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167 Scott Moss Dr HEALTH DEPARTMENT RELEASE For office use only *CDP File Number 193157- 1 ~F � Davie County Health Department fr 210 Hospital Street County ID Number. P.O. Box 848 Evaluated For. NEW Mocksville NC 27028 Phone:336-753-6780 Fax:336-753-1680 PERMIT VAUD UNTIL: Applicant: True Homes Property Owner: Taylor Williams Address: 2649 Brekonridge Centre' Drive Address: 2990 Bethesdia Place City: Charlotte City: Winston-Salem State2ip: NC 28110 State2ip: NC Phone#: (336)457-6682 Phone#: Property Location& Site Information CAddress 167 Scott Moss Dr Subdivision: Summer Hill Farm Phase: Lot 39 oad#Advance NC 27006SINGLE FAMILYTownship: tructure: Directions #of Bedrooms: 4 #of People: Markland Road 'Water Supply: PUBLIC Type of Business: Basement: ❑Yes Q No Total sq. Footage: No.Of Employees: 'Proposed Improvement: 'Release Conditions 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? OYes ONo Applicant/Legal Reps.Signature; *Date: *Issued By: 2140-Nations,Robert *Date of Issue: 0 8 / , 2 6 / a 0 1 6 Authorized State Agent: *Site Plan/Drawing attached.** O Hand Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE a'r��d Davie County Health Department CDP File Number: 193157 - 1 210 Hospital Street ' P.O.Box 848 County File Number. Mocksville NC 27028 Date: 0 8 / 2 6 ,2 0 1 6 �oww�j0i cinch Scale: OBlock Drawing Type: Health Department Release ON/A i I � 4 i Page Z6 2w Davie Coiuity Health Department 418 IVSD Environmental Health Section _ (� P.O. Bot 818 ��` 210 Hospital Street ��YA Courier# .• �U�'S09-40-OG 1911 Mocksville,NC 27028 Ay Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 61Phone Number356 iRkL5l - 3D Ik (Home) Mailing Address: 02 (Work) /vex o,6 /5 e� Detailed Direction o Site: O 'V �� SSRaajD T ccs N Property Address: a*:�- � Please Fill In The Following Information About The EXISTING Facility: I � �SQ Name System Installed Under: !rJf4Q�Aot� Typ Of Facility: Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People:', Is The Facility Currently Vacant? YeNo If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In Theollowin Information About The NETVFacility: Zi Type Of Facility: Q 6 D Number Of Bedrooms: Number of People Pool Size: k3� Qe ze: Other:. Requeste Date Requested: n ) For Environmental Health Office Use Only ppr ved Disapproved Comments: '/y , �o!�• o� Environmental Health Specialist Date: Cc _ *The signing of this form by the Envi onmental Health taff 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:$ Date: Paid By: Received By: Account#: Invoice#: (Bill 30' RY F I Lor 39 I LOT 40 31250f sq.ft. 11, PG. 372 KLI AMS D! D.B. PIN lV PA 770 SCREEN 0 O 10 PORCH 39.5' m 12645.5' N ?5 SF sod a6 ao ao 1316, sod 16.17 (IF APPLICABLE) i I PROPOSED HOUSE 780 SFII 6' • GARAGE 39.5' 14' h 6 39.5' • _ Gc co PORCH 20'$ r4lWJCfi L N 40'FY. CONC OR/VE' 0 125.00' ---N8570 22"W �d SCOTCH MOSS DRI VE 20' PA VED TRUE H0� .5n' P/IRI Ir` RAv OPERATION PERMIT or nice use univ 40 . Davie County Health Department *CDP Fite Number. .193157-1, 210 Hospital Street P.O.Box 848 County ID N;umben Mocksville; NC 2702$; Evatuatetl,„For NEVI/ Phone:336-753-6780 Fax:336-753-1680 Township: 7Add ant: True Homes Property Owner. Taylor Williams ss: 2649Brekonddge Centre' Drive Address: 2990 Bethesdia Place y: Charlotte City: Winston-Salem State2ip: NC 28110 StatefZip: NC Phone#: (336)457-6682 .641.Phon Property Location & Site Information r dress/Road#: Subdivision: Summer Hill Farm Phase: Lot: 39 167 Scott Moss Dr Advance NC 27006 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: 'Water Supply: PUBLIC *IP Issued by. 2325-Mitchell.Brittany "System Classification/Description: TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP *CA issued by: 2140-Nations.Robert SeproliteSystem? QYes *No Design Flow: 4 8 0 *Distribution Type: PUMP TO GRAVITY Pump Required? *Yes QNo Soil Application Rate: 0 - 2 7 5 *Pre Treatment: Drain field N trification Field 1 7 4 5 Sq.ft. *System Type: INFILTRATOR aUICK 4 STANDARD No.Orcin Lines 4 Installer Ronnie Overbee Total Trench Length: 4 3 6 fl. Certification#: 1143 Trench Spacing: _ 9 Qlnches O.C. Q Feet O.C. *EH S: 2140-Nations,Robert Trench Width: _ 3 Inches gFeet Date: 0 9 u' 1 0 / .2 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. 