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139 River Road Lot 6Davie County, NC a I Tax Parcel Report Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: Thursday, January 5, 2017 i I� 14 I f, 155 171 WARNING: THIS IS NOT A SURVEY Parcel Information E8070B0009 Township: Shady Grove 5871954613 Municipality: 8303361 Census Tract: 37059-803 HUGHES HAROLD LEE Voting Precinct: EAST SHADY GROVE 139 RIVER ROAD Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R-20 NC Zoning Overlay: 27006-7640 Voluntary Ag. District: LOT 6 GREENWOOD LAKE Fire Response District: Land Value: Total Assessed Value: 1.12 Elementary School Zone: 4/2014 Middle School Zone: 009550017 Soil Types: 0003 Flood Zone: 053 Watershed Overlay: Outbuilding & Extra Freatures Value: Total Market Value: ADVANCE SHADY GROVE WILLIAM ELLIS GnB2 DAVIE COUNTY No 9t xl� avieounty, C All data is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS websfte shall hold harmless the [DN County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of the use or Inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF:. COMPLETION *NOTE: Issued in Corripliance w{th-G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment andDisposal Rules (10 NCAC 10A .1934-.1968) Permit. Number / Name �w • Date3432- •{IIIA; ,� � � • Location T r{ Subdivision Name Lot Size 4_ No. Bedrooms_ Garbage ,Disposal Auto Dish Washer Auto Wash Machine Type Water* Supply "This permit Void if sev I� Improvements permit by "Contact a rep"resentative;of the Davie County Health Department for final inspection of this system betweenw8:30 9:30 A.M.or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634=5985, Final Installation. Diagram-. ,. System Installed by '- IIIII . ' Ij " Certificate of Completion " Date 'The signing of this certificate shall indicate that the system descri edabove has been installed in compliances with;' y the standards set forth in the, above. regulation, but shall in NO way be taken as a,guarantee that the system will function'` satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name Date ' Locationy — -- - Subdivision Name d Lot NdV14�-- Sec. or Block No. Lot Size = House Mobile Home _ Business Speculation No. Bedrooms - "� No. Baths _ No. in Family' Garbage Disposal YES B NO ❑ Specifications for System: Auto Dish Washer YES [] NO ❑ Auto Wash Machine YES Q NO ❑ Type Water Supply r *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by - *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by - Certificate of Completion=s `- Date 4 *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. A t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION , Date Lot Size�� AREA 3 AREA 4 FACTORS AREA 1 AREA 2 1) Topography/ Landscape Position 4' S � S 4P S PS '.) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S � S S � ' S PS U U U 1) Soil Structure (12-36 in.) Clayey Soils S S S <:T�77 S PS U U U U Soil Depth (inches) S PS S PS S S PS U U Soil Drainage: Internal S jPS S S U U S U External S— P� � SS — (7s/ S PS U U U U �) Restrictive Horizons .. Available Space S S S S PS U Other (Specify) S PS PS S PS S PS U U U )) Site Classification TUU U—UNSUITABLE Recommendations/Comments: Described by SITE DIAGRAM DCHD (6-82) S—SUITABLE PS—Provisionally Suitable Title Date u`s'e ryG� 74 1460,7re, V APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home P orij 1. Permit Requested By 3� /=��� Busines /PF�one ,�6_ -� 2. Address Z_*5-- X 2 70 7- 3. Property Owner if Different than Above Addressi 4. Permit To: a) Install_ Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimension4 Z Bed Rooms 3 Bath Rooms— Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes ¢ duels 2 �t9 ra bage disposal 7 lavatory ; showers d- washing machine dishwasher; sinks 8. a) Type water supply: Public —I Private Community b) Has the water supply system been approved? Yes ZZ No- 9.,,a) o 9.