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123 Cornwallis Drive Lot 34 .• , DAVIE COUNTY HEALTH DEPARTMENT + Environmental Health Section • P.O.Boa 848/210 hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990003916 Tax PIN/EH#: 5841-05-8308 Billed To: Bruce Aubrey Subdivision Info: Pudding Ridge Lot#034 Reference Name: Location/Address: 376 Cornwallis Drive-27028 Prol2osed Facility: Residence ATC Number: 4350 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD rGOFF FIVE YEARS. Environmental Health Specialist's Signature: fG y��� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) Mar 08 06 02:20p davie' county envhealth 336 751 8766 p,2 bc ITE EVALUATIONAMPROVEMENT PERMIT&ATC avie County Health Department 3 2(o b ,�� nvironmental Health Section 33(f, 3��- 4 Ce- I P.O.Box 848/210 HospWJ Street t Mocksville,NC 27(128 „t 36)751-8760/Fax(336)'51-8786 AppliclilllS a m,}rovement Permit 0 Authorization To Construct(ATC) it Both ORTANT*'*THIS APPLICATION CANNOT BE PROCESSED L:NLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLE'T'IN for instructions. APPLICANT INFORMATION Name to be BilleCc,vactPersor ,—,,,- Billing Address_� ls�Oo�J�J I I D 1J ore Phone`7 - 2 S City/State/ZIP�-L,>�E Bt.iiness Phone? �-351 --GgcO x�9z Name on Permit/ATC if Different t tan Above Mailing Address City/S:ate/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan aril;t accompany this application. (Permit is valid for 60 months with site plan,no expiration with cot tplete plat) StreetAddress'S-76, :t,r�S_ '_City K tom TaxPIN#�8 �O�B3o Subdivision Name DA t r a(� Section/Lot# o, Lot Size I&l x24--&k/.S4 r- Di�rejcctions To Site: fie tT t 1 C FYIow-. 't t7 wErsT� (Zt�uY e,J 'IKtj-rcy l g!L"J D-,, La-yc't C" Club Q b6 )ec,4b A C.42s .0A) Q4"GuAL4-t5, DP-tVL- - - Lx-e t5 a HT&4F,7 D nL 1j12. Date House/Facility Comers Flagg:d �ZO-C1(n If the answer to any of the following questions is"yes",supporting documoc iation mast be attached. Are there any existing wastewater systems on the site? OY,:s PNo Does the site containjuristlicdonal wetlands? DY-3 BNo Are there any easements or rilsht-of-ways on the site? OY,:s RNo Is the site subject to approval by another public agency? ❑Y.:s 8No Will wastewater other than dcmestic sewage be generated? 0Y.-3 QNo IF RESIDENCE FILL OUT THF;BOX BELOW #People 2 #Bedrooms V #Bathroomt 5Garden Tub/Whiripool Vales nNo Basement:1-Yes GNo Basement Plumbing: WYes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business _ Total Square Foo:age of Building___#People #Sinks #Commodes #Showers _ #Urinals Estimated Water Usage(gallons per day) (Attach dOCltmentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:$Conventional C1Accepted Olanovative OAlt,mative 00ther Water Supply Type:p(Coumy/City U ater O New Well CIEm:isting Well 0 Community Well Do you anticipate additions or expanc.ans of the facility this system is intended to serve?11 Yes VC No If yes,what type? This is to certify that the information lirovided on this application is true ani correct to the best of my knowledge. I understand that any permit(s)or ATC(s)issued hercaller are subject to suspension or revoc ttion if the site is altered,the intended use changes,or if the information submitted in this app/cation is falsified or changed !undt stand that f am responsible for all charges incurred from this application. I hereby grant:•ight of entry to the Authorized Reprtsentative of the Davie County Health Department to