicable feet 3. Any other setback(.1950)requirements Supply line 1. Material supply line is constructed of diameter inches 2. Length of supply line(2'min.) 3. Amount of fall in supply line(1/8"per foot min) 4. Distance from ST/PT to the nitrification field/dist.device) feet Septic Tank/Pump Tank 1. Visually inspect top of tanks(s),interior&exterior walls,baffle wall and bottom 2. Any honeycombing or exposed rebar present? Circle: YES or NO 3. Visually inspect sanitary tee,lids,and air vent for roper installation ansealt 4. Tank Serial Numbers: STB PT A (A�tn 1'1 5. ST w/in 6"finished grade?Circle: Sr N 6. Date of manufacture: ST - PT 7. Liquid capacity of tanks.ST �'�]� PT I 8. Effluent filter type 9. Pipe penetration seal present?Circle: YES or NO 10. Riser(s)present?Circle: YES or No Riser Type 11. Pump Tank riser 6"above finished grade?Circle: YES or NO 12. Riser approved?Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation 2. Trench Depth Readings(inches) 3. Number of Trenches Distance between trenches 4. Trench Width 5. Aggregate material type and size 3 4 5 6 57 (Circle) 6. Aggregate Depth(inches) 7. Nitrification lines installed on contour?Circle: YES or NO 8. Innovative system type Installer certified for installation?Circle: YES or NO 9. 2'earthen dam between ST(or d-box)and beginning of nitrification line?Circle:YES or NO 10. Stepdowns a. 2'undisturbed earthen dam(s) Circle: YES or NO b. Proper rise over stepdowns?Circle: YES or NO c. Solid pipe used? Solid,Corrugated or other? d. Elevation of each stepdown e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO Distribution Devices 1. Type Is the device watertight? Is it level? 2. Distance from Dist device to trenches feet 3. Record elevations:Inlets Outlets L` i � � � � CD� � � � t � �� �� ' �� _ . ._