2A 4 Inches Approval tatusa Maximum Trench DepthIM.6 �:Approv+eClDlsapproved Inches � j Maximum Soil Cover. 2 4 Inches CDP Fite Number . 193157 - I Septic Tank County ID Number. . Manufacturer. WMS Lat. Long: STB: 793 Gallons: 1000 Installer. Ronnie Overbee Date: 0 7 / 3 1 / 2 0 1 5 Certification#: 1143 THS: 2140-Nations,Robert 'Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. El Yes O No Date: 0 9 / 1 0 / a 0 1 5 Reinforced Tank: ❑ Yes R No Approval Status Piece Tank: ❑ Yes O No Approved❑ Disapproved . Pump Tank Manufacturer, WMs Installer. Ronnie Overbee PT: 121 Certification#: 1143 Gallons: 1000 THS: 2140-Nations,Robert Date: 0 8 / 0 4 / 2 0 1 5 Date: 0 9 / 1 0 / a 0 1 5 RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) App,,roval Status Reinforced Tank: 1:1 Yes El NO °� ��� '� ��' �' ��� ' tied Approved Cl Disapproved r 1 Piece Tank: El Yes ❑ NO ��� , a Supply Line Pie Size: a inch diameter Installer, Ronnie Overbee Pipe Length: 3 1 1 feet Certification#: 1143 "Schedule: 40 THS: Pressure Rated 9 Yes ❑ No Date: 0 9 / 1 0 / -1 0 1--5 Approved fittings f Yes ❑ No Approver Status r .w Approved❑. Disapproved. Pump Requirement Type: zoeie Installer, RonnteOverbee (D7osinglume: - Gal Certification#: 1143 Draw Down: Inches THS: 2140-Nations,Robes 'Chain: OTHER Date: 0 9 / 1 6 / x 0 1 5 Valves Accessible ® Yes ❑ No Flow Adjustment valve ® Yes ❑ No Check-valve ® Yes ❑ NOApproval&tatus- F PVC Unions ® Yes ❑ N0 Approied L� ►sppoved Vent Hole ® Yes ❑ No AF ` Anti-siphon Hole 91 Yes ❑ No CDP File Number 193157-.1 County ID Number: Electric E ui ment ("�N�EMA Box or Equivalent ❑ Yes ❑ No Installer. Box 12 in, Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No 'EHS: Pump Manually Operable ❑ Yes ❑ No f 'Activation Method: Date: Alarm Audible El 'Yes+ ElNO Approval Status v appro O pppri>'ve C] Disved x F Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert 'Operation Permit completed by' 01 Authorized State Age Date of Issue. 0 9 1 g a 0 1 5 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,1 5A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served bye TYPE III B. sewage_septic system. Rule.1961 requires that a Type TYPEIIIB. septic system meet the following criteria:< Minimum System Review By The Local Health Department: SYRS. Management Entity: OWNER Minimum System InspectionlMaintenance Frequency ByCertified Operator. NIA Reporting Frequency By Certified Operator.NIA Rule.1,961 requires that a Type IV and V septic,systems designed fora home/business owner must maintain a valid contract With a public management entity with`a certified operator ora private certified operatorfor the life of the septic system.' Rule.1961 requires that Type VI septic systems designed for a hom e/business owner m ust maintain a valid contract with a public management entity with a certified operator for the life of the septic system. issuance6of an,Operation Permit for a system required t beuires a contract shall be executed Wmain eeen i ed by a public. ement rior.to the or private msystem owner and a an gament 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 forthe.continued proper performance of the system. ftshall also be a condition of ,the'�Operation Permit thatsubsequenCown ersof the,system s execute such a contract. @Hand Drawing 0Import Drawing •c ,.3 **Site Plan/Drawing attached.