conduct necessary inspections to dr teJ a co li770 wi ��applicable�ay.s and rules on the above described property located in Davie nd o y � '01 tiL✓�/v tLYYI(�S t5 Site Revisit Charge owner's or owner's legal rerrresendtive signature Date(s):_ 6 Client Notification Date: Date ERS._ / '� Signgivcn Oy []Yes Account (P Revised 2/06 Invoice# �f '0C' 6 17 Mar- 15-06 09: 51A Shannon Conrad 3367233179 P.02 ,:vie-County, North Carolina Spatial Data Explorer Page l of'2 4 ,b Spatial Data L311111[pPilrer North Carolina Click on the Map to: Map Li Cr)Zoomin 0 ZoomOut O Recenter Map 0 Identify; Parcels LDraw L Zoom Factor: zx � �,)Radius Search(feet) 0 Draw select Boundary NW �+� A NE ❑Census Tre City Bound county Zot 4579 Multi Syi 7rJ�4 � j � n E911 Fire 1 n Flood Pana ? Flood Zone 'dl Parcels 1421 n School Dis- 8301 Multi syi 6841068908 Q �Solis Town ZOnir -ZOO , l Townships Multi SY1 8221 fir 2201 n Voting Pmc Infrastructu I I Driveways 'P U Rail Lines 9045 1017 7 n Street Cent U USINC Hint Multi syi SW ,�, /SE L n Parcel Data Find l 4joinhig Parcels L,�Aerial Phot Physical • Lend Unit/Type: ;/LT L.�Creeks and • Deed Book/Page:00555/0360 n E911 Addrs • Deed Dateart :2004/06/07 Fin:Da • County ID:E5020AU013 • Safes Price:$45,000.00 n p • Account NumDi3r 000082522854 • Property Address: schools • PIN:51341058308 000376 000376 DR Draw L • Legal1:LOT 13 PUDDING RIDGE • County7.oning•R-A • Owner Name-RUCK MICHAEL S • Census Code, MA1`0 • Owner/Add2ss 1 RUCK MICHAEL S • City Code' • Owner/Address 2 RUCK CHRYSTAL • Fire District.,FARMINGTON This map is prep. • OwneNAddress 3 235 TOM BARBER ROAD • Flood Zone:ZONE X inventory of real I within this jurisdic • City,State ZLp. CLEVELAND,NC 27013-0000 • Flood community.370306 compiled from rei • Land Value.$45,600.00 • Flood Panel.0025 C plats.and other F and data Users i • Building Valu4. 50.00 • Flood Map Date:12.17.1993 hereby notified th http://sdx.roktecli.t)ct/servleticom.esri.esrimap.Esrimap?Name—Davie&Cmd=C1 k&l.eft—l... 3/15/2006 04/07/06 09:00 FAX 1 908 351 1386 HAYWARD 0 002 APPLICATION FOR'SI7E EVALUATION/IMPROVEMENT PERMIT&ATC Davie County Health Department Environmental Health Section P.O.Boz 843/210 Hospits I Street Moekaville.NC 27028 (336)751-8760/Fate(336)731-8786 ApplitationFor Srtt E�aluatfoa;ler�roveteeatYemut U AuthorintionToCohstrtwr ATC) Il Both IMPORTAM"'THIS APPIICLTION CANNOT ES PROCnMO L NLFSS ALL OF TH9 REQUIRED INFORMATION IS PROVIDED. RrSer to the INFORMATION BULLS IN for iesauctiow. APPLICANT INFORMATION Nemo m be Billed ���� ph���. -�_ T�t> (� 21 Co.tact Pa9oo 6te Billing Addren Billed ,O L,dtLb Flame Pho w GSty/Stakizip,M7UG�1t Q;�17•S Bu_istess Phone�f -StFflt7 x`fb9 z. Nxnw an PrnrdrIATC if Direrew tau Above Mailing AMmaa L51y/S:�tcllsp PROPERTY INFORMATION NOTE: A tatrvcy plat or site peau rnu it socotnpaay this application. (Permit is olid for 60 ttsamhs wide sib plan,no expiration with am Mete plsR) StttctAddress�i'M C09f*]At lLe '_City VJA 7.xPudfl SSY/o$B3o� Subdivision Name DD t ra(A g LDCh t-- Sectlon/LotII o Lot Sits 6:.& X ! Directions To site: '&--K­r !_f•-C Frat3..,..�GYrn..2A\ I=RfCuvas.+�YorJ�ytt1� (g�Y ons R�bDi�►G oezbaG It'r0fb ats�,w.twAcus D2�L>�-• - Ctrs' is ea �Gu�s�as.1D of t7orew,sct:S D✓cs. Date Soulr0wility Comm Flamed If the amwta to bogy of the fdlowiae Owtioos a'yss',Supportmg docomertitian wast be astschA Are these my esusWg watlewaut systean an the dm? oY is jttNo Docs the site cemrala Jutislictimal wedands? 