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686 Crescent Dr Davie County,NC Tax Parcel Report Thursday,February 23, 2017 4T DR GPI ............... ............ . ........ ............... --.E].......................... ........................... .............. �. . •.;_ .yam�:;,;. WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: J10000002906 Township: Calahaln NCPIN Number: 4798708677 Municipality: Account Number: 82525576 Census Tract: 37059-801 Listed Owner 1: STROUD JAMES LEE Voting Precinct: SOUTH CALAHALN Mailing Address 1: 1813 RIDGE ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag.District: No Legal Description: 28.891 AC CRESCENT DR Fire Response District: COUNTY LINE Assessed Acreage: 26.13 Elementary School Zone: COOLEEMEE Deed Date: 1/2004 Middle School Zone: SOUTH DAVIE Deed Book/Page: 005320251 Soil Types: PaD,PcC2,ChA,CeB2,RwA,WATER Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: 0.00 Outbuilding 8r Extra 0.00 Freatures Value: Land Value: 79480.00 Total Market Value: 79480.00 Total Assessed Value: 79480.00 O Ate All data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davis,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to noUNrt NC or arising out of the use or Inability to use the GIS data provided by this website. ' f OPERATION PERMIT EEvaluated ice se n v s; Davie County Health Department Number, 233884-1 210 Hospital Street 47ss�oasr� P.O.Box 848 umber. Mocksville NC 27028 r. NEW Phone: 336-753-6780 Fax:336-753-1680 Applicant: Freedom Homes Property Owner: James Stroud and Richard Address: 1124 Charlotte Hwy Address: 1813 Ridge Road City: Troutman City: Mocksville State/Zip: NC 28166 State/Zip: NC 27028 Phone#: (704)528-7960 Phone#: (352)216-1441 Propeqy Location & Site Information Address/Road#: X0 Subdivision: Phase: Lot: Cresent Drive Mocksville NC 27028 Directions Address/Road Structure: SINGLE FAMILY Hwy 64 West, left on Godbey Rd. to end. Turn left on Davie Academy Rd. cross 1-40 on the right. #of Bedrooms: 3 #of People: 2 "Water Supply: NEwwELL *IP Issued by. 2140-Nations,Robert *System Class ifiication/Description: TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS *CA issued by: 2140-Nations,Robert Seprolite System? ( Yes (QNo Design Flow: 3 6 0 GRAVITY-SERIAL Pump Required? Distribution Type: QYes QNo Soil Application Rate: 0 - a 7 5 *Pre Treatment: Drain field N trification Field 1 3 0 9 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD No. Drain Lines 3 Installer: Tim Abee Total Trench Length: 3 3 0 ft. Certification#: 1011 Trench Spacing: _ 9 Inches O.C. ()Inches O.C. EH S: 2140-Nations,Robert Trench Width: _ ()Inches3 Feet Date: 0 a / a 1 / a 0 1 7 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches ApprovalStatus M'aximum Trench Depth: 3 6 [E'-Approved Disapproved Inches ,; Maximum Soil Cover. 2 4 inches CDP File Number 233884 - 1 Septic Tank County ID Number: 4798708677 Manufacturer. Shoaf Lat. STB: 760 Long: Tim Abee Gallons: 1000 Installer Date: 1 0 / 1 7 / x 0 1 6 Certification#: 1011 *EHS: 2140-Natk=.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter 0 a / a 1 / 2 0 1 7 ST Marker. E3 Yes � NO Date: Approval Status Reinforced Tank: E] Yes Cl No ®;Approved❑ Disapproved 1 Piece Tank: ❑ Yes Cl No Pump Tank Manufacturer, Installer PT: Certification#: Gallons: *EH S: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ NO (Min.6 in.) Approval Status inforced Tank: ❑ Yes El '�� e „ Approvecfi❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No ' Supply Line FPipe ize: inch diameter Installer gth: feet Certification#: Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: / Approved fittings ❑ Yes ❑ NO Approval Status ❑,Approved❑ Disapproved Pump Requirement CDosing p Type: Installer Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chan: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ N o Check-valve ❑ Yes ❑ NO Approval Status' PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ NO CDP'File Number 233884 - 1 County ID Number: 4798708677 Electric Equipment N EMA 4X Box or Equivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj. Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No 'Activation Method: Date: Alarm Audible ❑ Yes ❑ No Approval Status Approved❑,E�tsapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert 'Operation Permit completed by: Authored, Sta a fkcjent Date of Issue: 0 a a 1 / a 0 1 7 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 III G. sewage septic system. Rule.1961 requires that a Type TYPE lu G• septic system meet the following criteria: Minimum System Review ByThe Local Health Department: WA Management Entity: OWNER Minimum System InspectioniMaintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator. NIA 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 operatoror 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 operator forthe 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 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 Qlmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT ' Davie County Health Department CDP File Number: 233884- 1 210 Hospital Street 4798708577 P.O.Box 848 County File Number: Mocksville NC 27028 Date: ! ! Q Inch DrawingDrawing Type: Operation Permit Scale: . OB A k -;� 0 ----------------- ----------------1 { a 10 - - ------ ---- ----------- -7-7--7 I ""..'r•--- 171 y 4E[ ` r Well Construction Permit For Office Use Only Davie County Health Department FICDPFileumber 233884 210 Hospital Street umber.4798708677 P.O. Box 848 --y'' Mocksville NC . 27028 Tax Lot#: Tax Block#: Phone:336-753-6780 Fax:336-753-1680 Evaluated For. WELL PERMIT VALID UNTIL: 2/8/2022 r erty Owner. ,lames Stroud Applicant- Freedom Homes ress: 1813 Ridge Road Address: 1124 Charlotte Hwy CRY: Mocksville CRY: Troutman StatefZip: NC 27028 State/Zip: NC 28166 (70 Phone 4)8 76-5866�:: Property Location & Site Information rddress/Road #: Subdivision: Phase: Lot: resent Drive *Proposed use of Well: ocksville NC 27028 If Other: Latitude Longitude Directions Site Address:Cresent Drive Directions:Hwy 64 West,left on Godbey Rd.to end. Turn left on Davie Academy Rd.cross 1.40 on the right. Well Contractor information Drilling Contractor Driller Registration Permit Conditions *Permit Conditions well location,construction and protection must meet all state and total regulations and must be inspected and approved by an authorized representative of the local Health Department.The permit may be revoked at any time for failure to complywith existing regulations.The siting of approved well construction area(s)by the Health Department is to provide protection from the known possible sources of contamination.The approved well area(s)may not be changed without written permission from an authorized representative of the Local Health Department.No volume of quaray of water is guaranteed by the Health Department *Issued By: 2140-Nations, Robert *Date of Issue;0 , 2 0 1 8 , 2 r 0 , 1 , 7 Authorized State Agen . t2rHand Drawing Qlmport Drawing Owner/Applicant Signature: **Site Pian/Drawing attached.