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117 Essex Farm Road Lot 2Dav >.017 I [all NAll data la provided as is withoutwarranty or guarantee of any kind¢itlurexpressed or Implied Including but not limited tothe Davie County, Implied warrantlss of merchantability or Rtnem for a particular use. All users of Davie County's GIS webstte shag hold harmless the T County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and ail claims or reuses ofactlon due to C or arising out of the use or inability to use the GIS data provided by this website. WARNING: THIS IS NOT A SURVEY Parcel Information`::., Parcel Number: F8030A0002 Township: Shady Grove NCPIN Number: 5870539306 Municipality: Account Number: 8306549 Census Tract: 37059.803 Listed Owner 1: BOONE MICHAEL RAY Voting Precinct: EAST SHADY GROVE Mailing Address 1: 117 ESSEX FARM ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27006 Voluntary Ag. District: .. No Legal Description: LOT 2 ESSEX FARM PHASE 1 Fire Response District: ADVANCE Assessed Acreage: 0.69 Elementary School Zone: SHADY GROVE Deed Date: 6/2016 - Middle School Zone: WILLIAM ELLIS Deed Book/Page: 010221103 Soil Types: GnB2 Plat Book: 0009 Flood Zone: Plat Page: _ 289 Watershed Overlay: DAVIE COUNTY Building Value: _ 242710.00 Outbuilding & Extra Freatures Value: 2660.00 Land Value: 48450.00 Total Market Value: 293820.00 Total Assessed Value: 293820.00 [all NAll data la provided as is withoutwarranty or guarantee of any kind¢itlurexpressed or Implied Including but not limited tothe Davie County, Implied warrantlss of merchantability or Rtnem for a particular use. All users of Davie County's GIS webstte shag hold harmless the T County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and ail claims or reuses ofactlon due to C or arising out of the use or inability to use the GIS data provided by this website. OPERATION PERMIT DaviO County Health Department 210 Hospital Street - � � P.O. Box 848 , =^' NC 27028 ",Mocksville, Phone: 336-753.6780 Fax: 336-753.1680 ; Applicant RS Parker Homes Property owner. RS Parker Homes 4 5. :sq. ft. Address. 502 Hickory Ridge Dr 'Address: 502 Hickory Ridge Dr Total Trench Length: -City:Greensboro .3 6 It. Trench Spacing: Cay: Greensboro , -State2ip: , -NC -27409 jState2ip: NC 27409 Phone #• - (336),362-8970.' . °Phone #: (336) 362-8970 3 Inches gFeet r, Property Location & Site Information #: --- SubdNision7 ESSeX Faint Phase:Lot: 2 inches CAddress/Road Essex Farm Rd l 6 --=Advance NC 27006 Directions - -' $tnlcture '' =:Hwy! 64 E. left on Cornatzer Rd. Essex Farm on left 4 SINGLE-FAMILY , # of Bedrooms: 4 6 # of People: Inches Water Supply: PUBLIC ` =Natioris;RobeA "IP Issued by "``2140 'System Classification/Description: l TYPE 111 G. OTHER NON -COW. TRENCH SYSTEMS 'CA issued by: 2140 Nallom Robert SaproliteSystem? QYes ®No Desi n Flow _... 9=- , _ -4< 8 0: I GRAVITY -SERIAL Pump . 'DistribuGonType: seQNo7 So-il.ARRt"tion Rate: 0 a 3 5 - - Dr Ndrification Field .. 1 7 4 5. :sq. ft. No. Drain Lines 5 Total Trench Length: 4 .3 6 It. Trench Spacing: 9 Inches O.C. SFeet — O.C. Trench Width: 3 Inches gFeet - Aggregate Depth: inches Minimum Trench Depth: 3 6 - Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches 'System Type: INFILTRATOR QUICK 4. STANDARD Installer: Frank Transou. Certification #: 2771 'EH S: 2140 - Nations. Robert Date: 0 5/ x 6/ 2 0 1 6 CDP File Number 200214-1 County ID Number 5870539306 ' Septic Tank` Manufacturer. Shoal Lat.. ' STB: 760 Long- Gallons. 