11V%IBNO Arc there zW cu an=«ft-&-of-'mays an the t m? oY•ts RNo Ia the site subject to approt al by another public agency? []Y.;1 HNa will vgaotvascrolLd 16.n tkmestie k+hGe be 6Laanted? ❑Y�a�Ne IF RESIDENCE FILL OUT THE BOX BELOW [#-People 2 #Bedraoms S iZoortttGftdrn T WWhirlpoo)V9Y s ONO Basetumt:VWcs GNo Baselnmt P1uwbwS:%Yes 0No IF NON-RESID19NCE FILL OUT'THE BOX BEWW Type of Facility/Businas Total Square Footage of BuildiaL_ S People #Sink! IT Coanaoc-a 9 Showcr3 _ P Urinals. Hctinuted water Usage(gallons per day) (Attach documentation rAsimiW fae7ity water cOn,4uattption) FOODSERVICE ONLY_ 3 Seta T)rxystrmnrgwAed:)dCcnvwtimsl GAcespwd DIA"vative OAttrrwmve DOdtrt was=S■Pply Tip .Kcmm lcity%acct o TIL~weu pExhziag Weg G eomxmmay well m you anticipate additiaas or espans ars of the tlnlity this syitpn is inter lett loserver G Ya Id No If ya,vhat type? This is to testify ftt the i dwMatioa IKnvided on this application is true ani a ormt to dw beet of my Ioowdrdgo. I wdcnwW that any ptYmit(s)or AMa)lamed h&wterate subject to seapamlen or tevar anon if the sin:is alwtvA dna lawn"n"use chasteas,er if Cha intteovation athnitted is leis app?ntloa is fihified or cbtmged I wadi tgand that Ian responsible for alt diatyat kewred from this applkerfos. I ha&y ga.t:iglu of eouy m the Audwirtd Rowsentative of dee Dane County Health Depattntma In caodaet neotttsuy to date?? w mampTsare with applicable fags and rules oo dee above dawAbcd pwpo ly located in Davie t.a=ty and awncd by_„ Situ Revisit charp property w='3 or owner's kzd tnmunmive sigr ak- C3em Nm ift6on Date: Date EHS•— SipL 6ivw ME OND Auca®t AL Revised 7/06 hnoicto I BARBARA C. LOMAX 160 I 820 56 68 N 550 54 44 W ,� DB. 153 K7. 119 310.68 N 750 16 06 E ` t 67 44 l N 720 26' 51 E N 38045 4r1M± " + 71 78 S 87006 48" JE1P 25.00 \ N 700 02' 20" E f lr 69 51 M In,-p9- 54—E N 670 03' 30"E 60 32 r' �� 1 I � .� N 650 17' 21 E 043-'S3" IP �.` �' 38 Q�.. __.-� _ � r 113 56 634 60• � - --- t . . _PARKING 64 34 33 E / 4 �' ` t N . 85 86 y � Y I14 4 r O C , �. r s N Si 9 43 E ...., .:.. .. ..., F .. .: 9 306 • -z. tir c_ J lI 0131k' tY•- f' �:.' °d v. ''` � :r � but \1 t DRIVE 1 r i [ 15 F J 7 ° GENERAL koT'E% —BOUNDARY SURVEY PREPARED BY GRADY L: TUTTEROW, REGI STEP LAND SURVEYOR, DATED MARCH 16, 1992.11 pi l >' DED BY SOUTHERN A N< , —EXISTING TOPOGRAPHIC INFORMATION PROVI MARCH 99� 2 _ a L r. r. • R w - .t L • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section T Soil/Site Evaluation NAME //� G e DATE EVALUATED _�/•Z�/� ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On-Site Well �� Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Slo e % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: / EVALUATED BY: LONG-TERM ACCEPTANCE R TE• -� OTHER(S) PRESENT: REMARKS: o'el'&'y d CfQ iC � 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 (:lay 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 Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure ,3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 .t; Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 990005883 Tax PIN/EH #: E5020A0034 Billed To: Benchmark Custom Homes, Inc. Subdivision Info: Pudding Ridge Lot # 34 Address: PO Box 1715 Location/Address: 123 Cornwallis Drive -27028 City: Clemmons, Property Size: 1.09 Reference Name: Proposed Facility: Residential **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: NtNew ❑Repair ❑Expansion Permit Valid for: D5 Years ❑No Expiration Residential