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376 Cornwallis Drive Lot 13 HEALTH DEPARTMENT RELEASE For Office Use Only *CDP File Number 140052-2 Davie County Health Department f 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 VALID 0 4 / a 1 / a 0 2 1 UNTIL F"�A pplicant: Andrew and Amy Backus Property Owner. Andrew and Amy Backus ddress: 376 Cornwallis Drive Address: 376 Cornwallis Drive City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone#: (571)265-7511 Phone#: (571)265-7511 Property Location& Site Information rAddress376Comwallis Drive Subdivision: Pudding Ridge Phase: Lot: 13 ad# Mocksville NC 27028SINGLE FAMILYTownship: ructure: Directions #of Bedrooms: 4 #of People: Hwy 158,left on Farmington Rd.left on Pudding Ridge Rd.Left into Golf Course on Right 'Water Supply: PUBLIC Basement: R Yes Q No Type of Business: 7 Total sq.Footage: No.Of Employees: "Proposed Improvement: 'Release Conditions ; There could be as much as 100 to 150 feet of septic lines removed and then replaced on the end of the system. 1 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: 21 -Natio *Date of Issue: 0 4 / .1 1 / 2 0 1 6 Authorized SQ—; en **Site Plan/Drawing attached.** 01-land Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE 140052 - 2 se���Eq Davie County Health Department CDP File Number: t✓Y h 210 Hospital Street P.O.Bax 848 County File Number: Mocksville NC 27028 Date: 0 4 / ,2 1 / 2 0 1 6 �a 0Inch Scale: OBIock ":..ft. Drawing Type: Health Department Release ON/A I ' _. _.........._?__. _ __ . _ .._ ._..____._ _ _ _.__.. _._. ._ __..____ _ �........... . . .._ FI ; ► j � � Ill � ax , i � i i I t _ . r I . 0 1 , ,�. ki i I f I I. I i : I JL if V e -------------- -­----------------- ------I �71 ------------- ... ......... ---------- I I i P _.. . .�._._ a..ge 2 of 2 Davie County Health Department 10 18 j� Environmental Health Section _ P4 P.O. Box 848 1 210 Hospital Street �� I C� OU �� Courier# : 09-40-06 c Mocksville, NC 27028 / Phone:(336)—753-67II0 Fax:(336)—751 -8786 �`� {�t"-�(J����1 b; ON-SITE WASTEWATER CE ---- FOR DWELLING (Check One) Replacement Re o elingnnec ian etj Name:� (Q,1111 r'q!V t V Kl � Phone Nu ber 5� 2 "' Home) Mailing Address: (Work) Email Detailed Directions To Site., /na ,J nn 2 Property Address: �� W ( O r�l,�al�1 pnr t Pu&Vl a RIA!J1 Lot (") Please Fill In The Following Information v AbThe EXISTING Facility: Name System Installed Under: L"U Type Of Facility:_ Date System Installed(Month/Date/Year): 2 L'U Number Of Bedrooms:_�_Number Of People: Is The Facility Currently Vacant? Yes ❑ No x If Yes,For How Long? Any Known Problems? Yes ❑ NoX If Yes,Explain: / L Please Fill In The Following Information About The NEW Facility: V'5Z- �l Type Of Facility: 0 q Vt j P P d I Number Of Bedrooms: Number of People Requested By: Date Requested: (Sig atur ) For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited)that the on-site wastewater system will function properly for any given period of time. Payment: Cash ❑ Check ❑ Money Order ❑ # Amount:$ Date: Paid By: Received By: Account#: Invoice#: 5'7 Ct r rx uja�L� S � 3w zg� 5 � O 7Lo VO �Ib� V0 !� Zzo J / D �U qcxt,L l ?L t7-o Z(4' � tSv 1o't3a _ Ito O 1 Qv tW To ;vTbtoo�u Q Z - �E I �� P W �►. 7. 5c,10 ZAI 3 C �� vllrvk-"C.-kvllvtp,/ 7- /U � L� v 40 L !(of O /d To Yo 7v Cyu -7,- gu go /Co //O iZL ria iy6 r5v /!d0 e7S6 /5e, 190 �U Zia !90 !