1000 Installer. Frank Transou Date: 0 3/ 0 6/ 2 0 1 6 Certification #: 2771 THS: 2140 - Nations, Robert 'Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter ST Marker. El Yes ®No Date: 0 5/ 2 6 / 2 0 1 6 Reinforced Tank: [I Yes ®-NO -.� t, �ApprovalS#atus 1 PieceTankc ❑Yes � No ,, , :.®�App[ovetl �+Dlsapp�oveds°`,;j Pump Tank Manufacturer. Shoaf Installer Frank Transou - = PT:' ;42 Certification #: 2771 "Gallons: `1250 THS.2140-Nations, Robert - Date: -1 a_-] 2 .7 '/ a 0-:1 5 Date: 0 5./ a 6/ a 0 1 6 RiserSealed ® Yes ❑ No RiserHeighe Yes - -- ❑ NO (Min. in.) - Approval Status Reinforced Tank,- p Yes ❑ No __ ®gpproved ❑ Dlsapproyed 1 Fiace Tank: ®:_YeS_�_..❑,N0 _ Supply Line Pipe Size-, a inch diameter Installer. Frank Transou - Poe Length: 4 0 feet Certification #: 2771 *LHS: 2140-.Nations, Robert *Schedule: 40 Pressure Rated ® Yes ❑ No Date: 0 5/ 2 6/ 2 0 1 6 Approved ftfings- (9 Yes ❑ No Approval Status App'rivetl ❑ DlsapproVed Pump Requirernint Pump Type: Zoeler Installer: Frank Transou Dosing Volume: — Gal Certification#: 2771 Draw Down: Inches *EHS: 2140 - Nations, Robert *Chain: ROPE Date: 0 5/ 2 6 / 3 0 1 6 Valves Accessible p Yes ❑ No J Flow Adjustment Valve ® Yes ❑ No Check-valve 0 Yes ❑ No "Approvaistatus PVC Unions ® Yes ❑ No ® Approved Disapproved Vent Hole Q Yes ❑ No — Anti-siphon Hole p Yes ❑ No CSP File,Number 200214 1 NEMA_4XBox or Equivalent : [j] Yes -, Box 12 inches Above Grade ® Yes _ Box, Adj. To Pump Tank T Yes Conduit Sealed ® Yes Pump Manually Operable ® Yes *Activation Method: PIGGYBACK Electric ❑ No ❑ No ❑ No ❑ No ❑ No County ID Number:709306 quipment — Installer: Frank Transou Certification #: - 2771 -; Alarm Audible ®.Yes _ O No: 1. Alarm Visible to ' ❑:Yes _.❑N. o.: 2140 - Nations, Robert 'Operation Permit completed -by: Authorized State Agent: — *EH S: 2140- Nations, Robert Date: 0 5 / 2 6 / 2 0 1 6. ti Date of issue: 0 5/ 2 6 /. 2 0 1 6 O.wner/ApplicantSignature: `- This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for ::Sewage Treatment and Disposal,15A NCACA8A :1900 et Seq., and all conditions of the Improvement_ Permit and Construction Author¢ation. This property is served by a TYPE III G. sewage septic system. _ _�:: Rule :196Lrequires-that a Type TYPE III G. septic system meet the following criteria: Minimum,System Review ByThe Local Health Department: WA Management_Entity: OWNER - , Minimum 7Systern InspectioniMaintenance Frequency By Certified Operator: WA Reporting Frequency By Certified Operator. wA 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 operator or a private certified operator forthe life of the septic system. _ . Rule .1961 requires that Type VI septic systems designed fora hometbusiness 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 Perm it 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 systema ft shall also be a condlion of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing **Site, Plan/Drawing attached.