Specifications: # Bedrooms_'3 #BathroomsOYI # People 2 Basement 51 Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design F1ow(GPD)-3 (L0 Type .of Water Supply: $County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: S stem Type LTAR Initial u o '0N Repair t;0)0/,0 Environmental Health Specialist i.p. 11-06 Date D j I� :fT� c,rJ aet�S ,(U . AkI2eA 6 P 5 f APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERNIIT & ATC E C E' V Eavie County Environmental Health P.O. Boz 848/210 Hospital Street C e0 MAY 2 5 2012 9Mocksville, NC 27028 0`� (336)753-6780/ Fax (336)753-1680 Application FcP provement Permit ❑ Authorization To Construct (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name &,7,, I /l�q/ �v�TO� D l� Contact Person e5l7ew,? JoLths�s� Address P4> Pei/715` Home Phone YlV S(.S,s City/State/ZIP e l.2 Business Phone �16-160s` Email ge4e Name on Permit/ATC if Different than Above Mailing Address ° City/State/Zip YKUFhK l Y 11N 1 UFC A 11U1N 'Late House/PacilitV comers NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Owner's Address 11t uL4, 11f ' City/State/.' PropertyAddress 1'1-3 Curr►•.ya iS f. City '-uc Lot Size [.Dgt Tax PIN# a ( `L$--ryI1 f Subdivision Name(if applicable) :,, Section/Lot# Directions To Site: - p " '- L 157- G -o7 o Included: ❑ Site Plan ❑Plat(to scale) If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? _Yes i -No Does the site contain jurisdictional wetlands? _Yes t—No Are there any easements or right-of-ways on the site? _Yes Flo Is the site subject to approval by another public agency? z. -No Will wastewater other than domestic sewage be generated? _Yes —Yes IF RESIDENCE FIT J, Ol JT THE BOX BELOW # People #Bedrooms __ # Bathrooms a t .-) Garden Tub/Whirlpool des ❑No Basement: [des ❑No Basement Plumbing: ❑Yes 2< IF NON -RESIDENCE FTTJ, 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: Elffonventional ❑Accepted ❑Innovative ❑Alternative []Other 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 [-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 corners and locating and flagging or staking Pe housacili location, proposed well location and the location of any other amenities. Site Revisit Charge Property own r' or owner's legal representative signature Date(s): S J S oZ? !o? Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # --� v Page 1 of 1 =0 Ill 100ft http://maps.roktech.net/davie_gomaps/index.html 5/25/2012 A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005883 Billed To: Benchmark Custom Homes, Inc. Reference Name: Proposed Facility: Residential Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: E5020A0034 Subdivision Info: Pudding Ridge Lot # 34 Location/Address: 123 Cornwallis Drive -27028 1.09 Date Evaluated: 'Rwz Community Evaluation By: Auger Boring Pit Public .,/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % $°� 2'%s HORIZON I DEPTH 10 - Texture group C Consistence F& Ar P17 Structure 13 Mineralogy HORIZON H DEPTH 6-25 - Texture group 45 Consistence Structure v alZ ` 14 Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy Sc SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE n SITE CLASSIFICATION: P LONG-TERM ACCEPTANCE RATE: REMARKS: EVALUATION BY. PAAd W4�01WMW- OTHER(S) PRESENT: niw6o 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 YYY_et 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 Mineralog 1:1, 2:1, Mixed lYQte� Horizon depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)