� lGo ryo leo �Zo !rU !ov 10 7-c. Uu $"u yo io Zv !o U OPERATION PERMIT or ice use UnIV Davie County Health Department *CDP File Number 140052-1 210 Hospital Street P.O.Box 848 County ID Number. Mocksville NC 27028 Evaluated For. EXPANSION Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Robert J. Landry Property owner: Robert J. Landry Address: 376 Cornwallis Drive Address: 376 Cornwallis Drive City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)416-3918 Phone#: (336)416-3918 Propeqy Location & Site Information Address/Road #: Subdivision: Pudding Ridge Phase: Lot: 13 376Comwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, left on Farmington Rd. left on Pudding of Bedrooms: 4 Ridge Rd. Left into Golf Course on Right #of People: *Water Supply: PUBLIC *IP Issued by. 2144-Nations,Robert *System Classification/Description: TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140.Nations,Robert SaproliteSystem? QYes QNo Design Flow: 4 8 0 *Distribution Type: GRAVITY-SERIAL Pump Required? QYes QNo Soil Application Rate: 0 - 1 7 5 *Pre Treatment: Drain field r cation Field 4 3 6 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD rain Lines a Installer: Brett McMahan Trench Length: 1 0 8 8• Certification#: 1120 Trench Spacing: _ 9 Inches O.C. Feet O.C. *EH S: 2140-Nations,Robert Trench Width: Inches _ 3 Feet Date: 0 9 2 2 / 2 0 1 4 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4Inches Ap�provif Status Maximum Trench Depth: 3 6 ![E,Approved D Disapproved Inches Maximum Soil Cover: a 4 Inches CDP File Number 140052 - 1 Septic Tank County ID Number: r��t Lat. Long: Installer: Date: Certification#: 'EHS: *Filter Brand: ST Marker: ❑ Yes ❑ No Date: Approval Status Reinforced Tank: ❑ Yes ❑ NO Piece Tank: ❑ Yes ED) No p Approved D Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: *EHS; Date: / 1 Date: RiserSealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved 1 Piece Tank; ❑ Yes ❑ No LL Supply Line CPipe Size: inch diameter Installer: Pipe Length: feet Certification#: 'Schedule: 'EHS: Pressure Rated ❑ Yes ❑ No Date: f Approved fittings ❑ Yes ❑ No Approval Status Cl Approved❑ Disapproved Pump e e e Pump Type: Installer: Dosing Volume: — Gal Certification#: Draw Down: Inches 'EHS: *Chap: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N O Check-valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hale ❑ Yes ❑ No Anti-siphon Hole 0Yes ❑ No CDP File Number 140052 - 1 County ID Number: Electric Equipment 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: Approval Status Alarm Audible ❑ Yes ❑ No 0 ❑ Approved❑ disapproved Alarm Visible ❑ Yes ❑ No 2140-Nations.Robert *Operation Permit completed by: le Authorized State Ag Date of Issue: 0 9 2 2 2 0 1 4 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 el. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE 11 A sewage septic system. - Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed fora horne/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a horne/business owner must maintain a valid contract with a public management entity with 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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 140052 - 1 Davie County Health Department CDP File Number: 290 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: Olnch Drawing Drawing Type: Operation Permit Scale: O = ft. ON/A I i 1 Iwl ►__ I_ I IE _I s j I IL do I � 7 I I ! — I d F _ t . ' CONSTRUCTION For Office Use Only AUTHORIZATION 'CDP File Number 140052- 1 "�"'� --•- ''� Davie Co,ynty Health Department County ID Number ' ra 210 Hospital Street Evaluated For: EXPANSION . r-- P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax:336-753-1680 0 7 / 3 0 / 2 0 1 9 Applicant: Robert J. Landry Property Owner: Robert J. Landry Address: 376 Cornwallis Drive Address: 376 Cornwallis Drive City: Mocksville City: Mocksville State2ip: NC 27028 State2ip: NC 27028 Phone 9: (336)416-3918 Phone 9- (336)416-3918 Property Location & Site Information r37Address/Road : Subdivision: Pudding Ridge Phase: Lot: 13 6Cornwallis Drive Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 158, left on Farmington Rd. left on Pudding Ridge Rd. Left into Golf Course on Right 9 of Bedrooms: 4 #of People: 'Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Minimum Soil Cover. 