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115 Lost Farm Dr Lot 31
,:. CONSTRUCTION For.office Use Only s z t AUTHORIZATION *CDP Fite NUmber 232878-1 Davie County Health De a D County ID Number SU0514933 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 1 / 1 0 / 2 0 a a Applicant: J. Reader Construction r perty Owner. J.Reader Construction Address: PO Box 828 ress: PO Box 828 City: Clemmons City: Clemmons StatetZip: NC 27012 State0p: NC 27012 Phone#: (336)345-0767 Phone#: (336)345.0767 Property Location & Site Information Address/Road#: Subdivision: Magnolia Acres Phase: Lot: 31 PO Box 828 Clemmons NC 27012 Directions Structure: SINGLE FAMILY Hwy 158 East, left on Hwy 801, left on Peoples Creek Rd. #of Bedrooms: 4 right into Magnolia Acres #of People: 5 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: Site Classification: Pmvisiomllysatable 3 6 Inches Minimum Soil Cover. 4 Saprolite System? QYes QNo Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 2 7 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE III G.OTHER NON-CONY.TRENCH SYSTEMS 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 7 4 5 Sq.ft. Pump Tank: Gallons No. Drain Lines 5 1-Piece:QYes QNo Total Trench Length: 4 3 6 8 GPM—vs— ft. TDH Trench Spacing: Inches O . _ 9 @Feet 0 CC Dosing Volume: _ Gallons Trench Width: Q Inches Depth: _ 3 s Feet Grease Trap: Gallons Aggregate inches Pre-Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 0111 O IV ovnn i of 4 CDP File Number 232878- 1 County ID Number. 0514933 ► r, ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but,has Available Space rDesign System Trench Spacing: 0Inches 0. . ification: Provisionally Suitable 9 s Feet O.C. Trench Width: 3 8 Feet Inches w: 4 8 0 —. Aggregate Depth: Soil Application Rate: 0 - 2 5 inches -� *System Classification/Description: Minimum Trench Depth: 3 6 Inches TYPE III G.OTHER NON-COW.TRENCH SYSTEMS Minimum Soil Cover a 4 Inches *Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field Inches a 1 3 3 Sq.ft. No. Drain Lines *Distribution Type: GRAVITY-SERIAL. 6 Total Trench Length: 5 3 3 ft, Pump Required: OYes dNo 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. Septic lines can be no deeper than 36 Inches.It trench bottoms can't be held at 36 inches,a pump tank must be used. "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. ; This Authorization for Wastewater system Construction shall bevalld fora person equal to the perlod of validity 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 wlldity of the Construction Permit,the Information submitted in the application for a permit or Construction Authorization Is found to have been Incorrect,falsified or changed,or the site is altered,the permit orConstruction Authortzation shall become Invalid,and may be suspended or revoked(.193718?).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 Applicant/Legal Reps.Signature Required? Oyes ONO Applicant/Legal Reps.Signature* Date:, „ 2140-Nations,Robe 0 1 / 1 0 / 2 0 1 7 Issued By, Date of Issue. - 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. 210 Hospital Street 5880514933 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 01 / 1 0 / 2 0 17 pinch Drawing Drawing Type: Construction Authorization Scale: . Oft, /A ONN/A � F e J a I I l � s i � I I I I •-� •c I � I I I s I CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number. P.O.Box 848 5$80514933 Mocksville NC 27028 County File Number: Date: _g .1 / 10 / 2017 Click below to Import an Image from an external location: Drawing Type:Construction Authorization IMPROVEMENT PERMIT For office Use Only 'CDP File Number 232878-1 :'=�`• Davie County Health Department 210 Hospital Street County ID Number.5880514933 P.O.Box 848 Evaluated For NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 1/10/2022 "NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: J. Reader Construction Property Owner. J. Reader Construction Address: PO Box 828 Address: PO Box 828 CRY: Clemmons CRY: Clemmons State/ZIP: NC 27012 State2ip: NC 27012 Phone#: (336)345-0767 Phone#: (336)345-0767 Property Location & Site Information Fddress/Road#: Subdivision: Magnolia Acres Phase: Lot: 31 828 ns NC 27012 Directions Structure: SINGLE FAMILY Hwy 158 East, left on Hwy 801, left on Peoples #of Bedrooms: 4 Creek Rd. right into Magnolia Acres #of People: 5 *Water Supply: PUBLIC System Specifications nitial System 'Site asst Ica an: Provisionally Suitable Minimum Trench Depth: 3 6 Inches Saprolite System? QYes QNo Maximum Trench Depth: 3 6 Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 2 7 5 1-Piece: QYes (F)No "System Classification/Description: Pump Required: QYes 0 N OMay Be Required TYPE III G.OTHER NON-COM/.TRENCH SYSTEMS Pump Tank: Gallons 'Proposed System: 25%REDUCTION 1-Piece: QYes QNo Repair System Required:QYes ONO ONo, but has Available Space Repair System 'Site Classification: Provisiona►IySuitable Minimum Trench Depth: 3 6 Inches Soil Application Rate: 0 2 2 5 Maximum Trench Depth: 3 6 Inches u 'System Classification/Description: Pump Required: QYes QNo O Maybe Required TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS *Proposed System: 25%REDUCTION Pagel of 3 � J CDP File Number 232878 - 1 County ID Number. 5880514933 *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 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 valld fore years from date of Issue with a site plan(means a drawing not necessarily drawn to sale 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 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 sale of one inch equals no morethan 60 feet,that includes:the specific location of"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 locatior%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 lssue: 0 1 / 1 0 2 0 1 7 Authorized State Agent: OValid without Expiration? O Create CA? @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 232878 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 5880514933 P.O.Boras County File Number: Mocksville NC 27028 Date: Q Inch Drawing Drawing Type: Improvement Permit Scale: , pBbck QN/A Jft, � I aY "r�, y. G_ , �.. — � _� 1 0 I I 3 I mol I I � I I I I i IMPROVEMENT PERMIT Davie County Health Department 210 Hospital street CDP File Number: 232878 - 1 P.O.Box 848 5880514933 Mocksville NC 27028 County File Number: Date: 01 ! le l2017 Click below to import an image from an external location:Drawing Type: Improvement Permit APPLICATION-'FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County EnvironmentaFHealth' 41 .&Box-848/210 Hospital Street Mocksville,NC_27028 ;, (336)753-6780/.Fax.(33.6)753 1680 � . t Applicatio Site Evaluation/ImprovemeniPermitAuthorization 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 Contact Person 5 A9eki /5,,, Address Z �ftome.Phone 334-3.95.0747 City/State/ZIPG/ern wt deo G �7aBusiness Phone S wf+ Email )awo _� ��ad�y.c��wstr����Oc+.Gc�+�i�` Email: SayH� Name on Permit/ATC if Different than Above ` Mailing Address P.0 ()o City/State/Zip PROPERTY INFORMATION.; 1' A *Date House/Facili Corners Flagged NOTE: A survey plat or site plan must accompany this(application. Included: VSit6 Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name "� . .cel�✓ (p is fi�ch'�^ ; , „ Phone Number. 3 3G - 3,yh Owner's Address !�, C, /3a X ra2� City/State/Zip G/-eot ,. w s /I�L17-12 Property Address 11h 1,651' Farm d,- ' Cit "Aid✓mNc.e- ._ Lot Size . fit 1107K3 Tax PIN# 5$f091yg33 Subdivision Name(if applicable) Inegilelia, 4e✓e 5. Section/Lot# Directions To Site: 101 S -Pv L-r vn Pic/ , C/«k . 