** WELL CONSTRUCTION PERMIT Davie County Health Department CDP File Number: 233884 r o 210 Hospital Street 4798708677 P.O.Box 848 County File Number. Mocksville NC 27028 Date: 0 .2 / 0 8 / 2 0 1 7 Q Inch OBloDrawing Type: Well Permit Scale: ON/A , N� ft. lwz' ! ! Cha ! ! � I Y CONSTRUCTION For office Use Only AUTHORIZATION 'CDP File Number 2338U-1 40 Davie County Health Department County ID Number.4798708677 210 Hospital Street Evaluated For. NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 a / 0 8 / 2 0 a a Applicant: Freedom Homes Property Owner. James Stroud and Richard Walbaum Address: 1124 Charlotte Hwy Address: 1813 Ridge Road City Troutman City: Mocksville StatefZip: NC 28166 StatefZip: NC 27028 Phone#: (704)528-7960 Phone#: (352)216-1441 Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Cresent Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West, left on Godbey Rd. to end.Tum left on Davie Academy Rd. cross 1-40 on the right. #of Bedrooms: 3 #of People: 2 *Water Supply: NEW WELL System Specifications Minimum Trench Depth: 3 6 (Design Classification: Provisionanysuitable Inches rolite S tem? Minimum Soil Cover.`a 4 Inches System? OYes QNo Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 2 7 5 Maximum Soil Cover. a 4 Inches "System Classirreation/Description: `Distribution Type: GRAVITY-SERIAL TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS Septic Tank: _ 1 0 0 0 Gallons `Proposed System: 25%REDUCTION 1-Piece: OYes Q N o Pump Required: OYes QNo OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No.Drain Lines 3 1-Piece:OYes ONo Total Trench Length: 3 2 7 ft GPM vs— ft. TDH Trench Spacing: _ 9 Feet ches C.0 Dosing Volume: _ Gallons Trench Width: Inches 3 Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 0111 OIV Dano 1 ^V1 V Y It CDP File Number 233884 - 1 County ID Number.479870877 ❑ Open Pump System Sheet Repair System Required:@Yes ONO ONo, but has Available Space rDesign System Trench Spacing: Q Inches 0. . ification: PS Shallow Placement — 9 • Feet O.C. Trench Width: Q Inches w: 6 _ 3 _ e Feet Soil Application Rate: Aggregate Depth: 0 � 7 5 inches u *System Classification/Description: Minimum Trench Depth: 3 4 Inches TYPE III G.OTHER NON-CONY.TRENCH SYSTEMS Minimum Soil Cover a a Inches `Proposed System: 25%REDUCTION Maximum Trench Depth: 3 4 Inches Maximum Soil Cover: a a Nitrification Field 3 0 9 Inches Sq. ft. No. Drain Lines 3 "Distribution Type: GRAVITY-SERIAL Total Trench Length: 3 2 7 ft Pump Required: QYes GNo OMay Be Required PreTreatment: ONSF OTS-1 OTS-11 "Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. "Permit Conditions The issuance of this permit 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 forwastewater system Construction shall be valid fora person equal to the period of wlldity of the Impmvemtnt Perm 1%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 validity of the Constructlot Permit,the Information submitted In the application for a permit or Construction Authodzation Is found to have been Incorrect,falsified or changed,or the site Is altered,the permit orConstruction Authorization shall become Invalid,and may be suspended or revoked(.1937(g)).The person owning orcontrolling 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 ji�No Applicant/Legal Reps. Signature* Date: *Issued By., 2140-Nations.Robert Date of Issue: 0 2 0 8 2 0 1 7 Authorized State Agen :1 Malfunction Log Oyes Hand Drawing O lmportDrawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number. 