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733 Yadkin Valley Rd , � �PERATIaN PERMIT or ice se n v Davie County Health Department "CDP File Number 13837Z-1 �i�� 21q Hospitai Street c�-000-oo-t2�a-o2 ,� � P.O, Bvx 848 County ID Number. ''°•'' Mocksville NC �7028 Evaivateci For. �1E� Phone:336-753-6�8Q Fax:336-753-168Q Township: Applicant: James C. Stel'rt Property Owner: �ames C. Stem Address: �g�p Beeson Park Lane Address: 1850 Beeson Park�.ane ��Y� Kemersviile ��Y� Kemersville StatelZiP= NC 272$4 state2ip: �C 27284 Phnne#: {336)443-157Q Phone#. (336}403-157p Pro ert Lo�ation 8 Site tnformatian AddresstRoad#: SUbdNiSI0f1: Phase: Lot: Yadkin Valiey Rflad Mocksville NC 27028 Directions strocture: MULTf FAMILY 1-4D East#a Hwy 801, left going North right on Yadkin Va11ey Rd. at stopfight. Lat on left after Shopping #of Bedmams: 6 �enter #af people: $ 'Vl/ater Supply: wA 'IP issued by. 2i4o-Na�ions,�abert "5ystem Classifieation/Descnption: 'iYPE tll B.SYSTEM V1/fStt�IGI.E EFFLUEM'PUME' *CA issued by: 2�a0-Nat�ons,Rabert �aprotite System? (�Yss �1.AJo Desi�n Flow: � ,� �} xDistribution'Cype: pUMPTOGRAvrnr Pump Required? (�Yes (�No 5�i1 Ah�plic�tion R�te: � , a � 5 •pre Treatment: Dr�in fleld (��rifiCatian Fi81d a � 1 $ S�� "System Type: i�FIL'TRATORQUICK4STANDARD Na. Drain �ines 5 Installer: �rian McDaniel Toial Trench l.ength: 6 6 � R• Certification#: Trench Spacing: _ � Inches O.C. .......�„� .�....�. � Feet C1.C. xE�t S: 2iap-Nat�uns.Roben Tr�ench Width: 3 (nches — . «� Feet Date: 0 5 / 1 8 / a 0 1 5 Aggregate Depth: in�hes W Minimum Trench Depth: 3 � Inches Minimum Soil Cover. � � Approvat StBtus , In�ches Maximum T�enct� D�pth: 3 6 � }#pproved� flisapproved Inches Maximum Soil Cover: � � Inches �DP File Number �38�77 ' fi County ID Number: c�-aoo-oo-124•02 Se ti� Tank Manufacturer. &hoaf Lat. . � Long: STB: � . �ailons: 125Q lnstaper. �nan McDaniel Date: �} a / a q / a 0 1 5 �ertification#; 'EH S: 2140-Nat�ons.Robert *FilterBrand: POLYLOKPL-122Witf�PipeAdapter ST Marker: ❑ Yes � No Date: � 5 / 1 8 / a 0 1 5 Reinforced Tank: ❑ Yeg � Np APprav�l Status 1 Piece Tank: ❑ Y�S 17 No 'Q Approv+�d❑ Disapprorred Pump Tank Manufacturer. Shoad InstaUer. �rian McDaniel pT: �� Certification#: Gallons: 2150 �EHS: ��a•Nations,Robert Date: � � l � � la � 1a �acg: � 51 � a 1 a � �. s RiserSealed � YeS ❑ NO RiserHeght: DD YeS ❑ ND {Min.6 in.) qPProvaE S#atus Reinforced Tank: O Yes Cl No � Apprc�ved� Disapprove+� ' 1 Piece T�nk: p Yes ❑ NO Suppiy �ine Pipe Size; � inch diameter Instaper: Snan McDaniel Pipe Length: � 0 0 feet CertificaGon#: *EH S: 2140•tQations,Robert *Schedule: �Q Pr�ssu�e Rated [] Yes ❑ No Date; 0 5 / I 8 / a 0 �. 5 Approved f'rttings � YeS ❑ NO Appcovat Status O Approved� aisappr�aved ui e Pump Type: Z°Q�er InstaUe� �rian McDaniQl Dasing Volume: — �a� �ertification#: . . _ � . . _ Oraw Down: (nches 'EHS: 2140-Nations,Robert *cna«�: ��P� � s / 1 8 / a 0 1 5 Date: Valves Accessible p Yes ❑ ND Flow Adjustment Vatve p Ye$ ❑ No cneck-va�ve D Yes O No Appro�ral status PVC tlnions Q Yes ❑ No �) Approved Cl I�isapproved Vent Hole � Yes ❑ No Anti-siphan Hole 0 Yes ❑ No CDP Fite Numb�r 138�77 ' 1 County ID Number: ��OOU-UO•12a-02 � • Ete�ctric E ui ment NEMA4X B�x ar Equivalenx ❑ YQS ❑ No lnsta�er: Box 12 inches Above Grade Q Yes ❑ NO � Certification#: Box Adj.To Pump Tank ❑ YeS ❑ NO Conduit Sealed ❑ Yes ❑ Na "EHS; Pump Manualty0perabt� ❑ YeS ❑ NO "Activation Methad: Oate: � � _ ' 'Approva!Status Alarm Audibl� I� Yes C� No �1 Approved C] DisaPPra�ved . Alarm visibls ❑ YeS Q Na 29d0-Nations,F2pbert "Qperation Permit completed by� Authorized State Agent�... Date of Issu�: �' S � 1 8 / � 0 1 5 OwneNApplicant Signe�ture: This system has been instatted in compliance wdh applicabl� NC General Statutes:Article 11,Chapter 130p, Rules tor Sewage Treatm�nt and Dispasat,15A NCAC �8A .