1 a Saprolite System? OYes ONo Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: .1 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons 'Proposed System: 25%REDUCTION 1-Piece: Oyes ONo Pump Required: OYes ONo O May Be Required Nitrification Field 4 3 6 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1-Piece: OYes ONo Total Trench Length: 1 0 9 ftGPM—vs— ft. TDH Trench Spacing: — 9 8Feet O.C.Inches O.C. Dosing Volume: _ Gallons (� Trench Width: 3 Inches Feet Grease Trap: jGallonsAggregate Depth: inchesPre-Treatment: ONSF OTS-1 -II Septic Tank Installer Grade Level Required: OI 011 0111 O Pagel of 3 CDP File Number 140052 - 1 County ID Number: ❑ Open Pump System Sheet RepairSysfem Regbired:OYes ONo ONo, but has Available Space rDesign System 8 Inches 0. . Trench Spacing: ification: Provisionally Suitable — 9 Feet 0.6 Trench Width: Inches w: 4 8 0 — 3 Feet Soil Application Rate: 0 7 5 Aggregate Depth: inches Minimum Trench Depth: � 4 'System Classification/Description: Inches TYPE 11 A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches 'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Nitrification Field 1 7 4 5 Sq. ft. Inches No. Drain Lines 4 'Distribution Type: GRAVITY-SERIAL Total Trench Length: 4 3 6ft. Pump Required: QYes ()No OMay 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 bythe 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 130A-336(b)}If the Installation has not been completed during the period of validity of the construction Permit,the Information submitted In theapplicatlon 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 forassuring 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 7 / 3 1 / 2 0 1 4 Authorized State Agent: - Malfunction Log Oyes 01-land Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 140052 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 7 / 3 1 / 2 0 1 4 Qlnch DiraNjine Drawing Type: Construction Authorization Scale: . 013lock QN/A ld Cu G�l/L W 3 46 LqZ4 rh �a b I6 Paae 3 of 3 APPLICATION FOR•SITE EVALUATIONAMPROVEMENT PERMIT & ATC ,ficI&IVED Davie County Environmental Health P.O.Box 848/210 Hospital Street 'Date. Mocksville,NC 27028 a (336)753-6780/Fax(336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System X❑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 Robert J. LandryContact Person Address 376 Cornwallis Drive Home Phone City/State/ZIP_Mocksville NC 27028 Business Phone_3364163918 Email landry2176@gmail.com 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 Name Phone Number Owner's Address City/State/Zip Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: / Specify Problem Occurring �l u flu ffl vsiaf;4 //tiIS1A11� l�1QQ/L v��✓OOi'j'ls, e 4 N. 0oYK5, I �J IF RESIDENCE FILL OUT THE BOX-BELOW #People 2_ #Bedrooms r„r 4 #Bathrooms 3 Garden Tub/Whirlpool X❑Yes ❑No ( Basement: ❑Yes ❑XNo Basement Plumbing: ❑Yes ❑XNo 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 ❑Alternative ❑Other Water Supply Type: ❑X 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 X❑ No If yes,what type? Not if I add the next line 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 charges,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 andflagging or staking the house/facility location,proposed well location and the location of any other amenities. Dr.Robert J.Landry Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Client Notification Date: 7.24.14 EHS: Date Sign given ❑Yes ❑No Account# V Z 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 OPERATION PERMIT G Account #: 989900635 Tax PIN/EH#: 5841-05-8308 Billed To: Southern Homes of Davie Subdivision Info: Pudding Ridge Lot#013 Reference Name: Location/Address: 376 Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 16lx266x159x ATC Number: 4350 **NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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 s a guarantee that the system will function satisfactorily for any given period of time. System Type: S.T.Manufactur Tank Date Tznlc Size/ Pump Tank Size / System Installed By: &45dtOeE.H. Specialist: /�� Date: 6 Iq \—\DO�i 1U� ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900635 