210 Hospital Street 4798708677 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 2 / 0 8 / 2 0 1 7 O Inch Drawing Drawing Type: Construction Authorization Scale: . Oslock Q N/A �JT -L lilt i 4W • I I I F4 E I I I P I I I CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: P.O.sox sas 4798708677 Mocksville NC 27028 County File Number: Date: .s .2 / 0 8 / 2 0 1 7 Click below to Import an image from an extemal location: Drawing Type:Construction Authorization t ' IMPROVEMENT PERMIT For office useonly *CDP Fite Number 233884-1 Davie County Health Department 210 Hospital Street County ID Number 4798708677 •.._1• P.O. Bax 848 Evaluated For. NEW, Mocksville - NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERIAIT VALID UNTIL 218/2022 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Freedom Homes rAddress: erty owner. James Stroud and Richard Address: 1124 Charlotte Hwy 1813 Ridge Road City: Troutman Mocksville StatefZip: NC 28166 StatefZip: NC 27028 Phone#: (704)528-7960 Phone#: (352)216-1441 Proeerty Location & Site Information Address/Road M. Subdivision: Phase: Lot: Cresent Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 64 West, left on Godbey Rd. to end. Turn left on #of Bedrooms: 3 Davie Academy Rd. cross 1-40 on the right. #of People: 2 "Water Supply: NEW WELL System Specifications nitiai S stem *Site Classification: PmvisionallySuitaWe Minimum Trench Depth: 3 6 Inches Saprolite System? OYes Q,ido Maximum Trench Depth: 4 Inches Design Flow: 3 6 0 Septic Tank: Gallons Soil Application Rate: 0 2 7 5 1-Piece: OYes QNo 'System Classification/Description: Pump Required: OYes 0 N OMay Be Required TYPE III G.OTHER NON-COW.TRENCH SYSTEMS Pump Tank: Gallons *Proposed System: 251%,REDUCTION 1-Piece: OYes ONo Repair System Required:@Yes ONO ONo, but has Available Space Repair System *Site Classification: PS Shallow Placemnt Minimum Trench Depth: 3 4 Inches Soil Application Rate: 0 x 7 5 Maximum Trench Depth: 3 4 Inches u - *System Class ification/Description: Pump Required: OYes a No O May be Required TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS 'Proposed System: 25°I°REDUCTION Pagel of 3 233884- 1 4798708677 CDP 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 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. Site Plan The Improvement Permit shall be valld for S years from date of Issue with a site plan(means a drawing not necessarily drawn to scale that shows the existing and proposed property tines 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 valld without expiration with prat(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 Departm ent 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,prat,or Intended use changes(NCGS 130A335(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)� ApplicanULegal Reps. Signature Required? Oyes No ApplicanVlLegal Reps. Signature*, Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 a 0 8 a 0 1 7 Authorized State Age n OValid without Expiration? O Create CA? @Hand Drawing 0Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPR(5VEMENT PERMIT 233884 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 4798708677 P.O.Box 848 County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , , QBlock QNIA ft, { t —17 70 10, I I_ �e� I 1 I I i i C f � I fLL 0 777 7`1 - IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 233884 - 9 P.O.Box s48 4798708677 Mocksvilte NO 27028 County File Number: Date: 0 2 / 0 8 / 2-0 17 Click below to import an Image from an external location:Drawing Type: Improvement Permit NCDENR Division•of Environmental Health On-Site Wastewater Section *Date: e a / e s / e i 7 Soil/Site Evaluation *File#: a 3 3 a s 4 For On-Site Wastewater System PIN #: 4798708677 *OwnerJames Stroud and