** OPERATION PERMIT 200214- 9 Davie County Health Department CDP File Number: 210 Hospital Street 5870539306 P.O.sox 848 County File Number: Mocksville NC 27028 Date: : W W Olnch Drawing Drawing Type: Operation Permit Scale: . OBlock ON/A — —PES Sy '�c�• - 160;6 f.Y�. rr---IQ - o 15 _ ' i ael - 6 ' _ l0 IT c`�G I 0 Applicant: Address: City: State/Zip: Phone #: CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC .., 27028 Phone: 336-753-6780 Fax: 336-753-1'680 RS Parker Homes 502 Hickory Ridge Dr Greensboro NC 27409 (336)362-8970 02/a4/20.21 Property Owner. RS Parker Homes Address: 502 Hickory Ridge Dr City: Greensboro State/Zip: NC Phone #: (336) 362-8970 27409 Address/Road #: Subdivision: Essex Farm Phase: Lot: 2 117 Essex Farm Rd Advance NC 27006 Directions Structured SINGLE FAMILY ' - Hwy 64 E. left on Cornatzer Rd. Essex Farm on left i # of Bedrooms: 4 # of People: *Water Supply: PUBLIC / -_ Minimum Trench Depth: a 4 S itessification: Provisionally Suitable Inches Minimum Soil Cover: System? OYes ®No 1 a Inches low: 48 0 Maximum Trench Depth: 36Inches Maximum Soil Cover:oppication Rate: 0 a 7 55 a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY -SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank. 1 0 0 0 Gallons *Proposed System: 25% REDUCTION 1 -Piece: OYes ®NO Pump Required: OYes ® No O May Be Required Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: Gallons No. Drain Lines 3 1 -Piece: OYes ONo Total Trench Length: 4 3 6 GPM—vs— ft. TDH ft, Trench Spacing: _ 9 O ® Inches O.C. Dosing Volume: _ Gallons Feet O.C. Trench Width: 3 Inches Feet — Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01011 0111 01V / � - CDP File Number 200214 -1 County ID Number: 5870539306 c ❑ Open Pump System Sheet ®Yes O No O No, but has Available *Site Classification: Provisionally Suitable Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 4 Total Trench Length: 4 3 6 ft, Trench Spacing: 9 O Inches 0.1 ® Feet O.C. Trench Width: — 3 O Inches ® Feet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover. a 4 Inches *Distribution Type: GRAVITY -SERIAL Pump Required: Oyes ®No O May Be Required Pre -Treatment: O NSF OTS -I OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 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. 2000 0 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 at the same time 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 the application 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 (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ONO Applicant/Legal Reps. Signature- Date: / / *Issued By: 2140 - Nations, Robert Date of Issue: 0 a / a 4 / a 0 1 6 Authorized State Agent: function Log OY@S ( �: —® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department ' 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing nrawinn Tvne- Construction Authorization CDP File Number: 200214 - 1 County File Number: 5870539306 Date: 02/ 24/ 2 0 1 6 O Inch Scale: , O Block rl AI IA - -1 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 200214 -1 P.O. Box 848 5870539306 - Mocksville NC 27028 County File Number: Date: 0.1/ 044 /.2.0.1.6, Click below to import an image from an external location: Drawing Type: Construction Authorization Page 3 of 3 2e> �57 7Ce0 c> P1 P2 SAP R SITE EVALUATIONANTROVEMENT PERMIT & ATC 9 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 .(336)751-8760/ Fax (336)751-8786 application ¢({@IEValuatio provement Permit D Authorization To Construct(ATC) ❑ Both fyp �� l� N stem []Repair to Existing System DExpansion/Mod�crtion of Existing System or Facility c aNR_..nF G +•*IM 0R7AN7°i• THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED Name to be Billed ASC /0crVT4op/?dN r Cgt. /ae Contact Person id.PRv 247C,61- Billing 47e£.eBilling Address Ad -&x 3fo Home Phone City/State/ZIP IAC- 27028 Business Phone 7S/ - 730o r Name on PemtitlATC if Different than Above Murll Cl T-11NrU1QV IIUIN-varenousetracuny uomersrta