** ''` OPERATION PERMIT 193157 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksvilie NC 27028 Date: 1 Olnch Drawing Drawing Type: Operation Permit Scale: , OBlack ONiA F+1 JI _ -. �. Tl � ala f CONSTRUCTION For Office'Use Only AUTHORIZATION *CDP Fife Number 193157;-1 ° Davie County Health Department County ID Number. 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 6 / 0 4 / a 0 a 0 Applicant: True Homes Property Owner. Taylor Williams Address: 2649 Brekonridge Centre'Drive Address: 2990 Bethesdia Place City: Charlotte City: Winston-Salem State/Zip: NC 28110 State/Zip: NC Phone#: (336)457-6682 Phone#: Property Location & Site Information rAddress/Road#: Subdivision: Summer Hill Farm Phase: Lot: 39 and Road NC 28110 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesigan sification: Provisionally Suitable Inches Minimum Soil Cover. System? OYes QNo 1 a Inches ow: 4 $ 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: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: DYes @No Pump Required: @Yes ONo ( May Be Required' Nitrification Field 1 7 4 5 Sq.ft. Pump Tank: 1 0 0 0 Gallons No.Drain lines 6 1-Piece:DYes ONo Total Trench Length: 4 3 6 ft, GPM—vs— ft. TDH Trench Spacing: Inches O.C. — 9 . 2Feet O.C. Dosing Volume: Gallons. Trench Width: 21nches — 3 Feet Grease Trap: Gallons Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade,Level Required: 01 011 0111 01V Drann I of 4 CDP File Number 193157- 1 County ID Number. ' ' ' ❑ Open Pump System Sheet Repair System Required:@Yes ONo ONo, but has Available Space rDesign System Q Inches 0. . Trench Spacing: Q ification: Provisionally Suitable — 9 Feet O.C. Trench Width: Inches w: 4 8 0 ,-,_,_, _ 3, s}Feet Soil Application Rate: 0 a 7 5 Aggregate Depth: inches Minimum Trench Depth: 2 4 'System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Nitrification Field 1 7 4 5 Sq.ft. Maximum Soil Cover: a 4 Inches No. Drain Lines 4 "Distribution Type: PUMP TO GRAVITY Total Trench Length: 4 3 6 ft. Pump Required: @Yes ONo 0May Be Required Pre Treatment: 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 far Wastewater System Construction shall bevalld fora person equal to the period 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 valldity of the Construction Permlt,the information submitted In the application fora 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 4 1 .2 0 1 5 Authorized State Agent: Malfunction Log OYes @Hand Drawing 01mport Drawing **Site Plan/Drawing attached.** Page 2 of 3 •. • CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 193157 - 1 210 Hospital Street P.O.Box Bas County File Number: Mocksville NC 27028 Date: 0 6 / 0 4 / 2 0 1 5 Q Inch Drawing Drawing Type: ,Construction Authorization Scale: . QNiA k ft. utl— ,• - kloiI 1 �- CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: 193157- 1 P.O.Box 848 Mocksvitle NC 27028 County File Number: Date: .0 .6 / 0 4 / 2 0 1 5 Click below to Import an Image from an extemal location: Drawing Type:Construction Authorization IMPROVEMENT PERMIT For Office UseOnly F*CDP Number 193157-1 Davie County Health Department 210 Hospital Street D Number. P.O.Box 848 Evaluated For. NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 4/20/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: True Homes Property Owner. Taylor Williams Address: 2649 Brekonridge Centre' Drive Address: 2990 Bethesdia Place City: Charlotte City: Winston-Salem State2ip: NC 28110 State/Zip: NC Phone#: (336)457-6682 Phone#: PropeEly Location & Site Information Address/Road#: Subdivision: Summer Hill Farm Phase: lot: 39 Off Markland Road Charlotte NC 28110 Directions Structure: SINGLE FAMILY Markland Road #of Bedrooms: 4 #of People: *Water Supply: PUBLIC System Specifications nidal S stem *Site Classification: Provisionally Suitable Minimum Trench Depth: Inches Saprolite System? OYes OQ No Maximum Trench Depth: . Inches Design Flow: 4 8 0 Septic Tank: 1 0 0 0 Gallons Soil Application Rate: 0 . 