�900 ei. Seq.,and all conditions of the fmprovemsnt Permit and Construetion Autho�ization.This property is served by a TYPE 1[I B. sewage s��tic system. Rule .1961 requires thet a Type ��8• septic system meet the following criteria: Minimum System Review ByThe Local Healf� D�partment: ��s! Management Enti�y: D�ER Minimum System InspectionA�laintenance F�quen�yByCertified Operat4�: wa Reporting Frequency By Certified Operator: W'� Rule.1961 �equi�es that a Type!V�nd V septic systems desgned for a homelbusiness owner must maintain a valid cont�act w�h a public mansgement entiry w�h a certified operator+ar a privat�c+ertified operator for the�ife of the septic system. Rule .1961 requires that Type VI septic systems designed for a home/business awner must maintain a valid�contract with� public m�nagement entitywith a�ertified operator forthe life of the septic sysfem. Rule. 1961 (2)te)requires a contract shall b�executed between the s�rstem dwner and a management ent�y prior to the issua�ce of an Operation Permit for e syStem required ta be meintained by a public Qr private manag�ment ent�y, unless the system owner and certified operator are the same. The contract shall require specif�c requirements formaintenance and operation, responsibiities of the ownerand systems aperator,provisions that the cont�act shall be in effect for as long as the system is in use,and otherre�us'remertts forthe continued proper perfnrmance of the system. tt shall atsn be a cond�ion of the Operation Permit that subsequent owners:of the systems execute such a contract. C.�Hand Drawing C�Import Drawing **Site PIan/Drawing attached.** OPERATION PERMlT ,��7� _ ,� DavieCountyHealthDepartment COP File Number: 21�F{ospita)Street C7-000-00-124-02 p.�.�oxsas �aunty File Number: Mocksvilie Nc 270z$ D�te. / ! � Q Inch Drawin� Drawing Type: C�peration Permit Scale: , . , pSiock = .ft. 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I__ . , : _� . _ � _ �_�� I � I_ _I I � � 1� __�� .___ __.�.� __. �� _.n.i . _ � � � � : � � I�__� _I_._sl :�m l � =� .. _� ____.__... _ ._�. _.�. . _. � ____ .... .4 ..� __ . t �__.. � . . , :.-` ` .—..,...-.,...�.. . , ... � . . �� `` � � , i__ � ' I k , ; � � �_ , � �� 3 ; i � _ �� t .�__�� _� � � � �__ I_ ; , _ —�-� ;� 1 ; 1 j �� _. ._ � . _�__ _�._�. .�� .__�_.. __ . � .� .. . � _a �_ _. _.x �_. __� _ y _. ... _ __r_ __ ..� . _� ._ . .. . _. . �,�, �� _�� . { , . , i ; , : � a � � � � � , . � � , , "'� , �_ � , ,. _._.�.� � �._______:Q` _ _?�� _ ►�_.�. _____ _.__�____��__�� __.�.._ ..____�.__._�..�:�.___� ._.. �___ �.._��._- --.� ._�. ..l..._ _�._____1.._�__� ._._l�.w_ � ��... n . COiVSTRUCTION For Office Use Onlv ' �AUTHORIZATI4N "CDP File Number 138377- 1 '�°=�°�, Oavie County Health Department County ID Number: C7-000-00-124-02 � �'r=��' � 210 Hospital Street Evaluated For: NEW F'.,�- � °.v� P.O. Box 848 Township: � MOCkSVllle NC 27028 PER�AIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 1 � 1 � � a 0 1 9 Applicant: James C.Stem Property Owner: James C. Stem Address: 1850 Beeson Park Lane Address: 1850 Beeson Park Lane City: Kernersville City: Kernersville State2ip: NC 27284 State2ip: NC 27284 Phone#; �336)403-1570 Phone N: (336)403-1570 Propertv Location & Site Information AddresslRoad #: Subdivisan: Phase: Lot: Yadkin Valley Road Mocksville NC 27028 Directions Structure: MULTI FAMILY 1-40 East to Hwy 801, left going North right on Yadkin Valley Rd. at stoplight. Lot on left after Shopping Center #of Bedrooms: 6 #of People: 8 *Water Supply: N�n Svstem Specifications Minimum 7rench Depth: a 4 Site CIOSsifiC8t1o11: ProvisionaftySuitable Inches Minimum Soil Cover. Saprolite System? QYes QNo 1 a Inches Design Flow: � a � tvtaximum Trench Depth: 3 6 Inches Soil Application Rate: Maximum Soil Cover: a 4 0 . a 3 5 Inches "System ClassificationlDescription: 'Distribution Type: PUMP TO GRAVITY 7YPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 a 5 0 Gallons xProposed 5ystem: 25%REDUCTION 1-Piece: QYes QNo Pump Required: QYes allo QMay Be Required N itrification Field � 6 � � Sq. ft. Pump Tank: 1 a 5 0 Gallons No. Drain Lines 6 1-Piece: QYes QNo Total Trench Length: 6 5 5 ft, GPM—vs— ft. TDH Trench Spacing: _ g Qlnches O.C. Dosin Volume: _ Gallons QFeet O.G g Trench Width: Inches — _ 3 . (�Feet Grease Trap: Gallons Aggregate