• a) Property Dimensions 3 0 7- b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you, anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the be t of my knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) HEALTH DEPARTMENT RELEASE Davie County Health Department E 210 Hospital Street E1VIA . - P.O. Box 848 Date: Q` Mocksville �27 28 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Superior Pools/Eric Address: 20315 Knox Road City: Cornelius State2ip: NC 28031 Phone #: (704) 896-7665 For Office Use Only ;CDP File Number 204139 -1 County ID Number: valuated For. HDRMWC PERMIT VAUD 0 a/ a 3/ a 0 1 6 UNTIL: �,`Property Owner: Harold Huges Address: 139 River Rd City: Advance State0p: NC 27006 Phone M (336) 941-3660 r Property Location & Site Information Address River Road Subdivision: Greenwood Lakes Phase: Lot 6 Road # Advance NC 27028 'Structure: SINGLE FAMILY # of Bedrooms: 3 *Water Supply: NIA Basement: n Yes Q No 'Proposed Improvement: Pool # of People: Township: Directions Hwy 158 East right on Hwy 801, Left on Underpass Rd. Left on River Rd Type of Business: Total sq. Footage: No. Of Employees: Maintain 15 foot setback to any portion of the septic system. If septic issues occurr in the future, install french drain between septic and pool. 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: 2140-Natis a 3 a e 1 6'Issued By: Dateossue: Authorized State Ag **Site Plan/Drawing attached.** } @Hand Drawing OlmportDrawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 200139-1 County File Number: Date: 02/23/2016 Olnch Scale: OBlock O N/A rage t or Z `t4 . . . . ......... f. ......... ------- : � t : e .............« ....ems. :....»,... - ....,,...... « �.-...«�.... _...--...-.. „- i , .......,............ ..y...e.........,�...._........ I -.........«.�......m.........,........»« ......««..».. Y I .«........« «....« .«..««.....,«« «.gym «....�.,. rage t or Z Davie County Health Department 40�i8 -' Environmental Health Section P.0. Box 818 RECEIVE IRWIN,210 Hospital Street. p U �� Courier #: 0940-06 FEB 19 2056 Mocksvillc, NC 27028 Phonc: (336) - -i DC HEALTH Frac: (336) - 753-1680 4C`y ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: Phone Number j `1(� 7 6 " (Home) ,��..� t���, ; � c~ �� � \ �, � C� c � ) Mailing Address: 1� (O -�1 \ 5 ylr\ 0 X nl _ (Work) Detailed Directions To Site: Property Address: \M(-- '15c -'7M Email Address: pkv a: r c5 n .rte: • c_c� :� . M Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: f'b rk& k S Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes N If Yes, For How Long? Any Known Problems? Yes ') If Yes, Explain: Please Fill In The FolloRingformation About The NEW Facility: Type Of Facility: Number Of Bedrooms Pool Size: I I Garage Size: Other: Requested By: Approved Disapproved Comments: Environmental Health Specialist Number of People Date Requested: -7) -- i (r, - / k) For Environmental Health Office Use Only 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 peri9d of Payment: Cash Check Money Order # Paid By:_ Account #: Amount:$ ived By:_ Invoice #: Date: 0211612016 16:34 TAX) P.0021003 Davie County Health Department Environmental Health Section P.O. Box 848 210 Hospit,,d Street Courier # ; 09-40-06 Mocksville, NC 27028 M1 Phone: (336) - 753 - 6780 - F&T. (8$6) - 733-1680 ON -SIVE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: &P'?_C•i n C' TaM'Ac" Phone Number (Home) Mailing Address: D0115 (Work) \NC_ a 2©� l Email Address: Detailed Directions To Site Property Address; Please Fill In The Following Informattion About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Sedrooms._�Number Of People: Is The Facility Currently Vacant? Yes( Nd, If Yes, For How Long? Any Known Problems? Yes N If'Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: Requested By: Date Requested: -3-16 - t A For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Bnvironmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Arnount:$. Paid By: Received By: Account #: Invoice Date: oj2016 16:34 Ifm 02116/2016 15:57 TAX} P.0021003 Ty?e of Application: ❑New System []Repair to Existing System OExpansion/Modification of Existing System or Facility ***IMpORT"T*** .THIS APPLICATION C4NNOT.BE PROCESSED UNLESS ALL OF THE REQUnftCEI QED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APkICANT INFORMATION PROPERTY INFORMATION *Date House/Facility Corners F NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan OPlat(to scale) (Permit is valid for 6P months with site plan, no expiration with complete plat.) Owner's Name o., . _ u .0-4. Phon Number Owner's Address City/St to/Zip VI CI V% e0? L *1-2c � Property Address City � 'r , i 7a b (Z Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "yes", supporting