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1765 Peoples Creek RdHEALTH DEPARTMENT RELEASE For Office use Only *CDPFile Number :189151 -1 Davie County Health Department nO12oe000sol 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Bob Shelton Address: 1765 Peoples Creek Rd City: Advance State2ip: NC 27006 Phone #: (336) 345-2008 County ID Number: 'Evaluated For: HDR/WWC PERMIT VALID 0 1/ 0 8/ a 0 a 1 LNTI L: Property Owner: John Vaneendenburg Address: 111 Est 107th Street Circle City: Bloomington State0p: MN 55420 Phone #: Property Location & Site Information Address 1765 Peoples Creels Road Subdivision: Road# Advance NC 27006 Township: Directions Hwy 64 East, lett on Hwy 801. right at second Peoples Creek Road entrance in Advance beside Florist. 'Structure: BUSINESS # of Bedrooms: 4 of People: 'Water Supply: N/A Basement: FlYes ❑ No 'Proposed Imoroyement: Warehouse Phase: Lot Type of Business: Total sq. Footage: No. Of Employees: I This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? QYes ©No Applicant/Legal Reps. Signature: *Date: *Issued By: 2140 -Nations, Robert *Date of Issue: 1 / 0 8 / 2 0 1 6 Authorized State Agent: **Site Plan/Drawing attached.** ` ( Hand Drawing 0Import Drawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 199151 -1 County File Number: G'12013000301 Date: 01 /08/2016 Olnch Scale: _. OBIock ON/A • CONSTRUCTION AUTHORIZATION °"- Davie County Health Department 210 Hospital Street .,,,. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons State2ip: NC 27012 Phone #: (336) 624-7791 Address/Road #: Thoroughbred Lane Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: PUBLIC For Office Use Onlv "CDP`File Number 199145-1 County ID Number. C416OA0022 Evaluated For: NEW \ Township: 0 1/ 0 8/ a 0 a 1 Property Owner: Terry M. Summers Address: 6637 Gentry Circle Apt 104 City: Clemmons State2ip: NC 27012 Phone #: (336) 624-7791 Subdivision: Whip -O -Will Phase: Lot: 22 Directions Hwy 601 N. right on Hwy 801 turn right on Cana Road, right on Brangus Way ,,,Left on Meadowlark Lane, right on Thoroughbred Lane on the Left Donn 1 ^f 4 Minimum Trench Depth: a 4 Inches \Site Classification: Provisionally Suitable Saprolite System? OYes @No Minimum Soil Cover 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 1 7 5 Maximum Soil Cover: a 4 Inches "System Classification/Description: "Distribution Type: GRAVITY- PARALLEL (eq. d -box) TYPE If A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons "Proposed System: 25% REDUCTION 1 -Piece: OYes QQ No Pump Required: OYes QNo OMay Be Required Nitrification Field a 7 4 3 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes ONo Total Trench Length: 6 8 6 GPM—vs— ft. TDH ft. Trench Spacing:9 _ Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 @Inches — . `'Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI oil 0111 OIV Donn 1 ^f 4 CDP File Number 199145 -1 County ID Number: C4160AO02Z ' ❑ Open Pump System Sheet it System Kequirea:%v t eb IJIIU vivo, WUL [I d5 r+vdndr)ie Opdce "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 for a person equal to the period of validity of the Improvement Penult, not to exceed five years, and maybe issued at the same time the Improvement Permit issued (NCGS 130A-336(11)). If the installation has not been completed during the period of validity of the Construction Peril% 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(8)). 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 Authorized State Agent: Date of ssue:. A 1/ 0 8% a 0 1 6 Malfunction Log Oyes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 Trench Spacing: 9 0Inches 0. 'Site Classification: Provisionally Suitable — ar Feet O.C. Design Flow: Trench Width: QInches 3. Feet 4 8 0 V Depth: SoilAggregate Application Rafe:. 0 1 7 5 inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS; Minimum Soil Cover. 1 a inches Maximum Trench Depth: 3 6 'Proposed System: 25% REDUCTION Inches Maximum Soil Cover: a 4 N Krification Field 7 4 3 Inches .2 Sq. ft. No. Drain Lines "Distribution Type: PUMP TO GRAVITY 6 Total Trench Length: 6 8 6 Pump Required: (S)Yes ONo OMay Be Required ft 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 for a person equal to the period of validity of the Improvement Penult, not to exceed five years, and maybe issued at the same time the Improvement Permit issued (NCGS 130A-336(11)). If the installation has not been completed during the period of validity of the Construction Peril% 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(8)). 