Depth: - � inches pre-Treatment: QNSF OTS-I OTS-II Septic Tank Installer Grade Level Required: Q I �I) �(II D IV Page 1 of 3 CDP File Number 138377 - 1 County ID Number: C7-00o-00-124-02 . • � � ❑ Open Pump System Sheet RepairSystem Required:UYeS ONo ONo, but has Available Space epair Svstem ' Trench Spacing: Q Inches O.C. "Site Cl2SSIfiCetlO�: Provisionally Suitable 9 Q Feet O.C. Trench Width: Inches Design Flow: � a � — 3 � Feet Soil Application Rate: Aggregate Depth: inches � . a a s ` Minimum Trench Depth: a � "System Classification/Description: , Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a Inches tvlaximum Trench Depth: a $ Inches �Proposed System: 25%REDUCTION hlaximum Soil Cover: 1 S Nitrification Field 3 a � g Sq ft Inches No. DrainLines 'Distribution7ype: PUMPTOGRAVITY � TotalTrench Length: 8 � � ft Pump Required: QYes ONo �May Be Required Pre-Treatment: �NSF OTS-I OTS-II 'Site Modiiications No grading or construction activity is allo�ved in areas designated for system and repair without approval of Health Department. �� 7 'Permit Conditions The issuance of this pertnit by the Health Department in no way guarantees the issuance of other permits.The permit hotder is responsible tor checking�vith appropriate goveming bodies in meeting their requirements. R; 2 Thls Authorization tor Wastewater System Construction shall bevalid for a person equal to the period of valid'Ry of the ImprovemeM Permit,not to exoeed tive years,and may be Issued atthe s�netime the Improv+em�t Permit Issued(NCGS 130A-336(b)).It the installation has not been completed during the period oi wlidity of the ConsVuctlon Permit,the IMormation submitted In theapplfcation for a perm)t or Construc�on Authorizarion is tound to have been�ncorrec�falsifled or changed,w the site is altered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).The person owning or corttrollirg the system shall be responsible forassuring compliance with the laws,rules,and permit conditions regarding system Ixa�on,installatlon,operation,maintenanc�monitoring,reporting and repalr (1938(b)). ApplicanULegal Reps. Signatur�e Required? OYes ONO Applicant/Legal Reps. Signature� Date: � � "IssUed By: 2140-Nations,Robert Date of Issue� 1 1 � 1 ? / a 0 1 4 Authorized State Agent: tvlalfunction Log QYeS OHand Drawing Olmport Drawing **Site PIanlDrawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZA710N 138377 - 1 , Davie County Heaith Department CDP File Number: , ' 210 Hospital Street C7-o0b-00-124-02 P.o.Box sas County File Number: Mocksvilte Nc z7o2s Date: 1 1 / 1 � / a 8 1 4 Qlnch Dra`vina Drawing Type: Construc#ion Authorization Scale: � . , ON�A k — . �ft. � . __ -� �t,a��v� _ _ _ _ _ __ i_ �. �_�C_-� U � Ii.� � _ �� t�� _ _ _ 1"_"''" r j ��f ( b � , . 1 � _ _ :___ ---'"" / . _ _ _ / o . /� `� � s _ _ _ . _ '�� , r . __o _ _ �-% � � � � � � _ , �,�° _,$ � _ _ _i_ _ _ . _ _ ; _. . _ : � � _ _ � � _ _ _ - . ; Qa � ' : _ . _ ,: . ' �j ,,,� �. �'� $`�� _ : . �� - ` � nr� _ �.�� . �,-�ll _ � � _ . -� _ _-- P� �� _ _ _ _ _ _ , _ _ , `�' �� r _ _ _ _ Paae 3 of 3 � .� CONSTRUCTION For ottice use omv � • AUTHORIZATION RECEIVED �CDP File Number 138377- 1 + °''¢""' Davie County Health Department Counry ID Number: • �> .---, � C7-000-00-124-02 , � N� ' ��"� 210 Hospital Street 9 Evaluated For: NEW ha� 0 � 2014. �. ��•• .r P.O. Box 848 Township: `=�' D(��-L�ALTH� Mocksville NC `27"02`� PERt.1IT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 Q1 8 / 1 3 / a 0 1 9 Applicant: James C. Stem pA.� Property Owner: James C.Stem Address: 1850 Beeson Park Lane '��'� ress: 1850 Beeson Park Lane U��' City: Kernersville g�qelv �� ° City: Kemersville State2ip: NC 27284 StateFlip: NC 27284 Phone n; (336)403-1570 Phone x: (336)403-1570 PropertY Location 8� Site Information Address�Road #: Subdivision: Phase: Lot: Yadkin Valley Road Mocksville NC 27028 Directions Structure: MULTI FAMILY I-40 East to Hwy 801, left going North right on Yadkin Valley Rd. at stoplight. Lot on left after Shopping Center n of Bedrooms: �(0 �� i�I•3 f�d� #of People: 8 `I�G J_ �7j *Water Supply: wA v -�� Q System Specifications ' hAinimum 7rench Depth: a 4 Site Cl2SsiftCBtiOn: Provisionalty Suitable Inches Minimum Soil Cover. 