13 t- en 644 bran be.-5t-4 Ili h 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 _\tNo Does the site contain jurisdictional wetlands? _Yes )LNo Are there any easements or right-of-ways on the site?. . . .. YYes 16 No 5. Is the site subject to approval by another public agency? Yes 7N - Will wastewater other than domestic sewage be generated? Yes X No IF RESIDENCE FILL OUT THE BOX BELOW; #People �� #Bedrooms , H . #,Bathrooms , Garden Tub/Whirlpool es ❑No Basement: ❑YesL�o Basement Plumbing:; 0"Yes* ,ONo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building `#People #Sinks #Commodes #Showers tAUrinals Estimated Water Usage(gallons per day) (Attach documentation of similarfacility water consumption) FOODSERVICE ONLY: #Seats 1 Type system requested: ❑Accepted ❑Innovative. ❑Alternative ❑Other-f-oHveti fkn It Water Supply Type: 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 PSNo 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 Z-1Z Date(s): A icant's ignature Client Notification Date: t EHS: Pro owner's or owner's legal representative signature Da e G (l Account# ®�b Revised 11/16 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_ LOIT Soil/Site Evaluation 6 J� APPLICANT'S NAME l_ /�� ���°r DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE SUBDIVISION �/ ROAD NAME C°��/J�S lqee,o 0 Water Supply: On-Site Well Community Publicy Evaluation By: Auger Boring Pit t___1_ Cut FACTORS 1 2 3 4 5 6 7 Landscapeposition L Slope% HORIZON I DEPTH !� Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence / Structure SLG_- / Mineralogy - HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: U< EVALUATION BY: LONG-TERM ACCEPTANCE RATE: �f OTHER(S)PRESENT: REMARKS: &2A '� LEGEND Landscape Position W � 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 clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE ois 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(01-90) N ROBERT L. POTTS D.B. 188 PG. 184 I — �� _ ' I � �� --�- S 83'27 24,•=07.20 — � f I S 83'2 2g"E 107.20' T� � I �—�__ I ' -- -- 1 � � I ' I '_—__— I — --. � _ 30� t��� � I I - 1 I I ' � � _ � ' � � I I I �'. I I I ' I I I ' ' I I � ` � ' I �� ' , i � ; i ; ; i � �� �1 I ' I ' 1 � ' I ' 1 � ' I � ' I � °' I N ' � f � � I � � ' W I� � � M � M � Tol � ; � � o � I � MM o t�- � � I � r 33 Z 32 � � M� . � I I Z � � ¢c,L � o � e.�. � r ,..�s - _ _ — 18.73 18.42 '� 4.Op'g � _ 33�G0� f� 13.92' I I r� � ~ � HOUSE N I I I .t �s.u' g e.ae'8�iso' —� Iie.—�s I � � GARAiCE i� I I L�_..,� � � I I II ( 24.75' _. _ � �,.-�-�- - I ' I � �►1 �� I � � I � � I I � I I �� '��`I�pI I I^ � I � � I I i is i i� � I I � �---_ � � � i r ; — _ _ _ _ _ _ _ _ � _ _ _ ` — _ — — — — — — — � I — I — _i � "'- -" -- -- � ts' uTnrtv 4 — � —' — — � _ - - - I I I I �'_ � �� _� � _ —�. _ � �. � - `- ~ �� �� _ 1 �� � ____ � I uwuw�c� �� _ _ — — — � � � � I � _ _ N 86'S 44 0"W 107.00' �' �' 1 --- � N 86�54'40"W 107.nn' ._._ _'.- � _� �� �� LOST FARM DRIVE �- - - - - - - - - �' -- �.� I �� � � � — � - ` - _ - - - — � I �� � SITE � 1 � LOST FARfd DR TULIP MAGNOLIA DR � o � 8 pEop�e� �a � LOCATION MAP \\\��\��\\Ii l{ I 11 f I!l//1�i/// o�`��Q.'�N •• �AAO ��'�i. : O: ••oFEss��••.�i % , ? : Q ^,, •. 2 � ' � SEAL 9� � - _ ��.. � L-2890 �.� � = : ti�'•.�Ya �:-.'�'; � 2 • . S�a���,.�� s : .� /,����iR�C�'I A RO � ���`��\ ����iirut�: u i ;i ti�u��`'� SITE PLAN ONLY THIS WAS MAPPED FROM A DEED OR RECORD PLAT AND NOT FROM A SURVEY 6Y M E. 1 1 1 .i •1 ■�■�■�■�■� FOR J. READER CONSTRUCTION SCALE TOWNSFiIP COUNIY STATE DATE'S 1" = 30' SHAOY GROVE pAVIE N.C. 11-29-16 LOT 31 P.B. 8 PG. 75 MAGNOIIA ACRES PHASE 2 JOHN RICHAR� HOWARD JOB N0. SURVEYING 16050 P.O. BOX 276 ADVANCE, N,C, (336) 998-5396