documcntati must be attached. Are there any existing wastewater systems on the site? ❑'Yes 1 Does the site contain jurisdictional wetlands? ❑ s Are there any easements or right-of-ways on the site? QYes ❑ Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be szenerated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathros Garden Tub/Whirlpool C1Yes o Basement es ❑No Basement Plumbing: ❑Yes 21,go 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 ltheri t-�CC�y,-\ Water Supply Type: ❑ County/City Water 0 Now Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? U Yes 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 permits) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changas, 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 onduct.necessary inspections to determine compliance with applicable laws and rul derstand that I am respo b] or the proper identification and labeling of property lines and corners and locating and,flag ing>aking the hie/facility location, proposed wall location and the location of any other amenities. Property o n r' or o ner al representative signature L 11 Site Revisit Charge 6� 00 (31 Name to be Billed Contact Person Billing Address b 1 Home Phone City/State/ZIP Business Phone Name on Permit/ATC ifDfferent than Above Mailina, Address City/State/Zin PROPERTY INFORMATION *Date House/Facility Corners F NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan OPlat(to scale) (Permit is valid for 6P months with site plan, no expiration with complete plat.) Owner's Name o., . _ u .0-4. Phon Number Owner's Address City/St to/Zip VI CI V% e0? L *1-2c � Property Address City � 'r , i 7a b (Z Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "yes", supporting documcntati must be attached. Are there any existing wastewater systems on the site? ❑'Yes 1 Does the site contain jurisdictional wetlands? ❑ s Are there any easements or right-of-ways on the site? QYes ❑ Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be szenerated? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms # Bathros Garden Tub/Whirlpool C1Yes o Basement es ❑No Basement Plumbing: ❑Yes 21,go 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 ltheri t-�CC�y,-\ Water Supply Type: ❑ County/City Water 0 Now Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? U Yes 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 permits) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changas, 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 onduct.necessary inspections to determine compliance with applicable laws and rul derstand that I am respo b] or the proper identification and labeling of property lines and corners and locating and,flag ing>aking the hie/facility location, proposed wall location and the location of any other amenities. Property o n r' or o ner al representative signature L 11 Site Revisit Charge 6� 00 (31 0211612016 15:57 (FAX) P.0031003 �y�trY ✓rYY f��rW Y� W �iWNtf Mb Iw�w.W is K �.w Mww'f �WII.rr M, w� w Mw Mf+M1M pp Y P4AN DRi Harold & EhM.y Hught NOTI �Plm wb] C� !o *ft"wa1 >n buAdkep kgp�cpen dWdl'+Mtt p'4'� W WhHgdbh ,� GRAPHIC SCALE 1 tre� SO fL d -LAT ZMOZP & S�IitiR13'T VWZ and SC"AtACEM M9"S tfCOrd RtfdrfnC*>k 4qt 4. F"k R 4f NJ4. Pa. 3, PQ. Al a 06. 2A Pq� 017 day. 71. Is AJ W4* 1 V444 Ne SLdTL' SURUMNG M F.du P.A. Bot 1082 , r4 Mw. N.C. AM72f 9.Y6 8-87.19 dD.R 1 l 1 r� �y�trY ✓rYY f��rW Y� W �iWNtf Mb Iw�w.W is K �.w Mww'f �WII.rr M, w� w Mw Mf+M1M pp Y P4AN DRi Harold & EhM.y Hught NOTI �Plm wb] C� !o *ft"wa1 >n buAdkep kgp�cpen dWdl'+Mtt p'4'� W WhHgdbh ,� GRAPHIC SCALE 1 tre� SO fL d -LAT ZMOZP & S�IitiR13'T VWZ and SC"AtACEM M9"S tfCOrd RtfdrfnC*>k 4qt 4. F"k R 4f NJ4. Pa. 3, PQ. Al a 06. 