1 � Saprolite System? QYes QNo Inches Design Flow: $ 4 � Maximum Trench Depth: 3 6 Inches Soil Application Rate: � � � 5 Ivtaximum Soil Cover: a 4 Inches 'System Classification/Description: "Distribution Type: PRESSURE MANIFOLO TYPE III B.SYSTEM WJSINGLE EFFLUENT PUMP Septic Tank: L 5 � � Gallons 'PfOpOSed SyStem: 25%REDUCTION 1-Piece: QYes QNo Pump Requi�ed: QYes QNo QMay Be Required Nitrification Field 3 0 5 5 Sq. ft. Pump Tank: 1 5 0 0 Gallons No. Drain Lines � 1-Piece: QYes QNo TotalTrench Length: � 6 4 � GP��A-vs-- ft. TDH Trench Spacing: _ 9 �Inches O.C. Dosin Volume: _ Gallons � Feet O.C. 9 Trench Width: Inches _ _ 3 �Feet Grease Trap: Galtons Aggregate Depth: inches Pre-Treatment: QNSF OTS-I C�TS-II Septic Tank Installer G rade Level Required: �I �I( �I II �IV Page 1 of 3 CDP F,ile Number 138377 - 1 County ID Number: C7-000-00-124-U2 . ' " ❑ Open Pump System Sheet - � RepairSystem Required:OYeS ONo ONo, but has Available Space � Repair Svstem Trench Spacing: �Inches O.C. 'SitB C18551fIC8ti0f1: ProvisionallySuitabte — 3 Feet O.C. Trench Width: Inches Design Flow: 8 4 � _ 3 •� Feet Aggregate Depth: Soil Apptication Rate: � a a 5 inches iy�inimum Trench Depth: a 4 Inches "System Classification/Description: lYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP �vlinimum Soil Cover. 1 � Inches Maximum Trench Depth: 'Proposed System: 2$%REDUCTION a $ Inches tvlaximum Soil Cover: Nitrification Field 3 � 3 3 1 � Inches Sq. ft. No. Drain Lines �Distribution 7ype: PRESSURE MANIFOLD � Total Trench Length: g 3 3 ft Pump Required: QYes �No �FAay Be Required Pre-Treatment: ONSF OTS-I OTS-II 'Site Modifications No grading or constNction activity is allo�ved in areas designated for system and repair�vithout approval of Health Department. �: 7; "Permit Conditions The issuance of this pennit by the Health Department in no vray guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. `'' .e� 2( This Authorization for Wastewater System Construction shall be vatid tor a person equal to the period of validiry of the Improvement Permit,not to exceed fiwe years,and may be is5ued atthe sxnetime the Improv+ement Pertnit fssued(NCGS�30A-336(b)).If the instatlation has not been completed during the perlod of wlidity oithe Construction Permit,the iMormation submitted in theapplication for a permit or Construction Authorization is found to have been incorrec�falsified or changed,or the site is attered,the permit or Construction Authorization shall become invalid,and may be suspended or revoked(.1937(g)).The person owning or cor�trolling the system shall be responsible for assuring compliance with the laws,rules,and permit conditlons regarding system Ixa�on,installation,opera6on,maintenance,monitoring,r�orting and repair (1938(b)). ApplicanULegal Reps. Signature Required? OYes ONO ApplicanULegal Reps. Signature: Date: � � "ISSUed By: 2140-Nations,Robert Date of Issue: � 8 � 1 3 � a 0 1 4 Authorized State Agent: ~�e��i� ��Aalfunction Lo9 OYes OHand Drawing Olmport Drawing **Site Ptan/Drawing attached.** Page 2 of 3 - ' � �� CONSTRUCTION AUTHORIZATION , . , Davie County Health Department CDP File Number: 138377 - 1 • � � 210 Hospitai Street ' County File Number: c�-000-oo-�2a-o2 ' P.O.Box 848 ' Mocksville NC 27028 Date: e s / 1 3 � a 0 1 4 � Q Inch DrawinQ Drawing Type: Construction Authorization Scale: . � . � QBiock = , Jft. QN/A � t t --� '�o w a�r� 1 ,,o � (C.�v►t�`�J"�o'�` �� , � � � 3 �.�� _ �� ${� ° • �,, `��n� �. . �. �'� _ , a�� z ��-� _ � _ �o .� �� _ —.— ,1 � ,,�._ �� '�� . �, b�~� �`b � l!`'` � � .t� �o� � -� ��, _ _ �� , � 5 c.