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 Authorized State Agent: Date of ssue:. A 1/ 0 8% a 0 1 6 Malfunction Log Oyes @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 199145 -1 County File Number: C416oA00n Date: 01/08/x016 Q Inch Scale:QBlock = ft. Q N/A - - -- ---- --- i i ��I If_I�I I I J II I I__ 1- II II I I•" `i CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville IVC 27028 CDP File Number: County File Number: 199145-1 C416DA0022 Date:.0 1/ 0 8/ 2 0 1 6 Click below to Import an image from an external location: Drawing Type: Construction Authorization 1836 .1836 . � D Phone: (336) - 753 - 6 - Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name: jprr Phone Number (Home) Mailing Address: I rl 1.5"I r19-...1L�'.1L (Work) A v/a-�e Q . N, �' . �'� C7 �p , Email Address: j0 b 32i pq92Il4k . n Detailed Directions To Property Address: Please Fill In The Following Information About The EXISTING Facility: C�ZIi� Name System Installed Under: Type Of Facility: y&wfiL O� Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes (90 If Yes, For How Long?. Any Known Problems? Yes & If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 1200 � ' IC�Vu'S-e Number Of Bedroom Number of People 1t?�57 Pool Size: P F Garage Size: Other: Requested By: Date Requested: (Signature) (�Appoye Disapproved Comments: / Y t % i , Environmental Health Specialist For Environmental Health Office Use Only Date: / — T— *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Paid By: Received By:_ Account #: IS' Invoice #: 1 9 NI NV (E 7rJU � - s Printed:Dec 18, 2015 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or inability to use the GIS data provided by this website. V a'\V- �>�F qX it X Printed:Oct 05, 2015 All data is provided as is without warranty or guarantee f any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. ,S" s John �av�e�endehhu� III �sT f0�k� 5-� CircQ� ,�loorning��n iV1N 550 Wt rehouse �o`�Al DAVIE COUNTY HEALTH DEPARTMENT awi�rriwf dJ�.NiU� S ~ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION <b fam010 'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Names ��° ��S / Date 3'��f-g 3 N 213 Location �,ct / N .7"cJG[J�tl D 'Vila Ltli9l 'I S -Sh0 fg _AP.A n /l! / J � !1 A9_[. Ce 6 A /'% l,'%17 �7�b� f e�olp's Subdivision Name Lot Size No. Bedrooms Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply Lot No. Sec. or Block No. House Mobile Home — Business ✓ Speculation No. Baths No. in Family — AJ• 1.3S -b YES ❑ NO ❑ Specifications for Syst m: YES E] NO ❑ YES ❑ NO ❑ 1-9 *This permit Void if sewage n described below is not alled within 36 months from date of issue. t}t _ 34,zr = t"FALL tk 2 3cc., t� \•t11CI ,*3 = Sol ltuek l�ci 1,,- 00 '0.6iF S�tPa' �i �UAvAC. 1 U IV( Improvements permit by�' 1) rar} Sem ?u,„,P d- w tax *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: pllj� 6A) System Installed by W, Certificate of Completion - n Date 34-y? 'The signing of this certificate shall indicate that the system describe above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. /i * = DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name _ Date Location _ Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business _ Speculation No. Bedrooms No. Baths _ _ No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO 0 Auto Wash Machine YES ❑ NO ❑ Type Water Supply _ —___— `This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion Date 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. l ' . DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name l''. - C - Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms — No. Baths _ _ No. in Famil _ Garbage Disposal YES ❑ NO ❑ Specifications for System:'r.;:'..: ' Auto Dish Washer YES E] NO E) Auto Wash Machine YES ❑ NO ❑ Type Water Supply *This permit Void if sewage system described below is not'installed within 36 months from date of issue_. `v Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by Certificate of Completion Date rr 'The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO Auto Wash Machine YES ❑ NO h Type Water Supply _— `This permit Void if sewage system described below is not installed within 36 months from date of issue. .i Improvements permit by *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by cl f 'i t t +� r f" I 1 Certificate of Completion Date *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPART IEcTT ENVIROPMENTAL HEALTH SECTION SOIL/SITE EVALUATIO17 ITA14EE Gy 7 ADDRESS LOT SIZE DATE l LOCATIO.,T TOPOGRAPHY: S ;2 '" — SOIL TEI'.TURE s A >, �. SOIL STRUCTURE, e DEPTH: RESTRICTIVE HORIZOITS t �G/vim PERCOLATION FATE: 1. 2. 3. Presoak Hark & time Drop Time Pate/iin. Inch A `Yq S� * CLASSIFICATIOIT:Suitable royisionally Suitable Unsuitable C01511MTTS e SANITARIAH SITE DIAGP,A:^t 6°X75 , o� I