2A Pq� 017 day. 71. Is AJ W4* 1 V444 Ne SLdTL' SURUMNG M F.du P.A. Bot 1082 , r4 Mw. N.C. AM72f 9.Y6 8-87.19 dD.R . I OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Schumacher Homes/David Address: 6349 Burnt Poplar Road City: Greensboro State/Zip: NC 27409 Phone #: (336) 215-0278 rror umce use univ *CDP:File Number 191381-1 5871.954613 County ID Number:; Evaluated For NEW Township:..... rproperty owner. Harold and Shirley Huges Address: 2701 Bridgeport Drive City: Winston-Salem State2ip: NC 27103 Phone #: (336) 462-7057 Property Location & Site information dress/Road #: Subdivision: Greenwood Lakes Phase: Lot: 6 River Road r Advance NC 27006 Directions 1-40 east to hwy 801 south left on Underpass Rd. Leff Structure: SINGLE FAMILY on River Rd. Job site on corner # of Bedrooms: 3 # of People: 'Water Supply: PUBLIC 'System Classification/Description: 'IP Issued by. 2140 - Nations, Robert t A. SYSTEM (SINGLE-FAMILY OR 480 Grua OR LESS) 'CA issued by: 2140. Nations. Robert SaproliteSystem? OYes @No Design Flow: 3 6 0 *Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required? O Yes Q No Soil Application Rate: 0 - 2 7 5 *Pre Treatment: Drain field Nitrification Field 1 . 3 0 9 Sq. ft. "System Type: INFILTRATOROUICK4 STANDARD No. Drain Lines 6 Installer: Tim Beeson Total Trench Length: 3 .2 8 8• Certification #: Trench Spacing: _ 9 Otnches O.C. • Feet O.G. 'EH S: 2140 - Nations. Robert Trench Width: _ 3 lnches SFeet 0 8% 1 2/ 2 0 1 5 Date: Aggregate Depth: inches Minimum Trench Depth: a 9 Inches Minimum Soil Cover. 1 7Inches Approval Status. - Maximum Trench Depth: '3 6 N Approved 0 Disaipproved Inches Maximum Soil Cover: a 4 Inches CDP File Number 191381 -1 Manufacturer. Shoaf STB: 760 Gallons: 1000 County ID Number: 5871-95.4613 c Tank Let. Long: Installer e Manufacturer, 21 Gallons: Date: Inches Risersealed ❑ Certification #: Date: 06/ 0 8/. 0 1 5 No (Min.6 in.) einforced Tank: ❑ Yes • ❑ No *EHS: 2140 - Nations. Robert "Filter Brand: POLYLOKPL-122 With Pipe Adapter NO PVC Unions ST Marker El Yes Vent Hole 0 No Date: g / 1 a / 0 1 5 nforced Tank: ElYes IE No Approval Siatus 1 Piece Tank: El Yes [B No 1 Approved ❑ Disapproved Pump Tank Manufacturer, 21 Gallons: Date: Inches Risersealed ❑ Yes ❑ NO RiserHei ht: ❑ Yes Yes ❑ No (Min.6 in.) einforced Tank: ❑ Yes ❑ No Piece Tank: ❑ Yes Yes ❑ NO % Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No I Pump Type: Installer. Certification #: *EHS: Date: Approval Status CI Approved ❑ Disapproved Supply Line Installer Certification #: *EHS: Date: Approval Status Installer. Dosing Volume:— Cal Certification #: Draw Down: Inches *Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ElN o Anti -siphon Hole ❑ Yes ❑ No I *EHS: Date: Approval Status ❑ Approved L7 Disapproved CDP File Number 1913$1 -1 County ID Number: 5871'95.4x13 14Mrin NEMA 4X Box or Equivalent ❑ Yes ❑ No Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ No *Activation Method: Alarm Audible '❑ Yes ❑ No AlarmVisible ❑ Yes ❑ No 2140 - Nations, Robert *Operation Permit completed bye Authorized State Age Apment Installer. Certification #: *EH S: Date of Issue: 0 8/ 1 a/ a 0 1 s Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq.,,and all conditions of the Improvement Permit and Construction Authorization. This property is served by.a YYPE 11 A. sewage septic system. Rule .1961 requires that a Type TYPE Ila septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A Management Entity: OWNER Minimum System InspectionlMaintenance Frequency ByCertified Operator: WA Reporting Frequency By Certified Operator NIA Rule .1961 requires that a Type IV and V septic systems designed far a home/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 fora home/business owner must maintain a valid contract with a public management entitywith a certified operator for the life of the septic system. Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained bya public or private management entity,unless' the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Perm it that subsequent owners of the systems execute such a contract. @Hand Drawing 01mportDrawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 191381 -1 County File Number: 5871-954613 27428 Date: Olnch Scale: OBiock ONIA i Jr ......... . .. li 14C, I� �J CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street .2 d,. P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Schumacher Homes/David Shuler Address: 6349 Burnt Poplar Road City: Greensboro State/Zip: NC 27409 �._Pho�ne#.