� _� __ _ � ' tl ' �o ''�" p� �� ' �� a l ��`r � � � Q _ _ _ _ _ Paae 3 of 3 .. , . CONSTRUCTION �or Office Use On�v ' AUTHORIZATION xCOP Fiie Number 138377-1 �°��'� Davie Coun Health De artment c7-000-oo-l2a-o2 tY P Caunty ID Number. � � � 210 Hospital Street Evaluated For: NEW . �.,,�r. P.O. Box 848 �Township: MoCksviile NC 27028 PERh11T VALI�UNTI�: Phane: 336-753-6780 Fax: 336-753-1680 0 8 / 1 3 � a 0 1 9 Applicant: James C. Stem Property Owner: James C. Stem ------ - - - -Address:----1850 Beeson Park Lane--- -------- Address:- ------1850 Beeson Park Lane ---------- - CRy: Kernersviile City: Kernersville State2ip: NC 27284 State2ip: NC 27284 Phone#: �336)403-1570 Phone#: (336)403-1570 Propertv Location � Site Informatfon _Address/Road_#� �Subdivision� P_hase: � Lot; Yadkin Vailey Road Mocksvilie NC 27028 Directions _—__—____--------- ---- _..----- Structure: MULTI FAMILY �-40 East to Hwy 801, left going North right on Yadkin Vailey Rd. at stopiight. Lot on teft after Shopping Center #of Bedrooms: 7 #of People: $ "Water Supply: N/A Svstem Specifications Minimum 7rench Depth: a 4 Si�B CIBSSifiC2ti0f1: Provisionally Suitable InChBS Minimum Soil Cover. 1 a Saprolite System? QYes QNo Inches Design Flow: $ 4 � Maximum Tr+ench Depth: 3 6 ��ches Soil Application Rate: � . a 3 5 Maximum Sail Cover: a 4 Inches "System Classification/Description: *Distribution Type: PRESSURE MANiFOLO TYPE Itl B.SYSTEM W/SINGLE EFFLUENT PUMP Septic 7ank: 1 5 0 0 Gallons "Proposed System: 25%REDUCTION 1-f�iece: QYes QNo Pump Required: QYes QNo QMay Be Required _ _ _. __ _. N�rification Field . 3 � 5 5 Sq. ft . PumpTank: 1 S 0 0 Gallons No. Drain Lines � 1-Piece: QYes QNo Total Trench Length: � 6 4 GPM-vs- ft. TDH ft. Trench Spacing: Inches O.C. - g $Feet O.C. Dosing Votume: _ Gallons Trench Width: Inches - 3 gFeet Grease Trap: Gallons Aggregate Oepth: inches Pre-Treatmeni: ONSF OTS-I C�TS-II Septic Tank InstallerGrade Level Required: Q) �II �III DIV Paqe 1 of 3 � � C7-000-00-i24-02 CDP File Number 138377- 1 Counry ID Number: ❑ Open Pump System Sheet RepairSystem Required:OYes ONo ONo, but has Availabie Space epair SVstem Trench Spacing: Q tnches O.C. `Site CI85SifiCatlOn: Provisionally Suitable — 3 Q Feet O.C. Trench Width: �Inches Design Flow: $ 4 � - � � Feet Soil Application Rate: A99regate Depth: e . a a s inches _____ ---.___ __ _ -- ------ _ __ _ _.__.-Minimum Trench Depth:- ___--------..------ - _._._---___ ___ ---- `System Classification/Description. 4 i tnches 'TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a Inches Maximum Trench Oepth: a 8 "Proposed System: 25°io REouCrtoN Inches Maximum Soil Cover: � 6 Inches NRrification Field 3 � 3 3 Sq. ft. � No. Drain Lines "Distribution Type: PRESSURE MANIFOLD � -- —�- _. Total Trench Length: 9 3 3 ft Pump Required: QYes �No �May Be Required _..�_------ –_.------------ - - -_.__- _..._.__.�Pre=Treatment:--ONSF—OTS-I—OTS-11 _--- ------- "Site Modificattons No grading or construction actNity is allowed in areas designated for system and repair without approval of Health Department. �� 7; 'Permit Conditions The issuance ofthis perrnit by the Health Department in no wayguarantees the issuance ofother permits.'The permit holder is responsible for checking with appropriate goveming bodies in meeting their requirements. p„ 2( This Authorizatfon for Wastewater System Construction shall bevalld tor a petson equal to the period of vatidiry of the Improvement Pertnit,not to exceed ilv�e years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)�If the Instatlation has not been carnpteted duHng the period of validity ofthe ConsVuatfon Permlt,the irtformatian submitted in theappllcation for a permit or Construction Authorization is lound W have been ir�correcR falslfiect w changed,or fhe site fs altere�d,the permft or Construction Authorization shall become Invalicl,and may be suspended or revoked(.1937{g)).The person owning or controlling the system shall be responsible forassuring oompliance with the laws,rutes,and pertnit conditions regarding system loca�on,installation,operatlon,maintena��monitoring,re�orting and repalr (1938(b)). ApplicanULegal Reps. Signature Required? QYes ONO ApplicanULegal Reps. Signature' Date:_ � � "ISSUed 8y: 2�40-Nations,Robert Oate of(ssue: . � $ � 1 3 � a 0 1 4 Authorized State Agent: Malfunction Log QYes OHand Drawing plmport Drawing **Site Pian/Drawing attached.