7 5 1-Piece: OYes ONo Pump Required: QYes0No''0May Be Required *System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 0 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:0 Yes ONo ONo, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: Inches Soil Application Rate: 0 a 7 5 Maximum Trench Depth: Inches *System Classification/Description: Pump Required: ®Yes O No O May be Required TYPE 111 B.SYSTEM W/SINGLE EFFLUENT PUMP *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 193157 " -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 bythe Health Department in no way guarantees the issuance of other permfts.The pepn it holder is responsible for checking with appropriate governing bodies in meeting their requirements. Site Plan The Improvement Permit shalt be valid for 5 years from date of Issue with a site plan(means a drawing not necessarily drawn to O scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the : alta for the proposed Wastewater system,and the location of water supplies and surface waters). 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 more than 60 fee;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 subdiAslon 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(NCGS 13OA-335(f)).The person owning orcontrolling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding systan location,Installation,operation,maintenance,monitoring, reporting,and repair(.1938(b)) Applicant/Legal Reps.Signature Required? OYes ONO Applicant/Legal Reps.Signature: Date: *Issued By: 2325-Mitchell,Brittany Date of Issue: 0 4 / a 0 / a 0 1 5 OValid without Expiration? Authorized State Agent: OCreate CA. @Hand Drawing Olmport Drawing .r **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 193157 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 04 / 20 / a015 Q inch Drawing Drawing Type: Improvement Permit Scale: . OBlo k = • �_ Ilni�ial E I I AD ------- E II I l APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC k AJ '` Davie County Environmental Health J9-31S-1 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 S/LI/l5 CS b" Application For: O Site Evaluation/improvement Permit V uthorization To Construct(ATC) O Both Type of Application: ❑New System 0Repair to Existing System CExpansiordModification of Existing System or Facility "* IMPORTANT'**THIS 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 Tl"N e P S Contact Person J&75C Billing Address game < PA ©!, Home Phone `37L QJ7. &G 0Z City/State/ZIP �l�Gy I�t �/yG :2Y7110 Business Phone 3aG, t/9 kLQ7 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:C Site Plan CPlat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name ! Phone Number Owner's Address -qSO (,;e dC4 Plaee_-51eb04/tritylStatelZip_LAJ,'ns u�. -5,-1,Ps+,,/UCi Property Address City Lot Size Tax PIN# q Subdivision Name(if app ' able) S,,rn/he* ,,_ Section/Lot# / Directions To Site: ,ela 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? GYes ONo Does the site contain jurisdictional wetlands? ZYes 1-:rNo Are there any easements or right-of-ways on the site? --!Yes ONo Is the site subject to approval by another public agency? [--,Yes ONo Will wastewater other than domestic sewage be generated? -]Yes ONo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms q— #Bathrooms Garden Tub/Whirlpool GYes ❑No Basement: 10Yes ONo Basement Plumbing: EYes DNo 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:gonventional LAccepted "Innovative jAlternative COther Water Supply Type:ACounty/City Water ❑New Well Ci Existing Well C Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?C 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locatm and 11 mor staking the houselfacility