eo NOTE: A survey plat or site plan must accompany this application. Included: []Site Plan lm(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat) Owner's Name�Se .Or'V£LoPr1£Ni carr irtG Phone Number 7J1-7.30 Owner's Address P08oj4u City/State/Zip __ZYee�goirst /�G 27o29 Property Adess City Lo[Size U. Tax PIN# Snhdivicinn Namrlif annlirahlel Fccrr F ... SnrtinnQ nt!! // - A Are there any existing wastewater systems on the site? Dyes "10 Does the site contain jurisdictional wetlands? OYes DNo Are there any easements or right-of-ways on the site? Gies ONo Is the site subject to approval by another public agency? DYes ffl�pp Will wastewater other than domestic sewage be generated? DYes BNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms#Bathrooms Garden Tub/Whirlpool DYes ONo Basement:: DYes[]No- - -Basement Plumbing: DYes ONo IF NON-REJSIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building - - # People 0 Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:��nConIventional DAccepted Omovative OAltemative DOther Water Supply Type: O'Ccunty/CityWater D New Well []Existing Well - [] Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes - ONo 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 locating an egging or staking the houselfacility location, proposed well location and the location of any other amenities. Site Revisit Charge Property r or o per's legal represents � re I Date(s): Client Notification Date: Data EHS: Sign given DYes ONo Account# Revised 11/06 - Invoice# 73 sign esnt. TIER ROAD SR 1616 ere hydmt rve Radius Chord Bearing and Distance Arc Length 1599.37' 301.00' 74'-12'-50" W 304.15' 304.61' . Cc 00 O 80°-33'-58" W 50.03' N o. o 30100 Sq.Ft. N 87'-35'-03" I o WYWAY 50' R 89.09' 0.691 Ac.+/- 35.00' S 0 E ustee 18 S 82'- ^ 28'-00" 50.00' f S 82'. o /r -109.61= _ _ 47"-48'-22" _ E_ 18.12' 18.22' I -10 N " 301.00' W 126.31' I ' 35.00' cc ® 74'-59'-02" E I 27.55' Ln ^ 30098 Sq.Ft. N I o I gp 3 e 48.79' 0.691 Ac.+/- 50.00' S 510-10'-24" E 35.00' S 82-28'-00" 0 _O I LL\ Q i+ t E E y 35.76' 1 50.00' S 30'-46'-33" 301.00' 35.00' 35.76' n _NQ n v n 2 50.00' S o © W 57.71' w 0La n I 00 a N h oL O L 30100 Sq.Ft. oo' C 0.691 Ac.+/- o I Ln 82'-28--00- I n 301,00, w 301,00' © I W 3 82-28•_00 • E 'n 30100 Sq.Ft. ^ O s 100,00' S 82'-28'-00• 0 90.39' 0.691 Ac.+/- 00' J S 82•_28' -00" E ozo I to I n 301.00' 1 _. In 00 © rn ^ , 00 . 30106 Sq.Ft. ' ro w 00 0.691 Ac.+/- I O !L _ S 82'-28'-00" E 00 00 v L7+ + N < C' nQu w a n-0 , 307.00' ^ o0 rj o m n N 0 " La �, a° 0 n ^ 0 301000 Sq.Ft. I y I o n © N O ^ 0.691 Ac.+/- 0 I I sz Z S 82 -IX 28'-00" i o I Z E 307.00' II 0 0 30® Sq.Ft. f o h 100.00- 700.00'- 9.65 0.691 Ac.+/- 0 N 82'- 50 -00" yy C1 S 82•-28'_00., 0 ¢ 3 TY<'1'AY S 82'-28'-00.. (Public) E 307.00' i N f -126.2 _ II C o © � Sq.Ft. n w �I - 83.37= _ R 00 3010 0.691 Ac.+/- o O } S 82'-28'-00" E o I w I o• I gg w a?301.00' 11 h 32070 Sq.Ft. 6. nN o^ n N 0.736 Ac.+/ - o ^ 30001 Sq.Ft. �. c I I n Lvi 0.689 Ac.+/- ^ ; ��\epot 30010 Sq.Ft. zo 0.689 Ac.+/- I 1 ^ _� L� n `C Z ��'-- br JZ' -el9n L_ I sign esnt. TIER ROAD SR 1616 ere hydmt rve Radius Chord Bearing and Distance Arc Length 1599.37' N 74'-12'-50" W 304.15' 304.61' 1599.37' N 80°-33'-58" W 50.03' 50.03' 1599.37' N 87'-35'-03" W 89.08' 89.09' 35.00' S 59'-55'-01" E 26.84' 27.55' 50.00' S 47"-48'-22" E 18.12' 18.22' 1599.37' N 83'-43'-31" W 126.31' 126.35' ' 35.00' N 74'-59'-02" E 26.84' 27.55' I 50.00' N 80°-23'-13" E 46.87' 48.79' 50.00' S 510-10'-24" E 35.00' 35.76' 0 50.00' S 10"-11'-55" E 35.00' 35.76' 1 50.00' S 30'-46'-33" W 35.00' 35.76' 2 50.00' S 86'-30'-33" W 57.71' 61.52' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 5870-6-226`5. Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 02 Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: 0.691 Ac. Date Evaluated: Ct- De -0- Water Supply: On -Site Well Community Public V/ Evaluation By: Auger Boring Pit ✓ Cut FACTORS (O,` - (0 4 5 6 1 7' Landscape position . Slope % . HORIZON I DEPTH Mineralogy HORIZON II DEPTH Texture group Consistence Structure . Mineraloev :.. . 'Texture gror Consistence Structure 1111 •®® s Mmeralo ! � : HORIZON IV DEPTH Texture group Consistence '.Structure.:., t. Mineralogy'. --:;'_SOILWETNESS: M®H M®N M -N M®N ®®1 LONG-TERM ACCEPTANCE RATE pal O ai A.)l n BITE CLASSIFICATION: 54 1 abte- EVALUATION BY: Kah 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 - Loarn ' SI - Silt. SICL - Silty clay loam SIL - Silty loam CL: - Clay loam SCL - Sandy clay loam. SC - Sandy clay. :SIC - Silty clay . C - Clay CONSTSTF.NCF Mois .. VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm " NS - Non sticky SS - Slightly sticky S Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure . -. SC - Single grain M Massive CR'- Crumb` GR - Granular -ABK - Angular blocky SBK - Subangular blocky : PL - Platy PR - Prismatic Mineralogy 1:1, 2:1, Mixed tYoteS _ , 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(provisionallysuitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/05 (Revisedl 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 #: 5870-64-2265.02: Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 02 Address: PO Box 340 Location/Address: Comatzer Rd -27006 City: Mocksville Property Size: 0.691 acre Reference Name: Brad Coe Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. Anr 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: ew ❑Repair. DExpansionn Permit Valid for: R!B'Years DNo Expiration Residential Specifications: # Bedrooms 1 # Bathrooms_ # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) DesignFlow(GPD): ou Type of Water Supply: PLounty/City ❑Well ❑Community. Well Site Modifications/PermitConditions:_ -A3 stated -in 15A-NCAC.38A.1969(5 spCefted-Systems'piay also -be used'- System e LTA In tial R 7 Repair Eavironmental Health Specialist_ J`ya f�evri � .ori. 0 `T. Date �&4-13--a -7 31 SAID APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health " 02. 0 0A P.O. Box 848/210 Hospital Street _ Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For. XSim Evaluation/Improvement Permit > Authorization To Construct(ATC) G Both Type of Application: kew System - L$epair to Existing System ❑Expansion/Modification of Existing System or Facility ***AfPOR7A,VT*** THIS APPLICATION CANNOT BE PROCESSED. UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. Name to be Billed S f NOfj'T-S - Contact Person Billing Address D f i C - Home Phone City/State/ZIP C Business Phone Name on Permit/ATC if Different I IUN NOTE: A survey plat or site plan must accompany this application. Included:XSite Plan DPlat(to scale) - (Permit is lid fo 60 months with site plan, no expiration with complete plat.) Owner's Name HIS FOt F V r 1AOrP)�S - Phone Number 33(0 "84h l' Owner's Address_apQ I-VVe(CorU C.