Tax PIN/EH #: 5841-05-8308 Billed To: Southern Homes of Davie Subdivision Info: Pudding Ridge Lot#013 Reference Name: Location/Address: 376 Cornwallis Drive-27028 Proposed Facility: Residence. Property Size: 16lx266x159x ATC Number: 4350 Site Type: ❑New ❑Repair ❑Expansion **NOTE**This Authorization to Constrict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms_3#Bathrooms Z #People Z Basement❑ Basement plumbing Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) F b Lot Size//,/x ZI9 f(/ySX 266. Type of Water Supply: J ounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) Tank Size/ GAL.Pump Tank N//f' GAL. I Trench Width 36 a Max.Trench Depth 34# Rock Depth /✓Zk Linear Ft. 3 Z /r[�[!!C.6I19��/ L Site Modifications/Conditions/Other: '4// 464 /a I�GivDO ,r � ^Cen ,.�4c r..rnc rnn.r vlcr "�,n tem. Contact the Davie County Environmental Health Section for final inspection of this system between Y 41' 8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760. .10 l a f:F' AJ) %A f, ^A EAI co 0 Dvironmental Health Specialise---- Date: 2 nrT-TT) 1 1/04(PPw;ca/1) clay 1,9 06 03:43davie county envhealth 336 751 8786 P.2 P�10 t TE EVALUATIONAMPROVEMENT PERMIT&ATC �-- vie County Health Department nvironmental Health.yeetion E8 _ 4 `�p08 .o.Box 8481210 Hospital Street Mocksville,NC 27028 (3 6)751-8760/Fax(336)7';1-8786 App hcatidp.For,,QSitio E tnFrovement Permit AAuthoriza.:on To Construct(ATC) Oilh •* RTANT***THIS APPLI(7APION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. ._tefer to the INFORMATION BULLETIN for instructions. APPLICANT 1NFOlRMATION_i1 Name to be Billed J�l/l�Iii✓/7C>yl�rS ! 0 L Cor:tact Person r X, Billing Address /dZ Home Phone - — City/State/ZIP `7Business Phone �v Name on Permit/ATC if Different than Above Mailing Address City/Stt:te/Zip PROPERTY INFORMATION_ NOTE: A survey plat or site plan m rsi accompany this application. (Permit is valid for 60 months with site plan,no expiration wit com alete plat.) Street Address_ Le--r< .�r. City Tax PIN# �iE6�Ja D/3 Subdivision Name />7l� £ Sectif tt/Lot#_1 Lot Size Directions To Site: /KE 17- / F s 644, 1 Lv er�d /9t L7 D� Ca sZt�Z eL-Zf1yG >S' Date House/Facility Corners Flag;o9 If the answer to any of the following qut stions is"yes",supporting document itiont be attached. Are there any existing waste nater systems on the site? ❑Ye: 4}IQo Does the site contain jurisdi ti anal wetlands? OYe; awo- Are there any casements or rigl t-of-ways on the site? pYcs tom. Is the site subject to approval by another public agency? OYe: l0 Will wastewater other than donicstic sewage be generated? ❑Ye: l3iVo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms 25 #Bathrooms �_ Garden Tub/Whirlpool 10fes UNo Basement:❑Yes 4.11d'o BasamentPlumbing: ❑Yes GKo IF NON-RESIDENCE FILL OUTTHE BOX BELOW Type of FacilityBtisiness _. Total Square Foota a of Building_ #People #Sinks #Commodes_ #Showers _ #Urinals Estimated Water Usage(gallons per day) (Attach docu-mentation of similar facility water consumption) FOODSERVICE ONLY:#Seats_ Type system requested: GConvcntional ❑Accepted Olnnovative OAlten tative OOther Water Supply Type: ountyxity Water U New Well OExis:ing Well C Community Well Do you anticipate additions or expansions of the facility this system is intends d to serve?0 Yes o If yes,what type? _ This is to certify that the information provided on this application is true and :oTrect to the best of my knowledge. I understand that any pennKs)or ATC(s)issued herea-IC-are subject to suspension or revocation if the site is altered,the intended use changes,or if the information submitted in this applict tion is falsified or changed. I understand that 1 am responsible for all charger incurred from this application. I hereby grant right of entry to the Authorized Represe tuative of the Davie County Health Department to conduct necessary inspections to dete..n--in7c compliance with appli ble laws and rules on the above described property located in Davie County and owned by /nr�l'fl /-Z.11�� / Site Revisit Charge operty owner's pr own ga a re;entative signature Date(s): C (� Client Notification Date: Date EHS: (n Sign given !]Yes ONo .account# "00 ✓2 '5r Revised 2/06 Invoice# /zo' GoMAPS - Davie County NC Public Access Page 1 of I Davie County, NC - GIS/Mapping System Click Here To Start Over Quick Search:(County ID c M '+ `^ Active Layer. 