location,proposed well location and the location of any other amenities. T 2, - Site Revisit Charge Propeowner's or owner's legal representative signature Date(s): Client Notification Date: Date EHS: Sign given GYes ONo Account# Revised 11/06 Invoice# • Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990005132 IMPROVEMENT PWaX AN/EH#: 5779-774502.39 Billed To:.AM&JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#39 Address: 4001-J Country Club Road Location/Address: Markland Road-27006 City: Winston=Salem ------Property Size: see map Reference Name: Proposed Facility: Residence *'NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Pewit Type: ONew ORepair OExpansion Permit Valid for: 05 Years ONo Expiration Residential Specifications: #Bedrooms #Bathrooms-4—#People Basemenfg"Basement plum bingv Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): Type of Water Supply: O/County/City OWell OCommunity Well Site ModificationslPernvt Conditions: As stated in 15A NC 18A.1969(5 accepted ht, nqPrl S stem T LTAR Initial JqeeLDfg of 1J` Repair I Ac 05 \ SitePlan i t. J 3r _ s Scpt•� / � 1 � v 1 Environmental Health Specialiir:�;;Qt z Date Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 Account #: 990005132 IMPROVEMENT PFi aMN/EH#: 5779-77-4502.39 Billed To: AM &JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#39 Address: 4001-J Country Club Road Location/Address: Markland Road-27006 City: Winston-Salem Property Size: see map Reference Name: Proposed Facility: Residence **NOTE**This-mprovement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. PemritType: ❑New ❑Repair ❑Expansion Permit Valid for: 05 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People_Bas ementdB asement plumbingl� Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD44 6/0 Type of Water Supply: vc'ounty/City ❑Well ❑Community Well Site Modifications/Permit Conditions; .AS stated in 15A NCAC 18A.1969(5 accepted Systems may alSn he ur"M System Type LTAR Initial Ac d 0,O t Repair 0-a75 Site Plan n J 1�2�Gir J:'Aiol 0 o stP16e, Cof - Area Sy in 4— kv � v Environmental Health Speciali Date • SITE EVALUATION/IMPROVEMENT PERMIT & ATC Q 2o�a Davie County Environmental Health 3 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 w\Ro�'� Go (336)751-8760/Fax(336)751-8786 App ication For: Fit aluation/Improvement Permit ❑Authorization To Construct(ATC) Q'Both Type of Appli a 'on: (S ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT***THIS 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 -LC Contact Person.j ,- W'e5-) Billing Address z!D 1_ LjA ,4 r Home Phone Ci �- 9-4 City/State/ZIP W-S C 2-7 Business Phone 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 NameC. Phone Number 7G�S5^ Owner's Address qw/S Coy,,fryLtjb 12d �C City/State/Zip W-S N C a 7 �f Property Address City Lot SizeS t`�-n-�' Tax PIN# Subdivision Name(if applicable),Suwmm2r 14-11 r-4-- Section/Lot# Directions To Site: 6 1 +6 t1,1 pg JAidd e- SC u r A r' d ` c�� C,croSS If the answer to any of the following questions is"yes",supporting documentation musi be attached. Are there any existing wastewater systems on the site? ❑Yes Cl1 ( Does the site contain jurisdictional wetlands? ❑Y 0'No Are there any easements or right-of-ways on the site? [ Yes ONO Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes SNIO IF RESIDENCE FILL OUT THE BOX BELOW #People L4 #Bedrooms _ athrooms 4— Garden Tub/Whirlpool PlZs ONO Basement: es ONO Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW -V4 JA Type of Facility/Bu-siness 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; onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: M ounty/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. 