( City/State/Zio(��I t�_'Y' Property Address _4- ��t-Ru-—City .Kit") (//,i,Glr - 5 Lot Size ' Tax PIN#���- Subdivision Name(ifa plicable) Section/L,ot# - Directions To Site: t t 5 rt t)Ct_ Ler r 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? - Dyes o - Does the site contain jurisdictional wetlands? - Dyes, Are there any easements or right -of --ways on the site? Dyes o Is the site subject to approval by another public agency? Dyes Will wastewater other than domestic sewage be generated? Dyes I o -. IF RESIDENCE FILL OUT THE BOX BELOW - # People # Bedrooms # Bathrooms - Garden Tub/Whirlpool es ON o Basement: CYes o Basement Plum inn: OYesx,40 - - 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: Yonventional CAccepted ❑Innovative CAltemative ❑Other - Water Supply Type: p(County/City Water . O New Well CExistIng Well ' ❑ Community Wel Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? - - �No . 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 die 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 rales. 1 understand that I -am responsive for the proper identification and labeling of property lines and comers and I�A. n nrn --- ?^ &yrz�t j� dA location, proposed well location and the location of any other amenities. representative e signarePo re=Date-, Dat Client Date - EHS: Sign given -Yes —No Account# Revised II/06 Invoice # _ rn N 8 rn M a. NC PIN: 5870536508 Raymond Jasper Perkins, Jr. Deed Book 845 ® 130 Plat Book 8 ® 274 Essex Farm, Phase 1 Plat Bookk99 6 289 3 I - GRAPHIC SCALE a 40 90 160 Notes Surveyor has made no Investigation or Independent search for easements of, record, encumbrances, restrlctive covenants, ownership, title evidence, or any other facts that an accurate ( IN FEET) and current title search may disclose, this survey Is performed 1 inch = 40 ft. without the benefit of a title search. Noticei By the use of this Preliminary Layout, RS Parker Homes has verified to Allied Land Surveying Company, P.A. the exterior house dimensions for this house/structure. House points and position shown on this map represent the points to be placed on the property. The owner/contractor has reviewed all house/structure dimensions, setbacks from property lines, and compliance with restrictive covenants and/or local governmental requirements on this drawing and by the acceptance of this layout authorizes Allied Land Surveying Company, P.A. To place the points as accurately as Is reasonable (typically 0.021:0, Owner/contractor Is to verify the placement of points set In field prior to the authorization of footings/brick masons/ construction to proceed. By the acceptance of this layout owner/ contractor fully accepts their responsibillty to verify points In field. The house points denoted by solld filled circles are the only points to be located In the field. All other bullding corner locatlons are to be the responsibility of .the contractor/developer. 3 field revision, ------- —_--------------- dates owner/contractor/allled staff Pro l C'4 rn al Preliminary Layout 117 Essex Farm Road Lot 2 Essex Farm, Phase 1 Plat Book 9, Page 289 Plat fort RS Parker Homes ALS Project Noi 11-534 Note: This plat does not represent a current field survey. All tot dimensions have been taken from the plat of Essex Farm, Phase 1, located In Plat book 9 Page 289. No title research has been performed or requested for the benefit of this plat. Allied Land Surveying Co., P.A. 4720 ICESTER MILL ROAD Surveyed lop WINSTON-SALEM, NORTH CAROLINA 27103 Brawn By, CS Phone: (336)765-2377 ❖ Fax: (336)760-8886 Project 11-534 e-mail: Info@Allied-EngSurv.com