14-0 Use Tap Tips GIs IM `�- PARCELS (Map Tips Available) Map Layers I Results 0 7 f G o tip 376 Ilk a. r v +rt, � r t a. a 4 http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?maimnapservice=gomaps&CFID=4129... 2/4/2008 Y DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPL F Tax PIN/EH#: 5840MMMY INFORMATION Billed To: Southern Homes of Davie Subdivision Info: Pudding Ridge Lot# 13 Reference Name: Wayne Frye Location/Address: Cornwallis Drive-27028 ���1 Proposed Facility: Residence Property Size: 16lx289xl55x2 Date Evaluated: "7 — '(7_0 r 7-gs Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca 'e position C. Slope % HORIZON I DEPTH Texture groupG Consistence r Structure !2 Mineralogy HORIZON H 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: • 5 EVALUATION BY: !����r'"�KSI doe J/(!� 444 LONG-TERM ACCEPTANCE RATE: ©• )_? OTHER(S)PRESENT: 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 )Yel 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 LN41eS 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 05/05 (Revised) ■■■■■■■■■■■■!■■!■■■■■rala■■■■■■■■■■■■■■■■■■■■■■:::_===••,■■■■■■■■■■■■ ■■■■■■■■It■■■■■■■■flip■■■■■■■■■■■■■■■■■■AV■�ICJr■■■■■■■■■!■■■■■■■■■■■■■ !■■■■■■■It■■■■!■■!!■!■■■■■■■!■■■■�■!!■��■Ilii■■■■■■■!■■■i■■■■■■■■■■■■■ ■■■■■■U►I■I■■/IGT%■■■\■■■■■■■■■■■■■■■r%■■11■■�===....'7■■■11■■■■■■■■■■■■ ■■■■■■■■■I■■■■■■■■■ii■■■■■■■■■\■■■■■■■■■11■■■■■■■■■■■■■■11■■■■■■■■■■■■ ■■■■■■ ■■■■■■ ■■■■..���������.rf■■■11■ ■■■■■■ ■■■11■■ ■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■11■■■f I■■■■■■■■■■!■■■f I■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■i l■■■■I■■■■■■■■■■■!■■■I■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■111111■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■Il!■■■■■■■■■■■[MEMO■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street ,• Mocksville,NC 27028 �� (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003916 Tax PIN/EH#: 5841-05-8308 13 Billed To: Bruce Aubrey Subdivision Info: Pudding Ridge Lot#9-14--- Reference Name: Location/Address: 376 Cornwallis Drive-27028 Proposed Facility: Residence Property Size: 16lx266xl59x **NO 1 T9*hlsgmprovemeent/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type# #People , #Bedrooms y _ #Baths Dishwasher: u Garbage Disposal: ff Washing Machine: Basement w/Plumbing: Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply C/o, Design Wastewater Flow(GPD) 4/8 Site: New Repair❑ System Specifications: Tank Size /OdoGAL. Pump Tank GAL. Trench Width<9& Rock Depth///t Linear Ft.3�/00 fan ft t^d in 15A NCAC 18A.1R3Z'91 Other: t=c_"i 2d ayatcros may also bo us� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m.on the da ion. Telephone#is(336)751-8760.**** /0 t7p Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) Davie County Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336) 751-8760/Fax (336) 751-8786 May 17, 2006 Mr. Bruce Aubrey 8 Woodwild Trail Metuchen,NJ 08840 Re: Pudding Ridge, Lot# 13,#12 Tax Pin#: 5841-05-8308 Dear Mr. Aubrey, As requested, a representative from this office visited the above site April 11, 2006,and May 17, 2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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 or the intended use change. Improvement Permit System To Serve: e Wastewater Design Flow: System Type: ❑Conventional �_"Klccept d ❑Innovativve,Q❑Alternative ❑Other System Location: Valid: ❑5 Years []No Expiration Site Modifications/Permit Conditions: Env_iro ntal Health Speciali Date ps-i.p.letter 2/06