** Page 2 of 3 � ' � CONSTRUCTlON AUTHORIZATION . - �avie County Hea�th�epartment CDP File Number: 138377 - 1 210 Hospital Street P.O.Box 848 County File Number: c�-000-oo-i2a-o2 Mocksville Nc 27028 Date: 0 8 l 1 3 I a 0 1 4 Q Inch Drawin� Drawing Type: Construction Authorization Scale: . , OB�ock = ,ft. QN/A ____- --- --. __....._----_:_..__.�_._. .... v , � _ ...__..._ .. ,. , . __ _.-:._ ---- _ ._ __._. - T o w a�,�------- 1 � . .. . _... _... .._. .. .� ..__:. . .__.,.__. . _.__... '`b v ___.._ . . _... .._. _ . _ _ �.� ti^.(�'�'+�i/ �'^ r_ �� , , _.; . _ . , _.. ...., .. _. ,.,. _ ,. v . ._...�o..�'C ...._._ . . ;. ,_ .. ._ : ._. .__ . . s� 3 _. .`''�'� .. . , _,. . _ _ --. __ _ _ , ,----- ..._ � c„ ;- _ , _ _ _. '��'... ._ .. . . `.. ,_.._ .. ..... , . _. _ ___ ; _ _ : _�------- — � . _.. -------- u ---____.� ,__, .__._._ _---._____ ___ _. _ ; �� ____ ._ . . .. ., ..�._ . _-- ,,__ __ . , _ __. - - _... _ _ ___ _ _�, ._ __ _ p _. _._ _. , �`� ;,r _ � _ .: _ h . _ . ;.b�6u _. __ .. _ _. ,�',� __. . .. _ _ _ _ _ , .. . _ . .__..�_ . _� .___ ... _._ _; _.�. ._ __ __a, _ _ __ . _ .. _ ; . _ � _ : _ . . . � _ �� _ : . ; .__ .. . .__ .. .. . ___ _ _ . : ,. ��:;,e � _ . . _�_� _. . _. _ . _. _ . . __ , . �o ,� ��,� _ ._ _ _ ; _ _ . __ r ,___ _ _ ;� �� . _ � _ _ _ _ __ h . _ . _ . _. _ -- : ----- ._ ,:_ t�.� ,,� _ . . _ _ _ �� ` . _ '� ,, _ .. `b�, . .;._. . . _ _ . _ c`� _ � b 4�/ / o u � �� o q -� _ �� _ _ __ _ _�,�._ � ,. �_ . � _ __ _ � _ . _ _ _ �_ _. . _ . . , _ ___ _ _ � � � � �� '� _ �°�� C�, �, _ � q a �o� � _ �,_ _ _ _ Q_ g�i�� ,-�,��,z c� , t . , . . a,{.�; � - IMPROVEMENT PERMIT , Fo�or��e use o�� "'R'�.q.� Davie County Health Department 'CDP File Number 138377-1 �'� 210 Hospital Street County ID Number:�c7-o00-oo.�2a-o2 �� ' � �� , ., �� P.O. Box 848 Evaluated For �..�NEW�:� '� ��,,�,• �� . � ,_� .` Mocksville NC 27028 Township: ' Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 6/17/2019 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: James C. Stem Property Owner: James C. Stem Address: 1850 Beeson Park Lane Address: 1850 Beeson Park Lane . City: Kernersville � City: Kernersville State/Zip: NC 27284 State/Zip: NC 27284 Phone#: (336)403-1570 Phone#: (336)403-1570 Pro ert Location & Site Information Address/Road#: Subdivision: Phase: Lot: Yadkin Valley Road Mocksville NC 27028 Directions structure: MULTI FAMILY I-40 East to Hwy 801, left going North right on #of Bedrooms: 7 Yadkin Valley Rd. at stoplight. Lot on left after #of People: g Shopping Center *Water Supply: N/A S stem S ecifications In�itial S�stem "SIteZ,as'I SITICatIOn: Provisionally Suitable Minimum Trench Depth: � 4 Inches Saprolite System? �Yes �No Maximum Trench Depth: 3 6 Inches Design Flow: 8 4 0 Septic Tank: 1 5 � � Gallons Soil Application Rate: 0 . � � 5 1-Piece: �Yes �No u Pump Required: �Yes �No O May Be Required *System Classification/Description: TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 S Q Qf Gallons 'Proposed System: 2s%RE�ucTioN 1-Piece: O Yes �No Repair System Required:�YeS O No O No, but has Available Space Repair Svstem *Site Classification: Provisionauy suitabie Minimum Trench Depth: � 4 Inches Soil Application Rate: 0 . a � 5 Maximum Trench Depth: � 8 Inches *System Classification/Description: Pump Required: �Yes 0 No �May be Required TYPE III B.SYSTEM WISIN�LE EFFLUENT PUMP *Proposed System: Page 1 of 3 a_ � . 138377 - 1 c�-000-oo-7za-oz CDP File'Number County ID Number: *Site Modifications � ❑ Open Fill Sheet No radin or construction activi is allowed in areas desi nated for s stem and re air without a Characters 9 9 tY� g y p pproval of Health Department. Rem��;�o 750 *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. R;m"�9 750 Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to . � scale 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 surtace waters). Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land O surveyor,drawn to a scale of one inch equals no more than 60 feet,that Includes:the specific location of the proposed facility and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surtace waters. Plat also means,for subdivislon 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 ls 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.Thls permit fs subJect to revocation If the site plan,plat,or fntended use changes(NCGS 130A-335(�).The person owning or controlling the system shall be responsible for assuring compliance with the Iaws,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: � � "ISSU@d By; 2140-Nations,Robert DBtB Of ISSUG': 0 6 � 1 � / a 0 1 4 OValid without Expiration? Authorized State Agent: �C�eate CA? �Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 , A � • IMPROVEMENT PERMIT 138377 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: c�-000-oaiza-oz Mocksville NC 27028 Date: / � �Inch Drawing Drawing Type: Improvement Permit Scale: , , O B�ock _ Q N/A ft. . � a � , \ � t o � �` � � � � —-( a � � a l Page 3 of 3 P1 P2 .. � - IMPROVEMENT PERMIT ' Davie County Health Department 2�o Hospital Street CDP File Number: 138377 - 1 P.O.Box 848 C7-000-00-124-02 Mocksville tvc Z�o2s County File Number: Date: .�.6:/ ,1.�, /,a.0,1,4. Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 . � . ,� � � • � APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health �� P.O. Box 848/210 Hospital Street PAID_. r jt G�5 h0� �_�(,� —� (,{ Mocksville,NC 27028 D�� 0' ��.s— (336)753-6780/Fax (336) 753-1680 Receivedb : M� �/, � � Application For: ❑ Site Evaluation/lmprovement Permit 0 Authorization To Construct(ATC) �Both Type of Application: �New 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 . 5� � � � f �� G� Name to be Billed �pNC� G si�r1 Contact Person �c,H�� C,�C� Billing Address \BSb 6f�ef� '"�A2�c- �.N Home Phone ��6.g'6�,�57D City/State/ZIP 1L�iaL�ivtu.E� NC. Z�7Z8�- Business Phone 3�,`)Z�,2�77 Name on Permit/ATC ifDifferentthan Above SqH� AS A'��1� MailingAddress I$Sb ��o��AW� 1,tJ City/State/Zip �,v�u.� 1JC27Z& PROPERTY INFORMATION *Date House/Facili Corners Fla ed 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.) fo S:.A� Owner's Name AF��►�► $q��aY � �1�w�W�A��b�T Phone Number Owner's Address 13C0'�wRav.T�C�Y�`�t..v� �13a City/State/Zip �� NC 2761Z Property Address Lo-r Z yAvt�lu VAVi.�/ �b. City a�YAU�E Lot Size S.3 A�� Tax PIN# 5$1��1$955 C"'j_�(1U-a{J-/1}F-OZ Subdivision Name(if applicable) yAo��t��ALvF�I 1ac.Q-�s, Section/Lot# Z. Directions To Site: �-�}0 'fo S01 Nc�Tu . ��-f�u Yavti�a�cau� �oAb q��e�siv��c��+� (ar�r�cc S1aot"f'11� C��fL LbY IS oN 1.'FX"r ALi�ti"f A M1L� If the answer o any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes �No Does the site contain jurisdictional wetlands? ❑Yes�No Are there any easements or right-of-ways on the site? ❑Yes f�No Is the site subject to approval by another public agency? ❑Yes�No Will wastewater other than domestic sewage be generated? ❑Yes �No IF RESIDENCE FILL OUT THE BOX BELOW #People $�` # Bedrooms � # Bathrooms 5 � L Garden Tub/Whirlpool ❑Yes �No Basement: �Yes ❑No� Basement Plumbing: ❑Yes ZCNo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusiness 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 OY�'�0�o��CoHP�Iu�`�1►S'�1-� Type system requested: 1)(Conventional ❑Accepted OInnovative ❑Alternative �SOther �1�"rwd �t�biV�DW�L. s�f�`� »F Ava�gt,E,Y�a,� 1� �s�� 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 ,R�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 Deparhnent to conduct necessary inspections to determine compliance with applicable laws an rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locat' and fla 'n or staking the house/facility location,proposed well location and the location of any other amenities. Pro erty owner's or owner's legal representative signature Site Revisit Charge �/ ! Date(s): �`) 1�`� Client Notification Date: Date EHS: % � Co,.�ta.�.c.-r SR� DFF� IS AG.�� '�v�w.s�Tio� Sign given ❑Yes ❑No � ��'1 Da�� AS'�A'� 0� ��fl�i-��►��. �yZ�� ,��,,, � 5' (�A�t.poN �=��-11'AL Account# ; 7( / Revised 11/06 �+c U��C v�F I.A,��b � � t . Invoice# ¢�G'`�117�NC.� W' Z '�J�OF��N1 D��,?1�1� Il�-LAW (�u.��1-lov.5�. Nv.i-�g�-�'�taoww� �t�c..ta.