(336) 215-0278 Address/Road #: Subdivision: River Road Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC i For Office Use Only *CDP File Number 191381-1 County ID Number: 5871-95-4613 Evaluated For: NEW �, Township: 0 4 / 15 / a0 a0 Property Owner: Harold and Shirley Huges Address: 2701 Bridgeport Drive City: Winston-Salem State/Zip: NC 27103 Phone #: (336) 462-7057 Phase: Lot: Directions 1-40 east to hwy 801 south left on Underpass Rd. Left on River Rd. Job site on corner tem Specifications /Site Minimum Trench Depth: a 4 Inches \Si Classification: Provisionally Saprolite System? ®No O Yes ® Minimum Soil Cover: Minimum a Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) 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: O Yes ® No Pump Required: O Yes ® No O May Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: OYes ONo Total Trench Length: 3 7 GPM --vs-- ft. TDH .2 ft Trench Spacing:_ 9 O ® Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01011 O III 01V / Page 1 of 3 CDP File Number 191381 = 1 Ir Kepalr System *Site Classification: Provisionally Suitable Design Flow: -4`, pl County ID Number: 5871-95-4613 Ifea:b 1 Ub V IVU \JIVU, UUL IIdJ 1AVdIIdU1U 0 Soil Application Rate: 0 a 5 *System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 3 0 9 Sq. ft. No. Drain Lines 41 Total Trench Length: 31.2 ft ❑ Open Pump System Sheet Trench Spacing: 9 O Inches O. ® Feet O.C. Trench Width: 3 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 - PARALLEL (eq. d -box) Pump Required: OYes (g No OMay 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. R. -i -,q 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. Ram;ct�9 2000 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 O No Applicant/Legal Reps. Signature- Date: *Issued By: 2140 - Nations, Robert Date of Issue: 0 4 / 1 5 / 2 0 1 5 Authorized State Agent: Malfunction Log Oyes ® 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 CDP File Number: County File Number: 5871-95-4613 te<0 A i Date: 14 / 15 / .1 0 15 Click below to import an image from an external location: Drawing Type: Construction Authorization ,- --t T A ^-f /— /S 1 Page 3 of 3 P1 P2 IMPROVEMENT PERMIT For Office Use Only ed R'ufa Davie County Health Department "CDP File Number 191381 -1 210 Hospital Street County ID Number: 5871-95-4613 � 1*•g q P.O. Box 848 Evaluated For: NEW Mocksville NC 27028 Township: Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 3/27/2020 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Schumacher Homes/David Address: 6349 Burnt Poplar Road City: Greensboro State/Zip: NC 27409 Phone #: (336) 215-0278 Property Owner: Harold and Shirley Huges Address: 2701 Bridgeport Drive City: Winston-Salem State/Zip: NC 27103 111�hone #: (336) 462-7057 Property Location & Site Information Address/Road #: Subdivision: Greer► WOO d � it l" Phase: River Road l7 Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC / *SiteInitial S stem asst ica ion: Provisionally Suitable Saprolite System? O Yes X No Design Flow: 3 6 0 Soil Application Rate: 0 a 7 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR *Proposed System: 25% REDUCTION Lot: to Directions 1-40 east to hwy 801 south left on Underpass Rd. Left on River Rd. Job site on corner Minimum Trench Depth: Maximum Trench Depth: Septic Tank: 1 -Piece: Pump Required: Pump Tank: 1 -Piece: Repair System Required: ®Yes O No ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Soil Application Rate: 0 a 5 *System Classification/Description: TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) \ *Proposed System: 25% REDUCTION a 4 Inches 3 6 Inches 1 0 0 0 Gallons O Yes ® No OYes ® No O May Be Required Gallons O Yes O No Minimum Trench Depth: a 4 Inches Maximum Trench Depth: 3 6 Inches Pump Required: OYes ® No O May be Required Page 1 of 3 CDP File Number 191381 - 1 County ID Number: 5871-95-4613 *Site Modifications ❑ Open Fill Sheet No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rs a�9 750 *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 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 surface 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 surface waters. Plat also means, for subdivision 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 is 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. This permit Is subject to revocation if the site plan, plat, or Intended use changes (NCGS 130A -335(f)). 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? Oyes ONO Applicant/Legal Reps. Signature: Date: / *Issued By: 2140 - Nations, Robert Date of Issue: 0 3 / a 7 0 1 5 00, Authorized State Ag OValid without Expiration? 9 Create CA? ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Improvement Permit N CDP File Number: 191381 - 1 County File Number: 5871-95-4613 27028 Date: / / Q Inch Scale: O Block Q N/A �— ft. Page 3 of 3 rM IF— Pi P2 • IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 191381 - 1 P.O. Box 848 5871-95-4613 Mocksville NC 2702$ County File Number: Date: .0.3./ a y/. 0 15 Click below to import an image from an external location: Drawing Type: Improvement Permit Page 3 of 3 P1 P2 ATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC (� ( Davie County Environmental Health i P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336) 753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both Type of Application:�lew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed 's s Contact Person Billing Address l03 (CLP- Home Phone City/State/ZIP sbtW0, k)O-* 2L7 -AM Business Phone 3'6G . 2L5 kyZ'Zg JF Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Faciljty Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan at(to scale) (Permit is valid for 60 months with site plan, no expiration with comple plat.) Owner's Name AR .5 ku. S Owner's Address 9' LD l Zr( O Property Address .v _e- Lot Size l . 12 Tax PIN# 5-8'1 l a.S4Ka Subdivision Name(if applicable) &-QAA,&Nw aXL Directions To Site: V0 Cosi AO 9.41 sang (Z-),~ Phone Nume4eer) 4U Z A qD t % City/State/Zip W - %5 bL L lLQ3 City .}�dL11a,.t�� Section R (0 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 ja'No Does the site contain jurisdictional wetlands? ❑ Yes , ?No Are there any easements or right-of-ways on the site? []Yes ❑No Is the site subject to approval by another public agency? ❑Yes HNo Will wastewater other than domestic sewage be generated? ❑Yes. 10 IF RESIDENCE FILL OUT THE BOX BELOW # People 6k Bedrooms_ # Bathrooms Garden Tub/Whirlpool DYesAjo Basement: ❑Yes Basement Plumbing: ❑Yes�No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facili Business Total Square F of Building # Peopl Sinks #Commodes #Showers # Urin E Water U ge (gallo per day) ach document n similar facility consumpti FOODSERVICE O eats Type system requested/ -Conventional ❑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 locat� staking the house/facility location, proposed well location and the location of any other amenities. P ow is or owner's legal representative signature Site Revisit Charge / r Date(s): Client Notification Date: Daw EHS: Sign given ❑Yes ❑No Revised 11/06 Account # I Invoice # V m- 441- oalbq DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION ( IIdl(jffiac� BIZ �6a e;s#!1I old, P(jq es _DAYJ SWb-V_' �, I Z AOr,")s 3 3� OZ62_02118'i VoL Pd- Water Supply: On -Site Well Community Evaluation By: Auger Boring 11 Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH Texture group C L_ L LL Consistence TS Structure Mineralogy HORIZON II DEPTH —I t -- Texture group C G C Consistence $ i^ Structure le Mineralogy HORIZON III DEPTH Texture group C Consistence ( s Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: / EVALUATION BY: b LONG-TERM ACCEPTANCE RATE: 7 O. �- 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 Moist VFR - Very friable FR - Friable FI - Firm VE - 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 shim 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) Lu ct 4) Ua J� C .1 NOTE: This plot was drawn from record Information and IS NOT the result of an ACTUAL FIELD SURVEY. The purpose of this plat Is to obtain permission to build from the local municipality. NOTE: Slate Surveying Co. P.A. hos mathematically placed the proposed structure on the property as shown. Dimensions are subject to actual survey. Contractor to review all dimensions for accuracy and compliance with restrictive convsnarts. DEVELOPMENT PLAN FOR: Harold & Shirley Hu, Plan # Spring Hill A Custom NOTE: Plan subject to approval by building inspection department prior to construction. GRAPHIC SCALE 50 0 25 50 too IN FEET _j 2001 1 inch = 50 ft. F s PLAT HAROLD & SHIRLEY HUGHES FOR and SCHU WHER HOMES Record References, Lot 6, Block 2 of GREENWOOD LAKE, PB. 3, Pg. 53 see DB. 955, Pg. 017 Scale Date TownshipCount State 1 in. = 50 ft. Jan. 21, 2015 Advance Davie NC Job No. SLATE SURVEYING CO. P.A. AR -M237 P.O. Box 1082 Checke, 12-15-1 DPO Kin , N.C. 27021 3361983-97431 J.D.S.