1 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 rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking t use/facility location,proposed well location and the location of any other amenities. Site Revisit Charge rop owner's or owner's legal representative signature Date(s): Client Notification Date: Date k EHS: Sign given ❑Yes ONO Account# Revised 11/06 Invoice# - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION ZRQEERTY INF RM TIO Account #: 990005132 Tax PIN/EH#: 5779- - SC-CTI o M Billed To: AM &JW Holdings LLC Subdivision Info: Summer Hill Farm Lot#39 Reference Name: Location/Address: Markland Road-27006 Proposed Facility: Residence Property Size: see map Date Evaluated: Water Supply: On-Site Well Communit Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Z__ I- L_ Slope% t 6 a HORIZON I DEPTH -7 0-1 0-0 Texture group (, SC.L. : Consistence kAIS dP + S P' Structure 9K Mineralogy 94 xe -XP HORIZON H DEPTH - -0 L Texture group Consistence p .5 N p Structure Mineralogy r c - HORIZON III DEPTH - Texture groupS S Consistence 5s5e Vr ss S Structure GQ Cit MineralogyP 1P' Y HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE D•a-1 SITE CLASSIFICATION: ` EVALUATION BYP'2' ec&.'A 1 LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: l REMARKS: LEGEND Landscape Position 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 Moist VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 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) T'rA n r _. . _.._ ---- ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■e■■■■■■■■s■■■■■■■■e■■■■■■■■■■e�■■e■■et■■e■e■e■ee■■■■■■eeee■■e■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■ee■eee■ee■■ecce■■■■■■■■■■■■■■■■e■■■ee■ee■eeeee■e■■■ee■■■■■■■■■t■ MEN ■■■■■■■■■■■■■■■rpt■■e■■■■■■■■■■■■�■■■■e■ee■■■■■■te■■■■■■ee■e■■■■e■ ■■■■■■■■■■■■■■■l1■i�■�e■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■tt■■ee■■■■■■e■■■■■■■■■■■t■►�■ca!■��■■e■e■e■ee■e■■■■■■e■e■■■e■e■■ ■■■■■■■■e■■■■■■■■■■■■■■rig■e■■■.■■■■■■■■es■■■■■e■■■■■e■■■■ee■■■■ee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ iiiiiiMENNENiiiiii iiiiiiiiiiiiMEMNONiiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■e■■■■■■■■■■■■■e■■■ee■■■e■■ee■ee■teeeee■e■■eee■■ee■■e■ ■■ee■■■e■■■■■e■■■■e■ee■■e■e■e■■■e■■■e■■■e■■tee■■■■e■■■et■■■t■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■etre■■e■■■■■e■■■■■■■■■■■■e■■■■■■■■■■■ese■e■e■e■■■■■ee■■e■e■e■eee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■t■■■■■e■■■■■■e■■■■■■■■ecce■■■■■e■■eee■etee■■■e■■■■e■ee■ee■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■t■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■■■t■■■■e■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DRAWING NAME. P:\2015\150143\Survey\150143–PLOT–C3D.dwg – PLOT – 5/18/2015 1:32 PM wLljlMIS DnaopMENr GROUP D.B. 856, PO 1028 P/N 5779774502 S857022'E 125100' JD'RY I LOT 39 LOT 40 31250.* sq.ft. O.B. 1L PG% 372 II^ INu#"s DEYaopmmr GROUP I I D.B 856, PLS 1028 PIN 5779774502 I I • PA no SWMV V• f0' Pa?CH I Ol 17.16' PRELIM/NARY SO. FT 'rte, J9sood d e m ro fdfe 455' N h 70TAL SF TD B/C' .34125 SF a6 s 2 I 16.17' I v 5'PUBLIC S/W: 625 SF(IF APPLICABLE) in it CN PROPOSED �o HOUSE 2767 SF HOUSE DRNE Sim HOUSE–Rl 780 5- I 39.5 286 SF RIW–BIC I 1% 6'- GARGE., SIDEWALK.• 26 SF ' PA 110.' 100 SF 14' If � 6 J9.5' SAD To B/G` 10,941 SF `O POR°y 2Of' SEWAMAW: 17,600 SF — I,L� — 40'FY cawc DAYW f0_S/DEwALK EAsswi7vr L bT 18' I 0'UnUTY EASEA/E7VT - 1 R/W I 125100' N857022'W EP R/W — — — — SL'1DMY MOSS OR/VF— — - - 20'PAVED TRIBE HOMES 50'PUBLIC R/W PLOT PLAN OF 167 SCOTCH MOSS DR/V£ P/N 5779872011 LOT 39 PHASE 1, SECTION 2 OF SUMMER HILL FARM GRAPHIC SCALE ADVANCy N.O 50 25 0 50 100 SHADY GROW 700NSH/P, DANE COUNTY Emmmmmommil DALE: 5-18-15. I» = SO FEET MAP RO AV J>�f1 DRAW BY ARG A DATE: 5-18--15 CHEMED BY BW DAVIS • MARTIN 0 POWELL ENGINEERS $ SURVEYORS PREUMINARYMAT 6415 OLD PLANK RD,HIGH POINT,NC 27265 Ndfar or sd« (336)886-4821 1 WWW.DMP-INC.COM I LICENSE:F-0245