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114 Tyler Ct ' - or fice use 051V - OPERATION PERMIT Davie County Health Department *CDP File Number. 157961 _A 210 Hospital Street F8-030--AO.OSB -= P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For- NEW- Phone:336-753-6780 Fax:336-753-1680 Township:' Applicant: RS Parker Homes CAddress: owner: RS Parker Homes Address: 502 Hickory Ridge Drive 502 Hickory Ridge Drive City: Greensboro y: Greensboro _ State/Zip: NC 27409 State/Zip: NC 27409 Phone#: Phone#: Property Location & Site Information r s/Road#: _ Subdivision: Essex Farm Phase: Lot: 68 Tyler Ct nce NC 27006 Directions Hwy 64 East, left on Cornatzer Rd, Appox.4 miles, stricture: SINGLE FAMILY Essex Farm on left past Beauchamp Rd #of Bedrooms: 4 #of People: *Water Supply: PUBLIC *IP Issued by. 2140-Nations,Roberc 'System Classification/Description: 'TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert SaproliteSystem? OYes ONo Design Flow: _ 4 g 0 *Distribution Type: GRAVITY,PARALLEL(eq.d-box) Pump Required? QYes QNo Soil Application Rate: 0 a a 5 *Pre Treatment: Drain field rNinification Field a 1 3 3 Sq•ft- *System Type: INFILTRATOROUICK4 STANDARD rain Lines 5 Installer: FranicTransou Total Trench Length: 5 3 4 ft. Certification#: 2771 Trench Spacing: 9 Inches O.C. p g' —_ • Feet O.C. 'EHS: 2140-Nations.Robert Trench Width: — 3 �,Feetes Date: 0 3 / a 3 / a 0 1 5 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, a 4 A Inches pprova 'Stattis` Maximum Trench Depth: 3 6 ® Approvetl O Disapproved Inches Maximum Soil Cover: . a 4 Inches CDP File Number 157961 - 1 Septic Tank County ID Number: F$-03o-Ao-06s - Manufacturer Shaof Lat. STB: 760 Long: Gallons: 1000 InstallerFrank Transou Certification#: 2771 Date: 1 0 / 0 2 / .2 0 1 4 *EH S: 2140-Nations,Robert *Filter Brand: POLYLOKPLA 22 With Pipe Adapter ST Marker. E] Yes 0 No Date: 0 3 / x 3 a 0 1 5 / Reinforced Tank: ElYes ® NO y` ApprovatStafus 1 Piece Tank: ❑ Yes` C] N o51 _® Approved❑;Disapproved Pump Tank Manufacturer. Installer . PT: Certification#: - Gallons: THS: Date: / / Date: / RiserSealed ❑ Yes ❑ No RiserHeighf: ❑ `Yes ❑ No (Min.6 in.) s � A- -I Status �� forcTank_ Ye s es ❑ No =❑ Approvetl❑ Disapproved 1 Piece Tank: ❑. Yes ❑ ..No_ _ Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification f*: *Schedule: THS: Pressure Rated ❑ Yes_ ❑ No Date: Approved fittings 11Yes C1 No Approval Status C] Approved❑ yDisapproved Pump Requirement Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment valve ❑ Yes ❑ No Check-valve ❑ Yes ❑ NO4' rArovahStatus PVC Unions El Yes ❑ No ❑ A'- ed❑ Disa roved pp Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No CDP'File Number 157961 - 1 County ID Number: F"30-AO.068 Electric E ui ment NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer. Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Box Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: / ApprovalStatus Alarm Audible ❑ Yes_ _ ❑ No ❑ Approved❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140•Nations,Robert *Operation Permit completed by: Authorized State Agent: 1C .— /_ Date of Issue: 0 3 / a 3 / 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;15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and .- Construction Authorization.This property is served by a TYPE II A sewage septic system. _ Rule.1961 requires that a Type TYPE li A septic system meet the following criteria: Minimum System Review By The Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator. NIA 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 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 ownerand certified operator are the some. 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 157961 - 1 Davie County Health Department CDP File Number: 210 Hospital Street F8-030-AO.068 P.O.Box 848 County File Number: Mocksvilte NC 27028 Date: r Q Inch DrawingDrawing Type: Operation Permit Scale: . OON Ack E � , i l 4-- r , t CONSTRUCTION For Office Use only AUTHORIZATION *CDP File Number Davie County Health Department County ID Number F8-030-AO-068 210 Hospital Street Evaluated For , NEW -� P.O. Box 848 Township: .� Mocksville.._-----._.- - --_._..__ .NC-- -27028_ _________-PERIAITVALIDUNTIL: Phone:336-753-6780 Fax:336-753-1680 0 9 / 1 - / .2 0 1 9 Applicant: RS Parker Homes rAdd rty Owner: RS Parker Homes Address: 502 Hickory Ridge Drive ss: 502Hickory Ridge Drive City:. Greensboro yGreensboro State2ip: NC 27409 State2ip: NC 27409 Phone#: Phone 4: - Property Location---Site-Information Address/Road #: Subdivision: Essex Farm Phase: Lot: 68 114 Tyler Ct Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 64 East, left on Cornatzer Rd. Appox. 