Richard Walbaum Proposed Facility SINGLE FAMILY Proposed Design Flow (.1949) Location of Site Cresent Drive Property Size 26 Water Supply NEW WELL Evaluation Method Pit 1d940 yorizon SOIL MORPHOLOGY Profile# Lan scape Depth 1941 Other Profile Sbpe� (IN) Mineralogy Matrix Mottle Factors Texture Structure Consistence Color Color 1 L 0-59 sc 3-Stng sbk fi s P .1942 Wet. 3 % .1943 Depth GPS Saprolde:on) .1944 Rest. Horizon EHS .1947 Class Ps Nations,Rabe Profile o 2 7 5 LTAR,_, 2 L 0-61 SC 3-Stng sbk fi Is P .1942 Wet. 3 % .1943 Depth GPS Saprolite:pn) .1944 Rest. Horizon 12 1947 Class Ps EHs I. Co ofile Nations.Robe 3 7 5 3 L 0-59 sc 3-Stng sbk fi s p .1942 Wet. 2 % .1943 Depth GPS Saprolite:On) .1944 Rest. Horizon rA 1947 Class Ps EHS Copy rotile Nations,Robe Profile rD 2 7 5 LTAR..� .1942 Wet. olo .1943 Depth GPS Saprold0n) .1944 Rest. Horizon Ann go EHS 1.1947 Class COOYLErofile Profile AR .1942 Wet. .1943 Depth GPS Saprolaccin) .1944 Rest. Horizon APIA EHS 1947 Class Co rorile Profile LTAR - Available Space(.1945) PS Other Factors(.1946) Site Classification (.1948)Ps Initial LTAR: o . 2 7 5 Repair LTAR: 9 2 7 5 Others Present: Comments: Evaluated By. Nations,Robert NCDENR Division of Environmental Health ' ' On-Site Wastewater Section oats: e s 0 Soil/Site Evaluation Fie M a 3 3 8 8 4 For O n-Site Wastewater System PIN #: 4 7 9 8 7 0 8 6 7 7 14940 Horizon SOIL MORPHOLOGY Lan scape .1941 Other Profile Profile# POS Depth Factors Slope°'o (IN) Mineralogy Matrix Mottle Texture Structure Consistence Color Color .1942 Wet. % 1943 Depth GPS Saprolite:00 1944 Rest, Horizon caEHS .1947 Class Copy-p—rofil Profile LTAR" • . .1942 Wet. % .1943 Depth Saprolite:00 .1944 Rest. GPS Horizon EHS LTAR.1947 Class Coot-Er ofit Profile .1942 Wet. % .1943 Depth GPS Saprolite:On) .194 tRest. .1947 Class EHS Copy roti) Profits LTAR • . .1942 Wet. 9'c .1943 Depth GPS Saprolde:on) .1944 Rest. Horizon EHS .1947 Class Copy�rofit Profile PAR .1942 Wet. % .1943 Depth GPS Saprolite:(in) .114 izRon i' EHS .1947 Class COIDY— ,roril Pronle LJ LTAR Comments: Attach Image •The "Open Drawing Form"button, opens the the drawing form. # The"Import"button, attaches the drawing, or other Image Into the space below. Open Drawing Form r?7 t H L�•► I q1, j} X3 Profile: 1 G X Y Z Profile: 2 X Y Z Profile: 3 I X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z + APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC -D avie County,;<Environmental�Health �' r P.O.Box 848%210 Hospital Street Mochsville,NC:27028 1 (336)753-6780/Fax(336)753 1680 ' ' ......: V App ication For: Site Evaluation/Imp rovementPermit ❑Authorization To Construct(ATC) ❑ Both Type of Application: mew 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 �r e"15Yy Ckowiz s ' Contact Person S+e2\xQ%,N IAK�rS Address 112q"C. kpoc`o-Fk ,)Iw C/ 1`'' Home Phone 7bK..5�8 74(00 City/State/ZIP Trourk-yinckt-x kAC 'g8l&G Business Phone?0Y-87(e-L86lc, Email -te v Ker r¢eao V+ S"cow` Email:Sfi�Q�¢ . WK¢ost� rett�,eti-1�ci Name on Permit/ATC if Different than Above %,- Mailing Address City/State/Zip PROPERTY INFORMATION_ t' ( ' '' Date House/Facility Corners NOTE: A survey plat or site plan must accompany thisl application.- Included: Site Plan ❑Plat(to scale) ` (Permit is valid for 60 months with site plan,no expiration with complete plat.), Owner's Name yy o_ rove! Phone Number N(41 Owner's Address IS Ct:a9 City/State/ZipynocY-Sy„I(Q_UC a?