�DE �crtH � � , . � _. ._ .. . . ` ` � ' DAVIE COUNTY HEALTH DEPARTMENT � � Environmental Heaith Section Soil/Site Evaluation � APPLICANT INFORMATION I'ROPERTY INFORMATION Account #: ��j�37 7 Tax PIN/EH#: �j�•�000�D-!z�-oL Billed To:��,��s-��`,,� Subdivision Info: ' Reference Name: Location/Address: yG��.j�U UC�,I`�c,t �O'!• Proposed Facility: Property Size: Date Evaluated: lo� �� ;, , ; 1, Water Supply: On-Site Well Community Public �i Evaluation By: Auger Boring Pit Cut , FACTORS 1 2 3 4 5 6 7 Landsca position V t� V Slo e % HORIZON I DEPTH O - p — � Texture grou ;$G C �, fi Consistence C �iSP cC �/' Structure � 5.�G Mineralo 5 � 5 HORIZON II DEPTH !� — �3 � o Texture rou G S Consistence i Structure Mineralo ' C/ S HORIZON III DEPTH Y Texture rou s i Consistence ( 5 3 . Structure K k ; Mineralo HORIZON IV DEP"1 H i� Texture rou ; Consistence � S tructure Mineralo SOIL WETNESS 3 RESTRIC'TIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE 6 + 3 O� �`J � SITE CLASSIFICATION: EVALUATION BY: � I � LONG-TERM ACCEPTANCE RATE: D '��J �• �2 � � OTHER(S)PRESENT: .� • j �M�s: � lo� � LEGEND � T.an s pe Pocition ' R-Ridge S -Shoulder L-Lineaz slope FS-Foot slope N-Nose slope i CC-Concave slope CV-Convex slope T-Terrace FP-Floud plain H-Head slope '' Texture � `i 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-Ciay � .ONSISTF.N . , i . 1YIQls� � 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-Angulaz blocky SBK -Subangulaz blocky PL-Platy PR-Prismatic , MineraloQv 1:1,2:1,Mixed LYQt�S Horizon depth-In inches � � � � � � } Depth of fill-In inches ! Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) ; Soil wemess-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-LonQ-Eerm accentance rate-aal/dav/ft2 Tu`un nvnc rno�„�o.�� ___ _ ; : , . i r . . - _ . , , •p�: .-,,_�,�� : . �' PIN�� 5873018955 � ��-_ - �y`--i '� � � t` - i5 r �LO`�- 2 YADKIN VALLEY ROAD - 5.3 ACRES � � - � , 316.1 . �-�;':�.,- �. . � _ t��5ql �r'f t � . `'�_� NOTES: f �� ' ��'t' � _ �_ i 1. *AREAS TO BE GRADED EXIST AROUND HOUSE ! ' � � �) � �'f ,,�1'� ` ' _ - STRUCTURES AND DRIVE PRIMARILY,BUT ARE UNKNOWN %\ �" 1' � j�l � ,� � � _ I AS OF THE DATE OF THIS APPLICATION/SITE PLAN � - �� ` , ' � I 2. WEL LOCATION TO BE DETERMINED. WILL COMPLY WITH � � �� `� - ��EXISTING TREE LINE/WO�DED BOUNDARY �� I / � i � APPLICABLE COUNTY AND ENVIRONMENTAL HEALTH � � /��f �I.EARE�,EXISTWG � � ' � -�ED DRNE � � � I REQUIREMENTS � / � - 3. AREA WHERE PROPOSED SEPTIC FIELD IS LOCATED IS � � ,_-�� / % i �� _ J / CLEARED. STRUCTURES ARE LOCATED IN THE EXISTWG � _--'- � ,� i / WOODED AREA. • / �'� � j ,� � � I 4. NO EXISTING SEPTIC AREAS AREP@ESENT ON SITE TO MY � i � '� SETBACK-FRONT YARD�40'� � �� ! / I, KNOWLEDGE. � ,� � I �� / � i / I , 2'ELEVATION CONTOURS;TYP. � � � 5. PROPERTYBOUNDARIESARESTAKEDONSITE. EXISTING / ,� - _ ;J__________J' i � I , TREE LINE AROUND CLEARED AREA IS SHOWN BY DASHED ,' __--- - � ` � / I LINE. ,A ,�--- � � . � / � i i 6. DRNE IS REQUIRED TO BE PAVED. WATER LINE�IF USED � � '��/ � � l\� �� / i i � RATHER THAN A WELL)WILL FOLLOW DRIVE FROM �� /'� �-� /j �\ �' �, / I YADKIN VALLEY ROAD. � i � I �\ , / 7. PROPERTY BOUNDARIES SHOWN ARE APPROXIMATE � �i� �_ _ � � �i� � � / I BASED ON DAVIE COUNTY GIS. CURRENT AVAILABLE / ,� ___-- �� WOODED;EXISTING �, � PLAT INFORMATION IS NOT LEGIBLE FOR ALL PROPERTY / � �� 1 �� J��', , I B UNDARY DIMENSIONS. i PREFERRED SEP�I�"�IELD LOCATION 1 �� !�' - / i �� / 8. C�URRENT DAVIE COUNTY ZONING IS R-A � �� `_ --'� �� ' li i � 1 __�,— i � 9. PROPOSED STRUCTURE LOCATIONS ARE NOT CURRENTLY / � ,' 1 � ' i � I STAKED � � � � � '�` / �� — -` �� ACCESSORY GUEST HOUSE IS LOCATED IN �� /� � ;.\\FRONT YARD BY EXCEPTION b�a)IN SECTION �,' � � l ' i � �,55.140 R-A DISTRICT,DAVIE COUNTY ZONING � � � � � � ORDf�lANCE. DISTANCE TO ROAD RIGHT OE'� / � ' � {�� WAYEX�E�DS,100��„��.' i � �� ♦ � i I � / � / / � ♦ i i � �--- � � ,'� " � � i � i � � i � � CLNARED;EXI$TING � � ��\ ,� � , f ,li i T i �J � I �� r i � f� � � � J' i I � � / � / i � i i / �� ' 718.5 / � � � i ��,, ` J, , � � � � --- / ' . 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