4 miles, Essex Farm on left past Beauchamp Rd #of Bedrooms: 4 N of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: 3 0 CDeisignnndFlow: Maximum ication: Provisionally Suitable Inches Minimum Soil Cover 1 stem? OYes 4&No Inches 4 $ 0 Trench Depth: 3 a Inches Soil Application Rate: Maximum Soil Cover: 1 4 0 a a 5 � Inches =System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE III E.PPBPS GRAVITY DOSED SYSTEM Septic Tank: 1 0 0 0 Gallons *Proposed System: 50%REDUCTION 1-Piece: OYes @No Pump Required: OYes ONo (g)May Be Required Nitrification Field x 1 3 3 Sq, ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 7 1-Piece: OYes (J)No Total Trench Length: 3 5 5 ft. GPM-vs— ft. TDH Trench Spacing: _ 8 Inches O.C. Dosing Volume: _ Gallons Feet O.C. g _ Trench Width: Inches a Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01011 0111 OIV CDP File Number 157961 - 1 County ID Number: F8-030-AO-068 ❑ Open Pump System Sheet Repair System Required:OYes- ONO ONo, but has Available Space rDesign System Trench Spacing: I nches O.C. - _ ification: Provisionary suitable __ __---_____._—__. -__ _ _ _ 8 - - -- Trench Width: QInches w: 3 5 5 – a V Feet Soil Application Rate: Aggregate Depth: inches _ 0 a � 5 .Minimum Trench Depth: 3 0 *System Classification/Description: Inches. TYPE III E.PPBPS GRAVITY DOSED SYSTEM Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 a . *Proposed System: 50%REDUCTION Inches Maximum Soil Cover: 1 4 Nitrification Field x 1 3 3 Inches Sq. ft. ------- -------- "Distdbution-Type:--GRAVI Y=PARALLEL(eq.d-box) No. Grain Lines 3 Total Trench Length: 3 5 5 ft. Pump Required: ()Yes ONO ®May Be Required 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. *• 7; '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. 2( This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be Issued atthe sametime the Improvement Permit issued(NCGS 930A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted in theapplication 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 Applicant/Legal Reps.Signature Required? Oyes ONo ApplicanVlegal Reps. Signature, Date: *Issued By: 2140-Nations,Robert Date of Issue: . 0 9 1 9 / 2 0 1 4 Authorized State Agent: �r Malfunction Log Oyes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 • CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 157961 - 1 210 Hospital Street P.O.Box 848 County File Number: F8-030-AO-068 Mocksville NC 27028 Date: 0- 9 / 1 9 / 2 0 1 4 ----- 0Inch Drawing Drawing Type: Construction Authorization Scale: . pBlock . = ft. Q N/A M ' ;rX ?• . .. . h ........... ..... y ..... Na G . � u . i _ APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Environmental Health P.O.Box 848/210 Hospital Street RECEIVED MocksviRe,NC 27028 jD (336)753-6780/Fax(336)753-1680 Date: �i r Date: Application For: ❑Site Eva�ation/lmprovement Permit uffir�thorization To Construct(�$@Fdjvel b Both Typ�f 9p tp r�J;Ww System ❑Repair to Existing System ❑Expansion/Modification of xis acility **'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 Y 6Contact Person J lq SA rv' Kr- Billing Address Mt HiCkovqr- Home Phone City/State/ZIP W_ Business Phone (n-q'7 •-1 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 yalid for 60 months with site plan,no expiration with complete plat.) 4 I_ Owner's Name .S. ✓ Phone Number -0 ' W e Owner's Address r- City/State/Zip rQpn6,0bro NC Property A dress I I!i l City AClMn CQ_ ��•�• Lot Size . Tax PIN# TOS o 5o-A,o"0 Subdivision Name(if applicable) Se ion/Lot# tt Directions To Site: On12dT©r1 T(J. Fq— If the answer to any of the following questions is"yes",supporting documentation be attached. .awAre there any existing wastewater systems on the site? ❑Yes o Does the site contain jurisdictional wetlands? []Yes Are there any easements or right-of-ways on the site? ❑Yes E� Is the site subject to approval by another public agency? ❑Yes CIN'l Will wastewater other than domestic sewage be generated? ❑Yes ap IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathroom Garden Tub/Whirlpool s ❑No Basement:❑Yes iPA� Basement Plumbing: ❑Yes 1?12 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: nventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: ounty/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑YesNII o 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 to t na andagging or sta in the house/facility location,proposed well location and the location of any other amenities. P e own is or ow#'s legal representative signature Site Revisit Charge Date(s): Ll Client Notification Date: Date I EHS: Sign given ❑Yes❑No Account# ' % Revised 11/06 Invoice# R-20 SETBACKS: TYLER CO UR T FRONT: 45' 50' R/W (PUBLIC) SIDE: 15' SIDE: 25'(STREET) REAR: 30' — N5 •55'01"A' N59•55 01,1r 10' UTILITY \ 'rd• EASEMENT 36.67' 69 67 PROPOSED RESIDENCE It 40 i � 21.67' oCq � co N 14.33' 12.00' 14.75' 91.67'1 14.33' 68 PROPOSED n RESIDENCE SETBACK L 2 12.42' 4.06' 16.83' _ S 8 =9e_8" 10.67 •� 8 NEGATIVE ACCESS EASEMENT 34-68 8 4.sr N87"35'03"1V HOME DIMENSIONS 89.09' NTS PRELIMINARY PLOT PLAN FOR: RSP BUILDERS LOT 68 OF ESSEX FARMS, PHASE 1— P.B. 9 PC. 388 GRAPHIC SCALE '° 0 20 40 s° Flaming 69interiolt Inc.. !!tiiiiiiii� 700 Carnegie Place Greensboro,NC 27409 ( IN FEET ) Phone:336.852.9797*Fax: 336.852.9766 1 inch = 40 & NCBELS C-0950 DATE: 09-09-14 REF: PR0J\1831-01\dwg\ESSEXFARM.dwg A PLICATION ITE EVALUATION/IMPROVEMENT PERMIT&ATC D ( 201 avie County Environmental Health 'Z 3 P.O.Box 848/210 Hospital Street A�G Mocksville,NC 27028 UM����H (336)751-8760/Fax(336)751-8786 , S1 A is idh ''r;ti iUY uation/Improvement Permit ❑Authorization To Construct(ATC) ❑Both Type of AppI uk-'❑New System r ❑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 ��73 Name to be Billed ASC Ay6lop",nm t mat, Contact Person jc,P,ay ,&rrr, Billing Address A-o-Qox 3140' Home Phone City/State2IP_goersuzc�'i�+G z 702 8 Business Phone 7S/- 7300 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 lat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name r45-,0"aap,w',,Ji cam%iaG Phone Number 7J'1-73-'- Owner's S/-73-'-Owner's Address eo JQ.X d� City/State/Zip�/oun.+zw.r /�G 17oZ8 Property Ates City Lot Size �* Tax PIN# - ZZGZ5- p Subdivision Name(if ap licable) P ES Sectio ot# �0 n A'` pirections To Site: C S 2 2 �� 0121 - F S -e— 6 If the answer to any of the following 4uestionsfis"yes",supporting documentatiog must be a hed. Are there any existing wastewater systems on the site? ❑Yes 2Wp, Does the site contain jurisdictional wetlands? Dyes❑No Are there any easements or right-of-ways on the site? Dries❑No Is the site subject to approval by another public agency? Dyes go— IF Will wastewater other than domestic sewage be generated? ❑Yes RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms _-PC #Bathrooms Garden Tub/Whirlpool Dyes ❑No Basement: Dyes ❑No Basement Plumbing: Dyes ❑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 ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:Crt"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. 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 locatingan ging or staking the house/facility location,proposed well location and the location of any other amenities. Site Revisit Charge Prope r s or o er's legal represents re Date(s): 7 Client Notification Date: Date EHS: Sign given Dyes❑No Account# Revised 11/06 Invoice 4 ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH#: 5870-64-2265.68 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot#68 Reference Name: Brad Coe Location/Address: Cornatzer Rd-27006 Proposed Facility: Residence Property Size: 0.689 Acre Date Evaluated: �i"" t 7 Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit 1 Cut FACTORS 147-7 )LL& 4 5 6 7 Landscape position (_ L Slope % 0 ' 171 HORIZON I DEPTH .-.,1(-7 Texture groupC G C Consistence LOof t Structure -5 3 k G Mineralogy k x HORIZON H DEPTH Texture groupkk ConsistenceStructure Mineralogy HORIZON Ill DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS I RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ' A L LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: `c��- ` EVALUATION BY:Rg) '.lV all� -vt, LONG-TERM ACCEPTANCE RATE: ©' OTHER(S)PRESENT- REM ARKS: RESENT:REMARKS: Ot w4-S l,t, 14 0."s u '5iC1_4 f✓�T af-ec4 T dr -5.011 Gov1,2 etclor (�Qr e Landscape Position LEGEND `_X e u U ex d 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 C 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 3Yet 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 Mineral== 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 surrace to free water or inches from land surface to soil colors with chroma 2 or less Classification-S(suitable),PS(p- sionally suitable),U(unsuitable) TAR-Long-term acceptance /day/ft2 DCHD 05/05 (Revisedl i Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville;NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004425 Tax PIN/EH #: 5870-64-2265.68 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot#68 Address: PO Box 340 Location/Address: Cornatzer Rd-27006 City: Mocksville Property Size: 0.689 acre Reference Name: Brad Coe 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. Permit Type: 011ew ❑Repair ❑Expansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms #Bathr6oms , #People. Basement❑ Basement plumbing❑ . - Non-Residential Specifications: Facility Type' #People #Seats Square Footage(or Dimensions of Facciility) Design Flow(GPD):Lk Type of Water Supply: NC;ounty/City ❑Well ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Permit Conditions: accepted Systems may also be usE_tld System Type LTAR h Initial .eCL c.0 w 0. as 5 4 Repair (Z-e C-A k 6 W C. a. Site Plan '�S 1, 73 ff` 5K44-eW yo n, � rT C �T� Environmental Health Specialist Date