©28 Property Address City T-Aoc.KSy-%ILQ- Lot Size ot(o,\3 Ac_ Tax PIN# 31,o00-oo-o24-O G lilt_70 9&77 Subdivision Name(if applicable) 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? Yes Y_No Does the site contain jurisdictional wetlands? " Yes '(No ” Are there any easements or right-of-ways on the site? _Yes .XNo Is the site subject to approval by another public agency? _Yes YNo Will wastewater other than domestic sewage be generated? YesXNo IF RESIDENCE FILL OUT THE BOX BELOW ' #People #Bedrooms 3 #;Bathrooms a Garden Tub/Whirlpool ❑Yes )-(No Basement: ❑Yes )(No Basement Plumbing: OYes )4No . 1 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: ccepted ❑Innovative ❑Alternative ❑Other -- Water Supply Type: ❑ County/City Water )KNew 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 permit(s)IP(s)or CA(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.Permits issued will expire 5 years from the date of issuance. 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 house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Date(s): Apnfirant' Signature Client Notification Date: EHS: operty o ier's or owner's legal representative signature 4Da Account# evised 11/16 Invoice# 5-8 KS-U ^ - ' o r w�ec 5!' N T � ( N All � �r ri } • 1A :1 NCDENI, ' Division of Environmental Health On-Site Wastewater Section 'Date: / Soil/Site Evaluation 'Fite#: a 1 9 3 8 5 For On-Site Wastewater System PIN #: 5821525526 '°OwnerTodd Allen Kelly Proposed Facility SINGLE FAMILY Proposed Design Flow (.1949) 3 6 e Location of Site Angell Road Property Size 4.034 Water Supply PUBLIC Evaluation Method Auger 1 40 Horizon SOIL MORPHOLOGY Profile# Lariscape Depth .1941 Other Profile 0e% Mineralogy Matrix Mottle Factors Slope p (IN)) Texture Structcture n Consistence Color Color 1 G — G. �j �'' •"� t?l� .1942 Wet. % .1943 Depth GPS Saprolite:On) .1944.Rest. Horizon EHS .1947 Class Profile LTAR -7 1 C_ P .1942 Wet. % CC40- .1943 Depth GPS Saprolite:Cn) .1944 Rest. Horizon MillEHS 1947 Class Cop orilePLofiie b 7 LTAR _ G- .1942 Wet. % 1943 Depth GPs Saprolite:00 .1944 Rest. Horizon raEHS 1947 Class I. Profile Copy rorile LTAR� •��S 1942 Wet. % .1943 Depth GPS Saprolite:Qn) ,1944 Rest. Horizon om .1947 Class ka EHS Copy rofile Profile LTAR .1942 Wet. .1943 Depth GPS Saprolite:(n) .1944 Rest. Horizon EHS 1947 Class Copy ofiie Profile LTAR Available Space(.1945) OtherFactors(.1946) Sae Classification (.1948) Initial LTAR:°. 7� Repair LTAR: Others Present: Comments: Evaluated By. Nations,Robert NCDENR ' Division of Environmental Health On-Site Wastewater Section Date: �e s �� J e s Soil/Site Evaluation Fie#: 2 1 9 3 8 s For On-Site Wastewater System PIN #: 5 8 2 1 5 2 5 5 a s 1 40 Horizon SOIL MORPHOLOGY Profile# LanTscape Depth .1941 Other Profile S�p�go �tN� Mineralogy Matrix Mottle Factors Texture Structure Consistence Color Color .1942 Wet. % .1943 Depth GPS Saprolite:on) .1944 Rest. Horizon EHS ._�. .1947 Class Copy�rofil Profile LTAR,_, • . _ .1942 Wet. Oj0 .1943 Depth GPS Saprolite:rn) .1944 Rest. Horizon ,_. .1947 Class EHS COpy0rofil Profile LTAR .1942 Wet. ofo .1943 Depth Saprolite:(in) .1944 Rest. GPS Horizon .1947 Class ra EHS Copy rofil Profile Tj LTAR • . ,1942 Wet. .1943 Depth GPS Saprolits:(in) .194 Rest. ,_. _.._. on .1947 Class ENS COpy0r0fi1 LTAR .1942 Wet. ofo 1943 Depth GPS Saprolite:frn) '1HoMonst. 1947 Class EHS Copy,PIrofil ProfileLJ LTAR Comments: Attach image The "Open Drawing Form"button, opens the the drawing farm. �_ The "Import"button, attaches the drawing, or other image into the space below. Open Drawing Form Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X Y Z Profile: X-. Y Z Profile: X Y Z , Profile: X Y Z Profile: X Y Z Profile: 12 X _ Y Z Profile: X,_____,_, Y Z